STAR HEALTH AND ALLIED INSURANCE COMPANY LIMITED

Registered Office: No.1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, [Link]- 28288800
Corporate Office: No. 148, Acropolis, Dr. Radha Krishnan Salai, Mylapore, Chennai - 600 004. Phone: 044 - 4788 6666
« Email : support@[Link] «Website : [Link] « CIN : L66010TN2005PLC056649 « IRDAI Regn. No. : 129

SMART HEALTH PRO

Unique Identification No.: SHAHLIP23172V012223

Preamble the local authorities, wherever applicable, and is under supervision of a registered and
The proposal, declaration and other documents given by the proposer shall be the basis of qualified medical practitioner AND must comply with all minimum criterion as under-
this Contract and is deemed to be incorporated herein. i) has qualified nursing staff under its employment;
ii) has qualified medical practitioner/s in charge;
SECTION I - DEFINITIONS iii) has fully equipped operation theatre of its own where surgical procedures are carried
out;
Standard Definitions iv) maintains daily records of patients and will make these accessible to the insurance
Accident: An accident means sudden, unforeseen and involuntary event caused by company's authorized personnel.
external, visible and violent means.
Day Care Treatment: Day care treatment means medical treatment, and/or surgical
Any one illness: Any one illness means continuous period of illness and includes relapse procedure which is:
within 45 days from the date of last consultation with the Hospital/Nursing Home where i. Undertaken under General or Local Anesthesia in a hospital/day care centre in less
treatment was taken. than 24 hrs because of technological advancement, and
AYUSH Day Care Centre: AYUSH Day Care Centre means and includes Community ii. which would have otherwise required hospitalization of more than 24 hours
Health Centre (CHC), Primary Health Centre (PHC), Dispensary, Clinic, Polyclinic or any Treatment normally taken on an out-patient basis is not included in the scope of this
such health centre which is registered with the local authorities, wherever applicable and definition
having facilities for carrying out treatment procedures and medical or surgical/para-
surgical interventions or both under the supervision of registered AYUSH Medical Dental Treatment: Dental treatment means a treatment related to teeth or structures
Practitioner (s) on day care basis without in-patient services and must comply with all the supporting teeth including examinations, fillings (where appropriate), crowns, extractions
following criterion: and surgery.
i. Having qualified registered AYUSH Medical Practitioner(s) in charge; Disclosure to information norm: The policy shall be void and all premium paid thereon
ii. Having dedicated AYUSH therapy sections as required and/or has equipped shall be forfeited to the Company in the event of misrepresentation, mis-description or non-
operation theatre where surgical procedures are to be carried out; disclosure of any material fact.
iii. Maintaining daily records of the patients and making them accessible to the insurance Domiciliary Hospitalization: Domiciliary hospitalization means medical treatment for an
company's authorized representative. illness/disease/injury which in the normal course would require care and treatment at a
AYUSH Hospital: An AYUSH Hospital is a healthcare facility wherein medical/surgical/ hospital but is actually taken while confined at home under any of the following
para-surgical treatment procedures and interventions are carried out by AYUSH Medical circumstances:
Practitioner(s) comprising of any of the following: i) the condition of the patient is such that he/she is not in a condition to be removed to a
a. Central or State Government AYUSH Hospital; or hospital, or
b. Teaching hospital attached to AYUSH College recognized by the Central Government/ ii) the patient takes treatment at home on account of non-availability of room in a hospital
Central Council of Indian Medicine/Central Council for Homeopathy; or Emergency Care: Emergency care means management for an illness or injury which
c. AYUSH Hospital, standalone or co-located with in-patient healthcare facility of any results in symptoms which occur suddenly and unexpectedly, and requires immediate care
recognized system of medicine, registered with the local authorities, wherever by a medical practitioner to prevent death or serious long term impairment of the insured
applicable, and is under the supervision of a qualified registered AYUSH Medical person's health.
Practitioner and must comply with all the following criterion:
i. Having at least 5 in-patient beds; Grace Period: "Grace period" means the specified period of time, immediately following
the premium due date during which premium payment can be made to renew or continue a
ii. Having qualified AYUSH Medical Practitioner in charge round the clock;
policy in force without loss of continuity benefits pertaining to waiting periods and coverage
iii. Having dedicated AYUSH therapy sections as required and/or has equipped of pre-existing diseases. Coverage need not be available during the period for which no
operation theatre where surgical procedures are to be carried out; premium is received. The grace period for payment of the premium for all types of
iv. Maintaining daily records of the patients and making them accessible to the insurance policies shall be: fifteen days where premium payment mode is monthly and
insurance company's authorized representative. thirty days in all other cases. Provided the insurers shall offer coverage during the grace
AYUSH Treatment: AYUSH Treatment refers to the medical and / or hospitalization treatments period, if the premium is paid in instalments during the policy period.
given under 'Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy systems'. Hospital: A hospital means any institution established for in-patient care and day care
Break in policy: "Break in policy" means the period of gap that occurs at the end of the existing treatment of illness and/or injuries and which has been registered as a hospital with the
policy term/installment premium due date, when the premium due for renewal on a given policy local authorities under Clinical Establishments (Registration and Regulation) Act 2010 or
or installment premium due is not paid on or before the premium renewal date or grace period. under enactments specified under the Schedule of Section 56(1) of the said act Or
complies with all minimum criteria as under:
Cashless facility: Cashless facility means a facility extended by the insurer to the insured i) has qualified nursing staff under its employment round the clock;
where the payments, of the costs of treatment undergone by the insured in accordance ii) has at least 10 in-patient beds in towns having a population of less than 10,00,000 and
with the policy terms and conditions, are directly made to the network provider by the at least 15 in-patient beds in all other places;
insurer to the extent pre-authorization is approved. iii) has qualified medical practitioner(s) in charge round the clock;
Condition Precedent: Condition Precedent means a policy term or condition upon which iv) has a fully equipped operation theatre of its own where surgical procedures are
the Insurer's liability under the policy is conditional upon. carried out;
v) maintains daily records of patients and makes these accessible to the insurance
Congenital Anomaly: Congenital Anomaly means a condition which is present since birth,
company's authorized personnel;
and which is abnormal with reference to form, structure or position.
a) Internal Congenital Anomaly: Congenital anomaly which is not in the visible and Hospitalization: Hospitalization means admission in a Hospital for a minimum period of
accessible parts of the body 24 consecutive 'In-patient Care' hours except for specified procedures/ treatments, where
b) External Congenital Anomaly: Congenital anomaly which is in the visible and such admission could be for a period of less than 24 consecutive hours.
accessible parts of the body Illness: Illness means a sickness or a disease or pathological condition leading to the
Co-Payment: Co-payment means a cost sharing requirement under a health insurance impairment of normal physiological function and requires medical treatment;
policy that provides that the policyholder/insured will bear a specified percentage of the (a) Acute condition - Acute condition is a disease, illness or injury that is likely to
admissible claims amount. A co-payment does not reduce the Sum Insured. respond quickly to treatment which aims to return the person to his or her state of
health immediately before suffering the disease/ illness/ injury which leads to full
Cumulative Bonus: Cumulative Bonus means any increase or addition in the Sum recovery
Insured granted by the insurer without an associated increase in premium.
(b) Chronic condition - A chronic condition is defined as a disease, illness, or injury that
Day Care Centre: A day care centre means any institution established for day care treatment has one or more of the following characteristics;
of illness and/or injuries or a medical setup with a hospital and which has been registered with 1. It needs ongoing or long-term monitoring through consultations, examinations,
Smart Health Pro Unique Identification No.: SHAHLIP23172V012223 POL / SHPRO / V.3 / 2024 1 of 14
 check-ups, and /or tests hospitalization was required, and
2. it needs ongoing or long-term control or relief of symptoms ii. The inpatient hospitalization claim for such hospitalization is admissible by the
3. it requires rehabilitation for the patient or for the patient to be specially trained to insurance company.
cope with it
4. it continues indefinitely Qualified Nurse: Qualified nurse means a person who holds a valid registration from the
5. it recurs or is likely to recur Nursing Council of India or the Nursing Council of any state in India.

Injury: Injury means accidental physical bodily harm excluding illness or disease solely Reasonable and Customary Charges: Reasonable and Customary charges means the
and directly caused by external, violent, visible and evident means which is verified and charges for services or supplies, which are the standard charges for the specific provider
certified by a Medical Practitioner. and consistent with the prevailing charges in the geographical area for identical or similar
services, taking into account the nature of the illness / injury involved.
Inpatient Care: Inpatient care means treatment for which the insured person has to stay in
Renewal: Renewal means the terms on which the contract of insurance can be renewed
a hospital for more than 24 hours for a covered event.
on mutual consent with a provision of grace period for treating the renewal continuous for
Intensive Care Unit: Intensive care unit means an identified section, ward or wing of a the purpose of gaining credit for pre-existing diseases, time-bound exclusions and for all
hospital which is under the constant supervision of a dedicated medical practitioner(s), and waiting periods.
which is specially equipped for the continuous monitoring and treatment of patients who are in Room Rent: Room Rent means the amount charged by a Hospital towards Room and
a critical condition, or require life support facilities and where the level of care and supervision Boarding expenses and shall include the associated medical expenses.
is considerably more sophisticated and intensive than in the ordinary and other wards.
Surgery or Surgical Procedure: Surgery or Surgical Procedure means manual and / or
ICU Charges: ICU (Intensive Care Unit) Charges means the amount charged by a operative procedure(s) required for treatment of an illness or injury, correction of
Hospital towards ICU expenses which shall include the expenses for ICU bed, general deformities and defects, diagnosis and cure of diseases, relief from suffering and
medical support services provided to any ICU patient including monitoring devices, critical prolongation of life, performed in a hospital or day care centre by a medical practitioner.
care nursing and intensivist charges.
Unproven/Experimental treatment: Unproven/Experimental treatment means the
Medical Advice: Medical Advice means any consultation or advice from a Medical treatment including drug experimental therapy which is not based on established medical
Practitioner including the issuance of any prescription or follow-up prescription. practice in India, is treatment experimental or unproven.
Medical Expenses: Medical Expenses means those expenses that an Insured Person has Specific Definitions
necessarily and actually incurred for medical treatment on account of Illness or Accident on Associated medical expenses: Associated Medical Expenses means expenses that
the advice of a Medical Practitioner, as long as these are no more than would have been shall include the applicable nursing charges, Operation theatre charges, Professional fees
payable if the Insured Person had not been insured and no more than other hospitals or of Medical Practitioner including Surgeon/ anaesthetist/ Physician/Specialist of the
doctors in the same locality would have charged for the same medical treatment. Hospital where the Insured Person has been admitted and treated and hence
Medical Practitioner: Medical Practitioner means a person who holds a valid registration Proportionate deduction will be applicable on these items.
from the Medical Council of any State or Medical Council of India or Council for Indian “Associated Medical Expenses” does not include cost of pharmacy and consumables, cost
Medicine or for Homeopathy set up by the Government of India or a State Government and of implants and medical devices and cost of diagnostics, ICU charges and hence
is thereby entitled to practice medicine within its jurisdiction; and is acting within its scope Proportionate deduction will not be applicable on these items.
and jurisdiction of license. Company / Insurer: Company / Insurer means Star Health and Allied Insurance Company
Medically Necessary Treatment: Medically necessary treatment means any treatment, Limited
tests, medication, or stay in hospital or part of a stay in hospital which: Dependent Child: Dependent Child means a child (natural or legally adopted) who is
i) is required for the medical management of the illness or injury suffered by the insured; financially dependent and does not have his / her independent sources of income and not
ii) must not exceed the level of care necessary to provide safe, adequate and over 25 years.
appropriate medical care in scope, duration, or intensity;
Diagnosis: Diagnosis means diagnosis by a registered medical practitioner, supported by
iii) must have been prescribed by a medical practitioner; clinical, radiological, histological, histo-pathological and laboratory evidence and also
iv) must conform to the professional standards widely accepted in international medical surgical evidence wherever applicable, acceptable to the Company.
practice or by the medical community in India.
Family: Family includes Insured Person, Spouse/ Live-in Partner/ Same Sex Partner,
Migration: "Migration" means a facility provided to policyholders (including all members dependent children between 91 days and 25 years of age not exceeding 3 in number.
under family cover and group policies), to transfer the credits gained for pre-existing
diseases and specific waiting periods from one health insurance policy to another with the Home: Home means the Insured Person's place of residence
same insurer. Home Care Treatment: Home Care Treatment means treatment availed by the Insured
Network Provider: Network Provider means hospitals or health care providers enlisted by Person at home, which in normal course would require care and treatment at a hospital but
an insurer, TPA or jointly by an Insurer and TPA to provide medical services to an insured by is actually taken at home provided that:
a cashless facility. a) The Medical practitioner advices the Insured person to undergo treatment at home
b) There is a continuous active line of treatment with monitoring of the health status by a
New Born Baby: Newborn baby means baby born during the Policy Period and is aged medical practitioner for each day through the duration of the home care treatment
upto 90 days. c) Daily monitoring chart including records of treatment administered duly signed by the
Non-Network Provider: Non-Network means any hospital, day care centre or other treating doctor is maintained
provider that is not part of the network. Insured Person: Insured Person means the name/s of persons named in the schedule of
Notification of Claim: Notification of claim means the process of intimating a claim to the the Policy for whom premium is paid.
insurer or TPA through any of the recognized modes of communication. In-Patient: In-Patient means an Insured Person who is admitted to Hospital and stays
Pre-Existing Disease: "Pre-existing disease (PED)" means any condition, ailment, injury there for a minimum periodof 24 hours for the sole purpose of receiving treatment.
or disease: Limit of Coverage: Limit of Coverage means Sum Insured plus Cumulative bonus earned
a) that is/are diagnosed by a physician not more than 36 months prior to the date of wherever applicable
commencement of the policy issued by the insurer;
or Policy Period/Policy year: Policy period / Policy year means a year following the
b) for which medical advice or treatment was recommended by, or received from, a commencement date and its subsequent annual anniversary
physician, not more than 36 months prior to the date of commencement of the policy. Policy term: Policy term means the period between the commencement date and expiry
Pre-hospitalization Medical Expenses: Pre-hospitalization Medical Expenses means date specified in the schedule
medical expenses incurred during pre-defined number of days preceding the Private Single A/c Room: Private Single A/c Room means a single occupancy air-
hospitalization of the Insured Person, provided that: conditioned room with attached wash room and a couch for the attendant. The room may
i. Such Medical Expenses are incurred for the same condition for which the Insured have a television and /or a telephone. Such room must be the most economical of all
Person's Hospitalization was required, and accommodations available in that hospital as single occupancy. This does not include
ii. The In-patient Hospitalization claim for such Hospitalization is admissible by the Deluxe room or a suite.
Insurance Company Shared Accommodation: Shared Accommodation means a room with two or more
Portability: "Portability" means a facility provided to the health insurance policyholders patient beds in a Hospital.
(including all members under family cover), to transfer the credits gained for, pre-existing Sum Insured: Sum Insured means the Sum Insured Opted for and for which the premium
diseases and specific waiting periods from one insurer to another insurer. is paid.
Post-hospitalization Medical Expenses: Post-hospitalization Medical Expenses means
SECTION II - COVERAGE
medical expenses incurred during pre-defined number of days immediately after the
insured person is discharged from the hospital provided that: In consideration of the premium paid, subject to the terms, conditions, exclusions and
i. Such Medical Expenses are for the same condition for which the insured person's definitions contained herein the Company agrees as under.

