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Policy Wordings

The Tata AIG MediCare Premier policy provides insurance coverage for medically necessary treatments for diseases, illnesses, or injuries, subject to the terms and conditions outlined in the policy. Coverage is limited to the sum insured specified in the policy schedule and is based on the declarations made by the policyholder. The document includes definitions of key terms related to the policy, including types of treatments, hospital requirements, and conditions for coverage.

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0% found this document useful (0 votes)

26 views60 pages

Policy Wordings

Uploaded by

George R Varghese

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Tata AIG MediCare Premier

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Policy Wordings

Tata AIG General Insurance Company Limited (We, Our or Us) will provide the insurance
cover, described in this Policy and any endorsements thereto, for the Insured Period, as
defined in the Policy schedule. The insurance cover provided under this Policy is only with
respect to such and so many of the benefits upto the Sum Insured as mentioned in the Policy
Schedule. Commencement of risk cover under the policy is subject to receipt of premium by
us. The statements and declarations contained in the Proposal signed by the Policyholder
(You) and/or medical reports 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.

Registered office: Peninsula Business Park, Tower A, 15th Floor, G.K Marg, Lower Parel, Mumbai - 400013, Maharashtra, India
24*7 Toll free No.: 1800 266 7780/1800 22 9966 (For Senior Citizens) • Email: customersupport@tataaig.com • Website: www.tataaig.com
IRDA of India Registration No.: 108 • CIN: U85110MH2000PLC128425 • UIN: TATHLIP24159V042324

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Preamble

While the policy is in force, if the Insured Person contracts any disease or suffers from any
illness or sustains bodily injury through accident and if such event requires the insured
Person to incur expenses for Medically Necessary Treatment, We will indemnify You for the
amount of such Reasonable and Customary Charges or compensate to the extent agreed,
upto the limits mentioned, subject to terms and conditions of the Policy. Each Benefit is
subject to its Sum Insured, but Our liability to make payment in respect of any and all
Benefits shall be limited to the Sum Insured unless expressly stated to the contrary.
In case of family floater policy, the sum insured for all or any of the benefits shall be on a per
policy per year basis unless explicitly stated to the contrary. In case of an individual policy,
the sum insured for all or any of the benefits shall be on a per insured per year basis unless
explicitly stated to the contrary.
The said Medically Necessary Treatment must be on the advice of a qualified Medical
Practitioner.

Section 1 – General Definitions

The terms defined below and at other junctures in the Policy Wording have the meanings
ascribed to them wherever they appear in this Policy and, where appropriate, references to
the singular include references to the plural; references to the male include the female and
third gender, references to any statutory enactment include subsequent changes to the
same:
i. Standard Definitions

1. Accident
An accident means sudden, unforeseen and involuntary event caused by external, visible
and violent means.

2. Any one illness

Any one illness means continuous period of illness and includes relapse within 45 days from
the date of last consultation with the Hospital/Nursing Home where treatment was taken.
3. AYUSH Day Care Centre
AYUSH Day Care Centre means and includes Community Health Centre (CHC), Primary
Health Centre (PHC), Dispensary, Clinic, Polyclinic or any such health centre which is
registered with the local authorities, wherever applicable and having facilities for carrying

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out treatment procedures and medical or surgical/para-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 all the following criterion:
i. Having qualified registered AYUSH Medical Practitioner(s) in charge;
ii. Having dedicated AYUSH therapy sections as required and/or has equipped operation
theatre where surgical procedures are to be carried out;

iii. Maintaining daily records of the patients and making them accessible to the
insurance company’s authorized representative.

4. AYUSH Hospital
An AYUSH Hospital is a healthcare facility wherein medical/surgical/para-surgical
treatment procedures and interventions are carried out by AYUSH Medical Practitioner(s)
comprising of any of the following:
a. Central or State Government AYUSH Hospital or
b. Teaching hospital attached to AYUSH college recognized by the Central Government/
Central Council of Indian Medicine/ Central Council for Homeopathy, or
c. AYUSH Hospital, standalone or co-located with in-patient healthcare facility of any
recognized system of medicine, registered with the local authorities, wherever
applicable, and is under the supervision of a qualified registered AYUSH Medical
Practitioner and must comply with all the following criterion:
i. Having atleast 5 in-patient beds;
ii. Having qualified AYUSH Medical Practitioner round the clock;
iii. Having dedicated AYUSH therapy sections as required and/or has equipped
operation theatre where surgical procedures are to be carried out
Maintaining daily records of the patients and making them accessible to the insurance
company's authorized representative.
5. AYUSH Treatment
AYUSH treatment refers to the medical and / or hospitalization treatments given under
Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy systems.

6. Break in Policy
Break in policy means the period of gap that occurs at the end of the existing policy
term/instalment premium due date, when the premium due for renewal on a given
policy or instalment premium due is not paid on or before the premium renewal date
or grace period.

7. Cashless facility
Cashless facility means a facility extended by the insurer to the insured where the payments,
of the costs of treatment undergone by the insured in accordance with the policy terms and

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conditions, are directly made to the network provider by the insurer to the
extent pre-authorization is approved.
8. Condition Precedent
Condition Precedent means a policy term or condition upon which the Insurer's liability
under the policy is conditional upon.
9. Congenital Anomaly:
Congenital Anomaly means a condition which is present since birth, and which is abnormal
with reference to form, structure or position.
a) Internal Congenital Anomaly
Congenital anomaly which is not in the visible and accessible parts of the body.
b) External Congenital Anomaly
Congenital anomaly which is in the visible and accessible parts of the body
10. Cumulative Bonus
Cumulative Bonus means any increase or addition in the Sum Insured granted by the insurer
without an associated increase in premium.
11. Day Care Centre
A day care centre means any institution established for day care treatment of illness and/or
injuries or a medical setup with a hospital and which has been registered with the local
authorities, wherever applicable, and is under supervision of a registered and qualified
medical practitioner AND must comply with all minimum criterion as under –
i. has qualified nursing staff under its employment;
ii. has qualified medical practitioner/s in charge;
iii. has fully equipped operation theatre of its own where surgical procedures are carried
out;
iv. maintains daily records of patients and will make these accessible to the insurance
company’s authorized personnel.

12. Day Care Treatment

Day care treatment means medical treatment, and/or surgical procedure which is:
i. undertaken under General or Local Anesthesia in a hospital/day care centre in less
than 24 hrs because of technological advancement, and
ii. which would have otherwise required hospitalization of more than 24 hours.
Treatment normally taken on an out-patient basis is not included in the scope of this
definition

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13. Dental Treatment
Dental treatment means a treatment related to teeth or structures supporting teeth including
examinations, fillings (where appropriate), crowns, extractions and surgery.
14. Domiciliary Hospitalization
Domiciliary hospitalization means medical treatment for an illness/disease/injury which in
the normal course would require care and treatment at a hospital but is actually taken while
confined at home under any of the following circumstances:
i. the condition of the patient is such that he/she is not in a condition to be removed to
a hospital, or
ii. the patient takes treatment at home on account of non-availability of room in a
hospital.
15. Grace Period
“Grace period” means the specified period of time, immediately following the premium due
date during which premium payment can be made to renew or continue a policy in force
without loss of continuity benefits pertaining to waiting periods and coverage of pre-existing
diseases. For single premium payment policies, coverage is not available during the period
for which no premium is received. However, If the premium is paid in instalments during the
policy period, coverage will be available during the grace period, within the policy period.
The grace period for payment of the premium shall be: fifteen days where premium payment
mode is monthly and thirty days in all other cases.
16. Hospital
A hospital means any institution established for in-patient care and day care treatment of
illness and/or injuries and which has been registered as a hospital with the local authorities
under Clinical Establishments (Registration and Regulation) Act 2010 or under enactments
specified under the Schedule of Section 56(1) and the said act Or complies with all minimum
criteria as under:
i. has qualified nursing staff under its employment round the clock;
ii. has at least 10 in-patient beds in towns having a population of less than 10,00,000
and at least 15 in-patient beds in all other places;
iii. has qualified medical practitioner(s) in charge round the clock;
iv. has a fully equipped operation theatre of its own where surgical procedures are
carried out;
v. maintains daily records of patients and makes these accessible to the insurance
company’s authorized personnel;

17. Hospitalization
Hospitalization means admission in a Hospital for a minimum period of 24 consecutive ‘In-
patient Care’ hours except for specified procedures/ treatments, where such admission
could be for a period of less than 24 consecutive hours.

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18. Illness
Illness means a sickness or a disease or pathological condition leading to the impairment of
normal physiological function and requires medical treatment.
(a) Acute condition
Acute condition is a disease, illness or injury that is likely to respond quickly to treatment
which aims to return the person to his or her state of health immediately before suffering the
disease/ illness/ injury which leads to full recovery
(b) Chronic condition
A chronic condition is defined as a disease, illness, or injury that has one or more of the
following characteristics:
i. it needs ongoing or long-term monitoring through consultations, examinations, check-
ups, and /or tests
ii. it needs ongoing or long-term control or relief of symptoms
iii. it requires rehabilitation for the patient or for the patient to be specially trained to cope
with it
iv. it continues indefinitely
v. it recurs or is likely to recur

19. Injury
Injury means accidental physical bodily harm excluding illness or disease solely and directly
caused by external, violent, visible and evident means which is verified and certified by a
Medical Practitioner.

20. Inpatient Care

Inpatient care means treatment for which the insured person has to stay in a hospital for
more than 24 hours for a covered event.

21. Maternity expenses

Maternity expenses means;
a. medical treatment expenses traceable to childbirth (including complicated deliveries
and caesarean sections incurred during hospitalization);
b. expenses towards lawful medical termination of pregnancy during the policy period.

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22. Medical Advice
Medical Advice means any consultation or advice from a Medical Practitioner including the
issuance of any prescription or follow-up prescription.

23. Medical Expenses:

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

24. Medical Practitioner

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

25. Medically Necessary Treatment

Medically necessary treatment means any treatment, tests, medication, or stay in hospital
or part of a stay in hospital which:
i. is required for the medical management of the illness or injury suffered by the insured;
ii. must not exceed the level of care necessary to provide safe, adequate and appropriate
medical care in scope, duration, or intensity;
iii. must have been prescribed by a medical practitioner;
iv. must conform to the professional standards widely accepted in international medical
practice or by the medical community in India.

26. Migration
“Migration” means a facility provided to policyholders (including all members under family
cover and group policies), to transfer the credits gained for pre-existing diseases and
specific waiting periods from one health insurance policy to another with the same insurer.
27. Network Provider
Network Provider means hospitals or health care providers enlisted by an insurer, TPA or
jointly by an Insurer and TPA to provide medical services to an insured by a cashless facility.
The updated list of Network Provider is available on Our website (www.tataaig.com).

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28. New Born Baby

Newborn baby means baby born during the Policy Period and is aged upto 90 days

29. Notification of Claim

Notification of claim means the process of intimating a claim to the insurer or TPA
through any of the recognized modes of communication

30. OPD treatment

OPD treatment means the one in which the Insured visits a clinic / hospital or associated
facility like a consultation room for diagnosis and treatment based on the advice of a Medical
Practitioner. The Insured is not admitted as a day care or in-patient.

31. Pre-Existing Disease

“Pre-existing disease (PED)” means any condition, ailment, injury or disease:
a) that is/are diagnosed by a physician not more than 36 months prior to the date of
commencement of the policy issued by the insurer; or
b) for which medical advice or treatment was recommended by, or received from, a
physician, not more than 36 months prior to the date of commencement of the policy.
32. Pre-hospitalization Medical Expenses
Pre-hospitalization Medical Expenses means medical expenses incurred during predefined
number of days preceding the hospitalization of the Insured Person, provided that:
i. Such Medical Expenses are incurred for the same condition for which the Insured
Person’s Hospitalization was required, and
ii. The In-patient Hospitalization claim for such Hospitalization is admissible by the
Insurance Company.

33. Portability
“Portability” means a facility provided to the health insurance policyholders (including all
members under family cover), to transfer the credits gained for, pre-existing diseases and
specific waiting periods from one insurer to another insurer.

