Preamble

This is a legal contract between the Policyholder and Aditya Birla Health Insurance subject to the receipt of full premium, Disclosure to information norm including the information provided by the Policyholder in the Proposal Form and the terms, conditions and exclusions of this Policy

If any claim arising as a result of an Injury or Illness that occurs during the Policy Period becomes payable, then We shall pay the Benefits specified below in accordance with the terms, conditions and exclusions of the Policy

Customer declaration:

I declare that I am not suffering from or been diagnosed with, advised taken treatment or observation is suggested or undergone any investigation or consulted a doctor or undergone or advised surgery for any one or more from the following

• High Blood Pressure, Heart Attack or any other Heart Disease, abnormal lipid levels;
• Stroke, Paralysis in any form, or any other Cerebrovascular Disease;
• Diabetes or thyroid/parathyroid or any other Endocrinal Disease, Any Kidney Disease;
• Acute / Chronic Liver (Failure/ Disease), Cirrhosis of Liver, Alcoholic liver disease; any pancreatic disease
• Any Lung Disease (e.g. Chronic Obstructive Pulmonary Diseases, Parenchymal lung Disease, Pulmonary Embolism etc.).
• Blood Disorders, Gastro-Intestinal Diseases, Ulcer or any other disorder of the bones, spine or muscle;
• Any Cancer or Cancerous growth;
• Any Mental or Psychiatric condition, any Genetic Disease, autoimmune or any disease related to central nervous system (disease related to brain); Congenital conditions;
• HIV / AIDS or AIDS related complications,
• Covid positive in last 3 months
• Any h/o sudden loss of weight in last 1 yr

Benefits covered under the Policy

The Benefits listed below shall be available to all Insured Persons as specified in the Policy Schedule or Certificate of Insurance.

We will indemnify the Reasonable and Customary Charges incurred towards Necessary Medical Treatment taken by the Insured Person during the Policy Period for an Illness, Injury or the conditions described in the Benefits below if it is contracted or sustained by an Insured Person during the Policy Period.

Benefits under this Section are subject to the terms, conditions and exclusions of this Policy and the availability of the Sum Insured and subject always to any sub-limits for the Benefit as specified in the Policy Schedule or Certificate of Insurance.

All claims must be made in accordance with the procedure set out in Section VI.1.

• Hospital Cash Benefit

  We will provide a Hospital Cash Benefit specified in the Policy Schedule or Certificate of Insurance for each continuous and completed period of 24 hours of Hospitalisation of the Insured Person during the Policy Period for treatment of an Illness or Injury provided that:

  • This Benefit shall be payable for a maximum number of days specified in the Policy Schedule or Certificate of Insurance, per Hospitalization event in respect of an Insured Person;
  • A Deductible as specified in the Policy Schedule or Certificate of Insurance is applicable under the Benefit;
  • This Benefit shall not be payable for more than the number of days per Policy Year as specified in the Policy Schedule or Certificate of Insurance.

• OPD Expenses

  We will cover the Reasonable and Customary Charges incurred for medically required consultations, visit(s) to a doctor, diagnostic tests and pharmacy expenses which are incurred on an out-patient basis up to the limits as specified in the Policy Schedule or Certificate of Insurance. Alternative Treatments shall also be covered under this Benefit.

Exclusions

We shall not be liable to make any payment for any claim under any Benefit in respect of any Insured Person directly or indirectly caused by, based on, arising out of, relating to or howsoever attributable to any of the following:

• Standard Exclusion

  • Investigation & Evaluation (Code- Excl04)

    • Expenses related to any admission primarily for diagnostics and evaluation purposes only are excluded.
    • Any diagnostic expenses which are not related or not incidental to the current diagnosis and treatment are excluded.

  • Rest Cure, rehabilitation and respite care (Code- Excl05)

    Expenses related to any admission primarily for enforced bed rest and not for receiving treatment. This also includes:

    • Custodial care either at home or in a nursing facility for personal care such as help with activities of daily living such as bathing, dressing, moving around either by skilled nurses or assistant or non-skilled persons.
    • Any services for people who are terminally ill to address physical, social, emotional and spiritual needs.

