STAR HEALTH AND ALLIED INSURANCE COMPANY LIMITED

Regd. & Corporate Office: 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam,
Chennai - 600 034. « Phone : 044 - 28288800 « Email : support@starhealth.in
Website : www.starhealth.in « CIN : U66010TN2005PLC056649 « IRDAI Regn. No. : 129

Kind Attention: Policyholder

Please check whether the details given by you about the insured persons in the proposal form (a copy of which was provided at the
time of issuance of cover for the first time) are incorporated correctly in the policy schedule. If you find any discrepancy, please inform
us within 15 days from the date of receipt of the policy, failing which the details relating to the person/s covered would be taken as
correct.
So also the coverage details may also be gone through and in the absence of any communication from you within 15 days from the
date of receipt of this policy, it would be construed that the policy issued is correct and the claims if any arise under the policy will be
dealt with based on proposal / policy details.

Customer Information Sheet - Arogya Sanjeevani Policy, Star Health and Allied Insurance Co Ltd.
Unique Identification No.: SHAHLIP22027V032122

SI. Refer to Policy

Title Description
No. Clause Number

1 Product Name Arogya Sanjeevani Policy, Star Health and Allied Insurance Co Ltd.
4.1
a. Hospitalization expenses- Expenses incurred on hospitalization for minimum period of 24 hours including pre-hospitalization
expenses for a period of 30 days and post hospitalization expenses for a period of 60 days.

b. Day Care Procedures- Medical expenses for day care procedures. 4.1.1

c. AYUSH Coverage- Expenses incurred on hospitalization under AYUSH Treatment. 4.2

What am I
2
covered
d. Expenses incurred on treatment of cataract. 4.3

e. Expenses incurred on dental treatment and Plastic Surgery: Necessitated due to disease or injury.
4.1.1
f. Ambulance Charges: Expenses on road Ambulance subject to a maximum of Rs.2000/- per hospitalization.

Following is a partial list of the policy exclusions. Please refer to the policy document for the complete list of exclusions:
7.1
a. Admission primarily for investigation & evaluation

b. Admission primarily for rest Cure, rehabilitation and respite care 7.2

What are the c. Expenses related to the surgical treatment of obesity that do not fulfill certain conditions 7.3
Major
3
Exclusions in
the policy d. Change-of-Gender treatments 7.4

e. Expenses for cosmetic or plastic surgery 7.5

f. Expenses related to any treatment necessitated due to participation in hazardous or adventure sports 7.6

a. Pre-Existing Diseases will be covered after a waiting period of forty eight (48) months of continuous coverage 6.1

b. Expenses related to the treatment of any illness within 30 days from the first policy commencement date shall be excluded
6.2
Waiting except claims arising due to an accident.
4
Periods
c. Specified surgeries/treatments/diseases are covered after specific waiting period of 24 months
6.3
d. Specified surgeries/treatments/diseases are covered after specific waiting period of 48 months

Payment
5 Payment on indemnity basis (Cashless / Reimbursement) 4.1
basis
In case of a claim, this policy requires you to share the following costs:
a. Expenses exceeding the following Sub-limits:
i. Room Charges(Hospitalization): 4.1
a. Room Rent - Up to 2% of SI, subject to max of INR 5,000 per day
6 Loss Sharing b. ICU charges - Up to 5% of SI subject to max of INR 10,000 per day.
c. In case Room/ICU/ICCU rent exceeds the limits specified the claim shall be subject to the proportionate
deduction.
ii. Cataract — Up to 25% of Sum Insured or Rs.40,000/- whichever is lower. 4.3
iii. Modern treatment methods and Advancements in technology: Up to 50% of the Sum insured. 4.6
b. Each and every claim under the Policy shall be subject to a Copayment of 5% applicable to claim amount admissible and
9.3
payable as per the terms and conditions of the Policy

Arogya Sanjeevani Policy, Star Health and Allied Insurance Co Ltd. Unique Identification No.: SHAHLIP22027V032122 POL / ASP / V.5 / 2021 1 of 10
 SI. Refer to Policy
Product Name Description
No. Clause Number
Renewal The policy shall ordinarily be renewable except on grounds of fraud, moral hazard, misrepresentation by the insured person.
7 10.16
Conditions Renewal shall not be denied on the ground that the insured had made a claim or claims in the preceding policy years.
Cumulative bonus:
Renewal
8 a. Increase in the sum insured by 5% in respect of each claim free year subject to a maximum of 50% of SI. 5
Benefits
b. In the event of claim the cumulative bonus shall be reduced at the same rate.
a. The Insured may cancel this Policy by giving 15 days' written notice, and in such an event, the Company shall refund premium on
short term rates for the unexpired Policy Period as per the rates detailed in the policy terms and conditions.
9 Cancellation 10.10
b. The Company may cancel the policy at any time on grounds of misrepresentation, non-disclosure of material facts, fraud by the
Insured Person by giving 15 days' written notice.
a. For Cashless Service:
(Insurer to provide the details /web link from where Hospital Network details can be obtained)
b. For Reimbursement of Claim : For reimbursement of claims the insured person may submit the necessary documents to
TPA/Company within the prescribed time limit as specified hereunder.
S No Type of Claim Prescribed Time limit
10 Claims Reimbursement of hospitalization, day care and pre 9
1 Within thirty days of date of discharge from hospital
hospitalization expenses
Within fifteen days from completion of post
2 Reimbursement of post hospitalization expenses
hospitalization treatment

For details on claim procedure please refer the policy document.

Insurer to provide the details of company officials.

Policy
servicing a. Details of Grievance redressal officer (Insurer to provide the link)
11 b. IRDAI Integrated Grievance Management System - https://igms.irda.gov.in/
/Grievances 11
/Complaints c. Insurance Ombudsman — The contact details of the Insurance Ombudsman offices have been provided as Annexure-B of
Policy document.
12 a. Free Look period of 15 days from the date of receipt of the policy shall be applicable at the inception. 10.19
b. Lifelong renewability (except on certain specific grounds) 10.16
c. Right to migrate from one product to another product of the company (Note: Insurer to provide e-mail and address of the Person
10.14
Insured's to be contacted)
Rights d. Right to port the from one company to another company (Note: Insurer to provide e-mail and address of the Person to be
10.15
contacted)
e. Change in SI during the policy term or at the time of renewal (Insurer to provide the contact details) 10.21
f. Insurer to specify the norms on TAT for Pre-Auth and Settlement of reimbursement. 9.1
Insured's
13 Please disclose all pre-existing disease/s or condition's before buying a policy. Non-disclosure may result in claim not being paid.
Obligations
LEGAL DISCLAIMER NOTE: The information must be read in conjunction with the product brochure and policy document. In case of any conflict between the Customer
Information Sheet and the policy document, the terms and conditions mentioned in the policy document shall prevail

Benefit Illustration in respect of policies offered on individual and family floater basis
Coverage opted on individual basis
Coverage opted on individual basis covering
covering each member of the Coverage opted on family floater basis with overall Sum insured
multiple members of the family under a single policy
family separately (Only one sum insured is available for the entire family)
Age (Sum insured is available for each member of the family)
(at a single point of time)
of the
Members Premium or
insured Premium consolidated Premium
Floater
(in yrs) Premium Sum Insured Premium Discount, After Sum Insured premium for After Sum Insured
Discount,
(Rs.) (Rs.) (Rs.) (if any) Discount (Rs.) all members Discount (Rs.)
(if any)
(Rs.) of family (Rs.)
(Rs.)
Illustration 1
64 16,675 5,00,000 16,675 16,675 5,00,000
Nil 29,500 4,490 25,010 5,00,000
58 12,825 5,00,000 12,825 12,825 5,00,000
Total Premium for all members of the family is Total Premium for all members of the family is Total Premium when policy is opted
Rs.29,500/-, when each member is Rs.29,500/-, when they are covered under a on floater basis is Rs.25,010/-,
covered separately. single policy.
Sum insured available for each individual is Sum insured available for each family member is Sum insured of Rs.5,00,000/-
Rs.5,00,000/- Rs.5,00,000/- is available for the entire family (2A)
Illustration 2
47 7,590 5,00,000 7,590 7,590 5,00,000
44 5,420 5,00,000 5,420 Nil 5,420 5,00,000 17,180 3,795 13,385 5,00,000
19 4,170 5,00,000 4,170 4,170 5,00,000
Total Premium for all members of the family is Total Premium for all members of the family is Total Premium when policy is opted
Rs.17,180/-, when each member is Rs.17,180/-, when they are covered under a on floater basis is Rs.13,385/-
covered separately. single policy.
Sum insured available for each individual is Sum insured available for each family member is Sum insured of Rs.5,00,000/-
Rs.5,00,000/- Rs.5,00,000/- is available for the entire family (2A+1C)
Note: Premium rates specified in the above illustration are standard premium rates without considering any loading. Also, the premium rates are exclusive of taxes applicable.
A-Adult | C-Child
Arogya Sanjeevani Policy, Star Health and Allied Insurance Co Ltd. Unique Identification No.: SHAHLIP22027V032122 POL / ASP / V.5 / 2021 2 of 10
 STAR HEALTH AND ALLIED INSURANCE COMPANY LIMITED
Regd. & Corporate Office: 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam,
Chennai - 600 034. « Phone : 044 - 28288800 « Email : support@starhealth.in
Website : www.starhealth.in « CIN : U66010TN2005PLC056649 « IRDAI Regn. No. : 129

AROGYA SANJEEVANI POLICY, STAR HEALTH AND ALLIED INSURANCE CO LTD.

