Religare Care Insurance Policy Wording

Policy Terms and Conditions
1. Definitions b. Does not have his independent sources of income; and

c. Has not attained Age 25 years.
For the purposes of interpretation and understanding of the product the Company has
defined, herein below some of the important words used in the product and for the 1.14 Emergency means a medical condition arising out of any Illness or Injury
remaining language and the words the Company believes to mean the normal meaning of contracted by the Insured Person and declared and certified by the Medical
the English language as explained in the standard language dictionaries. The words and Practitioner, attending to the Insured Person, that immediate treatment is
expressions defined in the Insurance Act, IRDA Act, Regulations notified by the Authority required to save the life of the Insured Person.
and Circulars and Guidelines issued by the Authority shall carry the meanings explained 1.15 Emergency Care means management for a severe Illness or Injury which
therein. The judicial pronouncements of the highest courts in India will have the effect on results in symptoms which occur suddenly and unexpectedly, and requires
the definitions and the language used in this product. The terms and conditions, coverage's immediate care by a Medical Practitioner to prevent death or serious long term
and exclusions, benefits, various procedures and concepts which have been built in to the impairment of the Insured Person's health.
product also carry the specified meaning assigned to them in the said language.
1.16 Hospital means any institution in India established for In-patient Care and Day
The terms defined below have the meanings ascribed to them wherever they appear in this Care Treatment of Illness and/or Injuries and which has been registered as a
Policy and, where appropriate, references to the singular include references to the plural; Hospital with the local authorities, wherever applicable, and is under the
references to the male include the female and references to any statutory enactment supervision of a registered and qualified Medical Practitioner AND must comply
include subsequent changes to the same and vice versa. with all minimum criteria as under :
1.1 Accident/Accidental means a sudden, unforeseen and involuntary event a. has at least 10 in-patient beds, in those towns having a population of less
caused by external and visible means. than 10,00,000 and 15 in-patient beds in all other places;
1.2 Acute means a disease, Illness or Injury that is likely to respond quickly to b. has qualified nursing staff under its employment round the clock;
treatment which aims to return the Insured Person to the state of health he was
in, immediately before suffering the disease, Illness or Injury or which leads to his c. has qualified Medical Practitioner in-charge round the clock;
full recovery. d. has a fully equipped operation theatre of its own, where Surgical
1.3 Age means the completed age of the Insured Person as on his last birthday. Procedures are carried out;
1.4 Ambulance means a road vehicle operated by a licensed/authorized service e. maintains daily records of patients and will make these accessible to the
provider and equipped for the transport and paramedical treatment of the Company's authorized personnel.
person requiring medical attention. 1.17 Hospitalization means the period for which the Insured Person is admitted in
1.5 Annexure means a document attached and marked as Annexure to this Policy. the Hospital as an in-patient and stays there for the sole purpose of receiving the
necessary and reasonable treatment for Illness or Injury sustained during the
1.6 Any One Illness means a continuous period of Injury or Illness and including Policy Period. The minimum period of stay shall be 24 (Twenty Four) consecutive
any relapse of that Illness or results of that Injury within 45 days from the date of hours. However, this time limit will not apply for Day Care Treatment.
discharge from the Hospital where the treatment was taken, provided that
occurrence of the same Injury or Illness after the completion of at least 45 days 1.18 Illness means a sickness (a condition or an ailment affecting the general
from the date of discharge from the Hospital where treatment was taken shall be soundness and health of the Insured Person's body) or a disease (affliction of the
deemed as fresh Injury or Illness. bodily organs having a defined and recognized pattern of symptoms) or a
pathological condition leading to the impairment of normal physiological function
1.7 Claim means a demand made in accordance with the terms and conditions of which manifests itself during the Policy Period and requires medical treatment. For
the Policy for payment of Medical Expenses or Benefits in respect of the Insured the avoidance of doubt, Illness does not mean and this Policy does not cover any
Person. mental illness or sickness or disease (including but not limited to a psychiatric
1.8. Company means Religare Health Insurance Company Limited. condition, disorganization of personality or mind, or emotions or behavior) even if
caused by or aggravated by or related to an Injury or Illness.
