TATA AIG MediCare Plus

Policy Wording

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 in excess
of Aggregate Deductible as mentioned in the Policy
Schedule. Commencement of risk cover under the
policy is subject to receipt of premium by us.
The statements contained in the Proposal signed
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: TATHLIP21253V022021
“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.

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: TATHLIP21253V022021
Preamble Dispensary, Clinic, Polyclinic or any such
While the policy is in force, if the Insured Person health centre which is registered with the
contracts any disease or suffers from any illness local authorities, wherever applicable and
or sustains bodily injury through accident and if having facilities for carrying out treatment
such event requires the insured Person to incur procedures and medical or surgical/para-
expenses for Medically Necessary Treatment, surgical interventions or both under the
We will indemnify You for the amount of supervision of registered AYUSH Medical
such Reasonable and Customary Charges or Practitioner (s) on day care basis without
compensate to the extent agreed, upto the limits in-patient services and must comply with
mentioned, subject to terms and conditions of all the following criterion:
the Policy. Each Benefit is subject to its Sum i. Having qualified registered AYUSH
Insured and deductible as specified in the Policy Medical Practitioner(s) in charge;
Schedule, but Our liability in aggregate to make
ii. Having dedicated AYUSH therapy
payment in respect of any and all Benefits shall
sections as required and/or has
be limited to the Sum Insured and will only begin
equipped operation theatre where
when the deductible is exceeded.
surgical procedures are to be carried
In case of family floater policy, the sum insured out;
& deductible for all or any of the benefits shall
iii. Maintaining daily records of the
be on a per policy per year basis. In case of an
patients and making them accessible
individual policy, the sum insured & deductible
to the insurance company’s
for all or any of the benefits shall be on a per
authorized representative.
insured person per year basis.
3. AYUSH Hospital
All claims under the policy benefits shall be
payable only if the aggregate of covered medical An AYUSH Hospital is a healthcare facility
expenses, in respect to hospitalization(s) in a wherein medical/surgical/para-surgical
policy year is in excess of deductible specified in treatment procedures and interventions
the policy schedule. In case of multi-year policy are carried out by AYUSH Medical
(i.e. tenure more than 1 year), such aggregate Practitioner(s) comprising of any of the
deductible would be applicable on annual basis. following :
The said Medically Necessary Treatment must be a. Central or State Government AYUSH
on the advice of a qualified Medical Practitioner. Hospital or
b. Teaching hospital attached to AYUSH
Section 1 – Definitions
college recognized by the Central
The terms defined below and at other junctures Government/ Central Council of
in the Policy Wording have the meanings Indian Medicine/ Central Council for
ascribed to them wherever they appear in this Homeopathy, or
Policy and, where appropriate, references to
c. AYUSH Hospital, standalone or co-
the singular include references to the plural;
located with in-patient healthcare
references to the male include the female and
facility of any recognized system of
references to any statutory enactment include
medicine, registered with the local
subsequent changes to the same:
authorities, wherever applicable,
i. Standard Definitions and is under the supervision of a
1. Accident qualified registered AYUSH Medical
An accident means sudden, unforeseen Practitioner and must comply with
and involuntary event caused by external, all the following criterion :
visible and violent means. i. Having atleast 5 in-patient beds;
2. AYUSH Day Care Centre^ ii. Having qualified AYUSH Medical
AYUSH Day Care Centre means and Practitioner round the clock;
includes Community Health Centre iii. Having dedicated AYUSH therapy
(CHC), Primary Health Centre (PHC), sections as required and/or has
2

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: TATHLIP21253V022021
 equipped operation theatre practitioner AND must comply with all
where surgical procedures are minimum criterion as under –
to be carried out; i. has qualified nursing staff under its
iv. Maintaining daily records of employment;
the patients and making them ii. has qualified medical practitioner/s
accessible to the insurance in charge;
company’s authorized
representative. iii. has fully equipped operation theatre
of its own where surgical procedures
4. Cashless facility are carried out;
Cashless facility means a facility extended iv. maintains daily records of patients
by the insurer to the insured where the and will make these accessible to
payments, of the costs of treatment the insurance company’s authorized
undergone by the insured in accordance personnel.
with the policy terms and conditions, are
directly made to the network provider by 9. Day Care Treatment
the insurer to the extent pre-authorization Day care treatment means medical
is approved. treatment, and/or surgical procedure
5. Congenital Anomaly: which is:

Congenital Anomaly means a condition i. undertaken under General or Local

which is present since birth, and which is Anesthesia in a hospital/day care
abnormal with reference to form, structure centre in less than 24 hrs because of
or position. technological advancement, and

a) Internal Congenital Anomaly ii. which would have otherwise required

hospitalization of more than 24
Congenital anomaly which is not in hours.
the visible and accessible parts of the
body. Treatment normally taken on an out-
patient basis is not included in the
b) External Congenital Anomaly scope of this definition.
Congenital anomaly which is in the 10. Deductible
visible and accessible parts of the
body. Deductible means a cost sharing
requirement under a health insurance
6. Condition Precedent policy that provides that the insurer will
Condition Precedent means a policy term not be liable for a specified rupee amount
or condition upon which the Insurer’s in case of indemnity policies and for a
liability under the policy is conditional specified number of days/hours in case
upon. of hospital cash policies which will apply
7. Cumulative Bonus before any benefits are payable by the
insurer.
Cumulative Bonus means any increase or
addition in the Sum Insured granted by the A deductible does not reduce the Sum
insurer without an associated increase in Insured.
premium. 11. Dental Treatment
8. Day Care Centre Dental treatment means a treatment
A day care centre means any institution related to teeth or structures supporting
established for day care treatment of illness teeth including examinations, fillings
and/or injuries or a medical setup with a (where appropriate), crowns, extractions
hospital and which has been registered and surgery.
with the local authorities, wherever 12. Domiciliary Hospitalization
applicable, and is under supervision Domiciliary hospitalization means medical
of a registered and qualified medical treatment for an illness/disease/injury
3

