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Policy Wordings

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Policy Wordings

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Jainy Sunil

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Policy Wordings

TATA AIG General Insurance Company Limited Polyclinic or any such health centre which is
(We, Our or Us) will provide the insurance, registered with the local authorities,
described in this Policy and any endorsements wherever applicable and having facilities for
thereto, for the Policy Period, as defined in the carrying out treatment procedures and
Policy to the Insured Person(s) named in the medical or surgical/para-surgical
Policy Schedule based on the Disclosure to interventions or both under the supervision
Information Norm, including in reliance upon the of registered AYUSH Medical Practitioner (s)
statements contained in the Proposal Form or any on day care basis without in-patient services
other mode of communication which shall be the and must comply with all the following
basis of this Policy and are deemed to be criterion:
incorporated herein in return for the receipt of
i. Having qualified registered AYUSH
the required premium in full and compliance with
Medical Practitioner(s) in charge;
all the applicable terms, conditions and
exclusions of this Policy and opted Plan. The ii. Having dedicated AYUSH therapy
insurance provided under this Policy is only in sections as required and/or has
force for the Insured Person with respect to such equipped operation theatre where
and so many of the benefits as indicated by the surgical procedures are to be carried
Sum Insured set opposite such benefit in the out;
Policy Schedule. iii. Maintaining daily records of the
Section 1 – Definitions patients and making them accessible
to the insurance company’s
The terms defined below and at other junctures in
authorized representative.
the Policy Wording have the meanings ascribed to
them wherever they appear in this Policy and 4. AYUSH Hospital
where appropriate, references to the singular An AYUSH Hospital is a healthcare facility
include references to the plural; references to the wherein medical / surgical / para-surgical
male includes other genders and references to treatment procedures and interventions are
any statutory enactment includes subsequent carried out by AYUSH Medical
changes to the same. Practitioner(s) comprising of any of the
i. Standard Definitions following:
1. Accident a. Central or State Government AYUSH
Hospital or
An accident means sudden, unforeseen and
involuntary event caused by external, visible b. Teaching Hospital attached to AYUSH
and violent means. college recognized by the Central
Government/ Central Council of Indian
2. Any one illness
Medicine/ Central Council for
Any one Illness means continuous period of Homeopathy, or
Illness and includes relapse within 45 days
c. AYUSH Hospital, standalone or
from the date of last consultation with the
co-located with in-patient healthcare
Hospital/Nursing Home where treatment
facility of any recognized system of
was taken.
medicine, registered with the local
3. AYUSH Day Care Centre^^ authorities, wherever applicable, and
is under the supervision of a qualified
AYUSH Day Care Centre means and includes
registered AYUSH Medical
Community Health Centre (CHC), Primary
Practitioner and must comply with all
Health Centre (PHC), Dispensary, Clinic,
the following criterion:
1

Regd Oﬃce: 15th Floor, Tower A, Peninsula Business Park, G. K. Marg, Lower Parel, Mumbai - 400 013
24x7 Toll Free Helpline No. 1800 266 7780 or 1800 22 9966 (For Senior Citizens)
Email: customersupport@tataaig.com  IRDA of India Registration No: 108  website: www.tataaig.com
CIN: U85110MH2000PLC128425 | UIN: TATHLIP24113V012324
Policy Wordings

i. Having atleast 5 in-patient beds; 8. Co-Payment

ii. Having qualified AYUSH Medical Co-payment means a cost sharing
Practitioner in charge round requirement under a health insurance
the clock; Policy that provides that the
policyholder/insured will bear a specified
iii. Having dedicated AYUSH
percentage of the admissible claims
therapy sections as required
amount. A co-payment does not reduce the
and/or has equipped operation
Sum Insured.
theatre where Surgical
Procedures are to be carried 9. Day Care Centre
out;
A day care centre means any institution
iv. Maintaining daily records of the established for Day Care Treatment of
patients and making them Illness and/or injuries or a medical setup
accessible to the insurance with a Hospital and which has been
company's authorized registered with the local authorities,
representative. wherever applicable, and is under
supervision of a registered and qualified
5. Cashless facility
Medical Practitioner AND must comply
Cashless facility means a facility extended with all minimum criterion as under –
by the Insurer to the insured where the
i. has qualified nursing staff under its
payments, of the costs of treatment
employment;
undergone by the insured in accordance
with the Policy terms and conditions, are ii. has qualified Medical Practitioner/s
directly made to the Network Provider by in charge;
the Insurer to the extent pre-authorization
iii. has fully equipped operation theatre
is approved.
of its own where Surgical Procedures
6. Condition Precedent are carried out;
Condition Precedent means a Policy terms iv. maintains daily records of patients
or condition upon which the Insurer’s and will make these accessible to the
liability under the Policy is conditional insurance company’s authorized
upon. personnel.
7. Congenital Anomaly: 10. Day Care Treatment
Congenital Anomaly means a condition Day care treatment means medical
which is present since birth, and which is treatment, and/or Surgical Procedure
abnormal with reference to form, structure which is:
or position.
i. undertaken under General or Local
a) Internal Congenital Anomaly Anesthesia in a Hospital/Day Care
Centre in less than 24 hrs because of
Congenital anomaly which is not in the
technological advancement, and
visible and accessible parts of the
body. ii. which would have otherwise required
Hospitalization of more than 24
b) External Congenital Anomaly
hours.
Congenital anomaly which is in the
Treatment normally taken on an out-patient basis
visible and accessible parts of the
is not included in the scope of this definition.
body.
2

11. Dental Treatment towns having a population of less than

10,00,000 and at least 15 in-patient
Dental treatment means a treatment
beds in all other places;
related to teeth or structures supporting
teeth including examinations, fillings (where iii. has qualified Medical Practitioner(s)
appropriate), crowns, extractions and in charge round the clock;
Surgery.
iv. has a fully equipped operation theatre
12. Domiciliary hospitalization of its own where Surgical Procedures
are carried out;
Domiciliary hospitalization means medical
treatment for an Illness/disease/Injury v. maintains daily records of patients
which in the normal course would require and makes these accessible to the
care and treatment at a Hospital but is insurance company’s authorized
actually taken while confined at home under personnel;
any of the following circumstances:
15. Hospitalization
i. the condition of the patient is such
Hospitalization means admission in a
that he/she is not in a condition to be
Hospital for a minimum period of 24
removed to a Hospital, or
consecutive ‘Inpatient Care’ hours except
ii. the patient takes treatment at home for specified procedures/ treatments, where
on account of non-availability of room such admission could be for a period of less
in a Hospital. than 24 consecutive hours.
13. Grace Period 16. Illness
Grace period means the specified period of Illness means a sickness or a disease or
time immediately following the premium pathological condition leading to the
due date during which a payment can be impairment of normal physiological
made to renew or continue a Policy in force function and requires medical treatment.
without loss of continuity benefits such as
(a) Acute condition
waiting periods and coverage of
Pre-Existing Diseases. Coverage is not Acute condition is a disease, illness or Injury
available for the period for which no that is likely to respond quickly to treatment
premium is received. which aims to return the person to his or
her state of health immediately before
14. Hospital
suffering the disease/ illness/ Injury which
A Hospital means any institution leads to full recovery
established for Inpatient Care and Day
(b) Chronic condition
Care Treatment of Illness and/or injuries
and which has been registered as a A chronic condition is defined as a disease,
Hospital with the local authorities under illness, or Injury that has one or more of the
Clinical Establishments (Registration and following characteristics:
Regulation) Act 2010 or under enactments i. it needs ongoing or long-term
specified under the Schedule of Section monitoring through consultations,
56(1) of the said act Or complies with all examinations, check-ups, and /or tests
minimum criteria as under:
ii. it needs ongoing or long-term control
i. has qualified nursing staff under its or relief of symptoms
employment round the clock;
iii. it requires rehabilitation for the
ii. has at least 10 in-patient beds in
3

patient or for the patient to be Medical Expenses means those expenses

specially trained to cope with it that an Insured Person has necessarily and
actually incurred for medical treatment on
iv. it continues indefinitely
account of Illness or Accident on the advice
v. it recurs or is likely to recur of a Medical Practitioner, as long as these
17. Injury are no more than would have been payable
if the Insured Person had not been insured
Injury means accidental physical bodily and no more than other Hospitals or
harm excluding Illness or disease solely and doctors in the same locality would have
directly caused by external, violent, visible charged for the same medical treatment.
and evident means which is verified and
certified by a Medical Practitioner. 23. Medical Practitioner

18. Inpatient Care Medical Practitioner means a person who

holds a valid registration from the Medical
Inpatient care means treatment for which Council of any State or Medical Council of
the Insured Person has to stay in a India or Council for Indian Medicine or for
Hospital for more than 24 hours for a Homeopathy set up by the Government of
covered event. India or a State Government and is thereby
19. Intensive Care Unit: entitled to practice medicine within its
jurisdiction; and is acting within its scope
Intensive care unit means an identiﬁed and jurisdiction of license.
section, ward or wing of a Hospital which is
under the constant supervision of a 24. Medically Necessary Treatment
dedicated Medical Practitioner(s), and Medically necessary treatment means any
which is specially equipped for the treatment, tests, medication, or stay in
continuous monitoring and treatment of Hospital or part of a stay in Hospital which:
patients who are in a critical condition, or
require life support facilities and where the i. is required for the medical
level of care and supervision is considerably management of the Illness or Injury
more sophisticated and intensive than in suﬀered by the insured;
the ordinary and other wards. ii. must not exceed the level of care
20. ICU Charges: necessary to provide safe, adequate
and appropriate medical care in
ICU (Intensive Care Unit) Charges means the scope, duration, or intensity;
amount charged by a Hospital towards ICU
expenses which shall include the expenses iii. must have been prescribed by a
for ICU bed, general medical support Medical Practitioner;
services provided to any ICU patient iv. must conform to the professional
including monitoring devices, critical care standards widely accepted in
nursing and intensivist charges. international medical practice or by
21. Medical Advice the medical community in India.

Medical Advice means any consultation or 25. Migration

advice from a Medical Practitioner "Migration" means, the right accorded to
including the issuance of any prescription or health insurance policyholders (including all
follow-up prescription. members under family cover and members
22. Medical Expenses: of group health insurance Policy), to
transfer the credit gained for pre-existing
4

conditions and time bound exclusions, with 31. Pre-hospitalization Medical Expenses
the same Insurer.
Pre-hospitalization Medical Expenses
26. Network Provider means Medical Expenses incurred during
predefined number of days preceding the
Network Provider means Hospitals or
Hospitalization of the Insured Person,
health care providers enlisted by an
provided that:
Insurer, TPA or jointly by an Insurer and
TPA to provide medical services to an i. Such Medical Expenses are incurred
insured by a Cashless Facility. for the same condition for which the
Insured Person’s Hospitalization
The updated list of Network Provider is
was required, and
available on Our website
(www.tataaig.com). ii. The In-patient Hospitalization claim
for such Hospitalization is admissible
27. Non-Network Provider
by the Insurance Company.
Non-Network means any Hospital, Day
32. Portability
Care Centre or other provider that is not
part of the network. "Portability" means, the right accorded to
individual health insurance policyholders
28. Notification of Claim
(including all members under family cover),
Notification of claim means the process of to transfer the credit gained for pre-existing
intimating a claim to the Insurer or TPA conditions and time bound exclusions, from
through any of the recognized modes of one Insurer to another Insurer.
communication.
33. Post-hospitalization Medical Expenses
29. OPD treatment
Post-hospitalization Medical Expenses
OPD treatment means the one in which the means Medical Expenses incurred during
Insured visits a clinic / Hospital or predefined number of days immediately
associated facility like a consultation room after the Insured Person is discharged from
for diagnosis and treatment based on the the Hospital provided that:
advice of a Medical Practitioner. The
i. Such Medical Expenses are for the
Insured is not admitted as a day care or
same condition for which the Insured
in-patient.
Person’s Hospitalization was
30. Pre-Existing Disease required, and
Pre-existing Disease means any condition, ii. The inpatient Hospitalization claim
ailment, Injury or disease: for such Hospitalization is admissible
a. That is/are diagnosed by a physician by the insurance company.
within 48 months prior to the effective 34. Qualified Nurse
date of the Policy issued by the
Qualified nurse means a person who holds
Insurer or its reinstatement or
a valid registration from the Nursing Council
b. For which Medical Advice or of India or the Nursing Council of any state
treatment was recommended by, or in India.
received from, a Physician within 48
35. Reasonable and Customary Charges
months Prior to the effective date of
the Policy issued by the Insurer or its Reasonable and Customary charges means
reinstatement. the charges for services or supplies, which
are the standard charges for the specific
5

provider and consistent with the prevailing Aggregate Deductible is an irrevocable cost
charges in the geographical area for sharing requirement under this Policy
identical or similar services, taking into which provides that We will not be liable for
account the nature of the Illness / Injury a specified amount in aggregate for all
involved. claims during the Policy Year.
36. Renewal 3. Bonus
Renewal means the terms on which the Bonus means an increase or addition in the
contract of insurance can be renewed on Sum Insured granted by the Insurer up to
mutual consent with a provision of Grace the specified percentage of Sum Insured,
Period for treating the renewal continuous without an associated increase in premium.
for the purpose of gaining credit for
4. Policy
Pre-Existing Diseases, time-bound
exclusions and for all waiting periods. Policy means the contract of insurance
including but not limited to Policy
37. Room Rent
Schedule, Endorsements, Policy Wordings
Room Rent means the amount charged by a (inbuilt covers & optional covers, if opted),
Hospital towards Room and Boarding Riders, etc., as applicable.
expenses and shall include the associated
5. Policy Period
Medical Expenses.
Policy Period means the time during which
38. Surgery or Surgical Procedure
this Policy is in effect. Such period
Surgery or Surgical Procedure means commences from Commencement Date
manual and / or operative procedure (s) and ends on the Expiry Date and specifically
required for treatment of an Illness or appears in the Policy Schedule.
Injury, correction of deformities and
6. Policy Schedule
defects, diagnosis and cure of diseases,
relief from suffering and prolongation of Policy Schedule means the Policy Schedule
life, performed in a Hospital or Day Care attached to and forming part of Policy.
Centre by a Medical Practitioner. 7. Policy Year
39. Unproven/Experimental treatment Policy Year means a period of twelve
Unproven/Experimental treatment means consecutive months beginning from the
the treatment including drug experimental date of commencement of the Policy
therapy which is not based on established Period and ending on the last day of such
medical practice in India, is treatment twelve-month period. For the purpose of
experimental or unproven. subsequent years, policy year shall mean a
period of twelve months commencing from
ii. Specific Definitions (Definitions other
the end of the previous policy year and
than as mentioned under Section 1 (i)
lapsing on the last day of such twelve-month
above)
period, or the Policy Expiry date whichever
1. Age is earlier.
Means the completed Age of the Insured 8. Shared Accommodation
Person on his / her last birthday as on date
Shared Accommodation means a Hospital
of commencement of the Policy and as per
room with two or more in-patient beds. This
the English calendar.
definition does not apply to ICU or ICCU.
2. Aggregate Deductible
9. Single Private Room
6