1.9 Congenital Anomaly means an external Congenital Anomaly refers to a
condition which is present since birth, in the visible and accessible parts of the 1.19 Injury means a bodily injury resulting solely and directly from an Accident which
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body, and which is abnormal with reference to form, structure or position. occurs during the Policy Period and which is not an Illness and which is caused by a
violent, unexpected and uncontrollable physical event which results solely and
An internal Congenital Anomaly refers to a metabolic or anatomic deviation from independently of any other causes.
the normal pattern of development that is apparent at birth or at a later stage.
1.20 In-patient Care means treatment for Illness or Injury for which the Insured
1.10 Co-payment means a cost-sharing requirement under this Policy that Person has to stay in a Hospital for more than 24 consecutive hours.
provides that the Policyholder will bear a specified percentage of the admissible
costs. A Co-payment does not reduce the Sum Insured. 1.21 Insured Person (Insured) means a person whose name specifically
appears under Insured in the Policy Certificate and with respect to whom the
1.11 Day Care Centre means any institution in India established for Day Care premium has been received by the Company.
Treatment of Illness and/or Injuries and which may be registered either as a
Hospital or a Day Care Centre with the local authorities, wherever applicable, and 1.22 Intensive/Critical Care Unit (ICU) means an identified section, ward or
is under the supervision of a registered and qualified Medical Practitioner AND wing of a Hospital which is under the constant supervision of a dedicated Medical
must comply with all minimum criteria as under : Practitioner, and which is specially equipped for the continuous monitoring and
treatment of patients who are in a critical condition, or require life support
a. has qualified nursing staff under its employment; facilities and where the level of care and supervision is considerably more
b. has qualified Medical Practitioner in-charge; sophisticated and intensive than in the ordinary and other wards.
c. has a fully equipped operation theatre of its own, where Day Care 1.23 Medical Advice means any consultation from a Medical Practitioner including
Treatment is carried out; the issue of any prescriptions or repeat prescriptions.
d. maintains daily records of patients and will make these accessible to 1.24 Medical Expenses means those necessary, reasonable and customary
the Company's authorized personnel. expenses that has necessarily and actually been incurred for medical treatment of
the Insured Person during the Policy Period on the written Medical Advice of a
1.12 Day Care Treatment means medical treatment and/or a Surgical Medical Practitioner due to Illness or Injury sustained by the Insured Person which
Procedure which is listed in Annexure “A” and which is : occurs during the Policy Period, and which includes the following :
a. undertaken under general or local anesthesia in a Hospital/Day a. Room, boarding and nursing expenses as charged by the Hospital where
Care Centre in less than 24 consecutive hours because of the Insured Person availed medical treatment
technological advancement, and
b. Intensive Care Unit (ICU) charges
b. which would have otherwise required Hospitalization of more than
24 consecutive hours. c. Fees charged by a surgeon, anesthetist and Medical Practitioner
Treatment normally taken on an out-patient basis is not included in the scope of d. Anesthesia, blood, oxygen, operation theatre charges, surgical
this definition. consumables, medicines and drugs, diagnostic materials and X-ray, dialysis,
chemotherapy, radiotherapy, cost of pacemaker, joint replacement, etc.
1.13 Dependent Child means a child (natural or legally adopted), who is :
1.25 Medical Practitioner means a person who holds a valid registration
a. Financially dependent on the Policyholder; from the medical council of any state of India and is thereby entitled to practice
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medicine within its jurisdiction; and is acting within the scope and jurisdiction of c. The maximum, total and cumulative liability of the Company for an Insured
his license. Person for any and all Claims incurred under this Policy during the Policy
Year in relation to any Insured Person shall not exceed the Sum Insured for
1.26 Medically Necessary means any treatment, tests, medication, or stay in
that Insured Person. All Claims shall be payable subject to the terms,
Hospital or part of a stay in Hospital which
conditions and exclusions of the Policy and subject to availability of the Sum
a. Is required for the medical management of the Illness or Injury suffered by the Insured.