  • Obesity/ Weight Control (Code- Excl06)

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

    • Surgery to be conducted is upon the advice of the Doctor
    • The surgery/Procedure conducted should be supported by clinical protocols
    • The member has to be 18 years of age or older and

    • Body Mass Index (BMI);

      • greater than or equal to 40 or

      • greater than or equal to 35 in conjunction with any of the following severe co-morbidities following failure of less invasive methods of weight loss:

        • Obesity-related cardiomyopathy
        • Coronary heart disease
        • Severe Sleep Apnea
        • Uncontrolled Type2 Diabetes

  • Change-of-Gender treatments: (Code- Excl07)

    Expenses related to any treatment, including surgical management, to change characteristics of the body to those of the opposite sex.

  • Cosmetic or plastic Surgery: (Code- Excl08)

    Expenses for cosmetic or plastic surgery or any treatment to change appearance unless for reconstruction following an Accident, Burn(s) or Cancer or as part of medically necessary treatment to remove a direct and immediate health risk to the insured. For this to be considered a medical necessity, it must be certified by the attending Medical Practitioner.

  • 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.

  • 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.

  • 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 as per Annexure VII and as disclosed in website (www.adityabirlahealth.com/healthinsurance) / 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.

  • Treatment for, Alcoholism, drug or substance abuse or any addictive condition and consequences thereof. (Code- Excl12)
  • Treatments received in heath hydros, nature cure clinics, spas or similar establishments or private beds registered as a nursing home attached to such establishments or where admission is arranged wholly or partly for domestic reasons (Code- Excl13).
  • Dietary supplements and substances that can be purchased without prescription, including but not limited to Vitamins, minerals and organic substances unless prescribed by a medical practitioner as part of hospitalization claim or day care procedure (Code- Excl14).
  • Refractive Error - Expenses related to the treatment for correction of eye sight due to refractive error less than 7 .5 dioptres. (Code- Excl15)

  • 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.

  • Sterility and Infertility: (Code- Excl17)

    Expenses related to sterility and infertility. This includes:

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

  • Maternity Expenses (Code - Excl18):

    • Medical treatment expenses traceable to childbirth (including complicated deliveries and caesarean sections incurred during hospitalization) except ectopic pregnancy;
    • Expenses towards miscarriage (unless due to an accident) and lawful medical termination of pregnancy during the policy period.