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: TATHLIP21253V022021
 which in the normal course would require consecutive ‘In-patient Care’ hours except
care and treatment at a hospital but is for specified procedures/ treatments,
actually taken while confined at home where such admission could be for a
under any of the following circumstances: period of less than 24 consecutive hours.
i. the condition of the patient is such 16. Illness
that he/she is not in a condition to Illness means a sickness or a disease
be removed to a hospital, or or pathological condition leading to the
ii. the patient takes treatment at home impairment of normal physiological
on account of non-availability of function and requires medical treatment.
room in a hospital. (a) Acute condition
13. Grace Period Acute condition is a disease, illness or
Grace period means the specified period of injury that is likely to respond quickly
time immediately following the premium to treatment which aims to return the
due date during which a payment can be person to his or her state of health
made to renew or continue a policy in force immediately before suffering the
without loss of continuity benefits such disease/ illness/ injury which leads
as waiting periods and coverage of pre- to full recovery.
existing diseases. Coverage is not available (b) Chronic condition
for the period for which no premium is
A chronic condition is defined as
received.
a disease, illness, or injury that
14. Hospital has one or more of the following
A hospital means any institution established characteristics:
for in-patient care and day care treatment i. it needs ongoing or long-
of illness and/or injuries and which has term monitoring through
been registered as a hospital with the local consultations, examinations,
authorities under Clinical Establishments check-ups, and /or tests;
(Registration and Regulation) Act 2010 or
ii. it needs ongoing or long-term
under enactments specified under the
control or relief of symptoms;
Schedule of Section 56(1) and the said act
Or complies with all minimum criteria as iii. it requires rehabilitation for the
under: patient or for the patient to be
specially trained to cope with it;
i. has qualified nursing staff under its
employment round the clock; iv. it continues indefinitely;
ii. has at least 10 in-patient beds in v. it recurs or is likely to recur;
towns having a population of less 17. Injury
than 10,00,000 and at least 15 in- Injury means accidental physical bodily
patient beds in all other places; harm excluding illness or disease solely
iii. has qualified medical practitioner(s) and directly caused by external, violent,
in charge round the clock; visible and evident means which is verified
iv. has a fully equipped operation and certified by a Medical Practitioner.
theatre of its own where surgical 18. Inpatient Care
procedures are carried out; Inpatient care means treatment for which
v. maintains daily records of patients the insured person has to stay in a hospital
and makes these accessible to the for more than 24 hours for a covered event.
insurance company’s authorized 19. Intensive Care Unit
personnel;
Intensive care unit means an identified
15. Hospitalization section, ward or wing of a hospital which
Hospitalization means admission in a is under the constant supervision of
Hospital for a minimum period of 24
4

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: TATHLIP21253V022021
 a dedicated medical practitioner(s), standards widely accepted in
and which is specially equipped for the international medical practice or by
continuous monitoring and treatment of the medical community in India.
patients who are in a critical condition, 24. Migration
or require life support facilities and
“Migration” means, the right accorded to
where the level of care and supervision
health insurance policyholders (including
is considerably more sophisticated and
all members under family cover and
intensive than in the ordinary and other
members of group health insurance
wards.
policy), to transfer the credit gained for
20. Medical Advice pre-existing conditions and time bound
Medical Advice means any consultation exclusions, with the same insurer.
or advice from a Medical Practitioner 25. Network Provider
including the issuance of any prescription Network Provider means hospitals or
or follow-up prescription. health care providers enlisted by an
21. Medical Expenses insurer, TPA or jointly by an Insurer and
Medical Expenses means those expenses TPA to provide medical services to an
that an Insured Person has necessarily and insured by a cashless facility.
actually incurred for medical treatment 26. Notification of Claim
on account of Illness or Accident on the Notification of claim means the process
advice of a Medical Practitioner, as long as of intimating a claim to the insurer or TPA
these are no more than would have been through any of the recognized modes of
payable if the Insured Person had not been communication.
insured and no more than other hospitals
27. OPD treatment
or doctors in the same locality would have
charged for the same medical treatment. OPD treatment means the one in which
the Insured visits a clinic / hospital or
22. Medical Practitioner associated facility like a consultation room
Medical Practitioner means a person who for diagnosis and treatment based on
holds a valid registration from the Medical the advice of a Medical Practitioner. The
Council of any State or Medical Council of Insured is not admitted as a day care or
India or Council for Indian Medicine or for in-patient.
Homeopathy set up by the Government of 28. Pre-Existing Disease
India or a State Government and is thereby
Pre-existing Disease means any condition,
entitled to practice medicine within its
ailment, injury or disease:
jurisdiction; and is acting within its scope
and jurisdiction of license. a. That is/are diagnosed by a physician
within 48 months prior to the
23. Medically Necessary Treatment
effective date of the policy issued by
Medically necessary treatment means any the insurer or its reinstatement or
treatment, tests, medication, or stay in
b. For which medical advice or treatment
hospital or part of a stay in hospital which:
was recommended by, or received
i. is required for the medical from, a Physician within 48 months
management of the illness or injury Prior to the effective date of the
suffered by the insured; policy issued by the insurer or its
ii. must not exceed the level of care reinstatement
necessary to provide safe, adequate 29. Pre-hospitalization Medical Expenses
and appropriate medical care in
Pre-hospitalization Medical Expenses
scope, duration, or intensity;
means medical expenses incurred during
iii. must have been prescribed by a predefined number of days preceding
medical practitioner; the hospitalization of the Insured Person,
iv. must conform to the professional provided that:
5

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: TATHLIP21253V022021
 i. Such Medical Expenses are incurred and for all waiting periods.
for the same condition for which the 35. Room Rent
Insured Person’s Hospitalization was
required, and Room Rent means the amount charged
by a Hospital towards Room and Boarding
ii. The In-patient Hospitalization claim expenses and shall include the associated
for such Hospitalization is admissible medical expenses.
by the Insurance Company.
36. Surgery or Surgical Procedure
30. Portability
Surgery or Surgical Procedure means
“Portability” means, the right accorded to manual and / or operative procedure
individual health insurance policyholders (s) required for treatment of an illness
(including all members under family or injury, correction of deformities and
cover), to transfer the credit gained for defects, diagnosis and cure of diseases,
pre-existing conditions and time bound relief from suffering and prolongation of
exclusions, from one insurer to another life, performed in a hospital or day care
insurer. centre by a medical practitioner.
31. Post-hospitalization Medical Expenses 37. Unproven/Experimental treatment
Post-hospitalization Medical Expenses Unproven/Experimental treatment means
means medical expenses incurred during
the treatment including drug experimental
predefined number of days immediately
therapy which is not based on established
after the insured person is discharged from
medical practice in India, is treatment
the hospital provided that:
experimental or unproven.
i. Such Medical Expenses are for
the same condition for which the ii. Specific Definitions (Definitions other than
insured person’s hospitalization was as mentioned under Section 1 (i) above)
required, and
ii. The inpatient hospitalization claim for 1. Age
such hospitalization is admissible by
Means the completed age of the Insured
the insurance company.
Person on his / her most recent birthday
32. Qualified Nurse as per the English calendar, regardless of
Qualified nurse means a person who the actual time of birth.
holds a valid registration from the Nursing
Council of India or the Nursing Council of 2. Policy
any state in India.
Policy means the contract of insurance
33. Reasonable and Customary Charges
including but not limited to Policy Schedule,
Reasonable and Customary charges means Endorsements , Policy Wordings and Riders.
the charges for services or supplies, which
are the standard charges for the specific 3. Policy period
provider and consistent with the prevailing
charges in the geographical area for Policy Period means the time during
identical or similar services, taking into which this Policy is in effect. Such period
account the nature of the illness / injury commences from Commencement Date
involved. and ends on the Expiry Date and specifically
34. Renewal appears in the Policy Schedule.
Renewal means the terms on which the 4. Policy Schedule
contract of insurance can be renewed on
mutual consent with a provision of grace Policy Schedule means the Policy Schedule
period for treating the renewal continuous attached to and forming part of Policy.
for the purpose of gaining credit for pre-
existing diseases, time-bound exclusions 5. Policy year
6