Smart Health Pro Unique Identification No.: SHAHLIP23172V012223 POL / SHPRO / V.3 / 2024 2 of 14
If during the period stated in the Policy Schedule the insured person sustains bodily injury Note: Payment of any claim under this benefit shall not be construed as a waiver of
or contracts any disease or suffer from any illness and if such disease or injury shall require Company's right to repudiate any claim on grounds of non disclosure of material fact or pre-
the Insured person, upon the advice of a duly qualified Medical Practitioner to incur existing disease, for hospitalization expenses under hospitalization provisions of the policy
Hospitalization expenses for Medical/Surgical treatment at any Nursing Home / Hospital in contract.
India as an In-patient, the Company will indemnify the Insured Person such expenses as
are reasonably and necessarily incurred under the Coverage but not exceeding the Limit of 11. Home Care Treatment: Payable up to 10% of the sum insured subject to maximum of
Coverage stated in the Policy schedule. Rs.5 lakhs in a policy year, for treatment availed by the Insured Person at home, only
1. Room (Private Single A/c Room), Boarding and Nursing Expenses as provided by the for the specified conditions mentioned below, which in normal course would require
care and treatment at a hospital but is actually taken at home provided that:
Hospital / Nursing Home
a) The Medical practitioner advises the Insured person to undergo treatment at home
Note: Associated Medical expenses which vary based on the room occupied by the
insured person will be considered in proportion to the room rent stated in the policy b) There is a continuous active line of treatment with monitoring of the health status by
a medical practitioner for each day through the duration of the home care treatment
schedule or actuals whichever is less. Proportionate deductions are not applied in
respect of the hospitals which do not follow differential billing or for those expenses in c) Daily monitoring chart including records of treatment administered duly signed
respect of which differential billing is not adopted based on the room rent by the treating doctor is maintained
d)
Insured can avail ‘'Home Care Treatment'' service on cashless / reimbursement
2. Surgeon, Anesthetist, Medical Practitioner, Consultants, Specialist Fees. basis, if availed from the list of our Network service providers given in our website
''[Link]''
3. Anesthesia, blood, oxygen, operation theatre charges, ICU charges, surgical
appliances, medicines and drugs, diagnostic materials and X-ray, diagnostic imaging List of Conditions covered under Home care treatment:
modalities, dialysis, chemotherapy, radiotherapy, cost of pacemaker, stent and similar 1. Fever and Infectious diseases which can be managed as Inpatient
expenses. With regard to coronary stenting, medicines, Implants and such other 2. Uncomplicated Urinary tract infections but needing Parenteral Antibiotics
similar items the Company will pay cost of stent as per the Drug Price Control Order 3. Asthma and COPD -Mild Exacerbations needing Home Nebulization
(DPCO) / National Pharmaceuticals Pricing Authority (NPPA) Capping. 4. Acute Gastritis/Gastroenteritis
5. I.V. Chemotherapy [Where advised by the doctor]
4. All day care procedures are covered. 6. Palliative Cancer care requiring medical assistance
5. Road Ambulance: Subject to an admissible hospitalization claim, road ambulance 7. Acute Vertigo
expenses incurred for the following are payable :- 8. Diabetic foot and Cellulitis
i. for transportation of the insured person by private ambulance service to go to 9. IVDP [Cervical and Lumbar disc diseases]
hospital when this is needed for medical reasons 10. Major Surgeries/Arthroplasties needing IV Antibiotics Post Discharge
or 11. Care for Brain and Spinal Injury Cases Post Discharge
ii. for transportation of the insured person by private ambulance service from one 12. Post CVA Care at Home after Discharge
hospital to another hospital for better medical treatment
12. Hospitalization expenses for treatment of New Born Baby: Hospitalization
or Expenses incurred in a hospital/ nursing home on treatment of the New born for any
iii. for transportation of the insured person from the hospital where treatment is disease, illness (including any congenital disorders) or accidental injuries are payable
taken to their place of residence (if it is in same city), provided the requirement of from Day 1 of its birth till the expiry date of the policy, up to 10% of the sum insured and
an ambulance to the residence is certified by the medical practitioner. maximum upto Rs. 2 lakhs. This sub-limit will not apply for treatment related to
6. Air Ambulance: Air ambulance expenses are payable subject to an admissible congenital internal disease / defects for the new born.
hospitalization claim, the Insured Person(s) is/are eligible for reimbursement of Conditions applicable for this section
expenses incurred towards the cost of air ambulance service up to 10% of sum a. This cover is available only if Mother is covered under this (Smart Health Pro)
insured per policy year, provided that policy for a continuous period of 12 months without break
a) It is for emergency care of the insured person which requires immediate and b. Intimation about the birth of the New Born should be given to the company and
rapid ambulance transportation to the hospital/medical centre that ground the coverage will be given to the New Born from the first day of its birth.
transportation cannot be provided. c. Exclusion no.1, (Code-Excl 01), Exclusion no.2 (Code-Excl 02), Exclusion no.3
b) Necessary medical treatment not being available at the location where the (Code-Excl 03) and Exclusion no.20 (Code-Excl 20) as stated under this policy
Insured Person is situated at the time of Emergency shall not apply for the New Born baby cover.
c) It is prescribed by a Medical Practitioner and is Medically Necessary; d. In the subsequent year if the policy holder opts the coverage for New Born and
d) The insured person is in India and the treatment is in India only pays the premium, the New Born Baby will be covered up to the Sum Insured
e) Such Air ambulance should have been duly licensed to operate as such by (without any underwriting and the entry age criteria)
Competent Authorities of the Government/s. e. Enhancement of sum insured is subject to underwriter's approval
7. Pre-hospitalization Expenses: Medical expenses incurred up to 60 days 13. AYUSH Treatment: Medical expenses for Inpatient Hospitalization incurred on
immediately before the insured person is hospitalized. treatment under Ayurveda, Unani, Siddha and Homeopathy systems of medicines in a
8. Post Hospitalization Expenses: Medical expenses incurred up to 180 days AYUSH Hospital is payable up to the sum insured.
immediately after the insured person is discharged from the hospital. Note: Yoga and Naturopathy systems of treatments are excluded from the scope of
coverage under AYUSH treatment
9. Domiciliary Hospitalization: Coverage for medical treatment (Including AYUSH) for
14. Coverage for Modern Treatment: The following procedures will be covered
a period exceeding three days, for an illness/disease/injury, which in the normal
(wherever medically indicated) either as in patient or as part of day care treatment in a
course, would require care and treatment at a Hospital but, on the advice of the
hospital upto sum insured (including Pre and Post hospitalization expenses) during
attending Medical Practitioner, is taken whilst confined at home under any of the the policy period;
following circumstances a) Uterine artery Embolization and HIFU
1. The condition of the patient is such that he/she is not in a condition to be removed b) Balloon Sinuplasty
to a Hospital, or c) Deep Brain Stimulation
2. The patient takes treatment at home on account of non-availability of room in a d) Oral Chemotherapy
hospital. e) Immunotherapy- Monoclonal Antibody to be given as injection
However, this benefit shall not cover Asthma, Bronchitis, Chronic Nephritis and f) Intra Vitreal injections
Nephritic Syndrome, Diarrhoea and all types of Dysenteries including Gastro- g) Robotic surgeries
enteritis, Diabetes Mellitus and Insipidus, Epilepsy, Hypertension, Influenza, Cough h) Stereotactic radio surgeries
and Cold, all Psychiatric or Psychosomatic Disorders, Pyrexia of unknown origin for i) Bronchical Thermoplasty
less than 10 days, Tonsillitis and Upper Respiratory Tract infection including Laryngitis j) Vaporisation of the prostate (Green laser treatment or holmium laser treatment)
and Pharyngitis, Arthritis, Gout and Rheumatism. k) IONM-(Intra Operative Neuro Monitoring)
10. Annual Health Checkup: Expenses incurred towards cost of health check-up up to l) Stem cell therapy: Hematopoietic stem cells for bone marrow transplant for
the limits mentioned in the table given below for each policy year (irrespective of haematological conditions
claim) which can be availed at any time during the policy year. 15. Cumulative Bonus: The insured person will be eligible for Cumulative bonus
calculated at 50% of sum insured for each claim free year and maximum up to 100% of
Limit Upto (Rs.) the sum insured
Sum Insured (Rs.)
Individual SI Floater SI Conditions
500000 1500 2500 1. The Cumulative bonus will be calculated on the expiring Sum Insured
1000000 2000 5000 2. If the insured opts to reduce the Sum Insured at the subsequent renewal, the limit
1500000 4000 8000 of indemnity by way of such Cumulative bonus shall not exceed such reduced
2000000 5000 10000 sum insured
3. Cumulative Bonus will not be reduced unless the same is utilized in the event of
2500000 5000 10000
claim.
5000000 5000 10000 4. During Renewal, Cumulative Bonus will be reduced only to the extent of utilized
7500000 8000 15000 portion and the unutilized Cumulative Bonus will be carried forward to the next
10000000 8000 15000 policy year.
Smart Health Pro Unique Identification No.: SHAHLIP23172V012223 POL / SHPRO / V.3 / 2024 3 of 14
16. Automatic Restoration of Sum Insured: There shall be automatic restoration of the Maximum number of
Sum Insured once by 100% subject to the following :- Wellness Points that
1.
The automatic restoration shall be immediately upon partial/full utilization of the [Link]. Activity can be earned under
limit of coverage.
each activity in a
2.
Such Restored Sum Insured can be utilized for all claims for subsequent policy year
Hospitalization during the policy period.
3.
The maximum liability of the Company in a Single claim under a policy year shall For Submission of Vaccination Certificate
not exceed the limit of coverage. 7. Eg: Vaccine for Covid, HPV, Pneumoccocal, Swine 20
Flu (H1N1), Hepatitis etc..
4.
The unutilized restored sum insured cannot be carried forward to the next policy
year. 8. For Submission of Preventive Eye Check-up report 20
An Insured Person with Smart Health Pro, Tenure 1 year, Third year 9. For Submission of Preventive Dental Check-up report 20
Illustration
in progress, Basic Sum Insured Rs.5,00,000/- For Submission of Mammography & PAP Test (for
10. 20
Available Benefit Limit Women) report
Automatic Admissible Utilization For Submission of Prostate specific antigen (PSA)
Claim Basic 11. 20
Number of Restoration of Sum test report (for Male persons aged > 50 yrs)
amount Sum Bonus claim
Claims of Sum Insured 12. Glaucoma Screening (for persons aged > 50 yrs) 20
(Rs.) Insured (Rs.) amount
Insured (Rs.)
(Rs.) 1. Sign up points for Enrolling to Wellness Program: Insured person(s) can earn
(Rs.)
100 reward points for enrolling in Star Wellness Program through Star Health
1st Claim 5,00,000 5,00,000 5,00,000 - 5,00,000 Basic SI (Full) Mobile application.
Bonus (full) + 2. Manage and Track Health
2nd Claim 7,00,000 - 5,00,000 5,00,000 7,00,000 Automatic a) Completion of Health Risk Assessment (HRA): The Health Risk Assessment
Restore (Full) (HRA) questionnaire is an online tool for evaluation of health and quality of
Available balance for next claim = Rs.3,00,000/- life of the Insured. It helps the Insured to introspect his/ her personal lifestyle.
The Insured can log into his/her account on the website [Link]
17. Star Wellness Program: This program intends to promote, incentivize and to reward and complete the HRA questionnaire. The Insured can undertake this once
the Insured Persons' healthy life style through various wellness activities. The per policy year.
wellness activities as mentioned below are designed to help the Insured person to On Completion of online HRA questionnaire, the Insured earns 150 wellness
earn wellness reward points which will be tracked and monitored by the Company. points.
The wellness points earned by the Insured Person(s) under the wellness program, Note: To get the wellness points mentioned under HRA, the Insured has to
can be utilized to get discount in premium during the renewal. complete the entire HRA within one month from the time he/she started HRA
This Wellness Program is enabled and administered online through Star Health Activity.
Mobile Applications. b) Preventive Risk Assessment: The Insured can also earn wellness points by
Note: The Wellness Activities mentioned in the table below (from Serial Number 1 to 6) undergoing diagnostic / preventive tests during the policy year. These tests
are applicable for the Insured person(s) aged 18 years and above only. The following should include the four mandatory tests mentioned below. Insured can take
table shows the discount on premium available under the Wellness Program; these tests at any diagnostic centre at Insured's own expenses.
- On submission of the test reports, Insured earns 200 reward points.
Wellness Points Earned Discount in Premium Note: These tests reports should be submitted together and within 30 days
from the date of undergoing such Health Check-Up.
200 to 350 4%
351 to 600 10% List of mandatory tests under Preventive Risk Assessment
601 to 750 14% 1. Complete Haemogram Test
2. Blood Sugar (Fasting Blood Sugar (FBS) + Postprandial (PP) [or] HbA1c)
751 and above 20% 3. Lipid profile (Total cholesterol, HDL, LDL, Triglycerides, Total Cholesterol /
*In case of floater policy the weightage is given as per the following table; HDL Cholesterol Ratio)
4. Serum Creatinine
Family Size Weightage
Self, Spouse** 1:1 3. Affinity towards wellness: Insured earns wellness reward points for
undertaking any of the fitness and health related activities as given below. List of
Self, Spouse** and Dependent Children (up to 18 years) [Link] Fitness Initiatives and Wellness points:
Self, Spouse** and Dependent Children (aged above 18 years) [Link] Wellness
Initiative
**Spouse / Live-in Partner / Same Sex Partner Points
Participating in Walkathon, Marathon, Cyclothon and similar
Note: In case of two year and three year policies, total number of wellness points earned activities
in the two year and three year period will be divided by two and three respectively.
- On submission of BIB Number along with the details of the