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34. Post-hospitalization Medical Expenses
Post-hospitalization Medical Expenses means medical expenses incurred during predefined
number of days immediately after the insured person is discharged from the hospital
provided that:
i. Such Medical Expenses are for the same condition for which the insured person’s
hospitalization was required, and
ii. The inpatient hospitalization claim for such hospitalization is admissible by the
insurance company

35. Qualified Nurse

Qualified nurse means a person who holds a valid registration from the Nursing Council of
India or the Nursing Council of any state in India.

36. Reasonable and Customary Charges

Reasonable and Customary charges means the charges for services or supplies, which are
the standard charges for the specific provider and consistent with the prevailing charges in
the geographical area for identical or similar services, taking into account the nature of the
illness / injury involved.

37. Renewal
Renewal means the terms on which the contract of insurance can be renewed on mutual
consent with a provision of grace period for treating the renewal continuous for the purpose
of gaining credit for pre-existing diseases, time-bound exclusions and for all waiting periods.

38. Room Rent

Room Rent means the amount charged by a Hospital towards Room and Boarding
expenses and shall include the associated medical expenses.

39. Surgery or Surgical Procedure

Surgery or Surgical Procedure means manual and / or operative procedure (s) required for
treatment of an illness or injury, correction of deformities and defects, diagnosis and cure of
diseases, relief from suffering and prolongation of life, performed in a hospital or day care
centre by a medical practitioner.

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40. Unproven/Experimental treatment
Unproven/Experimental treatment means the treatment including drug experimental therapy
which is not based on established medical practice in India, is treatment experimental or
unproven.

ii. Specific Definitions (Definitions other than as mentioned under Section 1 (i)
above)
1. Age
Means the completed age of the Insured Person on his / her most recent birthday as per the
English calendar, regardless of the actual time of birth.

2. Policy
Policy means the contract of insurance including but not limited to Policy Schedule,
Endorsements and Policy Wordings.

3. Policy period
Policy Period means the time during which this Policy is in effect. Such period commences
from Commencement Date and ends on the Expiry Date and specifically appears in the
Policy Schedule.

4. Policy Schedule
Policy Schedule means the Policy Schedule attached to and forming part of Policy

5. Policy year
Policy Year means a period of twelve months beginning from the date of
commencement of the Policy period and ending on the last day of such twelve-month
period. For the purpose of subsequent years, policy year shall mean a period of
twelve months commencing from the end of the previous policy year and lapsing on
the last day of such twelve-month period, till the Policy Expiry date

6. Shared Accommodation
Shared Accommodation means a hospital room with two or more patient beds. This
definition does not apply to ICU or ICCU.

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Section 2 – Benefits

Below listed benefits are payable subject to Terms and Conditions of the policy.
The company’s maximum liability in aggregate for payment of any claim under Section B1,
B2, B3, B4 and B7 shall not exceed the opted sum insured. However, any payment under
cumulative bonus shall be over and above.

The sequence of utilization of benefits for a claim shall be as per the following:

i. Sum Insured,
ii. Any accrued Cumulative Bonus, if applicable
iii. Restore benefit amount, if applicable

B1. In-Patient Treatment

We will cover for expenses for hospitalization due to disease/illness/Injury during the policy
period that requires an Insured Person’s admission in a hospital as an inpatient.
Medical expenses directly related to the hospitalization would be payable.
B2. Pre-Hospitalization expenses

We will cover for expenses for Pre-Hospitalization consultations, investigations and

medicines incurred upto 60 days before the date of admission to the hospital.

The benefit is payable if We have admitted a claim under section B1 or B4 or B6 or B31 of

this policy.
B3. Post-Hospitalization expenses

We will cover for expenses for Post-Hospitalization consultations, investigations and

medicines incurred after discharge from the hospital, upto number of days as specified in
the table below.

Basic Sum insured Number of days

Upto Rs. 50 Lacs 90 days
Rs.75 Lacs to Rs.3 Crore 200 days

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In case the insured person has opted sum insured Rs. 75 Lacs and above,
then We will arrange up to 15 physiotherapy sessions at home within India, wherever
available, within the city in which you reside through our empanelled service provider subject
to following conditions:

• This limit on physiotherapy sessions is applicable to each insured person, per post-
hospitalization event
• Availing the services for physiotherapy at home under this Benefit is at insured
person’s sole discretion and risk. We do not assume any liability towards quality of
service rendered, any immediate or consequential loss arising out of or in relation to
these services rendered by the empanelled service provider.
• The said physiotherapy must be advised in writing by the treating medical practitioner.
• The above services may be provided by the company /network providers or other
empaneled hospitals / service providers. Any additional expenses other than the
eligible expenses shall be borne by the insured person which shall not be covered
under this policy unless specified otherwise
• This facility may be availed through our website or our mobile application or through
calling our call centre on the toll free number specified in the policy schedule.
Alternatively, details of our empanelled service provider are available on our website
(www.tataaig.com)
• In case we or the empanelled service provider fails to provide any of the services as
mentioned in this policy or is unable to implement , in whole or in part due to force
majeure, non-availability of services, change in law, rule or regulations which affects
the services, or if any regulatory or governmental agency having jurisdiction over a
party takes a position which affects the services, then the service provider services
suspended, curtailed or limited performance shall not constitute breach of contract
and the company or the empanelled service provider shall have no liability
whatsoever including but not limited to any immediate or consequential loss resulting
therefrom.

The benefit is payable if We have admitted a claim under section B1 or B4 or B6 or B31 of

this policy.

B4. Day Care Procedures

We will cover expenses for Day Care Treatment due to disease/illness/Injury during the
policy period taken at a hospital or a Day Care Centre.
Treatment normally taken on out-patient basis is not included in the scope of this cover.

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B5. Organ Donor

We will cover for Medical and surgical Expenses of the organ donor for harvesting the organ
where an Insured Person is the recipient provided that:

i. The organ donor is any person whose organ has been made available in accordance
and in compliance with The Transplantation of Human Organs (Amendment) Bill,
2011 and the organ donated is for the use of the Insured Person, and
ii. We have accepted an inpatient Hospitalization claim for the insured member under
section B1 of this policy.

B6. Domiciliary Treatment

We will cover for expenses related to Domiciliary Hospitalization of the insured person if the
treatment exceeds beyond three days. The treatment must be for management of an illness
and not for enteral feedings or end of life care.

At the time of claiming under this benefit, we shall require certification from the treating
doctor fulfilling the conditions as mentioned under the general definitions (Section 1) of this
policy.

B7. Restore Benefit

We will automatically restore the Basic Sum Insured if the Sum Insured and accrued
Cumulative Bonus is insufficient to pay a claim during the policy year. This benefit can be
availed once during the policy year subject to the following conditions:

a. The restored sum insured can be used for any admissible claim under Sections B1
to B4, for the insured person(s) who have not claimed earlier under these Sections.
In case the insured has claimed under these sections, then this automatic restoration
benefit is available for admissions due to unrelated illness/diseases. However, this
benefit for related illness/diseases would be available, in case of claimed insured
person(s), for admissions after 45 days from the date of discharge of the earlier claim.
b. In case of Family Floater policy, Reinstatement of Sum Insured will be available for
all Insured Persons in the Policy on floater basis
c. For policy with Basic Sum Insured less than or Equal to Rs. 50 Lacs: This benefit
shall be applicable annually for policies with tenure of more than 1 year.
For policy with Basic Sum Insured Rs. 75 Lacs and above:

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This benefit shall be applicable annually for multiyear policies. However, for
single premium multiyear policies, the insured shall have the right to utilize the
available restorations anytime during the policy period, except for the first claim, for
e.g. a policy with tenure of 2 years where entire premium is paid upfront, the insured
is eligible for a total of 2 restorations anytime during the policy period except for the
first claim in each policy year.
d. The unutilized restored sum insured cannot be carried forward to the next policy year.
e. Restore will not trigger for the first claim under each policy year.
f. The maximum liability under a single claim under this benefit shall be the sum
Insured.
This benefit shall not be available for section B13 and B31 of this policy.

B8. AYUSH Benefit

We will cover Medical Expenses incurred for treatment as In-Patient or Day Care
Treatment in an AYUSH Hospital/ AYUSH day care centre.
This benefit shall also cover Pre-Hospitalization medical expenses for a period of upto
60 days before the date of admission to the AYUSH hospital/ AYUSH day care centre
and Post-Hospitalization Medical Expenses for a period upto number of days as specified
in the table below, subject to AYUSH In-Patient hospitalization or AYUSH day care
treatment claim being admissible under this benefit.

Basic Sum insured Number of days

Upto Rs. 50 Lacs 90 days
Rs.75 Lacs to Rs.3 Crore 200 days

Claims under this section shall be assessed as per the applicable insurance guidelines
related to AYUSH and benchmark rates as available on Ministry of AYUSH website
(https://ayushnext.ayush.gov.in/site/insurance-guidelines-related-to-ayush).
For your reference, the document has been uploaded on Our website under "Annexure B
for AYUSH Benefit" (www.tataaig.com).

B9. Ambulance Cover

We will cover for expenses incurred on transportation of Insured Person in a registered

ambulance to a Hospital for admission in case of an Emergency or from one hospital to
another hospital for better medical facilities and treatment, subject to limited as specified in
the table below.

Basic Sum Insured Limit

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Up to Rs. 50 Lacs Upto Rs. 5000 per hospitalization
Rs. 75 Lacs Upto Rs. 7500 per hospitalization
Rs. 1 Crore Upto Rs. 10000 per hospitalization
Rs. 2 Crore Upto Rs. 20000 per hospitalization
Rs. 3 Crore Upto Rs. 30000 per hospitalization

For this claim to be paid, the claim must be admissible under section B1 or B4 of this policy.

B10. Health Checkup

We will cover for expenses for a Preventive Health Check-up upto 1% of policy sum insured
subject to a maximum limit as specified in the table below. The limit is the maximum per
policy in case of floater policy and per insured person in case of individual policy

The benefit is payable every year irrespective of claims under the policy. This benefit has a
separate limit (over and above base sum insured) and does not affect cumulative bonus.

Basic Sum Insured (Rs.) Limit

Up to Rs. 50 Lacs Upto Rs. 10000
Rs. 75 Lacs Upto Rs. 15000
Rs. 1 Crore Upto Rs. 20000
Rs. 2 Crore Upto Rs. 25000
Rs. 3 Crore Upto Rs. 25000

For the purpose of this benefit, Preventive Health Check-up means medical test(s)
undertaken for general assessment of health status and does not include any diagnostic or
investigative medical tests for evaluation of illness or a disease.

B11. Compassionate travel

a) Domestic
In the event the Insured Person is Hospitalized in India for more than Five
consecutive days in a place where no adult member of his immediate family is
present, we will cover for expenses related to a round trip economy class air ticket,
or first-class railway ticket, to allow the Immediate Family Member be at his bedside
for the duration of his stay in the hospital.

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The benefit shall be payable if an inpatient Hospitalization claim for the
insured member is admissible under section B1 of this Policy.

b) Global (Applicable for sum insured above Rs. 50 Lacs):

In the event the Insured person is hospitalized outside India and claim is admissible
under section B13 (Global cover for Planned Hospitalization) of this policy, We will
cover expenses related to round trip economy class air ticket, to allow the Immediate
Family Member to accompany the Insured person for the purpose of planned
treatment outside India.
This benefit has a separate limit (over and above base sum insured) as specified in the
policy schedule and does not affect cumulative bonus. We shall require the following
additional documents (proof of travel) supporting the claim under this benefit: Copy of
Passport (in case of Global), Boarding Pass, or Railway ticket or any other document to
show proof of travel.

