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Policy Wordings

The TATA AIG MediCare Premier policy provides insurance coverage for medically necessary treatments during the insured period, subject to terms and conditions outlined in the policy. Coverage is based on the sum insured as specified in the policy schedule, and the policy is contingent upon the receipt of premium payments. Key definitions and terms related to the policy, including types of treatments and conditions for coverage, are detailed to clarify the scope and limitations of the insurance provided.

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59 views60 pages

Policy Wordings

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TATA AIG MediCare Premier

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.

TATA AIG General Insurance Company Limited

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 (including Modern Treatment Methods and Advancement in
Technologies), 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 out treatment procedures and
medical or surgical/para-surgical interventions or both under the supervision of registered AYUSH
TATA AIG General Insurance Company Limited
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 • TATA AIG MediCare Premier UIN: TATHLIP26052V052526
Page 2 of 60
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/installment premium due date, when the premium due for renewal on a given policy or
installment 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 conditions, are directly
made to the network provider by the insurer to the extent pre-authorization is approved.
TATA AIG General Insurance Company Limited
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 • TATA AIG MediCare Premier UIN: TATHLIP26052V052526
Page 3 of 60
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

TATA AIG General Insurance Company Limited

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. Emergency Care

Emergency care means management for an Illness or Injury which results in symptoms which occur
suddenly and unexpectedly, and requires immediate care by a medical practitioner to prevent death or
serious long term impairment of the Insured person's health.

16. 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.

17. 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;
TATA AIG General Insurance Company Limited
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 • TATA AIG MediCare Premier UIN: TATHLIP26052V052526
Page 5 of 60
18. 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.

19. 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

20. 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.

21. 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.

22. Maternity expenses

Maternity expenses means;

TATA AIG General Insurance Company Limited

23. Medical Advice

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

24. 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.

25. 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.

26. 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.

TATA AIG General Insurance Company Limited

28. 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).

29. New Born Baby

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

30. 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

31. 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.

32. 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.

33. 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

TATA AIG General Insurance Company Limited

34. 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.

35. 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

36. 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.

37. 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.

38. 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.

39. Room Rent

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

TATA AIG General Insurance Company Limited

41. 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. Modern Treatment Methods and Advancement in Technologies

The following Procedures shall be considered for Modern Treatment Methods and Advancement in
Technologies:

A. Uterine Artery Embolization and HIFU

B. Balloon Sinuplasty
C. Deep Brain stimulation
D. Oral chemotherapy
E. Immunotherapy-Monoclonal Antibody to be given as injection
F. Intra vitreal injections
G. Robotic surgeries
H. Stereotactic radiosurgeries
I. Bronchical Thermoplasty
J. Vaporisation of the prostrate (Green laser treatment or holmium laser treatment)
K. IONM - (Intra Operative Neuro Monitoring)
L. Stem cell therapy: Hematopoietic stem cells for bone marrow transplant for haematological
conditions to be covered.

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

TATA AIG General Insurance Company Limited

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

6. 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

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

8. Zone(s)
For the purpose of premium computation, the country is divided into following three Zones and
premium payable under this Policy will be computed based on the Zone as applicable for the ‘Address’
of the proposer/ Insured Person:

• Zone A: Mumbai (including Mumbai Metropolitan Region), Delhi (including National Capital
Region, Faridabad, Ghaziabad), Ahmedabad, Surat, Baroda and Hisar
• Zone B: Hyderabad (including Secunderabad), Sangareddy, Bengaluru, Kolkata (including
Kolkata Metropolitan Area, Howrah, Hoogly), Indore, Gwalior, Chennai, Chandigarh (including,
Mohali, Punchkula, Zirakpur), Pune (including Pimpri Chinchwad), Rajkot, Gandhinagar, Patan,
Mahesana, Sabarkantha, Banaskantha, Junagadh, Navsari, Kheda, Arvalli, Mahisagar, and
Surendranagar
• Zone C: Rest of India

Here ‘Address’ implies the place where the person ordinarily resides. In case proposed prospect(s) reside
at multiple addresses, then address of the person residing in the highest Zone will be considered.

TATA AIG General Insurance Company Limited

Section 2 – Benefits

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

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

TATA AIG General Insurance Company Limited

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.

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.
TATA AIG General Insurance Company Limited
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 • TATA AIG MediCare Premier UIN: TATHLIP26052V052526
Page 13 of 60
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:
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.

