Premium Rates / Chart :

Premium will be loaded by 10% for new entrants.

Terms & Conditions :

1. ENTIRE CONTRACT: The policy, proposal form, prospectus and declaration given by the insured shall constitute the complete contract of insurance. Only insurer may alter the terms and conditions of this policy / contract. Any alteration that may be made by the insurer shall only be evidenced by a duly signed and sealed endorsement on the policy.

2. COMMUNICATION: Every notice or communication to be given or made under this policy shall be delivered in writing at the address of the policy issuing office / Third Party Administrator as shown in the Schedule.

3. PAYMENT OF PREMIUM: The premium payable under this policy shall be paid in advance. No receipt for premium shall be valid except on the official form of the Company signed by a duly authorized official of the company. The due payment of premium and the observance and fulfillment of the terms, provisions, conditions and endorsements of this policy by the Insured Person in so far as they relate to anything to be done or complied with by the Insured Person shall be condition precedent to any liability of the Company to make any payment under this policy. No waiver of any terms, provisions, conditions and endorsements of this policy shall be valid, unless made in writing and signed by an authorized official of the Company.

4. The policy shall be deemed to be void ab-inito (since its inception) if the payment instrument is dishonoured for any reasons whatsoever and under this circumstance the Company shall not admit any liability whatsoever under this policy.

5. NOTICE OF CLAIM: Immediate notice of claim with particulars relating to Policy Number, ID Card No., Name of insured person in respect of whom claim is made, Nature of disease / illness / injury and Name and Address of the attending medical practitioner / Hospital/ Nursing Home etc. should be given to the Company / TPA while taking treatment in the Hospital / Nursing Home by Fax, Email. Such notice should be given within 48 hours of admission or before discharge from Hospital / Nursing Home, whichever is earlier, unless waived in writing by the Company.

6. CLAIM DOCUMENTS: Final claim along with hospital receipted original Bills/ Cash memos / reports, claim form and list of documents as listed below should be submitted to the Company / TPA within 7 (seven) days of discharge from the Hospital / Nursing Home.

1.  Original bills, receipts and discharge certificate / card from the hospital.
2.  Medical history of the patient recorded by the Hospital.
3. Original Cash-memo from the hospital (s) / chemist (s) supported by proper  prescription.
4. Original receipt, pathological and other test reports from a pathologist /  radiologist including film etc supported by the note from attending medical  practitioner / surgeon demanding such tests.
5. Attending Consultants / Anaesthetists / Specialist certificates regarding  diagnosis and bill / receipts etc.
6. Surgeon’s original certificate stating diagnosis and nature of operation  performed along with bills / receipts etc.
7.  Any other information required by TPA / Insurance Company.

All documents must be duly attested by the insured person.

In case of post hospitalisation treatment (limited to 60 days) all supporting claim papers / documents are listed above should also be submitted within 7 (seven) days after completion of such treatment (upto 60 days or actual period which ever is less) to the Company / T.P.A. In addition insured should also provide the Company / TPA such additional information and assistance as the Company / TPA may require in dealing with the claim.

NOTE: Waiver of the condition may be considered in extreme cases of hardship where it is proved to the satisfaction of the Company that under the circumstances in which the insured was placed it was not possible for him or any other person on behalf of the insured to give such notice or file claim within the prescribed time limit. Otherwise Company / TPA has a right to reject the claim.

7. PROCEDURE FOR AVAILING CASHLESS ACCESS  SERVICES IN NETWORK HOSPITAL / NURSING HOME:

1. Claim in respect of Cashless Access Services shall be through the TPA provided admission is in a listed hospital in the agreed list of the networked Hospitals / Nursing Homes and is subject to pre admission authorization. The TPA shall, upon getting the related medical details / relevant information from the insured person / network Hospital / Nursing Home, verify that the person is eligible to claim under the policy and after satisfying itself shall issue a pre-authorisation letter / guarantee of payment letter to the Hospital / Nursing Home mentioning the sum guaranteed as payable, also the ailment for which the person is seeking to be admitted as in- patient.
2. The TPA reserves the right to deny pre-authorisation in case the hospital / insured person is unable to provide the relevant information / medical details as required by the TPA. In such circumstances denial of Cashless Access should in no way be construed as denial of claim and /or deficiency of service. The insured person may obtain the treatment as per his / her treating doctor’s advice and later on submit the full claim papers to the TPA for reimbursement within 7 days of the discharge from Hospital / Nursing Home.
3. In case any information available to the TPA / Company which makes the claim inadmissible or doubtful requiring investigations, the authorisation of cashless facility shall be withdrawn. However this shall be done by the TPA before the patient is discharged from the Hospital.

8. NON ADMISSION OF CLAIM:

1. (I): Where the policy is being serviced by TPA, it shall repudiate the claim if not covered / not payable under the policy. The TPA shall mention the reasons for repudiation in writing to the insured person. The insured person may approach the policy issuing office of the Company for any grievance relating to the claim. The Company’s decision in this regard shall be final and binding on TPA.

