THE NEW INDIA ASSURANCE CO.

LTD
Regd. & Head Office: 87, M.G. Road, Fort, Mumbai – 400 001

NEW INDIA FLEXI FLOATER GROUP MEDICLAIM POLICY

1.0 Whereas Insured designated in the Schedule hereto has by a proposal and declaration
dated as stated in the Schedule which shall be the basis of this Contract and is deemed to
be incorporated herein, has applied to THE NEW INDIA ASSURANCE CO. LTD. (hereinafter
called the COMPANY) for the insurance herein after set forth in respect of
Employees/Members (including their eligible Family Members) named in the Schedule
hereto (herein after called the INSURED PERSON) and has agreed to pay premium of
Rs. 14800/- as consideration for such insurance.

2.0 NOW THIS POLICY WITNESSES that subject to the terms, conditions, exclusions and
definitions contained herein or endorsed or otherwise expressed here on the Company
undertakes that if during the period stated in the Schedule or during the continuance of
this policy by renewal any Insured Person shall contract any Illness (herein defined) or
sustain any Injury (herein defined) and if such Injury shall require any such Insured Person,
upon the advice of a duly qualified Medical practitioner (herein defined) or a surgeon to
incur Medical Expenses/Surgery at any Hospital / Day Care Center (herein defined) in India
as an Inpatient, the Company will pay to the Insured Person the amount of such expenses
as good fall under different heads mentioned below, and as are Reasonably and
Customarily, and Medically Necessarily incurred thereof by or on behalf of such Insured
Person.

2.1 Room, Boarding Expenses as provided by the hospital including Nursing charges, not
exceeding 1% of Sum Insured per day.

2.2 Intensive Care Unit (ICU) / Intensive Cardiac Care Unit (ICCU) expenses, not exceeding 2%
of the sum insured per day.

2.3 Surgeon, Anesthetist, Medical Practitioner, Consultants, Specialists Fees.

2.4 Anesthesia, Blood, Oxygen, Operation Theatre Charges, Surgical Appliances, Medicines &
Drugs, Diagnostic Materials and X-ray, Dialysis, Chemotherapy, Radiotherapy, Cost of
Pacemaker, Artificial Limbs & Cost of Organs and similar expenses.

2.5 Pre-hospitalization medical charges up to 30 days period.

2.6 Post-hospitalization medical charges up to 60 days period.

NOTE: SUB-LIMIT CLAUSE

1. The amounts payable under 2.3 and 2.4 shall be at the rate applicable to the entitled
room category. In case of admission to a room/ICU/ICCU at rates exceeding the limits as
mentioned under 2.1 and 2.2, the reimbursement/payment of all other expenses
incurred at the Hospital, with the exception of cost of medicines, shall be affected in the
same proportion as the admissible rate per day bears to the actual rate per day of room
rent/ICU/ICCU charges.

2. No payment shall be made under 2.3 other than as part of the hospitalization bill.

3. However, the bills raised by Surgeon, Anesthetist directly and not included in the
hospitalization bill may be reimbursed in the following manner:
 a. The reasonable, customary and Medically Necessary Surgeon fee and Anesthetist
fee would be reimbursed, limited to the maximum of 25% of Sum Insured. The
payment shall be reimbursed provided the insured pays such fee(s) through cheque
and the Surgeon / Anesthetist provides a numbered bill. Bills given on letter-head of
the Surgeon, Anesthetist would not be entertained.
b. Fees paid in cash will be reimbursed up to a limit of Rs. 10,000/- only, provided the
Surgeon/Anesthetist provides a numbered bill.

(N.B: Company’s Liability in respect of all claims admitted during the period of insurance shall
not exceed the Sum Insured per person mentioned in the schedule.)

2.7 LIMIT ON PAYMENT FOR CATARACT: Company’s liability for payment of any claim relating
to Cataract shall be limited to Actual or maximum of Rs.24000 (inclusive of all charges,
excluding service tax), for each eye, whichever is less.

2.8 AYUSH: Expenses incurred for Ayurvedic/Homeopathic/Unani Treatment are admissible

up to 25% of the sum insured provided the treatment for illness/disease and accidental
injuries, is taken in a Government hospital or in any institute recognized by Government
and /or accredited by Quality Council Of India / National Accreditation Board on Health,
excluding centers for spas, massage and health rejuvenation procedures.