B12. Consumables Benefit

We will pay for expenses incurred, for specified consumables listed in ‘Annexure I – List I-
Optional Items’ which are consumed during the period of hospitalization directly related to
the insured’s medical or surgical treatment of illness/disease/injury. Details of Annexure I-
List I-Optional items are available on our website (www.tataaig.com)

However, the following items shall be excluded from scope of this coverage:

• Items of personal comfort, toiletries, cosmetics and convenience shall be excluded

from scope of this coverage.
• External durable devices like Bilevel Positive Airway Pressure (BIPAP) machine,
Continuous Positive Airway Pressure (CPAP) machine, Peritoneal Dialysis (PD)
equipment and supplies, Nimbus/water/air bed, dialyzer and other medical
equipments.
• Any item which is neither medical consumable nor medically necessary nor
prescribed by Doctor.
For this claim to be paid, the main claim must be admissible under section B1 or B4 or B31
of this policy.

B13. Global Cover for Planned Hospitalization

a. Global Cover for Planned Hospitalization (Medical Expenses)

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We will cover for Medical Expenses of the Insured Person incurred outside
India, upto the sum insured, provided that the diagnosis was made in India and the
insured travels abroad for treatment.

The Medical Expenses payable shall be limited to Inpatient and daycare

Hospitalization. Any claim under this cover can be made only on reimbursement
basis. Cashless facility may be arranged on case to case basis. Insured person can
contact us for claim assistance.

The payment of claim under this benefit will be in Indian Rupees based on the rate of
exchange published by Reserve Bank of India (RBI), as on the date of invoice and
shall be used for conversion of foreign currency into Indian Rupees for claims
payment. If these rates are not published on the date of invoice, the exchange rate
next published by RBI shall be considered for conversion.

Only the balance basic sum insured along with Cumulative Bonus can be used for
this and not the restored sum insured.

We shall require the following additional documents supporting the claim under this
benefit:

• Proof of diagnosis in India

• Insured’s Passport and Visa

b. Visa Services Fees (Applicable only for Sum Insured above Rs.50 Lacs)

We will cover for reasonable and customary expenses incurred towards obtaining
visa for medical treatment of the insured person travelling abroad upto the sum
insured subject to claim being admissible under section B13 (a – Global Cover for
Planned Hospitalization (Medical Expenses)) of this policy.

• We shall require valid receipts/bills of visa fee services supporting the claim
under this benefit.

Special condition applicable for cover B13 (a) & (b):

Please note that, B13. ‘Global Cover for Planned Hospitalization’ as a Benefit is:

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a) not available under this policy and no claim shall be admissible under
this section where either the policyholder or any of the Insured Person(s) is a Foreign
National or their Residence Status at the time of proposal or anytime during the policy
period/ renewal is:
• Non-Resident Indian (NRI); or
• Overseas Citizen of India (OCI)

b) not available under this Policy and no claim shall be admissible under this section, if
the Policyholder or any of the Insured Person(s), as a Resident Indian National, has
agreed to opt out of this Benefit at the time of proposal or at renewal.

If the coverage under B13. ‘Global Cover for Planned Hospitalization’ is once opted out, then
neither the policyholder nor the Insured Person can take coverage under this benefit.

You are eligible for a premium discount as specified in the prospectus in case this special
condition, as mentioned above, is applicable to You/ Insured Person(s).
B14. Bariatric Surgery Cover

We will cover for reasonable and customary expenses for Bariatric Surgery if the insured
fulfills all of the following conditions:
i. Surgery to be conducted is upon the advice of the Doctor
ii. The member has to be 18 years of age or older and
iii. Body Mass Index (BMI) greater than or equal to 40 or
iv. BMI is greater than or equal to 35 in conjunction with any of the following severe co-
morbidities following failure of less invasive methods of weight loss:
a. Obesity-related cardiomyopathy
b. Coronary heart disease
c. Severe sleep apnea
d. Uncontrolled Type2 Diabetes
In view of this coverage getting extended, exclusion code (Code-Excl06) of this policy stands
deleted.
B15. In-Patient Treatment - Dental

We will cover for medical expenses incurred towards hospitalization for dental treatment
under anesthesia necessitated due to an accident/injury/illness.

B16. Vaccination cover

We will cover for expenses related to the cost of the following vaccines only:

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Basic Sum Vaccines covered
Insured
Up to Rs. 50 Without any waiting period:
Lacs
- Anti-rabies vaccine following an animal bite
- Typhoid vaccination
After 2 years of continuous coverage with Us:

- Human Papilloma Virus (HPV) vaccine

- Hepatitis B Vaccine

Rs. 75 Lacs to Without any waiting period:

Rs. 3 Crore.
- Anti-rabies vaccine following an animal bite
- Typhoid vaccination
After 2 years of continuous coverage with Us:

- Human Papilloma Virus (HPV) vaccine

- Hepatitis A Vaccine
- Hepatitis B Vaccine
- Tetanus, Diphtheria, Pertussis
- Pneumococcal

Expenses related to the doctor, nurse or any incidental expenses are not payable. This
benefit has a separate limit (over and above base sum insured) and does not affect
cumulative bonus.

B17. Hearing Aid

We will cover for reasonable charges for a hearing aid every third year. The maximum
amount payable is 50% of actual cost or Rs. 10,000/- per policy, whichever is lower.

The items must be prescribed by a specialized Medical Practitioner as medically necessary.

This benefit has a separate limit (over and above base sum insured) and does not affect
cumulative bonus.
B18. Daily Cash for choosing Shared Accommodation

We will pay a fixed amount per day as mentioned in the policy schedule if the Insured Person
is Hospitalized in Shared Accommodation in a Network Hospital for each continuous and

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completed period of 24 hours. The benefit payable per day would be 0.25%
of base sum insured and a maximum of Rs. 2000 per day.

For this claim to be paid, the main claim must be admissible under section B1 of this policy.
This benefit has a separate limit (over and above base sum insured) and does not affect
cumulative bonus.
B19. Daily Cash for Accompanying an Insured Child

We will pay a fixed amount per day, as mentioned in the policy schedule, if the Insured
Person Hospitalized is a child Aged 12 years or less, for one accompanying adult for each
complete period of 24 hours. The benefit payable per day would be 0.25% of base sum
insured and a maximum of Rs.2000 per day.

We will provide You a second opinion from Network Provider or Medical Practitioner, if an
Insured Person is diagnosed with the below mentioned Illnesses during the Policy Period.
The expert opinion would be directly sent to the Insured Person.

i. Cancer
ii. Kidney Failure
iii. Myocardial Infarction
iv. Angina
v. Coronary bypass surgery
vi. Stroke/Cerebral hemorrhage
vii. Organ failure requiring transplant
viii. Heart Valve replacement
ix. Brain tumors

This benefit can be availed by an insured person once during a Policy Year.
B21. Maternity Cover

We will cover for Maternity Expenses, upto limits as specified in the table below, per policy
subject to a waiting period of 4 years of continuous coverage under this policy .

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Basic Sum Insured Limit
Up to Rs. 50 Lacs A maximum of upto Rs 50,000/-. In case of birth of a girl
child, the maximum limit under this coverage would be
upto Rs 60,000/- per policy
Rs.75 Lacs to Rs.3 A maximum of upto Rs 1,00,000/-. In case of birth of a girl
Crore child, the maximum limit under this coverage would be
upto Rs 1,20,000/- per policy

We will not cover ectopic pregnancy under this benefit (although it shall be covered under
section B1).

Expenses incurred for following shall be excluded from the scope of this coverage:

• Expenses incurred for pre/post natal care

• Pre/Post hospitalization benefit (Section B2 and B3 of this policy)
In view of this coverage getting extended, maternity exclusion code 18 stands deleted.
However, no coverage is available for voluntary termination of pregnancy during the policy
period under this policy.

B22. Delivery Complications Cover

We will cover for medical expenses incurred for the medically necessary treatment of the
new born baby upto limits as specified in the table below, for complications related to delivery
if claim is admitted under the maternity benefit (B21) of this policy.

Basic Sum Insured Limit

Up to Rs.50 Lacs Upto Rs. 10000
Rs. 75 Lacs to Rs. 3 Crore Upto Rs. 25000

B23. First year Vaccinations

We will pay for vaccination expenses for up to one year after the birth of the child subject to
a limit of Rs. 10,000/- provided the child is covered with Us. In case of girl child, applicable
limit under this coverage would be Rs.15,000/-.

For the claim to be paid under this benefit, the expenses related to maternity should be
admissible under section B21 of this policy. The limit of Rs.10,000 (Rs.15,000 in case of girl
child) is a lifetime limit and not a policy limit which will be applicable for each child.

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B24. Prolonged Hospitalization Benefit

We will pay a fixed amount of 1% of sum insured, in the event of insured hospitalized for a
disease/illness/injury for a continuous period exceeding 10 days.

This benefit will be triggered provided that the hospitalization claim is accepted under section
B1 of this policy.

This benefit shall not be applicable for section B6 / B 31 of this policy.

This benefit has a separate limit (over and above base sum insured) and does not affect
cumulative bonus.
B25. High End Diagnostics

We will cover for reasonable charges incurred for the following diagnostic tests only on OPD
basis if required as part of a medically necessary treatment subject to limits as specified in
the table below, per policy year:
i. Brain Perfusion imaging
ii. Computed Tomography (CT) guided Biopsy
iii. Computed Tomography (CT) Urography
iv. Digital Subtraction Angiography (DSA)
v. Liver Biopsy
vi. Magnetic Resonance Cholangiography Scan
vii. Positron Emission Tomography Computed Tomography (PET CT)
viii. Positron emission tomography Magnetic Resonance Imaging (PET MRI)
ix. Renogram

Basic Sum Insured Limit

Up to Rs.50 Lacs Up to Rs. 25,000 per policy year
Rs. 75 Lacs to Rs. 3 Crore Up to Rs. 50,000 per policy year

This benefit has a separate limit (over and above base sum insured) and does not affect
cumulative bonus.
B26. OPD Treatment

Once the insured has completed two years of continuous coverage with Us, We will pay for
expenses related to consultations and pharmacy up to limits specified in the table below, per
policy year annually subject to policy terms and conditions.

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Basic Sum Insured Limit
Up to Rs.50 Lacs Upto Rs. 5,000/-
Rs.75 Lacs Upto Rs. 7,500/-
Rs. 1 Crore Upto Rs. 10,000/-
Rs. 2 Crore Upto Rs. 15,000/-
Rs. 3 Crore Upto Rs. 20,000/-

This benefit has a separate limit (over and above base sum insured) and does not affect
cumulative bonus.

B27. OPD Treatment - Dental

Once the Insured has completed two years of continuous coverage with Us, we will pay for
expenses related to the following dental treatments only subject to a maximum of limit
specified in the table below, per policy year annually:

- Root Canal Treatment (single or multiple sittings)

- Tooth extraction(s)
- Filling

Basic Sum Insured Limit

Up to Rs. 50 Lacs Upto Rs. 10,000/-
Rs. 75 Lacs Upto Rs. 12,500/-
Rs.1 Crore Upto Rs. 15,000/-
Rs.2 Crore Upto Rs. 20,000/-
Rs.3 Crore. Upto Rs. 25,000/-

This benefit has a separate limit (over and above base sum insured) and does not affect
Cumulative Bonus.
In view of this coverage getting extended, dental exclusion (General Exclusions ii. 1. ix) is
not applicable for this particular coverage.

B28. Emergency Air Ambulance Cover

We will pay for ambulance transportation of the Insured Person in an airplane or helicopter
subject to maximum of limit specified in the table below, for emergency life threatening
health conditions which require immediate and rapid ambulance transportation to the
hospital/medical centre for further medical management.

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The Medical Evacuation should be prescribed by a Medical Practitioner and should be
Medically Necessary.

This benefit shall only be payable if We have accepted an inpatient Hospitalization claim for
the Insured member under section B1 of this policy.

Basic Sum Insured Limit

Up to Rs.50 Lacs Up to Rs. 500,000
Rs.75 Lacs to Rs. 3 Crore Up to Rs. 500,000 for Non Network;
Upto Sum Insured for Network Provider

This benefit has a separate limit (over and above base sum insured) and does not affect
Cumulative Bonus.

B29. Accidental Death Benefit

If an Insured Person suffers an accident during the policy period and this is the sole and
direct cause of his death within 365 days from the date of accident, then We will pay a fixed
amount of 100% of the base Sum Insured, maximum up to Rs 50 Lacs.