1. (II): Where the policy is serviced by the Company and in case of repudiation of the claim, insured may approach the concerned Regional Office of the Company for redressal of any grievance relating to the claim.
2. In case claim is repudiated by the Company as per A (1) & A (II) the insured person may approach the Chief Manager Grievance Cell of the Company’s Regd. Office situated at A-25/27, Asaf Ali Road, New Delhi-110002.
3. The Central Government has established office of the Insurance Ombudsman for redressal of grievances and the insured may approach the Insurance Ombudsman for redressal of his grievance. The insured may visit the site of http://www.ombudsmanindia.org/ for details.

9. Any medical practitioner authorized by the TPA/ Company shall be allowed to examine the Insured Person with / without prior notice in case of any alleged injury of Disease requiring Hospitalisation when and so often as the same may reasonable be required on behalf of the TPA / Company.

10. FRAUD / MISREPRESENTATION / CONCEALMENT: The Company shall not be liable to make any payment under this policy in respect of any claim, if such claim be in any manner (intentionally or recklessly or otherwise) misrepresented or concealed or involve any non disclosure of material facts or making false statements or submitting fake bills whether by the Insured Person or Institution / Organization on his behalf. Such action shall render this policy null and void and all claims hereunder shall be forfeited. Company may take suitable legal action against the Insured Person / Institution / Organization as per Law.

11. CONTRIBUTION: If at the time when any claim arises under this policy, there is in existence any other insurance (other than Cancer Insurance Policy in collaboration with Indian Cancer Society) whether it be effected by or on behalf of any Insured Person in respect of whom the claim may have arisen covering the same loss, liability, compensation, costs or expenses, the company shall not be liable to pay or contribute more than its rateable proportion of any loss, liability, compensation, costs or expenses. The benefits under this policy shall however be in excess of the benefits available under Cancer Insurance Policy.

12. CANCELLATION CLAUSE: Company may at any time, cancel this Policy by sending the Insured 30 days notice be registered letter at the Insured’s last known address and in such an event the Company shall refund to the Insured a pro-rata premium for un-expired Period of Insurance. (such cancellation by the company may be for reasons such as intentional misrepresentation / malicious suppression of facts intended to misleading the insurance company about the acceptability of the proposal, lodging a fraudulent claim and such other intentional acts of the insured / beneficiaries under the policy). The Company shall, however, remain liable for any claim which arose prior to the date of cancellation. The Insured may at any time cancel this policy and in such event the Company shall allow refund of premium at Company’s short period rate only (table given here below) provided no claim has occurred during the policy period up to date of cancellation.

Period on Risk Rate of premium to be charged

• Upto 1 Month 1/4th of the annual rate
• Upto 3 Months ½ of the annual rate
• Upto 6 Months 3/4th of the annual rate
• Exceeding 6 months Full annual rate

13. ARBITRATION CLAUSE: If any dispute or difference shall arise as to the quantum to be paid under the policy (liability being otherwise admitted) such difference shall independently of all other questions be referred to the decision of a sole arbitrator to be appointed in writing by the parties or if they cannot agree upon a single shall be referred to a panel of three arbitrators, comprising of two arbitrators, one to be appointed by each of the parties to the dispute/ difference and the third arbitrator to be appointed by such two arbitrators and arbitration shall be conducted under and in accordance with the provisions of the Arbitration and Conciliation Act, 1996.

It is clearly agreed and understood that no difference or dispute shall be referable to arbitration as herein before provided, if the Company has disputed or not accepted liability under or in respect of this policy.
It is hereby expressly stipulated and declared that it shall be a condition precedent to any right of action or suit upon this policy that award by such arbitrator/ arbitrators of the amount of the loss or damage shall be first obtained.

14. DISCLAIMER OF CLAIM: It is also hereby further expressly agreed and declared that if the TPA/ Company shall disclaim liability in writing to the Insured for any claim hereunder and such claim shall not within 12 calendar months from the date of such disclaimer have been made the subject matter of a suit in a court of law, then the claim shall for all purposes be deemed to have been abandoned and shall not thereafter be recoverable hereunder.

15. PAYMENT OF CLAIM: The policy covers illness, disease or accidental bodily injury sustained by the insured person during the policy period any where in India and all medical / surgical treatment under this policy shall have to be taken in India and admissible claims thereof shall be payable in Indian currency without any interest thereof.

1. Payment of claim shall be made through TPA to the Hospital / Nursing Home     or to the Insured Person in case policy is serviced through TPA.
2.  In non TPA case the claim shall be paid to the insured person by the     Company.

Note: Please refer to the policy documents for the complete Insurance Policy subject to the insurance Company.

Exclusions :

The Company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any Insured Person in connection with or in respect of:

1. Any disease / health condition / illness / ailment or any condition arising therefrom other than those specified in the policy as covered.
2. Pre-existing health condition or disease or ailment / injuries: Any ailment / disease / injuries / health condition which are pre-existing (treated / untreated, declared / not declared in the proposal form), when the cover incepts for the first time are excluded upto 2 (two) years of this policy being in force continuously.

