Accident & Sickness Medical Expense

We will pay the Usual and Customary Charges, subject to the Deductible shown in the Policy Schedule or the Schedule of Benefits (refer to 'Schedule of Benefits' of this Policy), for Covered Medical Expenses incurred overseas by You which are not due to a Pre-existing Condition up to the maximum stated in the Policy Schedule or the Schedule of Benefits (refer to 'Schedule of Benefits' of this Policy), for the treatment of an Injury or Sickness sustained by You under the circumstances described in the Hazard(H-3) during an Insured Journey while this Policy is in effect while this Policy is in effect. Any medical services or series of services with a cost greater than $ US 1 shall not be covered by this Policy unless You consult with the Assistance Company and the cost for such services are authorized in advance by the Assistance Company.

Limitations
In no event will benefits continue to be provided by Us for any Covered Medical Expenses incurred after the Expiration Date of the Policy or Your return to India whichever is earlier. No benefits are payable for outpatient Covered Medical Expenses incurred after the Expiration date of the Policy.

However if, You are still confined in a Hospital overseas after the Expiration Date of the Policy, and Emergency Medical Evacuation is not appropriate or recommended by the Assistance Company, and continued treatment overseas as an Inpatient in a Hospital is Medically Necessary, we will continue to provide the benefits for Covered Medical Expenses incurred to the earlier of your Hospital Discharge or 60 Days after the Expiration Date of the Policy.

Definition

Covered medical expenses - means reasonable charges which are: 1) not in excess of Usual and Customary Charges; 2) not in excess of the maximum benefit amount payable per service as specified in the Policy Schedule or in the Schedule of Benefits; 3) made for services and supplies not excluded under the policy; 4) made for services and supplies which are a Medical Necessity; 5) made for services included in the Policy Schedule or in Schedule of Benefits; and 6) in excess of the amount stated as a deductible, if any. Covered medical expenses will be deemed “incurred” only: 1) when the covered services are provided; and 2) when a charge is made to the Insured Person for such services.

Hospital confined/ hospital confinement - means confined in a Hospital for at least 24 hours by reason of an Injury or Sickness for which benefits are payable.

Intensive care unit - means

• a specifically designated facility of the Hospital that provides the highest level of medical care; and
• which is restricted to those patients who are critically ill or injured

Such facility must be separate and a part from the surgical recovery room and from rooms, beds and wards customarily used for patient confinement.

Medical emergency - means the occurrence of a sudden, serious and unexpected Sickness or Injury. In the absence of immediate medical attention, a reasonable person could believe this condition would result in:

• Death;
• Permanent placement of the Insured’s health in jeopardy;
• Serious impairment of bodily functions; or
• Serious and permanent dysfunction of any body organ or part

Expenses incurred for "Medical Emergency" will be paid only for Sickness or Injury which fulfills the above conditions. These expenses will not be paid for minor injuries or minor sicknesses.

Medical necessity - means those services or supplies provided or prescribed by a Hospital or physician which are:

• Essential for the symptoms and diagnosis or treatment of the Sickness or Injury;
• Provided for the diagnosis, or the direct care and treatment of the Sickness or Injury;
• In accordance with the standards of good medical practice;
• Not primarily for the convenience of the Insured, or the Insured’s Physician; and
• The most appropriate supply or level of service which can safely be provided to the Insured.

The Medical Necessity of being Hospital Confined means that: 1) the Insured requires acute care as a bed patient; and 2) the Insured cannot receive safe and adequate care as an outpatient. This policy only provides payment for services, procedures and supplies which in the judgement of the Company are a Medical Necessity. No benefits will be paid for expenses which are determined not to be a Medical necessity, including any or all days of Hospital Confinement.

Physiotherapy - means any form of the following: physical or mechanical therapy; diathermy; ultra-sonic therapy; heat treatment in any form; manipulation or massage administered by a physician

Surgery
Treatment of bodily injuries/illness/disorders/deformities/defects by Incisions or Shockwaves or Lasers , including therapeutic Endoscopic procedures requiring the professional services of a qualified surgeon and the use of an Operation Theatre for repair of injuries/diagnosis and /or cure of diseases and /or relief of suffering and /or prolongation of life.

Hospital room and board expenses
1)daily semi-private room rate when Hospital confined; and 2) general nursing care provided and charged for by the Hospital.

Hospital miscellaneous expenses
1) while hospital confined; or 2) for pre-admission expenses for being Hospital Confined. Benefits will be paid for services and supplies such as: the cost of the operating room; laboratory tests; x-ray examination; anesthesia; drugs (excluding take home drugs) or medicines; therapeutic services; and supplies.

Surgical treatment
Physician’s fees for Inpatient surgery.

Anesthetist services
In connection with inpatient surgery.

Physician’s visits
When Hospital Confined. Benefits are limited to one physician’s visit per day. Benefits do not apply when related to surgery.

Diagnostic and pre-admission testing
Limited to routine tests such as: complete blood count; urinalysis; and chest x-ray. If otherwise payable under this policy, major diagnostic procedures such as: cat-scans; NMR’s; and blood chemistries will be paid under the "Hospital Miscellaneous Expenses" benefit.

Ambulance service
Medical transportation fees and services.

Exclusions
In addition to the General Exclusions listed in this Policy this coverage section shall not cover:

• services, supplies, or treatment, including any period of Hospital confinement, which were not recommended, approved, and certified as Medically Necessary by a Physician; or
• routine physicals or other examinations where there are no objective indications or impairment in normal health, and laboratory diagnostic or X-ray examinations except in the course of a disability established by the prior call or attendance of a Physician; or
• elective, cosmetic, or plastic surgery, except as a result of an Injury caused by a covered Accident while Our Policy is in force; or
• dental care, except as a result of Injury caused by Accident to Sound Natural Teeth while this Policy is in effect; or
• expenses incurred in connection with weak, strained, or flat feet, corns, calluses, or toenails; or
• the diagnosis and treatment of acne; or
• deviated septum, including sub mucous resection and/or other surgical correction thereof; or
• organ transplants that are considered experimental in nature; or
• well child care including exams and immunizations; or
• expenses which are not exclusively medical in nature; or
• any expenses incurred in India unless authorized and approved by Us in advance; or
• eyeglasses, contact lenses, hearing aids, and examination for the prescription or fitting thereof, unless Injury or Sickness has caused impairment of vision or hearing; or
• treatment provided in a government Hospital or services for which no charge is normally made; or
• mental, nervous, or emotional disorders or rest cures; or
• pregnancy and all related conditions, including services and supplies related to the diagnosis or treatment of infertility or other problems related to inability to conceive a child; birth control, including surgical procedures and devices; or
• medical expenses covered under any workers’ compensation or similar policy; or
• medical expenses incurred as the result of alcohol and/or drug abuse, addiction or overdose.