• Standard Exclusion

  • Treatment directly or indirectly arising from or consequent upon 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 defense, rebellion, uprising, revolution, insurrection, military or usurped acts, nuclear weapons / materials, chemical and biological weapons, ionizing radiation, contamination by radioactive material or radiation of any kind, nuclear fuel, nuclear waste.
  • Wilful or deliberate exposure to danger, intentional self- Injury, non- adherence to Medical Advice, participation or involvement in naval, military or air force operation.
  • Any Illness/Injury/Accident due to abuse of intoxicants or hallucinogenic substances, smoking cessation programs and the treatment of nicotine addiction unless prescribed by a Medical Practitioner.
  • All routine examinations and preventive health check-ups.
  • Circumcisions (unless necessitated by Illness or Injury and forming part of treatment.
  • Non- allopathic treatment, except as per coverage of AYUSH Treatment.
  • Conditions for which treatment could have been done on an out-patient basis without any Hospitalization.
  • Experimental treatment, investigational treatment, devices and pharmacological regimens.
  • Convalescence (except as per the coverage as coverage defined in Section III.B.22 - Recovery Benefit), cure, rest cure, sanatorium treatment, rehabilitation measures, private duty nursing
  • Preventive care, vaccination including inoculation and immunizations (except in case of post-bite treatment); any physical, psychiatric or psychological examinations or testing
  • Admission for nutritional and electrolyte supplements unless certified to be required by the attending Medical Practitioner as a direct consequence of an otherwise covered claim.
  • Hearing aids, spectacles or contact lenses including optometric therapy, multifocal lens.
  • Treatment for alopecia, baldness, wigs, or toupees, and all treatment related to the same.
  • Medical supplies including elastic stockings, diabetic test strips, and similar products.
  • Any expenses incurred on prosthesis, corrective devices external durable medical equipment of any kind, like wheelchairs crutches, instruments used in treatment of sleep apnea syndrome or continuous ambulatory peritoneal dialysis (C.A.P.D.) and oxygen concentrator for bronchial asthmatic condition, cost of cochlear implant(s) unless necessitated by an Accident or required intra-operatively. Cost of artificial limbs, crutches external appliance and/or device used for diagnosis or treatment. (except when used intra-operatively).
  • Parkinson and Alzheimer’s disease, general debility or exhaustion (“rundown condition”), sleep-apnea, stress.
  • External Congenital Anomalies, diseases or defects.
  • Stem cell therapy or surgery (except Hematopoietic stem cells for bone marrow transplant for hematological conditions), or growth hormone therapy.
  • Venereal disease, all sexually transmitted disease or Illness including but not limited to genital warts, Syphilis, Gonorrhea, Genital Herpes, Chlamydia, Pubic Lice and Trichomoniasis.
  • Expenses for organ donor screening, or save as and to the extent provided for in the treatment of the donor (including Surgery to remove organs from a donor in the case of transplant Surgery).
  • Admission for Organ Transplant but not compliant under the Transplantation of Human Organs Act, 1994 (amended).
  • Treatment and supplies for analysis and adjustments of spinal subluxation, diagnosis and treatment by manipulation of the skeletal structure; muscle stimulation by any means except treatment of fractures (excluding hairline fractures) and dislocations of the mandible and extremities.
  • Dentures and artificial teeth, Dental Treatment and Surgery of any kind, unless requiring Hospitalization due to an Accident.
  • Cost incurred for any health check-up or for the purpose of issuance of medical certificates and examinations required for employment or travel or any other such purpose.
  • Treatment for Rotational Field Quantum Magnetic Resonance (RFQMR), External Counter Pulsation (ECP), Enhanced External Counter Pulsation (EECP), Hyperbaric Oxygen Therapy.
  • Expenses which are medically not required such as items of personal comfort and convenience including but not limited to television (if specifically charged), charges for access to telephone and telephone calls (if specifically charged), food stuffs (save for patient’s diet), cosmetics, hygiene articles, body care products and bath additives, barber expenses, beauty service, guest service as well as similar incidental services and supplies, vitamins and tonics unless certified to be required by the attending Medical Practitioner as a direct consequence of an otherwise covered claim.
  • Treatment taken from a person not falling within the scope of definition of Medical Practitioner.
  • Treatment charges or fees charged by any Medical Practitioner acting outside the scope of license or registration granted to him by any medical council.
  • Treatments rendered by a Medical Practitioner who is a member of the Insured Person’s family or stays with him, save for the proven material costs are eligible for reimbursement as per the applicable cover.
  • Any treatment or part of a treatment that is not of a reasonable charge, is not a Medically Necessary Treatment; drugs or treatments which are not supported by a prescription.
  • Charges related to a Hospital stay not expressly mentioned as being covered, including but not limited to charges for admission, discharge, administration, registration, documentation and filing, including MRD charges (medical records department charges).
  • Non-medical expenses including but not limited to RMO charges, surcharges, night charges, service charges levied by the Hospital under any head and as specified in the Annexure V for non- medical expenses.
  • Treatment taken outside India.
  • In respect of the existing diseases, disclosed by the insured and mentioned in the Policy Schedule (based on insured's consent), policyholder is not entitled to get the coverage for specified ICD codes.

General Terms and Clauses

• Standard General Terms & Clauses

  • 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.

  • Condition Precedent to Admission of Liability

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

  • Complete Discharge

    Any payment to the policyholder, insured person or his/ her nominees or his/ her legal representative or assignee or to the Hospital, as the case may be, for any benefit under the policy shall be a valid discharge towards payment of claim by the Company to the extent of that amount for the particular claim.

  • Multiple Policies

    • 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.
    • ln 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.
    • lnsured 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.
    • lf 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.
    • Where an insured person has policies from more than one insurer to cover the same risk on indemnity basis, the insured person shall only be indemnified the treatment costs in accordance with the terms and conditions of the chosen policy.

  • Fraud

    lf any claim made by the insured person, is in any respect fraudulent, or if any false statement, or declaration is made or used in support thereof, or if any fraudulent means or devices are used by the insured person or anyone acting on his/her behalf to obtain any benefit under this policy, all benefits under this policy and the premium paid shall be forfeited.