Single Private Room means an Insurance Cover under this Policy.

air-conditioned room in a Hospital where a
13. You, Your, Insured Person
single patient is accommodated and which
has an attached toilet (lavatory and bath). means the person whose name specifically
Such room type shall be the most basic and appears in the Policy Schedule as an
the most economical of all accommodations Insured Person/ Policyholder.
available as a single occupancy room in that 14. Valued Provider – Pan India
Hospital. This does not include a deluxe
room or a suite or a VIP room. ‘Valued Provider - Pan India’ is a specific
network of Hospitals, designated as such
10. Sub-Limit and mentioned in the Policy Schedule. It
Sub-limit means a cost sharing requirement consists of a defined list of Hospitals or
under a health insurance Policy in which health care providers enlisted by Us, and/or
We would not be liable to pay any amount in TPA to provide medical services to an
excess of the pre-defined limit. The Insured Person by a Cashless Facility.
Sub-Limit as applicable under the Policy is Where the Policyholder has selected Value
specified in the Policy Schedule / Policy Plan, You shall be eligible only for ‘Valued
wordings, against the relevant Cover in Provider -Pan India’ and reference made to
force under the Policy. ‘Network Provider’ in the Policy wordings
shall be substituted with ‘Valued Provider -
11. Sum Insured
Pan India’, except for Section 4 Sub-section
“Sum Insured" refers to the amount (ii)21 Zone & Applicability of Plan under
specified in the Policy Schedule at the ‘Value Plan’. The updated list of Valued
inception of a Policy Year, excluding any Provider – Pan India is available on Our
Bonus. Sum Insured represents Our website (www.tataaig.com).
maximum, total and cumulative liability
15. Zone(s)
under the Policy, for all the Insured
Person(s) covered in aggregate, for the For the purposes of application of Higher
respective Policy Year. Zone Co-Payment and Premium calculation
and payment, India has been categorized in
• Upon the successful admission of a
3 different zones:
claim, the Sum Insured for the
remaining Policy Year shall be • Zone A: Mumbai (including Mumbai
accordingly reduced by the amount of Metropolitan Region), Delhi (including
the claim settled (inclusive of 'taxes') National Capital Region, Faridabad,
or admitted. Ghaziabad), Ahmedabad, Surat &
Baroda
• In cases where the Policy Period is 2/3
years, the specified Sum Insured in the • Zone B: Hyderabad (including
Policy Schedule signifies the limit for Secunderabad), Bengaluru, Kolkata,
the initial Policy Year. This limit shall Indore, Chennai, Chandigarh
expire at the conclusion of the first (including Mohali, Punchkula,
year, and fresh limit up to the opted Zirakpur), Pune (including Pimpri
Sum Insured will become available for Chinchwad) and Rajkot
the subsequent second/third year. • Zone C: Rest of India
12. We, Us, Our, Insurer It is hereby clarified that wherever the term
means The TATA AIG General Insurance ‘Pan India’ is mentioned, it includes all the
Company Limited that has provided three zones i.e. Zone A, Zone B & Zone C.
7

Please note that the above-mentioned Medically Necessary Treatment in a

categorization of zones is subject to change Hospital, due to disease/Illness/Injury,
at Our sole discretion. Any such change that requires an Insured Person’s
made which shall impact an existing admission in a Hospital for an Inpatient
policyholder, shall be intimated under 3 Care, during the Policy Period.
months’ notice and shall be applicable from
The Company shall indemnify Medical
the immediate next Renewal.
Expenses as listed below:
Section 2 – Benefits
i. Room Rent, Boarding, Nursing
If during the Policy Period one or more Insured Expenses as provided by the Hospital
Person(s) is required to be hospitalized for / Nursing Home upto the limit per
treatment of an Illness or Injury at a Hospital / day/room category as specified in the
Day Care Centre, following Medical Advice of a Policy Schedule
duly qualified Medical Practitioner, the
ii. Intensive Care Unit (ICU) / Intensive
Company shall indemnify Medically Necessary
Cardiac Care Unit (ICCU) expenses
expenses towards the Coverage mentioned in the
Policy Schedule for the amount of such iii. Surgeon, Anesthetist, Medical
Reasonable and Customary Charges or Practitioner, Consultants, Specialist
compensate to the extent agreed, upto the limits Fees whether paid directly to the
mentioned, subject to terms and conditions of the treating doctor / surgeon or to the
Policy . Provided further that, any amount Hospital
payable under the Policy shall be subject to the iv. Anesthesia, blood, oxygen, operation
terms of coverage (including any Co-Payment, theatre charges, surgical appliances,
Sub-Limit, Aggregate Deductible), exclusions, medicines and drugs, costs towards
conditions and definition contained herein. diagnostics, diagnostic imaging
Maximum liability of the Company under all such modalities and such similar other
Claims during each Policy Year shall be the expenses.
Floater Sum Insured opted and 5X Supercharge
Bonus (if accrued) specified in the Policy If the Insured Person is admitted in a room
Schedule. The coverages available to a specific whose category/Room Rent is higher than
Insured Person/ Policy shall be as per the Plan the one that is specified in the Policy
mentioned in the Policy Schedule. Schedule, then the Insured Person shall
bear a rate able proportion of the Room
In case of family floater Policy, the Sum Insured Rent and the total Associated Medical
& Aggregate Deductible, if applicable, shall be Expenses, including surcharge or taxes
for all Insured Persons on an aggregate basis, on thereon in the proportion of the ‘difference
a per Policy Year basis. between the Room Rent actually incurred &
Our maximum liability under the Policy for the Room Rent of the entitled room
payment of all claims arising out of Any One category/Room Rent limit‘ to ‘the Room
Illness in aggregate under B1, B2, B3, B4, B5, B6, Rent actually incurred’.
B7, B8, B9, C1 (if opted) and C3 (if opted) shall not • For the purpose of this Benefit
exceed the opted Sum Insured and accrued “Associated Medical Expenses” shall
Bonus under 5X Supercharge Bonus, subject to include the applicable nursing
the balance Sum Insured/ Sub-Limit (as charges, operation theatre charges,
applicable). fees of Medical Practitioner
B1. In-Patient Treatment including surgeon/ anesthetist/
specialist within the same Hospital
We will cover Medical Expenses for
8

where the Insured Person has been three consecutive days and is availed during
admitted. “Associated Medical the Policy Period. The treatment must be
Expenses” does not include cost of for management of an Illness and not for
pharmacy & consumables, cost of enteral feedings or end of life care.
implants & medical devices and cost of
At the time of claiming under this benefit,
diagnostics.
We shall require certification from the
• Proportionate deductions are not treating doctor fulfilling the conditions as
applicable for ICU Charges. mentioned under the general definitions
(Section 1) of this Policy.
• Such proportionate deductions, if any,
will not be applied in respect of the B6. Organ Donor
Hospitals which do not follow
We shall cover the Medical Expenses, up to
differential billing or for those
the limits as specified in the Policy
Associated Medical Expenses in
Schedule, incurred by or in respect of the
respect of which differential billing is
organ donor, for an organ transplant
not adopted based on the room
Surgery, solely towards the harvesting of
category
the organ donated subject to the following
B2. Pre-Hospitalization expenses conditions:
We will cover for expenses for Conditions
Pre-Hospitalization consultations,
i. The organ donation conforms to the
investigations and medicines incurred upto
Transplantation of Human Organs
90 days prior to the date of admission to the
(Amendment) Bill, 2011 and the organ is for
Hospital. Any pre-hospitalization expenses
the use of the Insured Person;
incurred prior to Policy Period shall not be
covered. ii. The Insured Person is the recipient of the
organ so donated by the organ donor and
The benefit is payable if We have admitted a
the claim of such Surgery is accepted by Us
claim under B1, B4 or B5.
under B1 of this Policy;
B3. Post-Hospitalization expenses
iii. The organ transplant is medically necessary
We will cover for expenses for for the Insured Person as certified by a
Post-Hospitalization consultations, Medical Practitioner
investigations and medicines incurred upto
iv. Claim under this section shall be assessed
90 days after discharge from the Hospital.
as per the claim of the recipient Insured
The benefit is payable if We have admitted a Person
claim under B1, B4 or B5.
What is not covered
B4. Day Care Treatment
i. Pre-Hospitalization Medical Expenses or
We will cover expenses for Day Care Post Hospitalization Medical Expenses of
Treatment, due to disease/Illness/Injury, the organ donor
taken in a Hospital or a Day Care Centre,
ii. Screening Expenses of the organ donor
during the Policy Period.
iii. Any other Medical Expense as a result of
B5. Domiciliary Treatment
harvesting from the organ donor
We will cover for expenses related to
iv. Costs directly or indirectly associated with
Domiciliary Hospitalization of the Insured
the acquisition of the donor’s organ
Person if the treatment exceeds beyond
9

v. Transplant of any organ/tissue where the Sum Insured, if the balance Sum Insured
transplant is experimental or investigational and accrued 5X Supercharge Bonus is
insufficient to pay an admissible claim
vi. Expenses related to organ transportation or
under B1 to B6. The restore benefit will be
preservation
available once during the Policy Year but
vii. Any other medical treatment or shall not be available for the first admissible
complication in respect of the donor, Hospitalization/ Domiciliary
consequent to harvesting. Hospitalization claim in each Policy Year.
B7. AYUSH Benefit^^ Notwithstanding the above, Our maximum
We will cover for Medical Expenses liability in aggregate for all claims during a
incurred for treatment as in-patient or Day Policy Year under B9 ‘Restore benefit’ shall
Care Treatment in an AYUSH Hospital/ not exceed the Sum Insured
AYUSH day care centre, for a room Restore benefit will be available once during
category/ Room Rent limit, as specified in the Policy Year subject to the following
the Policy Schedule and applicability of conditions:
Associated Medical Expenses.
a. The reinstated Sum Insured can be
This benefit shall also cover used by the Insured Person(s) for any
Pre-Hospitalization medical expenses for a claim (related or unrelated Illness/
period of upto 90 days before the date of Injury) under B1 to B6 of the Policy.
admission to the AYUSH hospital/ AYUSH
b. However, in case of Any One Illness,
day care centre and Post-Hospitalization
this benefit for related Illness/ Injury
Medical Expenses for a period upto 90 days,
would be available to the Insured
subject to AYUSH In-Patient hospitalization
Person(s), who have claimed earlier,
or AYUSH day care treatment claim being
only for Hospitalization/ Domiciliary
admissible under this benefit.
Hospitalization where date of
Claims under this section shall be assessed admission is beyond 45 days from the
as per the insurance guidelines related to date of discharge of the immediately
AYUSH and benchmark rates as available on preceding Hospitalization/ date of
Ministry of AYUSH website end of Domiciliary Hospitalization,
(https://ayushnext.ayush.gov.in/site/insura for which claim has been paid.
nce-guidelines-related-to-ayush).
c. In this Policy, the reinstated Sum
B8. Road Ambulance Cover Insured will be available for all
We will cover for expenses incurred on Insured Persons on floater basis.
transportation of Insured Person in a d. The unutilized restored Sum Insured
registered ambulance to a Hospital for cannot be carried forward to the next
admission in case of an Emergency or from Policy Year.
one Hospital to another Hospital for better
e. This benefit shall also be applicable
medical facilities and treatment, subject to a
annually for policies with tenure of
maximum limit as specified in the Policy
more than 1 year
Schedule per Hospitalization.
f. Restore will not trigger or be available
For this claim to be paid, the claim must be
for utilization for the first claim under
admissible under B1 or B4 of this Policy.
each Policy Year.
B9. Restore benefit
g. Accrued 5X Supercharge Bonus, if any,
We will automatically reinstate 100% of the
10

will not be reinstated. same condition for which the

Hospitalization claim was admissible. This
B10. Compassionate Travel
benefit will be triggered only if the In-patient
In the event the Insured Person is Treatment claim is admissible under B1 of
Hospitalized in India for more than Five this Policy.
consecutive days in a place where no adult
List of medical devices:
member of his immediate family is present,
We will cover expenses related to a round i. Crutches
trip economy class domestic air ticket, or
ii. Wheel chair
first class railway ticket, to allow the
Immediate Family Member be at his bedside iii. Walker
for the duration of his stay in the Hospital, iv. Walking stick
subject to a maximum limit as specified in
the Policy Schedule during a Policy Year. v. Lumbo-sacral belt

This beneﬁt shall be payable if We have The beneﬁt is payable subject to a

accepted an inpatient Hospitalization maximum limit as specified in the Policy
claim for the Insured Person(s) under In Schedule per Policy Year and this benefit
Patient Treatment (B1). has a separate limit (over and above base
Sum Insured), notwithstanding the
This benefit has a separate limit (over and exclusion mentioned under Section 3(ii)
above base Sum Insured). sub-section 2(xii).
We shall require additional documents as B13 Vaccination cover
proof of travel for supporting the claim
under this benefit. We will cover the cost of the following
vaccines if the Insured Person(s)is
B11. Prolonged Hospitalization Benefit vaccinated during the Policy Year:
We will pay a fixed amount as specified in - Anti-rabies vaccine following an animal bite
the Policy Schedule per Policy Year in the
event of Hospitalization of the Insured - Typhoid vaccine
Person for an Illness/disease/Injury for a The benefit is payable (notwithstanding the
continuous period exceeding 10 days, exclusion mentioned under Section
subject to Hospitalization at Our Network 3.ii.sub-section 1.viii), subject to a maximum
Provider. limit as specified in the Policy Schedule per
This benefit is over and above of the base Policy Year and this benefit has a separate
Sum Insured and can be availed only once limit (over and above the base Sum
per Policy Year at Policy level, provided Insured). Expenses related to the doctor,
that the In-patient Treatment claim is nurse or any incidental expenses are not
admissible under B1 of this Policy. payable.
B14. Second Opinion