Please refer the Illustrations to understand the calculation of discount in premium, a. 200
entry ticket taken to participate in the event and/or
weightage and the calculation.
The wellness services and activities are categorized as below: - On Achieving 20,000 Step count on Star Health Mobile
Application
Maximum number of Membership in a health club (50 points for each quarter) - In a
Wellness Points that Gym / Yoga Centre / Zumba Classes / Aerobic Exercise/ Sports
[Link]. Activity can be earned under b. 200
Club/ Pilates Classes/ Swimming / Tai Chi/ Martial Arts /
each activity in a Gymnastics/ Dance Classes
policy year Note: In case if Insured is not a member of any health club, he/she should join into
1. Sign up points for Enrolling to Wellness Program 100 club within 3 months from the date of the policy risk commencement date. Insured
person should submit the health club membership.
Manage and Track Health
2. a) Online Health Risk Assessment (HRA) 150 4. Stay Active: Insured earns wellness reward points on achieving the step count
target on 'Star Health Mobile application as mentioned below:
b) Preventive Risk Assessment 200
Criteria to get reward points
Affinity to Wellness
If the number of steps per day are minimum 8,000 or above for 16 days in a month, it
a) Participating in Walkathon, Marathon, Cyclothon
3. 200 will be considered as one active month and insured will get 20 reward points.
and similar activities
Note
b) Membership in a health club 200
· Incase if Insured achieves 10 active months in a policy year, he/ she will get
Stay Active - If the Insured member achieves the step 50 additional points as bonus.
4. 250
count target on mobile app · First month and last month in each policy year will not be taken into consideration
Sharing 'Active Life Success Story' through adoption for calculation of average number of steps per day under Stay Active.
5. 50
of Star Wellness Program · The mobile app must be downloaded within 30 days of the policy risk start date to
Condition Management Program (CMP): Weight avail this benefit.
6. Management, Diabetes Management, Hypertension, 150 · The average step count completed by an Insured member would be tracked on
De-Stress & Mind Body Healing Program. 'Star Mobile Application'.
Smart Health Pro Unique Identification No.: SHAHLIP23172V012223 POL / SHPRO / V.3 / 2024 4 of 14
 5. Condition Management Program c. Submission of Preventive Dental Check-up: Insured can earn 20 wellness
(i) Weight Management Program: reward points for submitting Dental Check-up report which includes
a) This Program will help the Insured persons with Over Weight and screening of oral cavity done by a qualified Dentist.
Obesity to manage their Body Mass Index (BMI) through the d. Submission of Mammography & PAP Test report: Insured can earn
empanelled wellness experts who will guide the Insured in losing 20 wellness reward points for submitting x-ray Mammogramgraphy or
excess weight and maintain their BMI. coloured doppler mammogram for preventive breast screening and PAP
- 150 wellness points will be awarded in case if the results are smear (biopsy) report.
achieved and maintained as mentioned below. e. Prostate specific antigen (PSA) test (applicable for Males aged > 50 yrs):
Sr. Name of the Values to be Criteria to get the Insured can earn 20 wellness reward points for submitting Prostate specific
No. Ailment submitted Wellness points antigen blood report.
Achieving and f. Glaucoma Screening (for persons aged > 50 yrs): Insured can earn
Obesity Height & Weight 20 wellness reward points by submitting reports of Glucoma screening test
1. maintaining the BMI
(If BMI is above 29) (to calculate BMI) of both eyes including tonometery. (slit lamp test), pachymeter test, visual
between 18 and 29
field test, dilated eye test and gonioscopy examination.
Reducing BMI by
Overweight two points and Terms and conditions applicable for wellness services
Height & Weight · Any information provided by the Insured in this regard shall be kept confidential.
2. (If BMI is between maintaining the
(to calculate BMI)
25 and 29) same BMI in the · There will not be any cash redemption against the wellness reward points.
policy year
· Insured should notify and submit relevant documents, reports, receipts etc
- Values (for BMI) shall be submitted for every 2 months (up to for various wellness activities within 1 month of undertaking such activity/test.
5 times in each policy year) · For services that are provided through empanelled service provider, Star
b) Incase if the Insured is not Overweight / Obese, the Insured can submit Health is only acting as a facilitator; hence would not be liable for any
his/her 'Active Life Success Story' through adoption of Star Wellness incremental costs or the services.
Activities with us. On submission of Active Life Success Story through · All medical services are being provided by empanelled health care service
adoption of Star Wellness Activities, Insured earns 50 wellness points. provider. We ensure full due diligence before empanelment. However
(ii) Chronic Condition Management Program: Insured should consult his/her doctor before availing/taking the medical
a) This Program will help the Insured suffering from Diabetes, advices/services. The decision to utilize these advices/services is solely at
Hypertension, Cardiovascular Disease or Asthma to track their health Insured person's discretion.
through the empanelled wellness experts who will guide the insured in · We reserve the right to remove the wellness reward points if found to be
maintaining/ improving the health condition. achieved in unfair manner.
- The Insured has to submit the test result values for every · Star Health, its group entities, or affiliates, their respective directors,
3 months maximum up to 3 times in a policy year. officers, employees, agents, vendors, are not responsible or liable for, any
- If the test result values are within +/- 10% range of the values actions, claims, demands, losses, damages, costs, charges and expenses
given below, for at least 2 times in a policy year, 150 wellness which a Member claims to have suffered, sustained or incurred, by way of
points will be awarded. and / or on account of the Wellness Program.
- These tests reports to be submitted within 1 month from the date · Services offered are subject to guidelines issued by IRDAI from time to time.
of undergoing the Health Check-Up
ILLUSTRATION OF BENEFITS
Values Criteria to
Sr. Name of the Test to be A 51 year old Individual Gopal and his wife Ramya along with their two
get the additional
No. Ailment submitted dependent children (aged below 18 yrs) buy a Smart Health Pro with Sum
Wellness points
Insured 10 Lacs, let's understand how they can earn Wellness Points. Gopal
Diabetes(Insured HbA1c £ 6.5 has declared that he is suffering from Diabetes. Ramya has declared her BMI
can submit either as 27. Gopal and Ramya enrolled under the Star wellness program and
HbA1c test value completed the following wellness activities.
(or) Fasting Blood Sugar Wellness Wellness
1. Fasting Blood (FBS) Range and 100 to 125 mg/dl Sr. Points Points
Sugar (FBS) Postprandial test Activity
No. Earned by Earned by
Range and value below 160 mg/dl Gopal Ramya
Postprandial test Sign up points for Enrolling to Wellness
value) 1. 100 100
Program
Systolic Range - 110 Manage and Track Health
Measured with - BP to 140 mmHg 2. a) Online Health Risk Assessment (HRA) 150 150
2. Hypertension
apparatus Diastolic Range - 70
to 90 mmHg b) Preventive Risk Assessment 200 200
Affinity to Wellness
LDL Cholesterol and
Cardiovascular Total Cholesterol / 100 to 159 mg/dl c) Participating in Walkathon, Marathon,
3. 3. 200 0
Disease HDL Cholesterol Cyclothon and similar activities
Ratio £ 4.0 d) Membership in a health club 100 150
FEV1 (PFC) is 75% Stay Active (Wellness points based on
4. 250 120
PFT (Pulmonary or more Step Count)
4. Asthma
Function Test) FEV1/ FVC is 70% or 5. For Sharing 'Active Life Success Story' 50 0
more 6. Condition Management Program (CMP) 150 150
b) In case if the Insured is not suffering from Chronic Condition/s 7. Submission of Vaccination Certificate 20 20
(Diabetes, Hypertension, Cardiovascular Disease or Asthma) For Submission of Preventive Eye Check-
he/she can opt for “De-Stress & Mind Body Healing Program”. 8. 20 0
up report
This program helps the Insured to reduce stress caused due to For Submission of Preventive Dental
internal (self-generated) & external factors and increases the 9. 0 20
Check-up report
ability to handle stress.
For Submission of Mammography & PAP
- On completion of De-stress & Mind Body Healing Program 10. 0 20
Test (for Women) report
150 wellness points will be awarded.
Note: This is a 10 weeks program which insured needs to For Submission of Prostate specific
complete without any break. 11. antigen (PSA) test report (for Male 20 0
persons aged > 50 yrs)
6. Reward points for Preventive Care: Insured can earn wellness reward points Glaucoma Screening (for persons aged >
for submitting the following health check-up reports once in a policy year which 12. 20 0
50 yrs)
he/ she had during the policy year.
a. Submission of Vaccination Certificate/s: Insured can earn 20 wellness Total Number of Wellness Points earned 1280 930
reward points by submitting the Vaccination certificate related to vaccine No of wellness points based upon weightage - 640 465
that he/she have had during the policy year. Eg: Vaccine for Covid, HPV, [Link] (1280X1/2) (930X1/2)
Swine Flu (H1N1), Hepatitis etc. Total Number of Wellness Points earned by Gopal and Ramya = 1105
b. Submission of Preventive Eye Check-up report: Insured can earn 20 (640+465)
wellness reward points for submitting Eye Check-up report which includes Based on the no of Wellness Points earned, Gopal & Ramya are eligible to
near and far vision (visual equity) and Colour vision test. get 20% discount on renewal premium
Smart Health Pro Unique Identification No.: SHAHLIP23172V012223 POL / SHPRO / V.3 / 2024 5 of 14
18. Value Added Services 5. Unlimited Automatic Restoration of Sum Insured: The policy provides automatic
a. Star Tele-health Services: Insured can consult with the In-house Medical restoration of sum insured subject to the following condition;
Practitioners between 8.00 am and 10.00 pm, who can help the Insured by · Sum Insured will be restored unlimited number of times and maximum up to
providing Medical advice, Second Medical Opinion and consultation on Diet & 100% each time, which can be utilized for a subsequent hospitalization.
Nutrition through Voice Call, Video Call & Online Chat provided in our 'Star
· The restoration will trigger immediately upon partial/ full utilization of the sum
Health' Mobile App. and for Consultation by Telephone (between 8.00 am to
insured, which can be utilized for a subsequent hospitalization.
10.00 pm) Insured can call to the phone number - 7676 905 905
b. Medical Concierge Services: The Insured can also contact Star Health to avail · On partial utilization of the Sum Insured, it will be restored up to extent of utilization.
services like, Emergency assistance information such as nearest ambulance / · On full utilization of the Sum Insured, it will be restored to 100%.
hospital / blood bank etc. · The Restored Sum Insured can be used for all claims including for modern
c. Digital Health Vault: A secured Personal Health records system for Insured to treatment, but for a subsequent hospitalization.
store/access and share health data with trusted recipients. Using this portal, · The maximum payable amount for a single claim under restoration benefit shall
Insured can store their health documents (prescriptions, lab reports, discharge not be more than the Sum Insured.
summaries etc.), track health data add family members.
d. Wellness Content: The wellness portal provides rich collection of health Unlimited Restoration – illustration
articles, blogs, tips and other health and wellness content. The contents have If there are 2 insured members with Sum Insured of 10 Lacs each, lets understand how
been written by experts drawn from various fields. Insured will benefit from restoration benefit will apply to each under different circumstances.
having one single and reliable source for learning about various health aspects
and incorporating positive health changes. Insured 1 Insured 2
e. Post Operative Care: It is done through follow up phone calls (primarily for Sum Insured Rs 10,00,000 Rs 10,00,000
surgical cases) for resolving their medical queries. No Claim Bonus (NCB) 0 Rs 5,00,000
f. Discounts from Network Providers: The Insured can avail discounts on the
Rs 15,00,000
services offered by our network providers which will be displayed in our website.
Total Available amount Rs 10,00,000 (Sum Insured 10 Lac
Terms and conditions applicable for value added services + NCB 5Lac)
· For services that are provided through empanelled service provider, Star Health
is only acting as a facilitator; hence would not be liable for any incremental costs 1st Claim Rs 5,00,000 Rs 5,00,000
or the services. 1st Claim paid amount Rs 5,00,000 Rs 5,00,000
· All medical services are being provided by empanelled health care service Claim Will the restoration kick in? Rs 5,00,000 Rs 5,00,000
provider. We ensure full due diligence before empanelment. However Insured Yes, Why - Since there is partial (Restored Sum (Restored Sum
should consult his/her doctor before availing/taking the medical utilization of Sum Insured. Insured) Insured)
advices/services. The decision to utilize these advices/services is solely at 15,00,000
Insured person's discretion. 10,00,000
Available amount for next claim (Restored SI 5Lac + (Restored SI 5Lac +
· Star Health, its group entities, or affiliates, their respective directors, officers, Balance SI 5Lac+
Balance SI 5Lac) NCB 5L)
employees, agents, vendors, are not responsible or liable for, any actions,
claims, demands, losses, damages, costs, charges and expenses which a 2nd Claim
Member claims to have suffered, sustained or incurred, by way of and / or on Rs 15,00,000 Rs 15,00,000
(For Same / different illness)
account of the Wellness Program
2nd Claim paid amount Rs 10,00,000 Rs 15,00,000
· Services offered are subject to guidelines issued by IRDAI from time to time. Claim Will the restoration kick in? Rs 10,00,000 Rs 10,00,000
SECTION III - OPTIONAL COVERS Yes, Why - Since there is full (Restored Sum (Restored Sum
utilization of Sum Insured. Insured) Insured)
The following Optional Covers are available on payment of additional Rs 10,00,000 Rs 10,00,000
premium/reduction in premium as shown in the policy schedule. Available amount for next claim (SI is Restored (SI is Restored
1. Cumulative Bonus Booster: The insured person will be eligible for additional up to 100%) up to 100%)
Cumulative bonus calculated at 50% of sum insured for each claim free year and 3rd Claim
maximum up to 600% of the sum insured Rs 11,00,000 Rs 11,00,000
(For Same / different illness)
Conditions applicable for Cumulative Bonus Booster 3rd Claim paid amount Rs 10,00,000 Rs 10,00,000
