CHOMP

Policy Wordings

Preamble

Section A: Definitions

Section B: Dental Treatment Covers

Section C: Value Added Services

Section D: Waiting Period and Exclusions

Section E: Terms & Conditions

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate
Office: 6th Floor, Leela Business Park, Andheri-Kurla Road, Andheri (East), Mumbai – 400 059. Chomp
UIN: HDFHLGP23112V012223
Preamble
We will provide Insurance coverage to the Insured Person(s) under this Policy up to Sum Insured and/or Sub-limits subject
to Terms, Conditions, Exclusions, waiting period, and other limits mentioned on the Schedule of Coverage in the Policy
Schedule/Certificate of Insurance. The Coverage under this Policy is subject to statements of Policyholder and/or Insured
Person(s) in the Proposal form/enrollment form, declaration and/or medical reports, and the terms and conditions of this
Policy.

Disclaimer: The Description mentioned under “In Simple Terms” throughout this Policy is only to aid understanding of the
offered cover. In case of dispute, the Terms and Conditions detailed in the Policy Document shall prevail.

Section A: Definitions

Certain words used in the Coverage description have specific meanings which are mentioned in Definitions and which
impacts the Coverage. All such words, where ever mentioned in this document are mentioned in Bold to enable you to
identify that particular word has a specific meaning for which You need to refer below Definitions

I. Standard Definitions

1. Accident or Accidental means a sudden, unforeseen and involuntary event caused by external, visible and violent
means

2. 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 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.

3. 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 within-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 at least 5 in-patient beds;
ii. Having qualified AYUSH Medical Practitioner in charge round the clock;

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate
Office: 6th Floor, Leela Business Park, Andheri-Kurla Road, Andheri (East), Mumbai – 400 059. Chomp
UIN: HDFHLGP23112V012223
 iii. Having dedicated AYUSH therapy sections as required and/or has equipped operation theatre
where surgical procedures are to be carried out;
iv. Maintaining daily records of the patients and making them accessible to the insurance company’s
authorized representative.
4. Cumulative Bonus means any increase or addition in the Sum Insured granted by the Insurer without an associated
increase in premium.

5. 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. Coverage need not be available during
the period for which no premium is received. The grace period for payment of the premium for all types of
insurance policies shall be: fifteen days where premium payment mode is monthly and thirty days in all other
cases. Provided the insurers shall offer coverage during the grace period, if the premium is paid in
instalments during the policy period (Note: In case of non-instalment premium payment, coverage shall not
be available for the period for which no premium is received).

6. Hospital means any institution established for In-patient Care and Day Care Treatment ofIllness and/or injuries and
which has been registered as a Hospital with the local authorities under the clinical Establishments (Registration and
Regulation) Act, 2010 or under the enactments specified under the Schedule of Section 56(1) of the said Act OR
complies with all minimum criteria as under:
 has at least 10 in-patient beds, in towns having a population of less than 10,00,000 and 15 in-patient beds in
all other places,
 has qualified nursing staff under its employment round the clock,
 has qualified Medical Practitioner(s) in charge round the clock,
 has a fully equipped operation theatre of its own where surgical procedures are carried out,
 maintains daily records of patients and will make these accessible to the insurance company’s authorized
personnel.

7. 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 .

8. Injury means Accidental physical bodily harm excluding Illness or disease solely and directly caused by external, violent
and visible and evident means which is verified and certified by a Dental Medical Practitioner .

9. Inpatient Care means treatment for which the insured person has to stay in a hospital for more than 24 hours for a
covered event.
10. Medically Necessary treatment means any dental treatment, test, medication, or stay in Hospital or part of stay in
Hospital which
 Is required for the medical management of the Dental Illness or Injury or Condition suffered by the Insured
Person;
 Must not exceed the level of care necessary to provide safe, adequate and appropriate medical care in scope,
duration or intensity.
 Must have been prescribed by a Dental Medical Practitioner.
 Must conform to the professional standards widely accepted in international medical practice or by the medical
community in India.

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate
Office: 6th Floor, Leela Business Park, Andheri-Kurla Road, Andheri (East), Mumbai – 400 059. Chomp
UIN: HDFHLGP23112V012223
 11. 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
12. Migration means a facility provided to policyholders (including all members under family cover and group
policies), to transfer the credits gained for pre-existing diseases and specific waiting periods from one health
insurance policy to another with the same insurer.

13. 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.

14. 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

15. We/Our/Us means the HDFC ERGO General Insurance Company Limited
16. You/Your/Insured means the Insured Person/s who has/have purchased Insurance Cover under this Policy; of such
Insured Person/s.

II. Specified Definitions

1. AYUSH Treatment refers to the medical and/or hospitalisation treatments given under Ayurveda, Yoga and
Naturopathy, Unani, Siddha and Homeopathy systems.
2. 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/Health Service Provider or by the insurer to the extent pre-authorization is approved
3. Break in policy means the period of gap that occurs at the end of the existing policy term/insta llment
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.

4. Commencement Date means the date of commencement of insurance coverage under the Policy as specified in the
Policy Schedule/Certificate of Insurance.

5. Dental Clinic means places where dentists provide dental care with no inpatient facilities.

6. Dental hospital means places where dentists provide outpatient dental care with inpatient facilities

7. Dental Medical Expenses means those expenses that an Insured Person has necessarily and actually incurred for
dental treatment on the advice of a Dentist, 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 dental hospitals/dental clinics or dentists in the same locality
would have charged for the same dental treatment.

8. Dentist/Dental Medical Practitioner means a person who is registered with (i) the Dental Council of India, (ii) State
Dental Councils, (iii) Joint State Dental Councils or any other Dental council recognized as per Dentists Act, 1948 and its
subsequent amendments thereof.

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate
Office: 6th Floor, Leela Business Park, Andheri-Kurla Road, Andheri (East), Mumbai – 400 059. Chomp
UIN: HDFHLGP23112V012223
 9. Dental treatment means a medically necessary treatment related to teeth or structures supporting teeth, performed
by a dentist and as mentioned in your Policy Schedule/Certificate of Insurance

10. Dentistry includes—

 the performance of any surgical procedure on, and the treatment on any disease, deficiency or lesion of, human
teeth or jaws, and the performance of radiographic work in connection with human teeth or jaws or the oral
cavity;
 the giving of any anaesthetic in connection with any such operation or treatment;
 the mechanical construction or the renewal of artificial dentures or restorative dental appliances;
 the performance of any surgical procedure on, or the giving of any treatment, advice or attendance to, any person
preparatory to, or for the purpose of, or in connection with, the fitting, inserting, fixing, constructing, repairing or
renewing of artificial dentures or restorative dental appliances, and the performance of any such operation and
the giving of any such treatment, advice or attendance, as is usually performed or given by dentists;

11. Endorsement means a written amendment to the Policy that the Company makes (additions, deletions, modifications,
exclusions or conditions of an insurance Policy) which may change the terms or scope of the original Policy.
12. Family members means any one or more of the following family members of the Insured Person:
i. Legally wedded spouse
ii. Parents and parents-in-law
iii. Dependent Children
iv. Dependent Siblings.

13. Health Service Provider means any person or entity providing dental care services/treatments in individual capacity,
or through an aggregator under “Health Service Provider Agreement”

14. Health Service Provider Agreement means an agreement prescribing the terms and conditions of the services which
may be rendered to the Insured Persons under this Policy, and may be entered into between Health Service Provider
and Us.