B12. Medical Devices Cover At Your request, We will provide the

Insured Person second medical opinion
We will cover expenses incurred by the from Our empanelled service provider in
Insured Person towards renting or India, if an Insured Person is diagnosed
purchase of below mentioned medical with the below mentioned Illnesses during
devices during the Policy Year only if the the Policy Period. The expert opinion would
same is prescribed by the treating Medical be directly sent to the Insured Person.
Practitioner post Hospitalization for the
11

i. Cancer of communication like audio,

video, online portal, chat, digital
ii. Kidney Failure
customer application or any
iii. Myocardial Infarction other digital mode.
iv. Angina ii. Teleconsultation - Speciality
v. Coronary bypass Surgery We /Our empanelled Service Provider
vi. Stroke/Cerebral hemorrhage will arrange for teleconsultations upon
Insured Person’s request through
vii. Organ failure requiring transplant telecommunications and digital
viii. Heart Valve replacement communication technologies for
Insured Person’s health related
ix. Brain tumors complaints or preventive health care
Second Opinion will be based only on the by a qualified & specialist Medical
information and documentation provided to Practitioner/ Health Care
Us which will be shared with Our Professional, as per the
empanelled service provider. Conditions as limit/speciality specified in Your
mentioned under Disclaimer Clause Policy Schedule.
(applicable to B14, B15 & B16) in the Policy This service can only be availed
shall apply subject to conditions below:
B15. Wellness Services - Consultation will be provided
We / Our Empanelled Service Provider will through various specified modes
provide below mentioned wellness services of communication like audio,
designed to assist Insured Persons in video, online portal, chat, digital
maintaining and improving good health and customer application or any
fitness. These Wellness Services will be other digital mode.
available for the Insured Person during the iii. Ambulance Booking facility
Policy Period and as specified in the Policy
Schedule. We / Our empanelled Service Provider will
provide a facility to book a road ambulance
i. Teleconsultation - General in India, for transportation of an Insured
We /Our empanelled Service Provider Person to a Hospital for admission or from
will arrange for teleconsultations upon one Hospital to another Hospital for better
Insured Person’s request through medical facilities and treatment.
telecommunications and digital This booking service can be availed at Our
communication technologies for Network subject to the transportation of the
Insured Person’s health related Insured Person will be offered to the
complaints or preventive health care nearest Hospital.
by a qualified Medical Practitioner/
Health Care Professional, as per the Important: This service shall be subject to
limit specified in Your Policy availability of a competent service provider
Schedule. in Your area.
This service can only be availed iv. Emergency - Help me feature
subject to condition below: In case of an emergency, Insured
- Consultation will be provided Person will have an option to share
through various specified modes his/her location with the ‘designated
12

caregiver’ through Our customer communication like audio, video,

application provided the Insured online portal, chat, digital customer
Person has registered on Our App. application or any other digital mode.
The app will trigger a message and/ or Definition:
call to the designated caregiver
For the purpose of B15 of this Policy, a
informing about the emergency and
Health Care Professional is a person who
sharing the location of the Insured
holds a valid qualification from regulatory
Person.
body as set up by the Government of India
For the purpose of this benefit, or a State Government or any other relevant
‘designated caregiver’ shall mean authority and is engaged in actions with an
that individual who has been specified objective of maintaining and improving
as a caregiver at the time of individual’s good health.
registration in the customer App.
B16. Wellness Program
Please note
We / Our empanelled service provider will
- This service will be available subject to provide a wellness program designed to
suitable infrastructure, connectivity, promote wellness and fitness amongst the
device restrictions and device Insured Persons. This wellness program is
functionality. structured to reward the Insured Person in
the form of measurable wellness score for
v. Redeemable voucher/Discount on
the prescribed physical efforts/fitness
services
activity undertaken by such Insured Person
We / Our empanelled service provider during the Policy Period. This is a voluntary
will provide redeemable vouchers/ program available for Insured Person with
discount (as approved by the regulator Age above 18 years, at the start of the
from time to time) on certain specified Policy Year. It is advisable to the Insured
products/ services to promote Person to consult his/her physician before
wellness and fitness of the Insured starting any physical exercise/ activity.
Person.
It is a pre-condition for enrolment under
vi. Health Condition Management this wellness programme, that the Insured
We / Our empanelled service provider Person should have undergone the health
will provide consultative services risk assessment as specified below and
related to health conditions/ Illnesses depending on the outcome from health risk
with the objective of maintaining good assessment, the wellness reward and its
health and improving it through scoring should be administered. The
various health condition management earnings under the wellness program is
programmes including but not limited linked to Your wellness category and shall
to nutrition management, weight be valid for one year from the date of credit
management, chronic condition of daily score in Insured Person’s wellness
management, stress management, account, provided the Policy is renewed
health coach (as approved by the within the Grace Period. Daily score will be
regulator from time to time) and credited after the completion of a healthy
offered by Us. day.

Consultative services will be provided For the purpose of understanding if the

through various speciﬁed modes of daily score is credited on 1st Jan 2023 it will
be valid up to 31st Dec 2023.
13

i) Health risk assessment Insured Person has to undergo HRA in each

Policy Year to be eligible for wellness
We / Our empanelled service provider
rewards. If the Insured Person does not
will provide a health risk assessment
undergo assessment in the consecutive
(HRA) questionnaire, which is an
Policy Year, henceforth no rewards will be
online tool for evaluation of status of
earned for any physical activity undertaken.
health and quality of the Insured
However, earned rewards will be carried
Person’s life. This tool helps Insured
forward till its validity and will be available
Persons to review their lifestyle
for utilization.
practises which may impact their
health status. ii) Wellness Rewards
To undertake the health risk Mechanism to earn Wellness Reward:
assessment, You can log into Your
We will encourage physical exercise and
account on Our customer application.
fitness and recognise the effort by
This can be undertaken once a Policy
rewarding the Insured Person on daily
Year.
basis for each healthy day.
On completion of the health risk
A healthy day can be earned by undertaking
assessment and based on the Insured
below activity on a calendar day:
Person’s assessment results, We /
Our empanelled service provider will 1. Recording 10, 000 steps / day# in the
identify the wellness category in which activity tracking apps or fitness tracker
the Insured Person falls in. devices as prescribed by the company
or Our empanelled service provider:
Wellness categories for this purpose
or
are defined as below:
2. Burning 500 calories or more in a day
• Green – low risk for developing
through activity as measured by
lifestyle disease as compared to
fitness tracker devices.
peers in the same Age and
gender group. The company may at its discretion change
the above criteria and the same would be
• Yellow – moderate risk for
mentioned in the Policy Schedule/
developing lifestyle disease as
customer application.
compared to peers in the same
Age and gender group. Wellness reward will be earned depending
on the wellness category of the Insured
• Red – higher risk for developing
Person and as per the grid below:
lifestyle disease as compared to
peers in the same Age and Wellness category
gender group.
Green Yellow Red
The overall wellness category is valid till the Rewards per Healthy Day 10 7 5
expiry of the Policy Year in which the
Insured Person undergoes the assessment
Note:
and will be updated based on HRA results of
subsequent assessment undergone by the • HRA registration will be allowed
Insured Person in each consecutive Policy anytime during the Policy Year and
Year, subject to Renewal of the Policy healthy activities will be tracked
within the Grace Period. In the event of a throughout the Policy Year, however,
long-term Policy (greater than 1 year) the for each Policy Year , activities
14

completed in first 300 days of the fitness activities can be converted into
Policy Year will be considered for monetary value as per method defined
reward in the same year, activities below and can be utilized towards the
completed on or after 301st day of the payment of services/items under below
Policy Year will be carried forward to categories, available through Our Network/
the next Policy Year and will be empanelled service provider:
available for utilization in the next year
• OPD consultation/ treatment
provided the Policy has been inforce
or renewed with Us without any break • Pharmaceuticals
within the Grace Period. • Health-check-ups/ diagnostics
• In case of individual Policy, each • Health Supplements
Insured Person would be tracked
separately and shall earn wellness • Coverage of cost of treatment of any
reward based on one’s own individual admissible claim in respect of
performance/physical activity as per non-payable items that are specified
the grid above under the terms and conditions of the
base Policy
• In case of family floater Policy, each
Insured Person, with Age above 18 • Or any other items as prescribed by
years, at the start of the Policy Year, the company or Our empanelled
would be tracked separately and shall service provider as approved by the
earn wellness reward based on one’s Regulator as a redeemable item from
own individual performance/physical time to time.
activity as per the grid above. In order Note:
to compute the wellness reward for
such policies, average of individual • Wellness Reward can be converted
performance rewards would be into a monetary value after every
considered for computation of Healthy Day, during the Cover Period
wellness reward. • Monetary value of the Wellness score
• # The company may also use earned is equivalent to the:
alternative measurement criteria in Wellness score earned X (Per year
lieu of steps and calories burnt and Policy Premium without Taxes/
the same shall be mentioned on the 10,000).
Policy Schedule
o In case of Policy with tenure
• Data entered manually in the fitness more than one year, ‘per year
tracking apps or devices will not be Policy Premium without Taxes’ =
considered for tracking healthy day (Total Policy premium without
• Calories burnt during basic tax, for the tenure/ Policy
metabolism shall not be considered tenure).
for tracking healthy day (here basic o In case of family floater Policy,
metabolism refers to activities done reward will be calculated on
while at rest to maintain vital functions average premium per person
such as breathing and keeping warm which is equivalent to the Total
etc.) Policy premium without tax/
Mechanism to Utilise Wellness Reward: number of Insured Person(s)
covered in the Policy on floater
Wellness Reward accumulated through basis
15

Illustration
Zone Zone C
Plan Name Geo Plan
Age of the Insured Person 1 (Years) 39
Age of the Insured Person 2 (Years) 36
Age of the Insured Person 3 (Years) 7
Sum Insured opted under the Policy (Rs.) 5 Lacs
Plan Type Family Floater
Policy Tenure (years) 1
Total number of Insured Persons covered under the Policy 3
Net Premium paid (without Tax) - For all insured persons 12182
Wellness Category (post Health Risk Assessment) for adult Insured 1 Green
Wellness Category (post Health Risk Assessment) for adult Insured 2 Green

For adult Insured 1

Wellness Wellness Wellness Reward Wellness Reward valid up
Reward earned Reward credited after to 365 days (provided the
Healthy Day converted to Healthy Day Policy is active and
(per day by
Insured 1) Monetary Value Insured Person is
(per day) covered)
Date of credit of 365 days from the Date of
1 to 300 day 10 4.06 Wellness score credit of Wellness score

Date of Policy 365 days from:

301 day Anniversary - in case - Date of Policy
onwards 10 4.06 of Multi year Policy Anniversary - in case of
Date of Renewal - in Multi year Policy
case of 1 yr Policy - Date of Renewal - in case
of 1 yr Policy, as applicable
Maximum Total in a Policy 1482.14
Year

For adult Insured 2

Date of Policy 365 days from:

Steps to register for Wellness Program and • Activities completed on a calendar day
earn & spend Wellness Rewards will be considered as a Healthy Day
and reward will be credited to Insured
Step 1. Register yourself on customer
Person’s wellness account.
application
Step 4. Convert Healthy Day into monetary
• The Insured Person will download
value and spend
TATA AIG customer application on
Your device and complete registration • Insured Person will have an option to
process by providing Policy and convert the accumulated rewards into
Insured Person’s details. the monetary value and spend it on
items/ services offered under the
Step 2. Complete health risk assessment
Policy
• Submit response to the online health
• The unutilized rewards will be carried
questionnaire on Your device.
forward to next Policy Year till this
• On completion of the health risk Policy is renewed with Us within
assessment, a Wellness category will Grace Period and is inforce subject to
be assigned to the Insured Person for validity period of the reward point)
the Policy Year and will be updated
Disclaimer Clause (applicable to B14, B15
based on the latest health risk
& B16)
assessment in next Policy Year.
1. Availing the services under this benefit
Step 3. Comply with mechanism to earn
is purely upon the Insured Person’s
Wellness Rewards
sole discretion and risk.
• We will track the physical exercise and
2. For services that are provided through
fitness activities completed by the
empanelled service providers, We are
Insured Person, through the
acting as a facilitator; hence would not
customer app.
be liable for any incremental costs or
16

the services. Any additional services consultation.

