KOTAK HEALTH PREMIER POLICY WORDING This is a contract of

Kotak Health Premier – UIN: KOTHLIP21065V032021 Page 1 of 60

Kotak Mahindra General Insurance Company Ltd.

CIN: U66000MH2014PLC260291; Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai -

4000051. Office: 8th Floor, Zone IV, Kotak Infiniti, Bldg. 21,Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad (E),

Mumbai – 400097. India. IRDAI Reg. No. 152

KOTAK HEALTH PREMIER

POLICY WORDING

This is a contract of insurance between You and Us which is subject to the receipt of the premium in full

and the terms, conditions and exclusions of the Policy. This Policy has been issued on the basis of the

Disclosure to Information Norm, including the information provided by You in respect of the Insured Persons

in the Proposal Form. Please inform Us immediately of any change in the address, state of health or any

other changes affecting You or any Insured Person.

PART I

1. DEFINITIONS

For the purposes of this Policy, the terms specified below shall have the meaning set forth wherever

appearing/specified in this Policy or related Endorsements:

Where the context so requires, references to the singular shall also include references to the plural and

references to any gender shall include references to all genders. Further any references to statutory

enactment include subsequent changes to the same.

Accident

means sudden, unforeseen and involuntary event caused by external, visible

and violent means

Admission

means the Insured Person’s admission to a Hospital as an inpatient for the

purpose of medical treatment of an Injury and/or Illness

Alternative Treatment

(AYUSH)

refers to the medical and/ or hospitalization treatments given under

Ayurveda, Yoga and Naturopathy, Unani, Sidha and Homeopathy systems

AYUSH Hospital

is a healthcare facility wherein medical/surgical/para-surgical treatment

procedures and interventions are carried out by AYUSH Medical

Practitioner(s) comprising of any of the following:

a. Central or State Government AYUSH Hospital or

b. Teaching hospital attached to AYUSH College recognized by the Central

Government/Central Council of Indian Medicine/Central Council for

Homeopathy; or

c. AYUSH Hospital, standalone or co-located with in-patient healthcare

facility of any recognized system of medicine, registered with the local

authorities, wherever applicable, and is under the supervision of a

qualified registered AYUSH Medical Practitioner and must comply with

all the following criterion:

i. Having at least 5 in-patient beds;

ii. Having qualified AYUSH Medical Practitioner in charge round

the clock;

iii. Having dedicated AYUSH therapy sections as required and/or

has equipped operation theatre where surgical procedures are

to be carried out;

iv. Maintaining daily records of the patients and making them

accessible to the insurance company’s authorized

representative.

Kotak Health Premier – UIN: KOTHLIP21065V032021 Page 2 of 60

Kotak Mahindra General Insurance Company Ltd.

CIN: U66000MH2014PLC260291; Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai -

4000051. Office: 8th Floor, Zone IV, Kotak Infiniti, Bldg. 21,Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad (E),

Mumbai – 400097. India. IRDAI Reg. No. 152

AYUSH Day Care Centre

means and includes Community Health Centre (CHC), Primary Health

Centre (PHC), Dispensary, Clinic, Polyclinic or any such health centre which

is registered with the local authorities, wherever applicable and having

facilities for carrying out treatment procedures and medical or surgical/para-

surgical interventions or both under the supervision of registered AYUSH

Medical Practitioner (s) on day care basis without in-patient services and

must comply with all the following criterion:

i. Having qualified registered AYUSH Medical Practitioner(s) in

charge;

ii. Having dedicated AYUSH therapy sections as required and/or has

equipped operation theatre where surgical procedures are to be

carried out;

iii. Maintaining daily records of the patients and making them accessible

to the insurance company’s authorized representative.

Ambulance

means a road vehicle operated by a healthcare/ ambulance service provider

and equipped for the transport and paramedical treatment of the person

requiring medical attention

Any one Illness

means continuous period of illness and includes relapse within 45 days from

the date of last consultation with the Hospital/Nursing Home where treatment

was taken

Associated Medical

Expenses

means Room Rent, nursing charges, operation theatre charges, fees of

Medical Practitioners (including surgeons, anesthetists and specialists)

Base Sum

Insured

a. For Individual sum insured basis (Individual Policy), the amount specified

in the Policy Schedule against an Insured Person which is Our maximum,

total and cumulative liability for any and all claims arising during a Policy

Year in respect of that Insured Person.

b. For Family Floater sum insured basis (Floater Policy), the amount

specified in the Policy Schedule which is Our maximum, total and

cumulative liability for any and all claims arising during a Policy Year in

respect of any one and/or all Insured Persons.

If the Policy Period is more than one year, then the Base Sum Insured will

apply afresh to each Policy Year in the Policy Period, but any portion of the

Base Sum Insured which remains un-utilised in any Policy Year shall not be

carried forward to any subsequent Policy Year in the Policy Period.

Cashless Facility

means a facility extended by the insurer to the insured where the payments,

of the costs of treatment undergone by the insured in accordance with the

policy terms and conditions, are directly made to the network provider by the

insurer to the extent pre-authorization is approved

Claim

means a demand made by You for payment of any benefit under the Policy

in respect of an Insured Person

Condition Precedent

means a policy term or condition upon which the Insurer's liability under the

policy is conditional upon

Congenital Anomaly

means a condition which is present since birth, and which is abnormal with

reference to form, structure or position

a) Internal Congenital Anomaly

Congenital anomaly which is not in the visible and accessible parts of the

body.

b) External Congenital Anomaly

Congenital anomaly which is in the visible and accessible parts of the body.

Kotak Health Premier – UIN: KOTHLIP21065V032021 Page 3 of 60

Kotak Mahindra General Insurance Company Ltd.

CIN: U66000MH2014PLC260291; Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai -

4000051. Office: 8th Floor, Zone IV, Kotak Infiniti, Bldg. 21,Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad (E),

Mumbai – 400097. India. IRDAI Reg. No. 152

Co-Payment

means a cost sharing requirement under a health insurance policy that

provides that the policyholder/insured will bear a specified percentage of the

admissible claims amount. A co-payment does not reduce the Sum Insured.

Cumulative Bonus

means any increase or addition in the Sum Insured granted by the insurer

without an associated increase in premium

Day care centre

means any institution established for day care treatment of illness and/or

injuries or a medical setup with a hospital and which has been registered with

the local authorities, wherever applicable, and is under supervision of a

registered and qualified medical practitioner AND must comply with all

minimum criterion as under –

i. has qualified nursing staff under its employment;

ii. has qualified medical practitioner/s in charge;

iii. has fully equipped operation theatre of its own where surgical

procedures are carried out;

iv. maintains daily records of patients and will make these accessible to

the insurance company’s authorized personnel

Day Care Treatment

means medical treatment, and/or surgical procedure which is:

i. undertaken under General or Local Anaesthesia in a hospital/day

care centre in less than 24 hrs because of technological

advancement, and

ii. which would have otherwise required hospitalization of more than 24

hours

Treatment normally taken on an out-patient basis is not included in the scope

of this definition

Deductible

means a cost sharing requirement under a health insurance policy that

provides that the insurer will not be liable for a specified rupee amount in

case of indemnity policies and for a specified number of days/hours in case

of hospital cash policies which will apply before any benefits are payable by

the insurer. A deductible does not reduce the Sum Insured.

Dental treatment

means a treatment related to teeth or structures supporting teeth including

examinations, fillings (where appropriate), crowns, extractions and surgery

Disclosure to

information norm

The policy shall be void and all premium paid thereon shall be forfeited to

the Company in the event of misrepresentation, mis-description or non-

disclosure of any material fact.

Domiciliary

Hospitalisation

means medical treatment for an illness/disease/injury which in the normal

course would require care and treatment at a hospital but is actually taken

while confined at home under any of the following circumstances:

i. The condition of the patient is such that he/she is not in a condition

to be removed to a hospital, or

ii. The patient takes treatment at home on account of non-availability of

room in a hospital.

Emergency

means a serious medical condition or symptom resulting from Injury or

sickness which arises suddenly and unexpectedly, and requires immediate

care and treatment by a Medical Practitioner, generally received within 24

hours of onset to avoid jeopardy to life or serious long term impairment of the

Insured Person’s health, until stabilisation at which time this medical

condition or symptom is not considered an emergency anymore.

Emergency Care

means management for an illness or injury which results in symptoms which

occur suddenly and unexpectedly, and requires immediate care by a medical

practitioner to prevent death or serious long term impairment of the insured

person’s health

Kotak Health Premier – UIN: KOTHLIP21065V032021 Page 4 of 60

Kotak Mahindra General Insurance Company Ltd.

CIN: U66000MH2014PLC260291; Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai -

4000051. Office: 8th Floor, Zone IV, Kotak Infiniti, Bldg. 21,Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad (E),

Mumbai – 400097. India. IRDAI Reg. No. 152

Family Floater

means a Policy described as such in the Policy Schedule where You and

Your family members as mentioned in Eligibility (Part III) and named in the

Schedule are insured under this Policy as at the Policy Period Start Date.

The Sum Insured for a Family Floater means the sum shown in the Schedule

which represents Our maximum liability for any and all claims made by You

and/or all of Your family members mentioned in the Policy Schedule during

each Policy Period.

Grace Period

means the specified period of time immediately following the premium due

date during which a payment can be made to renew or continue a Policy in

force without loss of continuity benefits such as waiting periods and coverage

of Pre-existing diseases. Coverage is not available for the period for which

no premium is received.

Hospital

means any institution established for in-patient care and day care treatment

of illness and / or injuries and which has been registered as a hospital with

the local authorities under the Clinical Establishments (Registration and

Regulations) Act 2010 or under enactments specified under the Schedule of

Section 56(1) of the said Act Or complies with all minimum criteria as under:

i. has qualified nursing staff under its employment round the clock;

ii. has at least 10 inpatient beds, in those towns having a population of

less than 10,00,000 and 15 inpatient beds in all other places;

iii. has qualified medical practitioner (s) in charge round the clock;

iv. has a fully equipped operation theatre of its own where surgical

procedures are carried out

v. maintains daily records of patients and makes these accessible to

the insurance company's authorized personnel

Hospitalisation

means admission in a Hospital for a minimum period of 24 consecutive ‘In-

patient Care’ hours except for specified procedures/ treatments, where such

admission could be for a period of less than 24 consecutive hours

Illness

means a sickness or a disease or pathological condition leading to the

impairment of normal physiological function and requires medical treatment

(a) Acute condition - Acute condition is a disease, illness or injury that is

likely to 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 recovery.

(b) Chronic condition - A chronic condition is defined as a disease, illness,

or injury that has one or more of the following characteristics:

1. it needs ongoing or long-term monitoring through consultations,

examinations, check-ups, and / or tests

2. it needs ongoing or long-term control or relief of symptoms

3. it requires rehabilitation for the patient or for the patient to be

specially trained to cope with it

4. it continues indefinitely

5. it recurs or is likely to recur

Injury

means accidental physical bodily harm excluding illness or disease solely

and directly caused by external, violent, visible and evident means which is

verified and certified by a Medical Practitioner

Inpatient care

means treatment for which the insured person has to stay in a Hospital for

more than 24 hours for a covered event

Instalment Premium

Shall mean the defined proportion of the applicable annual premium with

respect to the Insured Person(s) payable at regular frequency as defined in

the Policy Schedule.

Kotak Health Premier – UIN: KOTHLIP21065V032021 Page 5 of 60

Kotak Mahindra General Insurance Company Ltd.

CIN: U66000MH2014PLC260291; Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai -

4000051. Office: 8th Floor, Zone IV, Kotak Infiniti, Bldg. 21,Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad (E),

Mumbai – 400097. India. IRDAI Reg. No. 152

Insured Person(s)

means the persons named in the Policy Schedule, who is/are covered under

this Policy, for whom the insurance is proposed and the appropriate premium

received

Intensive Care Unit

means an identified section, ward or wing of a hospital which is under the

constant supervision of a dedicated medical practitioner(s), and which is

specially equipped for the continuous monitoring and treatment of patients

who are in a critical condition, or require life support facilities and where the

level of care and supervision is considerably more sophisticated and

intensive than in the ordinary and other wards.

ICU Charges

ICU (Intensive Care Unit) Charges means the amount charged by a Hospital

towards ICU expenses which shall include the expenses for ICU bed,

general medical support services provided to any ICU patient including

monitoring devices, critical care nursing and intensivist charges.

Maternity expenses

Maternity expenses means;

a) medical treatment expenses traceable to childbirth (including complicated

deliveries and caesarean sections incurred during hospitalization);

b) expenses towards lawful medical termination of pregnancy during the

policy period

Medical Advice

means any consultation or advice from a Medical Practitioner including the

issuance of any prescription or follow-up prescription

Medical Expenses

means those expenses that an Insured Person has necessarily and actually

incurred for medical treatment on account of Illness or Accident on the advice

of a Medical Practitioner, as long as these are no more than would have

been payable if the Insured Person had not been insured and no more than

other hospitals or doctors in the same locality would have charged for the

same medical treatment.

Medically Necessary

Treatment

means any treatment, tests, medication, or stay in hospital or part of a stay

in hospital which

i. is required for the medical management of the illness or injury suffered by

the insured;

ii. must not exceed the level of care necessary to provide safe, adequate and

appropriate medical care in scope, duration, or intensity;

iii. must have been prescribed by a Medical Practitioner;

iv. must conform to the professional standards widely accepted in

international medical practice or by the medical community in India

Medical Practitioner

means a person who holds a valid registration from the Medical Council of

any State or Medical Council of India or Council for Indian Medicine or for

Homeopathy set up by the Government of India or a State Government and

is thereby entitled to practice medicine within its jurisdiction; and is acting

within its scope and jurisdiction of license

The term Medical Practitioner would include physician, specialist,

anaesthetist and surgeon but would exclude You and Your Immediate

Family. “Immediate Family would comprise of Your spouse, children,

brother(s), sister(s) and parent(s).

Migration

means, the right accorded to health insurance policyholders (including all

members under family cover and members of group health insurance policy),

to transfer the credit gained for pre-existing conditions and time bound

exclusions, with the same insurer

Network Provider

means Hospitals or health care providers enlisted by an insurer, TPA or

jointly by an Insurer and TPA to provide medical services to an insured by a

cashless facility

Kotak Health Premier – UIN: KOTHLIP21065V032021 Page 6 of 60

Kotak Mahindra General Insurance Company Ltd.

CIN: U66000MH2014PLC260291; Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai -

4000051. Office: 8th Floor, Zone IV, Kotak Infiniti, Bldg. 21,Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad (E),

Mumbai – 400097. India. IRDAI Reg. No. 152

New Born Baby

New born baby means baby born during the Policy Period and is aged upto

90 days.

Non-Network Provider

means any Hospital, day care centre or other provider that is not part of the

network

Notification of Claim

means the process of intimating a claim to the insurer or TPA through any of

the recognized modes of communication

OPD treatment

means the one in which the Insured visits a clinic / hospital or associated

facility like a consultation room for diagnosis and treatment based on the

advice of a Medical Practitioner. The Insured is not admitted as a day care

or in-patient.

Plan

means the Plan stated in the Policy Schedule which is applicable to all

Insured Persons and specifies the amounts of benefits available

Policy

means these Policy wordings, the Policy Schedule and any applicable

endorsements or extensions attaching to or forming part thereof. The Policy

contains details of the extent of cover available to You, what is excluded from

the cover and the terms & conditions on which the Policy is issued to You.

Policy Period

means the period commencing from Policy Start Date and time as specified

in Policy Schedule and terminating at midnight on the Policy End Date as

specified in Policy Schedule

Policy Schedule

means the schedule attached to and forming part of this Policy mentioning

the details of the Insured Persons, the Sum Insured, the period and the limits

to which benefits under the Policy are subject to, including any Annexures

and/or endorsements, made to or on it from time to time, and if more than

one, then the latest in time.

Policy Year

means a period of twelve months beginning from the Policy Period Start Date

and ending on the last day of such twelve-month period. For the purpose of

subsequent years, “Policy Year” shall mean a period of twelve months

beginning from the end of the previous Policy Year and lapsing on the last

day of such twelve-month period, till the Policy Period End Date, as specified

in the Policy Schedule.

Portability

means the right accorded to an individual health insurance policyholder

(including all members under family cover), to transfer the credit gained for

pre-existing conditions and time bound exclusions, from one insurer to

another insurer

Pre-existing Disease

means any condition, ailment, injury or disease

a) That is/are diagnosed by a physician within 48 months prior to the

effective date of the policy issued by the insurer or its reinstatement

b) For which medical advice or treatment was recommended by, or

received from, a physician within 48 months prior to the effective date of

the policy issued by the insurer or its reinstatement.

Pre-Hospitalisation

Medical Expenses

means medical expenses incurred during predefined number of days

preceding the hospitalization of the Insured Person, provided that:

i. Such Medical Expenses are incurred for the same condition for which the

Insured Person’s Hospitalization was required, and

ii. The In-patient Hospitalization claim for such Hospitalization is admissible

by the Insurance Company.

Post Hospitalisation

Medical Expenses

means medical expenses incurred during predefined number of days

immediately after the insured person is discharged from the hospital provided

that:

i. Such Medical Expenses are for the same condition for which the insured

person’s hospitalization was required, and

Kotak Health Premier – UIN: KOTHLIP21065V032021 Page 7 of 60

Kotak Mahindra General Insurance Company Ltd.

CIN: U66000MH2014PLC260291; Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai -

4000051. Office: 8th Floor, Zone IV, Kotak Infiniti, Bldg. 21,Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad (E),

Mumbai – 400097. India. IRDAI Reg. No. 152

ii. The inpatient hospitalization claim for such hospitalization is admissible by

the Insurance Company.

Qualified Nurse

means a person who holds a valid registration from the Nursing Council of

India or the Nursing Council of any state in India

Reasonable&

Customary Charges

means the charges for services or supplies, which are the standard charges

for the specific provider 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.

Renewal

means the terms on which the contract of insurance can be renewed on

mutual consent with a provision of grace period for treating the renewal

continuous for the purpose of gaining credit for pre-existing diseases, time-

bound exclusions and for all waiting periods

Room Rent

means the amount charged by a Hospital towards Room and Boarding

expenses and shall include the associated medical expenses

Surgery or Surgical

Procedure

means manual and / or operative procedure (s) required for treatment of an

illness or injury, correction of deformities and defects, diagnosis and cure of

diseases, relief from suffering and prolongation of life, performed in a

hospital or day care centre by a Medical Practitioner

Third Party

Administrator (TPA)

means any person who is registered under the IRDAI (Third Party

Administrators – Health Services) Regulations, 2016 notified by the Authority

and is engaged, for a fee or remuneration by an insurance company for the

purposes of providing health services as defined in those Regulations

Unproven/Experimental

Treatment

means the treatment including drug experimental therapy which is not based

on established medical practice in India, is treatment experimental or

unproven

You/Your/Policyholder

means the policyholder/Insured Person named in the Policy Schedule

We/ Our/Us

means Kotak Mahindra General Insurance Company Limited

PART II

2. WHAT WE WILL PAY (COVERS AVAILABLE UNDER THE POLICY)

The Covers available under this Policy are described below. Covers will be available to the Insured Person,

only if that particular cover is specifically mentioned in the Policy Schedule as per the Plan opted by You,

subject to

(a) availability of Base Sum Insured and Cumulative Bonus(if any)

(b) the terms, conditions and exclusions of this Policy and

Plan in force for the Insured Person as specified in the Policy Schedule

2.1 In-patient Treatment

We will indemnify the Medical Expenses incurred on the Insured Person’s Hospitalization that occurs during

the Policy Period following an Illness or Injury provided that:

(a) The Hospitalisation is for a minimum and continuous period of 24 hours

(b) the Hospitalisation is for Medically Necessary Treatment and follows the written advice of a Medical

Practitioner;

following:

i. Room Rent and other boarding charges;

ii. ICU Charges;

iii. Operation theatre expenses;

Kotak Health Premier – UIN: KOTHLIP21065V032021 Page 8 of 60

Kotak Mahindra General Insurance Company Ltd.