Unique Identification No.: SHAHLIP22027V032122

1. PREAMBLE 3.9. Condition Precedent means a Policy term or condition upon which the Company's
liability under the Policy is conditional upon.
This Policy is a contract of insurance issued by [name of the Company] (hereinafter called
3.10. Congenital Anomaly refers to a condition(s) which is present since birth, and
the `Company') to the proposer mentioned in the schedule (hereinafter called the 'Insured')
to cover the person(s) named in the schedule (hereinafter called the 'Insured Persons'). which is abnormal with reference to form, structure or position.
The policy is based on the statements and declaration provided in the proposal Form by the a) Internal Congenital Anomaly: Congenital anomaly which is not in the visible
proposer and is subject to receipt of the requisite premium. and accessible parts of the body.
b) External Congenital Anomaly: Congenital anomaly which is in the visible
2. OPERATIVE CLAUSE and accessible parts of the body.
If during the policy period one or more Insured Person (s) is required to be hospitalized for 3.11. Co-payment means a cost sharing requirement under a health insurance policy
treatment of an Illness or Injury at a Hospital/ Day Care Centre, following Medical Advice of that provides that the policyholder/insured will bear a specified percentage of the
a duly qualified Medical Practitioner, the Company shall indemnify Medically necessary, admissible claims amount. A co-payment does not reduce the Sum Insured.
expenses towards the Coverage mentioned in the policy schedule. 3.12. Cumulative Bonus means any increase or addition in the Sum Insured granted by
Provided further that, any amount payable under the policy shall be subject to the terms of the insurer without an associated increase in premium.
coverage (including any co-pay, sub limits), exclusions, conditions and definitions 3.13. Day Care Centre means any institution established for day care treatment of
contained herein. Maximum liability of the Company under all such Claims during each disease/ injuries or a medical setup within a hospital and which has been registered
Policy Year shall be the Sum Insured (Individual or Floater) opted and Cumulative Bonus (if with the local authorities,wherever applicable, and is under the supervision of a
any) specified in the Schedule. registered and qualified medical practitioner AND must comply with all minimum
criteria as under:
3. DEFINITIONS i. has qualified nursing staff under its employment;
The terms defined below and at other junctures in the Policy have the meanings ascribed to ii. has qualified medical practitioner (s) in charge;
them wherever they appear in this Policy and, where, the context so requires, references to iii. has a fully equipped operation theatre of its own where surgical procedures
the singular include references to the plural; references to the male includes the female are carried out
and references to any statutory enactment includes subsequent changes to the same.
iv. maintains daily records of patients and shall make these accessible to the
3.1. Accident means a sudden, unforeseen and involuntary event caused by external,
visible and violent means. Company's authorized personnel.
3.2. Age means age of the Insured person on last birthday as on date of 3.14. Day Care Treatment means medical treatment, and/or surgical procedure which is;
commencement of the Policy. i. undertaken under general or local anesthesia in a hospital/day care centre in
less than twenty four hours because of technological advancement, and
3.3. Any One Illness means continuous period of illness and it includes relapse within
ii. which would have otherwise required a hospitalisation of more than twenty
forty five days from the date of last consultation with the hospital where treatment
four hours. Treatment normally taken on an out-patient basis is not included in
has been taken.
the scope of this definition.
3.4. AYUSH Treatment refers to hospitalisation treatments given under Ayurveda,
Yoga and Naturopathy, Unani, Siddha and Homeopathy systems. 3.15. Dental Treatment means a treatment carried out by a dental practitioner including
examinations, fillings (where appropriate), crowns, extractions and surgery.
3.5. An AYUSH Hospital is a healthcare facility wherein medical/surgical/para-surgical
treatment procedures and interventions are carried out by AYUSH Medical 3.16. Disclosure to information norm: The policy shall be void and all premium paid
Practitioner(s) comprising of any of the following: thereon shall be forfeited to the Company in the event of misrepresentation, mis-
a. Central or State Government AYUSH Hospital or description or non-disclosure of any material fact.
b. Teaching hospital attached to AYUSH College recognized by the Central 3.17. Emergency Care: Emergency care means management for an illness or injury
Government/Central Council of Indian Medicine/Central Council for which results in symptoms which occur suddenly and unexpectedly, and requires
Homeopathy; or immediate care by a medical practitioner to prevent death or serious long term
c. AYUSH Hospital, standalone or co-located with in-patient healthcare facility of impairment of the insured person's health.
any recognized system of medicine, registered with the local authorities, 3.18. Family means, the Family that consists of the proposer and any one or more of the
wherever applicable, and is under the supervision of a qualified registered family members as mentioned below:
AYUSH Medical Practitioner and must comply with all the following criterion: i. legally wedded spouse.
i. Having at least 5 in-patient beds; ii. Parents and Parents-in-law.
ii. Having qualified AYUSH Medical Practitioner in charge round the clock; iii. dependent Children (i.e. natural or legally adopted) between the age 3 months
iii. Having dedicated AYUSH therapy sections as required and/or has to 25 years. If the child above 18 years of age is financially independent, he or
equipped operation theatre where surgical procedures are to be carried she shall be ineligible for coverage in the subsequent renewals.
out; 3.19. Grace Period means specified period of time immediately following the premium due
iv. Maintaining daily records of the patients and making them accessible to date during which a payment can be made to renew or continue the Policy in force
the insurance company's authorized representative. without loss of continuity benefits such as waiting period and coverage of pre-existing
3.6. AYUSH Day Care Centre means and includes Community Health Centre (CHC), diseases. Coverage is not available for the period for which no premium is received.
Primary Health Centre (PHC), Dispensary, Clinic, Polyclinic or any such health 3.20. Hospital means any institution established for in-patient care and day care
centre which is registered with the local authorities, wherever applicable and treatment of disease/ injuries and which has been registered as a hospital with the
having facilities for carrying out treatment procedures and medical or surgical/para-
local authorities under the Clinical Establishments (Registration and Regulation)
surgical interventions or both under the supervision of registered AYUSH Medical
Practitioner (s) on day care basis without in-patient services and must comply with Act, 2010 or under the enactments specified under Schedule of Section 56(1) of the
all the following criterion: said Act, OR complies with all minimum criteria as under:
i. Having qualified registered AYUSH Medical Practitioner(s) in charge; i. has qualified nursing staff under its employment round the clock;
ii. Having dedicated AYUSH therapy sections as required and/or has equipped ii. has at least ten inpatient beds, in those towns having a population of less than
operation theatre where surgical procedures are to be carried out; ten lakhs and fifteen inpatient beds in all other places;
iii. Maintaining daily records of the patients and making them accessible iii. has qualified medical practitioner (s) in charge round the clock;
to the insurance company's authorized representative. iv. has a fully equipped operation theatre of its own where surgical procedures
3.7. Break in Policy means the period of gap that occurs at the end of the existing policy are carried out
term, when the premium due for renewal on a given policy is not paid on or before v. maintains daily records of patients and shall make these accessible to the
the premium renewal date or within 30 days thereof Company's authorized personnel.
3.8. Cashless Facility means a facility extended by the insurer to the insured where the 3.21. Hospitalisation means admission in a hospital for a minimum period of twenty four
payments, of the costs of treatment undergone by the insured person in (24) consecutive 'In-patient care' hours except for specified procedures/
accordance with the Policy terms and conditions, are directly made to the network treatments, where such admission could be for a period of less than twenty four (24)
provider by the insurer to the extent pre-authorization is approved. consecutive hours.
Arogya Sanjeevani Policy, Star Health and Allied Insurance Co Ltd. Unique Identification No.: SHAHLIP22027V032122 POL / ASP / V.5 / 2021 3 of 10
3.22. Illness means a sickness or a disease or pathological condition leading to the 3.39. Post-hospitalisation Medical Expenses means medical expenses incurred
impairment of normal physiological function which manifests itself during the policy during the period of 60days immediately after the insured person is discharged
period and requires medical treatment. from the hospital provided that:
i. Acute Condition means a disease, illness or injury that is likely to response i. Such Medical Expenses are for the same condition for which the insured
quickly to treatment which aims to return the person to his or her state of health person's hospitalisation was required, and
immediately before suffering the disease/ illness/ injury which leads to full ii. The inpatient hospitalisation claim for such hospitalisation is admissible by the
recovery. Insurance Company.
ii. Chronic Condition means a disease, illness, or injury that has one or more of 3.40. Policy means these Policy wordings, the Policy Schedule and any applicable
the following characteristics endorsements or extensions attaching to or forming part thereof. The Policy contains
a) it needs ongoing or long-term monitoring through consultations, details of the extent of cover available to the Insured person, what is excluded from the
examinations, check-ups, and / or tests cover and the terms & conditions on which the Policy is issued to the Insured person
b) it needs ongoing or long-term control or relief of symptoms 3.41. Policy period means period of one policy year as mentioned in the schedule for
c) it requires rehabilitation for the patient or for the patient to be special which the Policy is issued
trained to cope with it 3.42. Policy Schedule means the Policy Schedule attached to and forming part of Policy
d) it continues indefinitely
3.43. Policy year means a period of twelve months beginning from the date of
e) it recurs or is likely to recur commencement of the policy period and ending on the last day of such twelve-month
3.23. Injury means accidental physical bodily harm excluding illness or disease solely period. For the purpose of subsequent years, policy year shall mean a period of twelve
and directly caused by external, violent and visible and evident means which is months commencing from the end of the previous policy year and lapsing on the last
verified and certified by a medical practitioner. day of such twelve-month period, till the policy period, as mentioned in the schedule