1. The Cumulative bonus will be calculated on the expiring Sum Insured Claim Will the restoration kick in? Rs 10,00,000 Rs 10,00,000
2. If the insured opts to reduce the Sum Insured at the subsequent renewal, the limit
Yes, Why - Since there is full (Restored Sum (Restored Sum
of indemnity by way of such Cumulative bonus will be calculated as per the
utilization of Sum Insured. Insured) Insured)
reduced sum insured.
3. Cumulative Bonus will not be reduced unless the same is utilized in the event of Conditions applicable for Optional Covers
claim 1. The above mentioned optional covers can be opted by the insured only at the time of
4. During Renewal, Cumulative Bonus will be reduced only to the extent of utilized inception.
portion and the unutilized Cumulative Bonus will be carried forward to the next
2. Once opted, the insured cannot opt out of the optional covers during renewal.
policy year.
Note List of Benefits which are part of sum insured or in addition to sum insured
1. This optional cover can be opted by insured having Sum Insured of Rs. 10 lakhs
Forming Part of Sum Insured
and above. [Link]. Coverage
/ In addition to Sum Insured
2. During renewal, if insured reduces the Sum Insured to below Rs. 10 lakhs, this
optional cover will not be available. Room Rent , Boarding, Nursing Expenses,
Surgeon, Anesthetist, Medical Practitioner,
2. Modification of Room Category: Through this optional cover, Insured person can Consultants, Specialist Fees, Anesthesia,
enhance/reduce the room category from Private Single A/c Room to Any Room / Blood, Oxygen, Operation theatre charges,
Shared Accommodation. 1 ICU charges, Surgical appliances, Medicines Forming Part of Sum Insured
Note and Drugs, Diagnostic materials and X-ray,
1. Enhancement of room category to Any Room can be opted by insured having Diagnostic imaging modalities, dialysis,
Sum Insured of Rs. 10 lakhs and above only. chemotherapy, radiotherapy, cost of
2. During renewal, if insured reduces the Sum Insured to below Rs. 10 lakhs, this pacemaker, stent and similar expenses.
enhancement of room category will not be available. 2 All day care treatments Forming Part of Sum Insured
3. Reduction of Pre-Existing Diseases Waiting Period: The Insured Person can 3 Coverage for Non-medical items (Consumables) Forming Part of Sum Insured
reduce the Pre-Existing Disease/s waiting period from 36 months to 24 / 12 months. 4 Road ambulance Forming Part of Sum Insured
This option is available only for the first purchase of this Smart Health Pro and also only 5 Air Ambulance Forming Part of Sum Insured
upto Sum Insured chosen at that time. This option is not available for renewal / ported /
migrated policies. Offering reduction of Pre-Existing Diseases waiting period is subject 6 Pre-Hospitalization Expenses Forming Part of Sum Insured
to Underwriter's approval. 7 Post Hospitalization Expenses Forming Part of Sum Insured
Note: If the Pre-Existing Disease/s falls under the list of specific disease waiting 8 Domiciliary Hospitalization Forming Part of Sum Insured
period (Exclusion No. 2 - Code Excl 02), the longer among the Pre-Existing Disease
9 Annual Health Check Up In addition to Sum Insured
and specific disease waiting period shall apply.
10 Home care treatment Forming Part of Sum Insured
4. Coverage for Non-medical Items (Consumables): Items as per List I will become
Hospitalization expenses for Treatment of
payable If there is an admissible claim under the policy for inpatient / day care 11 Forming Part of Sum Insured
New Born Baby
treatment.
12 AYUSH Treatment Forming Part of Sum Insured
(Exclusion No. 32 - Code Excl 37) as stated under this policy shall not apply if
insured opts this coverage. 13 Coverage for Modern Treatment Forming Part of Sum Insured
Smart Health Pro Unique Identification No.: SHAHLIP23172V012223 POL / SHPRO / V.3 / 2024 6 of 14
 SECTION IV - EXCLUSIONS ii. Any services for people who are terminally ill to address physical, social,
emotional and spiritual needs.
Standard Exclusions
1. Pre-Existing Diseases - Code Excl 01 6. Obesity/ Weight Control - Code Excl 06: Expenses related to the surgical treatment
A. Expenses related to the treatment of a pre-existing Disease (PED) and its direct of obesity that does not fulfil all the below conditions;
complications shall be excluded until the expiry of 36 months of continuous A. Surgery to be conducted is upon the advice of the Doctor.
coverage after the date of inception of the first policy with insurer. B. The surgery/Procedure conducted should be supported by clinical protocols.
B. In case of enhancement of sum insured the exclusion shall apply afresh to the C. The member has to be 18 years of age or older and,
extent of sum insured increase. D. Body Mass Index (BMI);
C. If the Insured Person is continuously covered without any break as defined under 1. greater than or equal to 40 or,
the portability norms of the extant IRDAI (Health Insurance) Regulations, then 2. greater than or equal to 35 in conjunction with any of the following severe
waiting period for the same would be reduced to the extent of prior coverage. co-morbidities following failure of less invasive methods of weight loss:
D. Coverage under the policy after the expiry of 36 months for any pre-existing a. Obesity-related cardiomyopathy.
disease is subject to the same being declared at the time of application and b. Coronary heart disease.
accepted by Insurer. c. Severe Sleep Apnea.
2. Specified disease/procedure waiting period - Code Excl 02 d. Uncontrolled Type2 Diabetes.
A. Expenses related to the treatment of the listed Conditions, surgeries/treatments
shall be excluded until the expiry of 24 months of continuous coverage after the 7. Change-of-Gender treatments - Code Excl 07: Expenses related to any treatment,
date of inception of the first policy with us. This exclusion shall not be applicable including surgical management, to change characteristics of the body to those of the
for claims arising due to an accident. opposite sex.
B. In case of enhancement of sum insured the exclusion shall apply afresh to the 8. Cosmetic or plastic Surgery - Code Excl 08: Expenses for cosmetic or plastic
extent of sum insured increase. surgery or any treatment to change appearance unless for reconstruction following an
C. If any of the specified disease/procedure falls under the waiting period specified Accident, Burn(s) or Cancer or as part of medically necessary treatment to remove a
for pre-Existing diseases, then the longer of the two waiting periods shall apply. direct and immediate health risk to the insured. For this to be considered a medical
D. The waiting period for listed conditions shall apply even if contracted after the necessity, it must be certified by the attending Medical Practitioner.
policy or declared and accepted without a specific exclusion. 9. Hazardous or Adventure sports - Code Excl 09: Expenses related to any treatment
E. If the Insured Person is continuously covered without any break as defined under necessitated due to participation as a professional in hazardous or adventure sports,
the applicable norms on portability stipulated by IRDAI, then waiting period for including but not limited to, para-jumping, rock climbing, mountaineering, rafting,
the same would be reduced to the extent of prior coverage. motor racing, horse racing or scuba diving, hand gliding, sky diving, deep-sea diving.
F. List of specific diseases/procedures.
10. Breach of law - Code Excl 10: Expenses for treatment directly arising from or
1. Treatment of Cataract and diseases of the anterior and posterior chamber
consequent upon any Insured Person committing or attempting to commit a breach of
of the Eye, Diseases of ENT, Diseases related to Thyroid, Benign diseases
of the breast. law with criminal intent.
2. Subcutaneous Benign Lumps, Sebaceous cyst, Dermoid cyst, Mucous cyst 11. Excluded Providers - Code Excl 11: Expenses incurred towards treatment in any
lip / cheek, Carpal Tunnel Syndrome, Trigger Finger, Lipoma, hospital or by any Medical Practitioner or any other provider specifically excluded by
Neurofibroma, Fibroadenoma, Ganglion and similar pathology. the Insurer and disclosed in its website / notified to the policyholders are not
3. All treatments (Conservative, Operative treatment) and all types of admissible. However, in case of life threatening situations or following an accident,
intervention for Diseases related to Tendon, Ligament, Fascia, Bones and expenses up to the stage of stabilization are payable but not the complete claim.
Joint Including Arthroscopy and Arthroplasty / Joint Replacement [other 12. Treatment for Alcoholism, drug or substance abuse or any addictive condition and
than caused by accident]. consequences thereof - Code Excl 12.
4. All types of treatment for Degenerative disc and Vertebral diseases
including Replacement of bones and joints and Degenerative diseases of 13. Treatments received in health hydros, nature cure clinics, spas or similar
the Musculo-skeletal system, Prolapse of Intervertebral Disc (other than establishments or private beds registered as a nursing home attached to such
caused by accident). establishments or where admission is arranged wholly or partly for domestic reasons -
5. All treatments (conservative, interventional, laparoscopic and open) related Code Excl 13.
to Hepato-pancreato-biliary diseases including Gall bladder and Pancreatic 14. Dietary supplements and substances that can be purchased without prescription,
calculi. All types of management for Kidney calculi and Genitourinary tract including but not limited to Vitamins, minerals and organic substances unless
calculi. prescribed by a medical practitioner as part of hospitalization claim or day care
6. All types of Hernia. procedure - Code Excl 14.
7. DesmoidTumor, Umbilical Granuloma, Umbilical Sinus, Umbilical Fistula.
15. Refractive Error - Code Excl 15: Expenses related to the treatment for correction of
8. All treatments (conservative, interventional, laparoscopic and open) related eye sight due to refractive error less than 7.5 dioptres.
to all Diseases of Cervix, Uterus, Fallopian tubes, Ovaries, Uterine
Bleeding, Pelvic Inflammatory Diseases. 16. Unproven Treatments - Code Excl 16: Expenses related to any unproven
9. All Diseases of Prostate, Stricture Urethra, all Obstructive Uropathies. treatment, services and supplies for or in connection with any treatment. Unproven
treatments are treatments, procedures or supplies that lack significant medical
10. Benign Tumours of Epididymis, Spermatocele, Varicocele, Hydrocele.
documentation to support their effectiveness.
11. Fistula, Fissure in Ano, Hemorrhoids, Pilonidal Sinus and Fistula, Rectal
Prolapse, Stress Incontinence. 17. Sterility and Infertility - Code Excl 17: Expenses related to sterility and infertility.
12. Varicose veins and Varicose ulcers. This includes;
a. Any type of contraception, sterilization.
13. All types of transplant and related surgeries.
b. Assisted Reproduction services including artificial insemination and advanced
14. Congenital Internal disease / defect (except for New Born in Section II-12).
reproductive technologies such as IVF, ZIFT, GIFT, ICSI.
3. 30-day waiting period - Code Excl 03 c. Gestational Surrogacy.
A. Expenses related to the treatment of any illness within 30 days from the first d. Reversal of sterilization.
policy commencement date shall be excluded except claims arising due to an
accident, provided the same are covered. 18. Maternity - Code Excl 18
B. This exclusion shall not, however, apply if the Insured Person has Continuous i. Medical treatment expenses traceable to childbirth (including complicated
Coverage for more than twelve months. deliveries and caesarean sections incurred during hospitalization) except
ectopic pregnancy.
C. The within referred waiting period is made applicable to the enhanced sum
insured in the event of granting higher sum insured subsequently. ii. Expenses towards miscarriage (unless due to an accident) and lawful medical
termination of pregnancy during the policy period.
4. Investigation & Evaluation - Code Excl 04
A. Expenses related to any admission primarily for diagnostics and evaluation Specific Exclusions
purposes only are excluded. 19. Circumcision (unless necessary for treatment of a disease not excluded under this
B. Any diagnostic expenses which are not related or not incidental to the current policy or necessitated due to an accident), Preputioplasty, Frenuloplasty, Preputial
diagnosis and treatment are excluded. Dilatation and Removal of SMEGMA - Code Excl 19.
5. Rest Cure, rehabilitation and respite care - Code Excl 05: Expenses related to any 20. Congenital External Condition / Defects / Anomalies(except to the extent covered
admission primarily for enforced bed rest and not for receiving treatment. This also under Section II-12) - Code Excl 20.
includes: 21. Convalescence, general debility, run-down condition, Nutritional deficiency states -
i. Custodial care either at home or in a nursing facility for personal care such as
Code Excl 21.
help with activities of daily living such as bathing, dressing, moving around either
by skilled nurses or assistant or non-skilled persons. 22. Intentional self–injury - Code Excl 22
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23. Injury/disease caused by or arising from or attributable to war, invasion, act of foreign D. Notification of Claim: Upon the happening of the event, notice with full
enemy, warlike operations (whether war be declared or not) - Code Excl 24. particulars shall be sent to the Company within 24 hours from the date of
occurrence of the event irrespective of whether the event is likely to give rise to a
24. Injury or disease caused by or contributed to by nuclear weapons/ materials - claim under the policy or not.
Code Excl 25. Note: Conditions C and D are precedent to admission of liability under the policy.
25. Expenses incurred on Enhanced External Counter Pulsation Therapy and related However the Company will examine and relax the time limit mentioned in these
conditions depending upon the merits of the case.
therapies, Chelation therapy, Hyperbaric Oxygen Therapy, Rotational Field Quantum
Magnetic Resonance Therapy, VAX-D, Low level laser therapy, Photodynamic E. Documents to be submitted for Reimbursement: The reimbursement claim is
therapy and such other therapies similar to those mentioned herein under this to be supported with the following documents and submitted within the
exclusion - Code Excl 26. prescribed time limit.
a. Duly completed claim form, and
26. Unconventional, Untested, Experimental therapies - Code Excl 27. b. Pre Admission investigations and treatment papers.
27. Autologous derived Stromal vascular fraction, Chondrocyte Implantation, Procedures c. Discharge Summary from the hospital.
using Platelet Rich plasma and Intra articular injection therapy - Code Excl 28. d. Cash receipts from hospital, chemists.
28. Biologicals, except when administered as an in-patient, when clinically indicated and e. Cash receipts and reports for tests done.