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: TATHLIP21253V022021
 Policy Year means a period of twelve We will cover for Medical and surgical
months beginning from the date of Expenses of the organ donor for harvesting
commencement of the Policy period the organ where an Insured Person is the
and ending on the last day of such recipient provided that:
twelve-month period. For the purpose of i. The organ donor is any person whose
subsequent years, policy year shall mean organ has been made available
a period of twelve months commencing in accordance and in compliance
from the end of the previous policy year
with The Transplantation of Human
and lapsing on the last day of such twelve-
Organs (Amendment) Bill, 2011 and
month period, till the Policy Expiry date.
the organ donated is for the use of
Section 2 – Benefits the Insured Person, and

The following benefits are payable subject to ii. We have accepted an inpatient
Terms and Conditions of the policy: Hospitalization claim for the
insured member under In Patient
B1. In-Patient Treatment Hospitalization Treatment (section
We will cover for expenses for B1).
hospitalization due to disease/illness/Injury
B6. Domiciliary Treatment
during the policy period that requires an
Insured Person’s admission in a hospital We will cover for expenses related to
as an inpatient. Domiciliary Hospitalization of the insured
person if the treatment exceeds beyond
Medical expenses directly related to the
three days. The treatment must be for
hospitalization would be payable.
management of an illness and not for
B2. Pre-Hospitalization expenses enteral feedings or end of life care.
We will cover for expenses for Pre- At the time of claiming under this benefit,
Hospitalization consultations, we shall require certification from the
investigations and medicines incurred treating doctor fulfilling the conditions as
upto 60 days before the date of admission mentioned under the general definitions
to the hospital. (Section 1) of this Policy.
The benefit is payable if We have admitted B7. AYUSH Benefit^
a claim under B1 or B4 or B6.
We will cover Medical Expenses incurred
B3. Post-Hospitalization expenses
for treatment as In-Patient or Day Care
We will cover for expenses for Post- Treatment in an AYUSH Hospital/ AYUSH
Hospitalization consultations, day care centre.
investigations and medicines incurred upto
This benefit shall also cover Pre-
90 days after discharge from the hospital.
Hospitalization medical expenses for a
The benefit is payable if We have admitted period of upto 60 days before the date of
a claim under B1 or B4 or B6. admission to the AYUSH hospital/AYUSH
B4. Day Care Procedures day care centre and Post-Hospitalization
We will cover expenses for listed Day Care Medical Expenses for a period upto 90 days,
Treatment due to disease/illness/Injury subject to AYUSH In-Patient hospitalization
during the policy period taken at a hospital or AYUSH day care treatment claim being
or a Day Care Centre. The list of such day admissible under this benefit.
care procedures covered is available on Claims under this section shall be assessed
our website (www.tataaig.com). as per the insurance guidelines related to
Treatment normally taken on out-patient AYUSH and benchmark rates as available
basis is not included in the scope of this on Ministry of AYUSH website (https://
cover. ayushnext.ayush.gov.in/site/insurance-
guidelines-related-to-ayush).
B5. Organ Donor
B8. Ambulance Cover
7

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: TATHLIP21253V022021
 We will cover for expenses incurred on consumable nor medically necessary
transportation of Insured Person in a nor prescribed by doctor.
registered ambulance to a Hospital for For this claim to be paid, the main
admission in case of an Emergency or from claim must be admissible under
one hospital to another hospital for better section B1 or B4 of this policy.
medical facilities and treatment, subject to
B11. In-Patient Treatment - Dental
Rs. 3000 per Hospitalization.
We will cover for medical expenses
For this claim to be paid, the claim must be
incurred towards hospitalization for dental
admissible under section B1 or B4 of this
treatment under anesthesia necessitated
policy.
due to an accident/injury/illness.
B9. Health Checkup
B12. Second Opinion
We will cover for expenses for a Preventive
We will provide You a second opinion from
Health Check-up upto 1% of previous
Network Provider or Medical Practitioner,
sum insured subject to a maximum of if an Insured Person is diagnosed with
Rs. 10,000/- per policy. The limit is the the below mentioned Illnesses during the
maximum per policy and more than one Policy Period. The expert opinion would be
insured can utilize the amount. directly sent to the Insured Person.
The benefit is payable once after block i. Cancer
of every two continuous claim free policy
years with us. This benefit has a separate ii. Kidney Failure
limit (over and above base sum insured) iii. Myocardial Infarction
and does not affect cumulative bonus. iv. Angina
Deductible shall not be applicable for this
v. Coronary bypass surgery
benefit.
vi. Stroke/Cerebral hemorrhage
B10. Consumables Benefit
vii. Organ failure requiring transplant
We will pay for expenses incurred, for
specified consumables which are listed in viii. Heart Valve replacement
‘Annexure I – List I as Optional Items’ ‘under ix. Brain tumors
‘Guidelines on Standardization in Health This benefit can be availed by an Insured
Insurance, 2016 and its amendments ’, Person once during a Policy Year.
which are consumed during the period
B13. Global Cover (Optional Cover)
of hospitalization directly related to the
insured’s medical or surgical treatment of We will cover for Medical Expenses of the
illness/disease/injury. Details of Annexure Insured Person incurred outside India,
I-List I-Optional items are available on our upto the sum insured, provided that the
website (www.tataaig.com). diagnosis was made in India and the
insured travels abroad for treatment.
However the following items shall be
excluded from scope of this coverage: The Medical Expenses payable shall
be limited to Inpatient and daycare
• Items of personal comfort, toiletries,
Hospitalization only on reimbursement
cosmetics and convenience shall be basis. Cashless facility may be arranged
excluded from scope of this coverage. on case to case basis. Insured person can
• External durable devices like Bilevel contact us for any claim assistance.
Positive Airway Pressure (BIPAP) The payment of any claim under this
machine, Continuous Positive Airway benefit will be in Indian Rupees based
Pressure (CPAP) machine, Peritoneal on the rate of exchange as on the date
Dialysis (PD) equipment and supplies, of invoice, published by Reserve Bank of
Nimbus/water/air bed, dialyzer and India (RBI) and shall be used for conversion
other medical equipments. of foreign currency into Indian Rupees
• Any item which is neither a medical for claims payment. If these rates are
8