15. Insured Person/You means the persons named in the Policy Schedule/Certificate of Insurance
16. Non-instalment Premium Payment refers to payment of premium for the entire policy period made in
advance as a single premium.

17. Policy means Policyholders and Insured Persons statements in the proposal form and Enrolment form, this Policy
wording (including endorsements and Clauses if any), Policy Schedule and Certificate of Insurance (as the same may
be amended from time to time) to which this Policy is attached.

18. Policyholder means Person who has proposed the Policy and in whose name the Policy is issued.

19. Policy Period means the period between the Commencement Date and the Expiry Date specified in the Policy
Schedule/Certificate of Insurance.

20. Policy Schedule means the document accompanying and forming part of the Policy that gives Insured’s details and of
insurance cover, Insured Persons, the Sum Insured, the period and the limits to which benefits under the Policy are
subject to (Schedule of coverage), including any Annexures and/or endorsements, made to or on it from time to time.

21. Pre-existing Dental Condition means any dental condition or injury

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate
Office: 6th Floor, Leela Business Park, Andheri-Kurla Road, Andheri (East), Mumbai – 400 059. Chomp
UIN: HDFHLGP23112V012223
 a) That is/are diagnosed by a dental medical practitioner within 12 months prior to the effective date of the
policy issued by the insurer or its reinstatement , or
b) For which medical advice or treatment was recommended by, or received from, a dental medical practitioner
within 12 months prior to the effective date of the policy issued by the insurer or its reinstatement.

22. Premium means the amount Insured pay the Company for this insurance. The Policy Schedule/Certificate of
Insurance shows the amount of premium for the Policy Period and all other taxes and levies.

23. Sum Insured means the amount shown in the Policy Schedule/Certificate of Insurance which represents Our
maximum liability for each Insured Person for any and all benefits claimed for during the Policy Year

24. Waiting Period means a period from the inception of this Policy during which specified dental treatments are not
covered. On completion of the Waiting Period, dental treatments shall be covered provided the Policy has been
continuously renewed without any break or within the grace period.

III. Simplified Dental Definitions

Dental Terms In Simple Terms

Bridges A fixed prosthesis for missing teeth. Bridges can be supported by natural teeth, implants or a
combination of teeth and implants.
Complete Dentures A complete denture is a removable appliance used when all teeth within a jaw have been lost and
need to be prosthetically replaced. In contrast to a partial denture which have few teeth missing in
the jaw, a complete denture is constructed when there are no more teeth left in an arch or jaw
Crowns A crown is a tooth-shaped cover placed over a tooth that is badly damaged or decayed. A crown is
made to look like and function like a tooth

Curretage A surgical process to treat gum related problems, where the gum is first cleaned to remove
tartar ,then cleaning and removal of inflammation under the gum tissue down to the root of the
teeth from bacterial infections
Cyst Enucleation It means removal or cleaning of the cyst by using laser or excavation method to destroy the further
growth or damage to the underlying structures.
Extraction The removal of a broken or decayed tooth from the socket in the bone.

Filling means a process of dental restoration in which the dentist first removes the decayed tooth material,
cleans the affected area, and then fills the cleaned out cavity with a filling material.
Fracture of Jaws It means discontinuity with joints due to injury or accidents causing the fractures or dislocation of
and Other facial facial bone.
bones
Gingival Flap It is a procedure that gets rid of bacteria living in pockets. During the procedure, a dentist cut
Surgery or Osseous open your gums, removes the bacteria, and repairs damaged bone and grafting to regenerate the
Surgery lost tissue and bone
Gingivectomy or It is a surgical procedure to treat pockets cause by gum disease , remove the diseased tissue and
Gingivoplasty reshape or recontouring the marginal and proximal gingival tissue
OSMF (Oral Excision of Bands cause ddue to irritation due to tobacco or vitamin deficiency casuing difficulty in
Submucous opening the mouth
Fibrosis)
Partial Dentures Partial dentures are dental appliances worn by people who have lost one or more teeth in an area in
the mouth. The replacement teeth are attached to a metal framework or resin frame work covered

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate
Office: 6th Floor, Leela Business Park, Andheri-Kurla Road, Andheri (East), Mumbai – 400 059. Chomp
UIN: HDFHLGP23112V012223
 by a plastic pink base colored to look like the gum tissue along with the attached clasps or rings to
hold
RCT (Root Canal A treatment to remove damaged or diseased tooth pulp. Once removed, the remaining space is
Treatment) cleaned and the tooth is sealed off with the thermoplastic material and closed with permanent
filling.
Space Infections It is when the dental infections spread to the sinus or spaces or lymph nodes causing swelling and
enlargement of lymph nodes causing pain and suffocation.
Temporomandibula It is the surgery of joint which helps in opening, closing of mouth and chewing the food due to
r joint Surgeries lateral movements
(TMJ)
Tumor Excision It means removal of the excessive growth tissue or cancer site removal

Section B: Dental Treatment Covers

We will pay for the Covers opted by Insured/Insured person up to the limits specified on the Schedule of Coverage in the Policy
Schedule/Certificate of Insurance

a) Restorative Treatment Cover

In Simple Terms: Teeth are not capable of self-healing and hence damage caused to teeth due to a chip, crack or cavity
requires treatments like fillings. Under this benefit you will be covered for restorative treatments mentioned below.

If Insured Person undergoes below Dental Treatment(s), during the Policy Period, We will pay Dental Medical Expenses
upto the Sum Insured.

Each payment under the Policy will be subject to per claim payout, number. of claims in a year, network type and Waiting
Period as specified on the Schedule of Coverage in the Policy Schedule/Certificate of Insurance

What is Covered? What is not Covered?

1. Fillings of any of the below material type including Pulp  General Exclusions as specified in Section D
Capping will be covered
(a) Silver Amalgam; OR
(b) GIC (Glass Ionomore Cement) Cement; OR
(c) Composite; OR
(d) GIC (Glass Ionomore Cement) Light Cure

b) Periodontal Treatment Cover

In Simple Terms: Gums and bone around your teeth are like the foundation of a house. Just like a house, the foundation
must be strong regardless of the beauty of the home. Similarly, bacterial infections in your gums and supporting structures

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate
Office: 6th Floor, Leela Business Park, Andheri-Kurla Road, Andheri (East), Mumbai – 400 059. Chomp
UIN: HDFHLGP23112V012223
 should be kept at bay to keep that beautiful smile. Under this benefit you will be covered for gum related treatments
mentioned below.

If Insured Person undergoes below Dental Treatment(s), during the Policy Period, We will pay Dental Medical Expenses
upto the Sum Insured.

Each payment under the Policy will be subject to per claim payout, number of claims in a year, network type and Waiting
Period as specified on the Schedule of Coverage in the Policy Schedule/Certificate of Insurance

What is Covered? What is not Covered?

1. Gum Related Treatments mentioned below will be  General Exclusions as specified in Section D
covered-  Curretage treatment followed by an extraction
(a) Curettage – manual or laser which is not claimed under this Policy is not
(b) Gingivectomy or gingivoplasty - manual covered
(c) Gingivectomy for Orthodontic - laser  Cost of Bone Graft is not covered under Gingival
(d) Gingival flap procedure/Osseous surgery (including flap procedure/Osseous surgery
root planning) - manual
(e) Crown Lengthening – manual or laser

c) Endodontic Treatment Cover

In Simple Terms:
Because, there is nothing more painful than a dental bill you did not expect
When you have a toothache, it can make life pretty miserable. Root Canal Treatment is, in short, a treatment for tooth pain
that involves removing the infection from the root which is causing the pain. The cleaned tooth is then protected using a
crown. We can help ease your pain, under this benefit you will be covered for below treatments

If Insured Person undergoes below Dental Treatment(s), during the Policy Period, We will pay Dental Medical Expenses
upto the Sum Insured.