hospitalization warranted - Code Excl 29. f. Receipts from doctors, surgeons, anesthetist.
g. Certificate from the attending doctor regarding the diagnosis.
29. Inoculation or Vaccination (except for post–bite treatment and for medical treatment h. KYC (Identity proof with Address) of the proposer, as per AML guidelines.
for therapeutic reasons) - Code Excl 31. i. NEFT documents viz., Customer name, Bank Account No., Name of the
30. Cost of spectacles and contact lens, hearing aids, Cochlear implants and procedures, Bank, IFSC code
walkers and crutches, wheel chairs, CPAP, BIPAP, Continuous Ambulatory Peritoneal j. CKYC No. of the proposer (if available)
Dialysis, infusion pump and such other similar aids - Code Excl 35. Note: For assistance call 24 hour help-line 044-69006900 or Toll Free No.
1800 425 2255, Senior Citizens may call at 044-40020888.
31. Any hospitalization which are not medically necessary / does not warrant
hospitalization - Code Excl 36. 3. Complete Discharge: Any payment to the policyholder, insured person or his/ her
nominees or his/ her legal representative or assignee or to the Hospital, as the case
32. Other Excluded Expenses as detailed in List I (68 items) of this policy and in the website may be, for any benefit under the policy shall be a valid discharge towards payment of
[Link] (except to those who opted for Optional Cover Section III – 4) - claim by the Company to the extent of that amount for the particular claim.
Code Excl 37.
4. Multiple Policies
33. Existing disease/s, disclosed by the Insured and mentioned in the policy schedule i.
ln case of multiple policies taken by an insured person during a period from one
under Permanent Exclusion (based on Insured's consent) - Code Excl 38. or more insurers to indemnify treatment costs, the insured person shall have the
right to require a settlement of his/her claim in terms of any of his/her policies. ln
SECTION V - CONDITIONS all such cases the insurer chosen by the insured person shall be obliged to settle
the claim as long as the claim is within the limits of and according to the terms of
Standard Conditions the chosen policy.
1. Disclosure of Information: The policy shall be void and all premium paid thereon ii. lnsured person having multiple policies shall also have the right to prefer claims
shall be forfeited to the Company in the event of misrepresentation, mis description or under this policy for the amounts disallowed under any other policy / policies
non-disclosure of any material fact by the policy holder. even if the sum insured is not exhausted. Then the insurer shall independently
settle the claim subject to the terms and conditions of this policy.
2. Claim Settlement
iii. If the amount to be claimed exceeds the sum insured under a single policy, the
A. Condition Precedent to Admission of Liability: The terms and conditions of insured person shall have the right to choose insurer from whom he/she wants to
the policy must be fulfilled by the insured person for the Company to make any claim the balance amount.
payment for claim(s) arising under the policy iv. Where an insured person has policies from more than one insurer to cover the
B. For Cashless Treatment same risk on indemnity basis, the insured person shall only be indemnified the
a. For assistance call 24 hour help-line 044-69006900 or Toll Free No. treatment costs in accordance with the terms and conditions of the chosen policy.
1800 425 2255, Senior Citizens may call at 044-40020888. 5. Fraud: lf any claim made by the insured person, is in any respect fraudulent, or if any
b. Inform the ID number for easy reference. false statement, or declaration is made or used in support thereof, or if any fraudulent
c. On admission in the hospital, produce the ID Card issued by the Company means or devices are used by the insured person or anyone acting on his/her behalf to
at the Hospital Helpdesk. obtain any benefit under this policy, all benefits under this policy and the premium paid
d. Obtain the Pre-authorisation Form from the Hospital Help Desk, complete shall be forfeited.
the Patient Information and resubmit to the Hospital Help Desk. Any amount already paid against claims made under this policy but which are found
e. The Treating Doctor will complete the Hospitalization/ treatment information fraudulent later shall be repaid by all recipient(s)/policyholder(s), who has made that
and the hospital will fill up expected cost of treatment. This form is submitted particular claim, who shall be jointly and severally liable for such repayment to the
insurer.
to the Company.
f. The Company will process the request and call for additional documents / For the purpose of this clause, the expression "fraud" means any of the following acts
committed by the insured person or by his agent or the hospital/doctor/any other party
clarifications if the information furnished is inadequate. acting on behalf of the insured person, with intent to deceive the insurer or to induce
g. Once all the details are furnished, the Company will process the request as the insurer to issue an insurance policy:
per the terms and conditions as well as the exclusions therein and either a) the suggestion, as a fact of that which is not true and which the insured person
approve or reject the request based on the merits. does not believe to be true.
h. In case of emergency hospitalization information to be given within 24 hours b) the active concealment of a fact by the insured person having knowledge or
after hospitalization. belief of the fact.
i. Cashless facility can be availed only in networked Hospitals. For details of c) any other act fitted to deceive, and
Networked Hospitals, the insured may visit [Link] or contact the d) any such act or omission as the law specially declares to be fraudulent.
nearest branch or refer to the list of Networked Hospitals provided with the The Company shall not repudiate the claim and / or forfeit the policy benefits on the
policy document. ground of Fraud, if the insured person / beneficiary can prove that the misstatement
j. KYC (Identity proof with Address) of the proposer, as per AML guidelines. was true to the best of his knowledge and there was no deliberate intention to
suppress the fact or that such misstatement of or suppression of material fact are
In non-network hospitals payment must be made up-front and then
within the knowledge of the insurer.
reimbursement will be effected on submission of documents.
Note: The Company reserves the right to call for additional documents wherever 6. Cancellation
required. i. The Policyholder may cancel his policy any time during the term by giving 7 days
Denial of a Pre-authorization request is in no way to be construed as denial of written notice. In such an event, The Company shall
treatment or denial of coverage. The Insured Person can go ahead with the a. refund proportionate premium for unexpired policy period, for policy term
treatment, settle the hospital bills and submit the claim for a possible upto one year and there is no claim (s) made during the policy period.
reimbursement. b. refund premium for the unexpired policy period, in respect of policies with
C. For Reimbursement claims: Time limit for submission of policy term more than 1 year and risk coverage for such policy years has not
[Link]. Type of Claim Prescribed time limit commenced.
ii. The Company may cancel the policy at any time on grounds of misrepresentation,
Reimbursement of hospitalization, Claim must be filed within 15 days non-disclosure of material facts, fraud by the Insured Person by giving 15 days'
1 day care and pre hospitalization from the date of discharge from written notice. There would be no refund of premium on cancellation on grounds
expenses the Hospital. of misrepresentation, non-disclosure of material facts or fraud
within 15 days after completion of Note: Incase of long term policies the refund will be given after adjusting the long term
Reimbursement of Post
2 180 days from the date of discount availed by the insured/ policyholder.
hospitalization
discharge from hospital
Smart Health Pro Unique Identification No.: SHAHLIP23172V012223 POL / SHPRO / V.3 / 2024 8 of 14
7. Migration: The insured person will have the option to migrate the policy to other of the respective area/region for redressal of grievance as per lnsurance Ombudsman
health insurance products/plans offered by the company by applying for migration of Rules 2017.
the Policy atleast 30 days before the policy renewal date as per IRDAI guidelines on Grievance may also be lodged at IRDAI lntegrated Grievance Management System -
Migration. lf such person is presently covered and has been continuously covered [Link]
without any lapses under any health insurance product/plan offered by the company,
the insured person will get the accrued continuity benefits in waiting periods as per 15. Nomination: The policyholder is required at the inception of the policy to make a
IRDAI guidelines on migration. nomination for the purpose of payment of claims under the policy in the event of death of
the policyholder. Any change of nomination shall be communicated to the company in
For Detailed Guidelines on migration, kindly refer the link writing and such change shall be effective only when an endorsement on the policy is
[Link] made. ln the event of death of the policyholder, the Company will pay the nominee {as
8. Portability: The insured person will have the option to port the policy to other insurers named in the Policy Schedule/Policy Certificate/Endorsement (if any)} and in case there
by applying to such insurer to port the entire policy along with all the members of the is no subsisting nominee, to the legal heirs or legal representatives of the policyholder
family, if any, at least 45 days before, but not earlier than 60 days from the policy renewal whose discharge shall be treated as full and final discharge of its liability under the policy.
date as per IRDAI guidelines related to portability. lf such person is presently covered Specific Conditions
and has been continuously covered without any lapses under any health insurance
policy with an lndian General/Health insurer, the proposed insured person will get the 16. The Insured Person/s shall obtain and furnish the Company with all original bills,
accrued continuity benefits in waiting periods as per IRDAI guidelines on portability. receipts and other documents upon which a claim is based and shall also give the
Company such additional information and assistance as the Company may require in
For Detailed Guidelines on portability, kindly refer the link dealing with the claim.
[Link]
17. All claims under this policy shall be payable in Indian currency.
9. Renewal of policy: The policy shall ordinarily be renewable except on grounds of
fraud, misrepresentation by the Insured Person. 18. The premium under this policy shall be payable in advance. No receipt of premium
i) Renewal shall not be denied on the ground that the insured person had made a shall be valid except on the official form of the company signed by a duly authorized
claim or claims in the preceding policy years. official of the company. The due payment of premium and the observance of fulfillment
of the terms, provision, conditions and endorsements of this policy by the Insured
ii) Request for renewal along with requisite premium shall be received by the
Person/s, in so far as they relate to anything to be done or complied with by the
Company before the end of the policy period.
Insured Person/s, shall be a condition precedent to any liability of the Company to
iii) At the end of the policy period, the policy shall terminate and can be renewed make any payment under this policy. No waiver of any terms, provisions, conditions,
within the Grace Period of 30 days to maintain continuity of benefits without and endorsements of this policy shall be valid unless made in writing and signed by an
break in policy. authorized official of the Company.
iv) Coverage is not available during the grace period.
19. Any medical practitioner authorized by the Company shall be allowed to examine the
v) No loading shall apply on renewals based on individual claims experience.
Insured Person in case of any alleged injury or diseases requiring Hospitalization
10. Withdrawal of policy when and as often as the same may reasonably be required on behalf of the Company
i. In the likelihood of this product being withdrawn in future, the Company will at Company's cost.
intimate the insured person about the same 90 days prior to expiry of the policy. 20. Notice and Communication: Any notice, direction or instruction given under this
ii. lnsured Person will have the option to migrate to similar health insurance product Policy shall be in writing and delivered by hand, post, or email to Star Health and
available with the Company at the time of renewal with all the accrued continuity Allied Insurance Company Limited, No.1, New Tank Street, Valluvar Kottam High
benefits such as cumulative bonus, waiver of waiting period as per IRDAI Road Nungambakkam Chennai 600034. Customer Care No. 044-69006900 or Toll
guidelines, provided the policy has been maintained without a break. Free No. 1800 425 2255, e-mail: support@[Link].
11. Moratorium Period: After completion of sixty continuous months of coverage (including Notice and instructions will be deemed served 7 days after posting or immediately
portability and migration) under the health insurance policy no look back to be applied. upon receipt in the case of hand delivery or e-mail
This period of sixty months is called as moratorium period. The moratorium would be 21. Territorial Limit: All investigations/treatments under this policy shall have to be taken
applicable for the sums insured of the first policy and subsequently completion of sixty in India.
continuous months would be applicable from date of enhancement of sums insured only
on the enhanced limits. After the expiry of Moratorium Period no health insurance claim 22. Automatic Termination: The insurance under this policy with respect to each relevant
shall be contestable except for proven fraud, nondisclosure, misrepresentation and Insured Person policy shall expire immediately on the earlier of the following events.
exclusions specified in the policy contract. The policies would however be subject to all ü Upon the death of the Insured Person This means that, the cover for the surviving
limits, sub limits, co-payments, deductibles as per the policy.
members of the family will continue, subject to other terms of the policy.
12. Possibility of Revision of Terms of the Policy including the Premium Rates: The
Company, may revise or modify the terms of the policy including the premium rates as 23. Policy disputes: Any dispute concerning the interpretation of the terms, conditions,
per the extant Guidelines. The insured person shall be notified thirty days before the limitations and/or exclusions contained herein is understood and agreed to by both
changes are effected. the Insured and the Company to be subject to Indian Law.

