{"uin":"MAXHLIP21176V022021","name":"Health Premia","url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021","insurer":{"slug":"niva-bupa-health-insurance","name":"Niva Bupa Health Insurance Co Ltd.","url":"https://indiainsurances.com/insurer/niva-bupa-health-insurance"},"line":"health","category":"health-indemnity","category_name":"Health insurance (hospitalisation)","irdai_type":"Revision","kind":"product","status":"unknown","approved_on":"2020-08-28","withdrawn_on":null,"summary":"Health Premia is a Niva Bupa indemnity health policy sold in Silver, Gold and Platinum plans as an Individual, Family Floater or Family First policy, with base sums insured from Rs 5 lacs to Rs 3 cr (Rs 1 lac to Rs 15 lacs per person under Family First). It has a 30-day initial wait, 24 months for pre-existing diseases and 12 months for listed conditions, 90 and 180 days of pre- and post-hospitalisation cover, a 100% re-fill, 10% yearly loyalty additions up to 100%, and international cover excluding USA and Canada on Gold and Platinum.","analysis":{"state":"extracted","analysed_at":"2026-10-16 07:11:56.326609+00","note":"Every stated fact carries a verbatim quote found in the cited clause."},"facts":[{"key":"plan_variants","label":"Plans and variants","section":"Overview","meaning":"The named plans inside this product (not cover types or payout options). Facts can differ between them.","status":"cross-checked","value":["Silver","Gold","Platinum"],"display":"Silver, Gold, Platinum","note":"Each plan is sold as an Individual, Family Floater or Family First policy; benefits and limits differ by plan and policy type.","quote":"Plans | Silver | Gold | Platinum ... product can be issued to an individual customer or to a family with up to 4 children (referred to as a ‘family floater’ policy) or extended family (referred to as a ‘family first’ policy)","sources":[{"clause":null,"heading":"Individual & Family Floater variant","page":70,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-individual-family-floater-variant"},{"clause":"1","heading":"Policy Design","page":1,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/172#c-1"}],"law":[]},{"key":"policy_term","label":"Policy term","section":"Eligibility","meaning":"How long one policy runs before it ends or must be renewed.","status":"cross-checked","value":"One year by default; two-year and three-year policy terms are also available.","display":"1 year (2 and 3 year options)","note":"From the prospectus.","quote":"The default policy term for all plans is one year. Two year and three year policy term options are also available under the product.","sources":[{"clause":"1","heading":"Policy Design","page":1,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/172#c-1"}],"law":[]},{"key":"claim_intimation","label":"Claim intimation deadline","section":"Claims","meaning":"How soon you must tell the insurer about a claim or hospitalisation.","status":"cross-checked","value":"Cashless: contact the insurer at least 72 hours before planned treatment; in an emergency within 48 hours of hospitalisation or before discharge, whichever is earlier. Reimbursement: written notice within 48 hours of admission or before discharge, whichever is earlier.","display":"72 hours before planned treatment; within 48 hours of emergency admission or before discharge","note":"Late intimation is condoned on merits if the delay was beyond the claimant's control. Optional Critical Illness Cover asks for written notice within 7 days. CIS says reimbursement documents are due within 30 days of the insured event.","quote":"We must be contacted to pre-authorize Cashless Facility for planned treatment at least 72 hours prior to the proposed treatment. ... If the Insured Person has been Hospitalized in an Emergency, We must be contacted to pre-authorize Cashless Facility within 48 hours of the Insured Person’s Hospitalization or before discharge from the Hospital, whichever is earlier. ... We shall be given written notice of the claim along with the following details within 48 hours of admission to the Hospital or before discharge from the Hospital, whichever is earlier ... We will condone such delay on merits where the delay has been proved to be for reasons beyond the claimant’s control.","sources":[{"clause":"6.2.15.2(a)(i)","heading":null,"page":59,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-6-2-15-2-a-i"},{"clause":"6.2.15.2(a)(ii)","heading":null,"page":59,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-6-2-15-2-a-ii"},{"clause":"6.2.15.2(b)","heading":null,"page":60,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-6-2-15-2-b"},{"clause":"6.2.15.5","heading":"Delay in Claim Intimation or Claim Documentation","page":62,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-6-2-15-5"}],"law":[{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Sec 1, Part A, V.1","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"},{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Sec 1, Part B, V.1","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"},{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Sec 1, Part C, V.1","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"},{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Para 20, 21","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"}]},{"key":"claim_documents","label":"Claim documents","section":"Claims","meaning":"Documents the insurer asks for when you claim.","status":"cross-checked","value":["Claim form duly completed and signed by the claimant","Details of past medical history record, first and subsequent consultation","Age / Identity proof document","Cancelled cheque/ bank statement / copy of passbook","Original discharge summary","Bar code sticker and invoice for implants and prosthesis","Original final bill from Hospital with detailed break-up and paid receipt","Room tariff of the entitled room category (Non-Network provider)","Original bills of pharmacy/medicines purchased","MLC/Panchnama / First Information Report (FIR) copy (medico-legal cases or Accident)","Original laboratory investigation, diagnostic, radiological & pathological reports"],"display":"Claim form, ID proof, bank details, discharge summary, final bill, pharmacy bills, investigation reports","note":"Post mortem report if the insured dies in hospital; extra documents for the optional Personal Accident and Critical Illness covers; passport copy for claims outside India. For cashless claims the network hospital sends the documents.","quote":"a) Claim form duly completed and signed by the claimant. ... b) Details of past medical history record, first and subsequent consultation. ... c) Age / Identity proof document of Insured Person ... d) Cancelled cheque/ bank statement / copy of passbook mentioning account holder’s name, IFSC code and account number ... e) Original discharge summary. ... f) Bar code sticker and invoice for implants and prosthesis (if used and only in case of Surgery/Surgical Procedure). ... g) Original final bill from Hospital with detailed break-up and paid receipt. ... h) Room tariff of the entitled room category (in case of a Non-Network provider and if room tariff is not a part of Hospital bill) ... i) Original bills of pharmacy/medicines purchased, or of any other investigation done outside Hospital with reports and requisite prescriptions. ... j) For Medico-legal cases (MLC) or in case of Accident ... MLC/Panchnama / First Information Report (FIR) copy attested by the concerned Hospital / police station (if applicable); ... k) Original laboratory investigation, diagnostic, radiological& pathological reports with supporting prescriptions. ... written notice accompanied by a copy of the post mortem report (if any) ... Passport copy with entry and exit stamps","sources":[{"clause":"6.2.15.3","heading":"Claims Documentation","page":60,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-6-2-15-3"}],"law":[{"title":"Master Circular on Health Insurance Business, 2024","section":"Ch I Para 17","url":"https://indiainsurances.com/law/irdai-health-mc-2024"},{"title":"Insurance Regulatory and Development Authority of India (Protection of Policyholders’ Interests, Operations and Allied Matters of Insurers) Regulations, 2024","section":"Reg 22","url":"https://indiainsurances.com/law/irdai-ppi-2024"},{"title":"Insurance Regulatory and Development Authority of India (Protection of Policyholders’ Interests, Operations and Allied Matters of Insurers) Regulations, 2024","section":"Reg 23","url":"https://indiainsurances.com/law/irdai-ppi-2024"},{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Sec 1, Part A, V.2","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"},{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Sec 1, Part B, V.3(iii)","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"},{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Sec 1, Part C, V.2","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"}]},{"key":"claim_settlement_time","label":"Claim settlement time promised","section":"Claims","meaning":"How quickly the policy says a claim is decided or paid, and from when that is counted (intimation or last document).","status":"conflicting","value":"The insurer settles or rejects a claim within 15 days from the claim submission date; delay attracts interest at 2% above the bank rate from receipt of claim intimation.","display":"15 days from claim submission","note":"Cashless discharge authorisation within three hours of final documents. CIS says: 'We shall settle or repudiate a claim within 30 days of the receipt of the last necessary information and documentation' and pre-auth TAT 4 hours.","quote":"i) The Company shall settle or reject a claim, as the case may be, within 15 days from the claim submission date. ... the Company shall be liable to pay interest from the date of receipt of claim intimation till the date of payment of claim at a rate of 2% above the bank rate ... Once the final authorization request is received for discharge, the same will be processed within three hours from the final documents received.","sources":[{"clause":"6.1.9(i)","heading":null,"page":53,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-6-1-9-i"},{"clause":"6.1.9(ii)","heading":null,"page":53,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-6-1-9-ii"},{"clause":"6.2.15.2(a)(ii)","heading":null,"page":59,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-6-2-15-2-a-ii"},{"clause":null,"heading":null,"page":2,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/173#c-s4"}],"law":[{"title":"The Insurance Act, 1938","section":"Section 64UM(4) to (6)","url":"https://indiainsurances.com/law/insurance-act-1938"},{"title":"Master Circular on General Insurance Business, 2024","section":"Ch I, Para 10","url":"https://indiainsurances.com/law/irdai-general-mc-2024"},{"title":"Master Circular on Health Insurance Business, 2024","section":"Ch I Para 15","url":"https://indiainsurances.com/law/irdai-health-mc-2024"},{"title":"Master Circular on Health Insurance Business, 2024","section":"Ch I Para 16","url":"https://indiainsurances.com/law/irdai-health-mc-2024"},{"title":"Insurance Regulatory and Development Authority of India (Protection of Policyholders’ Interests, Operations and Allied Matters of Insurers) Regulations, 2024","section":"Reg 22","url":"https://indiainsurances.com/law/irdai-ppi-2024"},{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Sec 1, Part A, V.2","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"},{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Sec 1, Part B, V.2","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"},{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Sec 1, Part B, V.3(i), V.3(ii)","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"},{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Sec 1, Part B, V.3(iii)","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"},{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Sec 1, Part C, V.3","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"},{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Sec 1, Part C, V.4","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"},{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Para 23","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"},{"title":"The Motor Vehicles Act, 1988: Chapter XI, insurance of motor vehicles against third party risks","section":"Section 149","url":"https://indiainsurances.com/law/motor-vehicles-act-1988"}]},{"key":"exclusions_main","label":"Main