3.24. In-Patient Care means treatment for which the insured person has to stay in a 3.44. Portability means the right accorded to an individual health insurance policyholder
hospital for more than 24 hours for a covered event. (includingall members under family cover), to transfer the credit gained for pre-
3.25. Insured Person means person(s) named in the schedule of the Policy. existing conditions and time bound exclusions, from one insurer to another insurer.
3.26. Intensive Care Unit means an identified section, ward or wing of a hospital which is 3.45. Qualified Nurse means a person who holds a valid registration from the Nursing
under the constant supervision of a dedicated medical practitioner(s), and which is Council of India or the Nursing Council of any state in India.
specially equipped for the continuous monitoring and treatment of patients who are 3.46. Renewal: Renewal means the terms on which the contract of insurance can be
in a critical condition, or require life support facilities and where the level of care and renewed on mutual consent with a provision of grace period for treating the renewal
supervision is considerably more sophisticated and intensive than in the ordinary continuous for the purpose of gaining credit for pre-existing diseases, time-bound
and other wards. exclusions and for all waiting periods.
3.27. ICU (Intensive Care Unit) Charges means the amount charged by a Hospital 3.47. Room Rent means the amount charged by a hospital towards Room and Boarding
towards ICU expenses on a per day basis which shall include the expenses for ICU expenses and shall include the associated medical expenses.
bed, general medical support services provided to any ICU patient including 3.48. Sub-limit means a cost sharing requirement under a health insurance policy in
monitoring devices, critical care nursing and intensivist charges. which an insurer would not be liable to pay any amount in excess of the pre-defined
3.28. Medical Advice means any consultation or advice from a Medical Practitioner limit
including the issue of any prescription or follow up prescription. 3.49. Sum Insured means the pre-defined limit specified in the Policy Schedule. Sum
3.29. Medical Expenses means those expenses that an insured person has necessarily Insured and Cumulative Bonus represents the maximum, total and cumulative
and actually incurred for medical treatment on account of illness or accident on the liability for any and all claims made under the Policy, in respect of that Insured
advice of a medical practitioner, as long as these are no more than would have been Person (on Individual basis) or all Insured Persons (on Floater basis) during the
payable if the insured person had not been insured and no more than other hospitals Policy Year.
or doctors in the same locality would have charged for the same medical treatment. 3.50. Surgery or Surgical Procedure means manual and / or operative procedure (s)
3.30. Medical Practitioner means a person who holds a valid registration from the required for treatment of an illness or injury, correction of deformities and defects,
Medical Council of any state or Medical Council of India or Council for Indian diagnosis and cure of diseases, relief of suffering and prolongation of life,
Medicine or for Homeopathy set up by the Government of India or a State performed in a hospital or day care centre by a medical practitioner.
Government and is thereby entitled to practice medicine within its jurisdiction; and 3.51. Third Party Administrator (TPA) means a Company registered with the Authority,
is acting within the scope and jurisdiction of the licence. and engaged by an insurer, for a fee or by whatever name called and as may be
3.31. Medically Necessary Treatment means any treatment, tests, medication, or stay mentioned in the health services agreement, for providing health services.
in hospital or part of a stay in hospital which 3.52. Waiting Period means a period from the inception of this Policy during which
i. is required for the medical management of illness or injury suffered by the insured; specified diseases/treatments are not covered. On completion of the period,
ii. must not exceed the level of care necessary to provide safe, adequate and diseases/treatments shall be covered provided the Policy has been continuously
appropriate medical care in scope, duration, or intensity; renewed without any break.
iii. must have been prescribed by a medical practitioner;
iv. must conform to the professional standards widely accepted in international 4. COVERAGE
medical practice or by the medical community In India. The covers listed below are in-built Policy benefits and shall be available to all Insured
3.32. Migration means, the right accorded to health insurance policyholders (including Persons in accordance with the procedures set out in this Policy.
all members under family cover and members of group Health insurance policy), to 4.1. Hospitalization: The Company shall indemnify medical expenses incurred for
transfer the credit gained for pre-existing conditions and time bound exclusions, Hospitalization of the Insured Person during the Policy year, up to the Sum Insured
with the same insurer. and Cumulative Bonus specified in the policy schedule, for,
3.33. Network Provider means hospitals enlisted by insurer, TPA or jointly by an insurer i. Room Rent, Boarding, Nursing Expenses as provided by the Hospital /
and TPA to provide medical services to an insured by a cashless facility. Nursing Home up to 2% of the sum insured subject to maximum of Rs.5000/-,
3.34. Non- Network Provider means any hospital that is not part of the network, per day.
ii. Intensive Care Unit (ICU) / Intensive Cardiac Care Unit (ICCU) expenses up to
3.35. Notification of Claim means the process of intimating a claim to the Insurer or TPA
5% of sum insured subject to maximum of Rs.10,000/- per day.
through any of the recognized modes of communication.
iii. Surgeon, Anesthetist, Medical Practitioner, Consultants, Specialist Fees
3.36. Out-Patient (OPD) Treatment means treatment in which the insured visits a clinic /
whether paid directly to the treating doctor / surgeon or to the hospital
hospital or associated facility like a consultation room for diagnosis and treatment
based on the advice of a medical practitioner. The insured is not admitted as a day iv. Anesthesia, blood, oxygen, operation theatre charges, surgical appliances,
care or in-patient. medicines and drugs, costs towards diagnostics, diagnostic imaging
modalities and such similar other expenses.
3.37. Pre-Existing Disease (PED): Pre existing disease means any condition, ailment,
injury or disease 4.1 .1. Other expenses
a) That is/are diagnosed by a physician within 48 months prior to the effective i. Expenses incurred on treatment of cataract subject to the sub limits
date of the policy issued by the insurer or ii. Dental treatment, necessitated due to disease or injury
b) For which medical advice or treatment was recommended by, or received iii. Plastic surgery necessitated due to disease or injury
from, a physician within 48 months prior to the effective date of the policy or its iv. All the day care treatments
reinstatement. v. Expenses incurred on Road Ambulance subject to a maximum of Rs.2000/-
c) A condition for which any symptoms and or signs if presented and have per hospitalisation.
resulted within three months of the issuance of the policy in a diagnostic illness Note:
or medical condition. 1. Expenses of Hospitalization for a minimum period of 24 consecutive
3.38. Pre-hospitalisation Medical Expenses means medical expenses incurred during hours only shall be admissible. However, the time limit shall not apply in
the period of 30days preceding the hospitalisation of the Insured Person, provided respect of Day Care Treatment
that: 2. In case of admission to a room/ICU/ICCU at rates exceeding the
i. Such Medical Expenses are incurred for the same condition for which the aforesaid limits, the reimbursement/payment of all other expenses
Insured Person's Hospitalisation was required, and incurred at the Hospital, with the exception of cost of medicines, shall be
ii. The In-patient Hospitalisation claim for such Hospitalisation is admissible by effected in the same proportion as the admissible rate per day bears to
the Insurance Company. the actual rate per day of Room Rent/ICU/ICCU charges.
Arogya Sanjeevani Policy, Star Health and Allied Insurance Co Ltd. Unique Identification No.: SHAHLIP22027V032122 POL / ASP / V.5 / 2021 4 of 10
4.2. AYUSH Treatment: The Company shall indemnify medical expenses incurred for d) Coverage under the policy after the expiry of 48 months for any pre-existing
inpatient care treatment under Ayurveda,Yoga and Naturopathy, Unani, Siddha disease is subject to the same being declared at the time of application and
and Homeopathy systems of medicines during each Policy Year up to the limit of accepted by us.
sum insured as specified in the policy schedule in any AYUSH Hospital. 6.2. First Thirty Days Waiting Period(Code- Excl03)
4.3. Cataract Treatment: The Company shall indemnify medical expenses incurred for i. Expenses related to the treatment of any illness within 30 days from the first
treatment of Cataract, subject to a limit of 25% of Sum Insured orRs.40,000/-, policy commencement date shall be excluded except claims arising due to an
whichever is lower, per each eye in one policy year. accident, provided the same are covered.
4.4. Pre Hospitalization: The company shall indemnify pre-hospitalization medical ii. This exclusion shall not, however, apply if the Insured Person has Continuous
expenses incurred, related to an admissible hospitalization requiring inpatient care, Coverage for more than twelve months.
for a fixed period of 30 days prior to the date of admissible hospitalization covered iii. The within referred waiting period is made applicable to the enhanced sum
under the policy. insured in the event of granting higher sum insured subsequently.
4.5. Post Hospitalisation: The company shall indemnify post hospitalization medical 6.3. Specific Waiting Period: (Code- Excl02)
expenses incurred, related to an admissible hospitalization requiring inpatient care, a) Expenses related to the treatment of the following listed conditions,
for a fixed period of 60 days from the date of discharge from the hospital, following surgeries/treatments shall be excluded until the expiry of 24/48 months of
an admissible hospitalization covered under the policy. continuous coverage, as may be the case after the date of inception of the first
4.6. The following procedures will be covered (wherever medically indicated) either as policy with the insurer. This exclusion shall not be applicable for claims arising
in patient or as part of day care treatment in a hospital up to 50% of Sum Insured, due to an accident.
specified in the policy schedule, during the policy period: b) In case of enhancement of sum insured the exclusion shall apply afresh to the
A. Uterine Artery Embolization and HIFU (High intensity focused ultrasound) extent of sum insured increase.
B. Balloon Sinuplasty c) If any of the specified disease/procedure falls .under the waiting period specified
C. Deep Brain stimulation for pre-existing diseases, then the longer of the two waiting periods shall apply.
D. Oral chemotherapy d) The waiting period for listed conditions shall apply even if contracted after the
policy or declared and accepted without a specific exclusion.
E. lmmunotherapy- Monoclonal Antibody to be given as injection
e) If the Insured Person is continuously covered without any break as defined
F. lntra vitreal injections
under the applicable norms on portability stipulated by IRDAI, then waiting
G. Robotic surgeries period for the same would be reduced to the extent of prior coverage.
H. Stereotactic radio surgeries
24 Months waiting period