13. Free Look Period: The Free Look Period shall be applicable on new individual health 24. Excluded Hospitals (providers): Insured can refer the company website using the
insurance policies and not on renewals or at the time of porting/migrating the policy. following link to get the list of excluded hospitals.
The insured person shall be allowed free look period of thirty days from date of receipt [Link]
of the policy document whether electronically or otherwise to review the terms and
conditions of the policy, and to return the same if not acceptable. 25. Revision of Sum Insured: Reduction or enhancement of Sum Insured is permissible
i. lf the insured has not incurred any claim during the Free Look Period, the insured only at the time of renewal. The acceptance for enhancement and the amount of
shall be entitled to a refund of the premium paid less any expenses incurred by enhancement will be at the discretion of the Company and subject to Exclusion
the Company on medical examination of the insured person Code Excl 01, Exclusion Code Excl 02 and Exclusion Code Excl 03.
ii. where the risk has already commenced and the option of return of the policy is 26. Relief under Section 80-D: Insured Person is eligible for relief under Section 80-D of
exercised by the insured person, a deduction towards the proportionate risk the IT Act in respect of the premium paid by any mode other than cash.
premium for period of cover or
iii. where only a part of the insurance coverage has commenced, such 27. Important Note
proportionate premium commensurate with the insurance coverage during such a) Where the policy is issued for more than 1 year, the Sum Insured including
period sublimits, automatic restoration benefit (if applicable) is for each of the year,
without any carry over benefit thereof. The said benefits / covers available for the
14. Redressal of Grievance: In case of any grievance the insured person may contact 2nd year or 3rd year cannot be utilized in the 1st year itself. The terms conditions
the Company through; and exceptions that appear in the Policy or in any Endorsement are part of the
Website : [Link] contract, must be complied with and applies to each policy year”.
E-mail : gro@[Link], grievances@[Link] b) Where the policy is issued on floater basis, the sum insured, cumulative bonus
Ph. No. : 044-69006900 | Toll Free No. 1800 425 2255 and other related benefits floats amongst the insured members.
Senior Citizens may call at 044-69007500
c) The Policy Schedule and any Endorsement are to be read together and any word or such
Courier/Post : Star Health and Allied Insurance Company Limited.,
meaning wherever it appears shall have the meaning as stated in the Act / Indian Laws.
4th Floor, Balaji Complex, No.15, Whites Lane,
d) The terms conditions and exceptions that appear in the Policy or in any
Whites Road, Royapettah, Chennai- 600014
Endorsement are part of the contract, must be complied with and applies to each
lnsured person may also approach the grievance cell at any of the company's relevant insured person. Failure to comply with may result in the claim being denied.
branches with the details of grievance.
e) The attention of the policy holder is drawn to our website [Link] for
lf lnsured person is not satisfied with the redressal of grievance through one of the anti fraud policy of the company for necessary compliance by all stake holders.
above methods, insured person may contact the grievance officer at 044-43664600.
For updated details of grievance officer, kindly refer the link 28. Customer Service: If at any time the Insured Person requires any clarification or
[Link] assistance, the insured may contact Star Health and Allied Insurance Company
lf lnsured person is not satisfied with the redressal of grievance through above Limited, No.1, New Tank Street, Valluvar Kottam High Road, Nungambakkam,
methods, the insured person may also approach the office of lnsurance Ombudsman Chennai 600034, during normal business hours.