2.9 Ambulances services – 1.0 % of the sum insured or actual, whichever is less, subject to
maximum of Rs. 3000/- in case patient has to be shifted from residence to hospital for
admission in Emergency Ward or ICU or from one Hospital to another Hospital by fully
equipped ambulance for better medical facilities.

2.10 Hospitalization expenses (excluding cost of organ) incurred on the donor during the course
of organ transplant to the insured person. The Company’s liability towards expenses
incurred on the donor and the insured recipient shall not exceed the sum insured of the
insured person receiving the organ.

3.0 DEFINITIONS:

3.1 ACCIDENT: An accident is a sudden, unforeseen and involuntary event caused by external,
visible and violent means.

3.2 ANY ONE ILLNESS means continuous Period of illness and it includes relapse within 45
days from the date of last consultation with the Hospital/Nursing Home where treatment
may have been taken.

3.3 CANCELLATION: Cancellation defines the terms on which the policy contract can be
terminated either by the insurer or the insured by giving sufficient notice to other which is
not lower than a period of fifteen days.

3.4 CASHLESS FACILITY means a facility extended by the insurer to the insured where the
payments, of the costs of treatment undergone by the insured in accordance with the
policy terms and conditions, are directly made to the network provider by the insurer to
the extent pre-authorization approved.

3.5 CONDITION PRECEDENT: Condition Precedent shall mean a policy term or condition upon
which the Insurer's liability under the policy is conditional upon.

3.6 CONGENITAL ANOMALY refers to a condition(s) which is present since birth, and which is
abnormal with reference to form, structure or position.
 3.6.1 CONGENITAL INTERNAL ANOMALY means a Congenital Anomaly which is not in the
visible and accessible parts of the body.
3.6.2 CONGENITAL EXTERNAL ANOMALY means a Congenital Anomaly which is in the
visible and accessible parts of the body

3.7 CO-PAYMENT: A co-payment is a cost-sharing requirement under a health insurance

policy that provides that the insured will bear a specified percentage of the admissible
claim amount. A co-payment does not reduce the sum insured.

3.8 CONTRIBUTION: Contribution is essentially the right of an insurer to call upon other
insurers, liable to the same insured, to share the cost of an indemnity claim on a ratable
proportion.

3.9 DAY CARE TREATMENT: Day care treatment refers to medical treatment, and/or Surgical
Operation which is:

- Undertaken under General or Local Anesthesia in a Hospital/Day Care Centre in less than
24 hours because of technological advancement, and
- Which would have otherwise required a hospitalization of more than 24 hours.

Treatment normally taken on an out-patient basis is not included in the scope of this
definition.

3.10 DEDUCTIBLE: A deductible is a cost-sharing requirement under a health insurance policy

that provides that the Insurer will not be liable for a specified rupee amount of the
covered expenses, which will apply before any benefits are payable by the insurer. A
deductible does not reduce the sum insured.

3.11 DENTAL TREATMENT: Dental treatment is treatment carried out by a dental practitioner
including examinations, fillings (where appropriate), crowns, extractions and surgery
excluding any form of cosmetic surgery/implants.

3.12 DOMICILIARY HOSPITALISATION: Domiciliary Hospitalization means medical treatment for

an Illness/Injury which in the normal course would require care and treatment at a
Hospital but is actually taken while confined at home under any of the following
circumstances:

- The condition of the patient is such that he/she is not in a condition to be removed to a
Hospital, or
- The patient takes treatment at home on account of non-availability of room in a
Hospital.

3.13 FLOATER BENEFIT means the Sum Insured as specified for a particular Insured and the
members of his/her family as covered under the policy and is available for any or all the
members of his/her family for one or more claims during the tenure of the policy.

3.14 HOSPITAL: A hospital means any institution established for Inpatient Care and Day Care
treatment of Illness and / or Injuries and which has been registered as a Hospital with the
local authorities under the Clinical Establishment (Registration and Regulation) Act, 2010
or under the enactments specified under the schedule of Section 56(1) of the said act OR
complies with all minimum criteria as under:

- has at least 10 inpatient beds, in those towns having a population of less than 10,00,000
and at least 15 inpatient beds in all other places;
 - has qualified nursing staff under its employment round the clock;
- has qualified medical practitioner (s) in charge round the clock;
- has a fully equipped operation theatre of its own where surgical procedures are carried
out
- maintains daily records of patients and will make these accessible to the Insurance
company’s authorized personnel.