CIN: U66000MH2014PLC260291; Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai -

4000051. Office: 8th Floor, Zone IV, Kotak Infiniti, Bldg. 21,Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad (E),

Mumbai – 400097. India. IRDAI Reg. No. 152

iv. Medical Practitioner’s fees including fees of specialists and anaesthetists treating the Insured

Person;

v. Qualified Nurses’ charges;

vi. Medicines, drugs and other allowable consumables prescribed by the treating Medical Practitioner;

vii. Investigative tests or diagnostic procedures directly related to the Injury/Illness for which the

Insured Person is Hospitalized

viii. Anaesthesia, blood, oxygen and blood transfusion charges;

ix. Surgical appliances and prosthetic devices recommended by the attending Medical Practitioner

that are used intra operatively during a Surgical Procedure.

x. Inpatient physiotherapy charges;

2.2 Day Care Treatment

We will indemnify the Medical Expenses incurred on the Insured Person’s Day Care Treatment during the

Policy Period following an Illness or Injury that occurs during the Policy Period provided that:

(a) the Day Care Treatment is for Medically Necessary Treatment and follows the written advice of a

Medical Practitioner;

(b) the Medical Expenses incurred are Reasonable and Customary ;

Further,

(a) We will only cover the Medical Expenses for those Day Care Treatments which are listed in Annexure

II of this Policy. The complete list of Day Care Treatments covered is also available on Our website

[www.kotakgeneralinsurance.com];

(b) We will not cover any OPD Treatment under this Benefit.

2.3 Pre-Hospitalization Medical Expenses and Post-Hospitalization Medical Expenses

We will indemnify the Insured Person’s Pre-Hospitalisation Medical Expenses and/or Post-Hospitalisation

Medical Expenses following an Illness or Injury that occurs during the Policy Period provided that:

(a) We have accepted a Claim for In-patient Treatment or Day Care Treatment under this Policy and the

Pre-Hospitalisation Medical Expenses and/or Post-Hospitalisation Medical Expenses relate to the

same Illness/medical condition;

Further,

(a) We will pay Pre-Hospitalisation Medical Expenses up to the number of days as mentioned in the

Policy Schedule preceding the Insured Person’s Admission to Hospital for In-patient Care or Day

Care Treatment;

(b) We will pay Post-Hospitalisation Medical Expenses up to the number of days as mentioned in the

Policy Schedule immediately following the Insured Person’s discharge from Hospital following In-

patient Care or Day Care Treatment.

2.4 Ambulance Cover

We will indemnify the amount incurred up to the limit specified in the Policy Schedule for the reasonable

expenses incurred by You on availing ambulance services offered by a healthcare or Ambulance service

provider for your necessary transportation to the Hospital for treatment of an Illness or Injury following an

Emergency provided that:

(a) We have accepted a Claim for In-patient Treatment or Day Care Treatment under the Policy and the

Ambulance service relates to the same illness / medical condition

(b) The necessity of the use of the Ambulance is certified by the treating Medical Practitioner;

Further,

Kotak Health Premier – UIN: KOTHLIP21065V032021 Page 9 of 60

Kotak Mahindra General Insurance Company Ltd.

CIN: U66000MH2014PLC260291; Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai -

4000051. Office: 8th Floor, Zone IV, Kotak Infiniti, Bldg. 21,Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad (E),

Mumbai – 400097. India. IRDAI Reg. No. 152

(a) We will also provide cover under this benefit if the Insured Person is required to be transferred from

one Hospital to another Hospital or diagnostic centre for advanced diagnostic treatment where such

facility is not available at the existing Hospital or the Insured Person is required to be moved to a

better Hospital facility due to lack of available/adequate treatment facilities at the existing Hospital.

(b) In case of Individual Policy, this payout will available on individual basis and in case of Floater Policy

the payout will be available on floater basis.

2.5 Organ Donor Cover

We will indemnify the In-patient Hospitalisation Medical Expenses towards the donor for harvesting the

organ up to the limits of the Base Sum Insured (subject to availability), provided that:

(a) We have accepted a Claim for In-patient Treatment under the Policy in respect of the Insured Person;

(b) The organ donor is any person in accordance with the Transplantation of Human Organs Act 1994

(amended) and other applicable laws and rules;

transplant on Medical Advise;

Further,

(a) In case of Individual Policy, this payout will available on individual basis and in case of Floater Policy

the payout will be available on floater basis.

(b) We will not cover expenses towards the donor in respect of:

(i) Any Pre-Hospitalization Medical Expenses or Post-Hospitalization Medical Expenses;

(ii) Costs directly or indirectly associated to the acquisition of the organ;

(iii) Any other medical treatment or complication in respect of the donor, consequent to harvesting.

2.6 Alternative Treatment

We will indemnify the Medical Expenses incurred on the Insured Person’s Alternative Treatment during the

Policy Period following an Illness or Injury that occurs during the Policy Period up to the limits of the Base

Sum Insured (subject to availability), provided that:

(a) The Alternative Treatment is administered by a Medical Practitioner;

(b) The Insured Person is admitted to Hospital (For AYUSH treatment) as an Inpatient for the Alternative

Treatment to be administered.

Further,

(a) In case of Individual Policy, this payout will available on individual basis and in case of Floater Policy

the payout will be available on floater basis.

2.7 Domiciliary Hospitalisation

We will indemnify the Medical Expenses incurred on the Insured Person’s Domiciliary Hospitalization during

the Policy Period following an Illness or Injury that occurs during the Policy Period up to the limits of the

Base Sum Insured (subject to availability), provided that:

(a) We will cover medical expenses of an Insured person for treatment of a disease, Illness or Injury

taken at home which would otherwise have required hospitalisation or since the Insured person's

condition did not allow a hospital transfer or a hospital bed was unavailable.

(b) The domiciliary hospitalisation is Medically Necessary and follows the written advice of a Medical

Practitioner

(d) The Insured Person's Domiciliary Hospitalisation extends for at least 3 consecutive days in which

case We will pay Medical Expenses from the first day of Domiciliary Hospitalisation;

Further,

Kotak Health Premier – UIN: KOTHLIP21065V032021 Page 10 of 60

Kotak Mahindra General Insurance Company Ltd.

CIN: U66000MH2014PLC260291; Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai -

4000051. Office: 8th Floor, Zone IV, Kotak Infiniti, Bldg. 21,Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad (E),

Mumbai – 400097. India. IRDAI Reg. No. 152

(a) We shall not indemnify for any Medical Expenses incurred for the treatment of any of the following

Illnesses/conditions under this Cover:

i. Asthma;

ii. Bronchitis;

iii. Chronic Nephritis and Chronic Nephritic Syndrome;

iv. Diarrhoea and all types of Dysenteries including Gastro-enteritis;

v. Diabetes Mellitus and Insipidus;

vi. Epilepsy;

vii. Hypertension;

viii. Influenza, cough and cold;

ix. All psychiatric or psychosomatic disorders;

x. Pyrexia of unknown origin for less than 10 days;

xi. Tonsillitis and Upper Respiratory Tract Infection including Laryngitis and Pharyngitis;

xii. Arthritis, Gout and Rheumatism.

(b) In case of Individual Policy, this payout will available on individual basis and in case of Floater Policy

the payout will be available on floater basis.

2.8 Annual Health Check-up

We will arrange for one free health check-up at Our Network Provider for each Insured Person that is above

18 years of Age, for each Policy Year for the specified tests. Availing the Annual Health Check-up will not

impact the Base Sum Insured or the Cumulative Bonus. This will be offered regardless of any claim

admitted/ registered under the Policy.

The health check-up will consist of the following tests for all eligible Insured Persons, however, these tests

are subject to revision at Our discretion and will be communicated to Insured Person(s).

(a) CBC;

(b) MER;

(d) Serum Creatinine;

(e) SGPT /SGOT

(f) ECG;

(g) Random Blood Sugar.

2.9 Restoration Benefit

We will provide a 100% restoration of the Base Sum Insured amount once in a Policy Year if the Base Sum

Insured and the Cumulative Bonus (if any) is insufficient as a result of previous Claims in that Policy Year,

provided that:

(a) The restored sum insured will not be available in respect of any Illness (including its complications)

for which a Claim has already been accepted / paid in that Policy Year for the same Insured Person.

(b) The restoration of sum insured shall not apply to the first claim in that Policy Year unless related to

an Injury due to Accident where the claim amount exceeds the Base Sum Insured.

Further,

(a) No Cumulative Bonus will apply on the restored sum insured;

(b) The restored sum insured will apply to all Insured Persons on the same basis as the Base Sum

Insured i.e. individual sum insured in case of Individual Policy and floater sum insured in case of

Floater Policy;

subsequent Policy Year;

(d) Restoration of sum insured will be in addition to the Base Sum Insured.

Kotak Health Premier – UIN: KOTHLIP21065V032021 Page 11 of 60

Kotak Mahindra General Insurance Company Ltd.

CIN: U66000MH2014PLC260291; Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai -

4000051. Office: 8th Floor, Zone IV, Kotak Infiniti, Bldg. 21,Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad (E),

Mumbai – 400097. India. IRDAI Reg. No. 152

2.10 Cumulative Bonus

We will increase Your Base Sum Insured by 10% subject to the maximum limit specified in the Policy

Schedule at the end of the Policy Year if the Policy is renewed with Us provided that:

(a) Cumulative Bonus will accrue only if no claims have been made in respect of the Insured Person(s)

in the expiring Policy Year;

(b) Cumulative Bonus under a Family Floater Policy will be available only to those Insured Persons who

were Insured Persons in the immediately completed Policy Year;

Further,

(a) If the Base Sum Insured is increased at the time of Renewal, then the Cumulative Bonus will be

calculated on the Base Sum Insured of the immediately completed Policy Year;

(b) If the Base Sum Insured is reduced at the time of Renewal, then the applicable Cumulative Bonus

will be applicable on the renewed policy Base Sum Insured.

the Policy before the expiry of the Grace Period.

(d) If the Policy Period is more than one year, then any Cumulative Bonus that has accrued for the Policy

Year will be credited at the end of the Policy Year and shall be available for any claims made in the

subsequent Policy Year.

(e) If the Insured Persons in the expiring Policy are covered on an individual basis and there is an

accumulated Cumulative Bonus for each Insured Person under the expiring Policy, and such expiring

Policy has been Renewed with Us on a floater basis then the Cumulative Bonus to be carried forward

for credit in such Renewed Policy shall be the lowest among all the Insured Persons.

(f) If the Insured Persons in the expiring Policy are covered on a floater basis and such Insured Persons

renew their expiring Policy with Us into two or more floater/individual policies then the Cumulative

Bonus of the expiring Policy shall be apportioned to such Renewed Policies in the proportion of the

Base Sum Insured of each Renewed Policy.

(g) Any earned Cumulative Bonus shall not be available for claims under Maternity Benefit, New Born

Baby Cover, Vaccination Expenses, Critical Illness Cover and Personal Accident Cover.

(h) The Cumulative Bonus is provisional and is subject to revision if a Claim is made after the acceptance

of renewal premium in respect of the expiring Policy Year. . Such awarded Cumulative Bonus shall

be withdrawn only in respect of the expiring year in which the Claim was admitted. Cumulative Bonus

will be provided if any Claim made under the Policy has been repudiated/withdrawn.

2.11 Second E-Opinion Cover

We will facilitate the Insured person for availing a Second E-Opinion on his / her medical condition occurring

during the Policy Period, provided that:

(a) We shall only provide access to an E-opinion and this shall not be deemed to substitute the Insured

Person’s visit or consultation to an independent Medical Practitioner;

Further,

(a) We do not assume any liability towards any loss or damage arising out of or in relation to any opinion,

advice, prescription, actual or alleged errors, omissions and representations made by the Medical

Practitioner.

(b) The Insured person is free to choose whether or not to obtain the expert opinion and if obtained whether

or not to act on it

2.12 Health and Rewards

We will provide incentives to reward the Insured Person(s) for taking care of his her health/fitness through

regular preventative and wellness habits. You can earn reward points for the activities mentioned below.

The activities may attract additional charges (decided at Our discretion) to be directly payable by You. The

Kotak Health Premier – UIN: KOTHLIP21065V032021 Page 12 of 60

Kotak Mahindra General Insurance Company Ltd.

CIN: U66000MH2014PLC260291; Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai -

4000051. Office: 8th Floor, Zone IV, Kotak Infiniti, Bldg. 21,Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad (E),

Mumbai – 400097. India. IRDAI Reg. No. 152

activities undertaken by You will be rewarded by Us in the form of reward points as per the terms and

conditions mentioned below. You can redeem these reward points in accordance with the redemption terms

and conditions.

 List of Wellness Activities:

(a) Health Risk Assessment (HRA)

Health Risk Assessment questionnaire is used as a tool for evaluation of health and quality of life. It

helps you to understand your lifestyle and its impact on your health status. The HRA will be an online

assessment provided by Us through vendor tie-ups. This can be undertaken only once per Insured

Person in a Policy Year.

You can earn 250 reward points on completion of HRA per Insured Person, in case of Individual Policy

and maximum up to 500 reward points per family in case of Floater Policy in a Policy Year.

Insured Person(s) only above 18 years of Age will be eligible to undergo HRA.

However, this shall not be deemed to substitute the Insured Person’s visit or consultation to an

independent Medical Practitioner. The Insured Person is free to choose whether or not to undergo the

same and if done whether or not to act on it.

We do not assume any liability towards any loss or damage arising out of or in relation to any opinion,

advice, prescription, actual or alleged errors, omissions and representations made thereby.

(b) Health Check-Up

The Company provides for health check-up as per Benefit 2.8 Annual Health Check-Up. You will be

provided reward points for undergoing the Health Check-Up. We will facilitate in booking the

appointment and arrange for the check-up through any of our Network Providers.

You can earn 500 reward points for undergoing Health Check-Up per Insured Person in case of

Individual Policy and a maximum of 1,500 reward points per family in case of Floater Policy in a Policy

Year. If the result of all the medical test parameters are within normal limit/ range, additional 500 reward

points per Insured Person in case of Individual Policy and a maximum of 1,500 reward points per family

in case of Floater Policy will be awarded in a Policy Year.

However, this shall not be deemed to substitute the Insured Person’s visit or consultation to an

independent Medical Practitioner. The Insured person is free to choose whether or not to undergo the

test and if done whether or not to act on it.

We do not assume any liability towards any loss or damage arising out of or in relation to any opinion,

advice, prescription, actual or alleged errors, omissions and representations made by the Medical

Practitioner.

You can also earn reward points by undergoing certain other diagnostic and preventive health check-

up at any diagnostic centre at Your own expenses. You shall have to submit medical reports of these

tests to Us.

List of the Tests eligible under this are mentioned below:

Name of the Test

Applicability

Heart related screening tests (2D

echo/ TMT/ ECG)

Individual above the age of 45 years

HbA1c / Complete lipid profile

Any age

PAP Smear/ Mammogram/ CA-125

Females above the age of 40 years

Prostate Specific Antigen (PSA)

Males above the age of 45 years

Kotak Health Premier – UIN: KOTHLIP21065V032021 Page 13 of 60

Kotak Mahindra General Insurance Company Ltd.

CIN: U66000MH2014PLC260291; Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai -

4000051. Office: 8th Floor, Zone IV, Kotak Infiniti, Bldg. 21,Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad (E),

Mumbai – 400097. India. IRDAI Reg. No. 152

Vitamin Profile test (D3, B12 and TSH)

Any age

USG whole abdomen

Any age

Kidney Function test

Any age

Renal function test

Any age

Cardiac biomarker test

Any age

Body Fat Analysis

Any age

You can earn 250 reward points for undergoing preventive check-up per test per Insured Person in

case of Individual Policy and a maximum of 1,500 reward points per family in case of Floater Policy in

a Policy Year. If the result of the medical test parameters mentioned above are within normal limits/

range, additional 250 reward points per test per Insured Person in case of Individual Policy and a

maximum of 1,500 reward points per family in case of Floater Policy will be awarded in a Policy Year.

One test will be considered only once for reward points during a Policy Year.

However, this shall not be deemed to substitute the Insured Person’s visit or consultation to an

independent Medical Practitioner. The Insured person is free to choose whether or not to undergo the

test and if done whether or not to act on it.

We do not assume any liability towards any loss or damage arising out of or in relation to any opinion,

advice, prescription, actual or alleged errors, omissions and representations made by the Medical

Practitioner.

(d) Fitness Initiatives

We will reward You for the following fitness & health related activities as given below which are

undertaken after Policy Start Date.

Fitness Activities

Reward Points

Participation in Professional sporting events like

Marathon/ Swimathon/Triathlon, etc.

500 points per event and 1000 points per

Policy Year

Gym/ Yoga membership for 1 year

1000 per Policy Year

Sports Activity membership (Swimming/ Tennis/

Badminton/ for 1 year

1000 per Policy Year

Share your Fitness story

250 per Policy Year

Winning Health Quiz/ Contests organized by Us

250 per event and 500 points per Policy

Year

 Terms for Reward Point Accumulation under Health and Rewards:

You can earn maximum 5,000 reward points per Insured Person in case of Individual Policy and a

maximum of 10,000 reward points per family in case of Floater Policy in a Policy Year. You should

notify and submit relevant documents, bills etc. for various wellness activities within sixty (60) days of

undertaking such activity.

 Redemption of Reward Points:

Each Reward Point will be equivalent to 0.25 Rupees.

You can redeem these Reward points (after conversion to the equivalent rupee amount) against any of

the following options:

(a) i) Outpatient medical expenses like consultation charges, medicine & drugs, dental expenses,

wellness & preventive care and other miscellaneous charges

ii) Diagnostic expenses and health check-ups through our Network providers.

Kotak Health Premier – UIN: KOTHLIP21065V032021 Page 14 of 60

Kotak Mahindra General Insurance Company Ltd.

CIN: U66000MH2014PLC260291; Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai -

4000051. Office: 8th Floor, Zone IV, Kotak Infiniti, Bldg. 21,Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad (E),

Mumbai – 400097. India. IRDAI Reg. No. 152

(b) In-patient Treatment and Day Care Treatment claims, provided that the Base Sum Insured,

Cumulative Bonus and Restoration Sum Insured (if applicable) are exhausted during the Policy

Year.

(d) Non-medical expenses listed under Annexure III

 Terms for Redemption:

(a) Reward points not redeemed in the given Policy Year can be carried forward for a maximum up to

1 year from the date of expiry of the Policy Year in which they are earned.

(b) Reward Points shall automatically lapse upon cancellation of the Policy. However, any unclaimed

and accrued Points (from Previous Policy Year/ month) shall be available for redemption up to 1

year from the date of cancellation of the Policy unless the policy has been cancelled by Us on

grounds of misrepresentation, fraud, nondisclosure or non-cooperation of the Insured.

earned at first. For e.g. If reward points are earned for undergoing “Preventive Check-Up – HbA1c/

Lipid Profile” then the same points cannot be used for claiming under the diagnostic expenses for

undergoing the said test.

(d) Redemption of the rewards points can be done twice during a Policy Year.

(e) Redemption of rewards points does not entail any cash benefit to be provided to You.

2.13 Value Added Benefits

The Benefits listed below are Value Added Benefits and shall be available to the Insured Persons specified

in the Policy Schedule. Benefits under this Section are subject to the terms, conditions and exclusions of

this Policy. The activities may attract additional charges (decided at Our discretion) to be payable by You

directly to the vendor.

Claims under this Section will not impact the Sum Insured or the eligibility for Cumulative Bonus.