Smart Health Pro Unique Identification No.: SHAHLIP23172V012223 POL / SHPRO / V.3 / 2024 9 of 14
 List of Insurance Ombudsman

AHMEDABAD BENGALURU BHOPAL

BHUBANESWAR
Office of the Insurance Ombudsman, Office of the Insurance Ombudsman, Office of the Insurance Ombudsman,
Office of the Insurance Ombudsman,
Jeevan Prakash Building, 6th floor, Jeevan Soudha Building, PID No. 57-27-N-19 1st floor, "Jeevan Shikha",
Ground Floor, 19/19, 24th Main Road, 62, Forest park,
Tilak Marg, Relief Road, Ahmedabad - 380 001. 60-B, Hoshangabad Road,
Bhubaneswar – 751 009.
Tel.: 079 - 25501201/02 JP Nagar, Ist Phase, Bengaluru – 560 078. Opp. Gayatri Mandir, Bhopal – 462 011.
Tel.: 0674 - 2596461 /2596455
Email: [Link]@[Link] Tel.: 080 - 26652048 / 26652049 Tel.: 0755 - 2769201 / 2769202
Email: [Link]@[Link]
JURISDICTION: Gujarat, Dadra & Nagar Email: [Link]@[Link] Email: [Link]@[Link]
JURISDICTION: Odisha.
Haveli, Daman and Diu. JURISDICTION: Karnataka. JURISDICTION: Madhya Pradesh Chattisgarh.

CHANDIGARH
Office of the Insurance Ombudsman, CHENNAI DELHI KOCHI
Jeevan Deep Building S.C.O. 20-27, Office of the Insurance Ombudsman, Office of the Insurance Ombudsman, Office of the Insurance Ombudsman,
Ground Floor Sector 17 – A, Fatima Akhtar Court, 4th Floor, 453, 2/2 A, Universal Insurance Building, 10th Floor, Jeevan Prakash,LIC Building,
Chandigarh – 160 017. Anna Salai, Teynampet, Chennai – 600 018. Asaf Ali Road, New Delhi – 110 002. Opp to Maharaja's College,[Link],
Tel.: 0172 - 2706468 Tel.: 044 - 24333668 / 24333678 Tel.: 011 - 23237539 Kochi - 682 011.
Email: [Link]@[Link] Email: [Link]@[Link] Email: [Link]@[Link] Tel.:0484-2358759
JURISDICTION: Punjab, Haryana (excluding JURISDICTION: Tamil Nadu, Puducherry JURISDICTION: Delhi & following Districts Email: [Link]@[Link]
Gurugram, Faridabad, Sonepat and
Town and Karaikal (which are part of of Haryana - Gurugram, Faridabad, JURISDICTION: Kerala, Lakshadweep,
Bahadurgarh), Himachal Pradesh, Union
Territories of Jammu & Kashmir,Ladakh & Puducherry). Sonepat & Bahadurgarh. Mahe-a part of Union Territory of Puducherry.
Chandigarh.

GUWAHATI HYDERABAD
Office of the Insurance Ombudsman, Office of the Insurance Ombudsman, KOLKATA
JAIPUR
Jeevan Nivesh, 5th Floor, Nr. Panbazar 6-2-46, 1st floor, "Moin Court", Lane Opp. Office of the Insurance Ombudsman,
Office of the Insurance Ombudsman,
over bridge, S.S. Road, Saleem Function Palace, A. C. Guards, Hindustan Bldg. Annexe, 7th Floor,
Jeevan Nidhi – II Bldg., Gr. Floor,
Guwahati – 781001(ASSAM). Lakdi-Ka-Pool, Hyderabad - 500 004. 4, C.R. Avenue, KOLKATA - 700 072.
Bhawani Singh Marg, Jaipur - 302 005.
Tel.: 0361 - 2632204 / 2602205 Tel.: 040 - 23312122 Tel.: 033 - 22124339 / 22124341
Tel.: 0141 – 2740363/2740798
Email: [Link]@[Link] Email: [Link]@[Link] Email: [Link]@[Link]
Email: [Link]@[Link]
JURISDICTION: Assam, Meghalaya, JURISDICTION: Andhra Pradesh, Telangana, JURISDICTION: West Bengal, Sikkim,
Manipur, Mizoram, Arunachal Pradesh, Yanam and part of Union Territory of JURISDICTION: Rajasthan.
Andaman & Nicobar Islands.
Nagaland and Tripura. Puducherry.

PATNA
Office of the Insurance Ombudsman,
2nd Floor, Lalit Bhawan,
LUCKNOW NOIDA Bailey Road, Patna 800 001.
Office of the Insurance Ombudsman, Office of the Insurance Ombudsman, Tel.: 0612-2547068
6th Floor, Jeevan Bhawan, Phase-II, Bhagwan Sahai Palace Email: [Link]@[Link]
Nawal Kishore Road, Hazratganj, 4th Floor, Main Road, Naya Bans, Sector 15, JURISDICTION: Bihar, Jharkhand.
Lucknow - 226 001. MUMBAI Distt: Gautam Buddh Nagar, U.P-201301.
Tel.: 0522 – 4002082/ 3500613 Office of the Insurance Ombudsman, Tel.: 0120-2514252 / 2514253
Email: [Link]@[Link] 3rd Floor, Jeevan Seva Annexe, Email: [Link]@[Link]
JURISDICTION: Districts of Uttar Pradesh: S. V. Road, Santacruz (W), JURISDICTION: State of Uttarakhand and
Lalitpur, Jhansi, Mahoba, Hamirpur, Banda, Mumbai - 400 054. the following Districts of Uttar Pradesh:
Chitrakoot, Allahabad, Mirzapur, Sonbhabdra, Tel.: 022-69038800/27/29/31/32/33 Agra, Aligarh, Bagpat, Bareilly, Bijnor,
Fatehpur, Pratapgarh, Jaunpur,Varanasi, Email: [Link]@[Link] Budaun, Bulandshehar, Etah, Kannauj,
Gazipur, Jalaun, Kanpur, Lucknow, Unnao, Mainpuri, Mathura, Meerut, Moradabad,
JURISDICTION: Goa, Mumbai Metropolitan
Sitapur, Lakhimpur, Bahraich, Barabanki, Muzaffarnagar, Oraiyya, Pilibhit, Etawah, PUNE
Region (excluding Navi Mumbai & Thane).
Raebareli, Sravasti, Gonda, Faizabad, Amethi, Farrukhabad, Firozbad, Gautam Buddh Office of the Insurance Ombudsman,
Kaushambi, Balrampur, Basti, Ambedkarnagar, nagar, Ghaziabad, Hardoi, Shahjahanpur, Jeevan Darshan Bldg., 3rd Floor,
Sultanpur, Maharajgang, Santkabirnagar, Hapur, Shamli, Rampur, Kashganj, C.T.S. No.s. 195 to 198, N.C. Kelkar Road,
Azamgarh, Kushinagar, Gorkhpur, Deoria, Mau, Sambhal, Amroha, Hathras, Narayan Peth, Pune – 411 030.
Ghazipur, Chandauli, Ballia, Sidharathnagar. Kanshiramnagar, Saharanpur. Tel.: 020-24471175
Email: [Link]@[Link]
JURISDICTION: Maharashtra, Areas of Navi
Mumbai and Thane (excluding Mumbai
Metropolitan Region).

Kindly refer our website, for future updates in Ombudsman address

Smart Health Pro Unique Identification No.: SHAHLIP23172V012223 POL / SHPRO / V.3 / 2024 10 of 14
 ITEMS THAT ARE TO BE SUBSUMED INTO ROOM CHARGES

[Link]. ITEM [Link]. ITEM

1 BABY CHARGES (UNLESS SPECIFIED/INDICATED) 20 LUXURY TAX

2 HAND WASH 21 HVAC
3 SHOE COVER 22 HOUSE KEEPING CHARGES
4 CAPS 23 AIR CONDITIONER CHARGES
5 CRADLE CHARGES 24 IM IV INJECTION CHARGES
6 COMB 25 CLEAN SHEET
7 EAU-DE-COLOGNE / ROOM FRESHNERS 26 BLANKET / WARMER BLANKET
8 FOOT COVER 27 ADMISSION KIT
9 GOWN 28 DIABETIC CHART CHARGES
10 SLIPPERS 29 DOCUMENTATION CHARGES / ADMINISTRATIVE EXPENSES
11 TISSUE PAPER 30 DISCHARGE PROCEDURE CHARGES
12 TOOTH PASTE 31 DAILY CHART CHARGES
13 TOOTH BRUSH 32 ENTRANCE PASS / VISITORS PASS CHARGES
14 BED PAN 33 EXPENSES RELATED TO PRESCRIPTION ON DISCHARGE
15 FACE MASK 34 FILE OPENING CHARGES
16 FLEXI MASK 35 INCIDENTAL EXPENSES / MISC. CHARGES (NOT EXPLAINED)
17 HAND HOLDER 36 PATIENT IDENTIFICATION BAND / NAME TAG
18 SPUTUM CUP
37 PULSEOXYMETER CHARGES
19 DISINFECTANT LOTIONS

ITEMS THAT ARE TO BE SUBSUMED INTO PROCEDURE CHARGES

[Link]. ITEM [Link]. ITEM

1 HAIR REMOVAL CREAM 13 SURGICAL DRILL

2 DISPOSABLES RAZORS CHARGES (for site preparations) 14 EYE KIT
3 EYE PAD 15 EYE DRAPE
4 EYE SHEILD 16 X-RAY FILM
5 CAMERA COVER 17 BOYLES APPARATUS CHARGES
6 DVD, CD CHARGES 18 COTTON
7 GAUSE SOFT 19 COTTON BANDAGE
8 GAUZE 20 SURGICAL TAPE
9 WARD AND THEATRE BOOKING CHARGES 21 APRON
10 ARTHROSCOPY AND ENDOSCOPY INSTRUMENTS 22 TORNIQUET
11 MICROSCOPE COVER
23 ORTHOBUNDLE, GYNAEC BUNDLE
12 SURGICAL BLADES, HARMONICSCALPEL,SHAVER