Each payment under the Policy will be subject to per claim payout, number of claims in a year, network type and Waiting
Period as specified on the Schedule of Coverage in the Policy Schedule/Certificate of Insurance

What is Covered? What is not Covered?

1. Root Canal Treatment of below type will be covered  General Exclusions as specified in Section D
– Anterior or Posterior Tooth  Re Root Canal Treatment done on incomplete or
faulty treatment done before the
2. Crowns of below material type will be covered commencement of this Policy will not be covered
– Metal or Ceramic material
 Crowns followed by a Root Canal Treatment
which is not claimed under this Policy will be
excluded
 Repair of Crowning done before commencement
of this Policy or during the Waiting Period will not
be covered

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate
Office: 6th Floor, Leela Business Park, Andheri-Kurla Road, Andheri (East), Mumbai – 400 059. Chomp
UIN: HDFHLGP23112V012223
d) Prosthetic Treatment Cover - Bridges

In Simple Terms:

If any of your teeth are missing or damaged, your dentist may recommend “bridging” the gap to replace that missing
tooth/teeth with a false tooth/teeth. Under this benefit you will be covered for getting your tooth “SUBSTITOOTHED”
(substituted)

If Insured Person undergoes below Dental Treatment(s), during the Policy Period, We will pay Dental Medical Expenses
upto the Sum Insured.

Each payment under the Policy will be subject to per claim payout, number of claims in a year, network type and Waiting
Period as specified on the Schedule of Coverage in the Policy Schedule/Certificate of Insurance

What is Covered? What is not Covered?

Bridges of below material type will be covered General Exclusions as specified in Section D
- Metal or Ceramic Material

e) Prosthetic Treatment Cover – Partial Dentures

In Simple Terms:

If any of your teeth are missing or damaged, your dentist may recommend putting dentures to replace that missing
tooth/teeth with a false tooth/teeth. Under this benefit you will be covered for getting your tooth “SUBSTITOOTHED”

If Insured Person undergoes below Dental Treatment(s), during the Policy Period, We will pay Dental Medical Expenses
upto the Sum Insured.

Each payment under the Policy will be subject to per claim payout, number of claims in a year, network type and Waiting
Period as specified on the Schedule of Coverage in the Policy Schedule/Certificate of Insurance

What is Covered? What is not Covered?

Partial Dentures of below type will be covered-  General Exclusions as specified in Section D
Cast Partial Denture

f) Prosthetic Treatment Cover – Complete Dentures

In Simple Terms:

If any of your teeth are missing or damaged, your dentist may recommend putting dentures to replace that missing
tooth/teeth with a false tooth/teeth. Under this benefit you will be covered for getting your tooth “SUBSTITOOTHED”

If Insured Person undergoes below Dental Treatment(s), during the Policy Period, We will pay Dental Medical Expenses
upto the Sum Insured.

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate
Office: 6th Floor, Leela Business Park, Andheri-Kurla Road, Andheri (East), Mumbai – 400 059. Chomp
UIN: HDFHLGP23112V012223
 Each payment under this Policy will be subject to per claim payout, number of claims in a year, network type and Waiting
Period as specified on the Schedule of Coverage in the Policy Schedule/Certificate of Insurance

What is Covered? What is not Covered?

Complete dentures of below type will be covered-  General Exclusions as specified in Section D
- Indian or Imported Material  Complete Dentures required other than due to
Accidental Injury will not be covered
 Complete Dentures required due to medical
illness or age or degenerative disease will not be
covered

g) Minor Surgical Procedures

In Simple Terms: Under this benefit you will be covered for small operations like removing wisdom teeth, grossly decayed
teeth etc.

If Insured Person undergoes below Dental Treatment(s), during the Policy Period, We will pay Dental Medical Expenses
upto the Sum Insured

Each payment under this Policy will be subject to per claim payout, number of claims in a year, network type and Waiting
Period as specified on the Schedule of Coverage in the Policy Schedule/Certificate of Insurance

What is Covered? What is not Covered?

Minor Surgeries of below type will be covered- General Exclusions as specified in Section D
a) Normal Extraction, or
b) Molar including Soft Tissue Impaction, or
c) Surgical Extraction, or
d) Impaction – completely bony
e) Cyst Enucleation

h) Major Surgeries Cover

In Simple Terms: Under this benefit you will be covered for dental surgeries requiring hospitalization (including In-patient
care AYUSH treatment in an AYUSH Hospital)

If Insured Person undergoes below Dental Treatment(s), during the Policy Period, We will pay Dental Medical Expenses
upto the Sum Insured.

Each payment under this Policy will be subject to per claim payout, number of claims in a year, network type and Waiting
Period as specified on the Schedule of Coverage in the Policy Schedule/Certificate of Insurance

What is Covered? What is not Covered?

Major Surgeries as mentioned below will be covered-  General Exclusions as specified in Section D
 Treatment of listed major surgeries which does

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate
Office: 6th Floor, Leela Business Park, Andheri-Kurla Road, Andheri (East), Mumbai – 400 059. Chomp
UIN: HDFHLGP23112V012223
 a) Fracture of Jaws and Other facial bones not lead to hospitalization will not be covered
b) Tumor Excision  Treatment required as a result of injury caused by
c) Space Infections foodstuffs or foreign bodies while eating, chewing
d) OSMF (Oral Submucous Fibrosis) -Excision of Bands or drinking
e) Temporomandibular joint Surgeries (TMJ)  Treatment of tumors which are malignant will not
be covered

i) Accidental Major Surgeries Cover

In Simple Terms: Under this benefit you will be covered for dental surgeries arising out of an accident and requiring
hospitalization (including In-patient care AYUSH treatment in an AYUSH Hospital)

If Insured Person undergoes below Dental Treatment(s), during the Policy Period, We will pay Dental Medical Expenses
upto the Sum Insured.

Each payment under this Policy will be subject to per claim payout, number of claims in a year, network type and Waiting
Period as specified on the Schedule of Coverage in the Policy Schedule/Certificate of Insurance

What is Covered? What is not Covered?

Major Surgeries arising as a result of an accidental injury  General Exclusions as specified in Section D
as mentioned below will be covered-  Major Surgeries required other than due to
a) Fracture of Jaws and Other facial bones Accidental Injury will not be covered
b) Temporomandibular joint Surgeries (TMJ)  Treatment of listed accidental major surgeries
which does not lead to hospitalization will not be
covered
 Treatment required as a result of injury caused by
foodstuffs or foreign bodies while eating, chewing
or drinking
 Treatment required as a result of routine body
movements such as stooping, twisting, bending
 Cost of damage to prosthetic devices will not be
covered

Section C: Value Added Services

In Simple Terms:

A stitch in time saves nine!