TATA AIG General Insurance Company Limited

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

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

At the request of the Insured Person, We/Our empanelled service provider will arrange for a Preventive
Health Check-up upto 1% of policy sum insured subject to a maximum limit as specified in the table
TATA AIG General Insurance Company Limited
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 • TATA AIG MediCare Premier UIN: TATHLIP26052V052526
Page 15 of 60
below. The limit is the maximum per policy in case of floater policy and per insured person in case of
individual policy. The health check-ups shall be arranged by Us on cashless basis at Our empanelled
service providers or at Insured Person’s residence, as per availability.

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 No Claim 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.

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 No Claim Bonus.
TATA AIG General Insurance Company Limited
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 • TATA AIG MediCare Premier UIN: TATHLIP26052V052526
Page 16 of 60
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
(Consumables Benefit)’ 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 (Consumables Benefit) 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)

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

TATA AIG General Insurance Company Limited

Only the balance basic sum insured along with No Claim 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:

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.

TATA AIG General Insurance Company Limited

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:

Basic Sum Insured Vaccines covered

Up to Rs. 50 Lacs Without any waiting period:

- 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

TATA AIG General Insurance Company Limited

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 No Claim 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 No Claim 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 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 No Claim 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.

TATA AIG General Insurance Company Limited

B20. Second Opinion

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 3 years of continuous coverage under this policy .

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 Crore A maximum of upto Rs 1,00,000/-. In case of birth of a girl 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:

TATA AIG General Insurance Company Limited

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.

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 No Claim Bonus.

B25. High End Diagnostics

TATA AIG General Insurance Company Limited

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 No Claim 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.

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 No Claim 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:
TATA AIG General Insurance Company Limited
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 • TATA AIG MediCare Premier UIN: TATHLIP26052V052526
Page 23 of 60
- 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 No Claim 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.

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 No Claim Bonus.

TATA AIG General Insurance Company Limited

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. No Claim Bonus

Under this section, the below mentioned ‘No claim Bonus’ options will be available as opted and
specified in the Policy Schedule.

Either of the two options is to be selected:

1) Cumulative Bonus
i. 50% cumulative bonus will be applied on the Sum Insured of the expiring Policy, on each
Renewal 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.
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.

2) Discount in Renewal Premium (No Claim Bonus)

TATA AIG General Insurance Company Limited

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:

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)

TATA AIG General Insurance Company Limited

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.

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.
TATA AIG General Insurance Company Limited
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 • TATA AIG MediCare Premier UIN: TATHLIP26052V052526
Page 27 of 60
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.

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.
TATA AIG General Insurance Company Limited
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 • TATA AIG MediCare Premier UIN: TATHLIP26052V052526
Page 28 of 60
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 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.
TATA AIG General Insurance Company Limited
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 • TATA AIG MediCare Premier UIN: TATHLIP26052V052526
Page 29 of 60
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.

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

TATA AIG General Insurance Company Limited

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 Healthy Day 10 7 5

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 301st 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.
− 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:

TATA AIG General Insurance Company Limited

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

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 policy 1
Net Premium paid (without Tax) 15,702
Wellness Category (post Health Risk Assessment) Green

Healthy Day Wellness Wellness Wellness Reward Wellness Reward valid up to

Reward Reward credited after 365 days (provided the
earned converted to Healthy Day policy is active and insured
(per day) Monetary is covered)
Value
(per day)
1 to 300 day 10 15.702 Date of credit of 365 days from the Date of
Wellness score credit of Wellness score

TATA AIG General Insurance Company Limited

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

•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 in force 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

TATA AIG General Insurance Company Limited

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 • TATA AIG MediCare Premier UIN: TATHLIP26052V052526
Page 33 of 60
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, 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 No Claim 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.
TATA AIG General Insurance Company Limited
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 • TATA AIG MediCare Premier UIN: TATHLIP26052V052526
Page 34 of 60
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

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. All the waiting periods shall be applicable individually for each
Insured Person.

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.