ITEMS THAT ARE TO BE SUBSUMED INTO COSTS OF TREATMENT

[Link]. ITEM [Link]. ITEM

1 ADMISSION / REGISTRATION CHARGES 10 HIV KIT

2 HOSPITALISATION FOR EVALUATION / DIAGNOSTIC PURPOSE 11 ANTISEPTIC MOUTHWASH
3 URINE CONTAINER 12 LOZENGES
4 BLOOD RESERVATION CHARGES AND ANTE NATAL BOOKING CHARGES 13 MOUTH PAINT
5 BIPAP MACHINE 14 VACCINATION CHARGES
6 CPAP / CAPD EQUIPMENTS 15 ALCOHOL SWABS
7 INFUSION PUMP — COST 16 SCRUB SOLUTION / STERILLIUM
8 HYDROGEN PEROXIDE / SPIRIT / DISINFECTANTS ETC 17 GLUCOMETER & STRIPS
9 NUTRITION PLANNING CHARGES - DIETICIAN CHARGES - DIET CHARGES 18 URINE BAG

Smart Health Pro Unique Identification No.: SHAHLIP23172V012223 POL / SHPRO / V.3 / 2024 11 of 14
 Non-Medical Items (Consumables) List I (68 items)
The following List I items are covered if the optional cover “Section III-4” is opted by the Insured
[Link]. ITEM [Link]. ITEM

1 BABY FOOD 35 OXYGEN CYLINDER (FOR USAGE OUTSIDE THE HOSPITAL)

2 BABY UTILITIES CHARGES 36 SPACER

3 BEAUTY SERVICES 37 SPIROMETRE

4 BELTS/ BRACES 38 NEBULIZER KIT

5 BUDS 39 STEAM INHALER

6 COLD PACK/HOT PACK 40 ARMSLING

7 CARRY BAGS 41 THERMOMETER

8 EMAIL / INTERNET CHARGES 42 CERVICAL COLLAR

FOOD CHARGES
9 43 SPLINT
(OTHER THAN PATIENT's DIET PROVIDED BY HOSPITAL)

10 LEGGINGS 44 DIABETIC FOOT WEAR

11 LAUNDRY CHARGES 45 KNEE BRACES (LONG/ SHORT/ HINGED)

12 MINERAL WATER 46 KNEE IMMOBILIZER/SHOULDER IMMOBILIZER

13 SANITARY PAD 47 LUMBO SACRAL BELT

14 TELEPHONE CHARGES 48 NIMBUS BED OR WATER OR AIR BED CHARGES

15 GUEST SERVICES 49 AMBULANCE COLLAR

16 CREPE BANDAGE 50 AMBULANCE EQUIPMENT

17 DIAPER OF ANY TYPE 51 ABDOMINAL BINDER

18 EYELET COLLAR 52 PRIVATE NURSES CHARGES- SPECIAL NURSING CHARGES

19 SLINGS 53 SUGAR FREE Tablets

CREAMS POWDERS LOTIONS (TOILETRIES ARE NOT PAYABLE, ONLY

20 BLOOD GROUPING AND CROSS MATCHING OF DONORS SAMPLES 54
PRESCRIBED MEDICAL PHARMACEUTICALS PAYABLE)

21 SERVICE CHARGES WHERE NURSING CHARGE ALSO CHARGED 55 ECG ELECTRODES

22 TELEVISION CHARGES 56 GLOVES

23 SURCHARGES 57 NEBULISATION KIT

ANY KIT WITH NO DETAILS MENTIONED [DELIVERY KIT, ORTHOKIT,

24 ATTENDANT CHARGES 58
RECOVERY KIT, ETC]
EXTRA DIET OF PATIENT
25 59 KIDNEY TRAY
(OTHER THAN THAT WHICH FORMS PART OF BED CHARGE)

26 BIRTH CERTIFICATE 60 MASK

27 CERTIFICATE CHARGES 61 OUNCE GLASS

28 COURIER CHARGES 62 OXYGEN MASK

29 CONVEYANCE CHARGES 63 PELVIC TRACTION BELT

30 MEDICAL CERTIFICATE 64 PAN CAN

31 MEDICAL RECORDS 65 TROLLY COVER

32 PHOTOCOPIES CHARGES 66 UROMETER, URINE JUG

33 MORTUARY CHARGES 67 AMBULANCE

34 WALKING AIDS CHARGES 68 VASOFIX SAFETY

Smart Health Pro Unique Identification No.: SHAHLIP23172V012223 POL / SHPRO / V.3 / 2024 12 of 14
[Link] Sum Insured (INR) 5 lacs 10 lacs 15 lacs 20 lacs 25 lacs 50 lacs 75 lacs 1 Crore
Room, Boarding and Private Private Private Private Private Private Private Private
1
Nursing charges Single A/c Room Single A/c Room Single A/c Room Single A/c Room Single A/c Room Single A/c Room Single A/c Room Single A/c Room
ICU/Operation Up to Up to Up to Up to Up to Up to Up to Up to
2
Theatre Charges sum insured sum insured sum insured sum insured sum insured sum insured sum insured sum insured
Road Ambulance
Up to Up to Up to Up to Up to Up to Up to Up to
3 Charges
sum insured sum insured sum insured sum insured sum insured sum insured sum insured sum insured
(per policy period)
Air Ambulance Up to 10% of Up to 10% of Up to 10% of Up to 10% of Up to 10% of Up to 10% of Up to 10% of Up to 10% of
4
(per policy year) sum insured sum insured sum insured sum insured sum insured sum insured sum insured sum insured
Pre Hospitalization
5 Up to 60 days Up to 60 days Up to 60 days Up to 60 days Up to 60 days Up to 60 days Up to 60 days Up to 60 days
Expenses incurred
Post Hospitalization
6 Up to 180 days Up to 180 days Up to 180 days Up to 180 days Up to 180 days Up to 180 days Up to 180 days Up to 180 days
Expenses incurred
Coverage for Coverage for Coverage for Coverage for Coverage for Coverage for Coverage for Coverage for
medical treatment medical treatment medical treatment medical treatment medical treatment medical treatment medical treatment medical treatment
Domiciliary (Including AYUSH) (Including AYUSH) (Including AYUSH) (Including AYUSH) (Including AYUSH) (Including AYUSH) (Including AYUSH) (Including AYUSH)
7
Hospitalization (for a period (for a period (for a period (for a period (for a period (for a period (for a period (for a period
exceeding three exceeding three exceeding three exceeding three exceeding three exceeding three exceeding three exceeding three
days) days) days) days) days) days) days) days)
Annual Health
8 Checkup Individual 1500/- 2000/- 4000/- 5000/- 5000/- 5000/- 8000/- 8000/-
Sum Insured(up to)
Annual Health
9 Checkup Floater 2500/- 5000/- 8000/- 10000/- 10000/- 10000/- 15000/- 15000/-
Sum Insured (up to)
Up to 10% of the Up to 10% of the Up to 10% of the Up to 10% of the Up to 10% of the Up to 10% of the Up to 10% of the Up to 10% of the
sum insured sum insured sum insured sum insured sum insured sum insured sum insured sum insured
Home care subject to subject to subject to subject to subject to subject to subject to subject to
10
treatment maximum of maximum of maximum of maximum of maximum of maximum of maximum of maximum of
Rs.5 lakhs in a Rs.5 lakhs in a Rs.5 lakhs in a Rs.5 lakhs in a Rs.5 lakhs in a Rs.5 lakhs in a Rs.5 lakhs in a Rs.5 lakhs in a
policy year policy year policy year policy year policy year policy year policy year policy year
Hospitalization
expenses for
11 treatment of New 50,000/- 1,00,000/- 1,50,000/- 2,00,000/- 2,00,000/- 2,00,000/- 2,00,000/- 2,00,000/-
Born Baby
(per policy period)
Up to Up to Up to Up to Up to Up to Up to Up to
12 AYUSH Treatment
sum insured sum insured sum insured sum insured sum insured sum insured sum insured sum insured
Coverage for Up to Up to Up to Up to Up to Up to Up to Up to
13
Modern Treatment sum insured sum insured sum insured sum insured sum insured sum insured sum insured sum insured
50% of sum 50% of sum 50% of sum 50% of sum 50% of sum 50% of sum 50% of sum 50% of sum
insured for each insured for each insured for each insured for each insured for each insured for each insured for each insured for each
claim free year claim free year claim free year claim free year claim free year claim free year claim free year claim free year
14 Cumulative Bonus subject to a subject to a subject to a subject to a subject to a subject to a subject to a subject to a
maximum upto maximum upto maximum upto maximum upto maximum upto maximum upto maximum upto maximum upto
100% of the sum 100% of the sum 100% of the sum 100% of the sum 100% of the sum 100% of the sum 100% of the sum 100% of the sum
insured insured insured insured insured insured insured insured
Automatic
15 Restoration of Once by 100% Once by 100% Once by 100% Once by 100% Once by 100% Once by 100% Once by 100% Once by 100%
Sum Insured
16 Wellness Discount Available Available Available Available Available Available Available Available
Day Care Up to Up to Up to Up to Up to Up to Up to Up to
17
Treatments sum insured sum insured sum insured sum insured sum insured sum insured sum insured sum insured
Optional Covers

Cumulative Bonus
1 Not Applicable 50% of sum insured for each claim free year subject to a maximum upto 600% of the sum insured
Booster

Modification of Shared
2 From Private Single A/C Room to Any Room / Shared Accommodation
Room Category Accommodation

Reduction of
Pre-Existing
3 From 36 months to 24 / 12 months
Diseases waiting
period

Coverage for
4 Non-medical Items Available
(Consumables)

Unlimited Automatic
5 Restoration of Each time up to 100% of sum insured and Unlimited number of times in a policy year
Sum Insured

Smart Health Pro Unique Identification No.: SHAHLIP23172V012223 POL / SHPRO / V.3 / 2024 13 of 14
 Benefit Illustration in respect of policies offered on individual and family floater basis
Coverage opted on individual
Coverage opted on individual basis covering multiple Coverage opted on family floater basis
basis covering each member
members of the family under a single policy with overall Sum Insured
of the family separately
Age of the (Sum Insured is available for each member of the family) (Only one Sum Insured is available for the entire family)
(at a single point of time)
Members
insured Premium or
Premium Premium
(in yrs) consolidated Floater
Premium Sum Insured Premium Discount, after Sum Insured after Sum Insured
premium for discount,
(Rs.) (Rs.) (Rs.) if any discount (Rs.) discount (Rs.)
all members if any
(Rs.) (Rs.)
of family (Rs.)
Illustration 1
41 10,631 10,00,000 10,631 10,631 10,00,000
Nil 19,235 3,847 15,388 10,00,000
37 8,604 10,00,000 8,604 8,604 10,00,000
Total Premium for all members of the family is
Total Premium for all members of the family is Rs.19,235/- Total Premium when policy is opted on floater basis is
Rs.19,235/- when each member is covered
when they are covered under a single policy. Sum Insured Rs.15,388/-. Sum Insured of Rs.10,00,000/-.
separately. Sum Insured available for each
available for each family member is Rs.10,00,000/- Is available for the entire family (2A)
individual is Rs.10,00,000/-
Illustration 2
49 14,387 10,00,000 14,387 14,387 10,00,000
45 10,631 10,00,000 10,631 10,631 10,00,000
23 6,284 10,00,000 6,284 Nil 6,284 10,00,000 43,870 15,028* 28,842 10,00,000
21 6,284 10,00,000 6,284 6,284 10,00,000
19 6,284 10,00,000 6,284 6,284 10,00,000
Total Premium for all members of the family is
Total Premium for all members of the family is Rs.43,870/-, Total Premium when policy is opted on floater basis is
Rs.43,870/-, when each member is covered
when they are covered under a single policy. Sum Insured Rs.28,842/- Sum Insured of Rs.10,00,000/-.
separately. Sum Insured available for each
available for each family member is Rs.10,00,000/- Is available for the entire family (2A+3C)
individual is Rs.10,00,000/-
Note: Premium rates specified in the above illustration are standard premium rates without considering any loading. Also, the premium rates are exclusive of taxes applicable.
* Family discount shown here is difference between Premium applicable for Individual Sum Insured and Floater Sum Insured
A-Adult | C-Child

Smart Health Pro Unique Identification No.: SHAHLIP23172V012223 POL / SHPRO / V.3 / 2024 14 of 14