This benefit is not applicable for dependent children covered in the policy.
B30. Cumulative Bonus

i. 50% cumulative bonus will be applied on the Sum Insured for next policy year under
the Policy after every claim free Policy Year, provided that the Policy is renewed with
Us and without a break. The maximum cumulative bonus shall not exceed 100% of
the Sum Insured in any Policy Year.
ii. If a Cumulative Bonus has been applied and a claim is made, then in the subsequent
Policy Year We will automatically decrease the Cumulative Bonus by 50% of the Sum
Insured in that following Policy Year. There will be no impact on the Inpatient Sum
Insured, only the accrued Cumulative Bonus will be decreased.
iii. In policies with a tenure of more than one year, the above guidelines of Cumulative
Bonus shall be applicable post completion of each policy year
iv. In relation to a Family Floater, the Cumulative Bonus so applied will only be available
in respect of those Insured Persons who were Insured Persons in the claim free Policy
Year and continue to be Insured Persons in the subsequent Policy Year.

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v. For purpose of computation of Cumulative Bonus, the percentage (%)
of Cumulative Bonus will be applied on the base Sum Insured only. Restored sum
insured will not be taken into consideration.
vi. Cumulative Bonus shall be provided only if No Claim Discount has not been availed
for the claim free previous Policy Year.

B31. Home Care Treatment Cover (Applicable only for Sum Insured
Rs.75 Lacs and above)
We will cover for reasonable and customary medical expenses incurred for treatment taken
at home, which are “Equivalent Medical charges” as defined in this policy, for below specified
conditions/illness upto the sum insured (excluding accrued cumulative bonus) for the
Insured Person’s medically necessary treatment at home. Restore benefit sum insured is
not applicable for this benefit.

Home Care Treatment means treatment availed by the Insured Person at home for below
listed conditions/ illness/ procedures, which in normal course would require hospitalization
of more than 24 hours or would have been admissible under Day Care Procedures but is
actually taken at home provided that:

a. The medical practitioner advices the insured person to undergo treatment at home.
b. There is a continuous active line of treatment with monitoring of the health status by
a medical practitioner for each day through the duration of the home care treatment.
c. Daily monitoring chart including records of treatment administered duly signed by the
treating doctor is maintained
d. Home care treatment is availed in India.
e. Home treatment services may be provided through network service provider/
empanelled service provider in select cities for select treatment procedures only.
Please contact us or visit our website (www.tataaig.com) for updated list of treatment
procedures and cities where home treatment service is provided
f. Insured shall be permitted to avail the services as prescribed by the medical
practitioner.
g. In case the insured intends to avail the services of non-network provider, claim shall
be subject to reimbursement, a prior approval from the insurer needs to be taken
before availing such services from a registered home care provider. Insurer shall
respond to approval request within 4 working hours of receiving the last necessary
requirement.

Specified conditions/ illness covered under Home care treatment:

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a. Dialysis at home
b. Chemotherapy at home
c. Pandemic Care at home for a maximum period of 15 days and maximum upto 25%
of the base sum insured excluding cumulative bonus (Pandemic as defined and
declared by World Health Organization (WHO) or any equivalent healthcare authority)

In this benefit, the following shall be covered if prescribed by the treating medical practitioner
and is related to treatment covered under the policy,

a. Diagnostic tests undergone at home or at diagnostics center

b. Medicines prescribed in writing
c. Consultation charges of the medical practitioner
d. Nursing charges related to medical staff
e. Medical procedures limited to parenteral administration of medicines
f. Including but not limited to cost of Pulse Oximeter, Oxygen cylinder and nebulizer
wherever applicable
For the purpose of this cover, “Equivalent Medical charges” shall mean the charges for
services or supplies, which are the standard/equivalent charges for the specific provider and
not more than the prevailing charges in the geographical area for identical or similar services
taken on inpatient/day care basis, considering the nature of the illness / injury involved.

B32. Wellness Services

We / our Empanelled Service Provider will provide below mentioned wellness

services designed to assist insured persons in maintaining and improving good health
and fitness. These Wellness Services will be available for the insured person during
the policy period and as specified in the Policy schedule.

i. Teleconsultation - General

We /our empanelled Service Provider will arrange for teleconsultations upon

insured person’s request through telecommunications and digital communication
technologies for insured person’s health related complaints or preventive health
care by a qualified Medical Practitioner/ Health Care Professional, as per the limit
specified in your Policy Schedule.

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This service can only be availed subject to condition below:
- Consultation will be provided through various specified modes of
communication (including but not limited to) like audio, video, online portal,
chat, digital customer application or any other digital mode.

ii. Teleconsultation - Speciality

We /Our empanelled Service Provider will arrange for teleconsultations upon

insured person’s request through telecommunications and digital communication
technologies for insured person’s health related complaints or preventive health
care by a qualified & specialist Medical Practitioner/ Health Care Professional, as
per the limit/speciality specified in your Policy Schedule.

This service can only be availed subject to conditions below:

- Consultation will be provided through various specified modes of
communication (including but not limited to) like audio, video, online portal,
chat, digital customer application or any other digital mode.

iii. Ambulance Booking facility

We / Our empanelled Service Provider will provide a facility to book a road

ambulance in India, for transportation of an Insured Person to a Hospital for
admission or from one hospital to another hospital for better medical facilities and
treatment.

This booking service can be availed at Our Network subject to the transportation
of the Insured Person will be offered to the nearest Hospital

iv. Emergency - Help me feature

In case of an emergency, insured person will have an option to share his/her

location with the ‘designated caregiver’ through our customer application provided
the insured person has registered on our App.
The app will trigger a message and call to the designated caregiver informing about
the emergency and sharing the location of the Insured Person.

For the purpose of this benefit, ‘designated caregiver’ shall mean that individual
who has been specified as a caregiver at the time of registration in the customer
App.

Please note
- This service will be available subject to suitable infrastructure, connectivity,
device restrictions and device functionality.
-

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v. Redeemable voucher/Discount on services

We / our empanelled service provider will provide redeemable vouchers/ discount
(as approved by the regulator from time to time) on certain specified products/
services to promote wellness and fitness of the insured person.

vi. Health Condition Management

We / our empanelled service provider will provide consultative services related to

health conditions/ illnesses with the objective of maintaining good health and
improving it through various health condition management programmes including
but not limited to nutrition management, weight management, chronic condition
management, stress management, health coach (as approved by the regulator
from time to time) and offered by us.

Consultative services will be provided through various specified modes of

communication (including but not limited to) audio, video, online portal, chat, digital
customer application or any other digital mode.

Definition:
For the purpose of section B 32 of this policy, a Health Care Professional is a person
who holds a valid qualification from regulatory body as set up by the Government of
India or a State Government or any other relevant authority and is engaged in
actions with an objective of maintaining and improving individual’s good health.

B33. Wellness Program

We / our empanelled service provider will provide a wellness program designed to

promote wellness and fitness amongst the insured persons. This wellness program
is structured to reward the insured person in the form of measurable wellness score
for the prescribed physical efforts/fitness activity undertaken by such insured person
during the policy period. This is a voluntary program available for insured with age
above 18 years, at the start of the policy year. It is advisable to the insured person to
consult his/her physician before starting any physical exercise/ activity.

It is a pre-condition for enrolment under this wellness programme, that the insured
person should have undergone the health risk assessment as specified below and
depending on the outcome from health risk assessment, the wellness reward and its
scoring should be administered. The earnings under the wellness program is linked
to your wellness category and shall be valid for one year from the date of credit of

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daily score in insured person’s wellness account, provided the policy is
renewed within the grace period. Daily score will be credited after the completion of
a healthy day.
For the purpose of understanding if the daily score is credited on 1st Jan 2024 it will
be valid up to 31st Dec 2024.
i) Health risk assessment

We / our empanelled service provider will provide a health risk assessment (HRA)
questionnaire, which is an online tool for evaluation of status of health and quality of
the insured person’s life. This tool helps insured persons to review their lifestyle
practises which may impact their health status.

To undertake the health risk assessment, you can log into your account on our
customer application. This can be undertaken once a policy year.

On completion of the health risk assessment and based on the insured person’s
assessment results, we / our empanelled service provider will identify the wellness
category in which the insured person falls in.

Wellness categories for this purpose are defined as below:

• Green – low risk for developing lifestyle disease as compared to peers in the
same age and gender group.
• Yellow – moderate risk for developing lifestyle disease as compared to peers in
the same age and gender group.
• Red – higher risk for developing lifestyle disease as compared to peers in the
same age and gender group.

The overall wellness category is valid till the expiry of the policy year in which the
insured undergoes the assessment and will be updated based on HRA results of
subsequent assessment undergone by the insured person in each consecutive policy
year, subject to renewal of the policy within the grace period. In the event of a long-
term policy (greater than 1 year) the insured has to undergo HRA in each policy year
to be eligible for wellness rewards. If the insured does not undergo assessment in
the consecutive policy year, henceforth no rewards will be earned for any physical
activity undertaken. However, earned rewards will be carried forward till its validity
and will be available for utilization.

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ii) Wellness Rewards

Mechanism to earn Wellness Reward:

We will encourage physical exercise and fitness and recognise the effort by rewarding
the insured person on daily basis for each healthy day.

A healthy day can be earned by undertaking below activity on a calendar day:

1. Recording 10, 000 steps / day# in the activity tracking apps or fitness
tracker devices as prescribed by the company or our empanelled service
provider: or
2. Burning 500 calories or more in a day through activity as measured by
fitness tracker devices.
The company may at its discretion change the above criteria and the same would be
mentioned in the policy schedule/ customer application.

Wellness reward will be earned depending on the wellness category of the insured
person and as per the grid below:

Wellness category
Green Yellow Red
Rewards per 10 7 5
Healthy Day

Note:

− HRA registration will be allowed anytime during the policy year and healthy
activities will be tracked throughout the policy year, however, for each policy year,
activities completed in first 300 days of the policy year will be considered for reward
in the same year, activities completed on or after 301 st day of the policy year will
be carried forward to the next policy year and will be available for utilization in the
next year provided the policy has been inforce or renewed with us without any
break within the grace period.

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− In case of individual policy, each insured person would be tracked
separately and shall earn wellness reward based on one’s own individual
performance/physical activity as per the grid above
− In case of family floater policy, each insured person, with age above 18 years, at
the start of the policy year, would be tracked separately and shall earn wellness
reward based on one’s own individual performance/physical activity as per the grid
above. In order to compute the wellness reward for such policies, average of
individual performance rewards would be considered for computation of wellness
reward.
− # The company may also use alternative measurement criteria in lieu of steps and
calories burnt and the same shall be mentioned on the policy schedule
− Data entered manually in the fitness tracking apps or devices will not be
considered for tracking healthy day
− Calories burnt during basic metabolism shall not be considered for tracking healthy
day (here basic metabolism refers to activities done while at rest to maintain vital
functions such as breathing and keeping warm etc.)
Mechanism to Utilise Wellness Reward:

Wellness Reward accumulated through fitness activities can be converted into

monetary value as per method defined below and can be utilized towards the payment
of services/items under below categories, available through our Network/ empanelled
service provider:

▪ OPD consultation/ treatment

▪ Pharmaceuticals
▪ Health-check-ups/ diagnostics
▪ Health Supplements
▪ Coverage of cost of treatment of any admissible claim in respect of non-payable
items that are specified under the terms and conditions of the base policy
▪ Or any other items as prescribed by the company or our empanelled service
provider as approved by the Regulator as a redeemable item from time to time.