VA 1

VA2

VA3

Online customer profile

Doctor directory

Doctor appointment

Online Pharmacy/ Online

Diagnostics tests booking

Online Pharmacy/ Online

Diagnostics tests booking

Online Pharmacy/ Online

Diagnostics tests booking

Health tips/ articles

Home Health

E-consultation

Dietician/ Nutritionist opinion

(a) Online customer profile

Based on the HRA taken and health check-ups, if any, undertaken by the Insured Person, We will

maintain an online customer profile through our vendor tie-up which can be accessed by the Insured

Person to review his Health status.

(b) Doctor directory

We will provide with or arrange for an online platform through our vendor tie-up for providing access to

information on general physicians, specialists and super specialists.

Kotak Health Premier – UIN: KOTHLIP21065V032021 Page 15 of 60

Kotak Mahindra General Insurance Company Ltd.

CIN: U66000MH2014PLC260291; Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai -

4000051. Office: 8th Floor, Zone IV, Kotak Infiniti, Bldg. 21,Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad (E),

Mumbai – 400097. India. IRDAI Reg. No. 152

We will provide with or arrange for an online platform through vendor tie-ups for fixing up doctor

appointments for the Insured Person(s).

(d) Online Pharmacy, Diagnostic tests and other Health/ Wellness Offering

We will facilitate the Insured Person for various offerings on health and wellness services like Diagnostic

Centers, Pharmacy, Gymnasiums, Yoga, etc. through the Network Providers/ vendor tie-ups.

(e) Health tips/ articles

We will provide You information on various health related applications, wellness training, maintaining

fitness and good health, information on various diseases, dietary plans, etc. through periodic

communications and through online platform.

(f) Home Health

We will provide through vendor tie-ups, Home Health services like physiotherapy, nursing care, trained

attendants and medical equipments, for the Insured Person.

(g) E-consultations

We will provide with or arrange for an online platform through vendor tie-ups for providing with E-

consultations to the Insured Person.

(h) Dietician & Nutritionist opinion

We will arrange for dieticians/ nutritionists through our vendor tie-ups to provide for counselling to the

Insured Person.

Terms and Conditions for 2.12 Health and Rewards and 2.13 Value Added Benefits

 Any information provided by You shall be kept confidential

 For services which are provided through empanelled medical experts/ centres/ service providers, We

are only acting as a facilitator, hence We would not be liable for any incremental cost of the services.

 All medical services are being provided by empanelled medical experts/ centres/ service providers who

are empanelled after full due diligence. Nonetheless, Insured Person may consult their personal doctor

before availing the medical services. The decisions to utilise the services will solely be at the Insured

Person’s discretion.

 We/Company/Us or its group entities, affiliates, officers, employees, agents, are not responsible for or

liable for any actions, claims, demands, losses, damages, costs, charges and expenses which an

Insured Person/ You may claim to have suffered or sustained or incurred by way of or on account of

utilization of any benefits specified herein.

 This shall not be deemed to substitute the Insured Person’s visit or consultation to an independent

Medical Practitioner. The Insured person is free to choose whether or not to undergo the same and if

done whether or not to act on it.

 We do not assume any liability towards any loss or damage arising out of or in relation to any opinion,

advice, prescription, actual or alleged errors, omissions and representations made by the Medical

Practitioner.

2.14 Hospital Daily Cash

We will pay the daily cash amount specified in the Policy Schedule for this Benefit for each and every

completed day of the Insured Person’s Hospitalization during the Policy Period provided that:

(a) We have accepted a Claim for In-patient Treatment under the Policy;

(b) The Insured Person’s Hospitalization extends for at least 3 consecutive days, in which case We will

make payment under this Benefit from the first day of Hospitalization;

specified in the Policy Schedule for this Benefit.

Kotak Health Premier – UIN: KOTHLIP21065V032021 Page 16 of 60

Kotak Mahindra General Insurance Company Ltd.

CIN: U66000MH2014PLC260291; Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai -

4000051. Office: 8th Floor, Zone IV, Kotak Infiniti, Bldg. 21,Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad (E),

Mumbai – 400097. India. IRDAI Reg. No. 152

Further,

(a) This benefit is applicable on an individual basis irrespective of type of policy (Individual/ Floater).

(b) The payment under this benefit is over and above the Base Sum Insured.

2.15 Convalescence Benefit

We will pay the amount specified in the Policy Schedule for this Benefit if the Insured Person is admitted in

Hospital for a minimum period of 10 consecutive days provided that:

(a) We have accepted a Claim for In-patient Treatment under the Policy in respect of the same

Hospitalization;

Further,

(a) We shall not be liable to make payment under this Benefit in respect of an Insured Person more than

once during the Policy Year.

(b) This benefit is applicable on an individual basis irrespective of type of policy (Individual/ Floater).

2.16 Home Nursing Benefit

We will indemnify the amount specified in the Policy Schedule for this Benefit incurred for medical care

services of a qualified nurse at the residence of the Insured Person following discharge from hospital after

treatment for Illness/ Injury provided that:

(a) We have accepted a Claim for In-patient Treatment under the Policy in respect of the same

Hospitalisation;

(b) Such medical care services are confirmed as being necessary by the attending Medical Practitioner

and the same relate directly to Illness/ Injury for which the Insured Person has undertaken treatment

during the hospitalisation

Further,

(a) The cover is applicable for a maximum of 15 days during the Policy Year and after the completion of

the number of days mentioned in the Post-Hospitalization Medical Expenses cover (2.3).

(b) In case of Individual policy, this payout will available on individual basis and in case of Floater Policy

the payout will be available on floater basis.

2.17 Daily Cash for Accompanying an Insured Child

We will pay the Daily Cash Amount specified in the Policy Schedule for this Benefit for each and every

completed day of the Insured Person’s Hospitalization during the Policy Period provided that:

(a) We have accepted a Claim for In-patient Treatment under the Policy;

(b) The Insured Person hospitalized is a Child aged 12 years or below

specified in the Policy Schedule for this Benefit.

Further,

(a) This benefit is applicable on an individual basis irrespective of type of policy (Individual/ Floater).

(b) The payment under this benefit is over and above the Base Sum Insured.

2.18 Compassionate Visit

We will indemnify the costs of a return journey undertaken by air/ rail/ road (to and fro) up to the limit

specified in the Policy Schedule under this Benefit for one of the Insured Person’s Immediate Relative to

travel from the place of the Immediate Relative’s residence to the Hospital where the Insured Person is

Kotak Health Premier – UIN: KOTHLIP21065V032021 Page 17 of 60

Kotak Mahindra General Insurance Company Ltd.

CIN: U66000MH2014PLC260291; Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai -

4000051. Office: 8th Floor, Zone IV, Kotak Infiniti, Bldg. 21,Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad (E),

Mumbai – 400097. India. IRDAI Reg. No. 152

hospitalized, in case Hospitalization of the Insured Person extends beyond 5 consecutive days provided

that:

(a) We have accepted a Claim for In-patient Treatment or Day Care Treatment under the Policy

Further,

(a) In case of Individual policy, this payout will available on individual basis and in case of Floater Policy

the payout will be available on floater basis.

(b) The payment under this benefit is over and above the Base Sum Insured.

spouse, children or parents.

2.19 Maternity Benefit

We will indemnify the Medical Expenses incurred up to the Maternity Benefit Sum Insured specified in the

Policy Schedule for the delivery of the Insured Person’s child (including cesarean section) or the Medically

Necessary and lawful medical termination of pregnancy during the Policy Period provided that:

(a) The treatment is taken as an In-patient in a Hospital;

(b) The cover shall be available to the Insured Person who has been continuously covered for at least

36 months under this Benefit subject to the Portability & Continuity Benefits as applicable.

Further,

(a) We shall not be liable to pay for more than 2 events of deliveries across all Policy Periods with Us;

(b) We will cover pre-natal and post-natal expenses up to the amount specified in the Policy Schedule

for this Benefit provided that We have accepted a Claim for delivery/termination under this Benefit;

In-patient Treatment;

(d) The payment under this benefit is over and above the Base Sum Insured.

Permanent Exclusion 3.5(15) of the Policy Wordings stands deleted to the extent of this Benefit only.

2.20 New Born Baby Cover

We will indemnify the Medical Expenses incurred on the Hospitalization of the Insured Person’s New Born

Baby during the Policy Period within the limits of the Maternity Sum Insured subject to the following:

(a) We have accepted a Claim for Maternity Benefit under the Policy.

Further,

(a) This benefit is applicable on an individual basis irrespective of type of policy (Individual/ Floater).

(b) Any pre and post hospitalization expenses for the new born shall not be covered under this benefit.

You can cover the New Born Baby beyond 90 days on payment of requisite premium for the New Born

Baby by way of an endorsement or at the next Renewal, whichever is earlier.

2.21 Vaccination Expenses

We will cover the Vaccination Expenses incurred on the Insured Person’s Baby during the Policy Period up

to the limit specified in the Policy Schedule subject to the following:

(a) We have accepted a Claim for Maternity Benefit under the Policy.

(b) The Insured Person whose maternity claim has been accepted by Us continues to renew the Policy

with Us subsequently.

Kotak Health Premier – UIN: KOTHLIP21065V032021 Page 18 of 60

Kotak Mahindra General Insurance Company Ltd.

CIN: U66000MH2014PLC260291; Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai -

4000051. Office: 8th Floor, Zone IV, Kotak Infiniti, Bldg. 21,Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad (E),

Mumbai – 400097. India. IRDAI Reg. No. 152

Further,

(a) The expenses will be covered from the birth till the Baby completes two years.

(b) Reimbursement claims for vaccination expenses can be submitted once during a Policy Year.

Permanent Exclusion 3.5 (22) of the Policy Wordings stands deleted to the extent of this Benefit only.

The Covers under Benefits 2.19, 2.20 and 2.21 are not available on a standalone basis and need to be

availed in conjunction only.

2.22 Air Ambulance Cover

We will indemnify the amount up to the limit specified in the Policy Schedule for the reasonable expenses

incurred by You for ambulance transportation in an airplane or helicopter for emergency life threatening

health conditions which require immediate and rapid ambulance transportation from the site of first

occurrence of the Illness /Accident to the nearest hospital provided that:

(a) We have accepted a Claim for In-patient Treatment or Day Care Treatment under the Policy and the

air ambulance service relates to the same Illness / medical condition

(b) The necessity of the use of the Air Ambulance is certified by the treating Medical Practitioner;

Further,

(a) We will also provide cover under this Benefit if the Insured Person is required to be transferred from

one Hospital to another Hospital or diagnostic centre for advanced diagnostic treatment where such

facility is not available at the existing Hospital or the Insured Person is required to be moved to a

better Hospital facility due to lack of available/adequate treatment facilities at the existing Hospital.

(b) Return transportation to Your home by air ambulance is excluded

the payout will be available on floater basis.

(d) The payment under this benefit is within the Base Sum Insured.

2.23 Critical Illness Cover

If the Insured Person is first diagnosed to be suffering from any of the following Critical Illnesses during the

Policy Period, We will pay sum insured upto the limit specified in the Policy Schedule for this Cover, subject

to the following:

(a) On payment of additional premium, cover would be provided to each individual for the Policy Period.

(b) We shall not be liable to accept any Claim under this Cover if it pertains to any Critical Illness

diagnosed within 90 days of the commencement of the first Policy Period of this Cover with Us;

Pre-Existing Condition(s)/Disease.

(d) We shall not be liable to make payment under this Cover for more than once in respect of any Insured

Person across all Policy Periods;

Further,

(a) This cover is applicable on an individual basis irrespective of type of policy (Individual/ Floater) and

available for Insured Persons aged 18 years or above.

(b) The payment under this benefit is over and above the Base Sum Insured and will not impact the Base

Sum Insured or the Cumulative Bonus (if any).

in respect of that Insured Person, but shall continue to be in force for other Insured Persons.

Kotak Health Premier – UIN: KOTHLIP21065V032021 Page 19 of 60

Kotak Mahindra General Insurance Company Ltd.

CIN: U66000MH2014PLC260291; Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai -

4000051. Office: 8th Floor, Zone IV, Kotak Infiniti, Bldg. 21,Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad (E),

Mumbai – 400097. India. IRDAI Reg. No. 152

(d) Notwithstanding any provision to the contrary in the Policy, this Cover will be applicable on a

worldwide basis;

(e) In the event of a Claim arising under this Cover, We shall be given written notice of the Claim within

30 days from the date of the first diagnosis of the Critical Illness and We shall be provided the

following information and documentation:

(i) The Claim documents stated in the Policy, provided that We will accept duly certified copies

of the listed documents if the originals are required to be submitted to any other insurance

company;

(ii) Written confirmation of the diagnosis of the Critical Illness from the treating Medical

Practitioner;

“Critical Illness” for the purpose of this Cover is as mentioned below:

 First diagnosis of the below-mentioned Illnesses more specifically described below

1. Cancer of specified severity

2. Kidney failure requiring regular dialysis;

3. Multiple Sclerosis with persisting symptoms;

4. Motor Neurone Disease with Permanent Symptoms

5. Benign Brain Tumor

6. Primary Pulmonary Hypertension

7. End Stage Liver Failure

 Undergoing for the first time of the following surgical procedures, more specifically described below:

8. Major Organ / Bone Marrow Transplant;

9. Open heart replacement or repair of heart valves

10. Open chest CABG

11. Aorta Graft Surgery

 Occurrence for the first time of the following medical events more specifically described below:

12. Coma of Specified Severity

13. Stroke resulting in permanent symptoms;

14. Permanent Paralysis of Limbs;

15. First Heart Attack of specified severity.

16. Third Degree (or Major) Burns

17. Deafness

18. Loss of Speech

The Critical Illnesses and the conditions applicable to the same are more particularly described in Annexure

IV.

2.24 Personal Accident Cover

We will pay Sum Insured upto the limit specified in the Policy Schedule for this Cover, subject to the

following:

(a) On payment of additional premium, cover would be provided to each individual for the Policy Period.

(b) We shall not be liable to make payment under this Cover for more than once in respect of any Insured

Person across all Policy Periods;

Further,

(a) This cover is applicable on an individual basis irrespective of type of policy (Individual/ Floater)

(b) The payment under this benefit is over and above the Base Sum Insured and will not impact the Base

Sum Insured or the Cumulative Bonus (if any).

worldwide basis;

Kotak Health Premier – UIN: KOTHLIP21065V032021 Page 20 of 60

Kotak Mahindra General Insurance Company Ltd.

CIN: U66000MH2014PLC260291; Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai -

4000051. Office: 8th Floor, Zone IV, Kotak Infiniti, Bldg. 21,Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad (E),

Mumbai – 400097. India. IRDAI Reg. No. 152

 Accidental Death

We will pay the Sum Insured upto the limit specified in the Policy Schedule if the Insured Person dies solely

and directly due to an Injury sustained in an Accident which occurs during the Policy Period, provided that

the Insured Person’s death occurs within 12 months from the date of that Accident.

Once a Claim has been accepted and paid under this Benefit then this Policy will automatically terminate

in respect of that Insured Person only.

 Permanent Total Disablement (PTD)

We will pay the Sum Insured upto the limit specified in the Policy Schedule if the Insured Person suffers

Permanent Total Disablement of the nature specified below solely and directly due to an Accident which

occurs during the Policy Period provided that the Permanent Total Disablement occurs within 12 months

from the date of that Accident:

(i) Loss of Use of both eyes, or Physical Separation/ Loss of Use of two entire hands or two entire feet,

or one entire hand and one entire foot, or of such Loss of Use of one eye and such Physical

Separation/ Loss of Use of one entire hand or one entire foot.

(ii) Physical Separation/ Loss of Use of two hands or two feet, or of one hand and one foot, or of Loss

of Use of one eye and Loss of Use of one hand or one foot.

(iii) If such Injury shall as a direct consequence thereof, permanently, and totally, disable the Insured

Person from engaging in any employment or occupation of any description whatsoever.

Once a Claim has been accepted and paid under this Benefit then the Personal Accident Cover will

automatically terminate in respect of that Insured Person only.

2.25 Cap on Room Rent

If We have accepted a Claim for In-patient Hospitalization under the Policy and if the Insured Person incurs

Room Rent that is higher than the eligible Room Rent as specified in the Policy Schedule then We will be

liable to pay only a rateable proportion of the Associated Medical Expenses incurred in the proportion of

the difference between the eligible Room Rent and the Room Rent actually incurred, provided that

Reasonable and Customary costs incurred on medicines/pharmacy, medical consumables, medical

implants and diagnostic costs will be reimbursed based on the actual amounts incurred.

Proportionate deductions will not be applied in respect of the hospitals which do not follow differential billing

or for those expenses in respect of which differential billing is not adopted based on the room category.

Further, proportionate deductions will not be applied in respect of ICU Charges.

In case this Cover is not opted for, Insured will get the eligible Room Rent and Associated Medical Expenses

subject to Base Sum Insured including Cumulative Bonus and Restoration Benefit, if applicable.

Under this Cover, the Insured is entitled for a discount in the premium on opting for Cap on Room Rent.

3. WHAT WE WILL NOT PAY (EXCLUSIONS APPLICABLE UNDER THE POLICY)

We shall not be liable to make any payment under this Policy directly or indirectly for/ caused by/ based

upon/ arising out of or howsoever attributable to any of the exclusions listed below. All waiting periods will

apply individually to each Insured Person:

Kotak Health Premier – UIN: KOTHLIP21065V032021 Page 21 of 60

Kotak Mahindra General Insurance Company Ltd.

CIN: U66000MH2014PLC260291; Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai -

4000051. Office: 8th Floor, Zone IV, Kotak Infiniti, Bldg. 21,Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad (E),

Mumbai – 400097. India. IRDAI Reg. No. 152

3.1 Pre-Existing Diseases (Code – Excl01)

a) Expenses related to the treatment of a pre-existing Disease (PED) and its direct complications shall be

excluded until the expiry of 48/ 36/ 24 months (as mentioned in the Policy Schedule) of continuous

coverage after the date of inception of the first policy with insurer.

b) In case of enhancement of sum insured the exclusion shall apply afresh to the extent of sum insured

increase.

c) If the Insured Person is continuously covered without any break as defined under the portability norms

of the extant IRDAI (Health Insurance) Regulations, then waiting period for the same would be reduced

to the extent of prior coverage.

d) Coverage under the policy after the expiry of 48 / 36/ 24 months (as mentioned in the Policy Schedule)

for any pre-existing disease is subject to the same being declared at the time of application and

accepted by Insurer.

3.2 30 Day Waiting Period (Code – Excl03)

a) Expenses related to the treatment of any illness within 30 days from the first policy commencement

date shall be excluded except claims arising due to an accident, provided the same are covered.

b) This exclusion shall not, however, apply if the Insured Person has Continuous Coverage for more than

twelve months.

c) The within referred waiting period is made applicable to the enhanced sum insured in the event of

granting higher sum insured subsequently.

3.3 Specified disease/ procedure waiting period (Code – Excl02)

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 date of inception of the first policy with us.

This exclusion shall not be applicable for claims arising due to an accident.

b) In case of enhancement of sum insured the exclusion shall apply afresh to the extent of sum insured

increase.

c) If any of the specified disease/procedure falls under the waiting period specified for pre-Existing

diseases, then the longer of the two waiting periods shall apply.

d) The waiting period for listed conditions shall apply even if contracted after the policy or declared and

accepted without a specific exclusion.

e) If the Insured Person is continuously covered without any break as defined under the applicable norms

on portability stipulated by IRDAI, then waiting period for the same would be reduced to the extent of

prior coverage.

f) List of specific diseases/procedures

(a) Cataract*;

(b) Benign Prostatic Hypertrophy;

(d) All types of Hernia, Hydrocele;

(e) Fissures and/or Fistula in anus, haemorrhoids/piles;

(f) Arthritis, gout, rheumatism and spinal disorders;

(g) Joint replacements unless due to Accident;

(h) Sinusitis and related disorders;

(i) Stones in the urinary and biliary systems;

(j) Dilatation and curettage, Endometriosis;

(k) All types of skin and internal tumors/ cysts/ nodules/ polyps of any kind including breast lumps unless

malignant;

(l) Dialysis required for chronic renal failure;

(m) Tonsillitis, adenoids and sinuses;

Kotak Health Premier – UIN: KOTHLIP21065V032021 Page 22 of 60

Kotak Mahindra General Insurance Company Ltd.