I. BronchicalThermoplasty 01. Benign ENT disorders
J. Vaporisation of the prostrate (Green laser treatment or holmium laser treatment) 02. Tonsillectomy
K. ION M - (antra Operative Neuro Monitoring) 03. Adenoidectomy
L. Stern cell therapy: Hematopoietic stem cells for bone marrow transplant for 04. Mastoidectomy
haematological conditions
05. Tympanoplasty
4.7. The expenses that are not covered in this policy are placed under List-I of 06. Hysterectomy
Annexure-A. The list of expenses that are to be subsumed into room charges, or
procedure charges or costs of treatment are placed under List-II,List-III and List-IV 07. All internal and external benign tumours, cysts, polyps of any kind,
including benign breast lumps
of Annexure-A respectively.
08. Benign prostate hypertrophy
5. CUMULATIVE BONUS (CB) 09. Cataract and age related eye ailments
Cumulative Bonus will be increased by 5% in respect of each claim free policy year (where 10. Gastric/ Duodenal Ulcer
no claims are reported), provided the policy is renewed with the company without a break 11. Gout and Rheumatism
subject to maximum of 50% of the sum insured under the current policy year. If a claim is 12. Hernia of all types
made in any particular year, the cumulative bonus accrued shall be reduced at the same 13. Hydrocele
rate at which it has accrued. However, sum insured will be maintained and will not be 14. Non Infective Arthritis
reduced in the policy year. 15. Piles, Fissures and Fistula in anus
Notes 16. Pilonidal sinus, Sinusitis and related disorders
i. In case where the policy is on individual basis, the CB shall be added and available
17. Prolapse inter Vertebral Disc and Spinal Diseases unless arising from accident
individually to the insured person if no claim has been reported. CB shall reduce
only in case of claim from the same Insured Person. 18. Calculi in urinary system, Gall Bladder and Bile duct, excluding malignancy.
ii. In case where the policy is on floater basis, the CB shall be added and available to 19. Varicose Veins and Varicose Ulcers
the family on floater basis, provided no claim has been reported from any member 20. InternalCongenitalAnomalies
of the family. CB shall reduce in case of claim from any of the Insured Persons. 48 Months waiting period
iii. CB shall be available only if the Policy is renewed/ premium paid within the Grace 1. Treatment for joint replacement unless arising from accident
Period. 2. Age-related Osteoarthritis & Osteoporosis
iv. If the Insured Persons in the expiring policy are covered on an individual basis as
specified in the Policy Schedule and there is an accumulated CB for such Insured 7. EXCLUSIONS
Person under the expiring policy, and such expiring policy has been Renewed on a The Company shall not be liable to make any payment under the policy, in respect of any
floater policy basis as specified in the Policy Schedule then the CB to be carried expenses incurred in connection with or in respect of:
forward for credit in such Renewed Policy shall be the one that is applicable to the
lowest among all the Insured Persons 7.1 Investigation & Evaluation - (Code - Excl 04)
a) Expenses related to any admission primarily for diagnostics and evaluation
v. In case of floater policies where Insured Persons Renew their expiring policy by
purposes.
splitting the Sum Insured in to two or more floater policies/individual policies or in
cases where the policy is split due to the child attaining the age of 25 years, the CB b) Any diagnostic expenses which are not related or not incidental to the current
of the expiring policy shall be apportioned to such Renewed Policies in the diagnosis and treatment
proportion of the Sum Insured of each Renewed Policy 7.2 Rest Cure, rehabilitation and respite care - (Code - Excl 05)
vi. If the Sum Insured has been reduced at the time of Renewal, the applicable CB a) Expenses related to any admission primarily for enforced bed rest and not for
shall be reduced in the same proportion to the Sum Insured in current Policy. receiving treatment. This also includes;
vii. If the Sum Insured under the Policy has been increased at the time of Renewal the i Custodial care either at home or in a nursing facility for personal care such
CB shall be calculated on the Sum Insured of the last completed Policy Year. as help with activities of daily living such as bathing, dressing, moving
around either by skilled nurses or assistant or non-skilled persons.
viii. If a claim is made in the expiring Policy Year, and is notified to Us after the
acceptance of Renewal premium any awarded CB shall be withdrawn ii. Any services for people who are terminally ill to address physical, social,
emotional and spiritual needs.
6. WAITING PERIOD 7.3 Obesity/ Weight Control - (Code - Excl 06): Expenses related to the surgical
treatment of obesity that does not fulfil all the below conditions:
The Company shall not be liable to make any payment under the policy in connection with
1) Surgery to be conducted is upon the advice of the Doctor
or in respect of following expenses till the expiry of waiting period mentioned below:
2) The surgery/Procedure conducted should be supported by clinical protocols
6.1. Pre-Existing Diseases(Code- Excl01)
3) The member has to be 18 years of age or older and
a) Expenses related to the treatment of a pre-existing Disease (PED) and its
direct complications shall be excluded until the expiry of 48 months of 4) Body Mass Index (BMI);
continuous coverage after the date of inception of the first policy with us. a) greater than or equal to 40 or
b) In case of enhancement of sum insured the exclusion shall apply afresh to the b) greater than or equal to 35 in conjunction with any of the following severe
extent of sum insured increase. co-morbidities following failure of less invasive methods of weight loss:
c) If the Insured Person is continuously covered without any break as defined i. Obesity-related cardiomyopathy
under the portability norms of the extant IRDAI (Health Insurance) ii. Coronary heart disease
Regulations then waiting period for the same would be reduced to the extent of iii. Severe Sleep Apnea
prior coverage. iv. Uncontrolled Type2 Diabetes
Arogya Sanjeevani Policy, Star Health and Allied Insurance Co Ltd. Unique Identification No.: SHAHLIP22027V032122 POL / ASP / V.5 / 2021 5 of 10
7.4 Change-of-Gender treatments - (Code - Excl 07): Expenses related to any 9. CLAIM PROCEDURE
treatment, including surgical management, to change characteristics of the body to
those of the opposite sex. I. Procedure for Cashless claims:
7.5 Cosmetic or plastic Surgery - (Code - Excl 08): Expenses for cosmetic or plastic (i) Treatment may be taken in a network provider and is subject to pre
authorization by the Company or its authorized TPA.
surgery or any treatment to change appearance unless for reconstruction following
an Accident, Burn(s) or Cancer or as part of medically necessary treatment to (ii) Cashless request form available with the network provider and TPA shall be
remove a direct and immediate health risk to the insured. For this to be considered a completed and sent to the Company/TPA for authorization.
medical necessity, it must be certified by the attending Medical Practitioner. (iii) The Company/ TPA upon getting cashless request form and related medical
information from the insured person/ network provider will issue pre-
7.6 Hazardous or Adventure sports - (Code - Excl 09): Expenses related to any authorization letter to the hospital after verification.
treatment necessitated due to participation as a professional in hazardous or
adventure sports, including but not limited to, Para jumping, rock climbing, (iv) At the time of discharge, the insured person has to verify and sign the
discharge papers, pay for non-medical and inadmissible expenses.
mountaineering, rafting, motor racing, horse racing or scuba diving, hand gliding,
sky diving, deep-sea diving. (v) The Company / TPA reserves the right to deny pre-authorization in case the
insured person is unable to provide the relevant medical details. (vi)In case of
7.7 Breach of law - (Code - Excl 10): Expenses for treatment directly arising from or denial of cashless access, the insured person may obtain the treatment as per
consequent upon any Insured Person committing or attempting to commit a breach treating doctor's advice and submit the claim documents to the Company /
of law with crimina.1 intent. TPA for reimbursement.
7.8 Excluded Providers - (Code - Excl 11): Expenses incurred towards treatment in II. Procedure for reimbursement of claims: For reimbursement of claims the insured
any hospital or by any Medical Practitioner or any other provider specifically person may submit the necessary documents to TPA (if applicable)/Company within
excluded by the Insurer and disclosed in its website / notified to the policyholders are the prescribed time limit as specified hereunder;
not admissible. However, in case of life threatening situations following an accident,
S.No. Type of Claim Prescribed Time limit
expenses up to the stage of stabilization are payable but not the complete claim.
Reimbursement of hospitalization, day Within thirty days of date of discharge
7.9 Treatment for, Alcoholism, drug or substance abuse or any addictive condition and 1.
care and pre hospitalization expenses from hospital
consequences thereof - (Code - Excl 12)
Reimbursement of post hospitalization Within fifteen days from completion of
7.10 Treatments received in health hydros, nature cure clinics, spas or similar 2.
expenses post hospitalization treatment
establishments or private beds registered as a nursing home attached to such
establishments or where admission is arranged wholly or partly for domestic 9.1 Notification of Claim: Notice with full particulars shall be sent to the Company/TPA
reasons - (Code - Excl 13) (if applicable) as under;
7.11 Dietary supplements and substances that can be purchased without prescription, i. Within24hours from the date of emergency hospitalization required or before
including but not limited to Vitamins, minerals and organic substances unless the Insured Person's discharge from Hospital, whichever is earlier.
prescribed by a medical practitioner as part of hospitalization claim or day care ii. At least 48 hours prior to admission in Hospital in case of a planned Hospitalization.
procedure - (Code - Excl 14) Note: Call the 24 hour help-line for assistance - 1800 425 2255 /1800 102 4477,
Senior Citizens may call at 044 40020888
7.12 Refractive Error - (Code - Excl 15): Expenses related to the treatment for
correction of eye sight due to refractive error less than 7.5 d ioptres. 9.2 Documents to be submitted: The reimbursement claim is to be supported with
the following documents and submitted within the prescribed time limit.
7.13 Unproven Treatments - (Code- Excl 16): Expenses related to any unproven i. Duly Completed claim form
treatment, services and supplies for or in connection with any treatment. Unproven
ii. Photo Identity proof of the patient
treatments are treatments, procedures or supplies that lack significant medical
documentation to support their effectiveness. iii. Medical practitioner's prescription advising admission
iv. Original bills with itemized break-up
7.14 Sterility and Infertility - (Code - Excl 17): Expenses related to sterility and
infertility. This includes: v. Payment receipts
(i) Any type of sterilization vi. Discharge summary including complete medical history of the patient along
(ii) Assisted Reproduction services including artificial insemination and with other details.
advanced reproductive technologies such as 1VF, Z1FT, GIFT, ICS1 vii Investigation/ Diagnostic test reports etc. supported by the prescription from
(iii) Gestational Surrogacy attending medical practitioner
(iv) Reversal of sterilization viii OT notes or Surgeon's certificate giving details of the operation performed (for