exclusions","section":"Exclusions","meaning":"What the policy does not pay for, in the policy's own words.","status":"cross-checked","value":["30-day waiting period for any Illness except Accident (Excl03)","Pre-existing Diseases until 24 months of continuous coverage (Excl01)","Listed conditions and surgeries until 12 months of continuous coverage (Excl02)","Investigation & Evaluation (Excl04)","Rest Cure, rehabilitation and respite care (Excl05)","Obesity/ Weight Control (Excl06)","Cosmetic or plastic Surgery (Excl08)","Hazardous or Adventure sports (Excl09)","Alcoholism, drug or substance abuse or any addictive condition","Sterility and Infertility (Excl17)","Maternity (Excl18)","Dental/oral treatment","Conflict & Disaster","Treatment or medical services received outside the geographical limits of India","AYUSH Treatment, except as mentioned under Section 3.6"],"display":"Waiting periods, investigation-only admissions, rest cure, obesity, cosmetic surgery, adventure sports, addiction, infertility, maternity, dental, war, treatment abroad","note":"Excl09 applies only to participation as a professional in hazardous or adventure sports. Maternity is paid under the Maternity Benefit (Floater and Family First only); treatment abroad is paid under Maternity (Platinum), Specified Illness Cover and International coverage; dental and refractive-error treatment are paid under Platinum OPD cover. The 30-day wait does not apply after more than twelve months of continuous cover. Annexure VII lists non-payable items.","quote":"30-day waiting period (Code- Excl03): ... Expenses related to the treatment of any Illness within 30 days from the first Policy commencement date shall be excluded except claims arising due to an Accident ... Pre-existing Diseases (Code–Excl01) ... excluded until the expiry of 24 months of continuous coverage after the date of inception of the first Policy ... Specified disease/procedure waiting period- Code- Excl02 ... Expenses related to the treatment of the listed conditions, surgeries/treatments shall be excluded until the expiry of 12 months of continuous coverage ... Investigation & Evaluation (Code-Excl04) ... Rest Cure, rehabilitation and respite care (Code-Excl05) ... Obesity/ Weight Control (Code-Excl06) ... Cosmetic or plastic Surgery (Code-Excl08) ... Hazardous or Adventure sports (Code-Excl09) ... Treatment for, alcoholism, drug or substance abuse or any addictive condition and consequences thereof. ... Sterility and Infertility (Code-Excl17) ... Maternity (Code-Excl18) ... Dental/oral treatment ... Conflict & Disaster ... Any treatment or medical services received outside the geographical limits of India. ... Any form of AYUSH Treatments, except as mentioned under Section 3.6","sources":[{"clause":"5.1.1.3","heading":"30-day waiting period","page":46,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-5-1-1-3"},{"clause":"5.1.1.1","heading":"Pre-existing Diseases (Code–Excl01)","page":44,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-5-1-1-1"},{"clause":"5.1.1.2","heading":"Specified disease/procedure waiting period- Code- Excl02","page":45,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-5-1-1-2"},{"clause":"5.1.2.1","heading":"Investigation & Evaluation (Code-Excl04)","page":46,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-5-1-2-1"},{"clause":"5.1.2.2","heading":"Rest Cure, rehabilitation and respite care (Code-Excl05)","page":46,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-5-1-2-2"},{"clause":"5.1.2.3","heading":"Obesity/ Weight Control (Code-Excl06)","page":46,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-5-1-2-3"},{"clause":null,"heading":"Cosmetic or plastic Surgery (Code-Excl08)","page":47,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-cosmetic-or-plastic-surgery-code-excl08"},{"clause":null,"heading":"Hazardous or Adventure sports (Code-Excl09)","page":47,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-hazardous-or-adventure-sports-code-excl09"},{"clause":null,"heading":"Excluded Providers (Code-Excl11)","page":47,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-excluded-providers-code-excl11"},{"clause":null,"heading":"Sterility and Infertility (Code-Excl17)","page":47,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-sterility-and-infertility-code-excl17"},{"clause":"5.1.2.15","heading":"Maternity (Code-Excl18)","page":48,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-5-1-2-15"},{"clause":"5.2.5","heading":"Dental/oral treatment","page":48,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-5-2-5"},{"clause":"5.2.3","heading":"Conflict & Disaster","page":48,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-5-2-3"},{"clause":"5.2.10","heading":null,"page":48,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-5-2-10"},{"clause":"5.2.13","heading":"AYUSH Treatment","page":49,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-5-2-13"}],"law":[{"title":"Insurance Regulatory and Development Authority of India (Protection of Policyholders’ Interests, Operations and Allied Matters of Insurers) Regulations, 2024","section":"Reg 11","url":"https://indiainsurances.com/law/irdai-ppi-2024"},{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Para 16","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"}]},{"key":"grievance","label":"Grievance route","section":"Claims","meaning":"Who to complain to first, as stated in the policy, before going to the Insurance Ombudsman.","status":"cross-checked","value":"Contact Niva Bupa customer service (website www.nivabupa.com, toll free 1860-500-8888, e-mail through the service platform) or the grievance cell at any branch; if not satisfied, the Grievance Redressal Officer, then GRO@nivabupa.com; then the Insurance Ombudsman.","display":"Niva Bupa customer service (1860-500-8888) or branch grievance cell, then Grievance Redressal Officer, then GRO@nivabupa.com","note":"Senior citizens: seniorcitizensupport@nivabupa.com. Grievances can also be lodged on the IRDAI Bima Bharosa portal. The CIS still prints old Max Bupa contact details (customercare@maxbupa.com, GRO@maxbupa.com, New Delhi address).","quote":"In case of any grievance the Insured Person may contact the company through: ... Website: www.nivabupa.com Toll free: 1860-500-8888 ... Email us through our service platform https://rules.nivabupa.com/customer-service/ ... Insured person may also approach the grievance cell at any of the company’s branches with the details of grievance. ... If Insured person is not satisfied with the redressal of grievance through one of the above methods, Insured Person may contact the grievance officer at: ... If the Insured person is not satisfied with the above, they can escalate to GRO@nivabupa.com. ... the insured person may also approach the office of lnsurance Ombudsman of the respective area/region","sources":[{"clause":"6.1.8","heading":"Redressal of Grievance","page":53,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-6-1-8"}],"law":[{"title":"Consumer Protection (Jurisdiction of the District Commission, the State Commission and the National Commission) Rules, 2021","section":"Rule 3","url":"https://indiainsurances.com/law/consumer-jurisdiction-rules-2021"},{"title":"Consumer Protection (Jurisdiction of the District Commission, the State Commission and the National Commission) Rules, 2021","section":"Rule 4","url":"https://indiainsurances.com/law/consumer-jurisdiction-rules-2021"},{"title":"Consumer Protection (Jurisdiction of the District Commission, the State Commission and the National Commission) Rules, 2021","section":"Rule 5","url":"https://indiainsurances.com/law/consumer-jurisdiction-rules-2021"},{"title":"The Consumer Protection Act, 2019","section":"Section 2(11)","url":"https://indiainsurances.com/law/consumer-protection-act-2019"},{"title":"The Consumer Protection Act, 2019","section":"Section 2(42)","url":"https://indiainsurances.com/law/consumer-protection-act-2019"},{"title":"The Consumer Protection Act, 2019","section":"Section 34","url":"https://indiainsurances.com/law/consumer-protection-act-2019"},{"title":"The Consumer Protection Act, 2019","section":"Section 69","url":"https://indiainsurances.com/law/consumer-protection-act-2019"},{"title":"The Insurance Act, 1938","section":"Section 38","url":"https://indiainsurances.com/law/insurance-act-1938"},{"title":"Master Circular on General Insurance Business, 2024","section":"Ch I, Para 12","url":"https://indiainsurances.com/law/irdai-general-mc-2024"},{"title":"Master Circular on Health Insurance Business, 2024","section":"Ch I Para 19","url":"https://indiainsurances.com/law/irdai-health-mc-2024"},{"title":"Master Circular on Health Insurance Business, 2024","section":"Ch I Para 20","url":"https://indiainsurances.com/law/irdai-health-mc-2024"},{"title":"Master Circular on Life Insurance Products, 2024","section":"Chapter 1, Para 13","url":"https://indiainsurances.com/law/irdai-life-products-2024"},{"title":"Master Circular on Life Insurance Products, 2024","section":"Chapter 1, Para 2","url":"https://indiainsurances.com/law/irdai-life-products-2024"},{"title":"Insurance Regulatory and Development Authority of India (Protection of Policyholders’ Interests, Operations and Allied Matters of Insurers) Regulations, 2024","section":"Reg 5(5), 5(6)","url":"https://indiainsurances.com/law/irdai-ppi-2024"},{"title":"Insurance Regulatory and Development Authority of India (Protection of Policyholders’ Interests, Operations and Allied Matters of Insurers) Regulations, 2024","section":"Reg 5(9)","url":"https://indiainsurances.com/law/irdai-ppi-2024"},{"title":"Insurance Regulatory and Development Authority of India (Protection of Policyholders’ Interests, Operations and Allied Matters of Insurers) Regulations, 2024","section":"Reg 25","url":"https://indiainsurances.com/law/irdai-ppi-2024"},{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Sec 1, Part A, VI.1","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"},{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Sec 1, Part A, VI.2","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"},{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Sec 1, Part A, VI.3","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"},{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Para 26","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"},{"title":"IRDAI (Insurance Products) Regulations, 2024","section":"Schedule III, Para 11","url":"https://indiainsurances.com/law/irdai-products-regs-2024"},{"title":"Review of revision in premium rates under health insurance policies for senior citizens, 2025","section":"Para 3","url":"https://indiainsurances.com/law/irdai-senior-premium-2025"},{"title":"Insurance Ombudsman Rules, 2017","section":"Rule 13","url":"https://indiainsurances.com/law/ombudsman-rules-2017"},{"title":"Insurance Ombudsman Rules, 2017","section":"Rule 14","url":"https://indiainsurances.com/law/ombudsman-rules-2017"}]},{"key":"sum_insured_options","label":"Sum insured options","section":"Cover","meaning":"The cover amounts you can choose from.","status":"cross-checked","value":"Individual and Family Floater: Rs 5 lacs, 7.5 lacs, 10 lacs, 15 lacs, 20 lacs, 30 lacs, 50 lacs, 1 cr, 2 cr or 3 cr. Family First: base sum insured per person Rs 1 lac to Rs 15 lacs in steps of Rs 1 lac (Silver 1 to 5 lacs, Gold 5 to 10 lacs, Platinum 10 to 15 lacs), plus a floater sum insured.","display":"Rs 5 lacs to Rs 3 cr (Individual / Family Floater); Rs 1 lac to Rs 15 lacs per person (Family First)","note":"The Individual / Family Floater table does not line up the sum insured columns with the Silver, Gold and Platinum headings, so which amounts belong to which plan is not clear. Family First floater sum insured = number of insured persons x base individual sum insured x multiplier factor (1.5 for 2 members, 1 for others).","quote":"Base Sum Insured (in Rs) | 5 lacs | 7.5 lacs | 10 lacs | 15 lacs | 20 lacs | 30 lacs | 50 lacs | 1 cr | 2 cr | 3 cr ... Base Individual Sum Insured (in Rs & per Insured Person) | 1 Lacs, 2 Lacs, 3 Lacs, 4 Lacs & 5 Lacs | 5 Lacs, 6 Lacs, 7 Lacs, 8 Lacs, 9 Lacs & 10Lacs | 10 Lacs, 11 Lacs, 12 Lacs, 13 Lacs, 14 Lacs & 15 Lacs ... Floater Sum Insured (in Rs) – (available on a floating basis over Base Individual Sum Insured)","sources":[{"clause":null,"heading":"Individual & Family Floater variant","page":70,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-individual-family-floater-variant"},{"clause":null,"heading":"Family First