With these value added services you can get your teeth examined and cleaned that in turn can help you avoid a mouthful of
tooth problems in future

Following value added services are offered to You through Our Health Service Provider subject to number of claims in a year
and Waiting Period as specified on the Schedule of Coverage in the Policy Schedule/Certificate of Insurance. Value added
services taken at a non-listed Health Service Provider will not be covered.

a) Preventive Consultation

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate
Office: 6th Floor, Leela Business Park, Andheri-Kurla Road, Andheri (East), Mumbai – 400 059. Chomp
UIN: HDFHLGP23112V012223
The service provided under this shall include unlimited physical and video dental consultations through Our Health Service
Provider

b) Preventive Investigation
The service provided under this shall include 5 (five) Intraoral Periapical (IOPA) X-ray through Our Health Service Provider

c) Preventive Cleaning
The service provided under this shall include 1 (one) prophylactic cleaning through Our Health Service Provider

Section D: Waiting Periods and Exclusions

In Simple Terms: The time span in months, after the purchase of the policy during which you cannot claim any benefit

I. Specific Waiting Period

a) Waiting Period as specified in Your Policy Schedule/Certificate of Insurance shall apply basis chosen Dental Treatments
b) Waiting Period of 12 months shall apply on Pre-existing dental condition for all Dental Treatments
c) In case of enhancement of sum insured the waiting period shall apply afresh to the extent of sum insured increase.
d) The waiting period for listed conditions shall apply even if contracted after the policy or declared and accepted
without a specific exclusion.
e) No waiting period will be applicable for Accidental Claims

In Simple Terms: To keep things transparent, here is a list of things we don’t cover

II. Standard Permanent Exclusions

We will not pay for any claim which is caused by, arising from or attributable to:

a) 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.

b) 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.

c) 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.

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate
Office: 6th Floor, Leela Business Park, Andheri-Kurla Road, Andheri (East), Mumbai – 400 059. Chomp
UIN: HDFHLGP23112V012223
 d) Treatment for, Alcoholism, drug or substance abuse or any addictive condition and consequences thereof. Code-
Excl12

e) Unproven Treatments: Code- Excl16

Expenses related to any unproven treatment, services and supplies for or in connection with any treatment. Unproven
treatments are treatments, procedures or supplies that lack significant medical documentation to support their
effectiveness.

III. Specific Permanent Exclusions

a) Claims arising during waiting period as specified in Your Policy Schedule/Certificate of Insurance

b) Any claim related to a dental treatment for which Medical Advice or treatment was recommended by a Dental
Medical Practitioner 12 months before Policy Period

c) 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, radiation of any kind

d) Any Insured Person committing or attempting to commit a breach of law with criminal intent, or intentional self-injury
or attempted suicide or suicide while mentally sound or unsound.

e) Any Insured Person’s participation or involvement in naval, military or air force operation, racing, diving, aviation,
scuba diving, parachuting, hang-gliding, rock or mountain climbing of a professional or semi-professional nature.

f) Congenital external diseases, defects or anomalies,

g) Treatment rendered by unlicensed Dental Medical Practitioner

h) Treatments rendered by a Dental Medical Practitioner who is a member of an Insured Person's family, or stays with
him.

i) dental consumables, including but not limited to toothbrushes, toothpaste, mouthwash and dental floss

j) Costs for any treatment required due to the actions of a third party, whether accidental or not, where in the capacity
of their work the third party should have professional indemnity insurance to meet any costs for which they are liable

k) Any treatment that is in a trial stage, or Treatment using any material, instrument, device, or medical supply that is in a
trial stage or any Treatment not recognized as dental practice by the Ministry of Health or by Dental Council of India or
any competent foreign authority

l) Prescription drugs and medications that need to be taken post treatment

m) Intentional injury by the policy holder to the Insured Person

n) Any treatment or part of a treatment that is not of a Reasonable and Customary charge and is not a Medically
Necessary treatment.

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate
Office: 6th Floor, Leela Business Park, Andheri-Kurla Road, Andheri (East), Mumbai – 400 059. Chomp
UIN: HDFHLGP23112V012223
 o) Any Claim arising due to Non-disclosure of Pre-existing Dental issues or Material fact as sought to be declared on the
Proposal form

p) Any claims arising caused by participating in any contact sport unless you were wearing a protective gum shield at the
time of the accident;

q) Any other dental service or treatment not specifically listed on the Policy Schedule/Certificate of Insurance

r) Any dental treatment which is done for cosmetic purposes only or performed mainly for aesthetic purposes, including
the transformation or extraction and replacement of healthy teeth in order to modify appearance.

s) dental treatment required as a result of tooth or mouth jewellery

t) Any costs for claims arising from pandemics/endemics

u) Treatment of an Injury arising whilst You are engaged in a brawl or fight, or taking part in inciting a brawl or fight.

v) Treatment of an Injury sustained while repairing/ restoring or replacing dental restorations

w) Charges for transportation costs; or professional advice given on the phone (except under Value Added Services)

x) Charges for sterilization of equipment, disposal of medical waste or other requirements mandated by regulatory
agencies and infection control

y) Temporary, transitional or interim dental services or treatments

z) Treatment of insured person who use consume tobacco in any form including but not limited to cigarettes / bidi/ e-
cigarettes/ paan masala/ betel leaf/ gutkha/ khaini and mawa. This exclusion will not be applicable to claims arising
out of accidents.

aa) Treatment of insured person who has undergone for following treatments/conditions/procedure within 12 months
before the policy commencement date

 Fillings/ Replacements of fillings

 Complete/Partial dentures
 Root Canal Treatment/Dental crowns / Inlay/ Onlay
 Gum Treatment
 Bridge/s
 Braces
 Implant/s
 Missing Tooth/Teeth

bb)Claims arising out of any of the following pre-existing diseases or their treatment, complications, recurrence if
diagnosed on or before policy commencement date
 Cancer / Leukemia /Oral Cancer
 Parkinson’s Disease

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate
Office: 6th Floor, Leela Business Park, Andheri-Kurla Road, Andheri (East), Mumbai – 400 059. Chomp
UIN: HDFHLGP23112V012223
  Angina
 Cerebral attack (infarction/ hemorrhage)
 Congenital Dental Deformity /Disorder
 Leukoplakia
 Epilepsy

Section E: Terms & Conditions

1. Standard General Conditions

1.1. Disclosure of Information

The policy shall be void and all premium paid thereon shall be forfeited to the Company in the event of misrepresentation, mis-
description or non-disclosure of any material fact by the Policyholder/Insured Person.

1.2. Condition Precedent to Admission of Liability

The terms and conditions of the policy must be fulfilled by the insured person/policyholder for the Company to make any
payment for claim(s) arising under the policy.

1.3. Claim Settlement (provision for Penal Interest)

a. The Company shall settle or reject a claim, as the case may be, within 15 days from the date of receipt of intimation.
b. 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 intimation to the date of payment of claim at a rate 2% above the bank rate.
In the case of delay in the payment of a claim, the Company shall be liable to pay interest to the Insured Personr from the date
of receipt of last necessary document to the date of payment of claim at a rate 2% above the bank rate.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.In case of
delay beyond stipulated 45 days, the Company shall be liable to pay interest to the Insured Person at a rate 2% above the bank
rate from the date of receipt of last necessary document to the date of payment of claim.

1.4. Complete Discharge

Any payment to the Policyholder, Insured Person or his/ her nominees or his/ her legal representative or assignee or to the
Dental Hospital/ Dental Clinic, 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.