availed, or expenses incurred on such 7. Any advice, recommendations or
services or benefits which are other suggestions made by any medical
than those covered under this Policy professional shall be solely based on
and explicitly excluded by this Policy, the information and documentation
shall not be covered under this Policy provided by the Insured Person to
and all expenses incurred shall be such medical professional. We shall
borne by the Insured Person. not be liable towards any loss or
3. We shall not be responsible for or damage (immediate or consequential)
liable for, any actions, claims, arising out of or in relation to any
demands, losses, damages, costs, opinion, advice, prescription, actual or
charges and expenses which Insured alleged errors, omissions and
Person claims to have suffered, representations made by the medical
sustained or incurred, by way of and / professional from whom We have
or on account of the benefit. We shall availed services or taken benefit or for
not be liable for any deficiency or any consequence of any act or
discrepancy in the services provided omission in reliance thereon.
by empanelled service provider under 8. We at Our discretion may provide
this Policy. discounts on any of the above services
4. Insured Person may consult any which may vary from time to time
medical professional at any subject to IRDAI regulations
empanelled service provider at its sole 9. Any discount offered under
discretion. The cost of service arising redeemable voucher/discount on
out of Insured Person choice of services by Our empanelled service
medical professional at any providers are subject to modification
empanelled service provider shall be or withdrawal. We do not assume any
completely borne by the Insured liability towards the quantum of
Person unless covered otherwise. discount, quality of product/services
However, the services under this and timeline within which the
Policy should not be construed to product/service is rendered.
constitute Medical Advice and/or
substitute the Insured Person's visit/ 10. For Ambulance Booking facility–
consultation to an independent a. These services are provided
Medical Practitioner/healthcare through Our empanelled service
professional. provider in select cities. Please
5. The Medical Practitioner may contact Us / refer to Our digital
suggest/recommend/prescribe over customer application for more
the counter medications based on the details on this service.
information provided, if required on a b. We do not assume any liability
case-to-case basis. Provided that any towards quality and turnaround
recommendation under this Policy times of service rendered, any
shall not be valid for any medico legal loss or damage arising out of or
purposes. in relation to these services
6. The Insured Person is free to choose rendered by the empanelled
whether or not to act on the service provider.
recommendation after seeking
17

c. This facility may be availed performance shall not constitute

through Our digital customer breach of contract and the company
application or through calling or the assistance service provider shall
Our call centre on the tollfree have no liability whatsoever including
number specified in the Policy but not limited to any loss or damage
Schedule. resulting therefrom.
11. Above mentioned services are 16. We shall not accept any liability
non-portable, annual contracts, towards quality of the services made
independent of Policy contract and available by service provider. The
not lifelong renewable. The Services service provider is responsible for
provided may be added / deleted / providing the availed services and We
modified at Our discretion and the are not liable for any defects or
same shall be notified to the deficiencies on the part of the service
policyholders in advance prior to provider.
change effective date.
B17. 5X Supercharge Bonus
12. Provision of these services is subject
i. We will provide 5X Supercharge Bonus
to availability as per the duration
in the form of 50% of the base Sum
specified by Us/the empanelled
Insured of the expiring Policy, on
service provider. Details are available
each Renewal of the Policy,
on Our website (www.tataaig.com)
irrespective of claims in preceding
13. Any service availed by the Insured Policy Years, provided that the Policy
Person under this Benefit will not is renewed with Us without a break.
impact Bonus if applicable. The total accrued 5X Supercharge
14. We reserve the right to change any Bonus shall not exceed 500% of the
service provider during the currency base Sum Insured in any Policy Year.
of the Policy or at Renewal. The same ii. In policies with a tenure of more than
shall be intimated to the Insured one year, Bonus shall accrue post
Person atleast 15 days prior to the completion of each Policy Year.
effective date of change. During such
iii. The 5X Supercharge Bonus so accrued
change, all the credits earned by the
will be available only in respect of
Insured Person shall be transferred
those Insured Person(s) who were
to the new service provider.
Insured Person(s) in the previous
15. In case We or the assistance service Policy Year and continue to be
provider fails to provide any of the Insured Person(s) in the subsequent
services as mentioned in this Policy Policy Year.
or is unable to implement, in whole or
iv. For the purpose of computation of 5X
in part due to force majeure,
Supercharge Bonus, the percentage
non-availability of services, change in
(%) of Bonus will be applied on the
law, rule or regulations which affects
Sum Insured of the expiring Policy
the services, or if any regulatory or
only. The Restore Benefit amount or
governmental agency having
the Restore Infinity amount (if opted)
jurisdiction over a party takes a
will not be taken into consideration for
position which affects the services ,
such computation.
then the assistance services’
suspended, curtailed or limited v. Any accrued 5X Supercharge Bonus
18

can only be utilized for an admissible

C4 Preventive Only at Inception of first
claim under benefit B1 to B8 and
Annual Health Policy /coverage
Optional Cover C3 if opted. Check-Up
vi. In case the Sum Insured under the Only at Inception of first
C5 Advanced Cover
Policy is reduced at the time of Policy /coverage
Renewal then the accrued 5X
Supercharge Bonus under this benefit C6 Accidental At Inception of first Policy
Death Benefit /coverage OR Renewal
shall be reduced in proportion to the
reduced Sum Insured.
C1. Restore Infinity
vii. 5X Supercharge Bonus will lapse if the
Policy is not renewed before Policy We will provide reinstatement of Sum
expiry (including the Grace Period). Insured unlimited number of times during a
Policy Year post exhaustion of the Restore
Optional Covers Benefit, as mentioned under B9 of this
The Optional Cover(s) can only be opted along Policy to pay an admissible Hospitalization
with the base covers under the Policy and cannot claim, subject to below conditions:
be opted in isolation or as a separate product. The a. Our maximum liability in aggregate
Optional cover(s) are provided as per the table for all claims arising out of a single
given below on payment of additional premium or Hospitalization shall not exceed the
discounts and subject to the terms and conditions Sum Insured.
and exclusions as stated in the Policy Terms and
Conditions and Exclusions. These Optional b. Claims falling under B1 to B4 shall be
Cover(s), if selected, should be opted for all only admissible under this optional
Insured Persons to be covered under the Policy cover.
unless stated otherwise and shall be available c. All other provisions and conditions
only if the same are specifically mentioned in the mentioned under B9 of this Policy
Policy Schedule. shall be applicable.
The insurance provided under these Optional d. This optional cover will not be
cover(s) are only with respect to such and so available for claims arising out of any
many of the coverages as are indicated in the type of Cancer Treatment &/or
Policy Schedule. Dialysis.
The availability of optional cover(s) shall be as per e. In the event of Portability, coverage
the grid below and once opted they will have to be for any Illness/Disease/Injury, which
mandatorily covered at each Renewal. falls under Section-3.i sub-section 1(i)
or (ii) or (iii) shall be available only after
S. Benefits Can be availed by the the Insured Person(s) has been
No. policyholder/Insured continuously covered under this
Person Policy for the respective waiting
C1 Restore Infinity Only at Inception of first periods as mentioned in the
Policy /coverage respective clauses.
C2 Emergency Air At Inception of first C2. Emergency Air Ambulance Cover
Ambulance Policy /coverage OR
Cover Renewal We will reimburse cost of air ambulance for
C3 Consumables Only at Inception of first transportation of the Insured Person in an
benefit Policy /coverage airplane or helicopter subject to maximum

of limit as speciﬁed in the Policy Schedule Medical Practitioner shall be excluded.

per Policy Year for Emergency Care of
For this benefit to be payable, there must be
life-threatening health conditions which
an admissible claim under B1 or B4 of this
require immediate and rapid ambulance
Policy. The assessment of payout under this
transportation to a Hospital for further
Optional Cover shall follow the assessment
medical management.
of claim done under B1 and B4 except for
The medical evacuation should be application of Associated Medical
prescribed by a Medical Practitioner and Expenses.
should be Medically Necessary.
C4. Preventive Annual Health Check-Up
This benefit shall only be payable if We have
Notwithstanding the exclusion mentioned
accepted an inpatient Hospitalization
under Section 3.ii (Specific
claim for the Insured Person under B1 of
Exclusions).1.(viii), At the request of the
this Policy and the transportation is carried
Insured Person, We/ Our empanelled
out within India.
service provider will arrange for below listed
This benefit has a separate limit (over and medical tests every Policy Year provided
above base Sum Insured). the Policy is in force with Us. The health
check-ups shall be arranged by Us only on
The Sum Insured as mentioned shall be on
cashless basis either at Our empanelled
a floater basis for all Insured Persons on a
service providers or at Insured Person’s
per Policy Year basis.
residence, as per availability.
For the purpose of this Optional Cover
Health Check Up will be available for all
Emergency Care means management for an
Insured Persons covered under the Policy
Illness or Injury which results in symptoms
irrespective of claim. Check-ups under this
which occur suddenly and unexpectedly,
benefit can be availed once in a Policy Year.
and requires immediate care by a Medical
Practitioner to prevent death or serious List of tests:
long term impairment of the Insured
a. Complete Blood Count with
Person’s health.
Erythrocyte Sedimentation Rate (CBC
C3. Consumables Benefit with ESR) test
Notwithstanding the exclusion mentioned b. Fasting Blood Sugar Test
under Section 3.ii (Specific Exclusions).1.(xi),
c. Hemoglobin A1C Test (Hba1c)
if this specific optional cover has been
opted, then We will pay for expenses d. Lipid Profile Test
incurred, for specified consumables, subject e. Liver Function Test
to balance Sum Insured, which are
mentioned in Annexure I – List I of optional f. Electrocardiogram (ECG) Test
items available on Our website g. Urine Routine Analysis
(www.tataaig.com) which are consumed
during the period of Hospitalization For the purpose of this benefit, Preventive
directly related to the Insured Person’s Health Check-up means the above medical
medical or surgical treatment of test(s) undertaken for general assessment
Illness/disease/Injury. of health status and does not include any
diagnostic or investigative medical tests for
However, any item which is i) neither a evaluation of Illness or a disease.
medical consumable; ii) nor medically
necessary; iii) nor prescribed by the treating C5. Advanced Cover
20

In lieu of the policyholder opting for this above mentioned Pre-Existing Disease.
Advanced Cover and paying additional
C6. Accidental Death Benefit
premium for the specific Insured Person(s),
the word “48 months” should be read as “30 In case an Insured Person suffers an
days” under Section3 (i) subsection 1(i) only Accident during the Policy Period and this
for the following named Pre-Existing is the sole and direct cause of his death
Diseases: within 365 days from the date of Accident,
then We will pay the Sum Insured as
a) Diabetes Mellitus (Type 2),
mentioned against the respective Insured
b) Hypertension, Person in the Policy Schedule. This benefit
is not applicable for insured children or
c) Hyperlipidemia &
Insured Person less than 18 years of Age as
d) Asthma on Policy commencement date.
The above substitution shall only be This benefit has a separate limit (over and
applicable for such specified Insured above base Sum Insured).
Person(s) for whom ‘Advanced Cover’ has
Section 3 – Exclusions
been opted and additional premium paid,
which shall be specified in the Policy We will neither be liable nor make any payment
Schedule. for any claim in respect of any Insured Person
which is caused by, arising from or in any way
The above would be applicable if the
attributable to any of the following exclusions.
above-named Pre-Existing Diseases have
been declared by You for the specific i. Standard Exclusions
Insured Person for whom this coverage has
1. Exclusions with waiting periods
been opted and the same has been
accepted by Us at the time of first coverage i. Pre-Existing Diseases Waiting Period
under this Policy. (Code- Excl 01):
The additional premium charged under this a. Expenses related to the treatment of a
optional cover shall be a rate applied on the Pre-Existing Disease (PED) and its
applicable base premium for that individual direct complications shall be excluded
at the Policy inception or on the Policy until the expiry of 48 months of
Renewal date. continuous coverage after the date of
inception of the first Policy with Us.
In case of Portability, the “30 days” as
mentioned above should be read as “0 b. In case of enhancement of Sum
Days” and waiver of waiting period for the Insured the exclusion shall apply
above named four Illnesses shall be afresh to the extent of Sum Insured
restricted to the lower of the expiring Sum increase.
Insured or opted Sum Insured under this c. If the Insured Person is continuously
Policy, provided the above named covered without any break as defined
Pre-Existing Diseases had been declared under the Portability norms of the
by You at the time of applying for the first extant IRDAI (Health Insurance)
Policy and mentioned as accepted under Regulations, then waiting period for
the expiring ported/Our Policy. the same would be reduced to the
If this optional cover is availed under the extent of prior coverage.
Policy then it has to be mandatorily opted d. Coverage under the Policy after the
for all Insured Persons who have any of the expiry of 48 months for any
21

Pre-Existing Disease is subject to the IV. Rheumatism

same being declared at the time of
V. Ligament, Tendon or Meniscal tear
application and accepted by Us.
VI. Prolapsed Inter-Vertebral Disc
ii. Specified Disease/Procedure Waiting
Period (Code- Excl 02): VII. Cholelithiasis
a. Expenses related to the treatment of VIII. Pancreatitis
the listed Conditions, IX. Fissure/fistula in anus, haemorrhoids,
surgeries/treatments shall be pilonidal sinus
excluded until the expiry of 24 months
of continuous coverage after the date X. Ulcer & erosion of stomach &
of inception of the first Policy with Us. duodenum
This exclusion shall not be applicable XI. Gastro Esophageal Reflux Disorder
for claims arising due to an Accident. (GERD)
b. In case of enhancement of Sum XII. Liver Cirrhosis
Insured, the exclusion shall apply
afresh to the extent of Sum Insured XIII. Perineal Abscesses
increase. XIV. Perianal / Anal Abscesses
c. If any of the specified XV. Calculus diseases of Urogenital
disease/procedure falls under the system Example: Kidney stone,
waiting period specified for Urinary bladder stone.
Pre-Existing Diseases, then the
XVI. Benign Hyperplasia of prostate
longer of the two waiting periods shall
apply. XVII. Varicocele
d. The waiting period for listed XVIII. Cataract, Retinal detachment,
conditions shall apply even if Glaucoma
contracted after the Policy or
XIX. Congenital Internal Diseases
declared and accepted without a
specific exclusion. List of procedure/surgeries/treatments:
e. If the Insured Person is continuously XX. Adenoidectomy
covered without any break as defined XXI. Mastoidectomy
under the applicable norms on
Portability stipulated by IRDAI, then XXII. Tonsillectomy
waiting period for the same would be XXIII. Tympanoplasty
reduced to the extent of prior
coverage. XXIV. Surgery for nasal septum deviation

List of Speciﬁc XXV. Nasal concha resection

disease/conditions/treatments: XXVI. Surgery for Turbinate hypertrophy
I. Tumors, Cysts, polyps including breast XXVII. Hysterectomy
lumps (benign)
XXVIII. Osteoarthritis, joint replacement,
II. Polycystic ovarian disease, osteoporosis,
Fibromyoma, Adenomyosis,
XXIX. Systemic connective tissue disorders,
Endometriosis
inﬂammatory polyarthropathies,
III. Prolapsed Uterus Rheumatoid, Gout
22

XXX. Cholecystectomy care such as help with activities

of daily living such as bathing,
XXXI. Hernioplasty or Herniorraphy
dressing, moving around either
XXXII. Surgery/procedure for Benign by skilled nurses or assistant or
prostate enlargement non-skilled persons.
XXXIII.Surgery for Hydrocele/ ii. Any services for people who are
Rectocele/Spermatocele terminally ill to address physical,
XXXIV.Surgery of varicose veins and social, emotional and spiritual
varicose ulcers needs.

