C M Y K
About the Bajaj Allianz Care First Plan
Bajaj Allianz Care First is a unique hospitalization-cum-insurance plan that takes care of your hospitalization
bills and also provides crucial financial support to your dependents in case of your unfortunate death. Unlike
ordinary annual Mediclaim policies, this is a 3-year risk cover plan that allows you to renew the policy after
every 3 years and keeps you covered till the age of 65 years. The premium rate is level and guaranteed for
the length of the each policy term of 3 years.
How does the plan work?
The Policy covers hospitalization expenses ranging from Rs. 1 lac to Rs. 7 lacs. This means, if you opt for a sum
assured of Rs. 5 lacs then you can avail up to Rs. 5 lacs every year to meet your hospitalisation expenses, subject
to limits on reimbursement of expenses and exclusions as mentioned below, and in the event of your unfortunate
death your dependent will get balance of any unclaimed sum assured as death benefit.
Key Benefits
_ Hospitalization Cover
_ Day Care Treatment
_ Pre-Hospitalization and Post-Hospitalization Cover
_ Cash Less Service Facility
_ Increased proportion of re imbursement of your hospitalisation expenses for every claim-free year
_ Death benefit
_ Tax Benefit
Hospitalization Cover
Following expenses incurred during hospitalization for continuous period of 24 hours for in-patient
treatment would be covered under the policy.
_ Room rent and Boarding expenses
_ Nursing expenses
_ Doctor’s fees
_ Operation theatre charges
_ Cost of Anesthesia, Blood, Oxygen, Medicines and Drugs, Diagnostic Materials and X-Ray, Artificial
Limb, and pacemaker
_ Enlisted day care expenses for specified treatments are also covered.
Day Care Treatment
If you require to undergo treatment for the illnesses or procedures like Eye surgery, Cataract, Lithotripsy
(kidney stone removal), Tonsillectomy, Dilatation & Curettage, Cardiac Catheterization, Hydrocoele Surgery,
Hernia repair surgery, wherein you don’t need to be hospitalised for at least 24 continuous hours, it will be
considered as proper hospitalization and the medical expense would be reimbursed .
Pre-Hospitalization and Post-Hospitalisation Cover
This plan covers the expenses associated with pre-hospitalisation treatment, for a period of 15 days prior to
the hospitalisation and post-hospitalisation expenses for a period of 30 days after the discharge from the
hospital.
Cash Less Service Facility
Cash Less Services (CLS) will help you avail of the hospitalisation benefits without any advance payment in
the hospital and facilitate quick delivery of services through Network Hospitals (NWH). Third Party Administrators
(TPA) of the Company facilitates the Cash Less Services. On issuance of the policy, The TPA will provide you
a photo identification card and a guide book, which would contain a list of NWH, the details explaing the process
for application of CLS and hospitalisation intimation form / pre-authorization form to be filled up by your
Sr. Illnesses/Procedures/Group of Illnesses* The lower of:
No % of sum assured Lump sum
1. Cataract 12% 25,000
2. Hysterectomy Abdominal/
vaginal, with or without BSO. 20% 40,000
3. Laparoscopic Hysterectomy 20% 50,000
4. Hydrocoele 15% 30,000
5. Hernia 20% 40,000
6. Trans Urethral resection of the Prostate 20% 40,000
7. Knee replacement 50% 150,000
8. Hip replacement 50% 175,000
9. Cholestectomy 20% 40,000
10. Lithotripsy 15% 30,000
11. Angioplasty 50% 150,000
12. Angiography 10% 20,000
13. Organ Transplant 50% 150,000
* Please refer to exclusions section for eligibility of benefits.
_ In case of Major Organ Transplant, the Company will pay an additional amount of 25% of the sum
assured as lump sum. Major Organ Transplant means the receipt of a transplant of a) Human bone
marrow using haematopoietic stem cells preceded by total bone marrow ablation; or b) One of the
following whole human organs: heart, lung, liver, kidney, pancreas (excluding the transplantation of the
islets of Langerhans only), that resulted from irreversible end-stage failure of the relevant organ. Other
stem cell transplants are excluded.
_ If hospitalisation has taken place due to Illnesses/Procedures/Group of Illnesses other than those listed
in the table then the company will reimburse 80% of following expenses:
Room rent and boarding expenses per day Maximum 1.5% of sum assured for non intensive
care unit and 3% of sum assured for intensive care unit
Doctor’s Fee Maximum 25% of the total medical expenses incurred on
in-patient treatment
Operation theatre charge Maximum twice of the per day room rent and boarding
expenses admissible under the policy on the date of surgery
/ medical procedure
Other Actual expenses on Nursing, Anesthesia, Blood, Oxygen,
Medicines and Drugs, Diagnostic Materials and X-Ray,
_ The Company will reimburse 80% of the costs of following implants subject to maximum reimbursement
limit as given below in the table;
Sr. Implants The lower of:
No. % of Sum Lump sum
Assured in Rs
1. Artificial limbs 30% 100,000
2. Cardiac Pacemaker – one chamber 20% 50,000
3. Cardiac Pacemaker – two chamber 50% 150,000
_ For each pre-hospitalisation and post-hospitalisation, expenses subject to limit of 10% of the reimbursable
hospitalisation expenses; 80% will be reimbursed.
_ In case of cancer or chronic renal failure, sum assured less any claim already paid or payable during
the policy year, will be paid immediately as lump sum and thereafter any claim, arising during the
policy term including renewals, due to or related with cancer or chronic renal failure will not be payable.