    Any amount already paid against claims made under this policy but which are found fraudulent later shall be repaid by all recipient(s)/policyholder(s), who has made that particular claim, who shall be jointly and severally liable for such repayment to the insurer.

    For the purpose of this clause, the expression "fraud" means any of the following acts committed by the insured person or by his agent or the hospital/doctor/any other party acting on behalf of the insured person, with intent to deceive the insurer or to induce the insurer to issue an insurance policy:

    • the suggestion, as a fact of that which is not true and which the insured person does not believe to be true;
    • the active concealment of a fact by the insured person having knowledge or belief of the fact;
    • any other act fitted to deceive; and
    • any such act or omission as the law specially declares to be fraudulent

    The Company shall not repudiate the claim and / or forfeit the policy benefits on the ground of Fraud, if the insured person / beneficiary can prove that the misstatement was true to the best of his knowledge and there was no deliberate intention to suppress the fact or that such misstatement of or suppression of material fact are within the knowledge of the insurer.

  • Cancellation

    The policyholder may cancel this policy by giving 15 days written notice and in such an event, the Company shall refund premium for the unexpired policy period as detailed below

    Notwithstanding anything contained herein or otherwise, no refunds of premium shall be made in respect of Cancellation where, any claim has been admitted or has been lodged or any benefit has been availed by the insured person under the policy.

    Cancellation Grid
    Period* for which risk is retained	Refund
    Less than 1 Month	75%
    1 Month- less than 3 Month	50%
    3 Months – less than 6 months	25%
    Beyond 6 Months	Nil

    The Company may cancel the policy at any time on grounds of misrepresentation non-disclosure of material facts, fraud by the insured person by giving 15 days' written notice. There would be no refund of premium on cancellation on grounds of misrepresentation, non-disclosure of material facts or fraud.

    The cancellation of Policy however is not applicable for Section III.A.8 “Sub-Limit for Specified Illness/conditions” and Section III.A.4 “Chronic Management Program”.

  • Migration

    The insured person will have the option to migrate the policy to other health insurance products/plans offered by the company by applying for migration of the policy atleast 30 days before the policy renewal date as per IRDAI guidelines on Migration. lf such person is presently covered and has been continuously covered without any lapses under any health insurance product plan offered by the company, the insured person will get the accrued continuity benefits in waiting periods as per IRDAI guidelines on migration.

    For Detailed Guidelines on migration, kindly refer the link

    https://www.adityabirlacapital.com/healthinsurance/#!/homepage

  • Withdrawal of Policy

    • ln the likelihood of this product being withdrawn in future, the Company will intimate the insured person about the same 90 days prior to expiry of the policy.
    • lnsured 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.

  • Moratorium Period

    After completion of eight continuous years under the Policy, no look back to be applied. This period of eight years is called as ‘Moratorium Period’. The moratorium would be applicable for the Sums Insured of the first Policy with Us and subsequently completion of eight continuous years would be applicable from date of enhancement of Sum Insured only on the enhanced limits. After the expiry of Moratorium Period, no health insurance claim shall be contestable except for proven fraud and permanent exclusions specified in the Policy contract. The Policy would however be subject to all limits, sub limits, co-payments, deductible as per the Policy contract.

  • Premium Payment in instalments

    lf the 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/Certificate of lnsurance, the following Conditions shall apply (notwithstanding any terms contrary elsewhere in the policy)

    • Grace Period of 15 days would be given to pay the instalment premium due for the policy.
    • During such grace period, coverage will not be available from the due date of instalment premium till the date of receipt of premium by Company.
    • 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.
    • No interest will be charged lf the instalment premium is not paid on due date
    • ln case of instalment premium due not received within the grace period, the policy will get cancelled.
    • ln the event of a claim, all subsequent premium instalments shall immediately become due and payable.
    • The company has the right to recover and deduct all the pending instalments from the claim amount due under the policy.

  • Possibility of Revision of Terms of the Policy lncluding the Premium Rates

    The Company, with prior approval of lRDAl, 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.