iii. 30 Days Waiting Period (Code- Excl 03): iii. Obesity/ Weight Control (Code- Excl 06):

a. Expenses related to the treatment of Expenses related to surgical treatment of

any Illness within 30 days from the obesity that does not fulﬁl the below
ﬁrst Policy commencement date shall conditions:
be excluded except claims arising due a. Surgery to be conducted is upon the
to an Accident, provided the same are advice of the Doctor.
covered.
b. The Surgery/Procedure conducted
b. This exclusion shall not, however, should be supported by clinical
apply if the Insured Person has protocols.
Continuous Coverage for more than
c. The member has to be 18 years of Age
twelve months.
or older and
c. The within referred waiting period is
d. Body Mass Index (BMI);
made applicable to the enhanced Sum
Insured in the event of granting i. greater than or equal to 40 or
higher Sum Insured subsequently.
ii. greater than or equal to 35 in
2. Medical Exclusions conjunction with any of the
following severe co-morbidities
i. Investigation and evaluation (Code- Excl
following failure of less invasive
04):
methods of weight loss:
a. Expenses related to any admission
1. Obesity-related cardiomyopathy
primarily for diagnostics and
evaluation purposes only are 2. Coronary heart disease
excluded.
3. Severe Sleep Apnea
b. Any diagnostic expenses which are not
4. Uncontrolled Type2 Diabetes
related or not incidental to the current
diagnosis and treatment are excluded. iv. Change-of-Gender treatments: Code-
Excl07:
ii. Rest cure, rehabilitation and respite care
(Code- Excl 05): Expenses related to any treatment,
including surgical management, to change
a. Expenses related to any admission
characteristics of the body to those of the
primarily for enforced bed rest and
opposite sex.
not for receiving treatment. This also
includes: v. Cosmetic or Plastic Surgery (Code- Excl
08):
i. Custodial care either at home or
in a nursing facility for personal Expenses for cosmetic or plastic Surgery or
23

any treatment to change appearance unless advanced reproductive technologies

for reconstruction following an Accident, such as IVF, ZIFT, GIFT, ICSI
Burn(s) or Cancer or as part of Medically
iii. Gestational Surrogacy
Necessary Treatment to remove a direct
and immediate health risk to the Insured iv. Reversal of sterilization
Person. For this to be considered a medical xii. Maternity (Code - Excl 18):
necessity, it must be certiﬁed by the
attending Medical Practitioner. 1. Medical treatment expenses traceable
to childbirth (including complicated
vi. Treatment for, Alcoholism, drug or deliveries and caesarean sections
substance abuse or any addictive condition incurred during Hospitalization)
and consequences thereof (Code- Excl 12). except ectopic pregnancy;
vii. Treatments received in health hydros, 2. Expenses towards miscarriage (unless
nature cure clinics, spas or similar due to an Accident) and lawful
establishments or private beds registered medical termination of pregnancy
as a nursing home attached to such during the Policy Period.
establishments or where admission is
arranged wholly or partly for domestic 3. Non-Medical Exclusions
reasons. (Code- Excl13) i. Hazardous or Adventure
viii. Dietary supplements and substances that Sports (Code- Excl 09):
can be purchased without prescription, Expenses related to any
including but not limited to Vitamins, treatment necessitated due to
minerals and organic substances unless participation as a professional in
prescribed by a Medical Practitioner as hazardous or adventure sports,
part of Hospitalization claim or day care including but not limited to,
procedure. (Code-Excl14) para-jumping, rock climbing,
ix. Refractive error (Code- Excl 15): Expenses mountaineering, rafting, motor
related to the treatment for correction of racing, horse racing or scuba
eye sight due to refractive error less than 7.5 diving, hand gliding, sky diving,
dioptres. deep-sea diving.

x. Unproven treatments (Code- Excl 16): ii Breach of law (Code- Excl 10):

Expenses related to any Unproven Expenses for treatment directly

Treatment, services and supplies for or in arising from or consequent upon
connection with any treatment. Unproven any Insured Person committing
treatments are treatments, procedures or or attempting to commit a
supplies that lack signiﬁcant medical breach of law with criminal
documentation to support their intent.
eﬀectiveness. iii. Excluded Providers: (Code-Excl
xi. Sterility and Infertility (Code- Excl 17): 11):

Expenses related to Sterility and infertility. Expenses incurred towards

This includes: treatment in any Hospital or by
any Medical Practitioner or any
i. Any type of contraception, sterilization other provider specifically
ii. Assisted Reproduction services excluded by the Insurer and
including artificial insemination and disclosed in its website / notified
24

to the Policyholders are not ix. Cost of dentures, dental

admissible. However, in case of implants and braces; Dental
life-threatening situations or Treatment or Dental Surgery of
following an Accident, expenses any kind unless incidental to an
up to the stage of stabilization admissible Hospitalization
are payable but not the claim where the cause of
complete claim. admission is Accident;
ii. Specific Exclusions (Exclusions other x. Any existing disease specifically
than as those mentioned under Section 3 mentioned as Permanent
(i) subsection 1, 2 &3 above) exclusion in the Policy
Schedule.
We will neither be liable nor make any
payment for any claim in respect of any xi. Non payable items as mentioned
Insured Person which is caused by, arising in Annexure I – List I of optional
from or in any way attributable to any of the items available on Our website
following exclusions. (www.tataaig.com)
1. Medical Exclusions 2. Non-Medical Exclusions
i. Alcoholic pancreatitis or i. War or any act of war, invasion,
Alcoholic liver disease; act of foreign enemy, war like
operations (whether war be
ii. Congenital External Diseases,
declared or not) or caused
defects or anomalies;
during service in the armed
iii. Stem cell therapy; however, forces of any country, civil war,
hematopoietic stem cells for public defence, rebellion,
bone marrow transplant for revolution, insurrection, military
haematological conditions will or usurped acts, nuclear
be covered under this Policy, weapons/materials, chemical
subject to applicable and biological weapons, ionising
Sub-Limits; radiation.
iv. Growth Hormone Therapy; ii. Nuclear, chemical or biological
v. Sleep-apnoea and Sleeping attack or weapons, contributed
disorder; to, caused by, resulting from or
from any other cause or event
vi. Admission primarily for contributing concurrently or in
administration (via any form or any other sequence to the loss,
mode) of immunoglobulin claim or expense. For the
infusion or supplementary purpose of this exclusion:
medications like Zolendronic
Acid, etc; • Nuclear attack or weapons
means the use of any
vii. Venereal disease, sexually nuclear weapon or device
transmitted disease or Illness; or waste or combustion of
viii. All preventive care including nuclear fuel or the
Health Check-ups, vaccination emission, discharge,
including inoculation and dispersal, release or escape
immunisations; of fissile/ fusion material
emitting a level of
25

radioactivity capable of products and bath additive,

causing any Illness, barber or beauty service, guest
incapacitating disablement service.
or death
vi. Treatment rendered by a
• Chemical attack or Medical Practitioner which is
weapons means the outside his discipline.
emission, discharge,
vii. Doctor’s fees charged by the
dispersal, release or escape
Medical Practitioner sharing
of any solid, liquid or
the same residence as an
gaseous chemical
Insured Person or who is an
compound which, when
immediate relative of an
suitably distributed, is
Insured Person's family.
capable of causing any
Illness, incapacitating viii. Hearing aids, spectacles or
disablement or death. contact lenses, etc. including
optometric therapy.
• Biological attack or
weapons means the ix. Any treatment and associated
emission, discharge, expenses for alopecia, baldness,
dispersal, release or escape wigs or toupees, medical
of any pathogenic (disease supplies including elastic
p r o d u c i n g ) stockings, diabetic test strips
micro-organisms and/or and similar products.
biologically produced toxins x. Any treatment or part of a
(including genetically treatment that does not form
modified organisms and part of ‘Reasonable and
chemically synthesized Customary Charges’, nor is
toxins) which are capable of medically necessary;
causing any Illness,
incapacitating disablement xi. Expenses which are either not
or death. supported by a prescription of a
Medical Practitioner or are not
iii. Any Insured Person’s related to Illness or disease for
participation or involvement in which claim is admissible under
naval, military or air force the Policy.
operation.
xii. Any external appliance and/or
iv. Intentional self-Injury or device used for diagnosis or
attempted suicide while sane or treatment except when used
insane. intra-operatively.
v. Items of personal comfort and xiii. Any Illness diagnosed or Injury
convenience like television sustained or where there is
(wherever specifically charged change in health status of the
for), charges for access to member after date of proposal
telephone and telephone calls, and before commencement of
internet, foodstuffs (except Policy and the same is not
patient’s diet), cosmetics, communicated and accepted by
hygiene articles, body care Us.
26

Section 4 – General Terms and Clauses the earliest, in any case not later
than 30 days from the date of
i. Standard General Terms & Clauses
receipt of last necessary
1. Disclosure of Information document. In such cases, the
The Policy shall be void and all Company shall settle or reject
premium paid thereon shall be the claim within 45 days from
forfeited to the Company in the event the date of receipt of last
of misrepresentation, misdescription necessary document.
or non-disclosure of any material fact iv. In case of delay beyond
by the policyholder. stipulated 45 days, the Company
(Explanation: "Material facts" for the shall be liable to pay interest to
purpose of this Policy shall mean all the policyholder at a rate 2%
relevant information sought by the above the bank rate from the
company in the proposal form and date of receipt of last necessary
other connected documents to enable document to the date of
it to take informed decision in the payment of claim.
context of underwriting the risk) (Explanation: "Bank rate" shall
2. Condition Precedent to Admission of mean the rate fixed by the
Liability Reserve Bank of India (RBl) at the
beginning of the financial year in
The terms and conditions of the Policy which claim has fallen due).
must be fulfilled by the Insured
Person for the Company to make any 4. Complete Discharge
payment for claim(s) arising under the Any payment to the policyholder,
Policy. Insured Person or his/ her nominees
3. Claim Settlement (provision for Penal or his/ her legal representative or
Interest) assignee or to the Hospital, as the
case may be, for any benefit under the
i. The Company shall settle or Policy shall be a valid discharge
reject a claim, as the case may towards payment of claim by the
be, within 30 days from the date Company to the extent of that amount
of receipt of last necessary for the particular claim.
document.
5. Multiple Policies
ii. In the case of delay in the
payment of a claim, the i. In case of multiple policies taken
Company shall be liable to pay by an Insured Person during a
interest to the policyholder from period from one or more
the date of receipt of last Insurers to indemnify treatment
necessary document to the date costs, the Insured Person shall
of payment of claim at a rate 2% have the right to require a
above the bank rate. settlement of his/her claim in
terms of any of his/her policies.
iii. However, where the In all such cases the Insurer
circumstances of a claim warrant chosen by the Insured Person
an investigation in the opinion of shall be obliged to settle the
the Company, it shall initiate and claim as long as the claim is
complete such investigation at within the limits of and
27

according to the terms of the policyholder(s), who has made that

chosen Policy. particular claim, who shall be jointly
and severally liable for such
ii. Insured Person having multiple
repayment to the Insurer.
policies shall also have the right
to prefer claims under this For the purpose of this clause, the
Policy for the amounts expression "fraud" means any of the
disallowed under any other following acts committed by the
Policy / policies even if the Sum Insured Person or by his agent or the
Insured is not exhausted. Then Hospital/doctor/any other party
the Insurer shall independently acting on behalf of the Insured
settle the claim subject to the Person, with intent to deceive the
terms and conditions of this Insurer or to induce the Insurer to
Policy. issue an insurance Policy:
iii. If the amount to be claimed a) the suggestion, as a fact of that
exceeds the Sum Insured under which is not true and which the
a single Policy, the Insured Insured Person does not
Person shall have the right to believe to be true;
choose Insurer from whom b) the active concealment of a fact
he/she wants to claim the by the Insured Person having
balance amount. knowledge or belief of the fact;
iv. Where an Insured Person has c) any other act fitted to deceive;
policies from more than one and
Insurer to cover the same risk
d) any such act or omission as the
on indemnity basis, the Insured law specially declares to be
Person shall only be fraudulent.
indemnified the treatment costs
in accordance with the terms The Company shall not repudiate the
and conditions of the chosen claim and / or forfeit the Policy
Policy. benefits on the ground of Fraud, if the
Insured Person / beneficiary can
6. Fraud prove that the misstatement was true
If any claim made by the Insured to the best of his knowledge and there
Person, is in any respect fraudulent, was no deliberate intention to
or if any false statement, or suppress the fact or that such
declaration is made or used in support misstatement of or suppression of
thereof, or if any fraudulent means or material fact are within the knowledge
devices are used by the Insured of the Insurer.
Person or anyone acting on his/her 7. Cancellation
behalf to obtain any benefit under this i. The policyholder may cancel this
Policy, all benefits under this Policy Policy by giving 15 days written
and the premium paid shall be notice and in such an event, the
forfeited. Company shall refund premium
Any amount already paid against for the unexpired Policy Period
claims made under this Policy but as detailed below.
which are found fraudulent later shall
be repaid by all recipient(s) /
28

Policy Period option to migrate the Policy to other

Length of time health insurance products/plans
Policy in force offered by the company by applying
1 Year 2 Years 3 Years
for Migration of the Policy at least 30
Upto 1 Month 75.00% 87.50% 91.5% days before the Policy Renewal date
>1 month & Upto 50.00% 75.00% 88.5% as per IRDAI guidelines on Migration.
3 Months lf such person is presently covered
>3 months & Upto 25.00% 62.50% 75% and has been continuously covered
6 Months without any lapses under any health
>6 months & Upto Nil 50.00% 66.5% insurance product/plan offered by the
12 Months company, the Insured Person will get
>12 months & Upto Not 25% 50% the accrued continuity benefits in
15 Months Applicable waiting periods as per IRDAI
guidelines on Migration.
>15 months & Upto Not 12.5% 41.5%
18 Months Applicable For Detailed Guidelines on Migration,
>18 months & Upto Not Nil 33% kindly refer Guidelines issued by IRDAI
24 months Applicable (Insurance Regulatory and
Development Authority of India) on
>24 months & Upto Not Not 8%
30 months Applicable Applicable Consolidated Guidelines on Product
Filing in Health Insurance Business –
Exceeding Not Not Nil Ref: IRDAI/HLT/REG/CIR/194/07/2020)
30 months Applicable Applicable
dated 22nd July 2020 and subsequent
amendments thereof.
Notwithstanding anything
contained herein or otherwise, 9. Portability
no refunds of premium shall be The Insured Person will have the
made in respect of Cancellation option to port the Policy to other
where, any claim has been insurers by applying to such Insurer
admitted or has been lodged or to port the entire Policy along with all
any benefit under this Policy the members of the family, if any, at
has been availed by the Insured least 45 days before, but not earlier
Person under the Policy. than 60 days from the Policy Renewal
ii. The Company may cancel the date as per IRDAI guidelines related to
Policy at any time on grounds of Portability. If such person is presently
misrepresentation covered and has been continuously
non-disclosure of material facts, covered without any lapses under any
fraud by the Policyholder/ health insurance Policy with an Indian
Insured Person by giving 15 General/Health Insurer, the proposed
days' written notice. There Insured Person will get the accrued
would be no refund of premium continuity benefits in waiting periods
on cancellation on grounds of as per IRDAI guidelines on Portability.
misrepresentation, For Detailed Guidelines on
non-disclosure of material facts Portability, kindly refer Guidelines
or fraud. issued by IRDAI (Insurance Regulatory
8. Migration and Development Authority of India)
on Consolidated Guidelines on
The Insured Person will have the Product Filing in Health Insurance
29