Note:

− Wellness Reward can be converted into a monetary value after every Healthy Day,
during the Cover Period
− Monetary value of the Wellness score earned is equivalent to the:
Wellness score earned X (Per year Policy Premium without Taxes/ 10,000).
o In case of policy with tenure more than one year, ‘per year policy Premium
without Taxes’ = (Total Policy premium without tax, for the tenure/ policy
tenure).
o In case of family floater policy, reward will be calculated on average
premium per person which is equivalent to the Total Policy premium without
tax/ number of Insured persons covered in the policy on floater basis

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Illustration

Age of the Insured Person (Years) 40

Sum Insured opted under the Policy (Rs.) 5 Lacs
Plan Type Individual
Policy Tenure (years) 1
Total number of members covered under the 1
policy
Net Premium paid (without Tax) 7931
Wellness Category (post Health Risk Green
Assessment)

Healthy Wellness Wellness Wellness Wellness Reward valid

Day Reward Reward Reward credited up to 365 days
earned converted to after Healthy (provided the policy is
(per day) Monetary Day active and insured is
Value covered)
(per day)
1 to 300 10 7.931 Date of credit of 365 days from the Date
day Wellness score of credit of Wellness
score
301 day 10 7.931 Date of Policy 365 days from:
onwards Anniversary - in - Date of Policy
case of Multi Anniversary - in case
year policy of Multi year policy
Date of renewal - Date of renewal - in
- in case of 1 yr case of 1 yr policy, as
policy applicable
Maximum Total in a 2894.82
Policy Year
Steps to register for Wellness Program and earn & spend Wellness Rewards

Step 1. Register yourself on customer application

• The insured person will download Tata AIG customer application on your device and
complete registration process by providing policy and insured person’s details.
Step 2. Complete health risk assessment

• Submit response to the online health questionnaire on your device.

• On completion of the health risk assessment, a Wellness category will be assigned
to the insured person for the policy year and will be updated based on the latest
health risk assessment in next policy year.
Step 3. Comply with mechanism to earn Wellness Rewards

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• We will track the physical exercise and fitness activities completed by
the insured person, through the customer app.
• Activities completed on a calendar day will be considered as a Healthy Day and
reward will be credited to insured person’s wellness account.
Step 4. Convert Healthy Day into monetary value and spend

• Insured person will have an option to convert the accumulated rewards into the
monetary value and spend it on items/ services offered under the policy
• The unutilized rewards will be carried forward to next Policy year till this policy is
renewed with us within grace period and is inforce subject to validity period of the
reward point)

Disclaimer (applicable to section B32 & B33)

1. Availing the services under this benefit is purely upon the Insured’s sole discretion
and risk.

2. For services that are provided through empanelled Service Providers, we are acting
as a facilitator; hence would not be liable for any incremental costs or the services.
Any additional services availed, or expenses incurred on such services or benefits
which are other than those covered under this policy and explicitly excluded by this
policy schedule, shall not be covered under this policy and all expenses incurred shall
be borne by the insured person.
3. We shall not be responsible for or liable for, any actions, claims, demands, losses,
damages, costs, charges and expenses which insured person claims to have
suffered, sustained or incurred, by way of and / or on account of the benefit. We shall
not be liable for any deficiency or discrepancy in the services provided by empanelled
service provider/network provider under this policy.
4. Insured person may consult any medical professional at any network
provider/empanelled service provider at its sole discretion. The cost of service arising
out of insured person choice of medical professional at any network
provider/emplaned service provider shall be completely borne by the insured person
unless covered otherwise. However, the services under this policy should not be
construed to constitute medical advice and/or substitute the insured person's visit/
consultation to an independent medical practitioner/healthcare professional
5. The medical practitioner may suggest/recommend/prescribe over the counter
medications based on the information provided, if required on a case-to-case basis.
Provided that any recommendation under this policy shall not be valid for any medico
legal purposes.
6. The insured person is free to choose whether or not to act on the recommendation
after seeking consultation.
7. Any advice, recommendations or suggestions made by any medical professional
shall be solely based on the information and documentation provided by the insured
person to such medical professional. We shall not be liable towards any loss or
damage (immediate or consequential) arising out of or in relation to any opinion,

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advice, prescription, actual or alleged errors, omissions and representations
made by the medical professional from whom we have availed services or taken
benefit or for any consequence of any act or omission in reliance thereon.
8. We at our discretion may provide discounts on any of the above services
9. Any discount offered under redeemable voucher/discount on services by our
empanelled service providers are subject to modification or withdrawal. We do not
assume any liability towards the quantum of discount, quality of product/services and
timeline within which the product/service is rendered.
10. For Ambulance Booking facility–
a. These services are provided through our empanelled service provider in select
cities. Please contact us / refer to our digital customer application for more
details on this service.
b. We do not assume any liability towards quality and turnaround times of service
rendered, any loss or damage arising out of or in relation to these services
rendered by the empanelled service provider.
c. This facility may be availed through Our digital customer application or through
calling Our call centre on the tollfree number specified in the Policy Schedule.
11. Above mentioned services are non-portable, annual contracts, independent of policy
contract and not lifelong renewable. The Services provided may be added / deleted /
modified at our discretion and the same shall be notified to the policyholders in
advance prior to change effective date.
12. Provision of these services is subject to availability as per the duration specified by
Us/the empanelled service provider. Details are available on our website
(www.tataaig.com)
13. Any service availed by the Insured Person under this Benefit will not impact
Cumulative Bonus if applicable.
14. We reserve the right to change any service provider during the currency of the policy
or at renewal. The same shall be intimated to the insured atleast 15 days prior to the
effective date of change. During such change, all the credits earned by the insured
person shall be transferred to the new service provider.
15. In case we or the assistance service provider fails to provide any of the services as
mentioned in this policy or is unable to implement, in whole or in part due to force
majeure, non-availability of services, change in law, rule or regulations which affects
the services, or if any regulatory or governmental agency having jurisdiction over a
party takes a position which affects the services , then the assistance services’
suspended, curtailed or limited performance shall not constitute breach of contract
and the company or the assistance service provider shall have no liability whatsoever
including but not limited to any loss or damage resulting therefrom.

Section 3 –Exclusions

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General Exclusions

We will neither be liable nor make any payment for any claim in respect of any Insured
Person which is caused by, arising from or in any way attributable to any of the following
exclusions, unless expressly stated to the contrary in this Policy.

i. Standard Exclusions

1. Exclusions with waiting periods

i. 30 Days Waiting Period (Code-Excl03):

a. Expenses related to the treatment of any illness within 30 days from the first
policy commencement date shall be excluded except claims arising due to an
accident, provided the same are covered.
b. This exclusion shall not, however, apply if the Insured Person has Continuous
Coverage for more than twelve months.
c. The within referred waiting period is made applicable to the enhanced sum
insured in the event of granting higher sum insured subsequently.

ii. Specified Disease/Procedure Waiting Period (Code-Excl02):

a. Expenses related to the treatment of the listed Conditions,
surgeries/treatments shall be excluded until the expiry of 24 months of
continuous coverage after the date of inception of the first policy with us. This
exclusion shall not be applicable for claims arising due to an accident.
b. In case of enhancement of sum insured the exclusion shall apply afresh to the
extent of sum insured increase.
c. If any of the specified disease/procedure falls under the waiting period
specified for pre-Existing diseases, then the longer of the two waiting periods
shall apply.
d. The waiting period for listed conditions shall apply even if contracted after the
policy or declared and accepted without a specific exclusion.
e. If the Insured Person is continuously covered without any break as defined
under the applicable norms on portability stipulated by IRDAI, then waiting
period for the same would be reduced to the extent of prior coverage.

f. List of Specific Diseases/procedures as furnished below:

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I. Tumors, Cysts, polyps including breast lumps (benign)
II. Polycystic ovarian disease
III. Fibromyoma
IV. Adenomyosis
V. Endometriosis
VI. Prolapsed Uterus
VII. Non-infective arthritis
VIII. Gout and Rheumatism
IX. Osteoporosis
X. Ligament, Tendon or Meniscal tear
XI. Prolapsed Inter Vertebral Disc
XII. Cholelithiasis
XIII. Pancreatitis
XIV. Fissure/fistula in anus, haemorrhoids, pilonidal sinus
XV. Ulcer & erosion of stomach & duodenum
XVI. Gastro Esophageal Reflux Disorder (GERD)
XVII. Liver Cirrhosis
XVIII. Perineal Abscesses
XIX. Perianal / Anal Abscesses
XX. Calculus diseases of Urogenital system Example: Kidney stone, Urinary bladder
stone.
XXI. Benign Hyperplasia of prostate
XXII. Varicocele
XXIII. Cataract
XXIV. Retinal detachment
XXV. Glaucoma
XXVI. Congenital Internal Diseases

The following treatments are covered after a waiting period of two years irrespective
of the illness for which it is done:
XXVII. Adenoidectomy
XXVIII. Mastoidectomy
XXIX. Tonsillectomy
XXX. Tympanoplasty
XXXI. Surgery for nasal septum deviation
XXXII. Nasal concha resection
XXXIII. Surgery for Turbinate hypertrophy
XXXIV. Hysterectomy
XXXV. Joint replacement surgeries Eg: Knee replacement, Hip replacement
XXXVI. Cholecystectomy
XXXVII. Hernioplasty or Herniorraphy

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XXXVIII. Surgery/procedure for Benign prostate enlargement
XXXIX. Surgery for Hydrocele/ Rectocele
XL. Surgery of varicose veins and varicose ulcers

iii. Pre-existing Diseases Waiting Period (Code-Excl01)

a. Expenses related to the treatment of a pre-existing Disease (PED) and its
direct complications shall be excluded until the expiry of 24 months of
continuous coverage after the date of inception of the first policy with us.
b. In case of enhancement of sum insured the exclusion shall apply afresh to the
extent of sum insured increase.
c. If the Insured Person is continuously covered without any break as defined
under the portability norms of the extant IRDAI (Health Insurance)
Regulations, then waiting period for the same would be reduced to the extent
of prior coverage.
d. Coverage under the policy after the expiry of 24 months for any pre-existing
disease is subject to the same being declared at the time of application and
accepted by us.

2. Medical Exclusions

i. Treatment for, Alcoholism, drug or substance abuse or any addictive condition and
consequences thereof .(Code-Excl12)
ii. Expenses related to surgical treatment of obesity that does not fulfil the below conditions
(Code-Excl06):
a. Surgery to be conducted is upon the advice of the Doctor
b. The surgery/Procedure conducted should be supported by clinical protocols
c. The member has to be 18 years of age or older and
d. Body Mass Index (BMI);
i. greater than or equal to 40 or
ii. greater than or equal to 35 in conjunction with any of the following severe
co-morbidities following failure of less invasive methods of weight loss:
1. Obesity-related cardiomyopathy
2. Coronary heart disease
3. Severe Sleep Apnea
4. Uncontrolled Type2 Diabetes

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iii. Investigation and evaluation (Code-Excl04):
a. Expenses related to any admission primarily for diagnostics and evaluation
purposes only are excluded.
b. Any diagnostic expenses which are not related or not incidental to the current
diagnosis and treatment are excluded.

iv. Expenses related to Sterility and infertility (Code-Excl17). This includes:

i. Any type of contraception, sterilization
ii. Assisted Reproduction services including artificial insemination and
advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI
iii. Gestational Surrogacy
iv. Reversal of sterilization

v. Refractive error (Code -Excl15): Expenses related to the treatment for correction of
eye sight due to refractive error less than 7.5 dioptres.
vi. Change-of-Gender treatments (Code- Excl 07): Expenses related to any treatment,
including surgical management, to change characteristics of the body to those of the
opposite sex

vii. Cosmetic or Plastic Surgery (Code – Excl08) : Expenses for cosmetic or plastic
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 remove
a direct and immediate health risk to the insured. For this to be considered a medical
necessity, it must be certified by the attending Medical Practitioner.
viii. Rest cure, rehabilitation and respite care (Code-Excl05):
a. Expenses related to any admission primarily for enforced bed rest and not for
receiving treatment. This also includes:
i. Custodial care either at home or in a nursing facility for personal care
such as help with activities of daily living such as bathing, dressing,
moving around either by skilled nurses or assistant or non-skilled
persons.
ii. Any services for people who are terminally ill to address physical, social,
emotional and spiritual needs.
ix. Unproven treatments (Code-Excl16) : Expenses related to any unproven treatment,
services and supplies for or in connection with any treatment. Unproven treatments are
treatments, procedures or supplies that lack significant medical documentation to
support their effectiveness.
x. Maternity (Code - Excl18):
a. Medical treatment expenses traceable to childbirth (including complicated
deliveries and caesarean sections incurred during hospitalization) except
ectopic pregnancy;