For the purpose of applying this condition, the date of inception of the Mediclaim policy taken from the Company shall be considered, provided the renewals have been continuous and without any break in period.

This exclusion shall also apply to any complications arising from pre existing ailments / diseases / injuries. Such complications shall be considered as a part of the pre existing health condition or disease. To illustrate if a person is suffering from hypertension or diabetes or both hypertension and diabetes at the time of taking the policy, then policy shall be subject to following exclusions.

1. Any disease covered under the policy other than those stated in clause 4.4, contracted by the Insured person during the first 30 (Thirty) days from the commencement date of the policy except treatment for accidental injuries.

1. The expenses on treatment of following ailments / diseases / surgeries for first two policy years are not payable.

If the continuity of the renewal is not maintained with the Company then subsequent cover shall be treated as fresh policy and clauses 2, 3, 4 shall apply afresh unless agreed by the Company and suitable endorsement is passed on the policy.

5. Injury or disease directly or indirectly caused by or arising from or attributable to War, Invasion, Act of Foreign Enemy, War like operations (whether war be declared or not) or by nuclear weapons / materials.
6. Circumcision (unless necessary for treatment of a disease included hereunder or as may be necessitated due to any accident), vaccination, inoculation or change of life or cosmetic or of aesthetic treatment of any description, hair transplant, plastic surgery other than as may be necessitated due to an accident or as a part of any illness / disease.
7. Surgery for correction of eye sight, cost of spectacles, contact lenses, hearing aids etc.
8. Convalescence, general debility. “ run down” condition or rest cure, congenital external diseases or defects or anomalies, sterility, any fertility, sub- fertility or assisted conception procedure, venereal diseases, intentional self- injury/ suicide, all psychiatric conception procedure, venereal diseases, intentional self- injury/ suicide, all psychiatric and psychosomatic disorders and diseases / accident due to and or use, misuse or abuse of drugs / alcohol or use of intoxicating substances or such abuse or addiction etc.
9. All expenses arising out of any condition directly or indirectly caused by, or associated with Human T-cell Lymphotropic Virus Type III (HTLD- III) or Lymohadinopathy Associated Virus (LAV) or the Mutants Derivative or Variations Deficiency Syndrome or any Syndrome or condition of similar kind commonly referred to as AIDS, HIV and its complications including sexually transmitted diseases.
10. Expenses incurred at Hospital or Nursing Home primarily for evalution / diagnostic purposes which is not followed by active treatment for the ailment during the hospitalised period.
11. Expenses on vitamins, tonics, mineral water and allied items unless forming part of treatment for injury or disease as certified by the attending physician.
12. Naturopathy treatment, unproven procedure or treatment, experimental or alternative medicine and related treatment including acupressure, acupuncture, magnetic and such other therapies etc.
13. Expenses incurred for investigation or treatment irrelevant to the diseases diagnosed during hospitalisation or primary reasons for admission. Private nursing charges, Referral fee to family doctors, Out station consultants / Surgeons fees etc.
14. External and / or durable Medical / Non medical equipment like Ambulatory devices i.e. Walker, Crutches, Belts, Collars, Caps, Splints, Slings, Braces, Stocking etc of any kind, CPAP, CAPD, Infusion pump, Diabetic foot wear, Glucometer/ Thermometer, nebuliser and similar related items etc and also any medical equipment which is subsequently used at home etc.
15. All non medical expenses including Personal comfort and convenience items or services such as telephone, television, Aya / barber or beauty services, diet charges, baby food, cosmetics, napkins, toiletry items etc., guest services and similar incidental expenses or services etc.
16. Change of treatment from one system of medicine to another unless necessitated and agreed / allowed by the TPA / Company.
17. Treatment of obesity or condition arising therefrom (including morbid obesity) and any other weight control programme, services or supplies etc.
18. Any treatment required arising from Insured’s participation in any hazardous activity such as scuba diving, motor racing, parachuting, hang gliding, rock or mountain climbing, other allied similar activities etc.
19. Any treatment received in convalescent home, convalescent hospital, health hydro, nature care clinic or similar establishments.
20. Any stay in the hospital for any domestic reason or where no active regular medical treatment is given by the specialist / physician.
21. Out Patient Diagnostic, Medical or Surgical procedures or treatments, non-prescribed drugs and medical supplies.
22. Massages, Steam bathing, Shirodhara and like treatment under Ayurvedic treatment.
23. Any kind of Service charges, Surcharges, Admission fees / Registration charges, File Charges etc levied by the hospital.
24. Doctor’s home visit charges, Attendant / Nursing charges during pre and post hospitalisation period.
25. Treatment which is continued before hospitalization and continued even after discharge for an ailment / disease / injury other than the one for which hospitalisation claim is made / admissible.