Business – Ref: health insurance product

IRDAI/HLT/REG/CIR/194/07/2020) available with the Company at
dated 22nd July 2020 and subsequent the time of Renewal with all the
amendments thereof. accrued continuity benefits such
as 5X Supercharge Bonus,
10. Renewal of Policy
waiver of waiting period as per
The Policy shall ordinarily be IRDAI guidelines, provided the
renewable except on grounds of Policy has been maintained
fraud, misrepresentation by the without a break.
Insured Person.
12. Moratorium Period
i. The Company shall endeavor to
After completion of eight continuous
give notice for Renewal.
years under the Policy no look back to
However, the Company is not
be applied. This period of eight years
under obligation to give any
is called as moratorium period. The
notice for Renewal.
moratorium would be applicable for
ii. Renewal shall not be denied on the sums insured of the first Policy
the ground that the Insured and subsequently completion of 8
Person had made a claim or continuous years would be applicable
claims in the preceding Policy from date of enhancement of sums
Years. insured only on the enhanced limits.
iii. Request for Renewal along with After the expiry of Moratorium Period
requisite premium shall be no health insurance claim shall be
received by the Company before contestable except for proven fraud
the end of the Policy Period. and permanent exclusions specified in
the Policy contract. The policies would
iv. At the end of the Policy Period, however be subject to all limits,
the Policy shall terminate and Sub-Limit, Co-Payments, Aggregate
can be renewed within the Deductibles as per the Policy
Grace Period of 30 days to contract.
maintain continuity of benefits
without break in Policy. 13. Possibility of Revision of Terms of the
Coverage is not available during Policy Including the Premium Rates
the Grace Period. The Company, with prior approval of
v. No loading shall apply on IRDAI, may revise or modify the terms
Renewals based on individual of the Policy including the premium
claims experience. rates. The Insured Person shall be
notified three months before the
11. Withdrawal of Policy changes are effected.
i. In the likelihood of this product 14. Free look period
being withdrawn in future, the
Company will intimate the The Free Look Period shall be
Insured Person about the same applicable on new individual health
90 days prior to expiry of the insurance policies and not on
Policy. Renewals or at the time of
porting/migrating the Policy.
ii. Insured Person will have the
option to migrate to similar The Insured Person shall be allowed
free look period of fifteen days from
30

date of receipt of the Policy document inform You of the same through an
to review the terms and conditions of interim reply.
the Policy, and to return the same if
Escalation Level 1
not acceptable.
For lack of a response or if the resolution
If the Insured Person has not made
still does not meet Your expectations, You
any claim during the Free Look Period,
can write to
the Insured Person shall be entitled
manager.customersupport@tataaig.com.
to
After investigating the matter internally and
i. a refund of the premium paid subsequent closure, We will send Our
less any expenses incurred by response within a period of 8 days from the
the Company on medical date of receipt at this email id.
examination of the Insured
Escalation Level 2
Person and the stamp duty
charges or For lack of a response or if the resolution
still does not meet Your expectations, You
ii. where the risk has already
can write to the Head - Customer Services at
commenced and the option of
head.customerservices@tataaig.com After
return of the Policy is exercised
examining the matter, We will send You
by the Insured Person, a
Our final response within a period of 7 days
deduction towards the
from the date of receipt of Your complaint
proportionate risk premium for
on this email id. Within 30 days of lodging a
period of cover or
complaint with Us, if You do not get a
iii. Where only a part of the satisfactory response from Us and You wish
insurance coverage has to pursue other avenues for redressal of
commenced, such proportionate grievances, You may approach Insurance
premium commensurate with Ombudsman appointed by IRDAI under the
the insurance coverage during Insurance Ombudsman Scheme.
such period.
16. Nomination
15. Redressal of Grievance
The policyholder is required at the
The Company is committed to extend inception of the Policy to make a
the best possible services to its nomination for the purpose of
customers. However, if You are not payment of claims under the Policy in
satisfied with Our services and wish to the event of death of the policyholder.
lodge a complaint, please feel free to Any change of nomination shall be
call Our 24X7 Toll free number communicated to the company in
<<1800-266-7780 or 022-66939500>> writing and such change shall be
(tolled) or You may email to the effective only when an endorsement
customer service desk at on the Policy is made. In the event of
customersupport@tataaig.com. After death of the policyholder, the
investigating the matter internally and Company will pay the nominee {as
subsequent closure, We will send Our named in the Policy
response within a period of 10 days Schedule/Endorsement (if any)} and
from the date of receipt of the in case there is no subsisting nominee,
complaint by the Company or its office to the legal heirs or legal
in Mumbai. In case the resolution is representatives of the policyholder
likely to take longer time, We will whose discharge shall be treated as
31

full and ﬁnal discharge of its liability counter oﬀer letter.

under the Policy.
c. In case, You neither accept
ii. Specific terms and clauses (terms and the counter offer nor revert
clauses other than those mentioned to Us within 15 days, We
under Section 4 (i) above) shall cancel Your
application and refund the
17. Insured Person
premium paid within next
i. Only those persons named as an 10 days subject to
Insured Person in the Schedule deduction of the Pre-Policy
shall be covered under this Check up charges, as
Policy. applicable.
ii. Any eligible person may be iv. Please note that We will issue
added during the Policy Period Policy only after getting Your
after his proposal has been consent.
accepted by Us, additional
19. Entire Contract
premium has been paid and We
have issued an endorsement i. This Policy, its Schedule,
confirming the addition of such endorsement(s), proposal
person as an Insured Person. constitutes the entire contract of
insurance. No change in this
18. Risk Loadings
Policy shall be valid unless
i. We may apply a risk loading on approved by Us and such
the premium payable (based approval be endorsed hereon.
upon the declarations made in
ii. This Policy and the Schedule
the proposal and the health
shall be read together as one
status of the persons proposed
contract and any word or
for insurance).
expression to which a specific
ii. The loading shall be applied meaning has been attached in
basis outcome of Our any part of this Policy or of the
underwriting. Schedule shall bear such
iii. These loadings are applied from meaning wherever it may
Commencement Date of the appear.
Policy including subsequent 20. Notices
Renewal(s) with Us or on the
i. Any notice, direction or
receipt of the request of
instruction under this Policy
increase in Sum Insured (for the
shall be in writing and if it is to:
increased Sum Insured).
a. Any Insured Person, then it
a. We will inform You about
shall be sent to You at Your
the applicable risk loading
address specified in the
through a counter offer
Schedule to this Policy and
letter.
You shall act for all Insured
b. You need to revert to Us Persons for these
with consent and additional purposes.
premium (if any), within 15
b. Us, it shall be delivered to
days of the issuance of such
32

Our address speciﬁed in 21. Zone & Applicability of Plan

the Schedule to this Policy.
Premium payable under the ‘Geo Plan’
No insurance agents,
will be computed based on the
brokers or other person or
residential location/address as
entity is authorised to
provided by the proposer/Insured
receive any notice, direction
Person in the proposal form.
or instruction on Our
behalf unless We have Premium to be received by Company
expressly stated to the before Policy Commencement date.
contrary in writing.

The payment of premium and applicability of Plan shall be as per the grid given below:
Plan Available for Premium Network Speciﬁc Co-Payment
Selected insured person(s) Applicable Applicable applicable#
residing in* as per:
Value Plan Anywhere Premium as Valued Provider – 30% Co-Payment if
within India per Value Plan Pan India^ Hospitalization happens
outside Our network of
Valued Provider – Pan
India.
Geo Plan Zone B or Premium as Network Provider 20% Co-Payment if
Zone C per Geo Plan Hospitalization happens
for Zone B or in Zone A. This
Zone C Co-Payment shall be
applied on both, cashless
as well as reimbursement
claims.

*Premium payable under the Policy will be be applicable to the Insured Person, if
computed based on the residential covered under Value Plan. List of Valued
location/address as provided by the Provider – Pan India will be updated from
proposer/Insured Person in the proposal time to time and will be available on Our
form and the plan opted. website www.tataaig.com
# This is over and above any other 22. Premium Refund in case of demise of
Co-Payment applicable under the Policy. the Insured Person
Change from Value Plan to Geo Plan shall The coverage for the Insured
not be permitted. Any change from Geo Person(s) shall automatically
Plan to Value Plan shall only be allowed at terminate in case of his/ her (Insured
the time of Renewal and shall be subject to Person) demise. However, the cover
underwriting. shall continue for the remaining
^For clarity: The “Valued Provider – Pan Insured Persons till the end of Policy
India” network list is diﬀerent from Our Period.
standard list of “Network Provider”. The Provided no claim has been made and
standard list of Network Provider shall not deletion from Policy takes place on
33

account of death of the Insured Event We or Our TPA*

Person during the Policy Period, must be informed:
pro-rata refund of premium of the
1 If any treatment for At least 48 hours
deceased Insured Person for the
which a claim may prior to the Insured
balance period of the Policy will be be made and that Person’s admission/
made. Refund will be made to the treatment requires start of treatment.
Policy holder or the nominee as the p l a n n e d
case may be in case of demise of the Hospitalization/
Policy holder. We would require Day Care
death certificate of the Deceased Treatment/
Insured Person for processing of the AYUSH/ Domiciliary
refund amount. Treatment:
The other Insured Persons may also 2 If any treatment for Within 24 hours of
apply to renew the Policy. In the event which a claim may the Insured Person’s
of change of Proposer, all relevant be made and that admission to
particulars in respect of such person treatment requires Hospital or at the
(including his/her relationship with the e m e r g e n c y time of discharge,
Hospitalization/ whichever is earlier.
Insured Person) must be submitted
Day Care
to the company along with the Treatment
application.
*TPA as mentioned in the Policy Schedule, if applicable
Section 5 – Claims Procedure and Claims
Payment
Timely intimation of claim in Our prescribed
This section explains about the procedure format is a pre-condition for admission of liability.
involved to file a valid claim by the Insured
Person and processes related to assessment, We may waive off this condition in extreme cases
cost sharing and management of the claim. All the of hardship where it is proved to Our satisfaction
procedures and processes such as Notification that under the circumstances in which You were
of Claim, availing cashless service, supporting placed, it was not possible for You or any other
claim documents and related claim terms of person to give notice or file claim within the
payment are explained in this section. prescribed time limit.

a. Notiﬁcation of Claim
Every claim needs to be notiﬁed to Us either
in writing or email or through a call to Our
tollfree number, as mentioned in the Policy
Schedule, within the stipulated timelines as
mentioned below.

b. Cashless Service

Treatment, Taken at: Cashless Service We must be given notice

Consultation or is Available: that the Insured Person
Procedure: wishes to avail cashless
service accompanied by
full particulars:
If any planned Network We will provide cashless At least 48 hours before
treatment, Provider service by making the planned
consultation or payment to the extent of Hospitalization
procedure for which a Our liability directly to
claim may be made: the Network Hospital.

If any treatment, Network We will provide cashless Within 24 hours of the

consultation or procedure Provider service by making Hospitalization and prior
for which a claim may be payment to the extent of to discharge
made, requiring emergency Our liability directly to
Hospitalization the Network Hospital.

c. Procedure for Cashless Service shall be communicated to the

Hospital by TPA/Us within 6
i. Cashless Service is only available at
hours of receipt of the
Our Network Provider/ Valued
documents.
Provider – Pan India, as applicable.
d. In case the ailment /treatment is
ii. In order to avail cashless treatment,
not covered under the Policy or
the following procedure must be
cashless is rejected due to
followed by You:
insuﬃcient documents
a. Prior to taking treatment and/or submitted, a rejection letter
incurring Medical Expenses at a would be sent to the Hospital
Network Hospital, You must call within 6 hours.
Our designated TPA/Us and
e. Rejection of cashless in no way
request pre-authorization.
indicates rejection of the claim.
b. Our designated TPA/We will You are required to submit the
check Your coverage as per the claim along with required
eligibility and send an documents for Us to decide on
authorization letter to the the admissibility of the claim.
provider. You have to provide
f. If the cashless is approved, the
the ID card issued to You along
original bills and evidence of
with any other information or
treatment in respect of the same
documentation that is requested
shall be left with the Network
by the TPA/Us to the Network
Hospital.
Hospital.
g. Pre-authorization does not
c. In case of deﬁciency in the
guarantee that all costs and
documents sent to TPA/Us for
expenses will be covered. We
cashless authorization, the same
35