  • Redressal of Grievance

    In case of a grievance, the Insured Person/ Policyholder can contact Us with the details through:

    Our website: www.adityabirlacapital.com/healthinsurance

    Email: care.healthinsurance@adityabirlacapital.com

    Toll Free : 1800 270 7000

    Address: Aditya Birla Health insurance Co. Limited
    9th Floor, Tower 1, One World Centre, Jupiter Mills Compound, 841, Senapati Bapat Marg, Elphinstone Road, Mumbai 400013

    lnsured person may also approach the grievance cell at any of the company's branches with the details of grievance

    lf lnsured person is not satisfied with the redressal of grievance through one of the above methods, insured person may contact the grievance officer at

    For updated details of grievance officer, refer the link https://www.adityabirlacapital.com/healthinsurance/#!/homepage

    For senior citizens, please contact the respective branch office of the Company or call at or may write an e- mail at seniorcitizen.abh@adityabirla.com.

    lf lnsured person is not satisfied with the redressal of grievance through above methods, the insured person may also approach the office of lnsurance Ombudsman of the respective area/region for redressal of grievance as per lnsurance Ombudsman Rules 2017. The contact details of the Ombudsman offices are provided on Our website and in this Policy at Annexure VI

    Grievance may also be lodged at IRDAI lntegrated Grievance Management System - https:/igms.irda.gov.in/

  • Nomination:

    The policyholder is required at the inception of the policy to make a nomination for the purpose of payment of claims under the policy in the event of death of the policyholder. Any change of nomination shall be communicated to the company in writing and such change shall be effective only when an endorsement on the policy is made. ln 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.

  • Claim Settlement (provision for Penal lnterest)

    • The Company shall settle or reject a claim, as the case may be, within 30 days from the date of receipt of last necessary document.
    • ln the case of delay in the payment of a claim, the Company shall be liable to pay interest to the policyholder from the date of receipt of last necessary document to the date of payment of claim at a rate 2% above the bank rate.
    • 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. ln such cases, the Company shall settle or reject the claim within 45 days from the date of receipt of last necessary document.
    • ln case of delay beyond stipulated 45 days, the Company shall be liable to pay interest to the policyholder at a rate 2% above the bank rate from the date of receipt of last necessary document to the date of payment of claim.

    (Explanation: "Bank rate" shall mean the rate fixed by the Reserve Bank of lndia (RBl) at the beginning of the financial year in which claim has fallen due)

• Specific Terms & Clauses

  • Eligibility

    Minimum Entry Age	1 day
    Maximum Entry Age	No Limit

    Following relationships can be covered as dependants:

    Self, lawfully wedded spouse (more than one wife)/ Partner (including same sex partners), son (biological/ adopted), daughter (biological/ adopted), mother (biological/ foster), father (biological/ foster), brother (biological/ step) sister (biological/ step, mother in-law, father in-law, son in-law, daughter in-law, brother in-law, sister in-law.

    For the purpose of this section, Partner shall be taken as declared at the time of Start Date and no change in the same would be accepted during a Policy Period. However, an Insured Person may request for change at the time of Renewal of the cover.

    It is further clarified that for the purpose of availing this Policy, the Policyholder shall ensure that the minimum number of Employees/members who will form a group to avail the Benefits under this Policy shall be 7

  • Material Change

    Material information to be disclosed includes every matter that the Policyholder/Insured Person is aware of, or could reasonably be expected to know, that relates to questions in the Proposal Form and which is relevant to Us in order to accept the risk of insurance. The Policyholder/Insured Person must exercise the same duty to disclose those matters to Us before the Renewal, extension, variation, endorsement of the contract. The Policy terms and conditions will not be altered.

  • Alterations in the Policy

    This Policy constitutes the complete contract of insurance. No change or alteration will be effective or valid unless approved in writing which will be evidenced by a written endorsement, signed and stamped by Us.

  • No Constructive Notice

    Any knowledge or information of any circumstance or condition in relation to the Policyholder/ Insured Person which is in Our possession and not specifically informed by the Policyholder / Insured Person shall not be held to bind or prejudicially affect Us notwithstanding subsequent acceptance of any premium.