Insured Person;
d. Any Claim under Benefit 1, Benefit 6, Benefit 7 and Benefit 8 shall always be
b. Must not exceed the level of care necessary to provide safe, adequate and subject to Clause 5.5.
appropriate medical care in scope, duration, or intensity;
e. Any Claim paid for Benefit 1 to Benefit 9 shall reduce the Sum Insured for the
c. Must have been prescribed by a Medical Practitioner; Policy Year and only the balance shall be available for all future claims for that Policy
Year.
d. Must conform to the professional standards widely accepted in international
medical practice or by the medical community in India. 2.1 Benefit 1 : Hospitalization Expenses
If an Insured Person is diagnosed with an Illness or suffers an Injury during the
1.27 Network Hospitals means Hospitals or other service providers that the
Policy Period and while the Policy is in force that requires:
Company has mutually agreed with, to provide services as covered under this
Policy. The list is available with the Company and subject to amendment from time a. In-patient Care : The Insured Person's Hospitalization, then the Company will
to time. indemnify the Medical Expenses incurred on Hospitalization, provided that the
Hospitalization was on the written advice of a Medical Practitioner.
1.28 Non-Network means any Hospital, Day Care Centre or other provider that
is not part of the Network Hospitals. b. Day Care Treatment : The Insured Person to undergo Day Care Treatment at a
Day Care Centre or Hospital, then the Company will indemnify the Medical
1.29 Policy means these Policy Terms & Conditions, the Proposal Form, Policy
Expenses incurred on that Day Care Treatment, provided that the treatment was
Certificate and Annexures which form part of the policy contract and shall be
taken on the written advice of a Medical Practitioner.
read together.
1.30 Policy Certificate means the certificate attached to and forming part of c. Conditions for Medical Expenses (Applicable only if specifically mentioned in the
this Policy. Policy Certificate)
1.31 Policyholder means the person named in the Policy Certificate as the i) Room, boarding and nursing expenses as charged by the Hospital where
Policyholder. the Insured Person availed medical treatment (Room Rent / Room
Category) :
1.32 Policy Period means the period commencing from the Policy Period Start
Date and ending on the Policy Period End Date as specified in the Policy I. If the Insured Person is admitted in a room where the Room Rent
Certificate. incurred or the Room Category is different than the one specified in
the Policy Certificate, then the Policyholder shall bear the ratable
If the Policy Period is more than 12 months, the Sum Insured shall apply on Policy
proportion of the total Variable Medical Expenses (including
Year basis.
surcharge or taxes thereon) in the proportion of the difference
1.33 Policy Period End Date means the date on which the Policy expires, as between the room rent actually incurred and the room rent limit or
specified in the Policy Certificate. the Room Rent of the entitled room category to the room rent
actually incurred.
1.34 Policy Period Start Date means the date on which the Policy commences,
as specified in the Policy Certificate. II. Room Rent = 1% of Benefit 1 Sum Insured per day. Any amount
accrued as No Claims Bonus under Clause 2.8 shall not form part of
1.35 Policy Year means a period of 12 consecutive months commencing from the
Sum Insured.
Policy Period Start Date or any anniversary thereof.
III. Room Category = Single Private Room. Any amount
1.36 Pre-existing Disease means any condition, ailment or Injury or related
condition for which the Insured Person had signs or symptoms, and/or were
Sum Insured.
diagnosed, and/or received Medical Advice/treatment within 48 months prior to
the first Policy issued by the Company. For the purpose of this Clause only, Single Private Room means a
Hospital room where a single patient is accommodated and which

1.37 Qualified Nurse means a person who holds a valid registration from the
has an attached toilet (lavatory and bath). The room should have the
nursing council of India or the nursing council of any state in India.
provision for accommodating an attendant. Such room shall be the
1.38 Reasonable Charges means the charges for services or supplies, which are most basic and the most economical of all accommodations available
the standard charges for the specific provider and consistent with the prevailing as a single room in that Hospital.
charges in the geographical area for identical or similar services, taking into
ii) Intensive Care Unit Charges (ICU Charges) :
account the nature of the Illness/Injury involved, by comparable providers only.