The term ‘Hospital’ shall not include an establishment which is a place of rest, a place for
the aged, a place for drug-addicts or place for alcoholics, a hotel or a similar place.

3.14.1 HOSPITALISATION means admission in a Hospital for a minimum period of 24 in patient

Care consecutive hours except for specified procedures/ treatments, where such
admission could be for a period of less than 24consecutive hours.

Anti-Rabies Vaccination Hysterectomy

Appendectomy Inguinal/Ventral/Umbilical/Femoral Hernia
Coronary Angiography Lithotripsy (Kidney Stone Removal)
Coronary Angioplasty Parenteral Chemotherapy
Dental surgery following an accident Piles / Fistula
Dilatation & Curettage (D & C) of Cervix Prostate
Eye surgery Radiotherapy
Fracture / dislocation excluding hairline Fracture Sinusitis
Gastrointestinal Tract system Stone in Gall Bladder, Pancreas, and Bile Duct
Haemo-Dialysis Tonsillectomy,
Hydrocele Urinary Tract System

OR any other Surgeries / Procedures agreed by TPA/Company which require less than
24 hours hospitalization due to advancement in Medical Technology.

Note: Procedures/treatments usually done in outpatient department are not payable

under the Policy even if converted as an In-patient in the Hospital for more than 24 hours.

3.14.2 Day Care Centre: A Day Care Centre means any institution established for Day Care
treatment of Illness and or Injuries or a medical setup within a Hospital and which has
been registered with the local authorities, wherever applicable, and is under supervision
of a registered and qualified Medical Practitioner AND must comply with all minimum
criteria as under:

1) has qualified nursing staff under its employment;

2) has qualified Medical Practitioner/s in charge;
3) Has a fully equipped operation theatre of its own where Surgeries are carried out;
4) Maintains daily records of patients and will make these accessible to the insurance
company’s authorized personnel.

3.15 ID CARD means the identity card issued to the insured person by the TPA to avail cashless
facility in network hospitals.

3.16 ILLNESS: Illness means a sickness or a disease or pathological condition leading to the
impairment of normal physiological function which manifests itself during the Policy
Period and requires medical treatment.
3.17 INJURY: Injury means accidental physical bodily harm excluding Illness or disease solely
and directly caused by external, violent and visible and evident means which is verified
and certified by a Medical Practitioner.

3.18 INPATIENT CARE: Inpatient Care means treatment for which the insured person has to
stay in a Hospital for more than 24 hours for a covered event.

3.19 INSURED PERSON means You and each of the others who are covered under this Policy as
shown in the Schedule.

3.20 INTENSIVE CARE UNIT (ICU): means an identified section, ward or wing of a Hospital which
is under the constant supervision of a dedicated Medical Practitioner, and which is
specially equipped for the continuous monitoring and treatment of patients who are in a
critical condition, or require life support facilities and where the level of care and
supervision is considerably more sophisticated and intensive than in the ordinary and
other wards.

3.21 MATERNITY EXPENSES: Maternity expense shall include:

a. Medical Treatment Expenses traceable to childbirth (including complicated deliveries

and caesarean sections incurred during Hospitalisation),
b. Expenses towards lawful medical termination of pregnancy during the Policy Period.

3.22 MEDICAL ADVICE: Any consultation or advice from a Medical Practitioner including the
issue of any prescription or repeat prescription.

3.23 MEDICAL EXPENSES: Medical Expenses means those expenses that an Insured Person has
necessarily and actually incurred for medical treatment on account of Illness or Injury on
the advice of a Medical Practitioner, as long as these are no more than would have been
payable if the Insured Person had not been insured and no more than other Hospitals or
doctors in the same locality would have charged for the same medical treatment.

3.24 MEDICALLY NECESSARY: treatment is defined as any treatment, tests, medication, or stay
in Hospital or part of a stay in Hospital which

- is required for the medical management of the Illness or Injury suffered by the insured;
- must not exceed the level of care necessary to provide safe, adequate and appropriate
medical care in scope, duration, or intensity;
- must have been prescribed by a Medical Practitioner;
- must confirm to the professional standards widely accepted in international medical
practice or by the medical community in India.