variant","page":74,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-family-first-variant"}],"law":[]},{"key":"initial_waiting","label":"Initial waiting period","section":"Waiting periods","meaning":"Days from the start of the first policy during which illness claims are not paid (accidents usually are).","status":"cross-checked","value":{"unit":"days","amount":30},"display":"30 days","note":"Accidents covered from day one. Optional Critical Illness Cover has a 90-day wait; Specified Illness Cover (abroad) and Premium Waiver need symptoms after 90 days.","quote":"Expenses related to the treatment of any Illness within 30 days from the first Policy commencement date shall be excluded except claims arising due to an Accident, provided the same are covered. ... b) This exclusion shall not, however, apply if the Insured Person has continuous coverage for more than twelve months.","sources":[{"clause":"5.1.1.3","heading":"30-day waiting period","page":46,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-5-1-1-3"}],"law":[]},{"key":"ped_waiting","label":"Pre-existing disease waiting period","section":"Waiting periods","meaning":"How long you wait before conditions you already had when you bought the policy are covered. The law caps it at 36 months.","status":"cross-checked","value":{"unit":"months","amount":24},"display":"24 months","note":"For the optional Critical Illness Cover the wording says 36 months, while the CIS says 48 months. Restarts for any increase in sum insured.","quote":"Expenses related to the treatment of a Pre-existing Disease (PED) and its direct complications shall be excluded until the expiry of 24 months of continuous coverage after the date of inception of the first Policy.. ... Coverage under the Policy after the expiry of 24 months for any Pre-existing Disease is subject to the same being declared at the time of application and accepted by Us.","sources":[{"clause":"5.1.1.1","heading":"Pre-existing Diseases (Code–Excl01)","page":44,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-5-1-1-1"}],"law":[{"title":"Master Circular on Health Insurance Business, 2024","section":"Ch I Para 8","url":"https://indiainsurances.com/law/irdai-health-mc-2024"},{"title":"Master Circular on Health Insurance Business, 2024","section":"Ch I Para 12","url":"https://indiainsurances.com/law/irdai-health-mc-2024"},{"title":"IRDAI (Insurance Products) Regulations, 2024","section":"Schedule III, Para 1.6","url":"https://indiainsurances.com/law/irdai-products-regs-2024"},{"title":"IRDAI (Insurance Products) Regulations, 2024","section":"Schedule III, Para 7","url":"https://indiainsurances.com/law/irdai-products-regs-2024"}]},{"key":"specific_waiting","label":"Specific illness waiting period","section":"Waiting periods","meaning":"Waiting period for a list of named illnesses and procedures (cataract, hernia, joint replacement...). With several tiers (24 and 36 months), the shortest in the answer, the others in the note.","status":"cross-checked","value":{"unit":"months","amount":12},"display":"12 months","note":"Benefit-specific waits: HIV / AIDS 48 months, mental illness 36 months, LASER surgery 36 months, maternity 24 months. Personal waiting periods in the schedule are 24 months.","quote":"Expenses related to the treatment of the listed conditions, surgeries/treatments shall be excluded until the expiry of 12 months of continuous coverage after the date of inception of the first Policy. This exclusion shall not be applicable for claims arising due to an Accident (covered from day 1) or Cancer (covered after 30-day waiting period). ... This benefit is provided subject to a Waiting Period of 48 months from inception of the cover with Us, with HIV / AIDS covered as a benefit ... must have been covered as an Insured Person for a period of 36 months of continuous coverage since the inception of the First Policy, with Mental Illness as a benefit, with Us. ... must have been covered as an Insured Person for a period of 36 months of continuous coverage since the inception of the First Policy with Us.","sources":[{"clause":"5.1.1.2","heading":"Specified disease/procedure waiting period- Code- Excl02","page":45,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-5-1-1-2"},{"clause":"3.17","heading":"HIV / AIDS","page":19,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-3-17"},{"clause":"3.19(d)","heading":null,"page":21,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-3-19-d"},{"clause":"3.20","heading":"LASER surgery cover","page":23,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-3-20"}],"law":[{"title":"Master Circular on Health Insurance Business, 2024","section":"Ch I Para 12","url":"https://indiainsurances.com/law/irdai-health-mc-2024"},{"title":"IRDAI (Insurance Products) Regulations, 2024","section":"Schedule III, Para 1.7","url":"https://indiainsurances.com/law/irdai-products-regs-2024"}]},{"key":"specific_waiting_list","label":"Illnesses with a specific waiting period","section":"Waiting periods","meaning":"The named illnesses and procedures that carry the specific waiting period.","status":"cross-checked","value":["Pancreatitis and stones in biliary and urinary system","Cataract, glaucoma and other disorders of lens, disorders of retina","Hyperplasia of prostate, hydrocele and spermatocele","Abnormal utero-vaginal bleeding, female genital prolapse, endometriosis/adenomyosis, fibroids, PCOD, or any condition requiring dilation and curettage or hysterectomy","Hemorrhoids, fissure or fistula or abscess of anal and rectal region","Hernia of all sites","Osteoarthritis, systemic connective tissue disorders, dorsopathies, spondylopathies, inflammatory polyarthropathies, arthrosis such as RA, gout, intervertebral disc disorders, arthroscopic surgeries for ligament repair","Chronic kidney disease and failure","Varicose veins of lower extremities","All internal or external benign or in situ neoplasms/tumours, cyst, sinus, polyp, nodules, swelling, mass or lump","Ulcer, erosion and varices of gastro intestinal tract","Surgical treatment for diseases of middle ear and mastoid (including otitis media, cholesteatoma, perforation of tympanic membrane), Tonsils and adenoids, nasal septum and nasal sinuses","Internal Congenital Anomaly","Surgery of Genito-urinary system unless necessitated by malignancy","Spinal disorders"],"display":"Kidney and gall stones, cataract, prostate, uterine conditions, piles, hernia, joint and spine disorders, kidney disease, varicose veins, benign growths, ulcers, ENT surgery and others","note":null,"quote":"i) Pancreatitis and stones in biliary and urinary system ... ii) Cataract, glaucoma and other disorders of lens, disorders of retina ... iii) Hyperplasia of prostate, hydrocele and spermatocele ... iv) Abnormal utero-vaginal bleeding, female genital prolapse, endometriosis/adenomyosis, fibroids, PCOD, or any condition requiring dilation and curettage or hysterectomy ... v) Hemorrhoids, fissure or fistula or abscess of anal and rectal region ... vi) Hernia of all sites, ... vii) Osteoarthritis, systemic connective tissue disorders, dorsopathies, spondylopathies, inflammatory polyarthropathies, arthrosis such as RA, gout, intervertebral disc disorders, arthroscopic surgeries for ligament repair ... viii) Chronic kidney disease and failure ... ix) Varicose veins of lower extremities ... x) All internal or external benign or in situ neoplasms/tumours, cyst, sinus, polyp, nodules, swelling, mass or lump ... xi) Ulcer, erosion and varices of gastro intestinal tract ... xii) Surgical treatment for diseases of middle ear and mastoid (including otitis media, cholesteatoma, perforation of tympanic membrane), Tonsils and adenoids, nasal septum and nasal sinuses ... xiii) Internal Congenital Anomaly ... xiv) Surgery of Genito-urinary system unless necessitated by malignancy ... xv) Spinal disorders","sources":[{"clause":"5.1.1.2","heading":"Specified disease/procedure waiting period- Code- Excl02","page":45,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-5-1-1-2"}],"law":[]},{"key":"moratorium","label":"Moratorium period","section":"Renewal and rights","meaning":"After this many months of continuous cover, the insurer cannot reject a claim for non-disclosure, except for proven fraud or permanent exclusions. The law sets 60 months.","status":"cross-checked","value":{"unit":"months","amount":60},"display":"60 months","note":"For an increased sum insured the sixty months count from the date of enhancement, for the increase only.","quote":"After completion of sixty continuous months of coverage (including portability and migration) in health insurance policy, no policy and claim shall be contestable by the insurer on the grounds of non-disclosure, misrepresentation, except on grounds of established fraud.","sources":[{"clause":"6.1.10","heading":"Moratorium Period","page":53,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-6-1-10"}],"law":[{"title":"Master Circular on Health Insurance Business, 2024","section":"Ch I Para 13","url":"https://indiainsurances.com/law/irdai-health-mc-2024"},{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Sec 1, Part B, IV.8","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"},{"title":"IRDAI (Insurance Products) Regulations, 2024","section":"Schedule III, Para 8","url":"https://indiainsurances.com/law/irdai-products-regs-2024"}]},{"key":"portability","label":"Portability","section":"Renewal and rights","meaning":"Whether you can move this policy to another insurer and keep waiting-period credit.","status":"cross-checked","value":"Yes. You can port the policy to another insurer and carry over credits for sum insured, no claim bonus, specific waiting periods, the pre-existing disease waiting period and the moratorium, subject to the acquiring insurer's underwriting.","display":"Yes, with waiting-period credit","note":"Migration to another Niva Bupa product with the same credits is also allowed (Section 6.1.15).","quote":"A Policyholder has the choice to port his/ her policies from one Insurer to another irrespective of individual or group policy subject to the Board approved underwriting policy of the insurers. The policyholder is entitled to transfer the credits gained to the extent of the Sum Insured, No Claim Bonus, specific waiting periods, waiting period for pre-existing disease , Moratorium period etc. from the Existing Insurer to the Acquiring Insurer","sources":[{"clause":"6.1.14","heading":"Portability","page":54,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-6-1-14"}],"law":[{"title":"Master Circular on Health Insurance Business, 2024","section":"Ch I Para 11","url":"https://indiainsurances.com/law/irdai-health-mc-2024"},{"title":"Master Circular on Health Insurance Business, 2024","section":"Ch I Para 12","url":"https://indiainsurances.com/law/irdai-health-mc-2024"},{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Sec 1, Part B, IV.6","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"},{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Sec 1, Part B, VII.3","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"},{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Para 24","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"},{"title":"IRDAI (Insurance Products) Regulations, 2024","section":"Schedule III, Para 1.4 and 1.5","url":"https://indiainsurances.com/law/irdai-products-regs-2024"},{"title":"IRDAI (Insurance Products) Regulations, 2024","section":"Schedule III, Para 10","url":"https://indiainsurances.com/law/irdai-products-regs-2024"}]},{"key":"lifelong_renewal","label":"Lifelong renewal","section":"Renewal and rights","meaning":"Whether the policy can be renewed for life without a maximum age.","status":"cross-checked","value":true,"display":"Yes","note":"Renewal can be refused for established fraud, non-disclosure or misrepresentation. CIS also says 'ordinarily renewable for life'. A child who has completed 31 must move to a separate policy.","quote":"We assure you renewability of your policy for lifetime, if you pay renewal premium within the grace period of 30 days of expiry of your previous policy. ... A health insurance policy shall be renewable except on grounds of established fraud or non-disclosure or misrepresentation by the insured.","sources":[{"clause":null,"heading":null,"page":1,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/172#c-s1"},{"clause":"6.1.3","heading":"Renewal of Policy","page":51,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-6-1-3"}],"law":[{"title":"Master Circular on Health