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: TATHLIP21253V022021
 not published on the date of invoice, the We will neither be liable nor make any payment
exchange rate next published by RBI shall for any claim in respect of any Insured Person
be considered for conversion. which is caused by, arising from or in any way
We shall require the following additional attributable to any of the following exclusions,
documents of the insured person for unless expressly stated to the contrary in this
supporting the claim under this benefit: Policy.
• Proof of diagnosis in India i. Standard Exclusions
1. Exclusions with waiting periods
• Insured’s Passport and Visa
i. Pre-existing Diseases Waiting
B14. Cumulative Bonus Period (Code- Excl 01):
i. 50% cumulative bonus will be applied a. Expenses related to the
on the Sum Insured for next policy treatment of a pre-existing
year under the Policy after every Disease (PED) and its direct
claim free Policy Year, provided complications shall be excluded
that the Policy is renewed with Us until the expiry of 36 months of
and without a break. The maximum continuous coverage after the
cumulative bonus shall not exceed date of inception of the first
100% of the Sum Insured in any Policy policy with us.
Year.
b. In case of enhancement of sum
ii. If a Cumulative Bonus has been insured the exclusion shall
applied and a claim is made, then apply afresh to the extent of
in the subsequent Policy Year We sum insured increase.
will automatically decrease the c. If the Insured Person is
Cumulative Bonus by 50% of the continuously covered without
Sum Insured in that following Policy any break as defined under
Year. There will be no impact on the portability norms of the
the Inpatient Sum Insured, only the extant IRDAI (Health Insurance)
accrued Cumulative Bonus will be Regulations, then waiting period
decreased. for the same would be reduced
iii. In policies with a tenure of more than to the extent of prior coverage.
one year, the above guidelines of d. Coverage under the policy after
Cumulative Bonus shall be applicable the expiry of 36 months for any
post completion of each policy year. pre-existing disease is subject
iv. In relation to a Family Floater, the to the same being declared
Cumulative Bonus so applied will at the time of application and
only be available in respect of those accepted by us.
Insured Persons who were Insured ii. Specified Disease/Procedure
Persons in the claim free Policy Year Waiting Period (Code- Excl 02):
and continue to be Insured Persons a. Expenses related to the
in the subsequent Policy Year. treatment of the listed
v. Cumulative Bonus shall not be Conditions, surgeries/
applicable for newly added members treatments shall be excluded
in the year of addition. until the expiry of 24 months
of continuous coverage after
vi. For purpose of computation of
the date of inception of the first
Cumulative Bonus, the percentage
policy with us. This exclusion
(%) of Cumulative Bonus will be
shall not be applicable for claims
applied on the Inpatient Sum Insured
arising due to an accident.
only.
b. In case of enhancement of sum
Section 3 – Exclusions
9

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: TATHLIP21253V022021
 insured the exclusion shall & duodenum
apply afresh to the extent of XVI. Gastro Esophageal Reflux
sum insured increase. Disorder (GERD)
c. If any of the specified disease/ XVII. Liver Cirrhosis
procedure falls under the
waiting period specified for XVIII. Perineal Abscesses
pre-Existing diseases, then XIX. Perianal / Anal Abscesses
the longer of the two waiting XX. C a l c u l u s d i s e a s e s o f
periods shall apply. Urogenital system
d. The waiting period for listed Example: Kidney stone,
conditions shall apply even if Urinary bladder stone.
contracted after the policy or XXI. Benign Hyperplasia of
declared and accepted without prostate
a specific exclusion.
XXII. Varicocele
e. If the Insured Person is
XXIII. Cataract
continuously covered without
any break as defined under the XXIV. Retinal detachment
applicable norms on portability XXV. Glaucoma
stipulated by IRDAI, then waiting XXVI. C o n g e n i t a l I n t e r n a l
period for the same would be Diseases
reduced to the extent of prior
coverage. The following treatments are covered
after a waiting period of two years
f. List of Specific Diseases/ irrespective of the illness for which it
procedures as furnished below: is done:
I. Tumors, Cysts, polyps XXVII. Adenoidectomy
including breast lumps
(benign) XXVIII. Mastoidectomy
II. Polycystic ovarian disease XXIX. Tonsillectomy
III. Fibromyoma XXX. Tympanoplasty
IV. Adenomyosis XXXI. Surgery for nasal septum
deviation
V. Endometriosis
XXXII. Nasal concha resection
VI. Prolapsed Uterus
XXXIII. Surgery for Turbinate
VII. Non-infective arthritis hypertrophy
VIII. Gout and Rheumatism XXXIV. Hysterectomy
IX. Osteoporosis XXXV. Joint replacement surgeries
X. Lig am en t, T en d on or Eg: Knee replacement, Hip
Meniscal tear (due to replacement
injury or otherwise) XXXVI. Cholecystectomy
XI. Prolapsed Inter Vertebral XXXVII. H e r n i o p l a s t y or
Disc (due to injury or Herniorraphy
otherwise)
XXXVIII. S u r g e r y / p r o c e d u r e
XII. Cholelithiasis for Benign prostate
XIII. Pancreatitis enlargement
XIV. Fissure/fistula in anus, XXXIX. Surgery for Hydrocele/
haemorrhoids, pilonidal Rectocele
sinus XL. Surgery of varicose veins
XV. Ulcer & erosion of stomach and varicose ulcers
10

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: TATHLIP21253V022021
 iii. 30 Days Waiting Period (Code- Excl 03): iii. Obesity/ Weight Control (Code-
a. Expenses related to the Excl 06)
treatment of any illness within Expenses related to surgical
30 days from the first policy treatment of obesity that does not
commencement date shall be fulfil the below conditions:
excluded except claims arising a. Surgery to be conducted is upon
due to an accident, provided the the advice of the Doctor;
same are covered.
b. The surgery/Procedure
b. This exclusion shall not, however, conducted should be supported
apply if the Insured Person has by clinical protocols;
Continuous Coverage for more
than twelve months. c. The member has to be 18 years
of age or older and
c. The within referred waiting
period is made applicable to the d. Body Mass Index (BMI);
enhanced sum insured in the i. greater than or equal to 40
event of granting higher sum or
insured subsequently. ii. greater than or equal to
2. Medical Exclusions 35 in conjunction with any
i. Investigation and evaluation of the following severe
(Code- Excl 04): co-morbidities following
failure of less invasive
a. Expenses related to any
methods of weight loss:
admission primarily for
diagnostics and evaluation 1. Obesity-related
purposes only are excluded. cardiomyopathy
b. Any diagnostic expenses which 2. Coronary heart
are not related or not incidental disease
to the current diagnosis and 3. Severe Sleep Apnea
treatment are excluded.
4. Uncontrolled Type2
ii. Rest cure, rehabilitation and Diabetes
respite care (Code- Excl 05):
iv. Change-of-Gender treatments
a. Expenses related to any (Code- Excl 07) :
admission primarily for
Expenses related to any treatment,
enforced bed rest and not for
including surgical management, to
receiving treatment. This also
change characteristics of the body to
includes:
those of the opposite sex.
i. Custodial care either
v. Cosmetic or Plastic Surgery (Code-
at home or in a nursing
Excl 08):
facility for personal care
such as help with activities Expenses for cosmetic or plastic
of daily living such as surgery or any treatment to change
bathing, dressing, moving appearance unless for reconstruction
around either by skilled following an Accident, Burn(s) or
nurses or assistant or non- Cancer or as part of medically
skilled persons. necessary treatment to remove a
direct and immediate health risk to
ii. Any services for people
the insured. For this to be considered
who are terminally ill to
a medical necessity, it must be
address physical, social,
certified by the attending Medical
emotional and spiritual
Practitioner.
needs.
vi. Treatment for, Alcoholism, drug or
11