1.5. Multiple Policies

a. In case of multiple policies taken by an Insured Person during a period from one or more insurers to indemnify treatment
costs, the Insured Person shall have the right to require a settlement of his/her claim in terms of any of his/her policies. In
all such cases the Insurer chosen by the Insured Person shall be obliged to settle the claim as long as the claim is within the
limits of and according to the terms of the chosen Policy.
b. Insured Person having multiple policies shall also have the right to prefer claims under this Policy for the amounts
disallowed under any other policy / policies even if the Sum Insured is not exhausted. Then the insurer shall independently
settle the claim subject to the terms and conditions of this Policy.

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate
Office: 6th Floor, Leela Business Park, Andheri-Kurla Road, Andheri (East), Mumbai – 400 059. Chomp
UIN: HDFHLGP23112V012223
c. If the amount to be claimed exceeds the Sum Insured under a single Policy, the Insured Person shall have the right to
choose Insurer from whom he/she wants to claim the balance amount.
d. Where the Insured Person has policies from more than one Insurer to cover the same risk on indemnity basis, the Insured
Person shall only be indemnified the treatment costs in accordance with the terms and conditions of the chosen Policy.

1.6. Moratorium Period

After completion of sixty continuous months of coverage (including portability and migration) in health insurance
policy, no policy and claim shall be contestable by the insurer on grounds of non-disclosure, misrepresentation,
except on grounds of established fraud. This period of sixty continuous months is called as moratorium period. The
moratorium would be applicable for the sums insured of the first policy. Wherever, the sum insured is enhanced,
completion of sixty continuous months would be applicable from the date of enhancement of sums insured only on
the enhanced limits.

1.7. Fraud
If any claim made by the Insured Person/Policyholder, 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/Policyholder 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)/Insured Person(s), who have 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/Policyholder or by his agent or the hospital/doctor/dentist/any other party acting on behalf of the Insured
Person/Policyholder, 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
Policyholder/Insured Person / beneficiary can prove that the mis-statement was true to the best of his knowledge and there
was no deliberate intention to suppress the fact or that such mis-statement of or suppression of material fact are within the
knowledge of the Insurer.

1.8. Free look Period

The insured person shall be allowed free look period of 30 days from date of receipt of the policy document 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. a refund of the premium paid less any expenses incurred by the Company on medical examination of the insured person
and the stamp duty charges or
b. where the risk has already commenced and the option of return of the policy is exercised by the insured person, a
deduction towards the proportionate risk premium for period of cover or
c. Where only a part of the insurance coverage has commenced, such proportionate premium commensurate with the
insurance coverage during such period.

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate
Office: 6th Floor, Leela Business Park, Andheri-Kurla Road, Andheri (East), Mumbai – 400 059. Chomp
UIN: HDFHLGP23112V012223
1.9. Renewal of Policy:

A health insurance policy shall be renewable except on grounds of established fraud or non-disclosure or
misrepresentation by the insured, provided the policy is not withdrawn and also subject to conditions stated under
Moratorium clause.

i. Renewal of a health insurance policy shall not be denied on the ground that the insured had made a
claim or claims in the preceding policy years, except for benefit based policies where the policy
terminates following payment of the benefit covered under the policy like critical illness policies.
ii. The company shall condone a delay in renewal up to the grace period from the due date of renewal
without considering such condonation as a break in policy.
iii. No loading shall apply on renewals based on individual claims experience
iv. The Company shall not resort to fresh underwriting unless there is an increase in sum insured. In case
increase in sum insured is requested by the Policyholder, the Insurer may underwrite only to the extent of
increased sum insured.
v. Renewal premium due can be paid prior to the due date as per norms set out by the Company.

1.10. Cancellation

The Policyholder may cancel this policy by giving 7 days’ written notice and in such an event, the Company shall
refund to the Insured a pro-rata premium for the unexpired Policy Period.

Note : For Policies where premium is paid by instalment : In case of admissible claim under the Policy, future
instalment for the current Policy Year will be adjusted in the claim amount and no refund of any premium will be
applicable during the Policy Year.

a. The Company may cancel the Policy at any time on grounds of established fraud or non-disclosure or
misrepresentation by the Insured Person by giving 15 days’ written notice. There would be no refund of premium
on cancellation on grounds of established fraud or non-disclosure or misrepresentation
b. Refund of Policy premium in case of death of Insured Person/s: Policy premium shall be refunded proportionately
for the deceased Insured Person, for the unexpired Policy Period in case of death of any Insured Person/s
c. Notwithstanding anything contained herein or otherwise, no refunds of premium shall be made in respect of
Cancellation where any claim has been admitted or any benefit has been availed by the Insured Person under
the Policy.

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate
Office: 6th Floor, Leela Business Park, Andheri-Kurla Road, Andheri (East), Mumbai – 400 059. Chomp
UIN: HDFHLGP23112V012223
1.11. Premium Payment in Instalments
If the Policyholder/Insured Person has opted for payment of Premium on an instalment basis i.e. Half Yearly, Quarterly or
Monthly, as mentioned in the Policy Schedule, the following Conditions shall apply (notwithstanding any terms contrary
elsewhere in the Policy):

a. Grace Period as mentioned in the table below would be given to pay the instalment premium due for the Policy

Options Instalment Premium Option Grace Period applicable

Option 1 Multi-Year / Yearly 30 days

Option 2 Half Yearly 30 days

Option 3 Quarterly 30 days

Option 4 Monthly 15 Days

b. If premium is paid in instalments then coverage will be available during the grace period also. (Note: In case of
non-instalment premium payment, coverage shall not be available for the period for which no premium is
received).
c. The Insured Person will get the accrued continuity benefit in respect of the “Waiting Periods”, “Specific Waiting Periods” in
the event of payment of premium within the stipulated Grace Period
d. No interest will be charged If the instalment premium is not paid on due date
e. In case of instalment premium due not received within the Grace Period, the Policy will get cancelled
f. In the event of a claim, all subsequent premium instalments shall immediately become due and payable
g. The Company has the right to recover and deduct all the pending instalments from the claim amount due under the
policy.

1.12. Instalment Premium payment through Auto Debit/ECS Facility

a. If premium payment is opted for by instalments through auto debit/ECS facility, a separate authorization form shall be
submitted by Policyholder/Insured Person specifying the frequency chosen for premium to be debited.
b. Where there is a change either in the terms and conditions of the coverage or Policy or in the premium rate, the ECS
authorization shall be obtained afresh.
c. The Policyholder/Insured Person has the option to withdraw from the ECS mode at least fifteen days prior to the due date
of instalment premium payable.
d. No additional charges will be levied or recovered in any manner from the benefits payable towards cancellation of the ECS
mode.

1.13. Possibility of Revision of terms of the Policy including the Premium Rates
The Company, with prior approval of IRDAI, 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.

1.14. Withdrawal of Policy

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

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate
Office: 6th Floor, Leela Business Park, Andheri-Kurla Road, Andheri (East), Mumbai – 400 059. Chomp
UIN: HDFHLGP23112V012223
1.15. Nomination
The Insured Person is required at the inception of the Policy to make a nomination for the purpose of payment of claims under
the Policy in the event of death of the Policyholder. Any change of nomination shall be communicated to the Company in
writing and such change shall be effective only when an endorsement on the Policy is made. In the event of death of the
Policyholder, the Company will pay the nominee {as named in the Policy Schedule/Policy Certificate/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.