Insurance Business, 2024","section":"Ch I Para 10","url":"https://indiainsurances.com/law/irdai-health-mc-2024"},{"title":"Master Circular on Health Insurance Business, 2024","section":"Ch II D.II","url":"https://indiainsurances.com/law/irdai-health-mc-2024"},{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Sec 1, Part B, IV.5","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"},{"title":"IRDAI (Insurance Products) Regulations, 2024","section":"Schedule III, Para 9","url":"https://indiainsurances.com/law/irdai-products-regs-2024"},{"title":"Review of revision in premium rates under health insurance policies for senior citizens, 2025","section":"Para 7","url":"https://indiainsurances.com/law/irdai-senior-premium-2025"}]},{"key":"claim_loading","label":"Premium loading after claims","section":"Renewal and rights","meaning":"Whether the premium can go up at renewal because you made a claim.","status":"cross-checked","value":"No. No loading applies on renewals based on individual claims experience.","display":"No","note":"A risk loading of up to 250% of premium can be applied from inception based on the declared health status. Renewal premium changes with age.","quote":"d) No loading shall apply on renewals based on individual claims experience. ... The maximum risk loading applicable shall not exceed more than 250% of the premium.","sources":[{"clause":"6.1.3","heading":"Renewal of Policy","page":51,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-6-1-3"},{"clause":"6.2.2(a)","heading":null,"page":55,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-6-2-2-a"}],"law":[{"title":"Master Circular on Health Insurance Business, 2024","section":"Ch I Para 10","url":"https://indiainsurances.com/law/irdai-health-mc-2024"},{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Sec 1, Part B, IV.5","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"},{"title":"IRDAI (Insurance Products) Regulations, 2024","section":"Schedule III, Para 9","url":"https://indiainsurances.com/law/irdai-products-regs-2024"},{"title":"IRDAI (Insurance Products) Regulations, 2024","section":"Schedule III, Para 4","url":"https://indiainsurances.com/law/irdai-products-regs-2024"},{"title":"Review of revision in premium rates under health insurance policies for senior citizens, 2025","section":"Para 7","url":"https://indiainsurances.com/law/irdai-senior-premium-2025"}]},{"key":"permanent_exclusions","label":"Permanent exclusions","section":"Exclusions","meaning":"Conditions or treatments that are never covered: the standard IRDAI exclusion codes Excl04 to Excl18 and the product's own permanent exclusions. Excl01 to Excl03 are waiting periods, not permanent exclusions.","status":"cross-checked","value":["Investigation & Evaluation (Excl04)","Rest Cure, rehabilitation and respite care (Excl05)","Obesity/ Weight Control (Excl06)","Change-of-Gender treatments (Excl07)","Cosmetic or plastic Surgery (Excl08)","Hazardous or Adventure sports (Excl09)","Breach of law (Excl10)","Excluded Providers (Excl11)","Treatment for alcoholism, drug or substance abuse or any addictive condition","Treatments received in heath hydros, nature cure clinics, spas or similar establishments (Excl13)","Dietary supplements and substances that can be purchased without prescription (Excl14)","Refractive Error less than 7.5 dioptres (Excl15)","Unproven Treatments (Excl16)","Sterility and Infertility (Excl17)","Maternity (Excl18)","Ancillary Hospital Charges","Circumcision unless necessary for the treatment of a disease or necessitated by an Accident","Conflict & Disaster","External Congenital Anomaly","Dental/oral treatment","Hormone Replacement Therapy","Multifocal Lens and ambulatory devices","Sexually transmitted Infections & diseases (other than HIV / AIDS)","Sleep disorders","Treatment or medical services received outside the geographical limits of India","Unrecognized Physician or Hospital","Artificial life maintenance for a person declared brain dead or in vegetative state","AYUSH Treatment, except as mentioned under Section 3.6"],"display":"Standard exclusions Excl04 to Excl18 plus ancillary charges, circumcision, war, external congenital anomaly, dental, hormone therapy, sleep disorders, treatment abroad and others","note":"The wording misprints the Excl12 label: the alcoholism exclusion is printed inside the Excl11 text and the 'Excl12' label sits on the Excl13 text. Some exclusions are lifted by benefits (Maternity Benefit, Platinum OPD for dental and refractive error, International coverage, Alternative Treatments). The optional Personal Accident and Critical Illness covers have their own exclusion lists (5.2.14, 5.2.15).","quote":"Investigation & Evaluation (Code-Excl04) ... Rest Cure, rehabilitation and respite care (Code-Excl05) ... Obesity/ Weight Control (Code-Excl06) ... Change-of-Gender treatments (Code-Excl07) ... Cosmetic or plastic Surgery (Code-Excl08) ... Hazardous or Adventure sports (Code-Excl09) ... Breach of law (Code-Excl10) ... Excluded Providers (Code-Excl11) ... Treatment for, alcoholism, drug or substance abuse or any addictive condition and consequences thereof. ... Treatments received in heath hydros, nature cure clinics, spas or similar establishments ... (Code-Excl13) Dietary supplements and substances that can be purchased without prescription ... (Code-Excl14) ... Refractive Error (Code-Excl15) ... Expenses related to the treatment for correction of eye sight due to refractive error less than 7.5 dioptres. ... Unproven Treatments (Code-Excl16) ... Sterility and Infertility (Code-Excl17) ... Maternity (Code-Excl18) ... Ancillary Hospital Charges ... Circumcision unless necessary for the treatment of a disease or necessitated by an Accident. ... Conflict & Disaster ... External Congenital Anomaly ... Dental/oral treatment ... Hormone Replacement Therapy ... Multifocal Lens and ambulatory devices such as walkers, crutches, splints, stockings of any kind ... Sexually transmitted Infections & diseases (other than HIV / AIDS) ... Sleep disorders ... Any treatment or medical services received outside the geographical limits of India. ... Unrecognized Physician or Hospital ... Artificial life maintenance for the Insured Person who has been declared brain dead or in vegetative state ... Any form of AYUSH Treatments, except as mentioned under Section 3.6","sources":[{"clause":"5.1.2.1","heading":"Investigation & Evaluation (Code-Excl04)","page":46,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-5-1-2-1"},{"clause":"5.1.2.2","heading":"Rest Cure, rehabilitation and respite care (Code-Excl05)","page":46,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-5-1-2-2"},{"clause":"5.1.2.3","heading":"Obesity/ Weight Control (Code-Excl06)","page":46,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-5-1-2-3"},{"clause":"5.1.2.14","heading":null,"page":47,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-5-1-2-14"},{"clause":null,"heading":"Cosmetic or plastic Surgery (Code-Excl08)","page":47,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-cosmetic-or-plastic-surgery-code-excl08"},{"clause":null,"heading":"Hazardous or Adventure sports (Code-Excl09)","page":47,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-hazardous-or-adventure-sports-code-excl09"},{"clause":null,"heading":"Breach of law (Code-Excl10)","page":47,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-breach-of-law-code-excl10"},{"clause":null,"heading":"Excluded Providers (Code-Excl11)","page":47,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-excluded-providers-code-excl11"},{"clause":"Excl12","heading":null,"page":47,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-excl12"},{"clause":null,"heading":"Refractive Error (Code-Excl15)","page":47,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-refractive-error-code-excl15"},{"clause":null,"heading":"Unproven Treatments (Code-Excl16)","page":47,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-unproven-treatments-code-excl16"},{"clause":null,"heading":"Sterility and Infertility (Code-Excl17)","page":47,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-sterility-and-infertility-code-excl17"},{"clause":"5.1.2.15","heading":"Maternity (Code-Excl18)","page":48,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-5-1-2-15"},{"clause":"5.2.1","heading":"Ancillary Hospital Charges","page":48,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-5-2-1"},{"clause":"5.2.2","heading":"Circumcision","page":48,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-5-2-2"},{"clause":"5.2.3","heading":"Conflict & Disaster","page":48,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-5-2-3"},{"clause":"5.2.4","heading":"External Congenital Anomaly","page":48,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-5-2-4"},{"clause":"5.2.5","heading":"Dental/oral treatment","page":48,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-5-2-5"},{"clause":"5.2.6","heading":"Hormone Replacement Therapy","page":48,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-5-2-6"},{"clause":"5.2.7","heading":null,"page":48,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-5-2-7"},{"clause":"5.2.8","heading":"Sexually transmitted Infections & diseases (other than HIV / AIDS)","page":48,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-5-2-8"},{"clause":"5.2.9","heading":"Sleep disorders","page":48,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-5-2-9"},{"clause":"5.2.10","heading":null,"page":48,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-5-2-10"},{"clause":"5.2.11","heading":"Unrecognized Physician or Hospital","page":48,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-5-2-11"},{"clause":"5.2.12","heading":null,"page":49,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-5-2-12"},{"clause":"5.2.13","heading":"AYUSH Treatment","page":49,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-5-2-13"}],"law":[{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Para 16","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"}]},{"key":"cancellation_refund","label":"Cancellation by you","section":"Renewal and rights","meaning":"What you get back if you cancel during the year.","status":"cross-checked","value":"You can cancel at any time with 7 days' written notice. For a term up to one year with no claim, proportionate premium for the unexpired period is refunded; for terms over one year, premium for policy years not yet started is refunded.","display":"Proportionate premium for unexpired period if no claim (1-year term)","note":"The wording does not state a refund for a one-year policy after a claim. CIS: no refund if health details were not disclosed correctly or for fraud. Optional International coverage extension cancelled before the trip: Rs. 300 or the premium, whichever is lower, is deducted.","quote":"The policy holder may cancel his/her policy at any time during the term, by giving 7 days’ notice in writing. The insurer shall: ... a) Refund proportionate premium for unexpired policy period, if the term of the policy upto one year and there is no claim(s) made during the policy period ... b) Refund premium for the unexpired policy period, in respect of policies with term more than 1 year and risk coverage for such policy years are not commenced","sources":[{"clause":"6.1.2","heading":"Cancellation","page":51,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-6-1-2"}],"law":[{"title":"The Insurance Act, 1938","section":"Section 64VB","url":"https://indiainsurances.com/law/insurance-act-1938"},{"title":"Master Circular on General Insurance Business, 2024","section":"Ch I, Para 8","url":"https://indiainsurances.com/law/irdai-general-mc-2024"},{"title":"Master Circular on Health Insurance Business, 2024","section":"Ch I Para 6","url":"https://indiainsurances.com/law/irdai-health-mc-2024"},{"title":"Master Circular on Life Insurance Products, 2024","section":"Chapter 1, Para 5","url":"https://indiainsurances.com/law/irdai-life-products-2024"},{"title":"Insurance Regulatory and Development Authority of India (Protection of Policyholders’ Interests, Operations and Allied Matters of Insurers) Regulations, 2024","section":"Reg 17","url":"https://indiainsurances.com/law/irdai-ppi-2024"},{"title":"Insurance Regulatory and Development Authority of India (Protection of Policyholders’ Interests, Operations and Allied Matters of Insurers) Regulations, 2024","section":"Reg 20(3) to 20(5)","url":"https://indiainsurances.com/law/irdai-ppi-2024"},{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Sec 1, Part A, III.2","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"},{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Sec 1, Part B, IV.4","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"},{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Sec 1, Part C, IV.3","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"}]},{"key":"territory","label":"Where it covers","section":"Overview","meaning":"Geographic area of cover: India only, worldwide, or listed countries. 