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: TATHLIP21253V022021
 substance abuse or any addictive caesarean sections incurred
condition and consequences thereof. during hospitalization) except
(Code- Excl 12) ectopic pregnancy;
vii. Treatments received in heath b. Expenses towards miscarriage
hydros, nature cure clinics, spas or (unless due to an accident) and
similar establishments or private lawful medical termination of
beds registered as a nursing home pregnancy during the policy
attached to such establishments or period.
where admission is arranged wholly 3. Non-Medical Exclusions
or partly for domestic reasons.
i. Hazardous or Adventure Sports
(Code -Excl13)
(Code- Excl 09):
viii. Dietary supplements and substances
Expenses related to any treatment
that can be purchased without
necessitated due to participation
prescription, including but not limited
as a professional in hazardous or
to Vitamins, minerals and organic
adventure sports, including but
substances unless prescribed by not limited to, para-jumping, rock
a medical practitioner as part of climbing, mountaineering, rafting,
hospitalization claim or day care motor racing, horse racing or scuba
procedure. (Code- Excl14) diving, hand gliding, sky diving, deep-
ix. Refractive error (Code- Excl 15): sea diving.
Expenses related to the treatment ii. Breach of law (Code- Excl 10):
for correction of eye sight due to Expenses for treatment directly
refractive error less than 7.5 dioptres arising from or consequent upon
x. Unproven treatments (Code- Excl any Insured Person committing or
16): attempting to commit a breach of law
Expenses related to any unproven with criminal intent.
treatment, services and supplies for iii. Excluded Providers (Code-Excl 11):
or in connection with any treatment. Expenses incurred towards treatment
Unproven treatments are treatments, in any hospital or by any Medical
procedures or supplies that lack Practitioner or any other provider
significant medical documentation specifically excluded by the Insurer
to support their effectiveness. and disclosed in its website /
xi. Sterility and Infertility (Code- Excl notified to the policyholders are not
17): admissible. However, in case of life
threatening situations or following an
Expenses related to Sterility and
accident, expenses up to the stage of
infertility. This includes:
stabilization are payable but not the
i. Any type of contraception, complete claim.
sterilization
ii. Specific Exclusions (Exclusions other
ii. Assisted Reproduction services than as mentioned under Section 3 (i)
including artificial insemination above)
and advanced reproductive
1. Medical Exclusions
technologies such as IVF, ZIFT,
GIFT, ICSI i. Alcoholic pancreatitis;
iii. Gestational Surrogacy ii. Congenital External Diseases,
defects or anomalies;
iv. Reversal of sterilization
iii. Stem cell therapy; however
xii. Maternity (Code - Excl 18) :
hematopoietic stem cells for
a. Medical treatment expenses bone marrow transplant for
traceable to childbirth (including haematological conditions will
complicated deliveries and 12

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: TATHLIP21253V022021
 be covered under benefit B1 hygiene articles, body care
or B4 of this policy; products and bath additive,
iv. Growth hormone therapy; barber or beauty service, guest
service.
v. Sleep-apnoea;
v. Treatment rendered by a
vi. A d m i s s i o n p r i m a r i l y f o r
Medical Practitioner which is
administration of Intra-articular
outside his discipline.
or intra-lesional injections or
Intravenous immunoglobulin vi. Doctor’s fees charged by the
infusion or supplementary Medical Practitioner sharing the
medications like Zolendronic same residence as an Insured
Acid; Person or who is an immediate
relative of an Insured Person’s
vii. Venereal disease, sexually
family.
transmitted disease or illness;
vii. Provision or fitting of hearing
viii. All preventive care, vaccination
aids, spectacles or contact
including inoculation and
lenses including optometric
immunisations;
therapy.
ix. Dental treatment or surgery
of any kind unless as a result viii. Any treatment and associated
of Accidental Bodily Injury to expenses for alopecia,
natural teeth and also requiring baldness, wigs, or toupees,
hospitalization & any dental medical supplies including
treatment other than specified elastic stockings, diabetic test
in ‘Inpatient Treatment – Dental’; strips, and similar products.
x. Any existing disease specifically ix. Any treatment or part of a
me nt i one d as P er m an en t treatment that is not of
exclusion in the Policy Schedule. a reasonable charge, not
medically necessary; drugs
2. Non-Medical Exclusions
or treatments which are not
i. War or any act of war, invasion, supported by a prescription.
act of foreign enemy, civil
x. Crutches or any other external
war, public defence, rebellion,
appliance and/or device used
revolution, insurrection,
for diagnosis or treatment
military or usurped acts, nuclear
(except when used intra-
weapons/materials, chemical
operatively and explicitly stated
and biological weapons, ionising
and covered in the policy).
radiation.
xi. Any illness diagnosed or injury
ii. A n y I n s u r e d P e r s o n ’ s
sustained or where there is
participation or involvement
change in health status of the
in naval, military or air force
member after date of proposal
operation.
and before commencement
iii. I n t e n t i o n a l s e l f - i n j u r y o r of policy and the same is not
attempted suicide while sane communicated and accepted
or insane. by us.
iv. Items of personal comfort and xii. Any claim within the deductible
convenience like television limit as specified in the policy
(wherever specifically charged schedule.
for), charges for access to
telephone and telephone calls, Section 4 – General Terms and Clauses
internet, foodstuffs (except Standard General Terms and Clauses:
patient’s diet), cosmetics, 1. Disclosure of Information
13

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: TATHLIP21253V022021
 The policy shall be void and all premium the rate fixed by the Reserve Bank
paid thereon shall be forfeited to the of India (RBl) at the beginning of
Company in the event of misrepresentation, the financial year in which claim has
misdescription or non-disclosure of any fallen due).
material fact by the policyholder.
4. Complete Discharge
(Explanation: “Material facts” for the
purpose of this policy shall mean all Any payment to the policyholder, insured
relevant information sought by the person or his/ her nominees or his/ her
company in the proposal form and other legal representative or assignee or to
the Hospital, as the case may be, for any
connected documents to enable it to
benefit under the policy shall be a valid
take informed decision in the context of
discharge towards payment of claim by the
underwriting the risk.)
Company to the extent of that amount for
2. Condition Precedent to Admission of the particular claim.
Liability
5. Multiple Policies
The terms and conditions of the policy
must be fulfilled by the insured person i. In case of multiple policies taken by an
for the Company to make any payment for insured person during a period from
claim(s) arising under the policy. one or more insurers to indemnify
treatment costs, the insured person
3. Claim Settlement (provision for Penal shall have the right to require a
Interest) settlement of his/her claim in terms
i. The Company shall settle or reject a of any of his/her policies. In all such
claim, as the case may be, within 30 cases the insurer chosen by the
days from the date of receipt of last insured person shall be obliged to
necessary document. settle the claim as long as the claim
ii. In the case of delay in the payment of is within the limits of and according
a claim, the Company shall be liable to the terms of the chosen policy.
to pay interest to the policyholder ii. Insured person having multiple
from the date of receipt of last policies shall also have the right to
necessary document to the date of prefer claims under this policy for
payment of claim at a rate 2% above the amounts disallowed under any
the bank rate. other policy / policies even if the sum
iii. However, where the circumstances insured is not exhausted. Then the
of a claim warrant an investigation insurer shall independently settle
in the opinion of the Company, it the claim subject to the terms and
shall initiate and complete such conditions of this policy.
investigation at the earliest, in any iii. If the amount to be claimed exceeds
case not later than 30 days from the sum insured under a single policy,
the date of receipt of last necessary the insured person shall have the
document. In such cases, the right to choose insurer from whom
Company shall settle or reject the he/she wants to claim the balance
claim within 45 days from the date of amount.
receipt of last necessary document. iv. Where an insured person has policies
iv. In case of delay beyond stipulated from more than one insurer to
45 days, the Company shall be liable cover the same risk on indemnity
to pay interest to the policyholder at basis, the insured person shall only
a rate 2% above the bank rate from be indemnified the treatment costs
the date of receipt of last necessary in accordance with the terms and
document to the date of payment of conditions of the chosen policy.
claim. 6. Fraud
(Explanation: “Bank rate” shall mean
14