  • Grace Period

    The Policy may be Renewed by mutual consent and in such event the Renewal premium should be paid to Us on or before the date of expiry of the Policy and in no case later than the Grace Period of 30 days from the expiry of the Policy. We will not be liable to pay for any claim arising out of an Illness/Injury/ Accident that occurred during the Grace Period. The provisions of Section 64VB of the Insurance Act 1938 shall be applicable. All policies Renewed within the Grace Period shall be eligible for continuity of cover.

  • Renewal Terms

    The Policy may be renewed by mutual consent and in such event the Renewal premium should be paid to Us on or before the date of expiry of the Policy and in no case later than the Grace Period of 30 days from the expiry of the Policy

    Renewals will not be denied except on grounds of misrepresentation, moral hazard, fraud, non-disclosure of material facts or non-co-operation by the Insured Person.

    Upon the Insured Person ceasing to be an Employee/member of the Policyholder or Us discontinuing/withdrawing this product, such Insured Person shall have the option to migrate to an approved retail health insurance policy available with Us.

  • Communication & Notices

    Any communication or notice or instruction under this Policy shall be in writing and will be sent to:

    • The Policyholder’s/Insured Person, at the address as specified in the Policy Schedule or Certificate of Insurance
    • To Us, at the address specified in the Policy Schedule or Certificate of Insurance.
    • No insurance agents, brokers, other person or entity is authorised to receive any notice on the behalf of Us unless explicitly stated in writing by Us.

  • Premium

    The premium for each Policy will be determined based on the available data of each group and applicable discounts and loadings. Payment of premiums will be available in single mode or instalment options of monthly/ quarterly/ half yearly as agreed with the Policyholder.

  • Special Provisions

    Any special provisions subject to which this Policy has been entered into and endorsed in the Policy or in any separate instrument shall be deemed to be part of this Policy and shall have effect accordingly.

  • Electronic Transactions

    The Policyholder agrees to comply with all the terms and conditions of electronic transactions as We shall prescribe from time to time, and confirms that all transactions effected facilities for conducting remote transactions such as the internet, World Wide Web, electronic data interchange, call centres, tele-service operations (whether voice, video, data or combination thereof) or by means of electronic, computer, automated machines network or through other means of telecommunication, in respect of this Policy and claim related details, shall constitute legally binding when done in compliance with Our terms for such facilities.

    Sales through such electronic transactions shall ensure that all conditions of Section 41 of the Insurance Act, 1938 prescribed for the proposal form and all necessary disclosures on terms and conditions and exclusions are made known to the Policyholder. A voice recording in case of tele-sales or other evidence for sales through the World Wide Web shall be maintained and such consent will be subsequently validated / confirmed by the Policyholder.

  • Policy Dispute

    Any dispute concerning the interpretation of the terms, conditions, limitations and/ or exclusions contained herein shall be governed by Indian law and shall be subject to the jurisdiction of the Indian Courts.

  • Records to be maintained

    You shall keep an accurate record containing all relevant medical records and shall allow Us or our representative(s) to inspect such records. You or the Insured Person as the case may be, shall furnish such information as may be required by Us under this Policy at any time during the Policy Period and up to three years after the Policy expiration, or until final adjustment (if any) and resolution of all claims under this Policy.

  • Assignment

    An Insured Person may assign the Benefits or any specific Benefit(s) under the Policy by giving written notice of the assignment and the terms and conditions of the assignment to Us. We will record the assignment in accordance with Section 38 of the Insurance Act 1938.

Other Terms and conditions

• Claims Process

  • Claims Administration & Process

    The fulfillment of the terms and conditions of this Policy (including payment of premium in full and on time) insofar as they relate to anything to be done or complied with by You or any Insured Person, including complying with the following in relation to claims, shall be Conditions Precedent to admission of Our liability under this Policy:

    • On the occurrence or discovery of any Illness or Injury that may give rise to a Claim under this Policy, the Claims Procedure set out below shall be followed.
    • The directions, advice and guidance of the treating Medical Practitioner shall be strictly followed. We shall not be obliged to make any payments that are brought about or contributed to as a consequence of or failure to follow such directions, Medical advice or guidance.
    • If requested by Us and at Our cost, the Insured Person must submit to medical examination by Our Medical Practitioner as often as We consider reasonable and necessary and We/Our representatives must be permitted to inspect the medical and Hospitalisation records pertaining to the Insured Person’s treatment and to investigate the circumstances pertaining to the claim.
    • We and Our representatives must be given all reasonable co-operation in investigating the claim in order to assess Our liability and quantum in respect of the claim.