1.16. Redressal of Grievance

In case of any grievance the insured person may contact the Company through:
 Website: www.hdfcergo.com
 Contact Us: 022 6234 6234 / 0120 6234 6234
 Contact Details for Senior Citizen: 022 – 6242 – 6226 | seniorcitizen@hdfcergo.com
 E-mail: grievance@hdfcergo.com

Insured Person may also approach the grievance cell at any of the Company’s branches with the details of grievance.
If Insured Person is not satisfied with the redressal of grievance through one of the above methods, Insured Person may
contact the grievance officerat cgo@hdfcergo.com

For updated details of grievance officer, kindly refer the link: https://www.hdfcergo.com/customer-voice/grievances

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate
Office: 6th Floor, Leela Business Park, Andheri-Kurla Road, Andheri (East), Mumbai – 400 059. Chomp
UIN: HDFHLGP23112V012223
 Contact Points First Contact Point Escalation level 1 Escalation level 2
https://
www.hdfcergo.com/ https://www.hdfcergo.com/ https://www.hdfcergo.com/
customer-care/ customer-care/grievances/ customer-care/grievances/
grievances escalation level 1 escalation level 2
Contact us at
Call - : 022 6234 Call - : 022 6234 6234 / 0120 Call - : 022 6234 6234 / 0120
6234 / 0120 6234 6234 6234 6234 6234
6234

https:// https://www.hdfcergo.com/ https://www.hdfcergo.com/

www.hdfcergo.com/ customer-care/grievances customer-care/grievances
customer-care/ Call - : 022 – 6242 – 6226 Call - : 022 – 6242 – 6226
Contact Point for grievances Email - Email -
Senior Citizen Call - : 022 – 6242 – seniorcitizen@hdfcergo.com seniorcitizen@hdfcergo.com
6226
Email -
seniorcitizen@hdfcer
go.com

Write to us at care@hdfcergo.com grievance@hdfcergo.com cgo@hdfcergo.com

The Grievance Cell, The Chief Grievance Officer,
HDFC ERGO General Insurance Registered &
Company Ltd., Corporate Office: HDFC House, 1st
Grievance cell of any of D-301, 3rd Floor, Floor,
Visit us
our Branch office Eastern Business District (Magnet 165-166 Backbay Reclamation, H.
Mall), T. Parekh
LBS Marg, Bhandup (West) Marg, Churchgate, Mumbai –
Mumbai-400078 400020

If Insured Person is not satisfied with the redressal of grievance through above methods, the Insured Person may also
approach the office of Insurance Ombudsman of the respective area/region for redressal of grievance as per Insurance
Ombudsman Rules 2017. Grievance may also be lodged at IRDAI Integrated Grievance Management System -
https://bimabharosa.irdai.gov.in/.
Latest contact details of Offices of Insurance Ombudsman are provided at Annexure A.

2. Specific General Conditions

A. In the event of any difference of opinion between our dentist and your dentist, our dentist’s opinion shall prevail

B. If there are treatment materials and methods recognized by the company as being similar or equivalent to the above
dental materials, the treatment methods will also be compensated.

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate
Office: 6th Floor, Leela Business Park, Andheri-Kurla Road, Andheri (East), Mumbai – 400 059. Chomp
UIN: HDFHLGP23112V012223
C. Geography
This Policy provides coverage throughout the territory of India

D. Endorsements
This Policy constitutes the complete contract of insurance. This Policy cannot be modified by anyone (including an
insurance agent or broker) except the Company. Any change or modification that the Company makes will be evidenced by
a written endorsement signed and stamped by the Company.
E. Communication & Notice
Policy and any communication related to the Policy shall be sent to through electronic modes or to the address of the
following:
a. The Policyholder’s, at the address/ e-mail address specified in the Policy Schedule.
b. To the Company, at the address specified in the Policy Schedule.
c. Insurance agents, brokers, other person or entity is/are not authorized to receive any notice on the behalf of
the Company, unless stated in writing by the Company.

F. Claim Procedure
On the occurrence of any event that may give rise to a Claim under this Policy, the Claims Procedure set out below shall be
followed.

i. Claims through Health Service Provider

Insured Person will have to follow below steps to avail claim through Our Health Service Provider for covered benefits.

Visit our Portal at www.hdfcergo.com or mobile application through link provided in the certificate or on the website. for
notification of claim and booking an appointment for dental treatment.

Applicable for all benefits except “Major Surgeries” cover and “Accidental Major Surgeries” cover.

ii. Claims other than Health Service Provider

a) Notification of a Claim
Notice with full particulars shall be sent to the Company as under:
 Within 24 hours from the date of emergency Hospitalization required or before the Insured Person’s
discharge from Hospital, whichever is earlier.
 At least 48 hours prior to admission in Hospital in case of a planned Hospitalization.
b) Cashless Claims
1) Procedure for Cashless Claims
 Treatment may be taken in a Network Provider and is subject to pre authorization by the Company.
 Cashless request form is available with the Network Provider.
 The Network Provider shall obtain the relevant information from the Insured Person / Policyholder and send a
Cashless Facility request to the Company for authorization.
 The Company upon getting cashless request form and related medical information from the Insured Person/
Network Provider shall issue pre-authorization letter to the Network Provider after verification.
 At the time of discharge, the Insured Person shall verify and sign the discharge papers along with final bill, pay
for non-medical and inadmissible expenses.
 The Company reserves the right to deny pre-authorization in case the Insured Person is unable to provide the
relevant medical details.

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate
Office: 6th Floor, Leela Business Park, Andheri-Kurla Road, Andheri (East), Mumbai – 400 059. Chomp
UIN: HDFHLGP23112V012223
 2) Conditions for obtaining Cashless facility for Hospitalization claims
i. Applicable only for “Major Surgeries” cover and “Accidental Major Surgeries” cover
ii. Cashless facility can be availed only at Our Network Provider. The complete list of Network Providers is
available on Our website and can be obtained by contacting Us.
iii. We reserve the right to modify, add or restrict any Network Provider for Cashless Facilities at Our sole
discretion. The same shall be duly updated on Our website. You shall check the updated list of Network
Providers before applying for Cashless Claim.
iv. Pre-authorization is valid for 15 days from date of issuance and if all the details of the Dental treatment,
including dates, Hospital and locations match with the details as per Cashless authorized.
v. We will make payment for the Cashless authorized amount directly to the Network Provider.
vi. If the claim is not notified to Us within the specified time limits, then We shall be provided the reasons for the
delay in writing. We will condone such delay on merits where the delay has been proved to be for reasons
beyond the claimant’s control.
c) Reimbursement Claims
Procedure for Reimbursement claims
For reimbursement of claims, the Insured Person shall submit the necessary documents to the Company within 30
days of date of discharge from the Hospital

iii. List of documents required for a Claim

1. Duly completed and signed claim form

2. Photo ID and Age Proof
3. Policy Number
4. KYC document, if claim amount is more than 1 Lakh
5. Name of the Insured Person(s) named in the Policy Schedule/Certificate of insurance availing treatment
6. Name and address of the attending Dental Medical Practitioner/Hospital
7. MLC / FIR Copy – in Accident cases only
8. History of alcohol consumption or any intoxication certified by first treating doctor in case of Accident cases,
9. Pre and Post Procedure Dental X-rays and Photographs (wherever applicable)
10. NEFT details & cancelled cheque of Claimant or Nominee (in case claimant expired), Provide legal heir certificate
in case nominee is minor.
11. Legal heir/succession certificate, wherever applicable
12. Any other relevant document required by Company for assessment of the claim
13. For Hospitalization claims, additional documents required
 Copy of the Hospital’s Registration Certificate/Hospital Registration number in case of Hospitalization in
any non-Network Provider of the Company or certificate from Hospital authorities providing facilities
available including number of beds
 Discharge Card / Day Care Summary / Transfer Summary
 Final Hospital bill with all original deposit and final payment receipt and refund receipt(s), if advance
amount refunded
 All previous consultation papers indicating history and treatment details for current Illness and advice for
current Hospitalization

Note:

 The Company shall only accept bills/invoices/medical treatment related documents only in the Insured
Person’s name for whom the claim is submitted.