surgical cases).
7.15 Maternity Expenses - (Code - Excl 18): ix. Sticker/Invoice of the Implants, wherever applicable.
i. Medical treatment expenses traceable to childbirth (including complicated
x. MLR(Medico Legal Report copyif carried out and FIR (First information report)
deliveries and caesarean sections incurred during hospitalization) except
if registered, where ever applicable.
ectopic pregnancy
xi. NEFT Details (to enable direct credit of claim amount in bank account) and
ii. expenses towards miscarriage (unless due to an accident) and lawful medical
cancelled cheque
termination of pregnancy during the policy period
xii. KYC (Identity proof with Address) of the proposer, where claim liability is
7.16 War (whether declared or not) and war like occurrence or invasion, acts of foreign above Rs 1 Lakh as per AML Guidelines
enemies, hostilities, civil war, rebellion, revolutions, insurrections, mutiny, military
xiii. Legal heir/succession certificate , wherever applicable
or usurped power, seizure, capture, arrest, restraints and detainment of all kinds.
xiv. Any other relevant document required by Company/TPA for assessment of the
7.17 Nuclear, chemical or biological attack or weapons, contributed to, caused by, claim.
resulting from or from any other cause or event contributing concurrently or in any [Note: Insurer may specify the documents required in original and waive off
other sequence to the loss, claim or expense. For the purpose of this exclusion; any of above required as per their claim procedure]
a) Nuclear attack or weapons means the use of any nuclear weapon or device or
Note:
waste or combustion of nuclear fuel or the emission, discharge, dispersal,
release or escape of fissile/ fusion material emitting a level of radioactivity 1. The company shall only accept bills/invoices/medical treatment related
documents only in the Insured Person's name for whom the claim is submitted
capable of causing any Illness, incapacitating disablement or death.
2. In the event of a claim lodged under the Policy and the original documents
b) Chemical attack or weapons means the emission, discharge, dispersal,
having been submitted to any other insurer, the Company shall accept the
release or escape of any solid, liquid or gaseous chemical compound which,
copy of the documents and claim settlement advice, duly certified by the other
when suitably distributed, is capable of causing any Illness, incapacitating insurer subject to satisfaction of the Company
disablement or death.
3. Any delay in notification or submission may be condoned on merit where delay
c) Biological attack or weapons means the emission, discharge, dispersal, is proved to be for reasons beyond the control of the Insured Person
release or escape of any pathogenic (disease producing) micro-organisms
and/or- biologically produced toxins (including genetically modified organisms 9.3 Co-payment: Each and every claim under the Policy shall be subject to a Copayment
and chemically synthesized toxins) which are capable of causing any Illness, of 5% applicable to claim amount admissible and payable as per the terms and
incapacitating disablement or death. conditions of the Policy. The amount payable shall be after deduction of the copayment.
7.18 Any expenses incurred on Domiciliary Hospitalization and OPD treatment 9.4 Claim Settlement (provision for Penal Interest)
i. The Company shall settle or reject a claim, as the case may be, within 30 days
7.19 Treatment taken outside the geographical limits of India from the date of receipt of last necessary document.
7.20 In respect of the existing diseases, disclosed by the insured and mentioned in the ii. In the case of delay in the payment of a claim, the Company shall be liable to
policy schedule(based on insured's consent), policyholder is not entitled to get the pay interest from the date of receipt of last necessary document to the date of
coverage for specified ICD codes. payment of claim at a rate 2% above the bank rate.
iii. However, where the circumstances of a claim warrant an investigation in the
8. MORATORIUM PERIOD opinion of the Company, it shall initiate and complete such investigation at the
After completion of eight continuous years under this policy no look back would be applied. earliestin any case not later than 30 days from the date of receipt of last
This period of eight years is called as moratorium period. The moratorium would be applicable necessary document. In such cases, the Company shall settle the claim within
for the sums insured of the first policy and subsequently completion of eight continuous years 45 days from the date of receipt of last necessary document.
would be applicable from date of enhancement of sums insured only on the enhanced limits. iv. In case of delay beyond stipulated 45 days the company shall be liable to pay
After the expiry of Moratorium Period no claim under this policy shall be contestable except for interest at a rate 2% above the bank rate from the date of receipt of last
proven fraud and permanent exclusions specified in the policy contract. The policies would necessary document to the date of payment of claim.
however be subject to all limits, sub limits, co-payments as per the policy. 9.5 Payment of Claim: All claims under the policy shall be payable in Indian currency only.
Arogya Sanjeevani Policy, Star Health and Allied Insurance Co Ltd. Unique Identification No.: SHAHLIP22027V032122 POL / ASP / V.5 / 2021 6 of 10
 10. GENERAL TERMS &CONDITIONS Notwithstanding anything contained herein or otherwise, no refunds of premium
shall be made in respect of Cancellation where, any claim has been admitted or has
10.1 Disclosure of Information: The Policy shall be void and all premium paid thereon been lodged or any benefit has been availed by the Insured person under the
shall be forfeited to the Company in the event of misrepresentation, mis-description Policy.
or non-disclosure of any material fact.
b) The Company may cancel the Policy at any time on grounds of
10.2 Condition Precedent to Admission of Liability: The due observance and mis-represenation, non-disclosure of material facts ,fraud by the Insured
fulfilment of the terms and conditions of the policy, by the insured person, shall be a Person, by giving 15 days' written notice. There would be no refund of
condition precedent to any liability of the Company to make any payment for premium on cancellation on grounds of mis-represenation ,non-disclosure of
claim(s) arising under the policy. material facts or fraud.
10.3 Material Change: The insured shall notify the Company in writing of any material 10.11 Automatic change in Coverage under the policy: The coverage for the Insured
change in the risk in relation to the declaration made in the proposal form or medical
Person(s) shall automatically terminate:
examination report at each Renewal and the Company may, adjust the scope of
1. In the case of his/ her (Insured Person) demise. However the cover shall
cover and / or premium, if necessary, accordingly.
continue for the remaining Insured Persons till the end of Policy Period. The
10.4 Records to be Maintained: The Insured Person shall keep an accurate record other insured persons may also apply to renew the policy. In case, the other
containing all relevant medical records and shall allow the Company or its insured person is minor, the policy shall be renewed only through any one of
representatives to inspect such records. The Policyholder or Insured Person shall his/her natural guardian or guardian appointed by court. All relevant
furnish such information as the Company may require for settlement of any claim under
particulars in respect of such person (including his/her relationship with the
the Policy, within reasonable time limit and within the time limit specified in the Policy
insured person) must be submitted to the company along with the application.
10.5 Complete Discharge: Any payment to the Insured Person or his/ her nominees or Provided no claim has been made, and termination takes place on account of
his/ her legal representative or to the Hospital/Nursing Home or Assignee, as the death of the insured person, pro-rata refund of premium of the deceased
case may be, for any benefit under the Policy shall in all cases be a full, valid and an insured person for the balance period of the policy will be effective.
effectual discharge towards payment of claim by the Company to the extent of that
2. Upon exhaustion of sum insured and cumulative bonus, for the policy year.
amount for the particular claim
However, the policy is subject to renewal on the due date as per the applicable
10.6 Notice & Communication terms and conditions.
i. Any notice, direction, instruction or any other communication related to the
Policy should be made in writing. 10.12 Territorial Jurisdiction: All disputes or differences under or in relation to the
interpretation of the terms, conditions, validity, construct, limitations and/or
ii. Such communication shall be sent to the address of the Company or through
exclusions contained in the Policy shall be determined by the Indian court and
any other electronic modes specified in the Policy Schedule.
according to Indian law.
iii. The Company shall communicate to the Insured at the address or through any
other electronic mode mentioned in the schedule. 10.13 Arbitration
i. If any dispute or difference shall arise as to the quantum to be paid by the
10.7 Territorial Limit: All medical treatment for the purpose of this insurance will have to
Policy, (liability being otherwise admitted) such difference shall independently
be taken in India only.
of all other questions, be referred to the decision of a sole arbitrator to be
10.8 Multiple Policies appointed in writing by the parties here to or if they cannot agree upon a single
1. In case of multiple policies taken by an insured during a period from the same arbitrator within thirty days of any party invoking arbitration, the same shall be
or one or more insurers to indemnify treatment costs, the policyholder shall referred to a panel of three arbitrators, comprising two arbitrators, one to be
have the right to require a settlement of his/her claim in terms of any of his/her
appointed by each of the parties to the dispute/difference and the third
policies. In all such cases the insurer if chosen by the policy holder shall be
arbitrator to be appointed by such two arbitrators and arbitration shall be
obliged to settle the claim as long as the claim is within the limits of and
conducted under a.nd in accordance with the provisions of the Arbitration and
according to the terms of the chosen policy.
Conciliation Act 1996, as amended by Arbitration and Conciliation
2. Policyholder having multiple policies shall also have the right to prefer claims
(Amendment) Act, 2015 (No. 3 of 2016).
under this policy for the amounts disallowed under any other policy / policies,
even if the sum insured is not exhausted. Then the Insurer(s) shall ii. It is clearly agreed and understood that no difference or dispute shall be
independently settle the claim subject to the terms and conditions of this policy. preferable to arbitration as herein before provided, if the Company has
3. If the amount to be claimed exceeds the sum insured under a single policy disputed or not accepted liability under or in respect of the policy.
after, the policyholder shall have the right to choose insurers from whom iii. It is hereby expressly stipulated and declared that it shall be a condition
he/she wants to claim the balance amount. precedent to any right of action or suit upon the policy that award by such
4. Where an insured has policies from more than one insurer to cover the same arbitrator/arbitrators of the amount of expenses shall be first obtained.