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: TATHLIP21253V022021
 If any claim made by the insured person, Length of time Tenure (Years)
is in any respect fraudulent, or if any false Policy in force
statement, or declaration is made or used
1 2 3
in support thereof, or if any fraudulent
means or devices are used by the insured Upto 1 Month 75.00% 87.50% 91.5%
person or anyone acting on his/her behalf >1 month & 50.00% 75.00% 88.5%
to obtain any benefit under this policy, all Upto 3 Months
benefits under this policy and the premium >3 months & 25.00% 62.50% 75%
paid shall be forfeited. Upto 6 Months
Any amount already paid against claims >6 months & Nil 50.00% 66.5%
made under this policy but which are Upto 12 Months
found fraudulent later shall be repaid by all >12 months & NA 25% 50%
recipient(s)/policyholder(s), who has made Upto 15 Months
that particular claim, who shall be jointly
>15 months & NA 12.5% 41.5%
and severally liable for such repayment to
Upto 18 Months
the insurer.
>18 months & NA Nil 33%
For the purpose of this clause, the
Upto 24 months
expression “fraud” means any of the
following acts committed by the insured >24 months & NA NA 8%
person or by his agent or the hospital/ Upto 30 months
doctor/any other party acting on behalf of Exceeding 30 NA NA Nil
the insured person, with intent to deceive months
the insurer or to induce the insurer to issue
Notwithstanding anything contained herein
an insurance policy:
or otherwise, no refunds of premium shall
a) the suggestion, as a fact of that which be made in respect of Cancellation where,
is not true and which the insured any claim has been admitted or has been
person does not believe to be true; lodged or any benefit has been availed by
b) the active concealment of a fact by the the insured person under the policy.
insured person having knowledge or ii. The Company may cancel the
belief of the fact; policy at any time on grounds of
c) any other act fitted to deceive; and misrepresentation non-disclosure of
d) any such act or omission as the law material facts, fraud by the insured
specially declares to be fraudulent. person by giving 15 days’ written
notice. There would be no refund of
The Company shall not repudiate the
claim and / or forfeit the policy benefits premium on cancellation on grounds
on the ground of Fraud, if the insured of misrepresentation, non-disclosure
person / beneficiary can prove that the of material facts or fraud.
misstatement was true to the best of his 8. Migration
knowledge and there was no deliberate The insured person will have the option to
intention to suppress the fact or that migrate the policy to other health insurance
such misstatement of or suppression of products/plans offered by the company by
material fact are within the knowledge of applying for migration of the policy at least
the insurer. 30 days before the policy renewal date as
7. Cancellation per IRDAI guidelines on Migration. lf such
i. The policyholder may cancel this person is presently covered and has been
policy by giving 15 days written continuously covered without any lapses
notice and in such an event, the under any health insurance product/
Company shall refund premium plan offered by the company, the insured
for the unexpired policy period as person will get the accrued continuity
detailed below: benefits in waiting periods as per IRDAI
15

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: TATHLIP21253V022021
 guidelines on migration. iv. At the end of the policy period, the
For Detailed Guidelines on Migration, kindly policy shall terminate and can be
refer Guidelines issued by IRDAI(Insurance renewed within the Grace Period
Regulatory and Development Authority of 30 days to maintain continuity
of India) on Migration and Portability of of benefits without break in policy.
Health Insurance policies – Ref: : IRDAI/ Coverage is not available during the
HLT/REG/CIR/194/07/2020) dated 22 nd grace period.
July 2020 and subsequent amendments v. No loading shall apply on renewals
thereof. based on individual claims experience.
9. Portability 11. Withdrawal of Policy
The insured person will have the option i. In the likelihood of this product being
to port the policy to other insurers by withdrawn in future, the Company
applying to such insurer to port the will intimate the insured person
entire policy along with all the members about the same 90 days prior to
of the family, if any, at least 45 days expiry of the policy.
before, but not earlier than 60 days ii. Insured Person will have the option
from the policy renewal date as per
to migrate to similar health insurance
IRDAI guidelines related to portability.
product available with the Company
If such person is presently covered and
at the time of renewal with all the
has been continuously covered without
accrued continuity benefits such as
any lapses under any health insurance
cumulative bonus, waiver of waiting
policy with an Indian General/Health
period as per IRDAI guidelines,
insurer, the proposed insured person
provided the policy has been
will get the accrued continuity benefits in
maintained without a break.
waiting periods as per IRDAI guidelines on
portability. 12. Moratorium Period
For Detailed Guidelines on Portability, kindly After completion of eight continuous
refer Guidelines issued IRDAI(Insurance years under the policy no look back to be
Regulatory and Development Authority applied. This period of eight years is called
of India) on Migration and Portability of as moratorium period. The moratorium
Health Insurance policies – Ref: : IRDAI/ would be applicable for the sums insured
HLT/REG/CIR/194/07/2020) dated 22 nd of the first policy and subsequently
July 2020 and subsequent amendments completion of 8 continuous years would
thereof. be applicable from date of enhancement of
sums insured only on the enhanced limits.
10. Renewal of Policy
After the expiry of Moratorium Period no
The policy shall ordinarily be health insurance claim shall be contestable
renewable except on grounds of fraud, except for proven fraud and permanent
misrepresentation by the insured person. exclusions specified in the policy contract.
i. The Company shall endeavor to give The policies would however be subject
notice for renewal. However, the to all limits, sub limits, co-payments,
Company is not under obligation to deductibles as per the policy contract.
give any notice for renewal. 13. Possibility of Revision of Terms of the
ii. Renewal shall not be denied on the Policy Including the Premium Rates
ground that the insured person The Company, with prior approval of
had made a claim or claims in the IRDAI, may revise or modify the terms of
preceding policy years. the Policy including the premium rates.
iii. Request for renewal along with The Insured Person shall be notified three
requisite premium shall be received months before the changes are affected.
by the Company before the end of 14. Free look period
the policy period. The Free Look Period shall be applicable
16