CIN: U66000MH2014PLC260291; Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai -

4000051. Office: 8th Floor, Zone IV, Kotak Infiniti, Bldg. 21,Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad (E),

Mumbai – 400097. India. IRDAI Reg. No. 152

(n) Gastric and duodenal erosions and ulcers;

(o) Deviated nasal septum;

(p) Varicose Veins/ Varicose Ulcers.

*Our maximum liability for any Claim for an Insured Person’s cataract treatment shall be 10% of the Base

Sum Insured up to a maximum of INR 100,000 per eye for each Policy Year of the Policy Period.

3.4 Maternity Benefit Waiting Period

Any treatment arising from or traceable to pregnancy, childbirth including caesarean section will not be

covered until 36 months of continuous coverage has elapsed for that particular Insured Person since the

inception of the Maternity Expenses Benefit under the Policy for that Insured Person.

This waiting period will be reduced by number of continuous preceding years of Maternity coverage of the

Insured Person under previous health insurance policy by Us or any other health insurance plan with an

Indian non-life insurer/ health insurer as per guidelines on portability issued by the insurance regulator.

3.5 Permanent Exclusions

We will not be liable under any circumstances, for any Claim in connection with or with regard to any of the

following permanent exclusions as specified below:

1. Investigation & Evaluation(Code- Excl04)

a) Expenses related to any admission primarily for diagnostics and evaluation purposes only are excluded.

b) Any diagnostic expenses which are not related or not incidental to the current diagnosis and treatment

are excluded

2. Rest Cure, rehabilitation and respite care (Code – Excl05)

a) Expenses related to any admission primarily for enforced bed rest and not for receiving treatment. This

also includes:

i. Custodial care either at home or in a nursing facility for personal care such as help with activities of

daily living such as bathing, dressing, moving around either by skilled nurses or assistant or non-

skilled persons.

ii. Any services for people who are terminally ill to address physical, social, emotional and spiritual

needs.

3. Obesity/ Weight Control (Code – Excl06)

Expenses related to the surgical treatment of obesity that does not fulfil all the below conditions:

1) Surgery to be conducted is upon the advice of the Doctor

2) The surgery/Procedure conducted should be supported by clinical protocols

3) The member has to be 18 years of age or older and

4) Body Mass Index (BMI);

a) greater than or equal to 40 or

b) greater than or equal to 35 in conjunction with any of the following severe co-morbidities

following failure of less invasive methods of weight loss:

i. Obesity-related cardiomyopathy

ii. Coronary heart disease

iii. Severe Sleep Apnea

iv. Uncontrolled Type2 Diabetes

Kotak Health Premier – UIN: KOTHLIP21065V032021 Page 23 of 60

Kotak Mahindra General Insurance Company Ltd.

CIN: U66000MH2014PLC260291; Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai -

4000051. Office: 8th Floor, Zone IV, Kotak Infiniti, Bldg. 21,Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad (E),

Mumbai – 400097. India. IRDAI Reg. No. 152

4. Change-of- Gender treatments (Code – Excl07)

Expenses related to any treatment, including surgical management, to change characteristics of the body

to those of the opposite sex.

5. Cosmetic or plastic Surgery (Code – Excl08)

Expenses for cosmetic or plastic surgery or any treatment to change appearance unless for reconstruction

following an Accident, Burn(s) or Cancer or as part of medically necessary treatment to remove a direct

and immediate health risk to the insured. For this to be considered a medical necessity, it must be certified

by the attending Medical Practitioner.

6. Hazardous or Adventure sports: (Code- Excl09)

Expenses related to any treatment necessitated due to participation as a professional in hazardous or

adventure sports, including but not limited to, para-jumping, rock climbing, mountaineering, rafting, motor

racing, horse racing or scuba diving, hand gliding, sky diving, deep-sea diving.

7. Breach of law (Code – Excl10)

Expenses for treatment directly arising from or consequent upon any Insured Person committing or

attempting to commit a breach of law with criminal intent.

8. Excluded Providers: (Code- Excl11)

Expenses incurred towards treatment in any hospital or by any Medical Practitioner or any other provider

specifically excluded by the Insurer and disclosed in its website / notified to the policyholders are not

admissible. However, in case of life threatening situations or following an accident, expenses up to the

stage of stabilization are payable but not the complete claim.

9. Code- Excl12

Treatment for, Alcoholism, drug or substance abuse or any addictive condition and consequences thereof

10. Code- Excl13

Treatments received in health hydros, nature cure clinics, spas or similar establishments or private beds

registered as a nursing home attached to such establishments or where admission is arranged wholly or

partly for domestic reasons.

11. Code- Excl14

Dietary supplements and substances that can be purchased without prescription, including but not limited

to Vitamins, minerals and organic substances unless prescribed by a medical practitioner as part of

hospitalization claim or day care procedure.

12. Refractive Error (Code- Excl15)

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

Kotak Health Premier – UIN: KOTHLIP21065V032021 Page 24 of 60

Kotak Mahindra General Insurance Company Ltd.

CIN: U66000MH2014PLC260291; Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai -

4000051. Office: 8th Floor, Zone IV, Kotak Infiniti, Bldg. 21,Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad (E),

Mumbai – 400097. India. IRDAI Reg. No. 152

13. Unproven Treatments (Code – Excl16)

Expenses related to any unproven treatment, services and supplies for or in connection with any treatment.

Unproven treatments are treatments, procedures or supplies that lack significant medical documentation to

support their effectiveness.

14. Sterility and Infertility (Code- Excl17)

Expenses related to sterility and infertility. This includes:

i. Any type of contraception, sterilization

ii. Assisted Reproduction services including artificial insemination and advanced reproductive

technologies such as IVF, ZIFT, GIFT, ICSI

iii. Gestational Surrogacy

iv. Reversal of sterilization

15. Maternity (Code- Excl18)

i. Medical treatment expenses traceable to childbirth (including complicated deliveries and

caesarean sections incurred during hospitalisation) except ectopic pregnancy

ii. Expenses towards miscarriage (unless due to an accident) and lawful medical termination of

pregnancy during the policy period.

16. Costs of routine medical, eye or ear examinations preventive health check-ups, spectacles, laser

surgery for correction of refractory errors, contact lenses, hearing aids, dentures or artificial teeth;

17. Any expenses incurred on prosthesis, corrective devices, external durable medical equipment of any

kind, like wheelchairs, crutches, instruments used in treatment of sleep apnea syndrome or continuous

ambulatory peritoneal dialysis (C.A.P.D.) and oxygen concentrator for bronchial asthmatic condition,

cost of cochlear implant(s) unless necessitated by an Accident or required intra-operatively;

18. Any expenses incurred on personal comfort, cosmetics, convenience and hygiene related items and

services, medical supplies including elastic stockings, diabetic test strips, and similar products.

19. Expenses incurred on all dental treatment unless necessitated due to an Accident and treatment is

taken in in-patient department of hospital or day care centre;

20. Acupressure, acupuncture, magnetic and such other therapies;

21. Circumcision unless necessary for treatment of an Illness or necessitated due to an Accident;

22. Vaccination or inoculation of any kind, unless it is post animal bite and there is hospitalisation as an in-

patient;

23. Intentional self-injury (whether arising from an attempt to commit suicide or otherwise)

24. Treatment relating to Congenital external Anomalies;

25. Any treatment related to sleep disorder or sleep apnoea syndrome, general debility, convalescence,

run-down condition;

26. Costs incurred for any health check-up or for the purpose of issuance of medical certificates and

examinations required for employment or travel or any other such purpose;

Kotak Health Premier – UIN: KOTHLIP21065V032021 Page 25 of 60

Kotak Mahindra General Insurance Company Ltd.

CIN: U66000MH2014PLC260291; Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai -

4000051. Office: 8th Floor, Zone IV, Kotak Infiniti, Bldg. 21,Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad (E),

Mumbai – 400097. India. IRDAI Reg. No. 152

27. Any treatment taken outside India;

28. Any treatment taken from anyone not falling within the scope of definition of Medical Practitioner. Any

treatment charges or fees charged by any Medical Practitioner acting outside the scope of licence or

registration granted to him by any medical council;

29. Any consequential or indirect loss arising out of or related to Hospitalization;

30. Any Injury or Illness directly or indirectly caused by or arising from or attributable to war, invasion, acts

of foreign enemies, hostilities (whether war be declared or not), civil war, commotion, unrest, rebellion,

revolution, insurrection, military or usurped power or confiscation or nationalisation or requisition of or

damage by or under the order of any government or public local authority;

31. Any Illness or Injury directly or indirectly caused by or contributed to by nuclear weapons/materials or

contributed to or arising from ionising radiation or contamination by radioactivity by any nuclear fuel or

from any nuclear waste or from the combustion of nuclear fuel;

32. All non-medical expenses listed in Annexure III (List I) of the Policy.

33. Any OPD treatment will not be covered

34. Treatment and supplies for analysis and adjustments of spinal subluxation, diagnosis and treatment by

manipulation of the skeletal structure; muscle stimulation by any means except treatment of fractures

(excluding hairline fractures) and dislocations of the mandible and extremities.

35. Treatment such as External Counter Pulsation (ECP), Enhanced External Counter Pulsation (EECP),

and Hyperbaric Oxygen Therapy will not be covered unless it forms a part of In-Patient Treatment in

case of hospitalisation or part of discharge advice upto the Post hospitalisation period as specified in

the Policy Schedule.

36. Any physical, medical condition or treatment that is specifically excluded in the Policy Schedule under

Important Conditions

4. CLAIM ADMINISTRATION

The fulfillment of the terms and conditions of this Policy (including payment of premium by the due dates

mentioned in the Policy Schedule) insofar as they relate to anything to be done or complied with by You or

any Insured Person, including complying with the following in relation to claims, shall be Condition

Precedent to admission of Our liability under this Policy:

(a) On the occurrence or discovery of any Illness or Injury that may give rise to a Claim under this Policy,

the Claims Procedure set out below shall be followed;

(b) If requested by Us and at Our cost, the Insured Person must submit to medical examination by Our

nominated Medical Practitioner as often as We consider reasonable and necessary and We/Our

representatives must be permitted to inspect the medical and Hospitalization records pertaining to

the Insured Person’s treatment and to investigate the facts surrounding the Claim. Such medical

examination will be carried out only in case of reimbursement claims with prior consent of the Insured

Person;

to assess Our liability and quantum in respect of such Claim;

(d) If the Insured Person suffers a relapse within 45 days of the date of discharge from Hospital for a

Claim that has been made, then such relapse shall be deemed to be part of the same Claim and all

limits for Any One Illness under this Policy shall be applied as if they were part of a single claim.

Kotak Health Premier – UIN: KOTHLIP21065V032021 Page 26 of 60

Kotak Mahindra General Insurance Company Ltd.

CIN: U66000MH2014PLC260291; Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai -

4000051. Office: 8th Floor, Zone IV, Kotak Infiniti, Bldg. 21,Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad (E),

Mumbai – 400097. India. IRDAI Reg. No. 152

5. CLAIMS PROCEDURE

On the occurrence or discovery of any Illness or Injury that may give rise to a Claim under this Policy, then

as a Condition Precedent to Our liability under the Policy the following procedure shall be complied with:

5.1 For Cashless Facility

Cashless Facility is only available at a Network Provider. The complete list of Network Providers is available

on Our website (The list is updated as and when there is any change in the Network Provider) or can be

obtained from Our call centre. In order to avail of Cashless Facility, the following procedure shall be

followed:

(a) Pre-authorization for Planned Hospitalization:

At least 48 hours prior to a planned Hospitalization, We or Our TPA shall be contacted to request pre-

authorization for availing the Cashless Facility for that planned Hospitalisation. Each such request must be

accompanied by all the following details:

(i) Pre-authorization form available at the hospital helpdesk to be duly filled in and signed by Insured

and treating doctor

(ii) Copy of the Health Card We have issued to the Insured Person;

(iii) Proposed date of Admission.

(iv) Medical papers viz. All prescriptions, medical investigation reports etc.

(v) Photo ID

(vi) Address proof, and photo to comply with KYC norms

If the foregoing information is not provided in full or is insufficient to ascertain the eligibility of the Claim

under the Policy, then We/Our TPA will request additional information or documentation in respect of that

request.

Once there is sufficient information to assess the eligibility of the Claim under the Policy, We/Our TPA will

issue the authorisation letter specifying the sanctioned amount, any specific limitation on the Claim and

non-payable items, if applicable, or reject the request for pre-authorisation specifying reasons for the

rejection.

Turn Around Time (TAT) for issue of Pre-Authorization within 6 hours from receipt of complete documents

In Case of Claim Contact Us at:

24x7 Toll Free number: 1800 266 4545 or may write an e- mail at care@kotak.com

In the event of claims, please send the relevant documents to:

Family Health Plan (TPA) Ltd,

Srinilaya – Cyber Spazio

Suite # 101,102,109 & 110, Ground Floor,

Road No. 2, Banjara Hills,

Hyderabad, 500 034.

(b) Pre-authorization for Emergency Care:

If the Insured Person has been admitted into Hospital for Emergency Care, We or Our TPA shall be

contacted to request pre-authorization for availing the Cashless Facility for that Emergency Care within 24

hours of commencement of Hospitalisation. Each such request must be accompanied by all the following

details:

Kotak Health Premier – UIN: KOTHLIP21065V032021 Page 27 of 60

Kotak Mahindra General Insurance Company Ltd.

CIN: U66000MH2014PLC260291; Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai -

4000051. Office: 8th Floor, Zone IV, Kotak Infiniti, Bldg. 21,Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad (E),

Mumbai – 400097. India. IRDAI Reg. No. 152

(i) Pre-authorization form available at the hospital helpdesk to be duly filled in and signed by Insured

and treating doctor

(ii) Copy of the Health Card We have issued to the Insured Person;

(iii) Medical papers viz. All prescriptions, medical investigation reports etc.

(iv) Photo ID

(v) Address proof, and photo to comply with KYC norms

If the foregoing information is not provided in full or is insufficient to ascertain the eligibility of the Claim

under the Policy, then We/ Our TPA will request additional information or documentation in respect of that

request.

Once there is sufficient information to assess the eligibility of the Claim under the Policy, We/Our TPA will

issue the authorisation letter specifying the sanctioned amount, any specific limitation on the Claim and

non-payable items, if applicable, or reject the request for pre-authorisation specifying reasons for the

rejection. In circumstances where We/Our TPA refuse the request for pre-authorisation as there is

insufficient Base Sum Insured or there is insufficient information to determine the admissibility of the request

for pre-authorisation, a claim for reimbursement may be submitted to Us in accordance with the procedure

set out below and We will consider the Claim in accordance with the policy terms, conditions and exclusions.

Turn Around Time (TAT) for settlement of Reimbursement is within 30 days from the receipt of the complete

documents.

We reserve the right to modify, add or restrict any Network Provider for Cashless Facilities in Our sole

discretion. Before availing Cashless Facilities, please check the applicable updated list of Network

Providers on Our website or by calling Our call centre.

5.2 For Reimbursement Claims

We shall be given written notice of the Claim for reimbursement along with the following details at least

within 30 days of the Insured Person’s discharge from Hospital:

(i) The Policy Number;

(ii) Name of the Policyholder;

(iii) Name and address of the Insured Person in respect of whom the request is being made;

(iv) Nature of Illness or Injury and the treatment/surgery taken;

(v) Name and address of the attending Medical Practitioner;

(vi) Hospital where treatment/surgery was taken;

(vii) Date of Admission and date of discharge;

(viii) Approximate claim amount (if available)

(ix) Any other information that may be relevant to the Illness/ Injury/ Hospitalization.

If the Claim is not notified to Us within 30 days of the Insured Person’s discharge from Hospital, then We

shall be provided the reasons for the delay in writing. We will condone such delay on merits where the delay

has been proved to be for reasons beyond the claimant’s control.

6. CLAIM DOCUMENTS

We shall be provided the following necessary information and documentation in respect of all Claims within

30 days of the Insured Person’s discharge from Hospital. For Claims under which the use of Cashless

Facility has been approved, We will be provided with these documents by the Network Provider immediately

following the Insured Person’s discharge from Hospital:

Kotak Health Premier – UIN: KOTHLIP21065V032021 Page 28 of 60

Kotak Mahindra General Insurance Company Ltd.

CIN: U66000MH2014PLC260291; Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai -

4000051. Office: 8th Floor, Zone IV, Kotak Infiniti, Bldg. 21,Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad (E),

Mumbai – 400097. India. IRDAI Reg. No. 152

(a) Duly completed Claim form signed by You and the Medical Practitioner (only for reimbursement

claims);

(b) Hospital discharge summary;

(d) Original bills and receipts from the Hospital/Medical Practitioner;

(e) Original bills from chemists supported by proper prescription;

(f) Original investigation test reports (including CT/MR/USG/ECG, as applicable) and payment receipts;

(g) Indoor case papers, if available;

(h) Implant Invoice/ Sticker, if available;

(i) Ambulance Invoice, if applicable;

(j) FIR (if done) or MLC (if conducted) for Accident cases ;

(k) Post mortem report (if conducted);

(l) KYC documents viz. Photo ID and address proof along with duly completed form.

(m) Any other document as required by Us or Our TPA to investigate the Claim or Our obligation to make

payment for it.

For claims under which cashless facility has been approved, following documents will be provided by the

Network hospital along with the above:

(n) Original Pre – authorization request

(o) Copy of Pre – authorization approval letter

(p) Copy of the photo identity document of the Insured Person;

(q) KYC documents obtained at the time of cashless facility.

 Additional Documents for Personal Accident Cover:

Accidental Death

(a) Original Death certificate issued by the office of Registrar of Birth & Deaths;

(b) Death summary issued by a Hospital, if applicable;

Permanent Total Disablement (PTD) resulting from Accident

(a) Original treating Medical Practitioner’s certificate describing the disablement;

(b) Photograph of the Insured Person reflecting the disablement;

(d) Any other medical, investigation reports, inpatient or consultation treatment papers, as applicable

Kotak Health Premier – UIN: KOTHLIP21065V032021 Page 29 of 60

Kotak Mahindra General Insurance Company Ltd.

CIN: U66000MH2014PLC260291; Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai -

4000051. Office: 8th Floor, Zone IV, Kotak Infiniti, Bldg. 21,Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad (E),

Mumbai – 400097. India. IRDAI Reg. No. 152

 Critical Illness Claim Documents

a. Common list of documents for all Critical Illness:

1) Duly completed claim form;

2) Certificate from the attending Medical Practitioner of the Insured Person confirming, inter alia,

i. Name of the Insured Person;

ii. Name, date of occurrence and medical details confirming the event giving rise to the Claim.

iii. Written confirmation from the treating Medical Practitioner that the event giving rise to the

Claim does not relate to any Pre-Existing Disease or any Illness or Injury which was diagnosed

within the first 90 days of commencement of first Policy Period with Us.

3) Original Policy document;

4) Original Discharge Certificate/Death Summary/Card from the hospital/ Medical Practitioner;

5) Original investigation test reports, indoor case papers;

6) In the cases where Critical Illness arises due to an Accident, FIR copy or medico legal certificate

(if done/conducted) will also be required wherever conducted. We may call for any additional

necessary documents/information as required based on the circumstances of the claim.

7) Any other documents as may be required by Us.