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b. Expenses towards miscarriage (unless due to an accident) and lawful
medical termination of pregnancy during the policy period
xi. Treatments received in heath hydros, nature cure clinics, spas or similar establishments
or private beds registered as a nursing home attached to such establishments or where
admission is arranged wholly or partly for domestic reasons. (Code -Excl13)
xii. Dietary supplements and substances that can be purchased without prescription,
including but not limited to Vitamins, minerals and organic substances unless prescribed
by a medical practitioner as part of hospitalization claim or day care procedure. (Code -
Excl14)

3. Non-Medical Exclusions

i. Hazardous or Adventure Sports (Code Excl09) : Expenses related to any treatment

necessitated due to participation as a professional in hazardous or adventure sports,
including but not limited to, para-jumping, rock climbing, mountaineering, rafting,
motor racing, horse racing or scuba diving, hand gliding, sky diving, deep-sea diving
ii. Breach of law (Code Excl10): Expenses for treatment directly arising from or
consequent upon any Insured Person committing or attempting to commit a breach
of law with criminal intent.
iii. Excluded Providers (Code-Excl11):Expenses incurred towards treatment in any
hospital or by any Medical Practitioner or any other provider specifically excluded by
the Insurer and disclosed in its website / notified to the policyholders are not
admissible. However, in case of life threatening situations or following an accident,
expenses up to the stage of stabilization are payable but not the complete claim .

ii. Specific Exclusions (Exclusions other than as mentioned under Section 3 (1, 2 & 3)
above)

1. Medical Exclusions

i. Alcoholic pancreatitis
ii. Congenital External Diseases, defects or anomalies;
iii. Stem cell therapy ; however hematopoietic stem cells for bone marrow transplant for
haematological conditions will be covered under benefit B1 or B4 of this policy;
iv. Growth hormone therapy;
v. Sleep-apnoea
vi. Admission primarily for administration of Intra-articular or intra-lesional injections or
Intravenous immunoglobulin infusion or supplementary medications like Zolendronic
Acid

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vii. Venereal disease, sexually transmitted disease or illness;
viii. All preventive care, vaccination including inoculation and immunisations (except in
case of post- bite treatment and other vaccines explicitly covered);
ix. Dental treatment or surgery of any kind except as specified in ‘Inpatient Treatment –
Dental’.
x. Any existing disease specifically mentioned as Permanent exclusion in the Policy
Schedule

2. Non-Medical Exclusions
i. War or any act of war, invasion, act of foreign enemy, war like operations (whether
war be declared or not or caused during service in the armed forces of any country),
civil war, public defence, rebellion, revolution, insurrection, military or usurped acts,
nuclear weapons/materials, chemical and biological weapons, ionising radiation.
ii. Any Insured Person’s participation or involvement in naval, military or air force
operation,
iii. Intentional self-injury or attempted suicide while sane or insane.
iv. Items of personal comfort and convenience like television (wherever specifically
charged for), charges for access to telephone and telephone calls, internet, foodstuffs
(except patient’s diet), cosmetics, hygiene articles, body care products and bath
additive, barber or beauty service, guest service
v. Treatment rendered by a Medical Practitioner which is outside his discipline
vi. Doctor’s fees charged by the Medical Practitioner sharing the same residence as an
Insured Person or who is an immediate relative of an Insured Person's family.
vii. Provision or fitting of hearing aids, spectacles or contact lenses including optometric
therapy unless explicitly stated and covered in the policy,
viii. Any treatment and associated expenses for alopecia, baldness, wigs, or toupees,
medical supplies including elastic stockings, diabetic test strips, and similar products.
ix. Any treatment or part of a treatment that is not of a reasonable charge, not medically
necessary; drugs or treatments which are not supported by a prescription.
x. Crutches or any other external appliance and/or device used for diagnosis or
treatment (except when used intra-operatively and explicitly stated and covered in
the policy).
xi. Any illness diagnosed or injury sustained or where there is change in health status of
the member after date of proposal and before commencement of policy and the same
is not communicated and accepted by us

Section 4 – General Terms and Clauses

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i. Standard General Terms and Clauses

1. Disclosure of Information

The policy shall be void and all premium paid thereon shall be forfeited to the
Company in the event of established fraud, misrepresentation, misdescription or non-
disclosure of any material fact by the policyholder.
(Explanation: "Material facts" for the purpose of this policy shall mean all relevant
information sought by the company in the proposal form and other connected
documents to enable it to take informed decision in the context of underwriting the
risk)
2. Condition Precedent to Admission of Liability
The terms and conditions of the policy must be fulfilled by the insured person for the
Company to make any payment for claim(s) arising under the policy.
3. Claim Settlement (provision for Penal Interest)
i. The Company shall settle or reject a claim, as the case may be, within 30 days
from the date of receipt of last necessary document.
ii. In the case of delay in the payment of a claim, the Company shall be liable to pay
interest to the policyholder from the date of receipt of last necessary document to
the date of payment of claim at a rate 2% above the bank rate.
iii. However, where the circumstances of a claim warrant an investigation in the
opinion of the Company, it shall initiate and complete such investigation at the
earliest, in any case not later than 30 days from the date of receipt of last
necessary document. In such cases, the Company shall settle or reject the claim
within 45 days from the date of receipt of last necessary document.
iv. In case of delay beyond stipulated 45 days, the Company shall be liable to pay
interest to the policyholder at a rate 2% above the bank rate from the date of
receipt of last necessary document to the date of payment of claim.

(Explanation: "Bank rate" shall mean the rate fixed by the Reserve Bank of India
(RBl) at the beginning of the financial year in which claim has fallen due).The
Clause shall be suitably modified by the insurer based on the amendment(s), if
any to the relevant provisions of Protection of Policyholder's Interests
Regulations, 2024)
4. Complete Discharge
Any payment to the policyholder, insured person or his/ her nominees or his/ her legal
representative or assignee or to the Hospital, as the case may be, for any benefit

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under the policy shall be a valid discharge towards payment of claim by the
Company to the extent of that amount for the particular claim.
5. Multiple Policies
i. In case of multiple policies taken by an insured person during a period from one
or more insurers to indemnify treatment costs, the insured person shall have the
right to require a settlement of his/her claim in terms of any of his/her policies. In
all such cases the insurer chosen by the insured person shall be obliged to settle
the claim as long as the claim is within the limits of and according to the terms of
the chosen policy.
ii. Insured person having multiple policies shall also have the right to prefer claims
under this policy for the amounts disallowed under any other policy / policies even
if the sum insured is not exhausted. Then the insurer shall independently settle
the claim subject to the terms and conditions of this policy.
iii. If the amount to be claimed exceeds the sum insured under a single policy, the
insured person shall have the right to choose insurer from whom he/she wants to
claim the balance amount and we will assist the insured person in facilitating the
same.
iv. Where an insured person has policies from more than one insurer to cover the
same risk on indemnity basis, the insured person shall only be indemnified the
treatment costs in accordance with the terms and conditions of the chosen policy.

6. Fraud
If any claim made by the insured person, is in any respect fraudulent, or if any false
statement, or declaration is made or used in support thereof, or if any fraudulent
means or devices are used by the insured person or anyone acting on his/her behalf
to obtain any benefit under this policy, all benefits under this policy and the premium
paid shall be forfeited.
Any amount already paid against claims made under this policy but which are found
fraudulent later shall be repaid by all recipient(s)/policyholder(s), who has made that
particular claim, who shall be jointly and severally liable for such repayment to the
insurer.
For the purpose of this clause, the expression "fraud" means any of the following acts
committed by the insured person or by his agent or the hospital/doctor/any other party
acting on behalf of the insured person, with intent to deceive the insurer or to induce
the insurer to issue an insurance policy:
a) the suggestion, as a fact of that which is not true and which the insured
person does not believe to be true;
b) the active concealment of a fact by the insured person having knowledge
or belief of the fact;
c) any other act fitted to deceive; and

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d) any such act or omission as the law specially declares to be fraudulent

The Company shall not repudiate the claim and / or forfeit the policy benefits on the
ground of Fraud, if the insured person / beneficiary can prove that the misstatement
was true to the best of his knowledge and there was no deliberate intention to
suppress the fact or that such misstatement of or suppression of material fact are
within the knowledge of the insurer.
7. Cancellation
I. The policyholder may cancel this policy by giving 7 days written notice and
in such an event, the Company shall refund proportionate premium for the
unexpired policy period provided no refunds of premium shall be made in
respect of Cancellation where any claim has been admitted or has been
lodged or any benefit under this Policy has been availed by the Insured
Person under the Policy.

II. The Company may cancel the policy at any time on grounds of established
fraud, misrepresentation or non-disclosure of material facts by the insured
person by giving 15 days' written notice. There would be no refund of
premium on cancellation on grounds of established fraud, misrepresentation
or non-disclosure of material facts.
8. Migration
The insured person will have the option to migrate the policy to other health insurance
products/plans offered by the company by applying for migration of the policy at least
30 days before the policy renewal date as per IRDAI guidelines. lf such person is
presently covered and has been continuously covered without any lapses under any
health insurance product/plan offered by the company, the insured person will get the
accrued continuity benefits in waiting periods as per IRDAI guidelines on migration.

For Detailed Guidelines on Migration, kindly refer Insurance Regulatory and

Development Authority of India (Insurance Products) Regulations, 2024 F. No.
IRDAI/Reg/8/202/2024 dated 20th March, 2024 and Master Circular on IRDAI
(Insurance Products) Regulations 2024- Health Insurance Ref:
th
IRDAI/HLT/CIR/PRO/84/5/ 2024 dated 29 May 2024 and subsequent amendments
thereof.

9. Portability
The insured person will have the option to port the policy to other insurers by applying
to such insurer to port the entire policy along with all the members of the family, if any,
at least 30 days before, but not earlier than 60 days from the policy renewal date as

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per IRDAI guidelines . If such person is presently covered and has been
continuously covered without any lapses under any health insurance policy with an
Indian General/Health insurer, the proposed insured person will get the accrued
continuity benefits in waiting periods as per IRDAI guidelines on portability.

For Detailed Guidelines on Portability, kindly refer Insurance Regulatory and

10. Renewal of Policy

The policy shall ordinarily be renewable except on grounds of established fraud, non-
disclosure or misrepresentation by the insured person.
i. Renewal shall not be denied on the ground that the insured person had made a
claim or claims in the preceding policy years.
ii. Request for renewal along with requisite premium shall be received by the
Company before the end of the policy period.
iii. Single premium payment mode Policy can be renewed within the Grace Period of
30 days to maintain continuity of benefits without break in policy. Coverage is not
available during the grace period after the end of the policy period. If not renewed
under the Grace Period, the Policy shall terminate at the end of the Grace period.
iv. The grace period for payment of the premium during the Policy Period, for
instalment premium shall be fifteen days where premium payment mode is
monthly.
v. Coverage during such grace period (in case of instalment premium):

a. Within the policy period - coverage will be available from the due date of
instalment premium till the date of receipt of premium by Company within
the grace period.
b. At the end of the policy period - the policy shall terminate and can be
renewed within the Grace Period of 30 days to maintain continuity of
benefits without break in policy. Coverage is not available during the grace
period after the end of the policy period.
vi. The insured person will get the accrued continuity benefit in respect of the "Waiting
Periods", "Specific Waiting Periods" in the event of payment of premium within the
stipulated grace Period.
vii. No loading shall apply on renewals based on individual claims experience

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11. Withdrawal of Policy

i. In the likelihood of this product being withdrawn in future, the Company will
intimate the insured person about the same 90 days prior to expiry of the policy.
ii. Insured Person will have the option to migrate to similar health insurance product
available with the Company at the time of renewal with all the accrued continuity
benefits such as cumulative bonus, waiver of waiting period as per IRDAI
guidelines, provided the policy has been maintained without a break.