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate
Office: 6th Floor, Leela Business Park, Andheri-Kurla Road, Andheri (East), Mumbai – 400 059. Chomp
UIN: HDFHLGP23112V012223
  In the event of a claim lodged under the Policy and the original documents having been submitted to any
other insurer, the Company shall accept the copy of the documents and claim settlement advice, duly
certified by the other insurer subject to satisfaction of the Company.
 If requested by the Company, at the Company’s cost, the Insured Person must submit to medical
examination by Medical Practitioner appointed by the Company as often as it is considered reasonable
and necessary and Company’s representatives must be permitted to inspect the medical and
Hospitalization records pertaining to the Insured Person’s treatment, and to investigate the
circumstances pertaining to the claim.
Any delay in notification or submission may be condoned on merit where delay is proved to be for reasons beyond the
control of the Insured Person.

We reserve the right to modify, add or restrict any Network Provider/Health Service Provider for Cashless facility at Our
sole discretion. We will make payment for the Cashless authorized amount directly to the Health Service Provider.
In no event shall HDFC ERGO be liable for any direct, indirect, punitive, incidental, special consequential damages or any
other damages whatsoever caused to the Policyholder/Insured of HDFC ERGO while receiving the services from Health
Service Provider

Contact Us

For any claim related query, intimation of claim and submission of claim related documents, You can contact HDFC ERGO
General Insurance Limited through:

Customer Service No. 022-62346234 /0120- 62346234

Claim Intimation:
Email: healthclaims@hdfcergo.com

Claim document submission HDFC ERGO General Insurance Co. Ltd.

at address Stellar IT Park, Tower-1, 5th Floor, C - 25, Noida, Sector 62, 201301,
Uttar Pradesh

Ombudsman Details

NAMES OF OMBUDSMAN AND ADDRESSES OF OMBUDSMAN CENTRES

S.No Office Details Jurisdiction of Office (Union Territory,District)

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate
Office: 6th Floor, Leela Business Park, Andheri-Kurla Road, Andheri (East), Mumbai – 400 059. Chomp
UIN: HDFHLGP23112V012223
 AHMEDABAD
Insurance Ombudsman
Office of the Insurance Ombudsman,
Jeevan Prakash Building, 6th floor,
1 Tilak Marg, Relief Road, Gujarat, Dadra & Nagar Haveli, Daman and Diu.
AHMEDABAD – 380 001.
Tel.: 079 - 25501201/02
Email: bimalokpal.ahmedabad@cioins.co.in

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

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

Email : bimalokpal.bhopal@cioins.co.in

4 BHUBANESWAR Odisha.
Insurance Ombudsman
Office of the Insurance Ombudsman,
62, Forest park,
Bhubaneswar – 751 009.
Tel.: 0674 - 2596461 /2596455
Email: bimalokpal.bhubaneswar@cioins.co.in

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

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

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate
Office: 6th Floor, Leela Business Park, Andheri-Kurla Road, Andheri (East), Mumbai – 400 059. Chomp
UIN: HDFHLGP23112V012223
 DELHI
Insurance Ombudsman
Office of the Insurance Ombudsman,
2/2 A, Universal Insurance Building,
Delhi & following Districts of Haryana - Gurugram,
7 Asaf Ali Road,
Faridabad, Sonepat & Bahadurgarh.
New Delhi – 110 002.
Tel.: 011 - 23237539
Email: bimalokpal.delhi@cioins.co.in

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

HYDERABAD
Insurance Ombudsman
Office of the Insurance Ombudsman,
6-2-46, 1st floor, "Moin Court",
Lane Opp. Saleem Function Palace, Andhra Pradesh, Telangana, Yanam and part of
9
A. C. Guards, Lakdi-Ka-Pool, Hyderabad - 500 Union Territory of Puducherry.
004.
Tel.: 040 - 23312122
Email: bimalokpal.hyderabad@cioins.co.in

JAIPUR
Insurance Ombudsman
Office of the Insurance Ombudsman,
Jeevan Nidhi – II Bldg., Gr. Floor,
10 Bhawani Singh Marg, Rajasthan.
Jaipur - 302 005.
Tel.: 0141- 2740363/2740798
Email: bimalokpal.jaipur@cioins.co.in

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

KOLKATA
Insurance Ombudsman
Office of the Insurance Ombudsman,
12 West Bengal, Sikkim, Andaman & Nicobar Islands.
Hindustan Bldg. Annexe, 7th Floor,
4, C.R. Avenue,
KOLKATA - 700 072.

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate
Office: 6th Floor, Leela Business Park, Andheri-Kurla Road, Andheri (East), Mumbai – 400 059. Chomp
UIN: HDFHLGP23112V012223
 Tel.: 033 - 22124339 / 22124341
Email: bimalokpal.kolkata@cioins.co.in

Districts of Uttar Pradesh : Lalitpur, Jhansi,

LUCKNOW Mahoba, Hamirpur, Banda, Chitrakoot, Allahabad,
Insurance Ombudsman Mirzapur, Sonbhabdra, Fatehpur, Pratapgarh,
Office of the Insurance Ombudsman, Jaunpur,Varanasi, Gazipur, Jalaun, Kanpur,
6th Floor, Jeevan Bhawan, Phase-II, Lucknow, Unnao, Sitapur, Lakhimpur, Bahraich,
13 Nawal Kishore Road, Hazratganj, Barabanki, Raebareli, Sravasti, Gonda, Faizabad,
Lucknow - 226 001. Amethi, Kaushambi, Balrampur, Basti,
Tel.: 0522 - 4002082 / 3500613 Ambedkarnagar, Sultanpur, Maharajgang,
Email: bimalokpal.lucknow@cioins.co.in Santkabirnagar, Azamgarh, Kushinagar, Gorkhpur,
Deoria, Mau, Ghazipur, Chandauli, Ballia,
Sidharathnagar.
MUMBAI
Insurance Ombudsman
Office of the Insurance Ombudsman,
3rd Floor, Jeevan Seva Annexe,
Goa, Mumbai Metropolitan Region (excluding Navi
14 S. V. Road, Santacruz (W),
Mumbai & Thane).
Mumbai - 400 054.
Tel.: 022 - 69038800/27/29/31/32/33
Email: bimalokpal.mumbai@cioins.co.in

NOIDA State of Uttarakhand and the following Districts of

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

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

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

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate
Office: 6th Floor, Leela Business Park, Andheri-Kurla Road, Andheri (East), Mumbai – 400 059. Chomp
UIN: HDFHLGP23112V012223
 Annexure I –

List I – Items for which coverage is not available in the policy

S. No. Item S. No. Item

OXYGEN CYLINDER (FOR USAGE OUTSIDE THE

1 BABY FOOD 35
HOSPITAL)

2 BABY UTILITIES CHARGES 36 SPACER

3 BEAUTY SERVICES 37 SPIROMETRE

4 BELTS/ BRACES 38 NEBULIZER KIT

5 BUDS 39 STEAM INHALER

6 COLD PACK/HOT PACK 40 ARMSLING

7 CARRY BAGS 41 THERMOMETER

8 EMAIL / INTERNET CHARGES 42 CERVICAL COLLAR

FOOD CHARGES (OTHER THAN PATIENT'S

9 43 SPLINT
DIET PROVIDED BY HOSPITAL)