If the Claim is not notified to Us within the time period specified above, then We shall be provided the

reasons for the delay in writing. We will condone such delay on merits where the delay has been proved

to be for reasons beyond the claimant’s control.

b. Specific Documentation Required for each of the Critical Illnesses

Please note that the following are illustrative lists and we may seek additional documentation based

on the facts and circumstances of the Claim and if done/conducted/available

1) CANCER OF SPECIFIED SEVERITY

i. Hospital Discharge Card photocopy

ii. Hospital Bills photocopy

iii. Pharmacy/Investigations Bills

iv. Investigations Reports

v. Details of the treatment received by the Insured Person from the inception of the ailment.

vi. Letter from treating consultant stating presenting complaints with duration and the past

medical history.

vii. Histopathology / Cytology / FNAC / Biopsy / Immuno-histochemistry reports.

viii. X-Ray / CT scan / MRI scan / USG / Radioisotope / Bone scan Reports.

ix. Blood Tests.

x. Any other specific investigation done to support the diagnosis like the PAP Smear/

Mammography, etc.

xi. Any other documents as may be required by Us.

Kotak Health Premier UIN: KOTHLIP21065V032021 Page 30 of 60

Kotak Mahindra General Insurance Company Ltd.

CIN: U66000MH2014PLC260291; Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai -

4000051. Office: 8th Floor, Zone IV, Kotak Infiniti, Bldg. 21,Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad (E),

Mumbai – 400097. India. IRDAI Reg. No. 152

2) KIDNEY FAILURE REQUIRING REGULAR DIALYSIS

i. Hospital Discharge Card photocopy

ii. Photocopy Hospital Bills.

iii. Pharmacy/Investigations Bills

iv. Investigations Reports

v. Consultation Paper stating the presenting complaints with duration, past medical history with

duration, treatment and medication advised.

vi. Blood Tests- Renal Function Tests specifically: Serum Creatinine, Blood Urea Nitrogen,

Serum Electrolytes done in the recent past (Not more than Two Week period from the date of

intimation of Loss)

vii. Dialysis Papers/Receipts done in recent past.

viii. Renal scan

ix. Letter from the nephrologists stating the diagnosis of End Stage Kidney Failure.

x. Any other documents as may be required by Us.

3) MULTIPLE SCLEROSIS WITH PERSISTING SYMPTOMS

i. Hospital Discharge Card photocopy

ii. Photocopy Hospital Bills.

iii. Pharmacy/Investigations Bills

iv. Investigations Reports

v. Consultation Paper stating the presenting complaints with duration, past medical history with

duration, treatment and medication advised.

vi. MRI / CT Scan Report.

vii. Electro-myogram report

viii. Biopsy / Cytology Report

ix. Specific Blood Tests: Creatinine Phosphokinase /Anti-nuclear antibodies, C- reactive protein

/autoimmune work up

x. Any other relevant Blood investigations.

xi. Confirmation from the Central/State Government Hospital about diagnosis of Multiple Sclerosis and

the duration of the same.

xii. Any other documents as may be required by Us.

4) MOTOR NEURONE DISEASE WITH PERMANENT SYMPTOMS

i. Hospital Discharge Card photocopy (in case of Hospitalization)

ii. Investigations Reports like Blood tests, EEG, Nerve Conduction test, etc

iii. MRI / CT scan Reports or any other Imaging technique Used during the diagnosis and treatment

iv. Electro-myogram Report

v. Consultation Paper stating the presenting complaints with duration, past medical history with

duration, treatment and medication advised.

vi. Subsequent details of the Treatment, with the Consultation papers from the Treating Neurologist/

Physician stating the Neurological deficit and the degree/current status

vii. Any other document as may be required by the company

5) BENIGN BRAIN TUMOR

i. Hospital Discharge Card photocopy

ii. Hospital Bills photocopy

iii. Pharmacy/Investigations Bills

iv. Investigations Reports

v. Details of the treatment received by the Insured Person from the inception of the ailment.

vi. Letter from treating consultant stating presenting complaints with duration and the past medical

history.

vii. Histopathology / Cytology / FNAC / Biopsy / Immuno-histochemistry reports.

viii. X-Ray / CT scan / MRI scan / USG / Radioisotope / Bone scan Reports.

Kotak Health Premier UIN: KOTHLIP21065V032021 Page 31 of 60

Kotak Mahindra General Insurance Company Ltd.

CIN: U66000MH2014PLC260291; Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai -

4000051. Office: 8th Floor, Zone IV, Kotak Infiniti, Bldg. 21,Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad (E),

Mumbai – 400097. India. IRDAI Reg. No. 152

ix. Blood Tests.

x. Neurological examination report by Neurologist

xi. Any other documents as may be required by Us.

6) PRIMARY PULMONARY HYPERTENSION

i. Hospital Discharge Card photocopy

ii. Photocopy Hospital Bills.

iii. Pharmacy/Investigations Bills

iv. Investigations Reports

v. Consultation Paper stating the presenting complaints with duration, past medical history with

duration, treatment and medication advised.

vi. MRI / CT Scan Report.

vii. Echocardiography report

viii. Computed tomography (CT), magnetic resonance imaging (MRI), and lung scanning

ix. Pulmonary angiography

x. Any other documents as may be required by Us.

7) END STAGE LIVER DISEASE / FAILURE

i. Hospital Discharge Card photocopy

ii. Photocopy Hospital Bills.

iii. Pharmacy/Investigations Bills

iv. Investigations Reports

v. Consultation Paper stating the presenting complaints with duration, past medical history with

duration, treatment and medication advised.

vi. Ultrasound scan of liver

vii. CT and/or MRI scan of the liver

viii. X-ray and Liver function test

ix. Biopsy / FNAC (where applicable)

x. Any other documents as may be required by Us.

8) MAJOR ORGAN /BONE MARROW TRANSPLANT

i. Hospital Discharge Card photocopy

ii. Photocopy Hospital Bills.

iii. Pharmacy/Investigations Bills

iv. Investigations Reports

v. Consultation Paper stating the presenting complaints with duration, past medical history with

duration, treatment and medication advised.

vi. Scan / Histopathology / Cytology / FNAC / Biopsy report suggesting irreversible & non-

compensatory changes of the particular organ. 8 Bone Marrow Biopsy Reports (Specifically In Case

of Bone Marrow Transplant)

vii. Letter from a specialist Doctor confirming the need of transplantation (Organs Specified are: Heart,

lung, Liver, pancreas, kidney, bone marrow)

viii. Any other documents as may be required by Us.

9) OPEN HEART REPLACEMENT OR REPAIR OF HEART VALVES

i. Hospital Discharge Card photocopy

ii. Photocopy Hospital Bills.

iii. Pharmacy/Investigations Bills

iv. Investigations Reports

v. Consultation Paper stating the presenting complaints with duration, past medical history with

duration, treatment and medication advised.

vi. X-ray and 2D-Echocardiography Report.

Kotak Health Premier UIN: KOTHLIP21065V032021 Page 32 of 60

Kotak Mahindra General Insurance Company Ltd.

CIN: U66000MH2014PLC260291; Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai -

4000051. Office: 8th Floor, Zone IV, Kotak Infiniti, Bldg. 21,Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad (E),

Mumbai – 400097. India. IRDAI Reg. No. 152

vii. Letter from the Cardiologist / Cardiothoracic Surgeon suggesting valve replacement with the type

of valve to be used.

viii. Any other documents as may be required by Us.

10) OPEN CHEST CABG

i. Photocopy Hospital Discharge Card

ii. Photocopy Hospital Bills.

iii. Pharmacy/Investigations Bills

iv. Investigations Reports

v. Consultation Paper stating the presenting complaints with duration, past medical history with

duration, treatment and medication advised.

vi. ECG at the time of detection of Coronary Artery Disease and Subsequent ECG’s

vii. Stress test/ Tread Mill Test

viii. Letter from treating consultant suggesting Coronary Angiography and CABG

ix. Coronary Angiography report / CT Angiography Report

x. Cardiac Enzymes Tests: Troponin T/Troponin I, CPK / CPK-MB, SGOT / SGPT,

xi. LDH / Electrolytes

xii. X-ray / 2D-Echocardiography Report

xiii. Thallium Scan Report

xiv. Any other documents as may be required by Us.

11) AORTA GRAFT SURGERY

i. Photocopy Hospital Discharge Card

ii. Photocopy Hospital Bills.

iii. Pharmacy/Investigations Bills

iv. Investigations Reports

v. Consultation Paper stating the presenting complaints with duration, past medical history with

duration, treatment and medication advised.

vi. ECG at the time of detection of Coronary Artery Disease and Subsequent ECG’s

vii. Stress test/ Tread Mill Test

viii. Letter from treating consultant suggesting Coronary Angiography and CABG

ix. Coronary Angiography report / CT Scan

x. Cardiac Enzymes Tests: Troponin T/Troponin I, CPK / CPK-MB, SGOT / SGPT,

xi. LDH / Electrolytes

xii. X-ray / 2D-Echocardiography Report

xiii. Thallium Scan Report

xiv. Bio-markers for Aortic dissection

xv. Any other documents as may be required by Us.

12) COMA OF SPECIFIED SEVERITY

i. Hospital Discharge Card photocopy

ii. Investigations Reports like Blood tests, EEG, etc

iii. MRI / CT scan Reports or any other Imaging technique Used during the diagnosis and treatment

iv. Subsequent details of the Treatment, with the Consultation papers from the Treating Neurologist/

Physician stating the Glasgow coma scale grading.

v. Indoor case papers and / or ICU case papers indicating the history, signs, symptoms, line of

treatment and daily charts like TPR, etc

vi. FIR / MLC / Panch nama for accident induced coma

vii. Any other document as may be required by the company

Kotak Health Premier UIN: KOTHLIP21065V032021 Page 33 of 60

Kotak Mahindra General Insurance Company Ltd.

CIN: U66000MH2014PLC260291; Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai -

4000051. Office: 8th Floor, Zone IV, Kotak Infiniti, Bldg. 21,Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad (E),

Mumbai – 400097. India. IRDAI Reg. No. 152

13) STROKE RESULTING IN PERMANENT SYMPTOMS

i. Hospital Discharge Card photocopy

ii. Photocopy Hospital Bills.

iii. Pharmacy/Investigations Bills

iv. Investigations Reports

v. Consultation Paper stating the presenting complaints with duration, past medical history with

duration, treatment and medication advised.

vi. Subsequent details of the Treatment, with the Consultation papers from the Treating Neurologist/

Physician stating the Neurological deficit.

vii. MRI / CT scan/ 2D Echocardiography Reports or any other Imaging technique Used during the

diagnosis and treatment of the Stroke

viii. Blood tests (Lipid profile/Random Blood Sugar / Prothrombin Time/APTT/ Bleeding Time/ Clotting

Time/Homocystiene levels)

ix. Any other documents as may be required by Us.

14) PERMANENT PARALYSIS OF LIMBS

i. Hospital Discharge Card photocopy

ii. Investigations Reports

iii. MRI / CT scan Reports or any other Imaging technique Used during the diagnosis and treatment of

the Stroke

iv. Electro-myogram Report

v. Consultation Paper stating the presenting complaints with duration, past medical history with

duration, treatment and medication advised.

vi. Subsequent details of the Treatment, with the Consultation papers from the Treating Neurologist/

Physician stating the Neurological deficit and the degree/current status and duration of the

Paralysis.

vii. Any other document as may be required by the company

15) FIRST HEART ATTACK - OF SPECIFIED SEVERITY

i. Hospital Discharge Card photocopy

ii. Photocopy Hospital Bills.

iii. Pharmacy/Investigations Bills

iv. Investigations Reports

v. Casualty Medical Officers/Emergency room papers with all details of Presenting Complaints and

the Medical Examination by the attending physician.

vi. Subsequent Consultation Papers with the treating Medical Practitioner and the treatment received

vii. ECG on admission and subsequent ECG’s

viii. Stress test/ Tread Mill Test

ix. Cardiac Enzymes Tests: Troponin T/Troponin I, CPK / CPK-MB, SGOT / SGPT, LDH / Electrolytes

x. X-ray / 2D-Echocardiography Report

xi. Thallium Scan Report

xii. Any other documents as may be required by Us.

Kotak Health Premier UIN: KOTHLIP21065V032021 Page 34 of 60

Kotak Mahindra General Insurance Company Ltd.

CIN: U66000MH2014PLC260291; Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai -

4000051. Office: 8th Floor, Zone IV, Kotak Infiniti, Bldg. 21,Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad (E),

Mumbai – 400097. India. IRDAI Reg. No. 152

16) THIRD DEGREE (OR MAJOR) BURNS

i. Hospital Discharge Card photocopy

ii. Photocopy Hospital Bills.

iii. Pharmacy/Investigations Bills

iv. Investigations Reports, treatment papers

v. Certificate from the treating specialist Doctor indicating the classification / degree of burns

vi. Following medico-legal documents if applicable

(i) FIR

(ii) Panchanama

(iii) Inquest Panchanama

(iv) Police Final Report/Charge Sheet (Based on FIR)

vii. Any other documents as may be required by Us.

17) DEAFNESS OR LOSS OF HEARING

i. Hospital Discharge Card photocopy

ii. Photocopy Hospital Bills.

iii. Pharmacy/Investigations Bills

iv. Investigations Reports

v. Consultation Paper stating the presenting complaints with duration, past medical history with

duration, treatment and medication advised.

vi. Pure tone testing report

vii. Audiometry report

viii. Confirmation of Diagnosis by ENT specialist along with duration

ix. All treatment papers and medical investigation test reports

x. Any other documents as may be required by Us.

18) LOSS OF SPEECH

i. Hospital Discharge Card photocopy

ii. Photocopy Hospital Bills.

iii. Pharmacy/Investigations Bills

iv. Investigations Reports

v. Consultation Paper stating the presenting complaints with duration, past medical history with

duration, treatment and medication advised.

vi. Confirmation of Diagnosis by ENT specialist along with cause and duration

vii. All treatment papers and medical investigation test reports

Any other documents as may be required by Us.

 Claims For Pre-Hospitalisation Medical Expenses And Post-Hospitalisation Medical Expenses

(a) All Claims for Pre-Hospitalisation Medical Expenses shall be submitted to Us within 30 days of the Insured

Person’s discharge from Hospital along with the following information and documentation:

(i) Duly Completed Claim Form

(ii) Investigation Payment Receipt

(iii) Original Investigation Report

(iv) Original Pharmacy Bills

(v) Original Pharmacy Prescription

(vi) Copy of Discharge Summary

(b) All Claims for Post-Hospitalisation Medical Expenses shall be submitted to Us within 30 days of the

completion of post hospitalisation period as mentioned in your plan. You need to send Medical Expenses

being incurred along with the following information and documentation:

Kotak Health Premier UIN: KOTHLIP21065V032021 Page 35 of 60

Kotak Mahindra General Insurance Company Ltd.

CIN: U66000MH2014PLC260291; Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai -

4000051. Office: 8th Floor, Zone IV, Kotak Infiniti, Bldg. 21,Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad (E),

Mumbai – 400097. India. IRDAI Reg. No. 152

(i) Duly Completed Claim Form

(ii) Original bills and receipts from the Hospital/Medical Practitioner;

(iii) Investigation Payment Receipt

(iv) Original Investigation Report

(v) Original Pharmacy Bills

(vi) Original Pharmacy Prescription

(vii) Copy of Discharge Summary

7. CLAIM SETTLEMENT (Provision for Penal Interest)

i. The Company shall settle or reject a claim, as the case may be, within 30 days from the date of receipt

of last necessary document.

ii. In the case of delay in the payment of a claim, the Company shall be liable to pay interest to the

policyholder from the date of receipt of last necessary document to the date of payment of claim at a

rate 2% above the bank rate.

iii. However, where the circumstances of a claim warrant an investigation in the opinion of the Company, it

shall initiate and complete such investigation at the earliest, in any case not later than 30 days from the

date of receipt of last necessary document. In such cases, the Company shall settle or reject the claim

within 45 days from the date of receipt of last necessary document.

iv. In case of delay beyond stipulated 45 days, the Company shall be liable to pay interest to the

policyholder at a rate 2% above the bank rate from the date of receipt of last necessary document to the

date of payment of claim.

(Explanation: "Bank rate" shall mean the rate fixed by the Reserve Bank of India (RBI) at the beginning of the

financial year in which claim has fallen due)

PART III

General Terms and Conditions

1. Eligibility

Self, Your legally married spouse, Your natural or adopted dependent children, Your parents, Your parents-in-

law and Your siblings

Natural/ Appointed Guardian can also take insurance for minor under their guardianship.

In case of multiple Insured Person(s) covered under a Policy, the covers mentioned in Part II are applicable to

all the Insured Person(s) in accordance with the premium paid and Plan opted unless specifically excluded as

per the terms and conditions of the respective Cover.

2. Disclosure of Information

The policy shall be void and all premium paid thereon shall be forfeited to the Company in the event of

misrepresentation, mis description or non-disclosure of any material fact by the policyholder.

(Explanation: "Material facts" for the purpose of this policy shall mean all relevant information sought by the

company in the proposal form and other connected documents to enable it to take informed decision in the

context of underwriting the risk)

Kotak Health Premier UIN: KOTHLIP21065V032021 Page 36 of 60

Kotak Mahindra General Insurance Company Ltd.

CIN: U66000MH2014PLC260291; Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai -

4000051. Office: 8th Floor, Zone IV, Kotak Infiniti, Bldg. 21,Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad (E),

Mumbai – 400097. India. IRDAI Reg. No. 152

3. Condition Precedent to Admission of Liability

The terms and conditions of the policy must be fulfilled by the insured person for the Company to make any

payment for claim(s) arising under the policy.

4. 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 may be, for any benefit under the policy shall be a valid discharge towards

payment of claim by the Company to the extent of that amount for the particular claim.

5. Material Change

Material information to be disclosed to Us includes every matter that You are aware of or could reasonably be

expected to know that relates to questions in the Proposal Form and which is relevant to Us in order to accept

the risk and the terms of acceptance of the risk.

6. No constructive Notice

Any knowledge or information of any circumstances or condition in Your connection in possession of any of Our

personnel and not specifically informed to Us by You shall not be held to bind or prejudicially affect Us

notwithstanding subsequent acceptance of any premium.

7. Terms and condition of the Policy

The terms and conditions contained herein and in the Policy Schedule shall be deemed to form part of the Policy

and shall be read together as one document.

8. Multiple Policies

i. In case of multiple policies taken by an insured person during a period from one 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. In 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 the

chosen policy.

ii. Insured person having multiple policies shall also have the right to prefer claims under this policy for the

amounts disallowed under any other policy / policies 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.

iii. If the amount to be claimed exceeds the sum insured under a single policy, the insured person shall

have the right to choose insurer from whom he/she wants to claim the balance amount.

iv. Where an insured person has policies from more than one insurer to cover the same risk on indemnity

basis, the insured person shall only be indemnified the treatment costs in accordance with the terms

and conditions of the chosen policy.

9. Fraud

If any claim made by the insured person, is in any respect fraudulent, or if any false statement, or declaration is

made or used in support thereof, or if any fraudulent means or devices are used by the insured person or anyone

acting on his/her behalf to obtain any benefit under this policy, all benefits under this policy and the premium

paid shall be forfeited.

Kotak Health Premier UIN: KOTHLIP21065V032021 Page 37 of 60

Kotak Mahindra General Insurance Company Ltd.

CIN: U66000MH2014PLC260291; Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai -

4000051. Office: 8th Floor, Zone IV, Kotak Infiniti, Bldg. 21,Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad (E),

Mumbai – 400097. India. IRDAI Reg. No. 152

Any amount already paid against claims made under this policy but which are found fraudulent later shall be

repaid by all recipient(s)/policyholder(s), who has made that particular claim, who shall be jointly and severally

liable for such repayment to the insurer.

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 acting on behalf of the insured person, with intent

to deceive the insurer or to induce the insurer to issue an insurance policy:

a) the suggestion, as a fact of that which is not true and which the insured person does not believe to be

true;

b) the active concealment of a fact by the insured person having knowledge or belief of the fact;

c) any other act fitted to deceive; and

d) any such act or omission as the law specially declares to be fraudulent

The Company shall not repudiate the claim and / or forfeit the policy benefits on the ground of Fraud, if the

insured person / beneficiary can prove that the misstatement 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

within the knowledge of the insurer.