TATA AIG General Insurance Company Limited

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

I. Tumors, Cysts, polyps including breast lumps (benign) (Arbud, Granthi, including arbud in
Sthana)
II. Polycystic ovarian disease (garbhashaya granthi), Fibromyoma {Aartav dushti (Sowmya
arbudham)}, Adenomyosis, Endometriosis (Udavarthani yoni vyaazpt)
III. Prolapsed Uterus (Yoni bhramsha)
IV. Gout and Rheumatism, (Vaathraktha and Aamvaat / Aadhya vata), Rheumatoid arthritis,
Non-infective arthritis (Sandhi shool {Dhatukshay janya or Avrodhjanya, both, Sandhigata
vata, Vata roga})
V. Ligament, Tendon or Meniscal tear (Sira, kandara, maamsgat vaat janya shool, sandhi shola)
VI. Prolapsed Inter-Vertebral Disc (Katishool, Greevashool, Grudhrasi vata) and Spinal Diseases
including spondylitis/spondylosis unless arising from Accident
VII. Cholelithiasis (yakrut roga)
VIII. Pancreatitis
IX. Fissure/fistula in anus, haemorrhoids, pilonidal sinus (Arsha, Parikartika, bhagandar,
gudagat vranshoth, nadi vrana)
X. Ulcer & erosion of stomach & duodenum
XI. Gastro Esophageal Reflux Disorder (GERD) (Parinamshool, annadravakhya shool, Amlapitta,
Grahani)
XII. Liver Cirrhosis
XIII. Perineal Abscesses (bhagandhara)
XIV. Perianal / Anal Abscesses
XV. Calculus diseases of Urogenital system Example: Kidney stone, Urinary bladder stone
(Ashmari of all types)
XVI. Benign Hyperplasia of prostate (Asththila vruddhi)
XVII. Varicocele (Vruddhi, Vrushanshoth)
XVIII. Cataract (avrana Shukla), Retinal detachment, Glaucoma (abhishyandha)
XIX. Congenital Internal Diseases
XX. Osteoarthritis and osteoporosis (Asthikshay/ asti gata vata)
XXI. Systemic connective tissue disorders, inflammatory polyarthropathies

TATA AIG General Insurance Company Limited

XXII. Adenoidectomy
XXIII. Mastoidectomy
XXIV. Tonsillectomy
XXV. Tympanoplasty
XXVI. Surgery for nasal septum deviation and Nasal concha resection
XXVII. Surgery for Turbinate hypertrophy
XXVIII. Hysterectomy
XXIX. Joint replacement (for example: Knee replacement, Hip replacement)
XXX. Cholecystectomy
XXXI. Hernioplasty or Herniorraphy
XXXII. Surgery/procedure for Benign prostate enlargement
XXXIII. Surgery for Hydrocele/ Rectocele/Spermatocele
XXXIV. Surgery of varicose veins and varicose ulcers
XXXV. Obesity / Weight control procedures including Gastric bypass surgeries

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. 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.

TATA AIG General Insurance Company Limited

iii. Obesity/ Weight Control (Code – Excl 06)

Expenses related to surgical treatment of obesity that does not fulfil the below conditions:
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

iv. 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

v. 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.

vi. Treatment for, Alcoholism, drug or substance abuse or any addictive condition and consequences
thereof .(Code - Excl12)
vii. 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)

TATA AIG General Insurance Company Limited

x. Sterility and infertility (Code-Excl17).

Expenses related to Sterility and infertility. 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
xi. Maternity (Code - Excl18):
a. Medical treatment expenses traceable to childbirth (including complicated deliveries
and caesarean sections incurred during hospitalization) except ectopic pregnancy;
b. Expenses towards miscarriage (unless due to an accident) and lawful medical
termination of pregnancy during the policy period

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 .

TATA AIG General Insurance Company Limited

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
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 form of Non-Allopathic treatment (except AYUSH Benefit), Hydrotherapy, Acupuncture,
Reflexology, Chiropractic treatment or any other form of indigenous system of medicine.
xi. 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. Nuclear, chemical or biological attack or weapons, contributed to, caused by, resulting from or
from any other cause or event contributing concurrently or in any other sequence to the loss,
claim or expense. For the purpose of this exclusion:
• Nuclear attack or weapons means the use of any nuclear weapon or device or waste or
combustion of nuclear fuel or the emission, discharge, dispersal, release or escape of
fissile/ fusion material emitting a level of radioactivity capable of causing any Illness,
incapacitating disablement or death

• Chemical attack or weapons means the emission, discharge, dispersal, release or escape
of any solid, liquid or gaseous chemical compound which, when suitably distributed, is
capable of causing any Illness, incapacitating disablement or death.
TATA AIG General Insurance Company Limited
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 • TATA AIG MediCare Premier UIN: TATHLIP26052V052526
Page 40 of 60
• Biological attack or weapons means the emission, discharge, dispersal, release or escape
of any pathogenic (disease producing) micro-organisms and/or biologically produced
toxins (including genetically modified organisms and chemically synthesized toxins)
which are capable of causing any Illness, incapacitating disablement or death.
iii. Any Insured Person’s participation or involvement in naval, military or air force operation,
iv. Intentional self-injury or attempted suicide while sane or insane.
v. 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
vi. Treatment rendered by a Medical Practitioner which is outside his discipline
vii. 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.
viii. Provision or fitting of hearing aids, spectacles or contact lenses including optometric therapy
unless explicitly stated and covered in the policy,
ix. Any treatment and associated expenses for alopecia, baldness, wigs, or toupees, medical
supplies including elastic stockings, diabetic test strips, and similar products.
x. 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.
xi. 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).
xii. 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.
xiii. If the Insured Person is under the influence of intoxicating liquor or drugs or other intoxicants,
except where the Insured Person is not directly responsible for the injury/accident though under
influence of intoxication.
xiv. Expenses which are either not supported by a prescription of a Medical Practitioner or are not
related to Illness or disease for which claim is admissible under the Policy.