reserve the right to review each and any attachments thereto

claim for Medical Expenses and like receipts or prescriptions in
accordingly coverage will be support of any amount claimed
determined according to the which will then become Our
terms and conditions of this property.
Policy.
c. All medical reports, case
d. Supporting Documentation & histories, investigation reports,
Examination indoor case papers/ treatment
papers (in reimbursement cases,
i. You or someone claiming on Your
if available), discharge
behalf shall provide Us with
summaries.
documentation, medical records and
information We or Our TPA may d. A precise diagnosis of the
request to establish the circumstances treatment for which a claim is
of the claim, its quantum or Our made.
liability for the claim within 15 days or
e. A detailed list of the individual
earlier of Our request or the Insured
medical services and treatments
Person’s discharge from
provided and a unit price for
Hospitalization or completion of
each in case not available in the
treatment.
submitted Hospital bill.
ii. Failure to furnish such evidence within
f. Prescriptions that name the
the time required shall not invalidate
Insured Person and in the case
nor reduce any claim if You can satisfy
of drugs: the drugs prescribed,
Us that it was not reasonably possible
their price and a receipt for
for You to give proof within such time.
payment. In case of pre/post
iii. We may accept claims where Hospitalization claim
documents have been provided after Prescriptions must be submitted
a delayed interval only in special with the corresponding
circumstances and for the reasons Doctor/Hospital invoice.
beyond the control of the Insured
g. All pre and post investigation,
Person.
treatment and follow up
iv. Such documentation will include the (consultation) records pertaining
following: to the present ailment for which
claim is being made, if and
a. Our claim form, duly completed
where applicable.
and signed for on behalf of the
Insured Person. We, upon h. Treating doctor’s certificate
receipt of a notice of claim, will regarding missing information in
furnish Your representative with case histories e.g. Circumstance
such forms as We may require of Injury and Alcohol or drug
for filing proofs of loss or You influence at the time of
may download the claim form Accident, if available.
from Our Web site. i. Copy of settlement letter from
b. Original Bills (pharmacy other insurance company or
purchase bill, consultation bill, TPA.
diagnostic bill, medical devices) j. Stickers and invoice of implants
36

used during Surgery. make any payment under this Policy

k. Copy of MLC (Medico legal case) unless:
records, if carried out and FIR - We have received all premium
(First information report), if payments in full and in time and
registered, in case of claims
- We have been provided with the
arising out of an Accident and
documentation and information
available with the claimant.
which We or Our TPA has
l. Regulatory requirements as requested to establish the
amended from time to time, circumstances of the claim, its
currently mandatory NEFT (to quantum or Our liability for it,
enable direct credit of claim and
amount in bank account) and
- unless You have complied with
KYC (recent ID/Address proof
Your obligations under this
and photograph) requirements.
Policy.
m. Legal heir/succession certificate,
b. This Policy only covers claims incurred
if required
within India, and payments under this
n. PM report (wherever applicable) Policy shall only be made in Indian
o. The Company reserves the right Rupees within India.
to call for additional documents c. Medical Expenses incurred for AYUSH
wherever required. treatment shall be assessed only
v. Note: In case You are claiming for the under benefit B7 of this policy and
same event under an indemnity based shall be admissible only if incurred
Policy of another Insurer and are within India.^^
required to submit the original d. Where an ailment/ Illness/ disease is
documents related to Your treatment excluded under both exclusions with
with that particular Insurer, then You waiting Periods (as specified under
may provide Us with the attested Section 3 (i) Sub section (1) and under
copies of such documents along with a any other Policy exclusion, then for
declaration from the particular assessment of liability, any expense
Insurer specifying the availability of related to that ailment/ Illness/
the original copies of the specified disease shall not be covered under
treatment documents with it. this Policy.
vi. We at Our own expense, shall have ii. Sequence of applicability & Utilization
the right and opportunity to examine
a. The sequence of assessment of claim
Insured Persons through Our
shall be as per table given below:
Authorised Medical Practitioner
whose details will be notified to
Insured Person when and as often as
We may reasonably require during the
pendency of a claim hereunder.
e. Claims Assessment and Payment
i. General
a. We shall be under no obligation to
37

Steps Assessment Where Age speciﬁc Where Age speciﬁc

Co-Payment is Co-Payment is not
applicable applicable
1 Amount of Claim Intimated √ √
2 Less Non-Payable expenses# √ √
3 =Admissible Expenses √ √
4 Less Associated Medical Expenses as √ √
defined under the Policy (if applicable)
5 =Admissible Claim √ √
6^ If Geo Plan is opted: Less
(Higher Zone Co-Payment* + Age linked (20%*+20%) 20%*
Co-Payment) OR OR
OR
Age linked Co-Payment; 20% 0%
If Value Plan is opted:
Less
(Out of Our network of Valued Provider –
Pan India Co-Payment* as defined in (30%*+20%) 30%*
Policy + Age linked Co-Payment) OR
OR
OR
Age linked Co-Payment 20% 0%
7 =Final Assessed Amount √ √
8 Less Aggregate Deductible (if Opted)** If applicable If applicable
9 =Final Assessed Liability √ √
10 Claim Payable subject to applicable Sub-Limit/ Voluntary Sub-Limit */ Balance
Sum Insured (including accrued 5X
Supercharge Bonus)/ Benefit Limit

# Deduction would vary depending upon whether For claims related to specific ailment/ Surgical
optional cover ‘Consumables Benefit’ is opted. Procedure where either Mandatory Sub-Limit
or Voluntary Sub-Limit (if opted) are applied
^ Depending upon the opted Plan – Value Plan or
during claim assessment, there neither Higher
Geo Plan
Zone Co-Payment nor outside Our network of
* If applicable Valued Provider- Pan India Co-Payment shall
** Aggregate Deductible, if opted, shall be be applicable. However, the Age linked
applicable on aggregate of all claims as assessed Co-Payment shall be applicable.
under the final assessed amount for a given b. The sequence of utilization of benefit
Policy Year. for a claim shall be in the following
The payment of any claim under this Policy shall order:
be subject to Aggregate Deductible (if 1. Sub-Limit subject to balance
applicable), Sub-Limits/benefit limits, balance Sum Insured/Sum Insured (as
Sum Insured and accrued 5X supercharge bonus, applicable),
if available.
38

2. Any accrued 5X Supercharge 4. Restore inﬁnity amount, if

Bonus, if applicable (B17) applicable (C1)
3. Restore beneﬁt amount, if Accidental Death Beneﬁt (C6) shall be
applicable (B9) assessed as per the Sum Insured of the
Optional Cover.
iii. Cost Sharing

A The following four cost sharing methods are mandatory and inbuilt in the Policy
1 Cost Sharing Mechanism Applicability on
2 Age linked Co-Payment Geo Plan & Value Plan
3 Higher Zone Co-Payment Geo Plan
4 Out of Our network of Valued Provider – Value Plan
Pan India Co-Payment
5 Mandatory Sub-Limits Geo Plan (Table I) & Value Plan (Table II)
B The following three cost sharing methods, are optional and applicable if opted by the
policyholder in lieu of which premium discount has been provided. The Optional cost
sharing method, if opted shall be mentioned in the Policy Schedule. Once opted, they shall
mandatorily continue for all the subsequent Renewals of the Policy, provided the Policy is
renewed with Us without any break.
Can be availed by the
Cost Sharing Mechanism Available under
policyholder/Insured
At Inception of first
5 Voluntary Sub-Limits Geo Plan & Value Plan
Policy/coverage OR Renewal
At Inception of first
6 Aggregate Deductible Geo Plan & Value Plan
Policy/coverage OR Renewal
At Inception of first
7 Shared Accommodation Geo Plan Policy/coverage OR Renewal

a. Age linked Co-Payment • if B9, B17 and C1 (if opted)

utilized for payment of claim
If the entry Age of the Insured Person
under aforementioned sections.
is 61 years or above at the time of first
coverage under this Policy, then such This Co-Payment shall not be
Insured Person shall bear 20% of applicable for benefits which are over
each admissible claim (over and above and above the Sum Insured.
any other Co-Payment, if applicable).
Exception to this clause:
This shall be applicable even in
Portability cases, irrespective of This Co-Payment shall not be applicable in
previous coverage. case of Migration from any active TATA AIG
indemnity health Policy to this product
This Co-Payment shall be applicable
provided, entry Age of the Insured Person
for all claims admitted under:
was less than 61 years at the time of first
• B1, B2, B3, B4, B5, B6, B7, B8 and coverage under the first indemnity health
C3 (if opted); and Policy with Us, subject to continuous
39

coverage without any break in the Policy. and the Insured Person avails
treatment outside Our network of
b. Higher Zone Co-Payment^^
“Valued Provider-Pan India”, then a
Wherever, Geo Plan has been opted Co-Payment of 30% will be applicable
and the Insured Person(s) undergoes for each such claim resulting from
medical treatment at a Hospital/ Day admission of the Insured Person in a
Care Centre/ AYUSH Hospital/ Hospital/ Day Care Centre/ AYUSH
AYUSH Day Care Centre in Zone A, Hospital/ AYUSH Day Care Centre.
then an additional Co-Payment of 20% However, no Co-Payment under this
will be applicable on each such claim. sub section shall be applicable if
Higher Zone Co-Payment shall be Hospitalization is for an Injury
applicable for all claims except for arising from an Accident.
claims for emergency Hospitalization For Clarity: This Co-Payment shall be
due to Injury arising from an applicable on claims admitted under:
Accident. Higher Zone Co-Payment
• B1, B4, B6, B7 and C3 (if opted); and
shall not be applicable for beneﬁts
which are over and above the Sum • B9, B17 and C1 (if opted) if utilized for
Insured. payment of claim under
aforementioned sections.
For Clarity: This Co-Payment shall be
applicable on claims admitted under: d. Mandatory Sub-Limits
• B1, B4, B6, B7 and C3 (if opted); and Our liability for any and all claims
related to Hospitalization/ Day Care
• if B9, B17 and C1 (if opted) utilized for
Treatment (including their associated
payment of claim under
Pre & Post Hospitalization expenses)
aforementioned sections.
arising out of following
c. Co-Payment for treatment availed ailments/Surgical Procedures shall
out of Our Network of Valued be restricted to the following
Provider – Pan India^^ Sub-Limits subject to availability of
Wherever, Value Plan has been opted Sum Insured and other terms and
conditions of the Policy.
Table I : Mandatory Sub-Limits applicable for Ailment/Surgical Procedure for Geo Plan (in INR)
Sub-Limit, as applicable to each Insured Person based
(Ailment/Surgical Procedure) on the Sum Insured
5 Lacs 7.5 Lacs 10 Lacs 15 Lacs 20 Lacs
Cataract Surgery (per eye) 40,000 56,000 80,000 120,000 160,000
Balloon Sinuplasty/ FESS 25,000 35,000 50,000 75,000 100,000
Oral chemotherapy 75,000 105,000 150,000 225,000 300,000
Immunotherapy- Monoclonal
125,000 175,000 250,000 375,000 500,000
Antibody all forms
Robotic surgeries 125,000 175,000 250,000 375,000 500,000
Stem cell therapy for
Hematopoietic stem cells for
125,000 175,000 250,000 375,000 500,000
bone marrow transplant for
hematological conditions
40

Table II: Mandatory Sub-limits applicable for Ailment/Surgical Procedure for Value Plan (in INR)

Sub-Limit, as applicable to each Insured Person based

(Ailment/Surgical Procedure)
on the Sum Insured
5 Lacs 7.5 Lacs 10 Lacs 15 Lacs 20 Lacs
Cataract Surgery (per eye) 45,000 60,000 90,000 1,30,000 1,75,000
Balloon Sinuplasty/ FESS 30,000 40,000 55,000 85,000 1,10,000
Oral chemotherapy 85,000 1,15,000 1,65,000 2,50,000 3,30,000
Immunotherapy- Monoclonal 1,40,000 1,95,000 2,75,000 4,15,000 5,50,000
Antibody all forms
Robotic surgeries 1,40,000 1,95,000 2,75,000 4,15,000 5,50,000
Stem cell therapy for Hematopoietic 1,40,000 1,95,000 2,75,000 4,15,000 5,50,000
stem cells for bone marrow transplant
for hematological conditions
Total Knee Replacement (per knee) 1,65,000 1,75,000 1,80,000 2,15,000 2,30,000
Any type of Hernia Surgery 70,000 75,000 75,000 95,000 1,00,000
Any type of Hysterectomy 70,000 75,000 75,000 95,000 1,00,000
Benign Prostate Hypertrophy 70,000 75,000 75,000 95,000 1,00,000
Stones of Renal System 70,000 75,000 75,000 95,000 1,00,000

e. Voluntary Sub-Limits ailments/Surgical Procedures shall

be restricted to the following
In lieu of premium discount opted by
Sub-Limits subject to availability of
You, the following Sub-Limits shall be
Sum Insured and other terms and
applicable in addition to the
conditions of the Policy.
Mandatory Sub-Limits. Our liability
for any and all claims related to This Voluntary Sub-Limit cover, if
Hospitalization/ Day Care opted, shall continue for all the
Treatment (including their associated subsequent Renewals of the Policy,
Pre & Post Hospitalization expenses) provided the Policy is renewed with
arising out of following Us without any break.