'As stated in the schedule' is not an answer.","status":"cross-checked","value":"India only, except Maternity Benefit (Platinum), Specified Illness Cover and International coverage, which pay outside India within the regions in the schedule (worldwide excluding USA & Canada).","display":"India; listed benefits worldwide excluding USA & Canada","note":"International coverage: not available in Silver; Gold one single trip up to 15 days, Rs 30 lacs; Platinum annual multi-trip up to 45 days per trip, Rs 1 cr. USA & Canada only with the optional Enhanced Geographical Scope. Emergency assistance services apply only within India.","quote":"All benefits are available in India only and all claims shall be payable in India in Indian Rupees only except for benefits and claims under Section 3.10 (Maternity Benefit) under platinum plan, Section 3.23 (Specified Illness cover) and Section 3.26 (International coverage). ... International coverage (outside India for worldwide excluding USA & Canada) | Not available | Condition: One single trip (max 15 days) per Insured Person; International Sum Insured: up to Rs. 30 Lacs per Insured Person | Condition: annual multi trip (Max 45 days coverage in a single trip); International Sum Insured: up to Rs. 1 Cr per Insured Person ... USA & Canada included for Maternity Benefit under platinum plan, Specified Illness under platinum plan and International coverage","sources":[{"clause":"6.2.8","heading":"Territorial Jurisdiction","page":56,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-6-2-8"},{"clause":null,"heading":"Benefits","page":70,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-benefits"},{"clause":null,"heading":"Optional Benefits","page":73,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-optional-benefits"}],"law":[]},{"key":"free_look","label":"Free-look period","section":"Renewal and rights","meaning":"Days after you receive the policy in which you can return it for a refund if you do not agree with its terms.","status":"conflicting","value":{"unit":"days","amount":30},"display":"30 days","note":"Refund less proportionate risk premium, medical examination and stamp duty costs; not on renewals. CIS says: 'within 15 days (30 days for policies with a term of 3 years, if sold through distance marketing) of receipt of the Policy document'.","quote":"The insured person shall be allowed free look period of thirty days from date of receipt of the policy document to review the terms and conditions of the policy.","sources":[{"clause":"6.1.1","heading":"Free Look Period","page":51,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-6-1-1"},{"clause":null,"heading":null,"page":2,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/173#c-s4"}],"law":[{"title":"Master Circular on Health Insurance Business, 2024","section":"Ch I Para 5","url":"https://indiainsurances.com/law/irdai-health-mc-2024"},{"title":"Master Circular on Life Insurance Products, 2024","section":"Chapter 1, Para 5","url":"https://indiainsurances.com/law/irdai-life-products-2024"},{"title":"Insurance Regulatory and Development Authority of India (Protection of Policyholders’ Interests, Operations and Allied Matters of Insurers) Regulations, 2024","section":"Reg 20(1), 20(2)","url":"https://indiainsurances.com/law/irdai-ppi-2024"},{"title":"Insurance Regulatory and Development Authority of India (Protection of Policyholders’ Interests, Operations and Allied Matters of Insurers) Regulations, 2024","section":"Reg 20(3) to 20(5)","url":"https://indiainsurances.com/law/irdai-ppi-2024"},{"title":"Insurance Regulatory and Development Authority of India (Protection of Policyholders’ Interests, Operations and Allied Matters of Insurers) Regulations, 2024","section":"Reg 20(6)","url":"https://indiainsurances.com/law/irdai-ppi-2024"},{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Sec 1, Part A, II.8","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"},{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Sec 1, Part A, III.2","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"},{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Sec 1, Part B, III.2","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"}]},{"key":"grace_period","label":"Grace period","section":"Renewal and rights","meaning":"Days you get after the due date to pay without losing cover or continuity.","status":"cross-checked","value":{"unit":"days","amount":30},"display":"30 days","note":"15 days for monthly instalments.","quote":"can be renewed within the Grace Period of 30 days (annual installment) to maintain continuity of benefits without break in policy ... i) Grace Period of 30 days in all types of policies, and a period of 15 days in case of monthly instalments.","sources":[{"clause":"6.1.3","heading":"Renewal of Policy","page":51,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-6-1-3"},{"clause":"6.2.13","heading":"Premium Payment in Installments","page":57,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-6-2-13"}],"law":[{"title":"The Insurance Act, 1938","section":"Section 50","url":"https://indiainsurances.com/law/insurance-act-1938"},{"title":"Master Circular on Health Insurance Business, 2024","section":"Ch I Para 8","url":"https://indiainsurances.com/law/irdai-health-mc-2024"},{"title":"Master Circular on Health Insurance Business, 2024","section":"Ch I Para 9","url":"https://indiainsurances.com/law/irdai-health-mc-2024"},{"title":"Master Circular on Life Insurance Products, 2024","section":"Chapter 1, Para 8","url":"https://indiainsurances.com/law/irdai-life-products-2024"},{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Sec 1, Part A, IV.2","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"},{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Sec 1, Part B, IV.2","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"},{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Para 3","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"},{"title":"IRDAI (Insurance Products) Regulations, 2024","section":"Schedule I, Para 1.2","url":"https://indiainsurances.com/law/irdai-products-regs-2024"},{"title":"IRDAI (Insurance Products) Regulations, 2024","section":"Schedule III, Para 1.3","url":"https://indiainsurances.com/law/irdai-products-regs-2024"}]},{"key":"eligibility_entry_age","label":"Entry age","section":"Eligibility","meaning":"The youngest and oldest age at which you can buy this policy.","status":"cross-checked","value":"Adults: 18 to 65 years (last birthday). Dependent children: 91 days to 30 years under a family floater policy.","display":"Adults 18 to 65 years; children 91 days to 30 years","note":"From the prospectus. Entry ages for Family First members are not stated separately; the prospectus introduction also says it covers 'senior citizens of any age'. Maternity needs the female insured aged 18 or above.","quote":"The range of entry ages for Adults under the policy is from 18 years (last birthday) to 65 years (last birthday). The range of entry ages for dependent children is from 91 days to 30 years under a family floater policy.","sources":[{"clause":"1","heading":"Policy Design","page":1,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/172#c-1"}],"law":[]},{"key":"premium_modes","label":"Premium payment options","section":"Premium","meaning":"How often you can pay: yearly, half-yearly, quarterly, monthly.","status":"cross-checked","value":["Annual","Half Yearly","Quarterly","Monthly"],"display":"Annual, half-yearly, quarterly, monthly","note":"On a claim, all remaining instalments for the year become due and may be deducted from the claim.","quote":"lf the insured person has opted for Payment of Premium on an instalment basis i.e. Half Yearly, Quarterly or Monthly ... Grace Period of 30 days (annual installment)","sources":[{"clause":"6.2.13","heading":"Premium Payment in Installments","page":57,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-6-2-13"},{"clause":"6.1.3","heading":"Renewal of Policy","page":51,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-6-1-3"}],"law":[]},{"key":"optional_covers","label":"Optional covers","section":"Cover","meaning":"Covers you can add for an extra premium. They change the answers above only if you buy them.","status":"cross-checked","value":["Personal Accident Cover","Critical Illness Cover","Enhanced Loyalty Additions","International coverage extension","Hospital Cash","Enhanced Geographical Scope for International Coverage","Health Coach"],"display":"Personal Accident, Critical Illness, Enhanced Loyalty Additions, International coverage extension, Hospital Cash, Enhanced Geographical Scope, Health Coach","note":"International coverage extension and Enhanced Geographical Scope are not available in Silver. Personal Accident and Critical Illness are for insured aged 18 and above.","quote":"The following optional benefits shall apply under the Policy only if it is specified in the Policy Schedule. Optional benefits can be selected by You only at the time of issuance of the First Policy or at Renewal on payment of the corresponding additional premium. ... Personal Accident Cover ... Critical Illness Cover ... Enhanced Loyalty Additions ... International coverage extension ... Hospital Cash ... Enhanced Geographical Scope for International Coverage ... Health Coach","sources":[{"clause":"4","heading":"Optional Benefits","page":33,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-4"},{"clause":"4.1","heading":"Personal Accident Cover","page":33,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-4-1"},{"clause":"4.2","heading":"Critical Illness Cover","page":37,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-4-2"},{"clause":"4.3","heading":"Enhanced Loyalty Additions","page":42,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-4-3"},{"clause":"4.4","heading":"International coverage extension","page":42,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-4-4"},{"clause":"4.5","heading":"Hospital Cash","page":43,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-4-5"},{"clause":"4.6","heading":"Enhanced Geographical Scope for International Coverage","page":43,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-4-6"},{"clause":"4.7","heading":"Health Coach","page":43,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-4-7"}],"law":[]},{"key":"grace_cover","label":"Cover during the grace period","section":"Renewal and rights","meaning":"Whether a claim during the grace period is paid.","status":"cross-checked","value":"Yes. Coverage is available during the grace period.","display":"Yes","note":"The grace period definition (2.11) says 'Coverage need not be available during the period for which no premium is received', which contradicts these clauses.","quote":"c) Coverage is available during the grace period ... ii) For policies where premium is paid in instalments only, the coverage will be given during grace period.","sources":[{"clause":"6.1.3","heading":"Renewal of Policy","page":51,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-6-1-3"},{"clause":"6.2.13","heading":"Premium Payment in Installments","page":57,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-6-2-13"}],"law":[]},{"key":"room_rent","label":"Room rent limit","section":"Limits and co-pay","meaning":"The most the policy pays per day for the hospital room, or the room category allowed. If you take a costlier room, other bills can be cut in proportion.","status":"cross-checked","value":"No rupee limit for most plans: room rent is covered up to the Sum Insured, but the Suite or above room category is excluded on some plans. Family First Silver: Option 1 Rs 3,000 per day or Shared Room, Option 2 Rs 5,000 per day or Single Private Room, whichever is lower.","display":"Up to Sum Insured (Suite or above excluded on some plans); Family First Silver Rs 3,000 or Rs 5,000 per day","note":"Family First table: Silver as above, Gold up to Sum Insured except Suite or above, Platinum up to Sum Insured. The Individual / Family Floater table prints only two cells for