Section 4 – General Terms and Clauses

i. Standard General Terms and Clauses

TATA AIG General Insurance Company Limited

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 15 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 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.

TATA AIG General Insurance Company Limited

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
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

TATA AIG General Insurance Company Limited

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. 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.

II. The Company may cancel the policy at any time on grounds of established fraud,
misrepresentation or non-disclosure of material facts by the Policyholder/ 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 to the
extent of the Sum Insured, No Claim Bonus, Specific Waiting periods, waiting period for pre-
existing diseases, Moratorium period etc. in the previous policy to the migrated policy, as
applicable.

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: IRDAI/HLT/CIR/PRO/84/5/ 2024 dated 29th 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 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 to the extent of the Sum Insured, No Claim Bonus, specific
TATA AIG General Insurance Company Limited
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 • TATA AIG MediCare Premier UIN: TATHLIP26052V052526
Page 44 of 60
waiting periods, waiting period for pre-existing disease , Moratorium period etc from the
Existing Insurer to the Acquiring Insurer in the previous policy, as applicable.

For Detailed Guidelines on Portability, 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: IRDAI/HLT/CIR/PRO/84/5/ 2024 dated 29th May 2024 and their subsequent
amendments thereof.

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 and thirty days in
all other cases (Annual/Half-Yearly/ Quarterly/Limited Premium paying term). .
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 to the extent of Sum Insured, No
Claim Bonus, Specified Waiting Periods, waiting periods for pre-existing diseases,
Moratorium period, as applicable, in the event of payment of premium within the stipulated
grace Period.

vii. No loading shall apply on renewals based on individual claims experience

TATA AIG General Insurance Company Limited

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 insured person shall be provided a free look period of thirty days beginning from the 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.

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/ 1800 22 9966
(For Senior Citizen) or 022-66939500 (toll charges apply), or email us at

TATA AIG General Insurance Company Limited

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(s) {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.

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

TATA AIG General Insurance Company Limited

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 loading shall only be applied basis an outcome of Our medical underwriting.
iii. These loadings are applied from Commencement Date of the Policy including subsequent
renewal(s) with Us and on the applicable sum insured for each Policy Year including increased sum
insured, if any
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.
c. In case, you neither accept the counter offer nor revert to Us within 15 days, We shall
cancel Your application and refund/ release the amount subject to deduction of the Pre-
Policy Check up charges, as applicable.
iv. 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.

TATA AIG General Insurance Company Limited

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
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 three Zones {as mentioned
in Section 1: ii. Specific Definitions. 8. Zone(s)} and the premium payable under this Policy will
be computed based on the residential location/address as provided by the proposer/Insured
Person in the proposal form.
Here ‘Address’ implies the place where the person ordinarily resides. In case proposed
prospect(s) reside at multiple addresses, then address of the person residing in the highest zone
will be considered.

Premium to be received by Company before Policy Commencement.

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
TATA AIG General Insurance Company Limited
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 • TATA AIG MediCare Premier UIN: TATHLIP26052V052526
Page 49 of 60
(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 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 Procedure: We or Our TPA* must be informed:

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

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

*TPA as mentioned in the policy schedule, if any

2. Cashless Service

Treatment, Treatment, Cashless Service is We must be given

Consultation or Consultation or Available: notice that the
Procedure: Procedure Taken at: Insured Person
wishes to take
advantage of the

TATA AIG General Insurance Company Limited

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

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

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

consultation or cashless service by the treatment or
procedure for which a making payment to Hospitalisation
claim may be made, the extent of Our
requiring emergency liability directly to
hospitalisation the Network
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.

TATA AIG General Insurance Company Limited

4. Supporting Documentation & Examination

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.

TATA AIG General Insurance Company Limited

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.

Claim assessment for policies with instalment Premium Payment Mode:

In the event of a claim, all subsequent premium instalments shall immediately become due and
payable.