12. Moratorium Period

After completion of five continuous years under the policy no look back to be applied.
This period of five years is called as moratorium period. The moratorium would be
applicable for the sums insured of the first policy and subsequently completion of five
continuous years would be applicable from date of enhancement of sums insured
only on the enhanced limits. After the expiry of Moratorium Period no health insurance
claim shall be contestable except for proven fraud and permanent exclusions
specified in the policy contract. The policies would however be subject to all limits,
sub limits, co-payments, deductibles as per the policy contract..

13. Possibility of Revision of Terms of the Policy Including the Premium Rates
The Company may revise or modify the terms of the Policy including the premium
rates. The Insured Person shall be notified three months before the changes are
effected.

14. Free look period

The Free Look Period shall be applicable on new individual health insurance policies
and not on renewals or at the time of porting/migrating the policy.
The insured person shall be allowed free look period of thirty days from date of receipt
of the policy document, whether received electronically or otherwise, to review the
terms and conditions of the policy, and to return the same if not acceptable.
If the insured has not made any claim during the Free Look Period, the insured shall
be entitled to a refund of the premium paid subject to deduction of proportionate risk
premium for the period of cover and the expenses, if any, incurred by Us on medical
examination of the proposer and stamp duty charges.

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15. Redressal of Grievance

At TATA AIG, we strive to provide the best service to our customers. If you’re not
satisfied and wish to lodge a complaint, please call our 24/7 toll-free number 1800-
266-7780 or 022-66939500 (toll charges apply), or email us at
customersupport@tataaig.com. We will investigate and respond within the
regulatory turnaround time (TAT).

Escalation Level 1
If you do not receive a response or are not satisfied with the resolution, please contact
us at manager.customersupport@tataaig.com.

Escalation Level 2
If you still need assistance, reach out to the Head of Customer Services at
head.customerservices@tataaig.com. We will provide our final response within the
regulatory TAT.
If you're still not satisfied after this process, you may approach the Insurance
Ombudsman of concerned jurisdiction.
You can also lodge a grievance on the Bima Bharosa Grievance Redressal Portal:
https://bimabharosa.irdai.gov. in
The name and address of the Insurance Ombudsman of competent jurisdiction is
provided under Annexure A of this Policy.

16. Nomination
The policyholder is required at the inception of the policy to make a 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 company in
writing and such change shall be effective only when an endorsement on the policy
is made. In the event of death of the policyholder, the Company will pay the nominee
{as named in the Policy Schedule /Endorsement (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 final discharge of its liability under the
policy.

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ii. Specific terms and clauses (terms and clauses other than those mentioned
under Section 4 (i) above)

17. Premium Payment

i. Premium to be paid for the Policy Period before Policy Commencement date as opted
by You in the proposal form.
ii. If you have opted to pay premium in full (lumpsum) upfront then the entire premium for
the policy period shall be paid before the policy commencement date with an option of
policy tenure 1/2/3 years.
iii. Long term premium discount of 5% and 10% is applicable for policy with tenure of 2 and
3 years respectively.

18. Insured Person

i. Only those persons named as an Insured Person in the Schedule shall be covered
under this Policy.
ii. Any person may be added during the Policy Period after his application has been
accepted by Us, additional premium has been paid and We have issued an
endorsement confirming the addition of such person as an Insured Person.
iii. We will be offering continuous renewal with no exit age subject to regular premium
payment and compliance with all provisions and terms & conditions of this policy by the
Insured Person.

19. Loadings
i. We may apply a risk loading on the premium payable (based upon the declarations
made in the proposal form and the health status of the persons proposed for insurance).
ii. The maximum risk loading applicable for an individual shall not exceed 100% of
premium per diagnosis / medical condition and an overall risk loading of over 150% of
premium per person.
iii. The loading shall only be applied basis an outcome of Our medical underwriting.
iv. These loadings are applied from Commencement Date of the Policy including
subsequent renewal(s) with Us or on the receipt of the request of increase in Sum
Insured (for the increased Sum Insured).
a. We will inform You about the applicable risk loading through a counter offer letter.
b. You need to revert to Us with consent and additional premium (if any), within 15
days of the issuance of such counter offer letter.

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c. In case, you neither accept the counter offer nor revert to Us within 15
days, We shall cancel Your application and refund the premium paid within next
10 days subject to deduction of the Pre-Policy Check up charges, as applicable.
v. Please note that We will issue Policy only after getting Your consent.

20. Entire Contract

i. This Policy, its Schedule, endorsement(s), proposal constitutes the entire contract of
insurance. No change in this policy shall be valid unless approved by Us and such
approval be endorsed hereon.
ii. This Policy and the Schedule shall be read together as one contract and any word or
expression to which a specific meaning has been attached in any part of this Policy
or of the Schedule shall bear such meaning wherever it may appear.

21. Change of Policyholder

i. The change of Policyholder is permitted only at the time of renewal.

ii. If the Insured Person is no longer eligible on grounds of age or dependency, the insured
member will be eligible to apply for a new policy and enjoy continuity benefits upto Sum
Insured.

22. Notices

i. Any notice, direction or instruction under this Policy shall be in writing and if it is to:
a. Any Insured Person, then it shall be sent to You at Your address specified in the
Schedule to this Policy and You shall act for all Insured Persons for these
purposes.
b. Us, it shall be delivered to Our address specified in the Schedule to this Policy.
No insurance agents, brokers or other person or entity is authorised to receive
any notice, direction or instruction on Our behalf unless We have expressly
stated to the contrary in writing.

23. Premium Payment Zone

For the purpose of premium computation, the country is divided into following three
Zones and premium payable under the policy will be computed based on the

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residential location/address as provided by the proposer/insured person in the
proposal form:

i. Zone A: Mumbai (including Mumbai Metropolitan Region), Delhi (including

National Capital Region, Faridabad, Ghaziabad), Ahmedabad, Surat &
Baroda
ii. Zone B: Hyderabad (including Secunderabad), Bengaluru, Kolkata, Indore,
Chennai, Chandigarh (including, Mohali, Punchkula, Zirakpur), Pune
(including Pimpri Chinchwad) and Rajkot
iii. Zone C: Rest of India

Please note that the above-mentioned categorization of zones is subject to change

at Our sole discretion. Any such change made which shall impact an existing
policyholder, shall be intimated under 3 months’ notice and shall be applicable from
the immediate next renewal.

24. Premium Refund in case of demise of the Insured Person

The coverage for the Insured Person(s) shall automatically terminate in case of his/ her
(Insured Person) demise. However, the cover shall continue for the remaining Insured
Persons till the end of Policy Period. The other insured persons may also apply to renew
the policy. In case, the other insured person is minor, the policy shall be renewed only
through any one of his/her natural guardian or guardian appointed by court. All relevant
particulars in respect of such person (including his/her relationship with the insured
person) must be submitted to the company along with the application. Provided no claim
has been made, and termination takes place on account of death of the insured person,
pro-rata refund of premium of the deceased insured person for the balance period of
the policy will be made.

Refund will be made to the Policy holder or the nominee in case of demise of the Policy
holder. We would require death certificate of the Deceased Insured Person for
processing of the refund amount.

Section 5 – Claims Procedure and Claims Payment

This section explains about the procedures involved to file a valid claim by the insured
member and processes related in managing the claim by TPA or Us. All the procedures and

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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

Procedure: informed:

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

2 If any treatment for which a claim may Within 24 hours of the Insured
be made and that treatment requires Person’s admission to Hospital.
emergency Hospitalisation

*TPA as mentioned in the policy schedule, if any

2. Cashless Service

Treatment, Treatment, Cashless We must be given

Consultation or Consultation or Service is notice that the
Procedure: Procedure Taken Available: Insured Person
at: wishes to take
advantage of the
cashless service
accompanied by
full particulars:

If any planned Network Hospital We will provide At least 48 hours

treatment, cashless service before the
consultation or by making planned treatment
procedure for payment to the or Hospitalisation
which a claim may extent of Our
be made: liability directly to
the Network
Hospital.

If any treatment, Network Hospital We will provide Within 24 hours

consultation or cashless service after the treatment
procedure for by making or Hospitalisation
which a claim may payment to the

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be made, extent of Our
requiring liability directly to
emergency the Network
hospitalisation Hospital.

3. Procedure for Cashless Service

i. Cashless Service is only available at Network Hospitals.
ii. In order to avail of cashless treatment, the following procedure must be followed by
You:
a. Prior to taking treatment and/or incurring Medical Expenses at a Network Hospital,
You must notify our designated TPA/Us and request pre-authorization.
b. For any emergency Hospitalisation, our designated TPA/We must be informed no
later than 24 hours of the start of Your hospitalization/ treatment.
c. For any planned hospitalization, our designated TPA/We must be informed atleast
48 hours prior to the start of your hospitalization/treatment.
d. Our designated TPA/We will check your coverage as per the eligibility and send
an authorization letter to the provider. You have to provide the ID card issued to
You along with any other information or documentation that is requested by the
TPA/Us to the Network Hospital.
e. In case of deficiency in the documents sent to TPA/Us for cashless authorization
or the ailment /treatment is not covered under the policy, the same shall be
communicated to the Hospital/You by TPA/Us.
f. In case the ailment /treatment is not covered under the policy or cashless is
rejected due to insufficient documents submitted, a rejection letter would be sent
to the Hospital/You by TPA/Us.
g. We/TPA will respond within TAT as prescribed by the Regulator under the Master
Circular on IRDAI (Insurance Products) Regulations 2024- Health Insurance Ref:
IRDAI/HLT/CIR/PRO/84/5/ 2024 and its subsequent amendments thereof.
h. Rejection of cashless in no way indicates rejection of the claim. You are required
to submit the claim along with required documents for us to decide on the
admissibility of the claim.
i. If the cashless is approved, the original bills and evidence of treatment in respect
of the same shall be left with the Network Hospital.
j. Pre-authorization does not guarantee that all costs and expenses will be covered.
We reserve the right to review each claim for Medical Expenses and accordingly
coverage will be determined according to the terms and conditions of this Policy.

4. Supporting Documentation & Examination

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i. We or Our TPA may require documentation, medical records and
information to establish the circumstances of the claim, its quantum or Our liability for
the claim within 15 days or earlier of Our request or the Insured Person’s discharge
from Hospitalization or completion of treatment.
ii. In case the delay is at Your end, failure to furnish such evidence 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 within such time.
iii. We may accept claims where documents have been provided after a delayed interval
only in special circumstances and for the reasons beyond the control of the Insured
Person.
iv. Such documentation will include the following:
a. Our claim form, duly completed and signed for on behalf of the Insured
Person.We, upon receipt of a notice of claim, will furnish Your representative with
such forms as We may require for filing proofs of loss or you may download the
claim form from our Web site.
b. Original Bills (pharmacy purchase bill, consultation bill, diagnostic bill) and any
attachments thereto like receipts or prescriptions in support of any amount
claimed which will then become Our property.
c. All medical reports, case histories, investigation reports, indoor case papers/
treatment papers (in reimbursement cases, if available), discharge summaries.
d. A precise diagnosis of the treatment for which a claim is made.
e. A detailed list of the individual medical services and treatments provided and a
unit price for each in case not available in the submitted hospital bill.
f. Prescriptions that name the Insured Person and in the case of drugs: the drugs
prescribed, their price and a receipt for payment. In case of pre/post
hospitalization claim Prescriptions must be submitted with the corresponding
Doctor/hospital invoice.
g. All pre and post investigation, treatment and follow up (consultation) records
pertaining to the present ailment for which claim is being made, if and where
applicable.
h. Treating doctor’s certificate regarding missing information in case histories e.g.
Circumstance of injury and Alcohol or drug influence at the time of accident, if
available
i. Copy of settlement letter from other insurance company or TPA
j. Stickers and invoice of implants used during surgery
k. Copy of MLC (Medico legal case) records, if carried out and FIR (First information
report) if registered, in case of claims arising out of an accident and available with
the claimant.
l. Regulatory requirements as amended from time to time, currently mandatory
NEFT (to enable direct credit of claim amount in bank account) and KYC (recent
ID/Address proof and photograph) requirements
m. Legal heir/succession certificate, if required

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n. PM report (wherever applicable)
o. The company reserves the right to call for additional documents wherever
required.
v. Note: In case You are claiming for the same event under an indemnity-based Policy
with Us and with another Insurer and are required to submit the original documents
related to Your treatment with that particular Insurer, then We will require the attested
copies of such documents along with a declaration from the particular Insurer
specifying the availability of the original copies of the specified treatment documents
with it.
We at our own expense, shall have the right and opportunity to examine insured persons
through Our Authorised Medical Practitioner whose details will be notified to insured person
when and as often as We may reasonably require during the pendency of a claim hereunder.
5. Claims Payment

i. We shall be under no obligation to make any payment under this Policy unless We have
received all premium payments in full in time and We have been provided with the
documentation and information We or Our TPA has requested to establish the
circumstances of the claim, its quantum or Our liability for it, and unless the Insured
Person has complied with his obligations under this Policy.
ii. This Policy only covers claims incurred within India (except in case of benefit B13-
Global cover for Planned Hospitalization, wherever applicable), and payments under
this Policy shall only be made in Indian Rupees within India.
iii. Medical Expenses incurred for AYUSH treatment shall be assessed only under
benefit B8 of this policy and shall be admissible only if incurred within India.
iv. The benefits/services/claims offered/payable under this policy including but not
limited to Section B10, B32 & B33 can be availed within India only.