10. Zone Classification

Zone I: Mumbai (including Thane and Navi Mumbai) and Delhi (including NCR areas)

Zone II: Kolkata, Hyderabad, Chennai, Pune, Bangalore and Gujarat

Zone III: Rest of India excluding the locations mentioned under Zone I & Zone II

 Identification of Zone will be based on the city of the Proposer.

 A single Zone shall be applicable to all members covered under the Policy.

 You also have an option of selecting another Zone from the applicable Zones of any of the Insured Person(s)

in the Policy.

 Option to select a Zone higher than that of the actual Zone is available on payment of relevant premium at

the time of buying the Policy or at the time of Renewal.

 Aforesaid Co-payments for claims occurring outside of the Zone will not apply in case of Hospitalisation due

to an Accident.

Co-payment

 Persons paying Zone I premium can avail treatment all over India without any Co-payment.

 Persons paying Zone II premium can avail treatment in Zone II and Zone III without any co-payment

 Persons paying Zone III premium can avail treatment in Zone III only without any co-payment

Co-payment for treatment in a Higher Zone

In case of treatment taken in a city, in a Zone higher than the eligible Zone for the Insured Person, the Co-

payment percentages as below shall apply:

Applicable Zone

Treatment Taken at

Co-payment applicable

Zone II

Zone I

10%

Zone III

Zone I

20%

Zone III

Zone II

10%

Kotak Health Premier UIN: KOTHLIP21065V032021 Page 38 of 60

Kotak Mahindra General Insurance Company Ltd.

CIN: U66000MH2014PLC260291; Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai -

4000051. Office: 8th Floor, Zone IV, Kotak Infiniti, Bldg. 21,Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad (E),

Mumbai – 400097. India. IRDAI Reg. No. 152

11. Underwriting and Loadings

We may apply a risk loading up to a maximum of 200 % per Insured Person on the premium payable (excluding

statutory levies & taxes) based on the declarations made in the proposal form and the health status of the

persons proposed for insurance.

Loadings will be applied from Inception Date of the first Policy including subsequent renewal(s). There will be no

loadings based on individual claims experience.

In case of loading on 2 or more ailments, the loadings shall apply in conjunction, however maximum risk loading

per individual shall not exceed 200% of Premium excluding applicable Taxes.

We will inform You about the applicable risk loading or special condition through a counter offer letter and We

will only issue the Policy once We receive your consent on the applicable additional premium.

In case policies are accepted with loadings, waiting period for Pre-Existing Disease Waiting Period (Section 3.1)

as well as 2 Year Waiting Period (Section 3.3) shall continue to be applicable.

12. Free Look Period

The Free Look Period shall be applicable on new individual health insurance policies and not on renewals or at

the time of porting/migrating the policy.

The insured person shall be allowed free look period of fifteen days from date of receipt of the policy document

to review the terms and conditions of the policy, and to return the same if not acceptable.

If the insured has not made any claim during the Free Look Period, the insured shall be entitled to

i. a refund of the premium paid less any expenses incurred by the Company on medical examination of

the insured person and the stamp duty charges or

ii. where the risk has already commenced and the option of return of the policy is exercised by the insured

person, a deduction towards the proportionate risk premium for period of cover or

iii. Where only a part of the insurance coverage has commenced, such proportionate premium

commensurate with the insurance coverage during such period;

13. Cancellation

i. The policyholder may cancel this policy by giving 15days' written notice and in such an event, the

Company shall refund premium for the unexpired policy period as detailed below.

For Policyholder’s initiated cancellation, the Company would compute refund amount as pro-rata (for

the unexpired duration) premium. This would further be deducted by 25% of computed refundable

premium.

Notwithstanding anything contained herein or otherwise, no refunds of premium shall be made in respect

of Cancellation where, any claim has been admitted or has been lodged or any benefit has been availed

by the insured person under the policy.

Kotak Health Premier UIN: KOTHLIP21065V032021 Page 39 of 60

Kotak Mahindra General Insurance Company Ltd.

CIN: U66000MH2014PLC260291; Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai -

4000051. Office: 8th Floor, Zone IV, Kotak Infiniti, Bldg. 21,Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad (E),

Mumbai – 400097. India. IRDAI Reg. No. 152

ii. The Company may cancel the policy at any time on grounds of misrepresentation non-disclosure of

material facts, fraud by the insured person by giving 15 days' written notice. There would be no refund

of premium on cancellation on grounds of misrepresentation, non-disclosure of material facts or fraud.

14. Cause of Action/ Currency for payments

No Claims shall be payable under this Policy unless the cause of action arises in India, unless otherwise

specifically provided in Policy. All Claims shall be payable in India and shall be in Indian Rupees only.

15. Policy Disputes

Any dispute concerning the interpretation of the terms, conditions, limitations and/or exclusions contained herein

is understood and agreed by both You and Us to be adjudicated or interpreted in accordance with Indian law

and only competent Courts of India shall have the exclusive jurisdiction to try all or any matters arising hereunder.

The matter shall be determined or adjudicated in accordance with the law and practice of such Court.

16. Portability

The insured person will have the option to port the policy to other insurers by applying to such insurer to port the

entire policy along with all the members of the family, if any, at least 45 days before, but not earlier than 60 days

from the policy renewal date as per IRDAI guidelines related to portability. If such person is presently covered

and has been continuously covered without any lapses under any health insurance policy with an Indian

General/Health insurer, the proposed insured person will get the accrued continuity benefits in waiting periods

as per IRDAI guidelines on portability.

For Detailed Guidelines on Portability, kindly refer: IRDAI/HLT/REG/CIR/003/01/2020

17. Migration

The insured person will have the option to migrate the policy to other health insurance products/plans offered by

the company by applying for migration of the policy atleast 30 days before the policy renewal date as per IRDAI

guidelines on Migration. If such person is presently covered and has been continuously covered 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 IRDAI guidelines on migration.

For Detailed Guidelines on Migration, kindly refer: IRDAI/HLT/REG/CIR/003/01/2020

18. Renewal of Policy

The policy shall ordinarily be renewable except on grounds of fraud, misrepresentation by the insured person.

i. The Company shall endeavor to give notice for renewal. However, the Company is not under obligation

to give any notice for renewal.

ii. Renewal shall not be denied on the ground that the insured person had made a claim or claims in the

preceding policy years.

iii. Request for renewal along with requisite premium shall be received by the Company before the end of

the policy period.

iv. At the end of the policy period, the policy shall terminate and can be renewed within the Grace Period

of atleast 30 days to maintain continuity of benefits without break in policy. Coverage is not available

during the grace period.

Kotak Health Premier UIN: KOTHLIP21065V032021 Page 40 of 60

Kotak Mahindra General Insurance Company Ltd.

CIN: U66000MH2014PLC260291; Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai -

4000051. Office: 8th Floor, Zone IV, Kotak Infiniti, Bldg. 21,Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad (E),

Mumbai – 400097. India. IRDAI Reg. No. 152

v. No loading shall apply on renewals based on individual claims experience.

19.

Withdrawal of Policy

i. In the likelihood of this product being withdrawn in future, the Company will intimate the insured person

about the same 90 days prior to expiry of the policy.

ii. Insured Person will have the option to migrate to similar health insurance product available with the

Company at the time of renewal with all the accrued continuity benefits such as cumulative bonus, waiver

of waiting period as per IRDAI guidelines, provided the policy has been maintained without a break.

20. Special Provision for Insured Person who are Senior citizen

The premium charged for health Insurance products offered to Senior citizens shall be fair, justified,

transparent and duly disclosed upfront. The insured shall be informed in writing of any underwriting loading

charged over and above the premium and the specific consent of the policyholder for such loadings shall

be obtained before issuance of policy.

21. Communications & Notices

Any communication, notice, direction or instruction given under this Policy shall be in writing and delivered

by hand, post, or facsimile to:

In Your case, at Your last known address per Our records in respect of this Policy.

In Our case, at Our address specified in the Policy Schedule.

No insurance agent, broker or any other person is authorised to receive any notice on Our behalf.

22. Customer Service

If at any time You require any clarification or assistance, You may contact Our offices at the address

specified in the Policy Schedule, during normal business hours or contact Our call centre.

23. Premium Payment in Instalments

If the insured person has opted for Payment of Premium on an instalment basis i.e. Half Yearly, Quarterly

or Monthly, as mentioned in the policy Schedule/Certificate of Insurance, the following Conditions shall

apply (notwithstanding any terms contrary elsewhere in the policy)

i. Grace Period of 15 days would be given to pay the instalment premium due for the policy.

ii. During such grace period, coverage will not be available from the due date of instalment premium

till the date of receipt of premium by Company.

iii. The insured person will get the accrued continuity benefit in respect of the "Waiting Periods",

"Specific Waiting Periods" in the event of payment of premium within the stipulated grace Period.

iv. No interest will be charged If the instalment premium is not paid on due date.

v. In case of instalment premium due not received within the grace period, the policy will get cancelled.

Kotak Health Premier UIN: KOTHLIP21065V032021 Page 41 of 60

Kotak Mahindra General Insurance Company Ltd.

CIN: U66000MH2014PLC260291; Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai -

4000051. Office: 8th Floor, Zone IV, Kotak Infiniti, Bldg. 21,Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad (E),

Mumbai – 400097. India. IRDAI Reg. No. 152

vi. In the event of a claim, all subsequent premium instalments shall immediately become due and

payable.

vii. The company has the right to recover and deduct all the pending installments from the claim amount

due under the policy.

24. ECS/ Auto Debit Payment Facility:

You are eligible for availing the ECS / Auto Debit payment facility for your premium payments under this

Policy. This facility can be opted for automatic premium payment under this Policy for such premium paying

term as availed by you under this Policy by submitting a duly signed ECS / Auto Debit mandate form. You

may opt for any premium payment term as per your convenience but in accordance with the Policy terms

and conditions. Please note that this facility may not be available for all the Banks at present however and

you are requested to kindly visit website: www.kotakgeneralinsurance.com to check the updated list of all

partner banks facilitating the ECS /Auto Debit facility from time to time. Additionally, the following conditions

shall apply in case of ECS / Auto Debit facility opted by you –

a. The premium payment under the Policy shall be subject to change on renewal which would be in

accordance with the terms and conditions of the Policy

b. The Policy shall get cancelled in the event of failure of ECS transaction towards payment of premium

under the Policy and/or non-receipt of premium within the Grace Period under the Policy

c. The renewal premium amount under the Policy shall be communicated to you in advance i.e. minimum

45 days before the renewal date

d. You have the right to withdraw the ECS /Auto Debit mandate by giving Us at least 15 days’ notice

before the due date of next premium due under the Policy

The term ECS / Auto Debit herein shall be governed by the Electronic Clearing Service (Debit) Procedural

Guidelines issued by the Reserve Bank of India (as may be amended from time to time) and shall mean an

electronic facility for effecting periodic insurance premium payment transactions in an automated manner.

25. Possibility

of Revision of Terms of the Policy Including the Premium Rates

The Company, with prior approval of IRDAI, may revise or modify the terms of the policy including the

premium rates. The insured person shall be notified three months before the changes are effected.

26. Electronic Transactions

You agree to adhere to and comply with all such terms and conditions as the Company may prescribe from

time to time, and hereby agrees and confirms that all transactions effected by or through facilities for

conducting remote transactions including the Internet, World Wide Web, electronic data interchange, call

centers, teleservice operations (whether voice, video, data or combination thereof) or by means of

electronic, computer, automated machines network or through other means of telecommunication,

established by or on behalf of the Company, for and in respect of the Policy or its terms, shall constitute

legally binding and valid transactions when done in adherence to and in compliance with the Company's

terms and conditions for such facilities, as may be prescribed from time to time.

Sales through such electronic transactions shall ensure that all conditions of Section 41 of the Insurance

Act, 1938 prescribed for the proposal form and all necessary disclosures on terms and conditions and

exclusions are made known to the Insured. A voice recording in case of tele-sales or other evidence for

sales through the World Wide Web shall be maintained and such consent will be subsequently

validated/confirmed by the Insured.

Kotak Health Premier UIN: KOTHLIP21065V032021 Page 42 of 60

Kotak Mahindra General Insurance Company Ltd.

CIN: U66000MH2014PLC260291; Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai -

4000051. Office: 8th Floor, Zone IV, Kotak Infiniti, Bldg. 21,Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad (E),

Mumbai – 400097. India. IRDAI Reg. No. 152

27. Moratorium Period

After completion of eight continuous years under the policy no look back to be applied. This period of eight

years is called as moratorium period. The moratorium would be applicable for the sums insured of the first

policy and subsequently completion of 8 continuous years 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 shall be contestable except for proven fraud and permanent exclusions specified in the policy

contract. The policies would however be subject to all limits, sub limits, co-payments, deductibles as per

the policy contract.

28. Nomination

The policyholder is required at the inception of the policy to make a 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 writing and such change shall be effective only when an endorsement on

the policy is made. In the event of death of the policyholder, the Company will pay the nominee {as named

in the Policy Schedule/Policy Certificate/Endorsement(if any)} and in case there is no subsisting nominee,

to the legal heirs or legal representatives of the policyholder whose discharge shall be treated as full and

final discharge of its liability under the policy.

29. Redressal of Grievance

In case of any grievance the insured person may contact the company through

Website: www.kotakgeneralinsurance.com

Toll free: 18002664545

E-mail: care@kotak.com

Fax: 022-28401823

Courier: Kotak General Insurance 2nd Floor, Zone II, Building No.21, Infinity IT park, Off Western Express

Highway, Goregaon, Mulund Link Road, Malad (E), Mumbai - 400097.

Insured person may also approach the grievance cell at any of the company's branches with the details of

grievance

If Insured person is not satisfied with the redressal of grievance through one of the above methods, insured

person may contact the grievance officer at grievanceofficer@kotak.com

For updated details of grievance officer, kindly refer the link:

https://www.kotakgeneralinsurance.com/customer-support/grievance-redressal-process

For senior citizens, please contact the respective branch office of the Company or call at 18002664545 or

may write an e- mail at seniorcitizen@kotak.com

If Insured person is not satisfied with the redressal of grievance through above methods, the insured person

may also approach the office of Insurance Ombudsman of the respective area/region for redressal of

grievance as per Insurance Ombudsman Rules 2017.

The details of the Insurance Ombudsman is available at:

https://www.kotakgeneralinsurance.com/customer-support/grievance-redressal-process

The updated details of Insurance Ombudsman offices are also available on the website of Executive

Council of Insurers: www.ecoi.co.in/ombudsman.html

The details of the Insurance Ombudsman is available at Annexure I

Grievance may also be lodged at IRDAI Integrated Grievance Management System –

https://igms.irda.gov.in/

Kotak Health Premier UIN: KOTHLIP21065V032021 Page 43 of 60

Kotak Mahindra General Insurance Company Ltd.

CIN: U66000MH2014PLC260291; Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai -

4000051. Office: 8th Floor, Zone IV, Kotak Infiniti, Bldg. 21,Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad (E),

Mumbai – 400097. India. IRDAI Reg. No. 152

Annexure I

Details of Insurance Ombudsman

Office Details

Jurisdiction of Office Union Territory, District

Ahmedabad: Office of the Insurance Ombudsman, 6th

Floor, Jeevan Prakash Bldg, Tilak Marg, Relief Road,

Ahmedabad - 380001.

Tel.: 079 – 25501201/ 02/ 05/ 06

Email: bimalokpal.ahmedabad@ecoi.co.in

Gujarat, Dadra & Nagar Haveli, Daman and Diu.

Bengaluru: Office of the Insurance Ombudsman,

Jeevan Soudha Building, PID No. 57-27-N-19 Ground

Floor, 19/19, 24th Main Road, JP Nagar, 1st Phase,

Bengaluru – 560 078.

Tel.: 080 - 26652048 / 26652049. Email:

bimalokpal.bengaluru@ecoi.co.in

Karnataka.

Bhopal: Office of the Insurance Ombudsman, Janak

Vihar Complex, 2nd Floor, 6, Malviya Nagar, Opp.

Airtel, Near New Market, BHOPAL(M.P.)- 462003

Tel.:- 0755-2769201 / 2769202, Fax : 0755-2769203

Email: bimalokpal.bhopal@ecoi.co.in

Madhya Pradesh and Chattisgarh.

Bhubneshwar: Office of the Insurance Ombudsman,

62, Forest park, Bhubneshwar – 751 009.

Tel.: 0674 - 2596461 /2596455, Fax: 0674 - 2596429,

Email: bimalokpal.bhubanes[email protected]n

Orissa.

Chandigarh: Office of the Insurance Ombudsman,

S.C.O. No. 101, 102 & 103, 2nd Floor, Batra Building,

Sector 17 – D, Chandigarh – 160 017.

Tel.: 0172 - 2706196 / 2706468, Fax: 0172 - 2708274

Email: bimalokpal.chandigarh@ecoi.co.in

Punjab, Haryana, Himachal Pradesh, Jammu &

Kashmir, Chandigarh.

Chennai: Office of the Insurance Ombudsman, Fatima

Akhtar Court, 4th Floor, 453,Anna Salai, Teynampet,

CHENNAI – 600 018.

Tel.: 044 - 24333668 / 24335284,

Fax: 044 - 24333664

Email: bimalokpal.chennai@ecoi.co.in

Tamil Nadu, Pondicherry Town and Karaikal (which

are part of Pondicherry).

New Delhi: Office of the Insurance Ombudsman, 2/2

A, Universal Insurance Building,

Asaf Ali Road, New Delhi – 110 002.

Tel.: 011 - 23239633 / 23237532 Fax: 011 - 23230858

Email: bim[email protected]

Delhi

Guwahati: Office of the Insurance Ombudsman,

Jeevan Nivesh, 5th Floor, Nr. Panbazar over bridge,

S.S. Road, Guwahati – 781001(ASSAM).

Tel.: 0361 - 2132204 / 2132205, Fax: 0361 - 2732937

Email: bimalokpal.guwahati@ecoi.co.in

Assam, Meghalaya, Manipur, Mizoram,

Arunachal Pradesh, Nagaland and Tripura.

Hyderabad: Office of the Insurance Ombudsman,

6-2-46, 1st floor, "Moin Court", Lane Opp. Saleem

Function Palace, A. C. Guards, Lakdi-Ka-Pool,

Hyderabad - 500 004.

Tel.: 040 - 65504123 / 23312122, Fax: 040 - 23376599

Email: bimalokpal.hyderabad@ecoi.co.in

Andhra Pradesh, Telangana, Yanam and part of

Territory of Pondicherry.

Kotak Health Premier UIN: KOTHLIP21065V032021 Page 44 of 60

Kotak Mahindra General Insurance Company Ltd.

CIN: U66000MH2014PLC260291; Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai -

4000051. Office: 8th Floor, Zone IV, Kotak Infiniti, Bldg. 21,Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad (E),

Mumbai – 400097. India. IRDAI Reg. No. 152

Jaipur: Office of the Insurance Ombudsman, Jeevan

Nidhi – II Bldg., Gr. Floor, Bhawani Singh Marg, Jaipur

- 302 005. Tel.: 0141 - 2740363, Email:

bimalokpal.jaipur@ecoi.co.in

Rajasthan.

Ernakulam: Office of the Insurance Ombudsman,2nd

floor, Pulinat Building, Opp. Cochin Shipyard, M.G.

Road, Ernakulum - 682 015.

Tel.:- 0484-2358759 / 2359338, Fax:- 0484-2359336,

Email: bimalokpal.ernakulum@ecoi.co.in

Kerala, Lakshadweep, Mahe-a part of Pondicherry.

Kolkata: Office of the Insurance Ombudsman,

Hindustan Bldg. Annexe, 4th Floor, 4, C.R. Avenue,

KOLKATA - 700 072.