Table A : Voluntary Sub-Limits applicable for Ailment/Surgical Procedure for Geo Plan (in INR)

Sub-Limit, as applicable to each Insured Person based

(Ailment/Surgical Procedure)
on the Sum Insured
5 Lacs 7.5 Lacs 10 Lacs 15 Lacs 20 Lacs
Total Knee Replacement (per knee) 150,000 157,500 165,000 195,000 210,000
Any type of Hernia Surgery 65,000 68,000 70,000 85,000 90,000
Any type of Hysterectomy 65,000 68,000 70,000 85,000 90,000
Benign Prostate Hypertrophy 65,000 68,000 70,000 85,000 90,000
Stones of Renal System 65,000 68,000 70,000 85,000 90,000
Cerebrovascular & Cardiovascular 250,000 275,000
41 300,000 325,000 350,000
Cancer 250,000 275,000 300,000 325,000 350,000
Renal Regd Oﬃce: 15th&Floor,
Complications Tower A, Peninsula Business Park, G. K. Marg, Lower Parel, Mumbai - 400 013
Disorders
250,000
24x7 Toll Free Helpline No. 275,000
1800 266 7780 300,000
or 1800 22 9966 (For Senior325,000
Citizens) 350,000
(excluding Stones of Renal System)
Email: customersupport@tataaig.com  IRDA of India Registration No: 108  website: www.tataaig.com
Breakage of Bones requiring
CIN: U85110MH2000PLC128425 | UIN: TATHLIP24113V012324
250,000 275,000 300,000 325,000 350,000
5 Lacs 7.5 Lacs 10 Lacs 15 Lacs 20 Lacs
Total Knee Replacement (per knee) 150,000 157,500 165,000 195,000 210,000
Any type of Hernia Surgery 65,000 68,000 70,000 85,000 90,000
Any type of Hysterectomy 65,000 68,000 70,000 85,000 90,000
Benign Prostate Hypertrophy
Policy Wordings
65,000 68,000 70,000 85,000 90,000
Stones of Renal System 65,000 68,000 70,000 85,000 90,000
Cerebrovascular & Cardiovascular 250,000 275,000 300,000 325,000 350,000
Cancer 250,000 275,000 300,000 325,000 350,000
Renal Complications & Disorders
(excluding Stones of Renal System) 250,000 275,000 300,000 325,000 350,000

Breakage of Bones requiring

250,000 275,000 300,000 325,000 350,000
Surgery under general anesthesia

Table B: Voluntary Sub-Limits applicable for Ailment/Surgical Procedure for Value Plan (in INR)

Sub-limit, as applicable to each Insured Person based

(Ailment/Surgical Procedure) on the Sum Insured
5 Lacs 7.5 Lacs 10 Lacs 15 Lacs 20 Lacs
Cerebrovascular & Cardiovascular 2,75,000 3,00,000 3,30,000 3,60,000 3,85,000
Cancer 2,75,000 3,00,000 3,30,000 3,60,000 3,85,000
Renal Complications & Disorders
(excluding Stones of Renal System) 2,75,000 3,00,000 3,30,000 3,60,000 3,85,000
Breakage of Bones requiring
2,75,000 3,00,000 3,30,000 3,60,000 3,85,000
Surgery under general anesthesia

Special condition applicable for annual basis.

above-mentioned Mandatory Sub-Limits and
Aggregate Deductible shall continue
Voluntary Sub-Limits
for all the subsequent Renewals of
In case more than one Sub-Limit is applicable to the Policy, provided the Policy is
an ailment/ procedure, covered under the Policy, renewed with Us without any break.
then the highest of applicable Sub-Limits, shall
Aggregate Deductible shall not be
be considered.
applicable to claims under B13, B14,
f. Aggregate Deductible B15, B16, C4 (if opted) and C6 (if
opted) of this Policy.
In lieu of premium discount opted by
You, Our liability under this Policy shall iv. Claims Procedure and management of
be subject to application of Aggregate services (B15, B16 &C4)
Deductible as mentioned in the Policy
Service may be availed through Our website
Schedule.
or Our mobile application or through calling
The Aggregate Deductible amount as Our call centre on the toll free number
specified in the Policy Schedule shall specified in the Policy Schedule. Alternatively,
be first deducted from the aggregate of details of Our empanelled service provider are
Final Assessed Amount (s) for all claims, available on Our website (www.tataaig.com).
during the Policy Year and Our liability
Supporting Documentation &
shall be restricted to the balance
Examination
amount, subject to availability of Sum
Insured and applicability of Sub-Limits. Insured Person or someone booking
services on Your behalf shall provide Us
In case of multi-year Policy (i.e. tenure
with identification documentation, medical
more than 1 year), such Aggregate
records and information We may request to
Deductible would be applicable on
establish the circumstances of the claim.
42

Section 6 - Dispute Resolution

Dispute Resolution Clause
i. Any and all disputes or diﬀerences under or in relation to this Policy shall be determined by the
Indian Courts and subject to Indian law.
^^Note: In compliance with IRDAI circular dated 31.01.2024, on ‘Guidelines on providing AYUSH coverage in
Health Insurance policies’ (Ref: IRDAI/HLT/CIR/GDL/31/01/2024), policy wordings have been modiﬁed.

Annexure A
NAMES OF OMBUDSMAN AND ADDRESSES OF OMBUDSMAN CENTRES
For updated list and details of Insurance Ombudsman Oﬃces, please visit website
http://www.cioins.co.in/ombudsman.html

Address and Contact Details

Ombudsman Territory, District

Ahemdabad Oﬃce of the Insurance Ombudsman,

Jeevan Prakash Building, 6th floor,
Tilak Marg, Relief Road, Gujarat, Dadra & Nagar Haveli,
Ahemdabad – 380 001. Daman and Diu
Tel.: 079 - 25501201/02/05/06
Email:bimalokpal.ahmedabad@cioins.co.in
Bengaluru Office of the Insurance Ombudsman,
Jeevan Soudha Building,PID No. 57-27-N-19
Ground Floor, 19/19, 24th Main Road, Karnataka
JP Nagar, Ist Phase, Bengaluru – 560 078.
Tel.: 080 - 26652048 / 26652049
Email: bimalokpal.bengaluru@cioins.co.in
Bhopal Office of the Insurance Ombudsman,
1st floor,"Jeevan Shikha", 60-B,Hoshangabad
Road, Opp. Gayatri Mandir,
Madhya Pradesh, Chhattisgarh
Bhopal – 462 011.
Tel.: 0755 - 2769201 / 2769202
Email: bimalokpal.bhopal@cioins.co.in
Bhubaneswar Office of the Insurance Ombudsman,
62, Forest park, Bhubaneswar – 751 009.
Odisha
Tel.: 0674 - 2596461 /2596455
Email:bimalokpal.bhubaneswar@cioins.co.in
Chandigarh Office of the Insurance Ombudsman, Punjab, Haryana (excluding
S.C.O. No. 101, 102 & 103, 2nd Floor, Gurugram, Faridabad, Sonepat
Batra Building, Sector 17 – D, and Bahadurgarh), Himachal
Chandigarh – 160 017. Pradesh, Union Territories of
Tel.: 0172 - 4646394 / 2706468 Jammu & Kashmir,Ladakh &
Email: bimalokpal.chandigarh@cioins.co.in Chandigarh

Address and Contact Details

Ombudsman Territory, District
Chennai Office of the Insurance Ombudsman,
Fatima Akhtar Court, 4th Floor, 453,
Tamil Nadu, PuducherryTown
Anna Salai, Teynampet, and Karaikal (which are part of
CHENNAI – 600 018. Puducherry)
Tel.: 044 - 24333668 / 24333678
Email: bimalokpal.chennai@cioins.co.in
Delhi Office of the Insurance Ombudsman,
2/2 A, Universal Insurance Building, Delhi & following Districts of
Asaf Ali Road, New Delhi – 110 002. Haryana - Gurugram, Faridabad,
Tel.: 011 - 23237539 Sonepat & Bahadurgarh
Email: bimalokpal.delhi@cioins.co.in
Guwahati Office of the Insurance Ombudsman,
Jeevan Nivesh, 5th Floor, Assam, Meghalaya, Manipur,
Nr. Panbazar over bridge, S.S. Road, Mizoram, Arunachal Pradesh,
Guwahati – 781001(ASSAM). Nagaland and Tripura
Tel.: 0361 - 2632204 / 2602205
Email: bimalokpal.guwahati@cioins.co.in
Hyderabad Office of the Insurance Ombudsman,
6-2-46, 1st floor, "Moin Court", Andhra Pradesh, Telangana,
Lane Opp. Saleem Function Palace, Yanam and part of Union
A. C. Guards, Lakdi-Ka-Pool, Territory of Puducherry
Hyderabad - 500 004.
Tel.: 040 - 23312122
Email: bimalokpal.hyderabad@cioins.co.in
Jaipur Office of the Insurance Ombudsman,
Jeevan Nidhi – II Bldg., Gr. Floor,
Bhawani Singh Marg, Rajasthan
Jaipur - 302 005.
Tel.: 0141- 2740363/2740798
Email: bimalokpal.jaipur@cioins.co.in
Ernakulam Office of the Insurance Ombudsman,
10th Floor, Jeevan Prakash,LIC Building, Kerala, Lakshadweep, Mahe-a
Opp to Maharaja's College,M.G.Road, part of Union Territory of
Ernakulam - 682 011. Puducherry
Tel.: 0484 - 2358759
Email: bimalokpal.ernakulam@cioins.co.in
Kolkata Office of the Insurance Ombudsman,
Hindustan Bldg. Annexe, 7th Floor, West Bengal, Sikkim, Andaman &
Nicobar Islands
4, C.R. Avenue, KOLKATA - 700 072.
Tel.: 033 - 22124339 / 22124341
Email: bimalokpal.kolkata@cioins.co.in

Address and Contact Details

Ombudsman Territory, District
Lucknow Oﬃce of the Insurance Ombudsman, Districts of Uttar Pradesh :
6th Floor, Jeevan Bhawan, Phase-II, Lalitpur, Jhansi, Mahoba,
Nawal Kishore Road, Hazratganj, Hamirpur, Banda, Chitrakoot,
Lucknow - 226 001. Allahabad, Mirzapur, Sonbhabdra,
Fatehpur, Pratapgarh,
Tel.: 0522 - 4002082 / 3500613
Jaunpur,Varanasi, Gazipur, Jalaun,
Email: bimalokpal.lucknow@cioins.co.in 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, Goa, Mumbai Metropolitan Region
3rd Floor, Jeevan Seva Annexe, (excluding Navi Mumbai & Thane)
S. V. Road, Santacruz (W),
Mumbai - 400 054.
Tel.: 022 - 69038800/27/29/31/32/33
Email: bimalokpal.mumbai@cioins.co.in

Oﬃce of the Insurance Ombudsman, State of Uttarakhand and the

Noida
Bhagwan Sahai Palace following Districts of Uttar
Pradesh: Agra, Aligarh, Bagpat,
4th Floor, Main Road, Naya Bans, Sector 15, Bareilly, Bijnor, Budaun,
Distt: Gautam Buddh Nagar, U.P-201301. Bulandshehar, Etah, Kannauj,
Tel.: 0120-2514252 / 2514253 Mainpuri, Mathura, Meerut,
Email: bimalokpal.noida@cioins.co.in Moradabad, Muzaﬀarnagar,
Oraiyya, Pilibhit, Etawah,
Farrukhabad, Firozbad, Gautam
Buddh nagar, Ghaziabad, Hardoi,
Shahjahanpur, Hapur, Shamli,
Rampur, Kashganj, Sambhal,
Amroha, Hathras,
Kanshiramnagar, Saharanpur

Patna Oﬃce of the Insurance Ombudsman, 2nd Bihar, Jharkhand

Floor, Lalit Bhawan, Bailey Road,
Patna 800 001.
Tel.: 0612-2547068
Email: bimalokpal.patna@cioins.co.in

Pune Oﬃce of the Insurance Ombudsman, Maharashtra, Areas of Navi

Jeevan Darshan Bldg., 3rd Floor, Mumbai and Thane (excluding
C.T.S. No.s. 195 to 198, N.C. Kelkar Road, Mumbai Metropolitan Region)
Narayan Peth, Pune – 411 030.
Tel.: 020-24471175
Email: bimalokpal.pune@cioins.co.in

Section 64VB of the Insurance Act, 1938 - Commencement of risk cover under the Policy is subject to
receipt of premium by TATA AIG General Insurance Company Limited.
Prohibition of Rebates - Section 41 of the Insurance Act, 1938 as amended by Insurance Laws
(Amendment) Act, 2015.
1. No person shall allow or oﬀer to allow, either directly or indirectly, as an inducement to any person
to take out or renew or continue an insurance in respect of any kind of risk relating to lives or
property in India, any rebate of the whole or part of the commission payable or any rebate of the
premium shown on the Policy, nor shall any person taking out or renewing or continuing a Policy
accept any rebate, except such rebate as may be allowed in accordance with the published
prospectuses or tables of the Insurer.
2. Any person making default in complying with the provisions of this section shall be liable for a
penalty which may extend to ten lakh rupees.

R1/PW/THSC/Mar 24

“Insurance is the subject matter of solicitation”. For more details on risk factors, terms and conditions, please read Policy
document carefully before concluding a sale.
46

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Policy Wordings

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i. Having atleast 5 in-patient beds; 8. Co-Payment

11. Dental Treatment towns having a population of less than

patient or for the patient to be Medical Expenses means those expenses

18. Inpatient Care Medical Practitioner means a person who

Medical Advice means any consultation or 25. Migration

Single Private Room means an Insurance Cover under this Policy.

Please note that the above-mentioned Medically Necessary Treatment in a

will not be reinstated. same condition for which the

This beneﬁt shall be payable if We have The beneﬁt is payable subject to a

B12. Medical Devices Cover At Your request, We will provide the

i. Cancer of communication like audio,

caregiver’ through Our customer communication like audio, video,

Consultative services will be provided For the purpose of understanding if the

i) Health risk assessment Insured Person has to undergo HRA in each

For adult Insured 1

Date of Policy 365 days from:

For adult Insured 2

Date of Policy 365 days from:

the services. Any additional services consultation.

c. This facility may be availed performance shall not constitute

can only be utilized for an admissible

of limit as speciﬁed in the Policy Schedule Medical Practitioner shall be excluded.

Pre-Existing Disease is subject to the IV. Rheumatism

List of Speciﬁc XXV. Nasal concha resection

XXX. Cholecystectomy care such as help with activities

a. Expenses related to the treatment of Expenses related to surgical treatment of

any treatment to change appearance unless advanced reproductive technologies

Expenses related to any Unproven Expenses for treatment directly

Expenses related to Sterility and infertility. Expenses incurred towards

to the Policyholders are not ix. Cost of dentures, dental

radioactivity capable of products and bath additive,

according to the terms of the policyholder(s), who has made that

Policy Period option to migrate the Policy to other

Business – Ref: health insurance product

full and ﬁnal discharge of its liability counter oﬀer letter.

Our address speciﬁed in 21. Zone & Applicability of Plan

account of death of the Insured Event We or Our TPA*

Treatment, Taken at: Cashless Service We must be given notice

If any treatment, Network We will provide cashless Within 24 hours of the

c. Procedure for Cashless Service shall be communicated to the

reserve the right to review each and any attachments thereto

used during Surgery. make any payment under this Policy

Steps Assessment Where Age speciﬁc Where Age speciﬁc

2. Any accrued 5X Supercharge 4. Restore inﬁnity amount, if

a. Age linked Co-Payment • if B9, B17 and C1 (if opted)

Sub-Limit, as applicable to each Insured Person based

e. Voluntary Sub-Limits ailments/Surgical Procedures shall

Sub-Limit, as applicable to each Insured Person based

Breakage of Bones requiring

Sub-limit, as applicable to each Insured Person based

Special condition applicable for annual basis.

Section 6 - Dispute Resolution

Address and Contact Details

Ahemdabad Oﬃce of the Insurance Ombudsman,

Address and Contact Details

Address and Contact Details

Oﬃce of the Insurance Ombudsman, State of Uttarakhand and the

Patna Oﬃce of the Insurance Ombudsman, 2nd Bihar, Jharkhand

Pune Oﬃce of the Insurance Ombudsman, Maharashtra, Areas of Navi

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