app/data/policy_terms.json

{
  "policy_id": "PLUM_OPD_2024",
  "policy_name": "Plum OPD Advantage",
  "effective_date": "2024-01-01",
  "policy_holder": {
    "company": "TechCorp Solutions Pvt Ltd",
    "employees_covered": 500,
    "dependents_covered": true
  },
  "coverage_details": {
    "annual_limit": 50000,
    "per_claim_limit": 5000,
    "family_floater_limit": 150000,
    "consultation_fees": {
      "covered": true,
      "sub_limit": 2000,
      "copay_percentage": 10,
      "network_discount": 20
    },
    "diagnostic_tests": {
      "covered": true,
      "sub_limit": 10000,
      "pre_authorization_required": false,
      "covered_tests": [
        "Blood tests",
        "Urine tests",
        "X-rays",
        "ECG",
        "Ultrasound",
        "MRI (with pre-auth)",
        "CT Scan (with pre-auth)"
      ]
    },
    "pharmacy": {
      "covered": true,
      "sub_limit": 15000,
      "generic_drugs_mandatory": true,
      "branded_drugs_copay": 30
    },
    "dental": {
      "covered": true,
      "sub_limit": 10000,
      "routine_checkup_limit": 2000,
      "procedures_covered": [
        "Filling",
        "Extraction",
        "Root canal",
        "Cleaning"
      ],
      "cosmetic_procedures": false
    },
    "vision": {
      "covered": true,
      "sub_limit": 5000,
      "eye_test_covered": true,
      "glasses_contact_lenses": true,
      "lasik_surgery": false
    },
    "alternative_medicine": {
      "covered": true,
      "sub_limit": 8000,
      "covered_treatments": [
        "Ayurveda",
        "Homeopathy",
        "Unani"
      ],
      "therapy_sessions_limit": 20
    }
  },
  "waiting_periods": {
    "initial_waiting": 30,
    "pre_existing_diseases": 365,
    "maternity": 270,
    "specific_ailments": {
      "diabetes": 90,
      "hypertension": 90,
      "joint_replacement": 730
    }
  },
  "exclusions": [
    "Cosmetic procedures",
    "Weight loss treatments",
    "Infertility treatments",
    "Experimental treatments",
    "Self-inflicted injuries",
    "Adventure sports injuries",
    "War and nuclear risks",
    "HIV/AIDS treatment",
    "Alcoholism/drug abuse treatment",
    "Non-allopathic treatments (except listed)",
    "Vitamins and supplements (unless prescribed for deficiency)"
  ],
  "claim_requirements": {
    "documents_required": [
      "Original bills and receipts",
      "Prescription from registered doctor",
      "Diagnostic test reports (if applicable)",
      "Pharmacy bills with prescription",
      "Doctor's registration number must be visible",
      "Patient details must match policy records"
    ],
    "submission_timeline_days": 30,
    "minimum_claim_amount": 500
  },
  "network_hospitals": [
    "Apollo Hospitals",
    "Fortis Healthcare",
    "Max Healthcare",
    "Manipal Hospitals",
    "Narayana Health"
  ],
  "cashless_facilities": {
    "available": true,
    "network_only": true,
    "pre_approval_required": false,
    "instant_approval_limit": 5000
  }
}