3.25 MEDICAL PRACTITIONER is a person who holds a valid registration from the Medical
Council of any State or Medical Council of India or Council for Indian Medicine or for
Homeopathy set up by the Government of India or a State Government and is thereby
entitled to practice medicine within its jurisdiction; and is acting within the scope and
jurisdiction of his license.

Note: The Medical Practitioner should not be the insured or close family members.

3.26 NETWORK HOSPITAL: All such Hospitals, Day Care Centers or other providers that the
Insurance Company / TPA have mutually agreed with, to provide services like cashless
access to policyholders. The list is available with the insurer/TPA and subject to
amendment from time to time.
3.27 NON-NETWORK HOSPITAL: Any Hospital, Day Care centre or other provider that is not part
of the Network.

3.28 OPD TREATMENT: OPD treatment is one in which the Insured visits a clinic / Hospital or
associated facility like a consultation room for diagnosis and treatment based on the
advice of a Medical Practitioner. The Insured is not admitted as a Day Care or Inpatient.

3.29 PERIOD OF INSURANCE means the period for which this Policy is taken as specified in the
Schedule.

3.30 PRE-EXISTING CONDITION/DISEASE: Any condition, ailment or Injury or related

condition(s) for which you had signs or symptoms, and / or were diagnosed, and / or
received medical advice / treatment within 48 months prior to the first policy issued by
the insurer.

3.31 PRE-HOSPITALISATION MEDICAL EXPENSES mean Medical Expenses incurred immediately

before the Insured Person is Hospitalized, provided that:

i. Such Medical Expenses are incurred for the same condition for which the Insured
Person’s Hospitalization was required, and
ii. The Inpatient Hospitalization claim for such Hospitalization is admissible by the
Insurance Company.

3.32 POST-HOSPITALISATION MEDICAL EXPENSES mean Medical Expenses incurred

immediately after the Insured Person is discharged from the Hospital provided that:

i. Such Medical Expenses are incurred for the same condition for which the Insured
Person’s Hospitalization was required, and
ii. The Inpatient Hospitalization claim for such Hospitalization is admissible by the
Insurance Company.

3.33 PORTABILITY: Portability means transfer by an individual health insurance policyholder

(including family cover) of the credit gained for pre-existing conditions and time-bound
exclusions if he/she chooses to switch from one insurer to another.

3.34 QUALIFIED NURSE: Qualified nurse is a person who holds a valid registration from the
Nursing Council of India or the Nursing Council of any state in India.

3.35 REASONABLE AND CUSTOMARY CHARGES: Reasonable charges means the charges for
services or supplies, which are the standard charges for the specific provider and
consistent with the prevailing charges in the geographical area for identical or similar
services, taking into account the nature of the Illness / Injury involved.

3.36 RENEWAL: Renewal defines the terms on which the contract of insurance can be renewed
on mutual consent with a provision of grace period for treating the renewal continuous
for the purpose of all waiting periods.

3.37 ROOM RENT: Room Rent means the amount charged by a Hospital for the occupancy of a
bed per day (twenty four hours) basis and shall include associated medical expenses.

3.38 SUM INSURED is the maximum amount of coverage opted for each Insured Person and
shown in the Schedule.

3.39 SURGERY means manual and / or operative procedure (s) required for treatment of an
Illness or Injury, correction of deformities and defects, diagnosis and cure of diseases,
relief of suffering or prolongation of life, performed in a Hospital or Day Care Centre by a
Medical Practitioner.
3.40 TPA: Third Party Administrators or TPA means any person who is licensed under the IRDA
(Third Party Administrators - Health Services) Regulations, 2001 by the Authority, and is
engaged, for a fee or remuneration by an insurance company, for the purposes of
providing health services.

3.41 UNPROVEN / EXPERIMENTAL TREATMENT: Treatment including drug experimental

therapy, which is not based on established medical practice in India, is treatment
experimental or unproven.

4.0 EXCLUSIONS:

The Company shall not be liable to make any payment under this policy in respect of any
expenses whatsoever incurred by any Insured Person in connection with or in respect of:

4.1 PRE-EXISTING DISEASES/ CONDITIONS / BENEIFTS will not be available for any
condition(s) as defined in the policy, until 48 months of continuous coverage have
elapsed, since inception of the first policy with us.

4.2 30 DAYS EXCLUSION Any Illness other than those stated in clause 4.3 below, contracted
by the insured person during first 30 days from the commencement date of the policy.
This exclusion will not apply if the policy is renewed with our Company without any break.
The exclusion does not also apply to treatment for any Injury.

4.3 WAITING PERIOD FOR SPECIFIED DISEASES/ALIMENTS/CONDITIONS: From the time of

inception of the cover, the policy will not cover the following diseases / ailments /
conditions for the duration shown below. This exclusion will be deleted after the duration
shown, provided the policy has been continuously renewed with our Company without
any break.

S No Name of Disease/Ailment/Surgery not covered for Duration

1 Any Skin disorder Two years
All internal & external benign tumors, cysts, polyps of any kind, including
2 Two years
benign breast lumps
3 Benign Ear, Nose, Throat disorders Two years
4 Benign Prostate Hypertrophy Two years
5 Cataract & age related eye ailments Two years
6 Diabetes mellitus Two years
7 Gastric/ Duodenal Ulcer Two years
8 Gout & Rheumatism Two years
9 Hernia of all types Two years
10 Hydrocele Two years
11 Hypertension Two years
Hysterectomy for Menorrhagia/Fibromyoma, Myomectomy and Prolapse
12 Two years
of uterus
13 Non Infective Arthritis Two years
14 Piles, Fissure and Fistula in Anus Two years
15 Pilonidal Sinus, Sinusitis and related disorders Two years
16 Prolapse Inter Vertebral Disc unless arising from accident Two years
17 Stone in Gall Bladder & Bile duct Two years
 18 Stones in Urinary Systems Two years
19 Unknown Congenital internal disease/defects Two years
20 Varicose Veins and Varicose Ulcers Two years
21 Age related Osteoarthritis & Osteoporosis Four years
22 Joint Replacements due to Degenerative Condition Four years

4.4 Permanent Exclusions: Any medical expenses incurred for or arising out of:

4.4.1 War invasion, Act of foreign enemy, War like operations, Nuclear weapons, ionizing
radiation, contamination by radio activity, by any nuclear fuel or nuclear waste or from
the combustion of nuclear fuel.

4.4.2 Circumcision, cosmetic or aesthetic treatment, plastic surgery unless required to treat
injury or illness.

4.4.3 Vaccination & Inoculation.

4.4.4 Cost of braces, equipment or external prosthetic devices, non-durable implants,

eyeglasses, Cost of spectacles and contact lenses, hearing aids including cochlear
implants, durable medical equipment.

4.4.5 All types of Dental treatments except arising out of an accident.

4.4.6 Convalescence, general debility, ‘Run-down’ condition or rest cure, obesity treatment
and its complications, congenital external disease/defects or anomalies, treatment
relating to all psychiatric and psychosomatic disorders, infertility, sterility, use of
intoxicating drugs/alcohol, use of tobacco leading to cancer.

4.4.7 Bodily injury or sickness due to willful or deliberate exposure to danger (except in an
attempt to save human life), intentional self-inflicted injury, , attempted suicide, arising
out of non-adherence to medical advice.

4.4.8 Treatment of any Bodily injury sustained whilst or as a result of active participation in
any hazardous sports of any kind.

4.4.9 Treatment of any bodily injury sustained whilst or as a result of participating in any
criminal act.

4.4.10 Sexually transmitted diseases, any condition directly or indirectly caused due to or
associated with Human T-Cell Lymphotropic Virus Type III (HTLB-III) or lymphotropathy
Associated Virus (LAV) or the Mutants Derivative or Variation Deficiency syndrome or
any syndrome or condition of a similar kind commonly referred to as AIDS.

4.4.11 Diagnosis, X-Ray or Laboratory examination not consistent with or incidental to the
diagnosis of positive existence and treatment of any ailment, sickness or injury, for
which confinement is required at a Hospital.

4.4.12 Vitamins and tonics unless forming part of treatment for injury or disease as certified by
the attending Medical Practitioner.

4.4.13 Maternity Expenses, except abdominal operation for extra uterine pregnancy (Ectopic
Pregnancy), which is proved by submission of ultra Sonographic Report and Certification
by Gynecologist that it is life threatening.

4.4.14 Naturopathy Treatment. AYUSH treatment is covered.

4.4.15 Instrument used in treatment of Sleep Apnea Syndrome (C.P.A.P.) and continuous
Peritoneal Ambulatory dialysis (C.P.A.D.) and Oxygen Concentrator for Bronchial
Asthmatic condition.

4.4.16 Genetic disorders and stem cell implantation / surgery.

4.4.17 Domiciliary Hospitalization.

4.4.18 Treatment taken outside India.

4.4.19 Experimental Treatment, Unproven treatment.

4.4.20 Change of treatment from one system to another unless recommended by the
consultant / hospital under whom the treatment is taken.

4.4.21 Any expenses relating to cost of items detailed in Annexure I.

4.4.22 Service charges or any other charges levied by hospital, except registration/admission
charges.

4.4.23 Treatment for Age Related Macular Degeneration (ARMD) , treatments such as
Rotational Field Quantum Magnetic Resonance (RFQMR), External Counter Pulsation
(ECP), Enhanced External Counter Pulsation (EECP), Hyperbaric Oxygen Therapy.

5.0 CONDITIONS:

5.1 COMMUNICATION: Every notice or communication to be given or made under this policy
shall be delivered in writing at the address as shown in the Schedule.

5.2 PREMIUM PAYMENT: The premium payable under this policy shall be paid in advance. No
receipt for Premium shall be valid except on the official form of the Company. The due
payment of premium and the observance and fulfillment of the terms, provisions,
conditions and endorsements of this policy by the Insured Person in so far as they relate
to anything to be done or complied with by the Insured Person shall be condition
precedent to any liability of the Company to make any payment under this policy. No
waiver of any terms, provisions, conditions and endorsements of this policy shall be valid,
unless made in writing and signed by an authorized official of the Company.

5.3 NOTICE OF CLAIM: Preliminary notice of claim with particulars relating to Policy Number,
name of insured person in respect of whom claim is to be made, nature of illness/injury
and Name and Address of the attending Medical Practitioner/Hospital/Nursing Home
should be given to the Company/TPA within 7 days from the date of hospitalization in
respect of reimbursement claims.

Final claim along with hospital receipted original Bills/Cash memos, claim form and
documents as listed in the claim form below should be submitted to the Policy issuing
Office/TPA not later than 30 days of discharge from the hospital. The insured may also be
required to give the Company/TPA such additional information and assistance as the
Company/TPA may require in dealing with the claim.

a. Bill, Receipt and Discharge certificate / card from the Hospital.

b. Cash Memos from the Hospitals(s) / Chemists(s), supported by proper prescriptions.
c. Receipt and Pathological test reports from Pathologist supported by the note from the
attending Medical Practitioner / Surgeon recommending such Pathological tests /
pathological.
d. Surgeon's certificate stating nature of operation performed and Surgeons’ bill and
receipt.
 e. Attending Doctor's/ Consultant's/ Specialist's / Anesthetist’s bill and receipt, and
certificate regarding diagnosis.
f. Certificate from attending Medical Practitioner / Surgeon that the patient is fully
cured.

Waiver: Waiver of period of intimation may be considered in extreme cases of hardships

where it is proved to the satisfaction of the Company/TPA that under the circumstances in
which the insured was placed it was not possible for him or any other person to give such
notice or file claim within the prescribed time limit. This waiver cannot be claimed as a
matter of right.

5.4 PHYSICAL EXAMINATION: Any medical practitioner authorized by the Company shall be
allowed to examine the Insured Person in case of any alleged injury or Disease requiring
Hospitalization when and as often as the same may reasonably be required on behalf of
the Company.

5.5 The Company shall not be liable to make any payment under this policy in respect of any
claim if such claim be in any manner fraudulent or supported by any fraudulent means or
device whether by the Insured Person or by any other person acting on his behalf.

5.6 CONTRIBUTION: If two or more policies are taken by Insured Person during a period from
one or more insurers to indemnify treatment costs, Company shall not apply the
contribution clause, but the Insured Person shall have the right to require a settlement of
his/her claim in terms of any of his/her policies.

1. In all such cases Company shall be obliged to settle the claim without insisting on the
contribution clause as long as the claim is within the limits of and according to the
terms of the policy.
2. If the amount to be claimed exceeds the Sum Insured under a single policy after
considering the deductibles or co-pay, the Insured Person shall have the right to
choose insurers by whom the claim to be settled. In such cases, the insurer may settle
the claim with contribution clause.
3. Except in benefit policies, in cases where Insured Person have policies from more than
one insurer to cover the same risk on indemnity basis, Insured Person shall only be
indemnified the Hospitalisation costs in accordance with the terms and conditions of
the policy.

Note: Insured Personmust disclose such other insurance at the time of making a claim
under this Policy.

5.7 CANCELLATION CLAUSE: The policy may be renewed by mutual consent. The company
shall not however be bound to give notice that it is due for renewal and the Company may
at any time cancel this Policy by sending the insured 30 days’ notice by registered letter at
the Insured’s last known address and in such event the Company shall refund to the
Insured a pro-rata premium for unexpired Period of Insurance. The Company shall,
however, remain liable for any claim which arose prior to the date of cancellation.
The Insured may at any time cancel this policy and in such event the Company shall allow
refund of premium at Company’s short period rate only (table given here below) provided
no claim has occurred up to the date of cancellation.

PERIOD OF RISK RATE OF PREMIUM TO BE CHARGED

th
Up to one month 1/4 of the annual rate
Up to three months ½ of the annual rate
th
Up to six months 3/4 of the annual rate
Exceeding six months Full annual rate
5.8 DISCLAIMER OF CLAIM: If the Company shall disclaim liability to the Insured for any claim
hereunder and if the Insured shall not within 12 calendar months from the date of receipt
of the notice of such disclaimer notify the Company in writing that he does not accept
such disclaimer and intends to recover his claim from the Company then the claim shall
for all purposes be deemed to have been abandoned and shall not thereafter be
recoverable hereunder.

5.9 All medical/surgical treatment under this policy shall have to be taken in India and
admissible claims thereof shall be payable in Indian currency.

7.1 MATERNITY EXPENSES BENEFIT EXTENSION (OPTIONAL COVER): This is an optional cover
which can be obtained on payment of 10% of the total basic premium for all the Insured
Persons under the Policy Total basic premium means the total premium computed before
applying Group Discount and / or High Claim Ratio Loading, Low Claim Discount and
special discount in lieu of agency commission.

7.2 Option for maternity Benefits has to be exercised at the inception of the policy period and
no refund is allowable in case of Insured’s cancellation of this option during currency of
the policy.

7.3 The maximum benefit allowable under this clause will be upto as agreed of the Sum
Insured opted by the member of the group whichever is lower.

7.4 Special conditions applicable to Maternity Expenses Benefit Extension:

1. These Benefits are admissible only if the expenses are incurred in Hospital as
inpatients in India.
2. A waiting period of 9 months is applicable for payment of any claim relating to normal
delivery or caesarian section or abdominal operation for extra uterine pregnancy. The
waiting period may be relaxed only in case of delivery miscarriage or abortion induced
by accident or other medical emergency.
3. Claim in respect of delivery for only first two children and / or surgeries associated
therewith will be considered in respect of any one Insured Person covered under the
Policy or any renewal thereof. Those Insured Persons who are already having two or
more living children will not be eligible for this benefit.
4. Expenses incurred in connection with voluntary medical termination of pregnancy
during the first 12 weeks from the date of conception are not covered.
5. Pre-natal and post-natal expenses are not covered unless admitted in Hospital and
treatment is taken there

Note: When Group Policy is extended to include Maternity Expenses Benefit, the
exclusion 4.13 of the policy stands deleted.

8.0 CASHLESS SERVICE THROUGH TPAS: Claims in respect of Cashless access services will be
through the agreed list of network of hospital and is subject to pre-admission
authorization. The TPA shall, upon getting the related medical information from the
insured person /network provider, verify that the person is eligible to claim under the
policy and after satisfying itself will issue a pre-authorization letter / guarantee of
payment letter to the hospital mentioning the sum guaranteed as payable also the
ailment for which the person is seeking to be admitted as a patient. The TPA reserves the
right to deny pre-authorization in case the insured person is unable to provide the
relevant medical details as required by the TPA. The TPA will make it clear to the insured
 person that denial of Cashless Access is in no way construed to be denial of treatment.
The insured person may obtain the treatment as per his /her treating Medical
Practitioners medical advice and later on submit the full claim papers to the TPA for
reimbursement.