    • Claims Procedure

      On the occurrence or the discovery of any Illness or Injury that may give rise to a claim under this Policy, then as a Condition Precedent to Our liability under the Policy the following procedure shall be complied with:

      • For Availing Cashless Facility

        • Cashless Facilities can be availed only at Our Network Providers.
        • We reserve the right to modify, add or restrict any Network Provider for Cashless Facilities at Our sole discretion. Before availing Cashless Facilities, please check the applicable updated list of Network Providers.

      • Process for Obtaining Pre-Authorisation for Planned Treatment:

        • We/TPA must be contacted to pre-authorise Cashless Facility for planned treatment at least 72 hours prior to the proposed treatment. Each request for pre-authorisation must be accompanied with all the following details:

          • The health card which We or the associated TPA has issued to the Insured Person supported with the Insured Person’s KYC documents.
          • The Policy number;
          • Name of the Policyholder/Employer;
          • Name and address of Insured Person/Employee/member in respect of whom the request is being made;
          • Nature of the Illness/Injury and the treatment/Surgery required;
          • Name and address of the attending Medical Practitioner;
          • Hospital where treatment/Surgery is proposed to be taken;
          • Proposed date of admission.
        • If these details are not provided in full or are insufficient for Us or the associated TPA to consider the request, We or the associated TPA will request additional information or documentation in respect of that request.
        • When We or the associated TPA have obtained sufficient details to assess the request, We or the associated TPA will issue the authorization letter specifying the sanctioned amount, any specific limitation on the claim, applicable Deductibles and non-payable items, if applicable, or We may reject the request for pre-authorisation specifying reasons for the rejection.
        • The authorization letter shall be issued to the Network Provider within 24 hours of receiving the complete information.
        • Once the request for pre-authorisation has been granted, the treatment must take place within 15 days of the pre-authorization date at a Network Provider and pre-authorization shall be valid only if all the details of the authorized treatment, including dates, Hospital and locations, match with the details of the actual treatment received. For Hospitalization where Cashless Facility is pre-authorised by Us or the associated TPA, We or the associated TPA will make the payment of the amounts assessed to be due directly to the Network Provider.

      • Process to be followed for Availing Cashless Facilities in Emergencies:

        • We or the associated TPA must be contacted to pre-authorise Cashless Facility within 24 hours of the Insured Person’s Hospitalization if the Insured Person has been Hospitalized in an Emergency. Each request for pre-authorisation must be accompanied with all the following details:

          • The health card We have issued to the Insured Person supported with the Insured Person’s KYC documents.
          • The Policy number;
          • Name of the Policyholder/Employer;
          • Name and address of Insured Person/Employee/member in respect of whom the request is being made;
          • Nature of the Illness/Injury and the treatment/Surgery required;
          • Name and address of the attending Medical Practitioner;
          • Hospital where treatment/Surgery is proposed to be taken;
          • Proposed date of admission.
          • Duly completed claim form / pre-authorization form.
        • If these details are not provided in full or are insufficient for Us to consider the request, We will request additional information or documentation in respect of that request.
        • When we have obtained sufficient details to assess the request, We will issue the authorization letter specifying the sanctioned amount, any specific limitation on the claim, applicable Deductibles and non-payable items, if applicable, or reject the request for pre-authorisation specifying reasons for the rejection.
        • The authorization letter shall be issued to the Network Provider within 24 hours of receiving the complete information.
        • Once the request for pre-authorisation has been granted, the treatment must take place within 15 days of the pre-authorization date at a Network Provider and pre-authorization shall be valid only if all the details of the authorized treatment, including dates, Hospital and locations, match with the details of the actual treatment received. For Hospitalization where Cashless Facility is pre-authorised by Us, We will make the payment of the amounts assessed to be due directly to the Network Provider.