three plans, so which plan excludes Suite rooms is not clear. A costlier room leads to proportionate deduction.","quote":"Room rent | Covered up to Sum Insured (except for Suite or above room category) | Covered up to Sum Insured ... Room rent | Option 1: Rs 3,000 per day or Shared Room; whichever is lower Option 2: Rs 5,000 per day or Single Private Room; whichever is lower | Covered up to Sum Insured (except for Suite or above room category) | Covered up to Sum Insured","sources":[{"clause":null,"heading":"Benefits","page":70,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-benefits"},{"clause":null,"heading":"Benefits","page":74,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-benefits-2"}],"law":[]},{"key":"room_category","label":"Room category allowed","section":"Limits and co-pay","meaning":"Shared room, single private room or any room, by plan, when the limit is a room type rather than a rupee amount.","status":"cross-checked","value":"Any room up to the Sum Insured except Suite or above on some plans; Platinum (Family First) has no room restriction; Family First Silver allows Shared Room (Option 1) or Single Private Room (Option 2).","display":"Any room except Suite or above (some plans); Family First Silver shared or single private room","note":"Individual / Family Floater table columns do not line up with the three plans.","quote":"Room rent | Covered up to Sum Insured (except for Suite or above room category) | Covered up to Sum Insured ... Room rent | Option 1: Rs 3,000 per day or Shared Room; whichever is lower Option 2: Rs 5,000 per day or Single Private Room; whichever is lower | Covered up to Sum Insured (except for Suite or above room category) | Covered up to Sum Insured","sources":[{"clause":null,"heading":"Benefits","page":70,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-benefits"},{"clause":null,"heading":"Benefits","page":74,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-benefits-2"}],"law":[]},{"key":"icu_limit","label":"ICU limit","section":"Limits and co-pay","meaning":"The most the policy pays per day for intensive care.","status":"cross-checked","value":"No separate ICU limit: Intensive Care Unit charges are paid as part of inpatient care up to the Sum Insured.","display":"No separate limit; up to Sum Insured","note":null,"quote":"h) Intensive Care Unit Charges. ... Inpatient care | Covered up to Sum Insured","sources":[{"clause":"3.1","heading":"Inpatient Care","page":10,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-3-1"},{"clause":null,"heading":"Benefits","page":70,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-benefits"}],"law":[]},{"key":"proportionate_deduction","label":"Proportionate deduction","section":"Limits and co-pay","meaning":"If you choose a room above your limit, whether the insurer reduces associated charges (doctor fees, tests, procedures) by the same proportion.","status":"cross-checked","value":"Yes. If the room category or room rent is above the eligible limit, only a pro-rated share of the Associated Medical Expenses (room rent, nursing, doctors' fees, operation theatre charges) is paid.","display":"Yes, pro-rated if room above eligibility","note":"Matters mainly for plans with a room limit (Family First Silver) or a Suite exclusion.","quote":"If the Insured Person is admitted in a Hospital room where the room category opted or Room Rent incurred is higher than the eligibility as specified in the Policy Schedule, then We shall be liable to pay only a pro-rated portion of the total Associated Medical Expenses ... Associated Medical Expenses shall include Room Rent, nursing charges, Medical Practitioners’ fees and operation theatre charges","sources":[{"clause":"3.1","heading":"Inpatient Care","page":10,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-3-1"}],"law":[]},{"key":"copay","label":"Co-payment","section":"Limits and co-pay","meaning":"The share of every admissible claim you pay yourself, and when it applies (age, zone, choice of hospital).","status":"cross-checked","value":"20% co-payment only if Zone 2 is chosen, for treatment in Mumbai (including Navi Mumbai & Thane), Delhi NCR, Kolkata & Gujarat State. OPD claims under International coverage carry a 20% co-payment.","display":"20% in Zone 2 for treatment in Mumbai, Delhi NCR, Kolkata, Gujarat","note":"Zone 1 (all India) has no zone co-payment. The zone co-payment does not apply to e-Consultation, Health Check-up, OPD, Specified Illness, International coverage, the optional covers and some other benefits.","quote":"If You select Zone 2, then 20% Co-payment will apply for treatment in Mumbai (including Navi Mumbai & Thane), Delhi NCR, Kolkata & Gujarat State. ... ii) The Insured Person will bear a 20% Co-Payment and We will indemnify the remaining part of the amount that We assess as admissible in respect of a claim under this Benefit.","sources":[{"clause":"6.2.11","heading":"Zonal pricing","page":57,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-6-2-11"},{"clause":"3.26(c)(ii)","heading":null,"page":27,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-3-26-c-ii"}],"law":[]},{"key":"deductible","label":"Deductible","section":"Limits and co-pay","meaning":"An amount of each claim or each year that you bear before the policy pays.","status":"not-stated","value":null,"display":null,"note":"The wording refers to a Deductible only 'if applicable'; no deductible amount or option is printed for this product.","quote":null,"sources":[],"law":[]},{"key":"disease_sublimits","label":"Disease or procedure sub-limits","section":"Limits and co-pay","meaning":"Caps on what is paid for named treatments (cataract, knee replacement...), even if the sum insured is higher.","status":"cross-checked","value":["Robotic surgeries: maximum INR 1 Lac, except robotic total radical prostatectomy, cardiac surgeries, partial nephrectomy and surgeries for malignancies","HIV / AIDS: Rs. 50,000","Listed mental disorders: Rs 50,000 or Rs 1,00,000 depending on plan","LASER surgery: Rs 50,000 (Gold), Rs 1,00,000 (Platinum), not available in Silver","Maternity: Rs 40,000 to Rs 200,000 by plan and sum insured (Family First Rs 35,000 to Rs 1,00,000)","Emergency ambulance at a non-network hospital: Rs. 2,000 per event"],"display":"Robotic surgery Rs 1 lac; HIV/AIDS Rs 50,000; mental disorders Rs 50,000 or Rs 1,00,000; LASER Rs 50,000 or Rs 1,00,000; maternity; ambulance Rs 2,000","note":"The Rs 50,000 / Rs 1,00,000 mental-disorder sub-limit applies cumulatively to the listed disorders (severe depression, schizophrenia, bipolar disorder and others). Plan-to-amount mapping in the Individual / Family Floater table is unclear because columns do not line up.","quote":"A limit of maximum INR 1 Lac will apply to all robotic surgeries, except the following: ... i) Robotic total radical prostatectomy ... ii) Robotic cardiac surgeries ... iii) Robotic partial nephrectomy ... iv) Robotic surgeries for malignancies ... a) This benefit is covered up to a limit of Rs. 50,000. ... Mental disorder treatment | Covered up to Sum Insured (sub-limit of Rs 50,000 applicable on few conditions) | Covered up to Sum Insured (sub-limit of Rs 1,00,000 applicable on few conditions) ... LASER surgery cover | Not available | Covered up to Rs 50,000 | Covered up to Rs 1,00,000 ... Maternity Benefit (covered for up to 2 pregnancies or terminations)(1) | Covered up to Rs 40,000 ... Covered up to Rs 200,000 (worldwide excluding USA & Canada) ... Covered up to Rs 35,000 ... Covered up to Rs 1,00,000 (worldwide excluding USA & Canada) ... Non-network Hospital: Covered up to Rs. 2,000 per event","sources":[{"clause":"3.25(b)","heading":null,"page":26,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-3-25-b"},{"clause":"3.17","heading":"HIV / AIDS","page":19,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-3-17"},{"clause":null,"heading":"Benefits","page":70,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-benefits"},{"clause":null,"heading":"Benefits","page":74,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-benefits-2"}],"law":[]},{"key":"pre_hospitalisation","label":"Pre-hospitalisation cover","section":"Cover","meaning":"Medical costs in the days before admission that are paid if related to the hospitalisation.","status":"cross-checked","value":{"unit":"days","amount":90},"display":"90 days","note":"Reimbursement basis only; not payable under Maternity, LASER surgery, Specified Illness Cover or International coverage.","quote":"We will pay above mentioned Pre-hospitalization Medical Expenses only for period up to 90 days immediately preceding the Insured Person’s admission for Inpatient Care or Day Care Treatment or Domiciliary Hospitalization or Modern Treatments.","sources":[{"clause":"3.2(a)","heading":null,"page":11,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-3-2-a-2"}],"law":[]},{"key":"post_hospitalisation","label":"Post-hospitalisation cover","section":"Cover","meaning":"Medical costs in the days after discharge that are paid if related to the hospitalisation.","status":"cross-checked","value":{"unit":"days","amount":180},"display":"180 days","note":"Reimbursement basis only.","quote":"We will pay Post-hospitalization Medical Expenses only for up to 180 days immediately following the Insured Person’s discharge from Hospital or Day Care Treatment or Domiciliary Hospitalization or Modern Treatments.","sources":[{"clause":"3.3(a)","heading":null,"page":12,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-3-3-a-2"}],"law":[]},{"key":"day_care","label":"Day-care treatments","section":"Cover","meaning":"Treatments needing less than 24 hours in hospital (chemotherapy, dialysis, cataract) and whether all or only listed ones are covered.","status":"cross-checked","value":"Covered up to the Sum Insured, but only the Day Care Treatments listed in Annexure III.","display":"Listed day care treatments (Annexure III), up to Sum Insured","note":"OPD treatment and diagnostic services are not covered under this benefit.","quote":"List of Day Care Treatments which are covered under the Policy are provided in Annexure III. ... b) Only those Day Care Treatments are covered that are mentioned under list of Day Care Treatments under Annexure III. ... Day Care Treatment | Covered up to Sum Insured","sources":[{"clause":"3.3(a)","heading":null,"page":12,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-3-3-a-2"},{"clause":"3.3(b)","heading":null,"page":12,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-3-3-b-2"},{"clause":null,"heading":"Benefits","page":70,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-benefits"}],"law":[]},{"key":"domiciliary","label":"Treatment at home","section":"Cover","meaning":"Whether treatment at home is covered when hospital admission is not possible or a doctor advises it.","status":"cross-checked","value":"Covered up to the Sum Insured on reimbursement only, if it lasts at least 3 consecutive days and the doctor confirms the patient could not be moved to hospital or no hospital bed was available.","display":"Yes, up to Sum Insured (reimbursement, min 3 days)","note":null,"quote":"We will indemnify on Reimbursement basis only, the Medical Expenses incurred for the Insured Person’s Domiciliary Hospitalization during the Policy Period following an Illness or Injury. ... a) The Domiciliary Hospitalization continues for at least 3 consecutive days ... b) The treating Medical Practitioner confirms in writing that the Insured Person’s condition was such that the Insured Person could not be transferred to a Hospital OR the Insured Person satisfies Us that a Hospital bed was unavailable. ... Domiciliary Hospitalization | Covered up to Sum Insured","sources":[{"clause":"3.5","heading":"Domiciliary Hospitalization","page":12,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-3-5"},{"clause":"3.5(a)","heading":null,"page":12,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-3-5-a"},{"clause":"3.5(b)","heading":null,"page":12,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-3-5-b"},{"clause":null,"heading":"Benefits","page":70,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-benefits"}],"law":[]},{"key":"ayush","label":"AYUSH treatment","section":"Cover","meaning":"Ayurveda, Yoga, Unani, Siddha and Homeopathy treatment in a recognised hospital, and any limit.","status":"cross-checked","value":"Inpatient treatment under Ayurveda, Unani, Siddha and Homeopathy in an AYUSH Hospital is covered up to the Sum Insured, with 90 days pre- and 180 days