6. Claim procedure and management of Wellness Services & Wellness Program

(Section B32 & B33)

i. Utilise Wellness Points:

Utilisation of Wellness points is only available at network service providers. To avail

products or services, Insured Person must visit our Customer application and buy the
required product/ services. On successful purchase, an amount equivalent to the
monetary value of the Earned Wellness points will be deducted from Your policy.

ii. Avail services under Benefits:

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Services are only available at network. To avail the same, following procedure
must be followed:

• Teleconsultation:
Insured person can gain access to tele/video/digital consultation with a general
physician/ specialist/psychiatrist, using our digital customer application.

• Ambulance booking facility:

Insured person can use our digital customer application to book an ambulance. This
service will be offered on best effort basis and does not have a legal binding on us.

• Emergency - Help me feature:

In case of an emergency, insured person can use Our Customer application to alert
designated caregiver, at a push of a button. An alert message will be sent to the
designated caregiver, informing him/her about the emergency. By opting this feature,
the insured person authorizes us/our empanelled service provider to share their geo-
location with the designated caregiver.
This service will be offered on best effort basis and does not have a legal binding on
us.

iii. Supporting Documentation & Examination

Insured Person or someone booking services on Your behalf shall provide Us with
identification documentation, medical records and information. We may request to
establish the circumstances of the claim.

Your claim will be processed including cashless and final bill authorization as
prescribed by the Regulator under the Master Circular on IRDAI (Insurance Products)
Regulations 2024- Health Insurance Ref: IRDAI/HLT/CIR/PRO/84/5/ 2024 and its
subsequent amendments thereof.

Section 6 - Dispute Resolution

1. Dispute Resolution Clause

Any and all disputes or differences under or in relation to this Policy shall be
determined by the Indian Courts and subject to Indian law.

Annexure A
NAMES OF OMBUDSMAN AND ADDRESSES OF OMBUDSMAN CENTRES

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

Sr.No Centre Address & Contact Jurisdiction of

. Office Union
Territory, District
1 AHMEDABAD Office of the Insurance Gujarat, Dadra &
Ombudsman, Nagar Haveli,
Jeevan Prakash Building, 6th floor, Daman and Diu
Tilak Marg, Relief Road,
AHMEDABAD – 380 001.
Tel.: 079 - 25501201/02/05/06
Email:
bimalokpal.ahmedabad@cioins.co.i
n

2 BENGALURU Office of the Insurance Karnataka

Ombudsman,
Jeevan Soudha Building,PID No. 57-
27-N-19
Ground Floor, 19/19, 24th Main
Road,
JP Nagar, Ist Phase, Bengaluru – 560
078.
Tel.: 080 - 26652048 / 26652049
Email:
bimalokpal.bengaluru@cioins.co.in
3 BHOPAL Office of the Insurance Madhya
Ombudsman, Pradesh,
1st floor,"Jeevan Shikha", Chhattisgarh
60-B,Hoshangabad Road, Opp.
Gayatri Mandir,
Bhopal – 462 011.
Tel.: 0755 - 2769201 / 2769202
Email:
bimalokpal.bhopal@cioins.co.in
4 BHUBHANESHWA Office of the Insurance Odisha
R Ombudsman,
62, Forest park,
Bhubaneswar – 751 009.
Tel.: 0674 - 2596461 /2596455
Email:
bimalokpal.bhubaneswar@cioins.c
o.in

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5 CHANDIGARH Office Of The Insurance Punjab, Haryana
Ombudsman, (excluding
Jeevan Deep Building SCO 20-27, Gurugram,
Ground Floor Sector- 17 A, Faridabad,
Chandigarh – 160 017. Sonepat and
Tel.: 0172 - 4646394 / 2706468 Bahadurgarh),
Email: Himachal
bimalokpal.chandigarh@cioins.co.i Pradesh, Union
n Territories of
Jammu &
Kashmir,Ladakh
& Chandigarh.
6 CHENNAI Office of the Insurance amil Nadu,
Ombudsman, PuducherryTow
Fatima Akhtar Court, 4th Floor, 453, n and Karaikal
Anna Salai, Teynampet, (which are part
CHENNAI – 600 018. of Puducherry)
Tel.: 044 - 24333668 / 24333678
Email:
bimalokpal.chennai@cioins.co.in
7 DELHI Office of the Insurance Delhi &
Ombudsman, following
2/2 A, Universal Insurance Building, Districts of
Asaf Ali Road, Haryana -
New Delhi – 110 002. Gurugram,
Tel.: 011 - 23237539 Faridabad,
Email: Sonepat &
bimalokpal.delhi@cioins.co.in Bahadurgarh
8 GUWAHATI Office of the Insurance Assam,
Ombudsman, Meghalaya,
Jeevan Nivesh, 5th Floor, Manipur,
Nr. Panbazar over bridge, S.S. Road, Mizoram,
Guwahati – 781001(ASSAM). Arunachal
Tel.: 0361 - 2632204 / 2602205 Pradesh,
Email: Nagaland and
bimalokpal.guwahati@cioins.co.in Tripura
9 HYDERABAD Office of the Insurance Andhra Pradesh,
Ombudsman, Telangana,
6-2-46, 1st floor, "Moin Court", Yanam and part
Lane Opp. Saleem Function Palace, of Union
A. C. Guards, Lakdi-Ka-Pool, Territory of
Hyderabad - 500 004. Puducherry
Tel.: 040 - 23312122
Email:
bimalokpal.hyderabad@cioins.co.in

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10 JAIPUR Office of the Insurance Rajasthan
Ombudsman,
Jeevan Nidhi – II Bldg., Gr. Floor,
Bhawani Singh Marg,
Jaipur - 302 005.
Tel.: 0141- 2740363/2740798
Email:
bimalokpal.jaipur@cioins.co.in
11 KOCHI Office of the Insurance Kerala,
Ombudsman, Lakshadweep,
10th Floor, Jeevan Prakash,LIC Mahe-a part of
Building, Union Territory
Opp to Maharaja's College of Puducherry
Ground,M.G.Road,
Kochi - 682 011.
Tel.: 0484 - 2358759
Email:
bimalokpal.ernakulam@cioins.co.in
12 KOLKATA Office of the Insurance West Bengal,
Ombudsman, Sikkim,
Hindustan Bldg. Annexe, 7th Floor, Andaman &
4, C.R. Avenue, Nicobar Islands
KOLKATA - 700 072.
Tel.: 033 - 22124339 / 22124341
Email:
bimalokpal.kolkata@cioins.co.in
13 LUCKNOW Office of the Insurance Districts of Uttar
Ombudsman, Pradesh :
6th Floor, Jeevan Bhawan, Phase-II, Lalitpur, Jhansi,
Nawal Kishore Road, Hazratganj, Mahoba,
Lucknow - 226 001. Hamirpur,
Tel.: 0522 - 4002082 / 3500613 Banda,
Email: Chitrakoot,
bimalokpal.lucknow@cioins.co.in Allahabad,
Mirzapur,
Sonbhabdra,
Fatehpur,
Pratapgarh,
Jaunpur,Varana
si, Gazipur,
Jalaun, Kanpur,
Lucknow,
Unnao, Sitapur,
Lakhimpur,
Bahraich,
Barabanki,
Raebareli,

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Sravasti, Gonda,
Faizabad,
Amethi,
Kaushambi,
Balrampur,
Basti,
Ambedkarnagar,
Sultanpur,
Maharajgang,
Santkabirnagar,
Azamgarh,
Kushinagar,
Gorkhpur,
Deoria, Mau,
Ghazipur,
Chandauli,
Ballia,
Sidharathnagar
14 MUMBAI Office of the Insurance Goa, Mumbai
Ombudsman, Metropolitan
3rd Floor, Jeevan Seva Annexe, Region
S. V. Road, Santacruz (W), (excluding Navi
Mumbai - 400 054. Mumbai &
Tel.: 022 - 69038800/27/29/31/32/33 Thane)
Email:
bimalokpal.mumbai@cioins.co.in
15 NOIDA Office of the Insurance State of
Ombudsman, Uttarakhand and
Bhagwan Sahai Palace the following
4th Floor, Main Road, Naya Bans, Districts of Uttar
Sector 15, Pradesh: Agra,
Distt: Gautam Buddh Nagar, U.P- Aligarh, Bagpat,
201301. Bareilly, Bijnor,
Tel.: 0120-2514252 / 2514253 Budaun,
Email: Bulandshehar,
bimalokpal.noida@cioins.co.in Etah, Kannauj,
Mainpuri,
Mathura, Meerut,
Moradabad,
Muzaffarnagar,
Oraiyya, Pilibhit,
Etawah,
Farrukhabad,
Firozbad,
Gautam Buddh
nagar,
Ghaziabad,

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Hardoi,
Shahjahanpur,
Hapur, Shamli,
Rampur,
Kashganj,
Sambhal,
Amroha,
Hathras,
Kanshiramnagar
, Saharanpur.

16 PATNA Office of the Insurance Bihar,

Ombudsman, Jharkhand
2nd Floor, Lalit Bhawan,
Bailey Road,
Patna 800 001.
Tel.: 0612-2547068
Email:
bimalokpal.patna@cioins.co.in
17 PUNE Office of the Insurance Maharashtra,
Ombudsman, Areas of Navi
Jeevan Darshan Bldg., 3rd Floor, Mumbai and
C.T.S. No.s. 195 to 198, N.C. Kelkar Thane
Road, (excluding
Narayan Peth, Pune – 411 030. Mumbai
Tel.: 020-24471175 Metropolitan
Email: Region)
bimalokpal.pune@cioins.co.in

Section 64VB of the Insurance Act, 1938 - Commencement of risk cover under the Policy
is subject to receipt of premium by Tata AIG General Insurance Company Limited.

Prohibition of Rebates - Section 41 of the Insurance Act, 1938 as amended by Insurance

Laws (Amendment) Act, 2015.
1. No person shall allow or offer to allow, either directly or indirectly, as an inducement
to any person to take out or renew or continue an insurance in respect of any kind of
risk relating to lives or property in India, any rebate of the whole or part of the
commission payable or any rebate of the premium shown on the policy, nor shall any
person taking out or renewing or continuing a policy accept any rebate, except such
rebate as may be allowed in accordance with the published prospectuses or tables
of the insurer.
2. Any person making default in complying with the provisions of this section shall be
liable for a penalty which may extend to ten lakh rupees.

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Tata AIG General Insurance Company Limited

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 (For Senior Citizens)

Email:customersupport@tataaig.com Website: www.tataaig.com IRDA of India Registration

No: 108

CIN: U85110MH2000PLC128425

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