TATA AIG General Insurance Company Limited

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:

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

TATA AIG General Insurance Company Limited

Annexure A
NAMES OF OMBUDSMAN AND ADDRESSES OF OMBUDSMAN CENTRES

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

Jurisdiction of Office
Sr.No. Centre Address & Contact Union Territory,
District

Office of the Insurance Ombudsman,

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

Office of the Insurance Ombudsman,

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

Office of the Insurance Ombudsman,

1st floor, "Jeevan Shikha",
60-B, Hoshangabad Road, Opp. Gayatri Madhya Pradesh,
3 BHOPAL
Mandir, Arera Hills Chhattisgarh
Bhopal – 462 011.
Tel.: 0755 - 2769201 / 2769202/

TATA AIG General Insurance Company Limited

Office of the Insurance Ombudsman,

62, Forest park,
Bhubaneswar – 751 009.
4 BHUBHANESHWAR Tel.: 0674 - 2596461 /2596455/ Odisha
2596429/ 2596003
Email:
bimalokpal.bhubaneswar@cioins.co.in

Punjab, Haryana
(excluding
Office Of The Insurance Ombudsman,
Gurugram,
Jeevan Deep Building SCO 20-27,
Faridabad, Sonepat
Ground Floor Sector- 17 A,
and Bahadurgarh),
5 CHANDIGARH Chandigarh – 160 017.
Himachal Pradesh,
Tel.: 0172 - 2706468
Union Territories of
Email:
Jammu & Kashmir,
bimalokpal.chandigarh@cioins.co.in
Ladakh &
Chandigarh.

Office of the Insurance Ombudsman,

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

Office of the Insurance Ombudsman,

2/2 A, Universal Insurance Building, Delhi & following
Asaf Ali Road, Districts of Haryana -
7 DELHI New Delhi – 110 002. Gurugram,
Tel.: 011 – 46013992/ 23213504/ Faridabad, Sonepat
23232481 & Bahadurgarh
Email: bimalokpal.delhi@cioins.co.in

Office of the Insurance Ombudsman,

Assam, Meghalaya,
8 GUWAHATI Jeevan Nivesh, 5th Floor,
Manipur, Mizoram,
Near Pan bazar, S.S. Road,
Arunachal Pradesh,
Guwahati – 781001(ASSAM).

TATA AIG General Insurance Company Limited

Office of the Insurance Ombudsman,

6-2-46, 1st floor, "Moin Court",
Lane Opp. Hyundai Showroom, Andhra Pradesh,
A. C. Guards, Lakdi-Ka-Pool, Hyderabad Telangana, Yanam
9 HYDERABAD - 500 004. and part of Union
Tel.: 040 – 23376991 / 23376599 / Territory of
23328709 / 23325325 Puducherry
Email:
bimalokpal.hyderabad@cioins.co.in

Office of the Insurance Ombudsman,

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

Office of the Insurance Ombudsman,

10th Floor, Jeevan Prakash, LIC
Building, Kerala,
Opp to Maharaja's College Ground, Lakshadweep, Mahe-
11 KOCHI M.G.Road, a part of Union
Kochi - 682 011. Territory of
Tel.: 0484 - 2358759 Puducherry
Email:
bimalokpal.ernakulam@cioins.co.in

Office of the Insurance Ombudsman,

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

TATA AIG General Insurance Company Limited

List of wards under

Office of the Insurance Ombudsman, Mumbai
3rd Floor, Jeevan Seva Annexe, Metropolitan Region
S. V. Road, Santacruz (W), excluding wards in
14 MUMBAI Mumbai - 400 054. Mumbai – i.e M/E,
Tel.: 022 - 69038800/27/29/31/32/33 M/W, N , S and T
Email: covered under Office
bimalokpal.mumbai@cioins.co.in of Insurance
Ombudsman Thane

TATA AIG General Insurance Company Limited

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

Office of the Insurance Ombudsman,

2nd Floor, Lalit Bhawan,
Bailey Road,
16 PATNA Bihar, Jharkhand
Patna 800 001.
Tel.: 0612-2547068
Email: bimalokpal.patna@cioins.co.in

Office of the Insurance Ombudsman, State of Goa and

17 PUNE Jeevan Darshan Bldg., 3rd Floor, State of Maharashtra
C.T.S. No.s. 195 to 198, N.C. Kelkar excluding areas of

TATA AIG General Insurance Company Limited

Office of the Insurance Ombudsman,

Area of Navi
2nd Floor, Jeevan Chintamani Building,
Mumbai, Thane
Vasantrao Naik Mahamarg, District, Raigad
18 THANE District, Palghar
Thane (West) District and wards of
Mumbai, M/East,
Thane - 400604
M/West, N, S and T."
Email: bimalokpal.thane@cioins.co.in

For updated list and details of Insurance Ombudsman Offices, please visit
https://www.cioins.co.in/Ombudsman

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.

TATA AIG General Insurance Company Limited

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