Tel.: 033 - 22124339 / 22124340, Fax : 033 -

22124341, Email: bimalok[email protected]n

West Bengal, Sikkim, Andaman & Nicobar Islands.

Lucknow: Office of the Insurance Ombudsman,6th

Floor, Jeevan Bhawan, Phase-II,

Nawal Kishore Road, Hazratganj, Lucknow - 226 001.

Tel.: 0522 - 2231330 / 2231331

Fax: 0522 - 2231310

Email: bim[email protected]o.in

Districts of Uttar Pradesh: Laitpur, Jhansi, Mahoba,

Hamirpur, Banda, Chitrakoot, Allahabad, Mirzapur,

Sonbhabdra, Fatehpur,

Pratapgarh, Jaunpur, Varanasi, Gazipur, Jalaun,

Kanpur, Lucknow, Unnao, Sitapur, Lakhimpur,

Bahraich, Barabanki, Raebareli, Sravasti, Gonda,

Faizabad, Amethi, Kaushambi, Balrampur, Basti,

Ambedkarnagar, Sultanpur, Maharajgang,

Santkabirnagar, Azamgarh, Kushinagar, Gorkhpur,

Deoria, Mau, Ghazipur, Chandauli, Ballia,

Sidharathnagar.

Mumbai: Office of the Insurance Ombudsman,

3rd Floor, Jeevan Seva Annexe, S. V. Road, Santacruz

(W), Mumbai - 400 054.

Tel.: 022 - 26106552 / 26106960 Fax: 022 - 26106052.

Email: bimalokpal.mum[email protected]

Goa, Mumbai Metropolitan Region excluding Navi

Mumbai & Thane

Noida: Office of the Insurance Ombudsman, Bhagwan

Sahai Palace, 4th Floor, Main Road, Naya Bans,

Sector-15, Distt: Gautam Buddh Nagar, Noida, U.P-

201301.

Tel.: 0120-2514250 / 2514252 / 2514253. Email:-

bimalokpal.noida@ecoi.co.in

State of Uttaranchal and the following Districts of

Uttar Pradesh: Agra, Aligarh, Bagpat, Bareilly,

Bijnor, Budaun, Bulandshehar, Etah, Kanooj,

Mainpuri, Mathura, Meerut, Moradabad,

Muzaffarnagar, Oraiyya, Pilibhit, Etawah,

Farrukhabad, Firozbad, Gautambodhanagar,

Ghaziabad, Hardoi, Shahjahanpur, Hapur,

Shamli, Rampur, Kashganj, Sambhal, Amroha,

Hathras, Kanshiramnagar, Saharanpur.

Patna: Office of the Insurance Ombudsman, 1st Floor,

Kalpana Arcade Building, Bazar Samiti Road,

Bahadurpur, Patna - 800 006. Tel.: 0612-2680952.

Email:- bimalok[email protected].in

Bihar and Jharkhand.

Pune: Office of the Insurance Ombudsman,

Jeevan Darshan Bldg., 3rd Floor, C.T.S. No.s. 195 to

198, N.C. Kelkar Road, Narayan Peth,

Pune – 411 030. Tel.: 020 – 41312555. Email:

bimalokpal.pune@ecoi.co.in

Maharashtra, Area of Navi Mumbai and Thane

excluding Mumbai Metropolitan Region.

Kotak Health Premier UIN: KOTHLIP21065V032021 Page 45 of 60

Kotak Mahindra General Insurance Company Ltd.

CIN: U66000MH2014PLC260291; Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai -

4000051. Office: 8th Floor, Zone IV, Kotak Infiniti, Bldg. 21,Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad (E),

Mumbai – 400097. India. IRDAI Reg. No. 152

Annexure II

List of Day Care Surgeries

Sr No

ENT

Stapedotomy

Tympanoplasty (Type II)

Myringoplasty(Type I Tympanoplasty)

Reduction of fracture of Nasal Bone

Revision stapedectomy

Excision and destruction of lingual tonsils

Labyrinthectomy for severe Vertigo

Conchoplasty

Stapedectomy under GA

Thyroplasty Type II

Ossiculoplasty

Tracheostomy

Myringotomy with Grommet Insertion

Excision of Angioma Septum

Tympanoplasty (Type III)

Turbinoplasty

Stapedectomy under LA

Incision & Drainage of Retro Pharyngeal

Abscess

Revision of the fenestration of the inner ear

Uvulo Palato Pharyngo Plasty

Tympanoplasty (Type IV)

Palatoplasty

Endolymphatic Sac Surgery for Meniere's

Disease

Tonsillectomy without adenoidectomy

Turbinectomy

Adenoidectomy with Grommet insertion

Removal of Tympanic Drain under LA

Adenoidectomy without Grommet insertion

Endoscopic Stapedectomy

Vocal Cord lateralisation Procedure

Fenestration of the inner ear

Incision & Drainage of Para Pharyngeal

Abscess

Incision and drainage of perichondritis

Transoral incision and drainage of a pharyngeal

abscess

Septoplasty

Tonsillectomy with adenoidectomy

Vestibular Nerve section

Tracheoplasty

Thyroplasty Type I

Excision of Ranula under GA

Pseudocyst of the Pinna - Excision

Meatoplasty

Incision and drainage - Haematoma Auricle

Ophthalmology

Incision of tear glands

Removal of Foreign body from cornea

Other operation on the tear ducts

Incision of the cornea

Incision of diseased eyelids

Other operations on the cornea

Excision and destruction of the diseased tissue

of the eyelid

Operation on the canthus and epicanthus

Removal of foreign body from the lens of the

eye

Removal of foreign body from the orbit and the

eye ball

Kotak Health Premier UIN: KOTHLIP21065V032021 Page 46 of 60

Kotak Mahindra General Insurance Company Ltd.

CIN: U66000MH2014PLC260291; Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai -

4000051. Office: 8th Floor, Zone IV, Kotak Infiniti, Bldg. 21,Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad (E),

Mumbai – 400097. India. IRDAI Reg. No. 152

Corrective surgery of the entropion and

ectropion

Surgery for cataract

Operations for pterygium

Treatment of retinal lesion

Corrective surgery of blepharoptosis

Removal of foreign body from the posterior

chamber of the eye

Removal of foreign body from conjunctiva

glaucoma surg

Biopsy of tear gland

Oncology

IV Push Chemotherapy

Telecobalt Therapy

HBI-Hemibody Radiotherapy

Telecesium Therapy

Infusional Targeted therapy

External mould Brachytherapy

SRT-Stereotactic Arc Therapy

Interstitial Brachytherapy

SC administration of Growth Factors

Intracavity Brachytherapy

Continuous Infusional Chemotherapy

3D Brachytherapy

Infusional Chemotherapy

Implant Brachytherapy

CCRT-Concurrent Chemo + RT

Intravesical Brachytherapy

2D Radiotherapy

Adjuvant Radiotherapy

3D Conformal Radiotherapy

100

Afterloading Catheter Brachytherapy

IGRT- Image Guided Radiotherapy

101

Conditioning Radiothearpy for BMT

IMRT- Step & Shoot

102

Extracorporeal Irradiation to the Homologous

Bone grafts

Infusional Bisphosphonates

103

Radical chemotherapy

IMRT- DMLC

104

Neoadjuvant radiotherapy

Rotational Arc Therapy

105

LDR Brachytherapy

Tele gamma therapy

106

Palliative Radiotherapy

FSRT-Fractionated SRT

107

Radical Radiotherapy

VMAT-Volumetric Modulated Arc Therapy

108

Palliative chemotherapy

SBRT-Stereotactic Body Radiotherapy

109

Template Brachytherapy

Helical Tomotherapy

110

Neoadjuvant chemotherapy

SRS-Stereotactic Radiosurgery

111

Adjuvant chemotherapy

X-Knife SRS

112

Induction chemotherapy

Gammaknife SRS

113

Consolidation chemotherapy

TBI- Total Body Radiotherapy

114

Maintenance chemotherapy

intraluminal Brachytherapy

115

HDR Brachytherapy

Electron Therapy

116

Mediastinal lymph node biopsy

TSET-Total Electron Skin Therapy

117

High Orchidectomy for testis tumours

Extracorporeal Irradiation of Blood Products

Plastic Surgery

Kotak Health Premier UIN: KOTHLIP21065V032021 Page 47 of 60

Kotak Mahindra General Insurance Company Ltd.

CIN: U66000MH2014PLC260291; Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai -

4000051. Office: 8th Floor, Zone IV, Kotak Infiniti, Bldg. 21,Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad (E),

Mumbai – 400097. India. IRDAI Reg. No. 152

118

Construction skin pedicle flap

125

Fibro myocutaneous flap

119

Gluteal pressure ulcer-Excision

126

Breast reconstruction surgery after mastectomy

120

Muscle-skin graft, leg

127

Sling operation for facial palsy

121

Removal of bone for graft

128

Split Skin Grafting under RA

122

Muscle-skin graft duct fistula

129

Wolfe skin graft

123

Removal cartilage graft

130

Plastic surgery to the floor of the mouth under

124

Myocutaneous flap

Urology

131

AV fistula - wrist

149

Ureter endoscopy and treatment

132

URSL with stenting

150

Vesico ureteric reflux correction

133

URSL with lithotripsy

151

Surgery for pelvi ureteric junction obstruction

134

Cystoscopic Litholapaxy

152

Anderson hynes operation

135

ESWL

153

Kidney endoscopy and biopsy

136

Haemodialysis

154

Paraphimosis surgery

137

Bladder Neck Incision

155

injury prepuce- circumcision

138

Cystoscopy & Biopsy

156

Frenular tear repair

139

Cystoscopy and removal of polyp

157

Meatotomy for meatal stenosis

140

Suprapubic cystostomy

158

surgery for fournier's gangrene scrotum

141

percutaneous nephrostomy

159

surgery filarial scrotum

142

Cystoscopy and "SLING" procedure

160

surgery for watering can perineum

143

TUNA- prostate

161

Repair of penile torsion

144

Excision of urethral diverticulum

162

Drainage of prostate abscess

145

Removal of urethral Stone

163

Orchiectomy

146

Excision of urethral prolapse

164

Cystoscopy and removal of FB

147

Mega-ureter reconstruction

165

Surgery for SUI

148

Kidney renoscopy and biopsy

166

URS + LL

Neurology

167

Facial nerve physiotherapy

174

Stereotactic Radiosurgery

168

Nerve biopsy

175

Percutaneous Cordotomy

169

Muscle biopsy

176

Intrathecal Baclofen therapy

170

Epidural steroid injection

177

Entrapment neuropathy Release

171

Glycerol rhizotomy

178

Diagnostic cerebral angiography

172

Spinal cord stimulation

179

VP shunt

173

Motor cortex stimulation

180

Ventriculoatrial shunt

Thoracic surgery

181

Thoracoscopy and Lung Biopsy

185

Thoracoscopy and pleural biopsy

Kotak Health Premier UIN: KOTHLIP21065V032021 Page 48 of 60

Kotak Mahindra General Insurance Company Ltd.

CIN: U66000MH2014PLC260291; Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai -

4000051. Office: 8th Floor, Zone IV, Kotak Infiniti, Bldg. 21,Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad (E),

Mumbai – 400097. India. IRDAI Reg. No. 152

182

Excision of cervical sympathetic Chain

Thoracoscopic

186

EBUS + Biopsy

183

Laser Ablation of Barrett's oesophagus

187

Thoracoscopy ligation thoracic duct

184

Pleurodesis

188

Thoracoscopy assisted empyaema drainage

Gastroenterology

189

Pancreatic pseudocyst EUS & drainage

199

Colonscopy stenting of stricture

190

RF ablation for barrett's Oesophagus

200

Percutaneous Endoscopic Gastrostomy

191

ERCP and papillotomy

201

EUS and pancreatic pseudo cyst drainage

192

Esophagoscope and sclerosant injection

202

ERCP and choledochoscopy

193

EUS + submucosal resection

203

Proctosigmoidoscopy volvulus detorsion

194

Construction of gastrostomy tube

204

ERCP and sphincterotomy

195

EUS + aspiration pancreatic cyst

205

Esophageal stent placement

196

Small bowel endoscopy (therapeutic)

206

ERCP + placement of biliary stents

197

Colonoscopy ,lesion removal

207

Sigmoidoscopy w / stent

198

ERCP

208

EUS + coeliac node biopsy

General Surgery

209

infected keloid excision

251

Pancreatic Pseudocysts Endoscopic Drainage

210

Incision of a pilonidal sinus / abscess

252

ZADEK's Nail bed excision

211

Axillary lymphadenectomy

253

Subcutaneous mastectomy

212

Wound debridement and Cover

254

Rigid Oesophagoscopy for dilation of benign

Strictures

213

Abscess-Decompression

255

Eversion of Sac

a) Unilateral

b)Bilateral

214

Cervical lymphadenectomy

256

Lord's plication

215

infected sebaceous cyst

257

Jaboulay's Procedure

216

Inguinal lymphadenectomy

258

Scrotoplasty

217

Incision and drainage of Abscess

259

Surgical treatment of varicocele

218

Suturing of lacerations

260

Epididymectomy

219

Scalp Suturing

261

Circumcision for Trauma

220

infected lipoma excision

262

Intersphincteric abscess incision and drainage

221

Maximal anal dilatation

263

Psoas Abscess Incision and Drainage

222

Piles

A)Injection Sclerotherapy

B)Piles banding

264

Thyroid abscess Incision and Drainage

223

liver Abscess- catheter drainage

265

TIPS procedure for portal hypertension

224

Fissure in Ano- fissurectomy

266

Esophageal Growth stent

225

Fibroadenoma breast excision

267

PAIR Procedure of Hydatid Cyst liver

Kotak Health Premier UIN: KOTHLIP21065V032021 Page 49 of 60

Kotak Mahindra General Insurance Company Ltd.

CIN: U66000MH2014PLC260291; Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai -

4000051. Office: 8th Floor, Zone IV, Kotak Infiniti, Bldg. 21,Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad (E),

Mumbai – 400097. India. IRDAI Reg. No. 152

226

Oesophageal varices Sclerotherapy

268

Tru cut liver biopsy

227

ERCP - pancreatic duct stone removal

269

Photodynamic therapy or esophageal tumour

and Lung tumour

228

Perianal abscess I&D

270

Excision of Cervical RIB

229

Perianal hematoma Evacuation

271

laparoscopic reduction of intussusception

230

Fissure in ano sphincterotomy

272

Microdochectomy breast

231

UGI scopy and Polypectomy oesophagus

273

Surgery for fracture Penis

232

Breast abscess I& D

274

Sentinel node biopsy

233

Feeding Gastrostomy

275

Parastomal hernia

234

Oesophagoscopy and biopsy of growth

oesophagus

276

Revision colostomy

235

UGI scopy and injection of adrenaline,

sclerosants - bleeding ulcers

277

Prolapsed colostomy- Correction

236

ERCP - Bile duct stone removal

278

Testicular biopsy

237

Ileostomy closure

279

laparoscopic cardiomyotomy( Hellers)

238

Colonoscopy

280

Sentinel node biopsy malignant melanoma

239

Polypectomy colon

281

laparoscopic pyloromyotomy( Ramstedt)

240

Splenic abscesses Laparoscopic Drainage

282

Keratosis removal under GA

241

UGI SCOPY and Polypectomy stomach

283

Excision Sigmoid Polyp

242

Rigid Oesophagoscopy for FB removal

284

Rectal-Myomectomy

243

Feeding Jejunostomy

285

Rectal prolapse (Delorme's procedure)

244

Colostomy

286

Orchidopexy for undescended testis

245

Ileostomy

287

Detorsion of torsion Testis

246

colostomy closure

288

lap.Abdominal exploration in cryptorchidism

247

Submandibular salivary duct stone removal

289

EUA + biopsy multiple fistula in ano

248

Pneumatic reduction of intussusception

290

Excision of fistula-in-ano

249

Varicose veins legs - Injection sclerotherapy

291

TURBT

250

Rigid Oesophagoscopy for Plummer vinson

syndrome

Orthopedics

292

Arthroscopic Repair of ACL tear knee

323

Partial removal of metatarsal

293

Closed reduction of minor Fractures

324

Partial removal of metatarsal

294

Arthroscopic repair of PCL tear knee

325

Revision/Removal of Knee cap

295

Tendon shortening

326

Amputation follow-up surgery

296

Arthroscopic Meniscectomy - Knee

327

Exploration of ankle joint

297

Treatment of clavicle dislocation

328

Remove/graft leg bone lesion

298

Arthroscopic meniscus repair

329

Repair/graft achilles tendon

299

Haemarthrosis knee- lavage

330

Remove of tissue expander

Kotak Health Premier UIN: KOTHLIP21065V032021 Page 50 of 60

Kotak Mahindra General Insurance Company Ltd.

CIN: U66000MH2014PLC260291; Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai -

4000051. Office: 8th Floor, Zone IV, Kotak Infiniti, Bldg. 21,Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad (E),

Mumbai – 400097. India. IRDAI Reg. No. 152

300

Abscess knee joint drainage

331

Biopsy elbow joint lining

301

Carpal tunnel release

332

Removal of wrist prosthesis

302

Closed reduction of minor dislocation

333

Biopsy finger joint lining

303

Repair of knee cap tendon

334

Tendon lengthening

304

ORIF with K wire fixation- small bones

335

Treatment of shoulder dislocation

305

Release of midfoot joint

336

Lengthening of hand tendon

306

ORIF with plating- Small long bones

337

Removal of elbow bursa

307

Implant removal minor

338

Fixation of knee joint

308

K wire removal

339

Treatment of foot dislocation

309

POP application

340

Surgery of bunion

310

Closed reduction and external fixation

341

intra articular steroid injection

311

Arthrotomy Hip joint

342

Tendon transfer procedure

312

Syme's amputation

343

Removal of knee cap bursa

313

Arthroplasty

344

Treatment of fracture of ulna

314

Partial removal of rib

345

Treatment of scapula fracture

315

Treatment of sesamoid bone fracture

346

Removal of tumor of arm/ elbow under RA/GA

316

Shoulder arthroscopy / surgery

347

Repair of ruptured tendon

317

Elbow arthroscopy

348

Decompress forearm space

318

Amputation of metacarpal bone

349

Revision of neck muscle ( Torticollis release )

319

Release of thumb contracture

350

Lengthening of thigh tendons

320

Incision of foot fascia

351

Treatment fracture of radius & ulna

321

calcaneum spur hydrocort injection

352

Repair of knee joint

322

Ganglion wrist hyalase injection

Paediatric surgery

353

Excision Juvenile polyps rectum

358

Sternomastoid Tenotomy

354

Vaginoplasty

359

Infantile Hypertrophic Pyloric Stenosis

pyloromyotomy

355

Dilatation of accidental caustic stricture

oesophagea

360

Excision of soft tissue rhabdomyosarcoma

356

Presacral Teratomas Excision

361

Excision of cervical teratoma

357

Removal of vesical stone

362

Cystic hygroma - Injection treatment

Gynaecology

363

Hysteroscopic removal of myoma

379

uterine artery embolization

364

D&C

380

Bartholin Cyst excision

365

Hysteroscopic resection of septum

381

Laparoscopic cystectomy

366

thermal Cauterisation of Cervix

382

Hymenectomy( imperforate Hymen)

367

MIRENA insertion

383

Endometrial ablation

Kotak Health Premier UIN: KOTHLIP21065V032021 Page 51 of 60

Kotak Mahindra General Insurance Company Ltd.