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: TATHLIP21253V022021
 on new individual health insurance policies com/grievance-redressal-policy)
and not on renewals or at the time of lf Insured person is not satisfied with
porting/migrating the policy. the redressal of grievance through
The insured person shall be allowed free above methods, the insured person may
look period of fifteen days from date of also approach the office of Insurance
receipt of the policy document to review Ombudsman of the respective area/region
the terms and conditions of the policy, and (details as mentioned in the Annexure A of
to return the same if not acceptable. this policy) for redressal of grievance as per
If the insured has not made any claim Insurance Ombudsman Rules 2017.
during the Free Look Period, the insured Grievance may also be lodged at IRDAI
shall be entitled to Integrated Grievance Management System
i. a refund of the premium paid (https://igms.irda.gov.in/)
less any expenses incurred by the 16. Nomination
Company on medical examination
The policyholder is required at the inception
of the insured person and the stamp
of the policy to make a nomination for
duty charges or
the purpose of payment of claims under
ii. where the risk has already the policy in the event of death of the
commenced and the option of return policyholder. Any change of nomination
of the policy is exercised by the shall be communicated to the company in
insured person, a deduction towards writing and such change shall be effective
the proportionate risk premium for only when an endorsement on the policy
period of cover or is made. In the event of death of the
iii. Where only a part of the insurance policyholder, the Company will pay the
coverage has commenced, nominee {as named in the Policy Schedule/
such proportionate premium Policy Certificate/Endorsement (if any)} and
commensurate with the insurance in case there is no subsisting nominee, to
coverage during such period; the legal heirs or legal representatives of
15. Redressal of Grievance the policyholder whose discharge shall be
treated as full and final discharge of its
In case of any grievance the insured person liability under the policy.
may contact the company through
ii. Specific terms and clauses
Website: www.tataaig.com (terms and clauses other than those
Toll Free: 1800 266 7780 or 1800 22 9966 mentioned under Section 4 (i) above)
(only for Senior Citizen policyholders) 17. Premium Payment
Email: customersupport@tataaig.com i. Premium to be paid for the Policy Period
Courier: Customer Support, TATA AIG before Policy Commencement date as
General Insurance Company Limited, opted by You in the proposal form.
7th and 8th Floor, Romell Tech Park, Cama ii. Long term premium discount of 5%
Industrial Estate, Western Express Highway, and 10% is applicable for policy with
Goregaon(E), Mumbai, Maharashtra 400063 tenure of 2 and 3 years respectively.
Insured person may also approach the 18. Insured Person
grievance cell at any of the company’s i. Only those persons named as an
branches with the details of grievance. Insured Person in the Schedule shall
If Insured person is not satisfied with the be covered under this Policy.
redressal of grievance through one of ii. Any person may be added during
the above methods, insured person may the Policy Period after his application
contact the grievance officer at manager. has been accepted by Us, additional
customersupport@tataaig.com. premium has been paid and We have
For updated details of grievance officer, issued an endorsement confirming
kindly refer the link (https://www.tataaig.
17

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: TATHLIP21253V022021
 the addition of such person as an the entire contract of insurance. No
Insured Person. change in this policy shall be valid
iii. We will be offering continuous unless approved by Us and such
renewal with no exit age subject approval be endorsed hereon.
to regular premium payment and ii. This Policy and the Schedule shall be
compliance with all provisions and read together as one contract and
terms & conditions of this policy by any word or expression to which a
the Insured Person. specific meaning has been attached
19. Loadings in any part of this Policy or of the
Schedule shall bear such meaning
i. We may apply a risk loading on the
wherever it may appear.
premium payable (based upon the
declarations made in the proposal 21. Sum Insured Enhancement and Change
form and the health status of the in deductible
persons proposed for insurance). i. Sum Insured and/or Deductible
ii.The maximum risk loading applicable can be changed only at the time
for an individual shall not exceed of renewal subject to underwriting
100% of premium per diagnosis / guidelines of the company.
medical condition and an overall risk ii. In case of increase in the Sum Insured
loading of over 150% of premium per waiting period and exclusions will
person. apply afresh in relation to the amount
iii. The loading shall only be applied by which the Sum Insured has been
basis an outcome of Our medical enhanced. For claims arising in
underwriting. respect of accident, injury or illness
iv. These loadings are applied from contracted or suffered during a
Commencement Date of the Policy preceding Policy period, liability of
including subsequent renewal(s) with the Company shall be only to the
Us or on the receipt of the request extent of the Sum Insured under the
of increase in Sum Insured (for the Policy in force at the time when it was
increased Sum Insured). contracted or suffered.
a. We will inform You about the 22. Change of Policyholder
applicable risk loading through The change of Policyholder is permitted
a counter offer letter. only at the time of renewal.
b. You need to revert to Us If the Insured Person is no longer eligible on
with consent and additional grounds of age or dependency, the insured
premium (if any), within 15 days member will be eligible to apply for a new
of the issuance of such counter policy and enjoy continuity benefits upto
offer letter. Sum Insured.
c. In case, you neither accept the 23. Notices
counter offer nor revert to Us i. Any notice, direction or instruction
within 15 days, We shall cancel under this Policy shall be in writing
Your application and refund the and if it is to:
premium paid within next 10
days subject to deduction of the a. Any Insured Person, then it shall
Pre-Policy Check up charges, as be sent to You at Your address
applicable. specified in the Schedule to
this Policy and You shall act for
v. Please note that We will issue Policy all Insured Persons for these
only after getting Your consent. purposes.
20. Entire Contract
b. Us, it shall be delivered to
i. This Policy, its Schedule, Our address specified in the
endorsement(s), proposal constitutes
18

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: TATHLIP21253V022021
 Schedule to this Policy. No Section 5 – Claims Procedure and Claims
insurance agents, brokers Payment
or other person or entity is
authorised to receive any This section explains about the procedures
notice, direction or instruction involved to file a valid claim by the insured
on Our behalf unless We have member and processes related in managing
expressly stated to the contrary the claim by TPA or Us. All the procedures and
in writing. processes such as notification of claim, availing
cashless service, supporting claim documents
and related claim terms of payment are
explained in this section.

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 Person’s
be made and that treatment requires 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
Failure to furnish such intimation within the time required shall not invalidate nor reduce any
claim if You can satisfy us that it was not reasonably possible for You to give proof of such
delay within such time. The Company may relax these timelines only in special circumstances
and for the reasons beyond the control of the insured.
*TPA as mentioned in the policy schedule
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 Insured
Procedure: Procedure Taken at: Person wishes to
take advantage of
the cashless service
accompanied by full
particulars:
I f a n y p l a n n e d Network Hospital We will provide At least 48 hours
t r e a t m e n t , cashless service by before the planned
consultation or making payment to treatment or
procedure for which the extent of Our Hospitalisation
a claim may be made: liability directly to the
Network Hospital.
I f a n y t r e a t m e n t , Network Hospital W e w i l l p r o v i d e Within 24 hours after
consultation or cashless service by t h e t r e a t m e n t o r
procedure for which making payment to Hospitalisation
a claim may be made, the extent of Our
requiring emergency liability directly to the
hospitalisation Network Hospital.

