Annexure A: Benefit chart

Total Cover-Add on
Sr. No of
Category Benefit(s) Sum Coverages/ Individual/Floater Sum Insured/Sub-limits
No. Lives
Insured Sub-limits (if any)
Hospitalization Basic Hospitalisation Sum insured Rs.-300000-400000-500000 Per Family as
1 Group1 106 13500000
Cover Expenses per demography provided
Hospitalization 30 days pre hospitalization and 60 days post
2 Group2 35 4000000 Pre-post Hospitaization
Cover hospitalization
3 Group3 19 Hospitalization 2500000 Reimbursement of
Not covered
Cover Organ Donor Expenses
Maternity Benefit - 9
9 month waiting period for maternity : Not applicable
Month Waiting Period
Waiver of 30 days
30 days waiting period : Not applicable
waiting period
Baby Day one cover Covered upto SI
Overall corporate buffer of Rs.1000000/- restricted upto
Corporate Buffer Cover
2x of family SI
Additional Sum insured
for Hospitalization due to Not covered
Critical illness
Covered upto 50% of SI. Covered only at Government
AYUSH Treatment
recognized AYUSH Hospitals
Cover for consultations, pharmacy, diagnostics, medical
Out Patient Cover and surgical procedures taken on an Out-Patient basis
upto Rs.5000/- per family
Hospital Cash Allowance Not covered
Lasik surgery Not covered
Infertility Treatment Not covered
Restoration of Sum
Not covered
Insured
Co-Payment No co-pay

5
 Cover-Add
Total on
Sr. No of
Category Benefit(s) Sum Coverages/ Individual/Floater Sum Insured/Sub-limits
No. Lives
Insured Sub-limits (if
any)
Domicillary
Covered upto 30% of SI
Hospitalization
Two years
Not applicable
waiting period
Pre and Post Covered upto Rs.10000/-or SI whichever is lower. This limit is over and
Natal above maternity sum insured
Room rent
No capping
capping
Emergency Emergency ambulance service for transporting Insured Person to
Ambulance Hospital in case of an emergency or from one hospital to another if
Expenses medical services required. up to Rs.2500/- per event
Recovery
Not covered
benefit
Stem cell
treatment Covered Upto SI
coverage
Recharge of
the Sum Not covered
Insured
Robotic
Covered upto SI
surgery
Gamma knife
/ Cyberknife Covered upto SI
surgery
Remicade,
Avastin Covered upto SI
Injection
Oral
Covered upto SI
chemotherapy
Pre-existing
Disease
Pre Existing Diseases covered from day 1
Exclusion
Waiver
Cochlear
Covered upto 50% of Sum Insured
Implant
Sleep Apnoea
Not covered
Syndrome

6
 Cover-Add
Total on
Sr. No of
Category Benefit(s) Sum Coverages/ Individual/Floater Sum Insured/Sub-limits
No. Lives
Insured Sub-limits
(if any)
Covered for Rs.50000/- For normal delivery and Rs.50000/- For C-
Maternity
Section. Maternity covered for only first 2 children. Maternity covered for
Cover
Self & spouse.
Limit for
Normal 50000
delivery
Limit for C-
50000
Section

“We hereby declare that though our aggregate turnover in any preceding financial year from 2017- 18 onwards is more than
the aggregate turnover notified under sub-rule (4) of rule 48, we are not required to prepare an invoice in terms of the
provisions of the said sub-rule.”