CIN: U66000MH2014PLC260291; Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai -

4000051. Office: 8th Floor, Zone IV, Kotak Infiniti, Bldg. 21,Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad (E),

Mumbai – 400097. India. IRDAI Reg. No. 152

368

Hysteroscopic adhesiolysis

384

vaginal wall cyst excision

369

LEEP

385

Vulval cyst Excision

370

Cryocauterisation of Cervix

386

Laparoscopic paratubal cyst excision

371

Polypectomy Endometrium

387

Repair of vagina ( vaginal atresia )

372

Hysteroscopic resection of fibroid

388

Hysteroscopy, removal of myoma

373

LLETZ

389

Ureterocoele repair - congenital internal

374

Conization

390

Vaginal mesh For POP

375

polypectomy cervix

391

Laparoscopic Myomectomy

376

Hysteroscopic resection of endometrial polyp

392

Repair recto- vagina fistula

377

Vulval wart excision

393

Pelvic floor repair( excluding Fistula repair)

378

Laparoscopic paraovarian cyst excision

394

Laparoscopic oophorectomy

Critical care

395

Insert non- tunnel CV cath

398

Insertion catheter, intra anterior

396

Insert PICC cath ( peripherally inserted central

catheter )

399

Insertion of Portacath

397

Replace PICC cath ( peripherally inserted

central catheter

Dental

400

Splinting of avulsed teeth

403

Oral biopsy in case of abnormal tissue

presentation

401

Suturing lacerated lip

404

FNAC

402

Suturing oral mucosa

405

Smear from oral cavity

Kotak Health Premier UIN: KOTHLIP21065V032021 Page 52 of 60

Kotak Mahindra General Insurance Company Ltd.

CIN: U66000MH2014PLC260291; Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai -

4000051. Office: 8th Floor, Zone IV, Kotak Infiniti, Bldg. 21,Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad (E),

Mumbai – 400097. India. IRDAI Reg. No. 152

Annexure III

List I - List of non-medical expenses

Sr.

No.

Items

Remarks

Baby Food

Not Payable

Baby Utilities Charges

Not Payable

Beauty Services

Not Payable

Belts/ Braces

Payable for cases who have undergone surgery of Thoracic or

Lumbar Spine.

Buds

Not Payable

Cold Pack/Hot Pack

Not Payable

Carry Bags

Not Payable

Email / Internet Charges

Not Payable

Food Charges (other than

Patient's Diet Provided by

Hospital)

Not Payable

Leggings

Payable in case of Bariatric and Varicose Vein Surgery

Laundry Charges

Not Payable

Mineral Water

Not Payable

Sanitary Pad

Not Payable

Telephone Charges

Not Payable

Guest Services

Not Payable

Crepe Bandage

Not Payable

Diaper Of Any Type

Not Payable

Eyelet Collar

Not Payable

Slings

Not Payable

Blood Grouping and Cross

Matching of Donors Samples

Not Payable

Service Charges Where Nursing

Charge Also Charged

Post Hospitalization Nursing Charges Not Payable

Television Charges

Not Payable

Surcharges

Not Payable

Attendant Charges

Not Payable

Extra Diet Of Patient (Other Than

That Which Forms Part Of Bed

Charge)

Not Payable

Birth Certificate

Not Payable

Certificate Charges

Not Payable

Courier Charges

Not Payable

Conveyance Charges

Not Payable

Medical Certificate

Not Payable

Medical Records

Not Payable

Kotak Health Premier UIN: KOTHLIP21065V032021 Page 53 of 60

Kotak Mahindra General Insurance Company Ltd.

CIN: U66000MH2014PLC260291; Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai -

4000051. Office: 8th Floor, Zone IV, Kotak Infiniti, Bldg. 21,Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad (E),

Mumbai – 400097. India. IRDAI Reg. No. 152

Photocopies Charges

Not Payable

Mortuary Charges

Payable Up to 24 Hrs, Shifting Charges Not Payable

Walking Aids Charges

Not Payable

Oxygen Cylinder (For Usage

Outside The Hospital)

Not Payable

Spacer

Not Payable

Spirometre

Not Payable

Nebulizer Kit

Not Payable

Steam Inhaler

Not Payable

Armsling

Not Payable

Thermometer

Not Payable

Cervical Collar

Not Payable

Splint

Not Payable

Diabetic Foot Wear

Not Payable

Knee Braces (Long/ Short/

Hinged)

Not Payable

Knee Immobilizer/Shoulder

Immobilizer

Not Payable

Lumbo Sacral Belt

Payable for cases who have undergone Surgery of Lumbar Spine

Nimbus Bed Or Water Or Air Bed

Charges

Not Payable

Ambulance Collar

Not Payable

Ambulance Equipment

Not Payable

Abdominal Binder

Payable in case of post-surgery patients of Major Abdominal

Surgery Including TAH, LSCS, Incisional Hernia Repair,

Exploratory Laparotomy for Intestinal Obstruction, Liver Transplant

Etc

Private Nurses Charges- Special

Nursing Charges

Not Payable

Sugar Free Tablets

Not Payable

Creams Powders Lotions

(Toiletries Are Not Payable, Only

Prescribed Medical

Pharmaceuticals Payable)

Not Payable

ECG Electrodes

Not Payable

Gloves

Sterilized Gloves Payable / Unsterilized Gloves not payable

Nebulisation Kit

Not Payable

Any Kit With No Details

Mentioned [Delivery Kit, Orthokit,

Recovery Kit, Etc]

Not Payable

Kidney Tray

Not Payable

Mask

Not Payable

Ounce Glass

Not Payable

Oxygen Mask

Not Payable

Kotak Health Premier UIN: KOTHLIP21065V032021 Page 54 of 60

Kotak Mahindra General Insurance Company Ltd.

CIN: U66000MH2014PLC260291; Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai -

4000051. Office: 8th Floor, Zone IV, Kotak Infiniti, Bldg. 21,Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad (E),

Mumbai – 400097. India. IRDAI Reg. No. 152

Pelvic Traction Belt

Payable in case of PIVD requiring traction

Pan Can

Not Payable

Trolly Cover

Not Payable

Urometer, Urine Jug

Not Payable

Ambulance

Payable - Ambulance from home to Hospital or inter-hospital shifts

is Payable/ RTA - As Specific Requirement for critical injury is

Payable

Vasofix Safety

Not Payable

List II – Items that are to be subsumed into Room Charges

Item

Baby Charges (Unless Specified/Indicated)

Hand Wash

Shoe Cover

Caps

Cradle Charges

Comb

Eau-De-Cologne / Room Freshners

Foot Cover

Gown

Slippers

Tissue Paper

Tooth Paste

Tooth Brush

Bed Pan

Face Mask

Flexi Mask

Hand Holder

Sputum Cup

Disinfectant Lotions

Luxury Tax

Hvac

House Keeping Charges

Air Conditioner Charges

Im Iv Injection Charges

Clean Sheet

Blanket/Warmer Blanket

Admission Kit

Diabetic Chart Charges

Documentation Charges / Administrative Expenses

Discharge Procedure Charges

Daily Chart Charges

Entrance Pass / Visitors Pass Charges

Expenses Related To Prescription On Discharge

File Opening Charges

Incidental Expenses / Misc. Charges (Not Explained)

Kotak Health Premier UIN: KOTHLIP21065V032021 Page 55 of 60

Kotak Mahindra General Insurance Company Ltd.

CIN: U66000MH2014PLC260291; Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai -

4000051. Office: 8th Floor, Zone IV, Kotak Infiniti, Bldg. 21,Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad (E),

Mumbai – 400097. India. IRDAI Reg. No. 152

List III – Items that are to be subsumed into Procedure Charges

List IV – Items that are to be subsumed into costs of treatment

Patient Identification Band / Name Tag

Pulseoxymeter Charges

No.

Item

Hair Removal Cream

Disposables Razors Charges (For Site Preparations)

Eye Pad

Eye Sheild

Camera Cover

Dvd, Cd Charges

Gause Soft

Gauze

Ward And Theatre Booking Charges

Arthroscopy And Endoscopy Instruments

Microscope Cover

Surgical Blades, Harmonicscalpel,Shaver

Surgical Drill

Eye Kit

Eye Drape

X-Ray Film

Boyles Apparatus Charges

Cotton

Cotton Bandage

Surgical Tape

Apron

Torniquet

Orthobundle, Gynaec Bundle

No.

Item

Admission/Registration Charges

Hospitalisation For Evaluation/ Diagnostic Purpose

Urine Container

Blood Reservation Charges And Ante Natal Booking Charges

Bipap Machine

Cpap/ Capd Equipments

Infusion Pump– Cost

Hydrogen Peroxide\Spirit\ Disinfectants Etc

Nutrition Planning Charges - Dietician Charges- Diet Charges

Hiv Kit

Antiseptic Mouthwash

Lozenges

Mouth Paint

Vaccination Charges

Kotak Health Premier UIN: KOTHLIP21065V032021 Page 56 of 60

Kotak Mahindra General Insurance Company Ltd.

CIN: U66000MH2014PLC260291; Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai -

4000051. Office: 8th Floor, Zone IV, Kotak Infiniti, Bldg. 21,Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad (E),

Mumbai – 400097. India. IRDAI Reg. No. 152

Annexure IV

List of Critical Illness

1) Cancer Of Specified Severity

I. A malignant tumor characterized by the uncontrolled growth and spread of malignant cells with

invasion and destruction of normal tissues. This diagnosis must be supported by histological evidence

of malignancy. The term cancer includes leukemia, lymphoma and sarcoma.

II. The following are excluded –

i. All tumors which are histologically described as carcinoma in situ, benign, pre-malignant,

borderline malignant, low malignant potential, neoplasm of unknown behavior, or non-invasive,

including but not limited to: Carcinoma in situ of breasts, Cervical dysplasia CIN-1, CIN - 2 and

CIN-3.

ii. Any non-melanoma skin carcinoma unless there is evidence of metastases to lymph nodes or

beyond;

iii. Malignant melanoma that has not caused invasion beyond the epidermis;

iv. All tumors of the prostate unless histologically classified as having a Gleason score greater

than 6 or having progressed to at least clinical TNM classification T2N0M0

v. All Thyroid cancers histologically classified as T1N0M0 (TNM Classification) or below;

vi. Chronic lymphocytic leukaemia less than RAI stage 3

vii. Non-invasive papillary cancer of the bladder histologically described as TaN0M0 or of a lesser

classification,

viii. All Gastro-Intestinal Stromal Tumors histologically classified as T1N0M0 (TNM Classification)

or below and with mitotic count of less than or equal to 5/50 HPFs;

ix. All tumors in the presence of HIV infection.

2) Kidney Failure Requiring Regular Dialysis

I. End stage renal disease presenting as chronic irreversible failure of both kidneys to function, as a

result of which either regular renal dialysis (haemodialysis or peritoneal dialysis) is instituted or renal

transplantation is carried out. Diagnosis has to be confirmed by a specialist medical practitioner.

3) Multiple Sclerosis With Persisting Symptoms

I. The unequivocal diagnosis of Definite Multiple Sclerosis confirmed and evidenced by all of the

following:

i. investigations including typical MRI findings which unequivocally confirm the diagnosis to be

multiple sclerosis and

ii. there must be current clinical impairment of motor or sensory function, which must have persisted

for a continuous period of at least 6 months.

II. Other causes of neurological damage such as SLE and HIV are excluded.

Alcohol Swabes

Scrub Solution/ Sterillium

Glucometer& Strips

Urine Bag

Kotak Health Premier UIN: KOTHLIP21065V032021 Page 57 of 60

Kotak Mahindra General Insurance Company Ltd.

CIN: U66000MH2014PLC260291; Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai -

4000051. Office: 8th Floor, Zone IV, Kotak Infiniti, Bldg. 21,Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad (E),

Mumbai – 400097. India. IRDAI Reg. No. 152

4) Motor Neurone Disease With Permanent Symptoms

I. Motor neuron disease diagnosed by a specialist medical practitioner as spinal muscular atrophy,

progressive bulbar palsy, amyotrophic lateral sclerosis or primary lateral sclerosis. There must be

progressive degeneration of corticospinal tracts and anterior horn cells or bulbar efferent neurons.

There must be current significant and permanent functional neurological impairment with objective

evidence of motor dysfunction that has persisted for a continuous period of at least 3 months.

5) Benign Brain Tumor

I. Benign brain tumor is defined as a life threatening, non-cancerous tumor in the brain, cranial nerves

or meninges within the skull. The presence of the underlying tumor must be confirmed by imaging

studies such as CT scan or MRI.

II. This brain tumor must result in at least one of the following and must be confirmed by the relevant

medical specialist.

i. Permanent Neurological deficit with persisting clinical symptoms for a continuous period of at

least 90 consecutive days or

ii. Undergone surgical resection or radiation therapy to treat the brain tumor.

III. The following conditions are excluded:

Cysts, Granulomas, malformations in the arteries or veins of the brain, hematomas, abscesses, pituitary

tumors, tumors of skull bones and tumors of the spinal cord.

6) Primary (Idiopathic) Pulmonary Hypertension

I. An unequivocal diagnosis of Primary (Idiopathic) Pulmonary Hypertension by a Cardiologist or

specialist in respiratory medicine with evidence of right ventricular enlargement and the pulmonary

artery pressure above 30 mm of Hg on Cardiac Cauterization. There must be permanent irreversible

physical impairment to the degree of at least Class IV of the New York Heart Association Classification

of cardiac impairment.

II. The NYHA Classification of Cardiac Impairment are as follows:

i. Class III: Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity

causes symptoms.

ii. Class IV: Unable to engage in any physical activity without discomfort.

Symptoms may be present even at rest.

III. Pulmonary hypertension associated with lung disease, chronic hypoventilation, pulmonary

thromboembolic disease, drugs and toxins, diseases of the left side of the heart, congenital heart

disease and any secondary cause are specifically excluded.

7) End Stage Liver Failure

I. Permanent and irreversible failure of liver function that has resulted in all three of the following:

i. Permanent jaundice; and

ii. Ascites; and

iii. Hepatic encephalopathy.

II. Liver failure secondary to drug or alcohol abuse is excluded.

Kotak Health Premier UIN: KOTHLIP21065V032021 Page 58 of 60

Kotak Mahindra General Insurance Company Ltd.

CIN: U66000MH2014PLC260291; Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai -

4000051. Office: 8th Floor, Zone IV, Kotak Infiniti, Bldg. 21,Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad (E),

Mumbai – 400097. India. IRDAI Reg. No. 152

8) Major Organ /Bone Marrow Transplant

I. The actual undergoing of a transplant of:

i. One of the following human organs: heart, lung, liver, kidney, pancreas, that resulted from

irreversible end-stage failure of the relevant organ, or

ii. Human bone marrow using haematopoietic stem cells. The undergoing of a transplant has to be

confirmed by a specialist medical practitioner.

II. The following are excluded:

i. Other stem-cell transplants

ii. Where only islets of langerhans are transplanted

9) Open Heart Replacement Or Repair Of Heart Valves

I. The actual undergoing of open-heart valve surgery is to replace or repair one or more heart valves,

as a consequence of defects in, abnormalities of, or disease affected cardiac valve(s). The diagnosis

of the valve abnormality must be supported by an echocardiography and the realization of surgery has

to be confirmed by a specialist medical practitioner. Catheter based techniques including but not limited

to, balloon valvotomy/valvuloplasty are excluded.

10) Open Chest CABG

I. The actual undergoing of heart surgery to correct blockage or narrowing in one or more coronary

artery(s), by coronary artery bypass grafting done via a sternotomy (cutting through the breast bone)

or minimally invasive keyhole coronary artery bypass procedures. The diagnosis must be supported by

a coronary angiography and the realization of surgery has to be confirmed by a cardiologist.

II. The following are excluded:

i. Angioplasty and/or any other intra-arterial procedures

11) Aorta Graft Surgery

The actual undergoing of major Surgery to repair or correct aneurysm, narrowing, obstruction or

dissection of the Aorta through surgical opening of the chest or abdomen. For the purpose of this cover

the definition of “Aorta” shall mean the thoracic and abdominal aorta but not its branches.

(i) The following conditions are excluded:

a. Surgery performed using only minimally invasive or intra-arterial techniques.

b. Angioplasty and all other intra-arterial, catheter based techniques, "keyhole" or laser procedures.

(ii) The diagnosis to be evidenced by any two of the following:

a. Computerized tomography (CT) scan

b. Magnetic Resonance Imaging (MRI) scan

c. Echocardigraphy (an ultrasound of the heart)

d. Angiography (Injecting X ray dye)

e. Abdominal ultrasound

12) Coma Of Specified Severity

I. A state of unconsciousness with no reaction or response to external stimuli or internal needs. This

diagnosis must be supported by evidence of all of the following:

i. no response to external stimuli continuously for at least 96 hours;

ii. life support measures are necessary to sustain life; and

Kotak Health Premier UIN: KOTHLIP21065V032021 Page 59 of 60

Kotak Mahindra General Insurance Company Ltd.

CIN: U66000MH2014PLC260291; Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai -

4000051. Office: 8th Floor, Zone IV, Kotak Infiniti, Bldg. 21,Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad (E),

Mumbai – 400097. India. IRDAI Reg. No. 152

iii. permanent neurological deficit which must be assessed at least 30 days after the onset of the

coma.

II. The condition has to be confirmed by a specialist medical practitioner. Coma resulting directly from

alcohol or drug abuse is excluded.

13) Stroke Resulting In Permanent Symptoms

I. Any cerebrovascular incident producing permanent neurological sequelae. This includes infarction of

brain tissue, thrombosis in an intracranial vessel, haemorrhage and embolisation from an extracranial

source. Diagnosis has to be confirmed by a specialist medical practitioner and evidenced by typical

clinical symptoms as well as typical findings in CT Scan or MRI of the brain. Evidence of permanent

neurological deficit lasting for at least 3 months has to be produced.

II. The following are excluded:

i. Transient ischemic attacks (TIA)

ii. Traumatic injury of the brain

iii. Vascular disease affecting only the eye or optic nerve or vestibular functions.

14) Permanent Paralysis Of Limbs

I. Total and irreversible loss of use of two or more limbs as a result of injury or disease of the brain or

spinal cord. A specialist medical practitioner must be of the opinion that the paralysis will be permanent

with no hope of recovery and must be present for more than 3 months.

15) Myocardial Infarction (First Heart Attack Of Specified Severity)

I. The first occurrence of heart attack or myocardial infarction, which means the death of a portion of

the heart muscle as a result of inadequate blood supply to the relevant area. The diagnosis for

Myocardial Infarction should be evidenced by all of the following criteria:

i. A history of typical clinical symptoms consistent with the diagnosis of acute myocardial infarction

(For e.g. typical chest pain)

ii. New characteristic electrocardiogram changes

iii. Elevation of infarction specific enzymes, Troponins or other specific biochemical markers.

II. The following are excluded:

i. Other acute Coronary Syndromes

ii. Any type of angina pectoris

iii. A rise in cardiac biomarkers or Troponin T or I in absence of overt ischemic heart disease OR

following an intra-arterial cardiac procedure

16) Third Degree Burns

I. There must be third-degree burns with scarring that cover at least 20% of the body’s surface area.

The diagnosis must confirm the total area involved using standardized, clinically accepted, body surface

area charts covering 20% of the body surface area.

17) Deafness

I. Total and irreversible loss of hearing in both ears as a result of illness or accident. This diagnosis

must be supported by pure tone audiogram test and certified by an Ear, Nose and Throat (ENT)

specialist. Total means “the loss of hearing to the extent that the loss is greater than 90decibels across

all frequencies of hearing” in both ears.

Kotak Health Premier UIN: KOTHLIP21065V032021 Page 60 of 60

Kotak Mahindra General Insurance Company Ltd.

CIN: U66000MH2014PLC260291; Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai -

4000051. Office: 8th Floor, Zone IV, Kotak Infiniti, Bldg. 21,Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad (E),

Mumbai – 400097. India. IRDAI Reg. No. 152

18) Loss Of Speech

I. Total and irrecoverable loss of the ability to speak as a result of injury or disease to the vocal cords.

The inability to speak must be established for a continuous period of 12 months. This diagnosis must

be supported by medical evidence furnished by an Ear, Nose, Throat (ENT) specialist.

II. All psychiatric related causes are excluded.