I. If the Insured Person is admitted in an ICU where the ICU charges
1.39 Rehabilitation means assisting an Insured Person who, following a medical
incurred are higher than the ICU limit specified below then the
condition, requires assistance in physical, vocational, independent living and
Policyholder shall bear the ratable proportion of the Variable
educational pursuits to restore him to the position in which he was in, prior to such
Medical Expenses in the proportion of the difference between the
medical condition occurring.
ICU Charges actually incurred and ICU Charges limit to the ICU
1.40 Sum Insured means the amount specified against each Insured Person in the Charges actually incurred.
Policy Certificate which represents the Company's maximum, total and
II. ICU Charges = 2% of Benefit 1 Sum Insured per day. Any amount
cumulative liability for that Insured Person for any and all Claims incurred in
respect of that Insured Person during the Policy Year.
Sum Insured.
1.41 Surgical Procedure means manual and/or operative procedure required for
iii) Fees charged by a surgeon, anesthetist and Medical Practitioner (Doctor /
treatment of an Illness or Injury, correction of deformities and defects, diagnosis
Surgeon Fees)
and cure of diseases, relief of suffering or prolongation of life, performed in a
Hospital by a Medical Practitioner. i. Upto 25% of Benefit 1 Sum Insured per Claim. Any amount accrued
as No Claims Bonus under Clause 2.8 shall not form part of Sum
1.42 Variable Medical Expense means those Medical Expenses which vary in
Insured.
accordance with the room rent or room category or ICU charges in a Hospital.
Any Claim under this Benefit can be made under Clause 5.2(a) & (b).
2.2 Benefit 2 : Pre-hospitalization and Post-hospitalization
2. Benefits
a. The Company will indemnify the Medical Expenses incurred for the Insured
General Conditions applicable to all Benefits: Person:
a. Any Benefit shall be available only if the same is specifically mentioned in i) during a period of 30 days immediately prior to the date of the Insured
the Policy Certificate. Person's admission to the Hospital; and
b. Admissibility of a Claim under Benefit 1 is a pre-condition to the admission ii) during a period of 60 days immediately following the date of the
of a Claim for Benefit 2 to Benefit 5 and the event giving rise to the Claim Insured Person's discharge from Hospital,
under the Benefit 1 shall be within the Policy Period for the Claim for such
Provided that, the Medical Expenses relate to the same Illness/Injury for which
Benefit to be accepted.
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the Company has accepted the Insured Person's Claim. III. Recharge of Sum Insured
b. If the provisions of Clause 5.6(d) of the Policy Terms & Conditions has been x) The balance of the Recharge shall be available during the Policy Year till it is
invoked, then: exhausted completely.
i) The date of admission to Hospital for the purpose of this Benefit shall be the xi) In case of portability, the credit for Sum Insured would be available only to
date of the first admission to the Hospital for that Any One Illness; and the extent of sum insured of the expiring policy, including the Recharge.
ii) The date of discharge from Hospital for the purpose of this Benefit shall be b. For additional understanding on the terms of this Benefit please refer to Exhibit –
the last date of discharge from the Hospital in relation to that Any One 1 in Annexure B.
Illness.
c. Any Claim under this Benefit can be made under Clause 5.2(a) & (b).
c. Any Claim under this Benefit can be made under Clause 5.2(b).