Cancer means the presence of one or more malignant tumours including leukaemia (other than chronic
lymphocytic leukaemia), lymphomas and hodgkins disease characterised by the uncontrollable growth
and spread of malignant cells and the invasion and destruction of normal tissue diagnosed by a Doctor
who is a consultant oncologist. This does not cover:
a. Tumours showing the malignant changes of carcinoma in situ (including cervical dysplacia CIN-1,
CIN-2, and CIN- 3) or, which are histologically described as pre malignant and Ductal carcinoma in
situ of the breast;
b. Melanomas of less than 1.5-mm maximum thickness as determined by histological examination
or less than
c. All hyperkeratoses or basal cells carcinomas of the skin;
d. All squamous cell carcinomas of the skin unless there has been a spread to other organs;
e. Kaposi’s sarcoma ;
f. Papillary carcinoma of the bladder and Prostatic cancers which are histologically described as TNM
Classification T1(includingT1(a) T2 (b) or are of another equivalent or lesser classification ) and
g. Hodgkins disease stage 1.
Chronic Renal Failure means end stage renal disease of chronic irreversible failure of kidneys of
the Life Assured undergoing regular peritoneal dialysis or haemodialysis or having had a renal
transplantation.
_ The 80% limit of reimbursement of expenses by the company as stated in the above paragraphs will
increase to 85% in the subsequent year following a claim free year and 90% in the subsequent year
following two-claim free years.
Grace Period, Lapse & Reinstatement
If any installment of premium is not received in full by the due date, the Company shall allow a grace period
of 15 days under all premium modes for premium to be received in full. If premium is not received within
the grace period then the policy will lapse without acquiring any surrender value or paid up value.
A lapsed policy may be revived within 30 days of the due date of the first unpaid premium and before the
expiry of the policy term subject to medical examination, at your expense, and payment of outstanding
premiums plus interest from the original due dates of premium payment.
Renewals:
The policy can be renewed within 30 days after the expiry of the current policy term for the sum assured same
as the existing sum assured and at the premium rates and terms & conditions prevailing at the time of renewal.
However if policy is not renewed within 30 days after the expiry of the current policy or new sum assured is
more than the existing sum assured then renewal of the policy would be subject to the life assured satisfying
company’s underwriting requirements.
Exclusions:
The Company shall not be liable to make any payment for the hospitalisation or medical expenses or any
claim which are attributable to, arise out of or are directly or indirectly connected to any of the following:
_ Hospitalisation and Hospital services not recommended and approved by a Doctor
_ Hosptalisation or Hospital services or claims arising out of a Pre-Existing Condition
_ Diagnosis, hospitalisation and/or treatment within the Waiting Period;
_ Expenses which are not actual and medically necessary;
_ Treatment for weight reduction or weight improvement;
_ Eye tests, refractive errors of the eyes and the provision of appliances, including spectacles, lenses,
hearing aids, and wheelchairs;
_ Any dental care or surgery of cosmetic nature, extraction of impacted tooth/teeth, orthodontics or
orthognathic surgery, or Temporomandibular Joint Disorder except as necessitated by an accidental
injury;
_ Treatment arising from pregnancy which shall include childbirth (including diagnostic tests for infertility),
infertility or impotency, miscarriage (except as a result of an Accident), abortion, sterilization and
contraception including any complications relating thereto;
_ Treatment for congenital conditions, including physical defects present from birth;
_ Expenses for seeing a general practitioner, routine health checks, precautionary services, acupuncture
and inoculation, and charges for telephone, television, newspapers and other ineligible non-medical
items whilst as an In-Patient or undergoing day-surgery;
_ Hospitalisation primarily for diagnosis, X-ray examinations, general physical or medical check-up;
_ Treatment arising from any geriatric, psycho-geriatric or psychiatric condition, insanity, mental or
nervous breakdown/disorder or “rest cures”;
attending doctor for hospitalisation in NWH. The TPA will maintain 24/7 helpline on toll free number to
facilitate any medical emergency requirement. To avail of the CLS facility all you need to do is to contact the
TPA at any of their offices which are convenient to you and submit the hospitalisation intimation form /
pre-authorization form. In case of an emergency you need to produce the photo identification card in NWH to
get admission and within 48 hours of hospitalisation you will have to contact the TPA to obtain CLS authorization.
If CLS is authorized then your hospitalisation expenses will directly be settled by the Company with NWH to
the extent it is reimbursable and the balance of the hospitalisation expenses would be settled by you at the time
of discharge.
Death Benefit
In case of unfortunate death of the life assured, the sum assured less all benefits already paid or payable in
that policy year shall be paid.
Tax Benefits
The premium paid towards Death benefit will be eligible for tax benefits under Section 80C of the Income Tax
Act 1961, and the premium paid towards hospitalisation benefit will be eligible for tax benefits under Section
80D of the Income Tax Act 1961.
Eligibility
Minimum Maximum
Entry Age 18 years 56 years
Sum Assured 100,000 700,000
Maximum Expiry Age 65 years
Policy Term 3 years
Premium Payment Frequency Yearly, Half-Yearly, Quarterly, Monthly
(Monthly mode is available through
ECS or Salary Deduction Only)
Limits on reimbursement of expenses
_ In a policy year, Company’s total liability towards reimbursement of medical expense or any other
benefit payment under the policy shall be limited to the sum assured.
_ If hospitalisation has taken place due to the following Illnesses/Procedures/Group of Illnesses, the
Company will reimburse 80% of medical expenses subject to maximum reimbursement limit as given
below in the table:
