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13 views36 pages

Policy Wordings

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abhiyog.1605

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TATA AIG General Insurance Company Limited (We, Our

or Us) will provide the insurance cover, described in this

Policy and any endorsements thereto, for the Insured
Period, as defined in the Policy schedule. The insurance
cover provided under this Policy is only with respect to
such and so many of the benefits upto the Sum Insured
as mentioned in the Policy Schedule. Commencement
of risk cover under the policy is subject to receipt of
premium by us.
The statements provided in the Proposal by the
Policyholder (You) shall be the basis of this Policy and
are deemed to be incorporated herein. The insurance
cover is governed by and subject to, the terms,
conditions and exclusions of this Policy.
For TATA AIG General Insurance Company
Limited

Authorized Signatory

Registered Office:
Peninsula Business Park, Tower A,
15th Floor, G. K. Marg,
Lower Parel, Mumbai- 400013,
Maharashtra, India
24x7 Toll Free No. 1800 266 7780 or 1800 22 9966
(Senior Citizen)
Visit us at www.tataaig.com
IRDA of India Registration No.:108
CIN: U85110MH2000PLC128425
UIN: TATHLIP23179V012223
“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.
1

Registered Office: Peninsula Business Park, Tower A, 15th Floor, G.K. Marg, Lower Parel, Mumbai - 400013,
24x7 Toll Free No: 1800 266 7780 or 1800 22 9966 (Senior Citizen)| Email: customersupport@tataaig.com
Website: www.tataaig.com | IRDA of India Registration No: 108 | CIN: U85110MH2000PLC128425
Tata AIG Elder Care UIN: TATHLIP23179V012223
Preamble illness and includes relapse within 45 days
from the date of last consultation with the
While the policy is in force, if the Insured Person Hospital/Nursing Home where treatment
contracts any disease or suffers from any illness was taken.
or sustains bodily injury through accident and
if such event requires the Insured Person 3. AYUSH Day Care Centre^
to incur expenses for Medically Necessary
Treatment, We will indemnify You for the AYUSH Day Care Centre means and
amount of such Reasonable and Customary includes Community Health Centre
Charges or compensate to the extent agreed, (CHC), Primary Health Centre (PHC),
up to the limits mentioned, subject to terms and Dispensary, Clinic, Polyclinic or any such
conditions of the Policy. Each Benefit is subject health centre which is registered with the
to its Sum Insured/ sub limit/ co-payment, but local authorities, wherever applicable and
Our liability in aggregate to make payment in having facilities for carrying out treatment
respect of any and all Benefits shall be limited procedures and medical or surgical/para-
to the Sum Insured unless expressly stated to surgical interventions or both under the
the contrary. supervision of registered AYUSH Medical
Practitioner (s) on day care basis without
In case of family floater policy, the sum insured in-patient services and must comply with
for all or any of the benefits shall be on a per all the following criterion:
policy per year basis unless explicitly stated to
the contrary. In case of individual policy, the sum i. Having qualified registered AYUSH
insured for all or any of the benefits shall be on Medical Practitioner(s) in charge;
per insured per year basis unless explicitly stated
ii. Having dedicated AYUSH therapy
to the contrary.
sections as required and/or has
The said Medically Necessary Treatment must be equipped operation theatre where
on the advice of a qualified Medical Practitioner. surgical procedures are to be carried
out;
Section 1 – Definitions
iii. Maintaining daily records of the
The terms defined below and at other junctures patients and making them accessible
in the Policy Wording have the meanings to the insurance company’s
ascribed to them wherever they appear in this authorized representative.
Policy and where appropriate, references to
4. AYUSH Hospital
the singular include references to the plural;
references to the male include other genders An AYUSH Hospital is a healthcare facility
and references to any statutory enactment wherein medical/surgical/para-surgical
include subsequent changes to the same: treatment procedures and interventions
are carried out by AYUSH Medical
i. Standard Definitions
Practitioner(s) comprising of any of the
following:
1. Accident
a. Central or State Government AYUSH
An accident means sudden, unforeseen
Hospital or
and involuntary event caused by external,
visible and violent means. b. Teaching hospital attached to AYUSH
college recognized by the Central
2. Any one illness
Government/ Central Council of
Any one illness means continuous period of Indian Medicine/ Central Council for

Cashless facility means a facility extended 10. Day Care Centre

by the insurer to the insured where the
A day care centre means any institution
payments, of the costs of treatment
established for day care treatment of illness
undergone by the insured in accordance
and/or injuries or a medical setup with a
with the policy terms and conditions, are
hospital and which has been registered
directly made to the network provider by
with the local authorities, wherever
the insurer to the extent pre-authorization
applicable, and is under supervision
is approved.
of a registered and qualified medical
6. Condition Precedent practitioner AND must comply with all
minimum criterion as under –
Condition Precedent means a policy terms
or condition upon which the insurer’s i. has qualified nursing staff under its
liability under the policy is conditional employment;
upon.
ii. has qualified medical practitioner/s
7. Congenital Anomaly: in charge;

iii. has fully equipped operation theatre

11. Day Care Treatment i. has qualified nursing staff under its
employment round the clock;
Day care treatment means medical
treatment, and/or surgical procedure ii. has at least 10 in-patient beds in
which is: towns having a population of less
than 10,00,000 and at least 15 in-
i. undertaken under General or Local patient beds in all other places;
Anesthesia in a hospital/day care
centre in less than 24 hrs because of iii. has qualified medical practitioner(s)
technological advancement, and in charge round the clock;

ii. which would have otherwise required iv. has a fully equipped operation
hospitalization of more than 24 theatre of its own where surgical
hours. procedures are carried out;

Treatment normally taken on an out- v. maintains daily records of patients

patient basis is not included in the and makes these accessible to the
scope of this definition. insurance company’s authorized
personnel;
12. Dental Treatment
15. Hospitalization
Dental treatment means a treatment
related to teeth or structures supporting Hospitalization means admission in a
teeth including examinations, fillings Hospital for a minimum period of 24
(where appropriate), crowns, extractions consecutive ‘In-patient Care’ hours except
and surgery. for specified procedures/ treatments,
where such admission could be for a
13. Grace Period period of less than 24 consecutive hours.
Grace period means the specified period of 16. Illness
time immediately following the premium
due date during which a payment can be Illness means a sickness or a disease
made to renew or continue a policy in force or pathological condition leading to the
without loss of continuity benefits such impairment of normal physiological
as waiting periods and coverage of pre- function and requires medical treatment.
existing diseases. Coverage is not available
for the period for which no premium is (a) Acute condition
received.
Acute condition is a disease, illness or
14. Hospital injury that is likely to respond quickly
to treatment which aims to return the
A hospital means any institution established person to his or her state of health
for in-patient care and day care treatment immediately before suffering the
of illness and/or injuries and which has
4

(b) Chronic condition 20. Medical Advice

A chronic condition is defined as Medical Advice means any consultation

a disease, illness, or injury that or advice from a Medical Practitioner
has one or more of the following including the issuance of any prescription
characteristics: or follow-up prescription.

i. it needs ongoing or long- 21. Medical Expenses:

term monitoring through
consultations, examinations, Medical Expenses means those expenses
check-ups, and /or tests that an Insured Person has necessarily and
actually incurred for medical treatment
ii. it needs ongoing or long-term on account of Illness or Accident on the
control or relief of symptoms advice of a Medical Practitioner, as long as
these are no more than would have been
iii. it requires rehabilitation for the payable if the Insured Person had not been
patient or for the patient to be insured and no more than other hospitals
specially trained to cope with it or doctors in the same locality would have
charged for the same medical treatment.
iv. it continues indefinitely
22. Medical Practitioner
v. it recurs or is likely to recur
Medical Practitioner means a person who
17. Injury holds a valid registration from the Medical
Council of any State or Medical Council of
Injury means accidental physical bodily
India or Council for Indian Medicine or for
harm excluding illness or disease solely
Homeopathy set up by the Government of
and directly caused by external, violent,
India or a State Government and is thereby
visible and evident means which is verified
entitled to practice medicine within its
and certified by a Medical Practitioner.
jurisdiction; and is acting within its scope
and jurisdiction of license.
18. Inpatient Care
23. Medically Necessary Treatment
Inpatient care means treatment for which
the insured person has to stay in a hospital
Medically necessary treatment means any
for more than 24 hours for a covered event.
treatment, tests, medication, or stay in
hospital or part of a stay in hospital which:
19. Intensive Care Unit:
i. is required for the medical
Intensive care unit means an identified
management of the illness or injury
section, ward or wing of a hospital which
suffered by the insured;
is under the constant supervision of
a dedicated medical practitioner(s),
ii. must not exceed the level of care
and which is specially equipped for the
necessary to provide safe, adequate
continuous monitoring and treatment of
and appropriate medical care in
patients who are in a critical condition,
scope, duration, or intensity;
or require life support facilities and
where the level of care and supervision iii. must have been prescribed by a
is considerably more sophisticated and
5

24. Migration 29. Pre-hospitalization Medical Expenses

“Migration” means, the right accorded to Pre-hospitalization Medical Expenses

health insurance policyholders (including means medical expenses incurred during
all members under family cover and predefined number of days preceding
members of group health insurance the hospitalization of the Insured Person,
policy), to transfer the credit gained for provided that:
pre-existing conditions and time bound
exclusions, with the same insurer. i. Such Medical Expenses are incurred
for the same condition for which the
25. Network Provider Insured Person’s Hospitalization was
required, and
Network Provider means hospitals or
health care providers enlisted by an ii. The In-patient Hospitalization claim
insurer, TPA or jointly by an Insurer and for such Hospitalization is admissible
TPA to provide medical services to an by the Insurance Company.
insured by a cashless facility.
30. Portability
26. Notification of Claim
“Portability” means, the right accorded to
Notification of claim means the process individual health insurance policyholders
of intimating a claim to the insurer or TPA (including all members under family
through any of the recognized modes of cover), to transfer the credit gained for
communication. pre-existing conditions and time bound
exclusions, from one insurer to another
27. OPD treatment insurer.
OPD treatment means the one in which 31. Post-hospitalization Medical Expenses
the Insured visits a clinic / hospital or
associated facility like a consultation room Post-hospitalization Medical Expenses
for diagnosis and treatment based on means medical expenses incurred during
the advice of a Medical Practitioner. The predefined number of days immediately
Insured is not admitted as a day care or after the insured person is discharged from
in-patient. the hospital provided that:

28. Pre-Existing Disease i. Such Medical Expenses are for

the same condition for which the
Pre-existing Disease means any condition, insured person’s hospitalization was
ailment, injury or disease: required, and
a. That is/are diagnosed by a physician ii. The inpatient hospitalization claim for
within 48 months prior to the such hospitalization is admissible by
effective date of the policy issued by the insurance company.
the insurer or its reinstatement or

33. Reasonable and Customary Charges 38. Age

Reasonable and Customary charges means Means the completed age of the Insured
the charges for services or supplies, which Person on his / her most recent birthday
are the standard charges for the specific as per the English calendar, regardless of
provider and consistent with the prevailing the actual time of birth.
charges in the geographical area for
identical or similar services, taking into 39. Policy
account the nature of the illness / injury
Policy means the contract of insurance
involved.
including but not limited to Policy Schedule,
34. Renewal Endorsements, Policy Wordings and Riders

Renewal means the terms on which the 40. Policy Period

contract of insurance can be renewed on
Policy Period means the time during
mutual consent with a provision of grace
which this Policy is in effect. Such period
period for treating the renewal continuous
commences from Commencement Date
for the purpose of gaining credit for pre-
and ends on the Expiry Date and specifically
existing diseases, time-bound exclusions
appears in the Policy Schedule.
and for all waiting periods.
41. Policy Schedule
35. Room Rent
Policy Schedule means the Policy Schedule
Room Rent means the amount charged
attached to and forming part of Policy.
by a Hospital towards Room and Boarding
expenses and shall include the associated 42. Policy Year
medical expenses.
Policy Year means a period of twelve
36. Surgery or Surgical Procedure months beginning from the date of
commencement of the Policy period
Surgery or Surgical Procedure means
and ending on the last day of such
manual and / or operative procedure
twelve-month period. For the purpose of
(s) required for treatment of an illness
subsequent years, policy year shall mean
or injury, correction of deformities and
a period of twelve months commencing
defects, diagnosis and cure of diseases,
from the end of the previous policy year
relief from suffering and prolongation of
and lapsing on the last day of such twelve-
life, performed in a hospital or day care
month period, till the Policy Expiry date.
centre by a medical practitioner.
43. Single Private Room
37. Unproven/Experimental treatment
Single Private Room means an air-
Unproven/Experimental treatment means
conditioned room in a hospital where
the treatment including drug experimental
a single patient is accommodated and
therapy which is not based on established
which has an attached toilet (lavatory
7

Registered Office: Peninsula Business Park, Tower A, 15th Floor, G.K. Marg, Lower Parel, Mumbai - 400013,
24x7 Toll Free No: 1800 266 7780 or 1800 22 9966 (Senior Citizen)| Email: customersupport@tataaig.com
Website: www.tataaig.com | IRDA of India Registration No: 108 | CIN: U85110MH2000PLC128425
Tata AIG Elder Care UIN: TATHLIP23179V012223
and bath). Such room type shall be the charged by the Hospital where the
most basic and the most economical of insured person availed medical
all accommodations available as a single treatment;
occupancy room in that Hospital. This does
not include a deluxe room or a suite or a ii. Fees charged by surgeon,
VIP room. anaesthetist, specialist, medical
practitioner
Section 2 – Benefits
Note: Associated Medical Expenses shall
The following benefits are payable subject to be applicable for Hospitals which follow
Terms and Conditions of the policy: differential billing based on the room
category.
B1. In-Patient Treatment
B2. Pre-Hospitalization expenses
We will cover for expenses for
hospitalization due to disease/illness/Injury We will cover for expenses for Pre-
during the policy period that requires an Hospitalization consultations,
Insured Person’s admission in a hospital investigations and medicines incurred
as an inpatient. upto 30 days before the date of admission
to the hospital.
Medical expenses directly related to the
hospitalization would be payable. The benefit is payable if We have admitted
a claim under B1 or B7.
If the Insured Person is admitted in a room
which is of higher category than Single B3. Post-Hospitalization expenses
Private, then the Insured Person shall
bear a rateable proportion of the total We will cover for expenses for Post-
Associated Medical Expenses (including Hospitalization consultations,
surcharge or taxes thereon), except investigations and medicines incurred upto
pharmacy charges, diagnostic costs, 60 days after discharge from the hospital.
costs of implants & medical devices and
consumables expenses, in the same The benefit is payable if We have admitted
proportion as the difference between the a claim under B1 or B7.
Incurred Room Rent and the Single Private
B4. Home Physiotherapy
Room Rent in that Hospital bears to the
Incurred Room Rent.
We will provide up to 10 physiotherapy
sessions at home within India, wherever
Expenses to be borne by Insured Person
available within the city in which you
={(Associated Medical Expenses) X
reside. This benefit will be arranged
(Incurred Room Rent– Eligible Room Rent
through our empanelled service provider
of the Eligible Room Category)} /Incurred
only and will be subject to following
Room Rent
conditions:
Associated Medical Expenses:
• The benefit is payable only if a claim
Below listed medical expenses, which vary is admissible for Joint Replacement
in accordance with the Room Rent or Room surgery, Stroke or Paralysis under
Category applicable in a Hospital: section B1 or B7 of this policy.

i. Room, boarding, nursing and • This benefit shall form the part of Post
operation theatre expenses as Hospitalization period.

Registered Office: Peninsula Business Park, Tower A, 15th Floor, G.K. Marg, Lower Parel, Mumbai - 400013,
24x7 Toll Free No: 1800 266 7780 or 1800 22 9966 (Senior Citizen)| Email: customersupport@tataaig.com
Website: www.tataaig.com | IRDA of India Registration No: 108 | CIN: U85110MH2000PLC128425
Tata AIG Elder Care UIN: TATHLIP23179V012223
• Limit on physiotherapy sessions is • In locations where we do
applicable to each insured person, not have empanelled service
per policy year. providers to offer this service,
We will reimburse up to `1000
• The said physiotherapy must be Per day for a maximum period
advised in writing by the treating of 7 days per person in a policy
medical practitioner. year, incurred by you, provided
such services are availed
• Any unutilized service will lapse at through a qualified nurse.
the end of the policy year and will not
be carried forward to the next policy b. Personalized Health Manager
year.
We/ our empaneled service provider
B5. Post Operative Care will offer telephonic assistance of a
personalized health manager, who
a. Home Nursing Services will assist in booking appointments of
the insured person and coordinating
If an insured person is hospitalized
with providers for below listed
for a medically necessary surgery
services, as per insured person’s
and requires to be attended by a
requirement.
Qualified Nurse after the discharge
from the hospital, to avail post- Personalized Health Manager shall
operative care, We will arrange for a only be responsible for booking
qualified nurse at home within India, and coordination on call, whereas,
wherever available, within the city in booking fees, cost of items or service
which you reside. This service will be charges, if any, shall be borne by
arranged through our empanelled the insured person. Coverage under
service provider and will be available this benefit will be subject to below
for a maximum period of 7 days per conditions:
person in a policy year. Coverage
under this benefit will be subject to • Services of Personalized Health
below conditions: Manager will be available only
during the Post Hospitalization
• Home Nursing Services shall period after a claim.
be availed within the Post
Hospitalization period for the • A hospitalization claim
claim. is admissible for medically
necessary surgery under B1 or
• The hospitalization claim is B7 of this policy.
admissible under B1 or B7.
Personalized Health Manager will help
• The said services must be in arranging and co ordinating below
advised in writing by the services:
treating medical practitioner.
i. Physiotherapy at home
• Any unutilized days of home
nursing services will lapse and ii. Nursing at home
will not be carried forward to
other insured person or to the iii. Compassionate Care attendant at
next policy year. home

B6. Compassionate Care (c) Transferring: the ability to move

from a bed to an upright chair or
If an insured person is hospitalized for a wheelchair and vice versa;
medically necessary treatment and post
discharge from the hospital is unable to (d) Mobility: the ability to move indoors
perform three or more of the below listed from room to room on level surfaces;
‘Activities of Daily Living’ independently
simultaneously, We will arrange for a (e) Toileting: the ability to use the
compassionate caregiver at the insured lavatory or otherwise manage
person’s home within India, wherever bowel and bladder functions so as
available. This service will be available, to maintain a satisfactory level of
through our empanelled service provider personal hygiene;
and for a maximum period of 14 days
per person in a policy year. Coverage (f) Feeding: the ability to feed oneself
under this benefit will be subject to below once food has been prepared and
conditions: made available.

• Compassionate care Services shall be B7. Day Care Procedures

availed within the Post Hospitalization
period for the claim. We will cover expenses for Day Care
Treatment due to disease/illness/Injury
• The hospitalization claim is admissible during the policy period taken at a hospital
under B1 or B7. or a Day Care Centre.

• Any unutilized days of compassionate Treatment normally taken on out-patient

care services will lapse and will not basis is not included in the scope of this
be carried forward to other insured cover.
person or to the next policy year.
B8. AYUSH Benefit^
• In locations where we do not have
empanelled service providers to offer We will cover Medical Expenses incurred
this service, We will reimburse up to for treatment as In-Patient or Day Care
`750 Per day for a maximum period Treatment in an AYUSH Hospital/ AYUSH
of 14 days per person in a policy year, day care centre, subject to applicability of
incurred by you. Associated Medical Expenses.

‘Activities of Daily Living’ This benefit shall also cover Pre-

Hospitalization medical expenses for a
Means below mentioned activities: period of upto 30 days before the date of
admission to the AYUSH hospital/ AYUSH
(a) Washing: the ability to wash in the day care centre and Post-Hospitalization
bath or shower (including getting Medical Expenses for a period upto 60 days,
into and out of the bath or shower) subject to AYUSH In-Patient hospitalization
or wash satisfactorily by other means; or AYUSH day care treatment claim being
admissible under this benefit.

Registered Office: Peninsula Business Park, Tower A, 15th Floor, G.K. Marg, Lower Parel, Mumbai - 400013,
24x7 Toll Free No: 1800 266 7780 or 1800 22 9966 (Senior Citizen)| Email: customersupport@tataaig.com
Website: www.tataaig.com | IRDA of India Registration No: 108 | CIN: U85110MH2000PLC128425
Tata AIG Elder Care UIN: TATHLIP23179V012223
Claims under this section shall be assessed e. Liver Function Test
as per the insurance guidelines related to
AYUSH and benchmark rates as available f. Electrocardiogram (ECG) Test
on Ministry of AYUSH website (https://
g. Urine Routine Analysis
ayushnext.ayush.gov.in/site/insurance-
guidelines-related-to-ayush). For the purpose of this benefit, Preventive
Health Check-up means medical test(s)
B9. Road Ambulance Cover
undertaken for general assessment of
We will cover for expenses incurred on health status and does not include any
transportation of Insured Person in a diagnostic or investigative medical tests
registered road ambulance to a Hospital for evaluation of illness or a disease.
for admission in case of an Emergency or
B11. Annual Preventive Health Consultation
from one hospital to another hospital for
better medical facilities and treatment, We/ our empaneled service provider
subject to a maximum of `5000 per will provide below preventive health
Hospitalization. consultations once every policy year.
These consultations will be available for
Mandatory co-payment of 20% shall not be
all Insured Persons covered under the
applicable on claim under this section.
Policy provided the policy is inforce with
For a claim to be payable under this us. Coverage under this benefit will not be
section, the claim must be admissible available on reimbursement basis.
under section B1 or B7 of this policy.
Health Consultations available for:
B10. Preventive Health Checkup
a. Dental Check up
We/ our empaneled service provider will
b. Eye Check up/ Ophthalmologist
provide below listed medical tests after a
Consultation
block of every two continuous claim free
years provided the policy is inforce with c. Orthopedic Consultation
us. Further utilization of benefit by insured
person under benefits B11 or B17 of this For the purpose of this benefit, Preventive
policy will not be considered as a claim. consultation means consultation(s)
undertaken for general assessment of
Health Check Up will be available for all health status and does not include any
Insured Persons covered under the Policy. investigative or follow up consultation(s)
Coverage under this benefit will not be for evaluation of illness or a disease.
available on reimbursement basis.
B12. Consumables Benefit
List of Health Check Ups:
We will pay for expenses incurred, for
a. Complete Blood Count with specified consumables which are listed
Erythrocyte Sedimentation Rate (CBC in ‘Annexure – 1 List 1 as Optional Items’
with ESR) test under ‘Master Circular on Standardization
of Health Insurance Products, 2020’ and
b. Fasting Blood Sugar Test
its amendments, which are consumed
c. Hemoglobin A1C Test during the period of hospitalization directly
related to the insured’s medical or surgical
d. Lipid Profile Test treatment of illness/disease/injury. Details
of Annexure I-List I-Optional items are
11

However, the following items shall be iv. In relation to a Family Floater, the
excluded from scope of this coverage: Cumulative Bonus so applied will
only be available in respect of those
• Items of personal comfort, toiletries, Insured Persons who were Insured
cosmetics and convenience shall be Persons in the claim free Policy Year
excluded from scope of this coverage. and continue to be Insured Persons
in the subsequent Policy Year.
• External durable devices like Bilevel
Positive Airway Pressure (BIPAP) v. For purpose of computation of
machine, Continuous Positive Airway Cumulative Bonus, the percentage
Pressure (CPAP) machine, Peritoneal (%) of Cumulative Bonus will be
Dialysis (PD) equipment and supplies, applied on the base Sum Insured
Nimbus/water/air bed, dialyzer and only.
other medical equipments.
B14. Medical Second Opinion
• Any item which is neither medical
consumable nor medically necessary We will provide You a medical second
nor prescribed by doctor. opinion from Network Provider, if an
Insured Person is diagnosed with the
For this claim to be paid, the main claim below mentioned Illnesses during the
must be admissible under section B1 or Policy Period. The expert opinion would
B7 of this policy. be directly sent to the Insured Person.

B13. Cumulative Bonus I. Cancer

i. 10% cumulative bonus will be applied II. Open Chest CABG

on the Sum Insured for next policy
year under the Policy after every III. First Heart Attack
claim free Policy Year, provided
that the Policy is renewed with Us IV. Kidney Failure
and without a break. The maximum
accrued cumulative bonus shall not V. Major Organ/Bone Marrow
exceed 100% of the Sum Insured in Transplant
any Policy Year.
VI. Multiple Sclerosis
ii. If a Cumulative Bonus has been
VII. Permanent Paralysis of Limbs and
applied and a claim is made, then
Stroke
in the subsequent Policy Year We
will automatically decrease the
This benefit can be availed by an insured
Cumulative Bonus by 10% of the
person once during a Policy Year.
Sum Insured in that following Policy
Year. There will be no impact on B15. High End Diagnostics
the Inpatient Sum Insured, only the
accrued Cumulative Bonus will be We will cover for reasonable charges
decreased. incurred for the following diagnostic tests
only on OPD basis if required as part of a
iii. In policies with a tenure of more than medically necessary treatment subject to
one year, the above guidelines of a maximum `20,000 per policy year:

We will cover for reasonable and customary g. In case the insured intends to
medical expenses incurred for treatment avail the services of non-network
taken at home, which are “Equivalent provider, claim shall be subject to
Medical charges” as defined in this policy, reimbursement, a prior approval
for below specified conditions/illness up to from the insurer needs to be taken
10% of the sum insured (excluding accrued before availing such services from
cumulative bonus) for the Insured Person’s a registered home care provider.
medically necessary treatment at home. Insurer shall respond to approval
request within 4 working hours
Home Care Treatment means treatment of receiving the last necessary
availed by the Insured Person at home requirement.
for below listed conditions/ illness/
procedures, which in normal course Specified conditions/ illness covered under
would require hospitalization of more than Home care treatment:
24 hours or would have been admissible
under Day Care Procedures but is actually a. Dialysis at home
taken at home provided that:
b. Chemotherapy at home
a. The medical practitioner advices the
c. Pandemic Care at home (Pandemic
insured person to undergo treatment
as defined and declared by World
at home.
Health Organization (WHO) or any

Registered Office: Peninsula Business Park, Tower A, 15th Floor, G.K. Marg, Lower Parel, Mumbai - 400013,
24x7 Toll Free No: 1800 266 7780 or 1800 22 9966 (Senior Citizen)| Email: customersupport@tataaig.com
Website: www.tataaig.com | IRDA of India Registration No: 108 | CIN: U85110MH2000PLC128425
Tata AIG Elder Care UIN: TATHLIP23179V012223
equivalent healthcare authority) through telecommunication and
digital communication technologies
In this benefit, the following shall be for insured person’s health related
covered if prescribed by the treating complaints or preventive health care
medical practitioner and is related to by a qualified Medical Practitioner.
treatment covered under the policy,
This service can only be availed
a. Diagnostic tests undergone at home subject to the condition below:
or at diagnostics center
• Maximum 12 teleconsultations
b. Medicines prescribed in writing per policy year will be offered
to each insured person covered
c. Consultation charges of the medical under the policy
practitioner
• Consultation will be provided
d. Nursing charges related to medical through various specified
staff modes of communication
(including but not limited to) like
e. Medical procedures limited
audio, video, online portal, chat,
to parenteral administration of
digital customer application or
medicines
any other digital mode.
f. Including but not limited to cost of
• If unutilised, the balance
Pulse Oximeter, Oxygen cylinder and
teleconsultation services will
nebulizer wherever applicable
lapse and will not be carried
forward to the next policy year.
For the purpose of this cover, “Equivalent
It will be the Insured Person’s
Medical charges” shall mean the charges
choice and responsibility to
for services or supplies, which are the
utilise the same within the
standard/equivalent charges for the
designated policy year. We shall
specific provider and not more than the
not be liable to provide any
prevailing charges in the geographical area
reminders or notifications for
for identical or similar services taken on
the same.
inpatient/day care basis, considering the
nature of the illness / injury involved.
b. Diet and Nutrition Consultation
B17. Wellness Services
With an objective of maintaining
good health, we / our empanelled
We / Our Empanelled Service Provider
service provider will offer diet
will provide below mentioned wellness
and nutrition consultation to the
services designed to assist insured persons
insured person. Consultation will
in maintaining and improving good health
be available on request and only
and fitness. These Wellness Services will be
through telecommunication and
available for the insured person during the
digital communication technologies
policy period and as specified in the Policy
(including but not limited to) like
schedule.
audio, video, online portal, chat,
a. Teleconsultation– General digital customer application or any
other digital mode.
We /Our empanelled Service Provider
will arrange for teleconsultations c. Discounts from Network Providers
upon insured person’s request
14

Registered Office: Peninsula Business Park, Tower A, 15th Floor, G.K. Marg, Lower Parel, Mumbai - 400013,
24x7 Toll Free No: 1800 266 7780 or 1800 22 9966 (Senior Citizen)| Email: customersupport@tataaig.com
Website: www.tataaig.com | IRDA of India Registration No: 108 | CIN: U85110MH2000PLC128425
Tata AIG Elder Care UIN: TATHLIP23179V012223
We will offer discounts on diagnostic Policy, shall not be covered under this
tests, medicine, medical devices, Policy and all expenses incurred shall
health supplements and other health be borne by the Insured Person.
related services offered through
our empanelled service providers. 3. We shall not be responsible for
Home delivery of pharmacy will also or liable for, any actions, claims,
be offered upon the request of the demands, losses, damages, costs,
insured person, wherever available. charges and expenses which Insured
Person claims to have suffered,
B18. Home Assessment and Modification for sustained or incurred, by way of and /
Elderly Care/ Disability or on account of the benefit. We shall
not be liable for any deficiency or
If an insured person is hospitalized for a discrepancy in the services provided
medically necessary treatment and post by empanelled service provider/
discharge from the hospital is required to network provider under this policy.
use a wheelchair/ ambulatory support then
we/ our empaneled service provider will 4. Insured Person may consult any
arrange for a home assessment to evaluate medical/ service professional at any
and recommend the modifications network provider/empanelled service
required in home to suit the mobility needs provider at its sole discretion. The
for elderly care/ disability. cost of service arising out of insured
Person choice of professional at
In addition, we will pay a fixed amount any network provider/empanelled
of `5000, to undertake home alteration, service provider shall completely be
if recommended by the home assessor borne by the Insured Person unless
arranged by us. Coverage under this covered otherwise. However, the
benefit is available subject to request for services under this policy should not
assessment received within six months be construed to constitute medical/
post discharge from the hospital and claim expert advice and/or substitute the
being admissible under section B1 of this Insured Person’s visit/ consultation to
policy. However, under this benefit the an independent Medical Practitioner/
claim will be paid only once in the policy Healthcare/ service professional.
lifetime for similar type of modification
recommended by our assessor. 5. Wherever applicable, the Medical
Practitioner may suggest/
Disclaimer (applicable to sections B4, recommend/prescribe over the
B5, B6, B10, B11, B14, B17, B18) counter medications based on the
information provided, if required on a
1. Availing service under any of these case-to-case basis. Provided that any
benefits is purely upon the Insured recommendation under this Policy
person’s sole discretion and risk. shall not be valid for any medico legal
purposes.
2. For services that are provided through
empanelled Service Providers, we are 6. The Insured Person is free to
acting as a facilitator; hence we would choose whether or not to act on
not be liable for any incremental the recommendation after seeking
costs or the services. Any additional consultation.
services availed, or expenses incurred
on such services or benefits which are 7. Any advice, recommendations or
other than those covered under this suggestions made by any medical/
policy and explicitly excluded by this service professional shall be solely
15

Registered Office: Peninsula Business Park, Tower A, 15th Floor, G.K. Marg, Lower Parel, Mumbai - 400013,
24x7 Toll Free No: 1800 266 7780 or 1800 22 9966 (Senior Citizen)| Email: customersupport@tataaig.com
Website: www.tataaig.com | IRDA of India Registration No: 108 | CIN: U85110MH2000PLC128425
Tata AIG Elder Care UIN: TATHLIP23179V012223
based on the information and Cumulative Bonus if applicable.
documentation provided by the
Insured Person to such professional. 13. We reserve the right to change any
We shall not be liable towards empanelled service provider during
any loss or damage (immediate the currency of the policy or at
or consequential) arising out renewal. The same shall be intimated
of or in relation to any service/ to the insured atleast 15 days prior to
opinion, advice, prescription, actual the effective date of change.
or alleged errors, omissions and
representations made by the 14. In case, We or the Empanelled
medical/ service professional from Service Provider fails to provide any
whom we have availed services or of the services as mentioned in this
taken benefit or for any consequence Policy or is unable to implement,
of any act or omission in reliance in whole or in part due to Force
thereon. Majeure, non-availability of Services,
change in law, rule or regulations
8. This facility may be availed through which affects the Services, or if any
our website or our mobile application regulatory or governmental agency
or through calling our call centre on having jurisdiction over a party
the toll free number specified in the takes a position which affects the
policy schedule. Alternatively, details services, then the Assistance Services’
of our empanelled service provider suspended, curtailed or limited
are available on our website (www. performance shall not constitute
tataaig.com). Breach of Contract and the Company
or the Empanelled Service Provider
9. We do not assume any liability shall have no liability whatsoever
towards quality and turnaround including but not limited to any loss
times of service rendered, any loss or or damage resulting therefrom.
damage arising out of or in relation
to these services rendered by the B19. Cost Sharing
empanelled service provider.
a. Mandatory Co-Payment
10. Above mentioned services are
non-portable, annual contracts, This policy is subject to a mandatory
independent of policy contract and co-payment of 20% and You shall be
not lifelong renewable. The Services liable to pay 20% of the admissible
provided may be added / deleted claim amount of each and every
/ modified at our discretion and claim. Co-payment shall be applicable
the same shall be notified to the for all claim under section B1, B2,
policyholders in advance prior to B3, B7, B8, B12, B15 and B16 of this
change effective date. policy.

11. Provision of these services is subject b. Sub-Limits on Specified Surgical

to availability as per the duration Procedure
specified by Us/the empanelled
The expenses payable during the
service provider. Details are available
entire policy year for following
on our website (www.tataaig.com)
surgical procedures, either as Day
12. Any service availed by the Insured Care or In-patient is limited to the
Person under section B10, B11 or amount mentioned in the table
B17 of this policy will not impact below:
16

We will neither be liable nor make any payment

Sum Insured Per Policy Year
for any claim in respect of any Insured Person
Zone of the which is caused by, arising from or in any way
insured attributable to any of the following exclusions,
(Premium unless expressly stated to the contrary in this
Payment `5 `25 Policy.
`10 Lacs
Zone, as Lacs Lacs
specified in i. Standard Exclusions
the policy
schedule) 1. Exclusions with waiting periods
` ` `
Zone A i. Pre-existing Diseases Waiting
50,000 75,000 1,00,000
Period (Code- Excl 01):
`
Zone B `47,500 `95,000
70,000 a. Expenses related to the
` ` ` treatment of a pre-existing
Zone C Disease (PED) and its direct
40,000 60,000 80,000
complications shall be excluded
b. Joint Replacement Surgery (per insured until the expiry of 24 months of
person) continuous coverage after the
date of inception of the first
Sum Insured Per Policy Year policy with us.

Zone of the b. In case of enhancement of sum

insured insured the exclusion shall
(Premium apply afresh to the extent of
Payment `5 `25 sum insured increase.
`10 Lacs
Zone, as Lacs Lacs
specified in c. If the Insured Person is
the policy continuously covered without
schedule) any break as defined under
` ` ` the portability norms of the
Zone A extant IRDAI (Health Insurance)
2,00,000 3,00,000 5,00,000
Regulations, then waiting period
` ` `
Zone B for the same would be reduced
1,90,000 2,85,000 4,75,000
to the extent of prior coverage.
` ` `
Zone C
1,60,000 2,50,000 4,00,000 d. Coverage under the policy after
the expiry of 24 months for any
• Sub-limits will also include the expenses pre-existing disease is subject
incurred on pre hospitalisation and post to the same being declared
hospitalisation expenses. at the time of application and
accepted by us.
• Mandatory co-payment of 20% shall not
be applicable on claim incurred for these ii. Specified Disease/Procedure Waiting
surgical procedures. Period (Code- Excl 02):

a. Expenses related to the treatment

of the listed Conditions, surgeries/

V. Endometriosis XXVII. Adenoidectomy

VI. Prolapsed Uterus XXVIII. Mastoidectomy

VII. Non-infective arthritis XXIX. Tonsillectomy

VIII. Gout and Rheumatism XXX. Tympanoplasty

a. Expenses related to the treatment of ii. Any services for people

any illness within 30 days from the who are terminally ill to
first policy commencement date shall address physical, social,
be excluded except claims arising due emotional and spiritual
to an accident, provided the same are needs.
covered.
iii. Obesity/ Weight Control (Code- Excl
b. This exclusion shall not, however, 06):
apply if the Insured Person has
Expenses related to surgical
Continuous Coverage for more than
treatment of obesity that does not
twelve months.
fulfil the below conditions:
c. The within referred waiting period
a. Surgery to be conducted is upon
is made applicable to the enhanced
the advice of the Doctor.
sum insured in the event of granting
higher sum insured subsequently.
b. The surgery/Procedure
conducted should be supported
2. Medical Exclusions
by clinical protocols.
i. Investigation and evaluation

Registered Office: Peninsula Business Park, Tower A, 15th Floor, G.K. Marg, Lower Parel, Mumbai - 400013,
24x7 Toll Free No: 1800 266 7780 or 1800 22 9966 (Senior Citizen)| Email: customersupport@tataaig.com
Website: www.tataaig.com | IRDA of India Registration No: 108 | CIN: U85110MH2000PLC128425
Tata AIG Elder Care UIN: TATHLIP23179V012223
c. The member has to be 18 years (Code- Excl 12).
of age or older and
vii. Treatments received in heath
d. Body Mass Index (BMI); hydros, nature cure clinics, spas or
similar establishments or private
i. greater than or equal to 40 beds registered as a nursing home
or attached to such establishments or
where admission is arranged wholly
ii. greater than or equal to or partly for domestic reasons.
35 in conjunction with any (Code- Excl13)
of the following severe
co-morbidities following viii. Dietary supplements and substances
failure of less invasive that can be purchased without
methods of weight loss: prescription, including but not limited
to Vitamins, minerals and organic
1. Obesity-related substances unless prescribed by
cardiomyopathy a medical practitioner as part of
hospitalization claim or day care
2. Coronary heart
procedure. (Code-Excl14)
disease
ix. Refractive error (Code- Excl 15):
3. Severe Sleep Apnea
Expenses related to the treatment
for correction of eye sight due to
4. Uncontrolled Type2
refractive error less than 7.5 dioptres.
Diabetes
x. Unproven treatments (Code-
iv. Change-of-Gender treatments:
Excl 16): Expenses related to any
Code- Excl07:
unproven treatment, services and
Expenses related to any treatment, supplies for or in connection with
including surgical management, to any treatment. Unproven treatments
change characteristics of the body to are treatments, procedures or
those of the opposite sex. supplies that lack significant medical
documentation to support their
v. Cosmetic or Plastic Surgery (Code- effectiveness.
Excl 08):
xi. Sterility and Infertility (Code- Excl
Expenses for cosmetic or plastic 17):
surgery or any treatment to change
appearance unless for reconstruction Expenses related to Sterility and
following an Accident, Burn(s) or infertility. This includes:
Cancer or as part of medically
i. Any type of contraception,
necessary treatment to remove a
sterilization
direct and immediate health risk to
the insured. For this to be considered
ii. Assisted Reproduction services
a medical necessity, it must be
including artificial insemination
certified by the attending Medical
and advanced reproductive
Practitioner.
technologies such as IVF, ZIFT,
GIFT, ICSI
vi. Treatment for, Alcoholism, drug or
substance abuse or any addictive
iii. Gestational Surrogacy
condition and consequences thereof
20

a. Medical treatment expenses traceable 1. Medical Exclusions

to childbirth (including complicated
deliveries and caesarean sections i. Alcoholic pancreatitis
incurred during hospitalization)
except ectopic pregnancy; ii. Congenital External Diseases, defects
or anomalies;
b. Expenses towards miscarriage
(unless due to an accident) and lawful iii. S t e m c e l l t h e r a p y ; h o w e v e r ,
medical termination of pregnancy hematopoietic stem cells for bone
during the policy period. marrow transplant for haematological
conditions will be covered under
3. Non-Medical Exclusions benefit B1 or B7 of this policy

i. Hazardous or Adventure Sports iv. Growth Hormone Therapy

(Code- Excl 09):
v. Sleep-apnoea
Expenses related to any treatment
necessitated due to participation vi. A d m i s s i o n p r i m a r i l y f o r
as a professional in hazardous or administration of Intra-articular
adventure sports, including but or intra-lesional injections or
not limited to, para-jumping, rock Intravenous immunoglobulin infusion
climbing, mountaineering, rafting, or supplementary medications like
motor racing, horse racing or scuba Zolendronic Acid
diving, hand gliding, sky diving, deep-
sea diving. vii. V e n e r e a l d i s e a s e , s e x u a l l y
transmitted disease or illness;
ii. Breach of law (Code- Excl 10):
viii. All preventive care, vaccination
Expenses for treatment directly including inoculation and
arising from or consequent upon immunisations (except in case of
any Insured Person committing or post- bite treatment and other
attempting to commit a breach of law vaccines explicitly covered);
with criminal intent.
ix. Dental treatment or surgery of any
iii. Excluded Providers: (Code-Excl 11): kind

Expenses incurred towards treatment x. Any existing disease specifically

in any hospital or by any Medical mentioned as Permanent exclusion
Practitioner or any other provider in the Policy Schedule.
specifically excluded by the Insurer
and disclosed in its website / 2. Non-Medical Exclusions
notified to the policyholders are not
i. War or any act of war, invasion, act
admissible. However, in case of life
of foreign enemy, war like operations
threatening situations or following an
(whether war be declared or not or
accident, expenses up to the stage of
caused during service in the armed
stabilization are payable but not the
forces of any country), civil war,
complete claim.
public defence, rebellion, revolution,
21

iv. Items of personal comfort and Section 4 – General Terms and Clauses
convenience like television (wherever
specifically charged for), charges for i. Standard General Terms & Clauses
access to telephone and telephone
calls, internet, foodstuffs (except 1. Disclosure of Information
patient’s diet), cosmetics, hygiene
articles, body care products and bath The policy shall be void and all
additive, barber or beauty service, premium paid thereon shall be
guest service. forfeited to the Company in the event
of misrepresentation, misdescription
v. Treatment rendered by a Medical or non-disclosure of any material fact
Practitioner which is outside his by the policyholder.
discipline.
(Explanation: “Material facts” for the
vi. Doctor’s fees charged by the Medical purpose of this policy shall mean
Practitioner sharing the same all relevant information sought by
residence as an Insured Person or the company in the proposal form
who is an immediate relative of an and other connected documents to
Insured Person’s family. enable it to take informed decision in
the context of underwriting the risk)
vii. Provision or fitting of hearing aids,
spectacles or contact lenses including 2. Condition Precedent to Admission
optometric therapy unless explicitly of Liability
stated and covered in the policy.
The terms and conditions of the
viii. Any treatment and associated policy must be fulfilled by the insured
expenses for alopecia, baldness, person for the Company to make any
wigs, or toupees, medical supplies payment for claim(s) arising under
including elastic stockings, diabetic the policy.
test strips, and similar products.
3. Claim Settlement (provision for
ix. Any treatment or part of a treatment Penal Interest)
that is not a part of ‘Reasonable and
Customary charges’, not medically i. The Company shall settle or
necessary; drugs or treatments which reject a claim, as the case may
are not supported by a prescription. be, within 30 days from the
date of receipt of last necessary
x. Crutches or any other external document.
appliance and/or device used for

Registered Office: Peninsula Business Park, Tower A, 15th Floor, G.K. Marg, Lower Parel, Mumbai - 400013,
24x7 Toll Free No: 1800 266 7780 or 1800 22 9966 (Senior Citizen)| Email: customersupport@tataaig.com
Website: www.tataaig.com | IRDA of India Registration No: 108 | CIN: U85110MH2000PLC128425
Tata AIG Elder Care UIN: TATHLIP23179V012223
ii. In the case of delay in the 5. Multiple Policies
payment of a claim, the
Company shall be liable to pay i. In case of multiple policies
interest to the policyholder taken by an insured person
from the date of receipt of last during a period from one or
necessary document to the date more insurers to indemnify
of payment of claim at a rate 2% treatment costs, the insured
above the bank rate. person shall have the right to
require a settlement of his/
iii. However, where the her claim in terms of any of
circumstances of a claim his/her policies. In all such
warrant an investigation in cases the insurer chosen by the
the opinion of the Company, it insured person shall be obliged
shall initiate and complete such to settle the claim as long as the
investigation at the earliest, claim is within the limits of and
in any case not later than 30 according to the terms of the
days from the date of receipt chosen policy.
of last necessary document. In
such cases, the Company shall ii. Insured person having multiple
settle or reject the claim within policies shall also have the
45 days from the date of receipt right to prefer claims under
of last necessary document. this policy for the amounts
disallowed under any other
iv. In case of delay beyond policy / policies even if the sum
stipulated 45 days, the insured is not exhausted. Then
Company shall be liable to pay the insurer shall independently
interest to the policyholder at settle the claim subject to the
a rate 2% above the bank rate terms and conditions of this
from the date of receipt of last policy.
necessary document to the date
of payment of claim. iii. If the amount to be claimed
exceeds the sum insured under
(Explanation: “Bank rate” shall a single policy, the insured
mean the rate fixed by the person shall have the right to
Reserve Bank of India (RBl) at choose insurer from whom he/
the beginning of the financial she wants to claim the balance
year in which claim has fallen amount.
due) .
iv. Where an insured person has
4. Complete Discharge policies from more than one
insurer to cover the same
Any payment to the policyholder, risk on indemnity basis, the
insured person or his/ her nominees insured person shall only be
or his/ her legal representative indemnified the treatment
or assignee or to the Hospital, as costs in accordance with the
the case may be, for any benefit terms and conditions of the
under the policy shall be a valid chosen policy.
discharge towards payment of claim
by the Company to the extent of that 6. Fraud
amount for the particular claim.
If any claim made by the insured
23

Any amount already paid against i. The policyholder may cancel this
claims made under this policy but policy by giving 15 days written
which are found fraudulent later notice and in such an event, the
shall be repaid by all recipient(s)/ Company shall refund premium
policyholder(s), who has made for the unexpired policy period
that particular claim, who shall be as detailed below.
jointly and severally liable for such
repayment to the insurer. Length of Tenure
time Policy 1 2 3
For the purpose of this clause, the in force Year Years Years
expression “fraud” means any of Upto 1 75.00% 87.50% 91.5%
the following acts committed by Month
the insured person or by his agent
>1 month 50.00% 75.00% 88.5%
or the hospital/doctor/any other
& Upto 3
party acting on behalf of the insured
Months
person, with intent to deceive the
>3 months 25.00% 62.50% 75%
insurer or to induce the insurer to
issue an insurance policy: & Upto 6
Months
a) the suggestion, as a fact of that >6 months Nil 50.00% 66.5%
which is not true and which the & Upto 12
insured person does not believe Months
to be true; >12 months NA 25% 50%
& Upto 15
b) the active concealment of a fact Months
by the insured person having >15 months NA 12.5% 41.5%
knowledge
& Upto 18
or belief of the fact; Months
>18 months NA Nil 33%
c) any other act fitted to deceive; & Upto 24
and months
>24 months NA NA 8%
d) any such act or omission as & Upto 30
the law specially declares to be months
fraudulent. Exceeding NA NA Nil
30 months
The Company shall not repudiate
the claim and / or forfeit the policy
benefits on the ground of Fraud, if Notwithstanding anything contained herein
the insured person / beneficiary can or otherwise, no refunds of premium shall
24

The insured person will have the option to 10. Renewal of Policy
migrate the policy to other health insurance
products/plans offered by the company by The policy shall ordinarily be
applying for migration of the policy at least renewable except on grounds of fraud,
30 days before the policy renewal date as misrepresentation by the insured person.
per IRDAI guidelines on Migration. lf such
person is presently covered and has been i. The Company shall endeavor to give
continuously covered without any lapses notice for renewal. However, the
under any health insurance product/ Company is not under obligation to
plan offered by the company, the insured give any notice for renewal.
person will get the accrued continuity
benefits in waiting periods as per IRDAI ii. Renewal shall not be denied on the
guidelines on migration. ground that the insured person
had made a claim or claims in the
For Detailed Guidelines on Migration, kindly preceding policy years.
refer Guidelines issued by IRDAI (Insurance
Regulatory and Development Authority iii. Request for renewal along with
of India) on Consolidated Guidelines on requisite premium shall be received
Product Filing in Health Insurance Business by the Company before the end of
– Ref: IRDAI/HLT/REG/CIR/194/07/2020) the policy period.
dated 22nd July 2020 and subsequent
iv. At the end of the policy period, the
amendments thereof.
policy shall terminate and can be
9. Portability renewed within the Grace Period
of 30 days to maintain continuity
The insured person will have the option of benefits without break in policy.
to port the policy to other insurers by Coverage is not available during the
applying to such insurer to port the grace period.
entire policy along with all the members
of the family, if any, at least 45 days v. No loading shall apply on renewals
before, but not earlier than 60 days based on individual claims

i. In the likelihood of this product being The insured person shall be allowed free
withdrawn in future, the Company look period of fifteen days from date of
will intimate the insured person receipt of the policy document to review
about the same 90 days prior to the terms and conditions of the policy, and
expiry of the policy. to return the same if not acceptable.

ii. Insured Person will have the option If the insured has not made any claim
to migrate to similar health insurance during the Free Look Period, the insured
product available with the Company shall be entitled to
at the time of renewal with all the
accrued continuity benefits such as i. a refund of the premium paid
cumulative bonus, waiver of waiting less any expenses incurred by the
period as per IRDAI guidelines, Company on medical examination
provided the policy has been of the insured person and the stamp
maintained without a break. duty charges or

12. Moratorium Period ii. where the risk has already

commenced and the option of return
After completion of eight continuous of the policy is exercised by the
years under the policy no look back to be insured person, a deduction towards
applied. This period of eight years is called the proportionate risk premium for
as moratorium period. The moratorium period of cover or
would be applicable for the sums insured
of the first policy and subsequently iii. Where only a part of the insurance
completion of 8 continuous years would coverage has commenced,
be applicable from date of enhancement of such proportionate premium
sums insured only on the enhanced limits. commensurate with the insurance
After the expiry of Moratorium Period no coverage during such period.
health insurance claim shall be contestable
except for proven fraud and permanent 15. Redressal of Grievance
exclusions specified in the policy contract.
The policies would however be subject In case of any grievance the insured person
to all limits, sub limits, co-payments, may contact the company through
deductibles as per the policy contract.
Website: www.tataaig.com
13. Possibility of Revision of Terms of the
Toll Free: 1800 266 7780 or 1800 22 9966
Policy Including the Premium Rates
(only for Senior Citizen policyholders)
The Company, with prior approval of
Email: customersupport@tataaig.com
IRDAI, may revise or modify the terms of
the Policy including the premium rates.
Courier: Customer Support, TATA AIG
The Insured Person shall be notified three
General Insurance Company Limited
months before the changes are effected.
7th and 8th Floor, Romell Tech Park, Cama
14. Free look period
Industrial Estate, Western Express Highway,
Goregaon(E), Mumbai, Maharashtra
The Free Look Period shall be applicable
400063
26

lf Insured person is not satisfied with 18. Insured Person

the redressal of grievance through
above methods, the insured person may i. Only those persons named as an
also approach the office of Insurance Insured Person in the Schedule shall
Ombudsman of the respective area/region be covered under this Policy.
(details as mentioned in the Annexure A of
this policy) for redressal of grievance as per ii. Any person may be added during
Insurance Ombudsman Rules 2017. the Policy Period after his application
has been accepted by Us, additional
Grievance may also be lodged at IRDAI premium has been paid and We have
Integrated Grievance Management System issued an endorsement confirming
(https://igms.irda.gov.in/) the addition of such person as an
Insured Person.
16. Nomination
iii. We will be offering continuous
The policyholder is required at the inception renewal with no exit age subject
of the policy to make a nomination for to regular premium payment and
the purpose of payment of claims under compliance with all provisions and
the policy in the event of death of the terms & conditions of this policy by
policyholder. Any change of nomination the Insured Person.
shall be communicated to the company in
writing and such change shall be effective 19. Loadings
only when an endorsement on the policy
is made. In the event of death of the i. We may apply a risk loading on the
policyholder, the Company will pay the premium payable (based upon the
nominee {as named in the Policy Schedule/ declarations made in the proposal
/Endorsement (if any)} and in case there is form and the health status of the
no subsisting nominee, to the legal heirs persons proposed for insurance).
or legal representatives of the policyholder
ii. The maximum risk loading applicable
whose discharge shall be treated as full
for an individual shall not exceed
and final discharge of its liability under the
100% of premium per diagnosis /
policy.
medical condition and an overall risk
ii. Specific terms and clauses (terms and loading of over 150% of premium per
clauses other than those mentioned person.
under Section 4 (i) above)
iii. The loading shall only be applied

iv. These loadings are applied from ii. If the Insured Person is no longer
Commencement Date of the Policy eligible on grounds of age or
including subsequent renewal(s) with dependency, the insured member
Us or on the receipt of the request will be eligible to apply for a new
of increase in Sum Insured (for the policy and enjoy continuity benefits
increased Sum Insured). upto Sum Insured.

a. We will inform You about the 22. Notices

applicable risk loading through
a counter offer letter. i. Any notice, direction or instruction
under this Policy shall be in writing
b. You need to revert to Us and if it is to:
with consent and additional
premium (if any), within 15 days a. Any Insured Person, then it shall
of the issuance of such counter be sent to You at Your address
offer letter. specified in the Schedule to
this Policy and You shall act for
c. In case, you neither accept the all Insured Persons for these
counter offer nor revert to Us purposes.
within 15 days, We shall cancel
Your application and refund the b. Us, it shall be delivered to
premium paid within next 10 Our address specified in the
days subject to deduction of the Schedule to this Policy. No
Pre-Policy Check up charges, as insurance agents, brokers
applicable. or other person or entity is
authorised to receive any
v. Please note that We will issue Policy notice, direction or instruction
only after getting Your consent. on Our behalf unless We have
expressly stated to the contrary
20. Entire Contract in writing.

i. This Policy, its Schedule, 23. Premium Payment Zone

endorsement(s), proposal constitutes
the entire contract of insurance. No For the purpose of premium computation,
change in this policy shall be valid the country is divided into following three
unless approved by Us and such Zones and premium payable under the
approval be endorsed hereon. policy will be computed based on the
residential location/address as provided
ii. This Policy and the Schedule shall be by the proposer/insured person in the
read together as one contract and proposal form:
any word or expression to which a
specific meaning has been attached a. Zone A: Mumbai including MMR/
in any part of this Policy or of the Thane, Delhi NCR/Faridabad/
Schedule shall bear such meaning Ghaziabad, Ahmedabad, Surat and
wherever it may appear. Baroda

21. Change of Policyholder b. Zone B: Hyderabad, Bengaluru,

Kolkata, Indore, Chennai, Chandigarh/

1. Notification of Claim

Treatment, Consultation or We or Our TPA* must be informed:

Procedure:
1 If any treatment for which a claim may At least 48 hours prior to the Insured
be made and that treatment requires Person’s admission.
planned Hospitalisation:
2 If any treatment for which a claim may Within 24 hours of the Insured Person’s
be made and that treatment requires admission to Hospital.
emergency Hospitalisation

*TPA as mentioned in the policy schedule, if applicable.

2. Cashless Service

T r e a t m e n t , T r e a t m e n t , Cashless Service is We must be given

C o n s u l t a t i o n o r C o n s u l t a t i o n o r Available: notice that the
Procedure: Procedure Taken at: Insured Person
wishes to take
advantage of the
cashless service
accompanied by full
particulars:

3. Procedure for Cashless Service with any other information

or documentation that is
i. Cashless Service is only available at requested by the TPA/Us to
Network Hospitals. the Network Hospital.

ii. In order to avail of cashless treatment, e. In case of deficiency in the

the following procedure must be documents sent to TPA/Us for
followed by You: cashless authorization, the
same shall be communicated
a. Prior to taking treatment and/ to the hospital by TPA/Us
or incurring Medical Expenses within 6 hours of receipt of the
at a Network Hospital, You must documents.
call our designated TPA/Us and
request pre-authorization. f. In case the ailment /treatment
is not covered under the policy
b. For any emergency or cashless is rejected due
Hospitalisation, our designated to insufficient documents
TPA/We must be informed submitted, a rejection letter
no later than 24 hours of the would be sent to the hospital
start of Your hospitalization/ within 6 hours.
treatment.
g. Rejection of cashless in no way
c. For any planned hospitalization, indicates rejection of the claim.
our designated TPA/We must You are required to submit
be informed atleast 48 hours the claim along with required
prior to the start of your documents for us to decide on
hospitalization/treatment. the admissibility of the claim.
d. Our designated TPA/We will h. If the cashless is approved,
check your coverage as per the original bills and evidence
the eligibility and send an of treatment in respect of the
authorization letter to the same shall be left with the
provider. You have to provide Network Hospital.
the ID card issued to You along
30

Registered Office: Peninsula Business Park, Tower A, 15th Floor, G.K. Marg, Lower Parel, Mumbai - 400013,
24x7 Toll Free No: 1800 266 7780 or 1800 22 9966 (Senior Citizen)| Email: customersupport@tataaig.com
Website: www.tataaig.com | IRDA of India Registration No: 108 | CIN: U85110MH2000PLC128425
Tata AIG Elder Care UIN: TATHLIP23179V012223
i. Pre-authorization does not b. Original Bills (pharmacy
guarantee that all costs and purchase bill, consultation
expenses will be covered. We bill, diagnostic bill) and any
reserve the right to review each attachments thereto like
claim for Medical Expenses and 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
4. Supporting Documentation & histories, investigation reports,
Examination indoor case papers/ treatment
papers (in reimbursement
i. You or someone claiming on cases, if available), discharge
Your behalf shall provide Us with summaries.
documentation, medical records
and information We or Our TPA d. A precise diagnosis of the
may request to establish the treatment for which a claim is
circumstances of the claim, its made.
quantum or Our liability for the
claim within 15 days or earlier of e. A detailed list of the individual
Our request or the Insured Person’s medical services and treatments
discharge from Hospitalisation or provided and a unit price for
completion of treatment. each in case not available in the
submitted hospital bill.
ii. Failure to furnish such evidence
within the time required shall not f. Prescriptions that name the
invalidate nor reduce any claim if Insured Person and in the case
you can satisfy us that it was not of drugs: the drugs prescribed,
reasonably possible for you to give their price and a receipt for
proof within such time. payment. In case of pre/
post hospitalization claim
iii. We may accept claims where Prescriptions must be submitted
documents have been provided with the corresponding Doctor/
after a delayed interval only in special hospital invoice.
circumstances and for the reasons
beyond the control of the Insured g. All pre and post investigation,
Person. treatment and follow up
(consultation) records
iv. Such documentation will include the pertaining to the present
following: ailment for which claim is being
made, if and where applicable.
a. Our claim form, duly completed
and signed for on behalf of h. Treating doctor’s certificate
the Insured Person.We, upon regarding missing information
receipt of a notice of claim, will in case histories e.g.
furnish Your representative Circumstance of injury and
with such forms as We may Alcohol or drug influence at the
require for filing proofs of loss time of accident, if available.
or you may download the claim
form from our Web site. i. Copy of settlement letter from
31

j. Stickers and invoice of implants - We have received all premium

used during surgery. payments in full in time and

k. Copy of MLC (Medico legal case) - We have been provided

records, if carried out and FIR with the documentation and
(First information report), if information which We or Our
registered, in case of claims TPA has requested to establish
arising out of an accident and the circumstances of the claim,
available with the claimant. its quantum or Our liability for
it, and
l. Regulatory requirements as
amended from time to time, - unless the Insured Person has
currently mandatory NEFT (to complied with his obligations
enable direct credit of claim under this Policy.
amount in bank account) and
KYC (recent ID/Address proof ii Medical Expenses incurred for AYUSH
and photograph) requirements. treatment shall be assessed only
under benefit B8 of this policy and
m. Legal heir/succession certificate, shall be admissible only if incurred
if required within India.^

n. PM report (wherever applicable) iii. This Policy only covers medical

treatment taken within India, and
v. Note: In case You are claiming for payments under this Policy shall only
the same event under an indemnity be made in Indian Rupees within
based policy of another insurer and India.
are required to submit the original
documents related to Your treatment 6. Claims Procedure and management of
with that particular insurer, then You services (Section B4, B5, B6, B10, B11,
may provide Us with the attested B17 & B18)
copies of such documents along with
a declaration from the particular Service may be availed through our website
insurer specifying the availability of or our mobile application or through
the original copies of the specified calling our call centre on the toll free
treatment documents with it. number specified in the policy schedule.
Alternatively, details of our empanelled
vi. We at our own expense, shall service provider are available on our
have the right and opportunity to website (www.tataaig.com).
examine insured persons through
Our Authorised Medical Practitioner Supporting Documentation &
whose details will be notified to Examination
insured person when and as often
as We may reasonably require during Insured Person or someone booking
the pendency of a claim hereunder. services on Your behalf shall provide Us
with identification documentation, medical
5. Claims Payment records and information We may request
to establish the circumstances of the claim.
i. We shall be under no obligation to

Jurisdiction of Office Union

Centre Address & Contact
Territory, District

Office of the Insurance Ombudsman, Jeevan

Prakash Building, 6th floor, Tilak Marg, Relief
Gujarat, Dadra & Nagar Haveli,
Ahemdabad Road, Ahemdabad – 380 001.
Daman and Diu
Tel.: 079 - 25501201/02/05/06
Email: bimalokpal.ahmedabad@cioins.co.in

Office of the Insurance Ombudsman, Jeevan

Soudha Building, PID No. 57-27-N-19 Ground
Floor, 19/19, 24th Main Road,
Bengaluru Karnataka
JP Nagar, Ist Phase, Bengaluru – 560 078.
Tel.: 080 - 26652048 / 26652049
Email: bimalokpal.bengaluru@cioins.co.in

Office of the Insurance Ombudsman,

1st floor,”Jeevan Shikha”, 60-B,Hoshangabad
Road, Opp. Gayatri Mandir,
Bhopal Madhya Pradesh, Chhattisgarh
Bhopal – 462 011.
Tel.: 0755 - 2769201 / 2769202
Email: bimalokpal.bhopal@cioins.co.in
33

Office of the Insurance Ombudsman,

62, Forest park, Bhubaneswar – 751 009.
Bhubaneswar Odisha
Tel.: 0674 - 2596461 /2596455
Email: bimalokpal.bhubaneswar@cioins.co.in

Office of the Insurance Ombudsman, Punjab, Haryana (excluding

S.C.O. No. 101, 102 & 103, 2nd Floor, Batra Gurugram, Faridabad, Sonepat
Building, Sector 17 – D, and Bahadurgarh), Himachal
Chandigarh
Chandigarh – 160 017. Pradesh, Union Territories of
Tel.: 0172 - 4646394 / 2706468 Jammu & Kashmir,Ladakh &
Email: bimalokpal.chandigarh@cioins.co.in Chandigarh

Office of the Insurance Ombudsman, Fatima

Akhtar Court, 4th Floor, 453, Tamil Nadu, PuducherryTown
Chennai Anna Salai, Teynampet,CHENNAI – 600 018. and Karaikal (which are part of
Tel.: 044 - 24333668 / 24333678 Puducherry)
Email: bimalokpal.chennai@cioins.co.in

Office of the Insurance Ombudsman, 2/2 A, Delhi & following Districts

Universal Insurance Building, Asaf Ali Road, of Haryana - Gurugram,
Delhi
New Delhi – 110 002. Tel.: 011 - 23237539 Faridabad, Sonepat &
Email: bimalokpal.delhi@cioins.co.in Bahadurgarh

Office of the Insurance Ombudsman, Jeevan

Nivesh, 5th Floor, Nr. Panbazar over bridge, Assam, Meghalaya, Manipur,
Guwahati S.S. Road, Guwahati – 781001(ASSAM). Mizoram, Arunachal Pradesh,
Tel.: 0361 - 2632204 / 2602205 Nagaland and Tripura
Email: bimalokpal.guwahati@cioins.co.in

Office of the Insurance Ombudsman,

6-2-46, 1st floor, “Moin Court”, Lane
Andhra Pradesh, Telangana,
Opp. Saleem Function Palace, A. C. Guards,
Hyderabad Yanam and part of Union
Lakdi-Ka-Pool, Hyderabad - 500 004.
Territory of Puducherry
Tel.: 040 - 23312122
Email: bimalokpal.hyderabad@cioins.co.in

Office of the Insurance Ombudsman, Jeevan

Nidhi – II Bldg., Gr. Floor, Bhawani Singh
Jaipur Marg, Jaipur - 302 005. Rajasthan
Tel.: 0141- 2740363/2740798
Email: bimalokpal.jaipur@cioins.co.in

Office of the Insurance Ombudsman, 10th

Floor, Jeevan Prakash,LIC Building, Opp to
Kerala, Lakshadweep, Mahe-a
Maharaja’s College,M.G.Road,
Ernakulam part of Union Territory of
Ernakulam - 682 011.
Puducherry
Tel.: 0484 - 2358759
Email: bimalokpal.ernakulam@cioins.co.in

Office of the Insurance Ombudsman,

Hindustan Bldg. Annexe, 7th Floor, 4, C.R.
West Bengal, Sikkim, Andaman
Kolkata Avenue, KOLKATA - 700 072.
& Nicobar Islands
Tel.: 033 - 22124339 / 22124341 Email:
bimalokpal.kolkata@cioins.co.in

Districts of Uttar Pradesh

: Lalitpur, Jhansi, Mahoba,
Hamirpur, Banda, Chitrakoot,
Allahabad, Mirzapur,
Sonbhabdra, Fatehpur,
Pratapgarh, Jaunpur,Varanasi,
Office of the Insurance Ombudsman, 6th Gazipur, Jalaun, Kanpur,
Floor, Jeevan Bhawan, Phase-II, Nawal Lucknow, Unnao, Sitapur,
Kishore Road, Hazratganj, Lakhimpur, Bahraich,
Lucknow
Lucknow - 226 001. Barabanki, Raebareli, Sravasti,
Tel.: 0522 - 4002082 / 3500613 Gonda, Faizabad, Amethi,
Email: bimalokpal.lucknow@cioins.co.in Kaushambi, Balrampur, Basti,
Ambedkarnagar, Sultanpur,
Maharajgang, Santkabirnagar,
Azamgarh, Kushinagar,
Gorkhpur, Deoria, Mau,
Ghazipur, Chandauli, Ballia,
Sidharathnagar

Office of the Insurance Ombudsman,

3rd Floor, Jeevan Seva Annexe, Goa, Mumbai Metropolitan
Mumbai S. V. Road, Santacruz (W), Mumbai - 400 054. Region (excluding Navi Mumbai
Tel.: 022 - 69038800/27/29/31/32/33 Email: & Thane)
bimalokpal.mumbai@cioins.co.in

State of Uttarakhand and the

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

Office of the Insurance Ombudsman, 2nd

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

Office of the Insurance Ombudsman, Jeevan

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

For updated list and details of Insurance Ombudsman Offices, please visit website http://www.
cioins.co.in/ombudsman.html

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/EC/Mar 24

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Policy Wordings

Uploaded by

Policy Wordings

Uploaded by

TATA AIG General Insurance Company Limited (We, Our

or Us) will provide the insurance cover, described in this

Cashless facility means a facility extended 10. Day Care Centre

iii. has fully equipped operation theatre

Treatment normally taken on an out- v. maintains daily records of patients

(b) Chronic condition 20. Medical Advice

A chronic condition is defined as Medical Advice means any consultation

i. it needs ongoing or long- 21. Medical Expenses:

24. Migration 29. Pre-hospitalization Medical Expenses

“Migration” means, the right accorded to Pre-hospitalization Medical Expenses

28. Pre-Existing Disease i. Such Medical Expenses are for

33. Reasonable and Customary Charges 38. Age

Renewal means the terms on which the 40. Policy Period

B6. Compassionate Care (c) Transferring: the ability to move

• Compassionate care Services shall be B7. Day Care Procedures

• Any unutilized days of compassionate Treatment normally taken on out-patient

‘Activities of Daily Living’ This benefit shall also cover Pre-

B13. Cumulative Bonus I. Cancer

i. 10% cumulative bonus will be applied II. Open Chest CABG

11. Provision of these services is subject b. Sub-Limits on Specified Surgical

We will neither be liable nor make any payment

Zone of the b. In case of enhancement of sum

a. Expenses related to the treatment

V. Endometriosis XXVII. Adenoidectomy

VI. Prolapsed Uterus XXVIII. Mastoidectomy

VII. Non-infective arthritis XXIX. Tonsillectomy

VIII. Gout and Rheumatism XXX. Tympanoplasty

a. Expenses related to the treatment of ii. Any services for people

a. Medical treatment expenses traceable 1. Medical Exclusions

i. Hazardous or Adventure Sports iv. Growth Hormone Therapy

Expenses incurred towards treatment x. Any existing disease specifically

12. Moratorium Period ii. where the risk has already

lf Insured person is not satisfied with 18. Insured Person

a. We will inform You about the 22. Notices

i. This Policy, its Schedule, 23. Premium Payment Zone

21. Change of Policyholder b. Zone B: Hyderabad, Bengaluru,

Treatment, Consultation or We or Our TPA* must be informed:

*TPA as mentioned in the policy schedule, if applicable.

T r e a t m e n t , T r e a t m e n t , Cashless Service is We must be given

3. Procedure for Cashless Service with any other information

ii. In order to avail of cashless treatment, e. In case of deficiency in the

j. Stickers and invoice of implants - We have received all premium

k. Copy of MLC (Medico legal case) - We have been provided

n. PM report (wherever applicable) iii. This Policy only covers medical

Jurisdiction of Office Union

Office of the Insurance Ombudsman, Jeevan

Office of the Insurance Ombudsman, Jeevan

Office of the Insurance Ombudsman,

Office of the Insurance Ombudsman,

Office of the Insurance Ombudsman, Punjab, Haryana (excluding

Office of the Insurance Ombudsman, Fatima

Office of the Insurance Ombudsman, 2/2 A, Delhi & following Districts

Office of the Insurance Ombudsman, Jeevan

Office of the Insurance Ombudsman,

Office of the Insurance Ombudsman, Jeevan

Office of the Insurance Ombudsman, 10th

Office of the Insurance Ombudsman,

Districts of Uttar Pradesh

Office of the Insurance Ombudsman,

State of Uttarakhand and the

Office of the Insurance Ombudsman, 2nd

Office of the Insurance Ombudsman, Jeevan

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