9.0 FRAUD, MISREPRESENTATION, CONCEALMENT: The policy shall be null and void and no
benefits shall be payable in the event of misrepresentation, misdescription or
nondisclosure of any material fact/particulars if such claim be in any manner fraudulent or
supported by any fraudulent means or device whether by the Insured Person or by any
other person acting on his/her behalf.

10.0 RENEWAL CLAUSE: The Company sends renewal notice as a matter of courtesy. If the
insured does not receive the renewal notice it will not amount to any deficiency of
service.

The Company shall not be responsible or liable for non-renewal of the policy due to non-
receipt /delayed receipt of renewal notice or due to any other reason whatsoever.

We shall be entitled to decline renewal if:

a) Any fraud, moral hazard/misrepresentation or suppression by You or any one acting

on Your behalf is found either in obtaining insurance or subsequently in relation
thereto, or non-cooperation of the Insured Person, or
b) We have discontinued issue of the Policy, in which event You shall however have the
option for renewal under any similar Policy being issued by Us; provided however,
benefits payable shall be subject to the terms contained in such other Policy, or
c) You fail to remit Premium for renewal before expiry of the Period of Insurance. We
may accept renewal of the Policy if it is effected within thirty days (grace period) of
the expiry of the Period of Insurance. On such acceptance of renewal, we, however
shall not be liable for any claim arising out of Illness contracted or Injury sustained or
Hospitalization commencing in the interim period after expiry of the earlier Policy and
prior to date of commencement of subsequent Policy.

11.0 MEDICAL EXPENSES FOLLOWING UNDER TWO POLICY PERIODS: If the claim event falls
within two policy periods, the claims shall be paid taking into consideration the available
sum insured in the two policy periods, including the deductibles for each policy period.
Such eligible claim amount to be payable to the insured shall be reduced to the extent of
premium to be received for the renewal/due date of premium of health insurance policy,
if not received earlier.

12.0 REPUDIATION OF CLAIM: A claim, which is not covered under the Policy conditions, can be
rejected. All the documents submitted to TPA shall be electronically collected by Us for
settlement and denial of the claims by the appropriate authority.

With Our prior approval Communication of repudiation shall be sent to You, explicitly
mentioning the grounds for repudiation, through Our TPA.

13.0 PROTECTION OF POLICY HOLDERS’ INTEREST: This policy is subject to IRDA (Protection of
Policyholders’ Interest) Regulation, 2002

14.0 GRIEVANCE REDRESSAL: In the event of Insured has any grievance relating to the
insurance, Insured Person may contact any of the Grievance Cells at Regional Offices of
the Company or Office of the Insurance Ombudsman under the jurisdiction of which the
Policy Issuing Office falls. The contact details of the office of the Insurance Ombudsman
are provided in the Annexure II.
15.0 PAYMENT OF CLAIM: The insurer shall settle the claim, including rejection, within thirty
days of the receipt of the last necessary document.

On receipt of the duly completed documents either from the insured or Hospital the claim
shall be processed as per the conditions of the policy. Upon acceptance of claim by the
insured for settlement, the insurer or their representative (TPA) shall transfer the funds
within seven working days. In case of any extra ordinary delay, such claims shall be paid
by the insurer or their representative (TPA) with a penal interest at a rate which is 2%
above the bank rate at the beginning of the financial year in which the claim is reviewed

All admissible claims shall be payable in Indian Currency only.

16.0 ARBITRATION: If we admit liability for any claim but any difference or dispute arises as to
the amount payable for any claim the same shall be decided by reference to Arbitration.

The Arbitrator shall be appointed in accordance with the provisions of the Arbitration and
Conciliation Act, 1996.

No reference to Arbitration shall be made unless We have Admitted our liability for a
claim in writing.

If a claim is declined and within 12 calendar months from such disclaimer any suit or
proceeding is not filed then the claim shall for all purposes be deemed to have been
abandoned and shall not thereafter be recoverable hereunder.