post-hospitalisation.","display":"Covered up to Sum Insured in an AYUSH Hospital","note":"Called 'Alternative Treatments'. Platinum OPD also covers AYUSH out-patient treatment in government or accredited institutes.","quote":"We will indemnify the Medical Expenses incurred on the Insured Person’s Hospitalization for Inpatient Care during the Policy Period on treatment taken under Ayurveda, Unani, Siddha and Homeopathy. ... a) The treatment should be taken in an AYUSH Hospital ... Pre-hospitalization Medical Expenses incurred for upto 90 days immediately preceding the Insured Person’s admission and Post-hospitalization Medical Expenses incurred for up to 180 days immediately following the Insured Person’s discharge will also be indemnified under this benefit ... Alternative Treatment | Covered up to Sum Insured","sources":[{"clause":"3.6","heading":"Alternative Treatments","page":13,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-3-6"},{"clause":null,"heading":"Benefits","page":70,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-benefits"}],"law":[{"title":"Guidelines on providing AYUSH coverage in Health Insurance policies, 2024","section":"Para 1","url":"https://indiainsurances.com/law/irdai-ayush-2024"},{"title":"Guidelines on providing AYUSH coverage in Health Insurance policies, 2024","section":"Para 2","url":"https://indiainsurances.com/law/irdai-ayush-2024"},{"title":"Master Circular on Health Insurance Business, 2024","section":"Ch I Para 1","url":"https://indiainsurances.com/law/irdai-health-mc-2024"},{"title":"Master Circular on Health Insurance Business, 2024","section":"Ch II A.I(1)","url":"https://indiainsurances.com/law/irdai-health-mc-2024"},{"title":"IRDAI (Insurance Products) Regulations, 2024","section":"Schedule III, Para 5","url":"https://indiainsurances.com/law/irdai-products-regs-2024"}]},{"key":"modern_treatments","label":"Modern treatments","section":"Cover","meaning":"Robotic surgery, immunotherapy, oral chemotherapy, stem cell therapy and the like, and any cap on them.","status":"cross-checked","value":"Covered up to the Sum Insured as inpatient or day care: uterine artery embolization and HIFU, balloon sinuplasty, deep brain stimulation, oral chemotherapy, immunotherapy, intra vitreal injections, robotic surgeries, stereotactic radio surgeries, bronchial thermoplasty, prostate vaporisation, IONM and stem cell therapy. Robotic surgeries are capped at INR 1 Lac except radical prostatectomy, cardiac, partial nephrectomy and malignancy surgeries.","display":"Up to Sum Insured; most robotic surgeries capped at INR 1 Lac","note":null,"quote":"i) Uterine Artery Embolization and HIFU (High intensity focused ultrasound) ... ii) Balloon Sinuplasty ... iii) Deep Brain stimulation ... iv) Oral chemotherapy ... v) Immunotherapy- Monoclonal Antibody to be given as injection ... vi) Intra vitreal injections ... vii) Robotic surgeries ... viii) Stereotactic radio surgeries ... ix) Bronchical Thermoplasty ... x) Vaporisation of the prostrate (Green laser treatment or holmium laser treatment) ... xi) IONM - (Intra Operative Neuro Monitoring) ... xii) Stem cell therapy: Hematopoietic stem cells for bone marrow transplant for haematological conditions to be covered. ... A limit of maximum INR 1 Lac will apply to all robotic surgeries, except the following: ... i) Robotic total radical prostatectomy ... ii) Robotic cardiac surgeries ... iii) Robotic partial nephrectomy ... iv) Robotic surgeries for malignancies ... Modern Treatments | Covered up to Sum Insured with sub-limit of Rs. 1Lac on few robotic surgeries","sources":[{"clause":"3.25(a)","heading":null,"page":25,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-3-25-a"},{"clause":"3.25(b)","heading":null,"page":26,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-3-25-b"},{"clause":null,"heading":"Benefits","page":70,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-benefits"}],"law":[{"title":"Master Circular on Health Insurance Business, 2024","section":"Ch I Para 2","url":"https://indiainsurances.com/law/irdai-health-mc-2024"}]},{"key":"organ_donor","label":"Organ donor expenses","section":"Cover","meaning":"Whether the donor's hospital costs for an organ transplant are paid.","status":"cross-checked","value":"Yes. The living organ donor's inpatient costs for harvesting the organ are covered up to the Sum Insured when the recipient's inpatient claim is accepted; donor pre- and post-hospitalisation costs are not covered.","display":"Yes, up to Sum Insured","note":"Organ transportation or preservation and donor complications are not covered.","quote":"We will indemnify the Medical Expenses incurred for a living organ donor’s treatment as an Inpatient for the harvesting of the organ donated. ... c) We have accepted the recipient Insured Person’s claim under Section 3.1 (Inpatient Care). ... b) Pre-hospitalization Medical Expenses or Post-hospitalization Medical Expenses of the organ donor. ... Living Organ Donor Transplant | Covered up to Sum Insured","sources":[{"clause":"3.7","heading":"Living Organ Donor Transplant","page":13,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-3-7"},{"clause":null,"heading":"Benefits","page":70,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-benefits"}],"law":[]},{"key":"ambulance","label":"Ambulance cover","section":"Cover","meaning":"Road (and air) ambulance cover and its limit.","status":"cross-checked","value":"Road ambulance in an emergency: up to the Sum Insured at a network hospital, up to Rs. 2,000 per event at a non-network hospital; one transfer per hospitalisation. Emergency medical evacuation (air ambulance) within India is part of Emergency Assistance Services.","display":"Network: up to Sum Insured; non-network: Rs. 2,000 per event","note":"Emergency assistance applies when travelling 150 km or more from home within India, on cashless basis. CIS says Rs. 2,000 'per hospitalization'.","quote":"We will indemnify the costs incurred, on transportation of the Insured Person by road Ambulance to a Hospital for treatment in an Emergency following an Illness or Injury. ... c) This benefit is available for only one transfer per Hospitalization. ... Emergency Ambulance | Network Hospital:Covered up to Sum Insured; Non-network Hospital: Covered up to Rs. 2,000 per event ... Emergency medical evacuation (air ambulance)","sources":[{"clause":"3.8","heading":"Emergency Ambulance","page":13,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-3-8"},{"clause":null,"heading":"Benefits","page":70,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-benefits"}],"law":[]},{"key":"restoration","label":"Restoration of sum insured","section":"Cover","meaning":"Whether the sum insured is refilled after it is used up in a year, how much, how often, and whether it works for the same illness.","status":"cross-checked","value":"Yes. A re-fill of up to 100% of the Base Sum Insured, once per Policy Year, for the same or a different illness, usable for inpatient, day care, AYUSH, organ donor and modern treatment claims. Not available under Family First.","display":"Up to 100% of Base Sum Insured, once a year, same or different illness","note":"Unused re-fill is not carried forward.","quote":"then We will provide an additional re-fill amount of maximum up to 100% of the Base Sum Insured. ... b) We will provide a re-fill amount only once in a Policy Year. ... b) This benefit is not available under Family First Policy. ... Re-fill benefit | Reinstate up to base Sum Insured. Applicable for same & difef rent illness as well","sources":[{"clause":"3.13","heading":"Re-fill Benefit","page":16,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-3-13"},{"clause":null,"heading":"Benefits","page":70,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-benefits"}],"law":[]},{"key":"no_claim_bonus","label":"No-claim or cumulative bonus","section":"Cover","meaning":"How much the cover grows each year, the maximum, whether it depends on not claiming, and what happens after a claim.","status":"cross-checked","value":"Loyalty Additions: the Sum Insured increases by 10% of the Base Sum Insured each year on renewal, up to 100%, irrespective of claims. With the optional Enhanced Loyalty Additions it is 20% a year up to 200%.","display":"10% a year up to 100%, irrespective of claims","note":"'Irrespective of claims status' is from the CIS. Under Family First the addition is per insured person and not on the floater sum insured. Accumulated bonus is reduced in proportion if the base sum insured is reduced.","quote":"We will provide Loyalty Additions in the form of Cumulative Bonus by increasing the Sum Insured applicable under the Policy by 10% of the Base Sum Insured of the immediately preceding Policy Year subject to a maximum of 100% of the Base Sum Insured. ... Loyalty additions through increase in Sum Insured by 10% of expiring Base Sum Insured in a Policy Year, maximum up to 100% of Base Sum Insured, irrespective of claims status ... the Loyalty Additions stated in Sections 3.16 (a) and 3.16 (b) shall automatically increase to 20% of Base Insured and the maximum Loyalty Additions shall not exceed 200% of the Base Sum Insured.","sources":[{"clause":"3.16(a)","heading":null,"page":17,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-3-16-a"},{"clause":"Row 2","heading":"What am I covered for","page":1,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/173#c-row-2"},{"clause":"4.3","heading":"Enhanced Loyalty Additions","page":42,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-4-3"}],"law":[]},{"key":"consumables","label":"Consumables and non-medical items","section":"Cover","meaning":"Gloves, PPE, syringes and other items hospitals bill that standard policies exclude; whether this policy pays them.","status":"cross-checked","value":"Not covered as a benefit: items in List I of Annexure VII, such as gloves and masks, are not payable; only 'allowable consumables' during hospitalisation are paid.","display":"Not covered (List I items such as gloves, masks)","note":"No consumables add-on is offered.","quote":"List I – Expenses not covered ... 56 | GLOVES ... 60 | MASK ... e) Intravenous fluids, blood transfusion, injection administration charges, allowable consumables and / or enteral feedings.","sources":[{"clause":null,"heading":"List I – Expenses not covered","page":104,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-list-i-expenses-not-covered"},{"clause":"3.1","heading":"Inpatient Care","page":10,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-3-1"}],"law":[]},{"key":"maternity","label":"Maternity cover","section":"Cover","meaning":"Whether childbirth costs are covered, the limit and the waiting period.","status":"cross-checked","value":"Covered under a Family Floater policy (insured and spouse) or a Family First policy (female insured aged 18 or above), not under an Individual policy, after 24 months of continuous cover; up to 2 pregnancies or terminations. Limit Rs 40,000 to Rs 200,000 by plan and sum insured (Family First Rs 35,000 to Rs 1,00,000).","display":"After 24 months; Rs 40,000 to Rs 200,000 by plan (Floater / Family First only)","note":"Pre- and post-hospitalisation and pre/post-natal expenses are not paid. Platinum maternity is also available abroad (excluding USA & Canada) on cashless basis. Family First: Silver Rs 35,000, Gold Rs 50,000, Platinum Rs 1,00,000.","quote":"i) The female Insured Person of Age 18 years or above is covered under a Family First Policy; or ... ii) Both the Insured Person and his / her legally married spouse are covered under a Family Floater Policy. ... b) This Benefit cannot be availed under an Individual Policy. ... must have been covered as an Insured Person for a period of 24 months of continuous coverage since the inception of the First Policy, with maternity as a benefit, with Us. ... only twice during the lifetime of the Policy including any Renewal thereafter for the delivery of a child or Medically Necessary and lawful termination of pregnancy up to maximum 2 pregnancies or terminations. ... Maternity Benefit (covered for up to 2 pregnancies or terminations)(1) | Covered up to Rs 40,000 ... Covered up to Rs 200,000 (worldwide excluding USA & Canada) ... Covered up to Rs 35,000 ... Covered up to Rs 1,00,000 (worldwide excluding USA & Canada)","sources":[{"clause":"3.10","heading":"Maternity Benefit","page":14,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-3-10"},{"clause":null,"heading":"Benefits","page":70,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-benefits"},{"clause":null,"heading":"Benefits","page":74,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-benefits-2"}],"law":[]},{"key":"newborn","label":"Newborn