19

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: TATHLIP21253V022021
3. Procedure for Cashless Service documents for us to decide on
the admissibility of the claim.
i. Cashless Service is only available at
Network Hospitals. h. If the cashless is approved,
the original bills and evidence
ii. In order to avail of cashless treatment,
of treatment in respect of the
the following procedure must be
same shall be left with the
followed by You:
Network Hospital.
a. Prior to taking treatment and/
i. Pre-authorization does not
or incurring Medical Expenses
guarantee that all costs and
at a Network Hospital, You must
expenses will be covered. We
call our designated TPA/Us and
reserve the right to review each
request pre-authorization.
claim for Medical Expenses and
b. For any emergency accordingly coverage will be
Hospitalisation, our designated determined according to the
TPA/We must be informed terms and conditions of this
no later than 24 hours of the Policy.
start of Your hospitalization/
4. Supporting Documentation &
treatment.
Examination
c. For any planned hospitalization,
i. You or someone claiming on
our designated TPA/We must
Your behalf shall provide Us with
be informed atleast 48 hours
documentation, medical records
prior to the start of your
and information We or Our TPA
hospitalization/treatment.
may request to establish the
d. Our designated TPA/We will circumstances of the claim, its
check your coverage as per quantum or Our liability for the
the eligibility and send an claim within 15 days or earlier of
authorization letter to the Our request or the Insured Person’s
provider. You have to provide discharge from Hospitalisation or
the ID card issued to You along completion of treatment.
with any other information
ii. Failure to furnish such evidence
or documentation that is
within the time required shall not
requested by the TPA/Us to
invalidate nor reduce any claim if
the Network Hospital.
you can satisfy us that it was not
e. In case of deficiency in the reasonably possible for you to give
documents sent to TPA/Us for proof within such time.
cashless authorization, the
iii. We may accept claims where
same shall be communicated
documents have been provided
to the hospital by TPA/Us
after a delayed interval only in special
within 6 hours of receipt of the
circumstances and for the reasons
documents.
beyond the control of the Insured
f. In case the ailment /treatment Person.
is not covered under the policy
iv. Such documentation will include
or cashless is rejected due
the following:
to insufficient documents
submitted, a rejection letter a. Our claim form, duly completed
would be sent to the hospital and signed for on behalf of the
within 6 hours. Insured Person.
g. Rejection of cashless in no way We, upon receipt of a notice
indicates rejection of the claim. of claim, will furnish Your
You are required to submit representative with such
the claim along with required forms as We may require for
20

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: TATHLIP21253V022021
 filing proofs of loss or you may (First information report), if
download the claim form from registered, in case of claims
our Web site. arising out of an accident and
b. Original Bills (pharmacy available with the claimant.
purchase bill, consultation k. Regulatory requirements as
bill, diagnostic bill) and any amended from time to time,
attachments thereto like currently mandatory NEFT (to
receipts or prescriptions in enable direct credit of claim
support of any amount claimed amount in bank account) and
which will then become Our KYC (recent ID/Address proof
property. and photograph) requirements.
c. All medical reports, case l. Legal heir/succession certificate
histories, investigation reports, , if required;
indoor case papers/ treatment m. PM report (wherever applicable
papers (in reimbursement and conducted);
cases, if available), discharge
summaries. n. If the original claim documents
mentioned above are submitted
d. A precise diagnosis of the to any other insurer, we would
treatment for which a claim is require:
made.
• Self –attested copies of the
e. A detailed list of the individual claim documents
medical services and treatments
provided and a unit price for • Certificate/Claim
each in case not available in the settlement letter from
submitted hospital bill. other insurer or TPA

f. Prescriptions that name the v. Note: In case You are claiming for
Insured Person and in the the same event under an indemnity
case of drugs: the drugs based policy of another insurer and
prescribed, their price and a are required to submit the original
receipt for payment. In case of documents related to Your treatment
pre/post hospitalization claim with that particular insurer, then You
Prescriptions must be submitted may provide Us with the attested
with the corresponding Doctor/ copies of such documents along with
hospital invoice. a declaration from the particular
insurer specifying the availability of
g. All pre and post investigation, the original copies of the specified
treatment and follow up treatment documents with it.
(consultation) records
pertaining to the present vi. We at our own expense, shall
ailment for which claim is being have the right and opportunity to
made, if and where applicable. examine insured persons through
an independent Medical Practitioner
h. Treating doctor’s certificate whose details will be notified to
regarding missing information insured person when and as often
in case histories e.g. as We may reasonably require during
Circumstance of injury and the pendency of a claim hereunder.
Alcohol or drug influence at the
time of accident, if available. 5. Claims Payment

i. Stickers and invoice of implants i. We shall be under no obligation

used during surgery. to make any payment under this
Policy unless We have received all
j. Copy of MLC (Medico legal case) premium payments in full in time
records, if carried out and FIR and We have been provided with
21

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: TATHLIP21253V022021
 the documentation and information difference shall independently of all other
We or Our TPA has requested to questions, be referred to the decision
establish the circumstances of the of a sole arbitrator to be appointed in
claim, its quantum or Our liability for writing by the parties here to or if they
it, and unless the Insured Person has cannot agree upon a single arbitrator
complied with his obligations under within thirty days of any party invoking
this Policy. arbitration, the same shall be referred to a
panel of three arbitrators, comprising two
ii. Medical Expenses incurred for AYUSH
arbitrators, one to be appointed by each
treatment shall be assessed only
of the parties to the dispute/difference
under benefit B7 of this policy and
and the third arbitrator to be appointed by
shall be admissible only if incurred
such two arbitrators and arbitration shall
within India.^
be conducted under and in accordance
iii. This Policy only covers medical with the provisions of the Arbitration and
treatment taken within India (except Conciliation Act 1996, as amended by
in case of benefit B13- Global cover, Arbitration and Conciliation (Amendment)
if opted), and payments under this Act, 2015 (No. 3 of 2016).
Policy shall only be made in Indian
It is clearly agreed and understood that no
Rupees within India.
difference or dispute shall be preferable
Section 6 - Dispute Resolution to arbitration as herein before provided, if
the Company has disputed or not accepted
1. Dispute Resolution Clause
liability under or in respect of the policy.
Any and all disputes or differences
3. It is hereby expressly stipulated and
under or in relation to this Policy shall
declared that it shall be a condition
be determined by the Indian Courts and
precedent to any right of action or suit
subject to Indian law.
upon the policy that award by such
2. Arbitration arbitrator/arbitrators of the amount of
If any dispute or difference shall arise as expenses shall be first obtained
to the quantum to be paid by the Policy,
(liability being otherwise admitted) such
^Note: In compliance with IRDAI circular dated 31.01.2024, on ‘Guidelines on providing AYUSH coverage
in Health Insurance policies’ (Ref: IRDAI/HLT/CIR/GDL/31/01/2024), policy wordings have been modified.

Annexure A
NAMES OF OMBUDSMAN AND ADDRESSES OF OMBUDSMAN CENTRES

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

22

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: TATHLIP21253V022021
 Jurisdiction of Office Union
Centre Address & Contact
Territory, District

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

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

23

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: TATHLIP21253V022021
 Jurisdiction of Office Union
Centre Address & Contact
Territory, District

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

24

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: TATHLIP21253V022021
 Jurisdiction of Office Union
Centre Address & Contact
Territory, District

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 or property in India, any rebate of the
Ombudsman Offices, please visit website http:// whole or part of the commission payable
www.cioins.co.in/ombudsman.html or any rebate of the premium shown on
the policy, nor shall any person taking out
Prohibition of Rebates - Section 41 of the
or renewing or continuing a policy accept
Insurance Act, 1938 as amended by Insurance
any rebate, except such rebate as may be
Laws (Amendment) Act, 2015.
allowed in accordance with the published
1. No person shall allow or offer to allow, prospectuses or tables of the insurer.
either directly or indirectly, as an 2. Any person making default in complying
inducement to any person to take out with the provisions of this section shall be
or renew or continue an insurance in liable for a penalty which may extend to
respect of any kind of risk relating to lives ten lakh rupees.
R1/PW/MC+/Mar 24

25

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: TATHLIP21253V022021