10 LEGGINGS 44 DIABETIC FOOT WEAR

11 LAUNDRY CHARGES 45 KNEE BRACES (LONG/ SHORT/ HINGED)

12 MINERAL WATER 46 KNEE IMMOBILIZER/SHOULDER IMMOBILIZER

13 SANITARY PAD 47 LUMBO SACRAL BELT

14 TELEPHONE CHARGES 48 NIMBUS BED OR WATER OR AIR BED CHARGES

15 GUEST SERVICES 49 AMBULANCE COLLAR

16 CREPE BANDAGE 50 AMBULANCE EQUIPMENT

17 DIAPER OF ANY TYPE 51 ABDOMINAL BINDER

PRIVATE NURSES CHARGES- SPECIAL NURSING

18 EYELET COLLAR 52
CHARGES

19 SLINGS 53 SUGAR FREE TABLETS

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate
Office: 6th Floor, Leela Business Park, Andheri-Kurla Road, Andheri (East), Mumbai – 400 059. Chomp
UIN: HDFHLGP23112V012223
 CREAMS POWDERS LOTIONS (TOILETRIES ARE NOT
BLOOD GROUPING AND CROSS MATCHING
20 54 PAYABLE, ONLY PRESCRIBED MEDICAL
OF DONORS SAMPLES
PHARMACEUTICALS PAYABLE)

SERVICE CHARGES WHERE NURSING CHARGE

21 55 ECG ELECTRODES
ALSO CHARGED

22 TELEVISION CHARGES 56 GLOVES

23 SURCHARGES 57 NEBULISATION KIT

ANY KIT WITH NO DETAILS MENTIONED [DELIVERY

24 ATTENDANT CHARGES 58
KIT, ORTHOKIT, RECOVERY KIT, ETC]

EXTRA DIET OF PATIENT (OTHER THAN THAT

25 59 KIDNEY TRAY
WHICH FORMS PART OF BED CHARGE)

26 BIRTH CERTIFICATE 60 MASK

27 CERTIFICATE CHARGES 61 OUNCE GLASS

28 COURIER CHARGES 62 OXYGEN MASK

29 CONVEYANCE CHARGES 63 PELVIC TRACTION BELT

30 MEDICAL CERTIFICATE 64 PAN CAN

31 MEDICAL RECORDS 65 TROLLY COVER

32 PHOTOCOPIES CHARGES 66 UROMETER, URINE JUG

33 MORTUARY CHARGES 67 AMBULANCE

34 WALKING AIDS CHARGES 68 VASOFIX SAFETY

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate
Office: 6th Floor, Leela Business Park, Andheri-Kurla Road, Andheri (East), Mumbai – 400 059. Chomp
UIN: HDFHLGP23112V012223
 List II – Items that are to be subsumed into Room Charges

Sl No Item
1 BABY CHARGES (UNLESS SPECIFIED/INDICATED)
2 HAND WASH
3 SHOE COVER
4 CAPS
5 CRADLE CHARGES
6 COMB
7 EAU-DE-COLOGNE / ROOM FRESHNERS
8 FOOT COVER
9 GOWN
10 SLIPPERS
11 TISSUE PAPER
12 TOOTH PASTE
13 TOOTH BRUSH

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate
Office: 6th Floor, Leela Business Park, Andheri-Kurla Road, Andheri (East), Mumbai – 400 059. Chomp
UIN: HDFHLGP23112V012223
 14 BED PAN
15 FACE MASK
16 FLEXI MASK
17 HAND HOLDER
18 SPUTUM CUP
19 DISINFECTANT LOTIONS
20 LUXURY TAX
21 HVAC
22 HOUSE KEEPING CHARGES
23 AIR CONDITIONER CHARGES
24 IM IV INJECTION CHARGES
25 CLEAN SHEET
26 BLANKET/WARMER BLANKET
27 ADMISSION KIT
28 DIABETIC CHART CHARGES
29 DOCUMENTATION CHARGES / ADMINISTRATIVE
EXPENSES
30 DISCHARGE PROCEDURE CHARGES
31 DAILY CHART CHARGES
32 ENTRANCE PASS / VISITORS PASS CHARGES
33 EXPENSES RELATED TO PRESCRIPTION ON DISCHARGE
34 FILE OPENING CHARGES
35 INCIDENTAL EXPENSES / MISC. CHARGES (NOT EXPLAINED)
36 PATIENT IDENTIFICATION BAND / NAME TAG
37 PULSEOXYMETER CHARGES

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate
Office: 6th Floor, Leela Business Park, Andheri-Kurla Road, Andheri (East), Mumbai – 400 059. Chomp
UIN: HDFHLGP23112V012223
 List III – Items that are to be subsumed into Procedure Charges

Sl No. Item
1 HAIR REMOVAL CREAM
2 DISPOSABLES RAZORS CHARGES (for site preparations)
3 EYE PAD
4 EYE SHEILD
5 CAMERA COVER
6 DVD, CD CHARGES
7 GAUSE SOFT
8 GAUZE
9 WARD AND THEATRE BOOKING CHARGES
10 ARTHROSCOPY AND ENDOSCOPY INSTRUMENTS
11 MICROSCOPE COVER
12 SURGICAL BLADES, HARMONICSCALPEL,SHAVER
13 SURGICAL DRILL
14 EYE KIT
15 EYE DRAPE
16 X-RAY FILM
17 BOYLES APPARATUS CHARGES
18 COTTON
19 COTTON BANDAGE
20 SURGICAL TAPE

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate
Office: 6th Floor, Leela Business Park, Andheri-Kurla Road, Andheri (East), Mumbai – 400 059. Chomp
UIN: HDFHLGP23112V012223
 21 APRON
22 TORNIQUET
23 ORTHOBUNDLE, GYNAEC BUNDLE

List IV – Items that are to be subsumed into costs of treatment

Sl No. Item
1 ADMISSION/REGISTRATION CHARGES
2 HOSPITALISATION FOR EVALUATION/ DIAGNOSTIC
PURPOSE
3 URINE CONTAINER
4 BLOOD RESERVATION CHARGES AND ANTE NATAL
BOOKING CHARGES
5 BIPAP MACHINE
6 CPAP/ CAPD EQUIPMENTS
7 INFUSION PUMP– COST
8 HYDROGEN PEROXIDE\SPIRIT\ DISINFECTANTS ETC
9 NUTRITION PLANNING CHARGES - DIETICIAN
CHARGES- DIET CHARGES
10 HIV KIT

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate
Office: 6th Floor, Leela Business Park, Andheri-Kurla Road, Andheri (East), Mumbai – 400 059. Chomp
UIN: HDFHLGP23112V012223
 11 ANTISEPTIC MOUTHWASH
12 LOZENGES
13 MOUTH PAINT
14 VACCINATION CHARGES
15 ALCOHOL SWABES
16 SCRUB SOLUTION/STERILLIUM
17 Glucometer& Strips
18 URINE BAG

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate
Office: 6th Floor, Leela Business Park, Andheri-Kurla Road, Andheri (East), Mumbai – 400 059. Chomp
UIN: HDFHLGP23112V012223