risk on indemnity basis, the insured shall only be indemnified the hospitalization 10.14 Migration: The Insured Person will have the option to migrate the Policy to other
costs in accordance with the terms and conditions of the chosen policy. health insurance products/plans offered by the company as per extant Guidelines
10.9 Fraud: If any claim made by the insured person, is in any respect fraudulent, or if related to Migration. If such person is presently covered and has been continuously
any .false statement, or declaration is made or used in support thereof, or if any covered without any lapses under any health insurance product/plan offered by the
fraudulent means or devices are used by the insured person or anyone acting on company, as per Guidelines on migration, the proposed Insured Person will get all
his/her behalf to obtain any benefit under this policy, all benefits under this policy the accrued continuity benefits in waiting periods as per below;
shall be forfeited. i. The waiting periods specified in Section 6 shall be reduced by the number of
Any amount already paid against claims which are found fraudulent later under this continuous preceding years of coverage of the Insured Person under the
policy shall be repaid by all person(s) named in the policy schedule, who shall be previous health insurance Policy.
jointly and severally liable for such repayment. ii. Migration benefit will be offered to the extent of sum of previous sum insured
For the purpose of this clause, the expression "fraud" means any of the following and accrued bonus/multiplier benefit (as part of the base sum insured),
acts committed by the Insured Person or by his agent, with intent to deceive the migration benefit shall not apply to any other additional increased Sum
insurer or to induce the insurer to issue a insurance Policy: Insured.
(a) the suggestion ,as a fact of that which is not true and which the Insured Person For Detailed Guidelines on migration, kindly refer the link
does not believe to be true; https://www.irdai.gov.in/ADMINCMS/cms/frmGuidelines_Layout.aspx?page=PageNo3987
(b) the active concealment of a fact by the Insured Person having knowledge or 10.15 Portability: The Insured Person will have the option to port the Policy to other
belief of the fact; insurers as per extant Guidelines related to portability. If such person is presently
(c) any other act fitted to deceive; and covered and has been continuously covered without any lapses under any health
(d) any such act or omission as the law specially declares to be fraudulent insurance plan with an Indian General/Health insurer as per Guidelines on
The company shall not repudiate the policy on the ground of fraud, if the insured portability, the proposed Insured Person will get all the accrued continuity benefits
person / beneficiary can prove that the misstatement was true to the best of his in waiting periods as Under;
knowledge and there was no deliberate intention to suppress the fact or that such i. The waiting periods specified in Section 6 shall be reduced by the number of
mis-statement of or suppression of material fact are within the knowledge of the continuous preceding years of coverage of the Insured Person under the
insurer. Onus of disproving is upon the policyholder, if alive, or beneficiaries. previous health insurance Policy.
10.10 Cancellation ii. Portability benefit will be offered to the extent of sum of previous sum insured
a) The Insured may cancel this Policy by giving 15days' written notice, and in and accrued bonus (as part of the base sum insured), portability benefit shall
such an event, the Company shall refund premium on short term rates for the not apply to any other additional increased Sum Insured.
unexpired Policy Period as per the rates detailed below; For Detailed Guidelines on portability, kindly refer the link
Refund % https://www.irdai.gov.in/ADMINCMS/cms/frmGuidelines_Layout.aspx?page=PageNo3987
Refund of Premium (basis Policy Period) 10.16 Renewal of Policy: The policy shall ordinarily be renewable except on grounds of
fraud, moral hazard, misrepresentation by the insured person. The Company is not
Timing of Cancellation 1 Yr
bound to give notice that it is due for renewal.
Up to 30 days 75.00% i. Renewal shall not be denied on the ground that the insured had made a claim
31 to 90 days 50.00% or claims in the preceding policy years
3 to 6 months 25.00% ii. Request for renewal along with requisite premium shall be received by the
6 to 12 months 0.00% Company before the end of the Policy Period.
Arogya Sanjeevani Policy, Star Health and Allied Insurance Co Ltd. Unique Identification No.: SHAHLIP22027V032122 POL / ASP / V.5 / 2021 7 of 10
 iii. At the end of the Policy Period, the policy shall terminate and can be renewed 12. TABLE OF BENEFITS
within the Grace Period to maintain continuity of benefits without Break in
Policy. Coverage is not available during the grace period. Arogya Sanjeevani Policy,
Name
iv. if not renewed within Grace Period after due renewal date, the Policy shall Star Health and Allied Insurance Co Ltd.
terminate. Product Type Individual/ Floater
10.17 Premium Payment In Installments: If the insured person has opted for Payment Category of Cover Indemnity
of Premium on an installment basis i.e. Half Yearly or Quarterly, as mentioned in
Your Policy Schedule/Certificate of Insurance, the following Conditions shall apply IN R
(notwithstanding any terms contrary elsewhere in the Policy) Sum insured On Individual basis — Si shall apply to each individual family
i. Grace Period of 15 days would be given to pay the installment premium due for member On Floater basis — SI shall apply to the entire family
the Policy. Policy Period 1 year
ii. During such grace period, Coverage will not be available from the installment Policy can be availed by persons between the age of 18 years and
premium payment due date till the date of receipt of premium by Company. 65years, as Proposer. Proposer with higher age can obtain policy
iii. The Benefits provided under — "Waiting Periods", "Specific Waiting Periods" for family, without covering self.
Sections shall continue in the event of payment of premium within the Policy can be availed for Self and the following family members
stipulated grace Period. i. legally wedded spouse.
iv. No interest will be charged If the installment premium is not paid on due date. Eligibility
ii. Parents and Parents-in-law .
v. In case of installment premium due not received within the grace Period, the iii. Dependent Children (i.e. natural or legally adopted) between
Policy will get cancelled. the age 3 months to 25 years. If the child above 18 years of age
10.18 Possibility of Revision of Terms of the Policy including the Premium Rates: is financially independent, he or she shall be ineligible for
The Company, with prior approval of IRDAI, may revise or modify the terms of the coverage in the subsequent renewals
policy including the premium rates. The insured person shall be notified three For Yearly payment of mode, a fixed period of 30 days is to be
months before the changes are affected. Grace Period allowed as Grace Period and for all other modes of payment a
10.19 Free look period: The Free Look Period shall be applicable at the inception of the fixed period of 15 days be allowed as grace period.
Policy and not on renewals or at the time of porting the policy.
Expenses of Hospitalization for a minimum period of
The insured shall be allowed a period of fifteen days from date of receipt of the 24 consecutive hours only shall be admissible
Hospitalisation
Policy to review the terms and conditions of the Policy, and to return the same if not
Expenses Time limit of 24 hrs shall not apply when the treatment is
acceptable.
If the insured has not made any claim during the Free Look Period, the insured shall undergone in a Day Care Centre.
be entitled to
i a refund of the premium paid less any expenses incurred by the Company on Pre Hospitalisation For 30 days prior to the date of hospitalization
medical examination of the insured person and the stamp duty charges; or
ii. where the risk has already commenced and the option of return of the Policy is Post Hospitalisation For 60 days from the date of discharge from the hospital
exercised by the insured, a deduction towards the proportionate risk premium
for period of cover or 1. Room Rent, Boarding, Nursing Expenses all inclusive as
iii. Where only a part of the insurance coverage has commenced, such provided by the Hospital / Nursing Home up to 2% of the sum
proportionate premium commensurate with the insurance coverage during insured subject to maximum of Rs.5000/- per day.
Sublimit for
such period; 2. lntensive Care Unit (ICU) charges/ Intensive Cardiac Care Unit
room/doctors fee
10.20 Endorsements (Changes in Policy) (ICCU) charges all inclusive as provided by the Hospital /
i. This policy constitutes the complete contract of insurance. This Policy cannot Nursing Home up to 5% of the sum insured subject to maximum
be modified by anyone (including an insurance agent or broker) except the of Rs.10,000/-, per day
company. Any change made by the company shall be evidenced by a written Cataract Up to 25% of Sum insured or Rs.40,000/-, whichever is lower, per
endorsement signed and stamped. Treatment eye, under one policy year.
ii. The policyholder may be changed only at the time of renewal. The new Expenses incurred for Inpatient Care treatment under Ayurveda,
policyholder must be the legal heir/immediate family member. Such change Yoga and Naturopathy, Unani, Siddha and Homeopathy systems
would be subject to acceptance by the company and payment of premium (if AYUSH
of medicines shall be covered upto sum insured, during each
any). The renewed Policy shall be treated as having been renewed without Policy year as specified in the policy schedule.
break.
The policyholder may be changed during the Policy Period only in case of his/her Pre Existing Only PEDs declared in the Proposal Form and accepted for coverage
demise or him/her moving out of India. Disease by the company shall be covered after a waiting period of 4 years
10.21 Change of Sum Insured: Sum insured can be changed (increased/ decreased) Increase in the sum insured by 5% in respect of each claim free
Cumulative
only at the time of renewal or at any time, subject to underwriting by the Company. year subject to a maximum of 50% of SI. In the event of claim the
bonus
For any increase in SI, the waiting period shall start afresh only for the enhanced cumulative bonus shall be reduced at the same rate.
portion of the sum insured. Co Pay 5% co pay on all claims
10.22 Terms and conditions of the Policy: The terms and conditions contained herein
and in the Policy Schedule shall be deemed to form part of the Policy and shall be
read together as one document. Annexure-A
10.23 Nomination: The policyholder is required at the inception of the policy to make a List I — Items for which coverage is not available in the policy
nomination for the purpose of payment of claims under the policy in the event of
death of the policyholder. Any change of nomination shall be communicated to the S.No. ITEM
company in writing and such change shall be effective only when an endorsement
1 BABY FOOD
on the policy is made. For Claim settlement under reimbursement, the Company
will pay the policyholder. In the event of death of the policyholder, the Company will 2 BABY UTILITIES CHARGES
pay the nominee {as named in the Policy Schedule/Policy Certificate/Endorsement 3 BEAUTY SERVICES
(if any)} and in case there is no subsisting nominee, to the legal heirs or legal
representatives of the Policyholder whose discharge shall be treated as full and 4 BELTS/ BRACES
final discharge of its liability under the Policy. 5 BUDS
11. REDRESSAL OF GRIEVANCE 6 COLD PACK/HOT PACK