      • For Reimbursement Claims:

        • For all claims for which Cashless Facilities have not been pre-authorised or for which treatment has not been taken at a Network Provider, We shall be given written notice of the claim along with the following details within 48 hours of admission to the Hospital or before discharge from the Hospital, whichever is earlier:

          • The Policy number;
          • Name of the Policyholder/Employer;
          • Name and address of the Insured Person/Employee/member in respect of whom the request is being made;
          • Health Card, photo ID, KYC documents;
          • Nature of Illness or Injury and the treatment/Surgery taken;
          • Name and address of the attending Medical Practitioner;
          • Hospital where treatment/Surgery was taken;
          • Date of admission and date of discharge;
          • Any other information that may be relevant to the Illness/ Injury/ Hospitalization;
          • Duly completed claim form.
        • If the claim is not notified to Us within the earlier of 48 hours of the Insured Person’s admission to the Hospital or before the Insured Person’s discharge from the Hospital, 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.

    • Claims Documentation:

      We or the associated TPA shall be provided the following necessary information and documentation in respect of all claims at the Insured Person’s expense within 30 days of the Insured Person’s discharge from the Hospital:

      • Claims for Pre-hospitalization Medical Expenses and Post- hosptialization Medical Expenses to be submitted to us within 30 days of the completion of the post- Hospitalisation treatment

      • For those claims for which the use of Cashless Facility has been authorised, We will be provided these documents by the Network Provider immediately following the Insured Person’s discharge from the Hospital:

        • Duly completed claim form;
        • Photo ID and Age proof;
        • Health Card, policy copy, photo ID, KYC documents;
        • Original discharge card / day care summary / transfer summary;
        • Original final Hospital bill with all original deposit and final payment receipt;
        • Original invoice with payment receipt and implant stickers for all implants used during Surgeries i.e. lens sticker and Invoice in cataract Surgery, stent invoice and sticker in Angioplasty Surgery;
        • All previous consultation papers indicating history and treatment details for current ailment;
        • All original diagnostic reports (including imaging and laboratory) along with Medical Practitioner’s prescription and invoice / bill with receipt from diagnostic center;
        • All original medicine / pharmacy bills along with the Medical Practitioner’s prescription;
        • MLC / FIR copy – in Accidental cases only;
        • Copy of death summary and copy of death certificate (in death claims only);
        • Pre and post-operative imaging reports – in Accidental cases only;
        • Copy of indoor case papers with nursing sheet detailing medical history of the Insured Person, treatment details and the Insured Person’s progress(if available);
        • KYC documents

        Where these details are not provided in full or are insufficient for Us to consider the request, We will request additional information or documentation in respect of that request.

        Additional documents in case of below covers

        In case of Contribution claims:

        • Photocopy of entire claim document duly attested by previous Insurer or TPA;
        • Original payment receipts for expenses not claimed/settled by previous insurer;
        • Discharge voucher/settlement letter by previous insurer.

    • Claims Assessment & Repudiation:

      • At Our discretion, We may investigate claims to determine the validity of a claim. This investigation will be conducted within 15 days of the date of assigning the claim for investigation and not later than 6 months from the date of receipt of claim intimation. All costs of investigation will be borne by Us and all investigations will be carried out by those individuals/entities that are authorised by Us in writing.

        If there are any deficiencies in the necessary claim documents which are not met or are partially met. We will send a maximum of 3 (three) reminders following which We will send a rejection letter or make a part-payment if we have not received the deficiency documents after 45 days from the date of the initial request for such documents.

      • We may decide to deduct the amount of claim for which deficiency is intimated to the Insured Person and settle the claim if We observe that such a claim is otherwise valid under the Policy. However documents/ details received beyond such period shall be considered if there are valid reasons for any delay.

      • Payment for reimbursement claims will be made to the Insured Person. In the unfortunate event of the Insured Person’s death, We will pay the nominee named in the Policy Schedule or Certificate of Insurance, or to the Insured Person’s legal heirs or legal representatives holding a valid succession certificate.

        For details on the claims process or assistance during the process, the claimant may contact Us at Our call centre on the toll free number specified in the Policy Schedule or Certificate of Insurance or through Our website. In addition, We will keep the claimant informed of the claim status and explain requirement of documents. Such means of communication shall include but not be limited to mediums such as letters, email, SMS messages, and information on Our Website.