baby cover","section":"Cover","meaning":"Whether a newborn is covered from birth and for what.","status":"cross-checked","value":"Yes. The new born baby's medical expenses are covered from delivery until the end of the Policy Year up to the Sum Insured, subject to 24 months of the parent's maternity cover; first-year vaccinations are covered. The baby must be added within 90 days.","display":"Covered from birth to end of policy year, up to Sum Insured","note":"Same eligibility as the Maternity Benefit, so not available under an Individual policy.","quote":"We will cover the Medical Expenses incurred towards the medical treatment of the Insured Person’s New Born Baby from the date of delivery until the expiry of the Policy Year, subject to continuous coverage of 24 months of that Insured Person since the inception of the First Policy which offers Maternity Benefit with Us ... b) The New Born Baby should be added as an endorsement within 90 days from date of delivery ... New Born Baby (covered uptill the end of Policy Year) (1) | Covered up to Sum Insured ... Vaccination of the new born baby | Covered until new born baby completes one year","sources":[{"clause":"3.11","heading":"New Born Baby","page":15,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-3-11"},{"clause":"3.11(b)","heading":null,"page":15,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-3-11-b"},{"clause":null,"heading":"Benefits","page":70,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-benefits"}],"law":[]},{"key":"mental_illness","label":"Mental illness","section":"Cover","meaning":"Cover for in-patient treatment of mental illness.","status":"cross-checked","value":"Inpatient treatment for mental illness is covered up to the Sum Insured after 36 months of continuous cover; listed severe disorders are sub-limited to Rs 50,000 or Rs 1,00,000 depending on plan.","display":"Up to Sum Insured after 36 months; listed disorders Rs 50,000 or Rs 1,00,000","note":"Sub-limited conditions include severe depression, schizophrenia, bipolar disorder, PTSD, eating, anxiety, OCD, panic, personality, conversion and dissociative disorders. Treatment must be in a Mental Health Establishment.","quote":"We will indemnify the expenses incurred by the Insured Person for Inpatient treatment for Mental Illness up to the limit as specified in Your Policy Schedule. ... must have been covered as an Insured Person for a period of 36 months of continuous coverage since the inception of the First Policy, with Mental Illness as a benefit, with Us. ... Mental disorder treatment | Covered up to Sum Insured (sub-limit of Rs 50,000 applicable on few conditions) | Covered up to Sum Insured (sub-limit of Rs 1,00,000 applicable on few conditions)","sources":[{"clause":"3.19","heading":"Mental Disorders Treatment","page":21,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-3-19"},{"clause":"3.19(d)","heading":null,"page":21,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-3-19-d"},{"clause":null,"heading":"Benefits","page":70,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-benefits"}],"law":[{"title":"Master Circular on Health Insurance Business, 2024","section":"Ch I Para 3","url":"https://indiainsurances.com/law/irdai-health-mc-2024"},{"title":"Master Circular on Health Insurance Business, 2024","section":"Ch III I","url":"https://indiainsurances.com/law/irdai-health-mc-2024"},{"title":"The Mental Healthcare Act, 2017","section":"Section 21(4)","url":"https://indiainsurances.com/law/mental-healthcare-act-2017"},{"title":"The Mental Healthcare Act, 2017","section":"Section 2(1)(s)","url":"https://indiainsurances.com/law/mental-healthcare-act-2017"},{"title":"The Mental Healthcare Act, 2017","section":"Section 21(1)","url":"https://indiainsurances.com/law/mental-healthcare-act-2017"}]},{"key":"health_checkup","label":"Health check-up","section":"Cover","meaning":"Free preventive check-ups and how often.","status":"cross-checked","value":"Free health check-up from Day 1, every year, for tests worth Rs 1,250 to Rs 10,000 per insured person depending on plan and sum insured. Family First Silver: once in two years, tests as per annexure.","display":"Annual from Day 1, Rs 1,250 to Rs 10,000 per person","note":"Family First Gold Rs 2,500, Platinum Rs 5,000. Silver and Gold on cashless basis only at empanelled providers; Platinum cashless or reimbursement. Unused amount is not carried forward.","quote":"Health Check-up (from Day 1) | Annual, Tests covered up to worth Rs 1,250 per Insured Person ... Annual, tests covered up to worth Rs 10,000 per Insured Person ... Health Check-up (from Day 1) | Once in two years, tests as per annexure","sources":[{"clause":null,"heading":"Benefits","page":70,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-benefits"},{"clause":null,"heading":"Benefits","page":74,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-benefits-2"}],"law":[]},{"key":"opd","label":"Out-patient (OPD) cover","section":"Cover","meaning":"Doctor consultations, tests and medicines without admission, and the limit.","status":"cross-checked","value":"Platinum plan only: OPD consultations, diagnostics, prescribed medicines, out-patient dental and refractive-error eye treatment up to Rs 50,000 per policy (Family First Rs 35,000); 80% of unused amount carried forward, total capped at 2.5 times the entitlement. Not available in Silver or Gold.","display":"Platinum only, up to Rs 50,000 per policy","note":"International coverage (Gold, Platinum) also pays OPD abroad with a 20% co-payment. Dental implants are not covered.","quote":"OPD cover | Not available | Not available | covered up to Rs 50,000 per policy ... OPD cover | Not available | Not available | covered up to Rs 35,000 per policy ... We will indemnify the Reasonable and Customary Charges incurred for OPD Treatment and/or Diagnostic Services and/or prescribed medicines for the OPD Treatment taken during the Policy Period. ... d) Dental / oral treatment, procedures and preventive, restorative services related to disease, disorder and conditions related to natural teeth taken on outpatient basis are covered under this benefit. ... e) Any eyesight / optical treatment taken to correct refractive errors of the eye (including routine eye examinations) on outpatient basis are covered under this benefit. ... then We will carry forward 80% of this unutilized amount to the immediately succeeding Policy Year, provided that the total amount (including the unutilized amount available under this Benefit) shall at no time exceed 2.5 times the amount of the entitlement","sources":[{"clause":null,"heading":"Benefits","page":70,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-benefits"},{"clause":null,"heading":"Benefits","page":74,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-benefits-2"},{"clause":"3.24","heading":"OPD Treatment and Diagnostic Services","page":25,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-3-24"},{"clause":"3.24(d)","heading":null,"page":25,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-3-24-d"},{"clause":"3.24(e)","heading":null,"page":25,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-3-24-e"},{"clause":"3.24(g)","heading":"If the Policy is Renewed with Us without any break and there","page":25,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-3-24-g"}],"law":[]},{"key":"zone_pricing","label":"Zone or city-based premium","section":"Premium","meaning":"Whether premium or co-pay depends on the city you are treated in.","status":"cross-checked","value":"Yes. Premium depends on the zone chosen: Zone 1 (all India) or Zone 2 (all India with a 20% co-payment for treatment in Mumbai including Navi Mumbai & Thane, Delhi NCR, Kolkata & Gujarat State).","display":"Yes, Zone 1 or Zone 2 (20% co-pay in listed cities)","note":null,"quote":"For the purpose of calculating premium, following zones are available: ... Zone 1: All India coverage ... If You select Zone 2, then 20% Co-payment will apply for treatment in Mumbai (including Navi Mumbai & Thane), Delhi NCR, Kolkata & Gujarat State.","sources":[{"clause":"6.2.11","heading":"Zonal pricing","page":57,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-6-2-11"}],"law":[]},{"key":"cashless","label":"Cashless treatment","section":"Claims","meaning":"Whether and where the insurer pays the hospital directly instead of you paying and claiming back.","status":"cross-checked","value":"Yes, at Network Providers with pre-authorisation; the wording also says cashless is offered in hospitals outside the network ('Cashless Everywhere').","display":"Yes, network hospitals (and Cashless Everywhere)","note":"The two sentences sit in the same clause and partly contradict each other. Pre/post-hospitalisation and domiciliary claims are reimbursement only; treatment abroad is cashless only.","quote":"Cashless Facility can be availed only at Our Network Providers or Service Providers (as applicable). ... Note: We offer Cashless Everywhere, even in hospitals which are not part of our network.","sources":[{"clause":"6.2.15.2(a)","heading":"For Availing Cashless Facility","page":58,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-6-2-15-2-a"},{"clause":"6.2.15.2(a)(xi)","heading":null,"page":59,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-6-2-15-2-a-xi"}],"law":[]},{"key":"claims_handled_by","label":"Claims handled by","section":"Claims","meaning":"The insurer itself or a third-party administrator (TPA).","status":"cross-checked","value":"Niva Bupa handles claims itself, not through a third-party administrator.","display":"Insurer (Niva Bupa), no TPA","note":"From the prospectus introduction; the wording does not name a TPA. Some services (emergency assistance, second opinion, health check-up) are run through Service Providers.","quote":"You talk to us directly, not through any third parties. ... We/Our/Us means Niva Bupa Health Insurance Company Limited.","sources":[{"clause":null,"heading":null,"page":1,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/172#c-s1"},{"clause":"2.79","heading":"We/Our/Us","page":10,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-2-79"}],"law":[]},{"key":"family_floater","label":"Family floater available","section":"Cover","meaning":"Whether one sum insured can be shared by the whole family.","status":"cross-checked","value":true,"display":"Yes","note":"Family Floater covers self, spouse and up to 4 children (under 30 at start). A Family First variant covers up to 19 relationships with an individual base sum insured each plus a shared floater sum insured.","quote":"Family Floater Policy means a Policy described as such in the Policy Schedule where the family members (two or more) named in the Policy Schedule are Insured Persons under this Policy. ... a maximum 4 children can be covered under the Policy as Insured Persons","sources":[{"clause":"2.50","heading":"Family Floater Policy","page":6,"url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171#c-2-50"}],"law":[]}],"documents":[{"kind":"wording","label":"Health Premia Policy Wording","pages":109,"fetched_at":"2026-10-16 07:11:41.201639+00","source_url":"https://transactions.nivabupa.com/pages/doc/policy_wording/Health-Premia-Policy-Wording.pdf?v=1.0","url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/171"},{"kind":"prospectus","label":"Health Premia Prospectus","pages":96,"fetched_at":"2026-10-16 07:11:41.201639+00","source_url":"https://transactions.nivabupa.com/pages/doc/prospectus/Health-Premia-Prospectus.pdf?v=1.4","url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/172"},{"kind":"cis","label":"Health Premia","pages":7,"fetched_at":"2026-10-16 07:11:41.201639+00","source_url":"https://transactions.nivabupa.com/pages/doc/Customer-Information/CIS_HealthPremia.pdf","url":"https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021/document/173"}],"versions":[],"where_to_buy":[],"claims_and_complaints":[],"notice":"Information, not advice. IndiaInsurances is not an insurer or an insurance intermediary, does not sell insurance and earns no commission. Policy terms change and your own policy schedule can differ: always confirm with the policy document and the insurer before you buy or claim.","cite_as":"Health Premia (UIN MAXHLIP21176V022021), IndiaInsurances, https://indiainsurances.com/policy/niva-bupa-health-insurance/health-premia-maxhlip21176v022021"}