Grievance — In case of any grievance relating to servicing the Policy, the insured person 7 CARRY BAGS
may submit in writing to the Policy issuing office or regional office for redressal. 8 EMAIL / INTERNET CHARGES
For updated details of grievance officer, kindly refer the link FOOD CHARGES (OTHER THAN PATIENT's DIET PROVIDED BY
https://www.starhealth.in/grievance-redressal 9
HOSPITAL)
For details of grievance officer, kindly refer the link (Link having details of grievance officer 10 LEGGINGS
on website to be provided)
11 LAUNDRY CHARGES
IRDAI Integrated Grievance Management System - https://igms.irda.gov.in/
Insurance Ombudsman — The insured person may also approach the office of Insurance 12 MINERAL WATER
Ombudsman of the respective area/region for redressal of grievance. The contact details 13 SANITARY PAD
of the Insurance Ombudsman offices have been provided as Annexure-B
14 TELEPHONE CHARGES
No loading shall apply on renewals based on individual claims experience.
lnsurance is the subject matter of solicitation 15 GUEST SERVICES
Arogya Sanjeevani Policy, Star Health and Allied Insurance Co Ltd. Unique Identification No.: SHAHLIP22027V032122 POL / ASP / V.5 / 2021 8 of 10
 List I — Items for which coverage is not available in the policy List II — Items that are to be subsumed into Room Charges
S.No. ITEM S.No. ITEM
16 CREPE BANDAGE 1 BABY CHARGES (UNLESS SPECIFIED/INDICATED)
17 DIAPER OF ANY TYPE 2 HAND WASH
3 SHOE COVER
18 EYELET COLLAR
4 CAPS
19 SLINGS
5 CRADLE CHARGES
20 BLOOD GROUPING AND CROSS MATCHING OF DONORS SAMPLES
6 COMB
21 SERVICE CHARGES WHERE NURSING CHARGE ALSO CHARGED 7 EAU-DE-COLOGNE / ROOM FRESHNERS
22 TELEVISION CHARGES 8 FOOT COVER
23 SURCHARGES 9 GOWN
24 ATTENDANT CHARGES 10 SLIPPERS
EXTRA DIET OF PATIENT (OTHER THAN THAT WHICH FORMS PART OF 11 TISSUE PAPER
25 12 TOOTH PASTE
BED CHARGE)
26 BIRTH CERTIFICATE 13 TOOTH BRUSH
27 CERTIFICATE CHARGES 14 BED PAN
15 FACE MASK
28 COURIER CHARGES
16 FLEXI MASK
29 CONVEYANCE CHARGES
17 HAND HOLDER
30 MEDICAL CERTIFICATE 18 SPUTUM CUP
31 MEDICAL RECORDS 19 DISINFECTANT LOTIONS
32 PHOTOCOPIES CHARGES 20 LUXURY TAX
33 MORTUARY CHARGES 21 HVAC
34 WALKING AIDS CHARGES 22 HOUSE KEEPING CHARGES
23 AIR CONDITIONER CHARGES
35 OXYGEN CYLINDER (FOR USAGE OUTSIDE THE HOSPITAL)
24 IM IV INJECTION CHARGES
36 SPACER
25 CLEAN SHEET
37 SPIROMETRE 26 BLANKET/WARMER BLANKET
38 NEBULIZER KIT 27 ADMISSION KIT
39 STEAM INHALER 28 DIABETIC CHART CHARGES
40 ARMSLING 29 DOCUMENTATION CHARGES / ADMINISTRATIVE EXPENSES
41 THERMOMETER 30 DISCHARGE PROCEDURE CHARGES
31 DAILY CHART CHARGES
42 CERVICAL COLLAR
32 ENTRANCE PASS / VISITORS PASS CHARGES
43 SPLINT
33 EXPENSES RELATED TO PRESCRIPTION ON DISCHARGE
44 DIABETIC FOOT WEAR 34 FILE OPENING CHARGES
45 KNEE BRACES (LONG/ SHORT/ HINGED) 35 INCIDENTAL EXPENSES / MISC. CHARGES (NOT EXPLAINED)
46 KNEE IMMOBILIZER/SHOULDER IMMOBILIZER 36 PATIENT IDENTIFICATION BAND / NAME TAG
47 LUMBO SACRAL BELT 37 PULSEOXYMETER CHARGES
48 NIMBUS BED OR WATER OR AIR BED CHARGES List III — Items that are to be subsumed into Procedure Charges
49 AMBULANCE COLLAR S.No. ITEM
50 AMBULANCE EQUIPMENT 1 HAIR REMOVAL CREAM
2 DISPOSABLES RAZORS CHARGES (for site preparations)
51 ABDOMINAL BINDER
3 EYE PAD
52 PRIVATE NURSES CHARGES- SPECIAL NURSING CHARGES
4 EYE SHEILD
53 SUGAR FREE TABLETS
5 CAMERA COVER
CREAMS POWDERS LOTIONS (Toiletries are not payable, only prescribed 6 DVD, CD CHARGES
54
medical pharmaceuticals payable)
7 GAUSE SOFT
55 ECG ELECTRODES
8 GAUZE
56 GLOVES 9 WARD AND THEATRE BOOKING CHARGES
57 NEBULISATION KIT 10 ARTHROSCOPY AND ENDOSCOPY INSTRUMENTS
ANY KIT WITH NO DETAILS MENTIONED [DELIVERY KIT, ORTHOKIT, 11 MICROSCOPE COVER
58
RECOVERY KIT, ETC] 12 SURGICAL BLADES, HARMONICSCALPEL,SHAVER
59 KIDNEY TRAY 13 SURGICAL DRILL
60 MASK 14 EYE KIT
61 OUNCE GLASS 15 EYE DRAPE
62 OXYGEN MASK 16 X-RAY FILM
63 PELVIC TRACTION BELT 17 BOYLES APPARATUS CHARGES
18 COTTON
64 PAN CAN
19 COTTON BANDAGE
65 TROLLY COVER
20 SURGICAL TAPE
66 UROMETER, URINE JUG 21 APRON
67 AMBULANCE 22 TORNIQUET
68 VASOFIX SAFETY 23 ORTHOBUNDLE, GYNAEC BUNDLE
Arogya Sanjeevani Policy, Star Health and Allied Insurance Co Ltd. Unique Identification No.: SHAHLIP22027V032122 POL / ASP / V.5 / 2021 9 of 10
 List IV — Items that are to be subsumed into costs of treatment List IV — Items that are to be subsumed into costs of treatment
S.No. ITEM S.No. ITEM

1 ADMISSION/REGISTRATION CHARGES 10 HIV KIT

2 HOSPITALISATION FOR EVALUATION/ DIAGNOSTIC PURPOSE 11 ANTISEPTIC MOUTHWASH

3 URINE CONTAINER 12 LOZENGES

BLOOD RESERVATION CHARGES AND ANTE NATAL BOOKING
4 13 MOUTH PAINT
CHARGES

5 PAP MACHINE 14 VACCINATION CHARGES

6 CPAP/ CAPD EQUIPMENTS 15 ALCOHOL SWABES

7 INFUSION PUMP— COST 16 SCRUB SOLUTION/STERILLIUM

8 HYDROGEN PEROXIDE\SPIRIT1 DISINFECTANTS ETC 17 Glucometer& Strips

NUTRITION PLANNING CHARGES - DIETICIAN CHARGES- DIET
9 18 URINE BAG
CHARGES

List of Insurance Ombudsman

BHOPAL
AHMEDABAD BENGALURU
Office of the Insurance Ombudsman, BHUBANESHWAR
Office of the Insurance Ombudsman, Office of the Insurance Ombudsman,
Janak Vihar Complex, 2nd Floor, Office of the Insurance Ombudsman,
Jeevan Prakash Building, 6th floor, Jeevan Soudha Building,
6, Malviya Nagar, Opp. Airtel Office, 62, Forest park, Bhubneshwar – 751 009.
Tilak Marg, Relief Road, PID No. 57-27-N-19 Ground Floor, 19/19,
Near New Market, Bhopal – 462 003. Tel.: 0674 - 2596461 /2596455
Ahmedabad – 380 001. 24th Main Road, JP Nagar,
Tel.: 0755 - 2769201 / 2769202 Fax: 0674 – 2596429
Tel.: 079 - 25501201/02/05/06 Ist Phase, Bengaluru – 560 078.
Fax: 0755 – 2769203 Email:
Email: bimalokpal.ahmedabad@cioins.co.in Tel.: 080 - 26652048 / 26652049
Email: bimalokpal.bhopal@cioins.co.in bimalokpal.bhubaneswar@cioins.co.in
JURISDICTION: Gujarat, Dadra & Nagar Email: bimalokpal.bengaluru@cioins.co.in
JURISDICTION: Madhya Pradesh JURISDICTION: Orissa.
Haveli, Daman and Diu. JURISDICTION: Karnataka.
Chattisgarh.
CHANDIGARH
CHENNAI ERNAKULAM
Office of the Insurance Ombudsman, DELHI
Office of the Insurance Ombudsman, Office of the Insurance Ombudsman,
S.C.O. No. 101, 102 & 103, 2nd Floor,
Fatima Akhtar Court, 4th Floor, 453, Office of the Insurance Ombudsman, 2nd Floor, Pulinat Bldg.,
Batra Building, Sector 17 – D,
Anna Salai, Teynampet, 2/2 A, Universal Insurance Building, Opp. Cochin Shipyard, M. G. Road,
Chandigarh – 160 017. Tel.: 0172 -
Chennai – 600 018. Asaf Ali Road, New Delhi – 110 002. Ernakulam - 682 015.
2706196 / 2706468 Fax: 0172 - 2708274
Tel.: 044 - 24333668 / 24335284 Tel.: 011 - 23232481/23213504 Tel.: 0484 - 2358759 / 2359338
Email: bimalokpal.chandigarh@cioins.co.in
Fax: 044 - 24333664 Email: bimalokpal.delhi@cioins.co.in Fax: 0484 - 2359336
JURISDICTION: Punjab, Haryana Email: bimalokpal.chennai@cioins.co.in Email: bimalokpal.ernakulam@cioins.co.in
JURISDICTION: Delhi &
(excluding Gurugram, Faridabad, Sonepat
JURISDICTION: Tamil Nadu, Following Districts of Haryana - Gurugram, JURISDICTION: Kerala, Lakshadweep,
and Bahadurgarh) Himachal Pradesh,
Tamil Nadu Puducherry Town and Karaikal Faridabad, Sonepat & Bahadurgarh. Mahe-a part of Union Territory of
Union Territories of Jammu & Kashmir,
(which are part of Puducherry). Puducherry.
Ladakh & Chandigarh.
HYDERABAD
GUWAHATI
Office of the Insurance Ombudsman, KOLKATA
Office of the Insurance Ombudsman, JAIPUR
6-2-46, 1st floor, "Moin Court", Office of the Insurance Ombudsman,
Jeevan Nivesh, 5th Floor,
Lane Opp. Saleem Function Palace, Office of the Insurance Ombudsman, Hindustan Bldg. Annexe, 4th Floor,
Nr. Panbazar over bridge, S.S. Road,
A. C. Guards, Lakdi-Ka-Pool, Jeevan Nidhi – II Bldg., Gr. Floor, 4, C.R. Avenue, KOLKATA - 700 072.
Guwahati – 781001(ASSAM).
Hyderabad - 500 004. Bhawani Singh Marg, Jaipur - 302 005. Tel.: 033 - 22124339 / 22124340
Tel.: 0361 - 2632204 / 2602205
Tel.: 040 – 23312122 Fax: 040 - 23376599 Tel.: 0141 - 2740363 Fax : 033 – 22124341
Email: bimalokpal.guwahati@cioins.co.in
Email: bimalokpal.hyderabad@cioins.co.in Email: bimalokpal.jaipur@cioins.co.in Email: bimalokpal.kolkata@cioins.co.in
JURISDICTION: Assam, Meghalaya,
JURISDICTION: Andhra Pradesh, JURISDICTION: Rajasthan. JURISDICTION: West Bengal, Sikkim,
Manipur, Mizoram, Arunachal Pradesh,
Telangana, Yanam and part of Union Andaman & Nicobar Islands.
Nagaland and Tripura.
Territory of Puducherry.
LUCKNOW MUMBAI
Office of the Insurance Ombudsman, Office of the Insurance Ombudsman, NOIDA PATNA
6th Floor, Jeevan Bhawan, Phase-II, Nawal 3rd Floor, Jeevan Seva Annexe, Office of the Insurance Ombudsman, Office of the Insurance Ombudsman,
Kishore Road, Hazratganj, S. V. Road, Santacruz (W), Bhagwan Sahai Palace 4th Floor, 1st Floor,Kalpana Arcade Building,
Lucknow - 226 001. Mumbai - 400 054. Main Road, Naya Bans, Sector 15, Bazar Samiti Road, Bahadurpur,
Tel.: 0522 - 2231330 / 2231331 Tel.: 022 - 26106552 / 26106960 Distt: Gautam Buddh Nagar, Patna 800 006. Tel.: 0612-2680952
Fax: 0522 - 2231310 Fax: 022 – 26106052 U.P-201301. Email: bimalokpal.patna@cioins.co.in
Email: bimalokpal.lucknow@cioins.co.in Email: bimalokpal.mumbai@cioins.co.in Tel.: 0120-2514252 / 2514253 JURISDICTION: Bihar,
JURISDICTION: Districts of Uttar Pradesh JURISDICTION: Goa, Mumbai Metropolitan Email: bimalokpal.noida@cioins.co.in Jharkhand.
Lalitpur, Jhansi, Mahoba, Hamirpur, Banda, Region excluding Navi Mumbai & Thane. JURISDICTION: State of Uttaranchal and
Chitrakoot, Allahabad, Mirzapur, the following Districts of Uttar Pradesh:
Sonbhabdra, Fatehpur, Pratapgarh, PUNE Agra, Aligarh, Bagpat, Bareilly, Bijnor,
Jaunpur,Varanasi, Gazipur, Jalaun, Kanpur, Office of the Insurance Ombudsman, Budaun, Bulandshehar, Etah, Kanooj,
Lucknow, Unnao, Sitapur, Lakhimpur, Jeevan Darshan Bldg., 3rd Floor, Mainpuri, Mathura, Meerut, Moradabad,
Bahraich, Barabanki, Raebareli, Sravasti, C.T.S. No.s. 195 to 198, N.C. Muzaffarnagar, Oraiyya, Pilibhit, Etawah,
Gonda, Faizabad, Amethi, Kaushambi, Kelkar Road, Narayan Peth, Farrukhabad, Firozbad,
Balrampur, Basti, Ambedkarnagar, Pune – 411 030. Tel.: 020-41312555 Gautambodhanagar, Ghaziabad, Hardoi,
Sultanpur, Maharajgang, Santkabirnagar, Email: bimalokpal.pune@cioins.co.in Shahjahanpur, Hapur, Shamli, Rampur,
Azamgarh, Kushinagar, Gorkhpur, Deoria, JURISDICTION: Maharashtra, Area of Navi Kashganj, Sambhal, Amroha, Hathras,
Mau, Ghazipur, Chandauli, Ballia, Mumbai and Thane excluding Mumbai Kanshiramnagar, Saharanpur.
Sidharathnagar. Metropolitan Region.

Arogya Sanjeevani Policy, Star Health and Allied Insurance Co Ltd. Unique Identification No.: SHAHLIP22027V032122 POL / ASP / V.5 / 2021 10 of 10