2.7 Benefit 7 : Care Anywhere
2.3 Benefit 3 : Ambulance Cover
a. Company will indemnify up to the amount specified against this Benefit in the
a. The Company will indemnify up to the amount specified against this Benefit in the Policy Certificate for the Medical Expenses incurred outside India, in respect of
Policy Certificate, for the reasonable expenses necessarily incurred on availing the Insured Person during the Policy Year, provided that:
Ambulance services offered by a Hospital or by an Ambulance service provider
i) The Medical Expenses incurred are in respect of the major Illness specified
for the Insured Person's necessary transportation to the nearest Hospital in case
below only:
of an Emergency provided that the necessity of the Ambulance transportation is
certified by the treating Medical Practitioner. I. Cancer
b. Any Claim under this Benefit can be made under Clause 5.2(a) & (b). II. Benign Brain Tumour
2.4 Benefit 4 : Daily Allowance III. Major Organ Transplant / Bone Marrow Transplant
a. The Company will pay the amount specified against this Benefit in the Policy IV. Heart Valve Replacement
Certificate for each continuous and completed period of 24 hours of
V. Coronary Artery Bypass Graft
Hospitalization of the Insured Person, provided that:
ii) The Medical Expenses incurred are only for In-patient Care or Day Care
i) The Hospitalization is only for In-patient Care; and
Treatment undertaken in any Hospital.
ii) The Company will not be liable to make payment under this Benefit for
For the purposes of this Benefit, Hospital shall mean “Any institution
more than 5 consecutive days of Hospitalization for Any One Illness.
established for In-patient Care and Day Care Treatment of Injury or
b. Any Claim under this Benefit can be made under Clause 5.2(b). Illness and which has been registered as a Hospital or a clinic as per law rules
and/or regulations applicable for the country where the treatment is taken.
2.5 Benefit 5 : Organ Donor Cover
The term Hospital shall not include a place of rest, a place for the aged, a
a. The Company will indemnify up to the amount specified against this Benefit place for drug-addicts or a place for alcoholics or a hotel, health spa or
in the Policy Certificate for the Medical Expenses incurred in respect of the massage center or the like.”
donor for any organ transplant surgery conducted on the Insured Person
iii) Any payments under this Benefit shall always be made in India, in Indian
during the Policy Year, provided that:
Rupees and on a re-imbursement basis only. The rate of exchange as
i) The organ donor is an eligible donor in accordance with The published by Reserve Bank of India (RBI) as on the date of payment to the
Transplantation of Human Organs Act, 1994 (amended) and other Hospital shall be used for conversion of foreign currency amounts into
applicable laws and rules. Indian Rupees for payment of any Claim under this Benefit. Where on the
date of discharge, RBI rates are not published, the rates next published by
ii) The organ donated is for the Insured Person's use.
RBI shall be considered for conversion.
iii) The Company will not be liable to pay the Medical Expenses incurred by the
iv) The Company shall be liable to make payment under this Benefit only if
donor's for Benefit 2 or any other Medical Expenses in respect of the
prior written notice of at least 7 days is given to the Company.
donor consequent to the harvesting.
v) Clause 4.3(a)(xxi) and Clause 5.6(a) is superseded to the extent covered
b. Clause 4.3(a)(xviii) is superseded to the extent covered under this Benefit.
under this Benefit.
c. Any Claim under this Benefit can be made under Clause 5.2(a) & (b).
b. Any Claim under this Benefit can be made under Clause 5.2(b).
2.6 Benefit 6 : Recharge of Sum Insured
2.8 Benefit 8 : No Claims Bonus
a. If a Claim is payable under the Policy, then the Company agrees to automatically
a. At the end of each Policy Year, the Company will provide 10% of the Sum Insured
make the re-instatement of up to the Sum Insured for that Policy Year only
applicable on the last completed Policy Year, on a cumulative basis as a No Claims
provided that:
Bonus for each completed and continuous Policy Year, provided that no Claim has
i) The Recharge shall be utilized only after the Sum Insured and No Claims occurred in the expiring Policy Year and subject to:
Bonus have been completely exhausted in that Policy Year.
i) In any Policy Year, the accrued No Claims Bonus, (including any carried
ii) A Claim will be admissible under the Recharge only if the Claim is admissible forward Cumulative Bonuses if the portability provisions in Clause 4.2 have
under the Benefit 1. been applied), shall not exceed 50% of the total of Sum Insured available in
the renewed Policy.
iii) The Recharge shall be available only for all future Claims and not in relation
to any Illness or Injury for which a Claim has already been admitted for that ii) The No Claims Bonus shall not enhance or be deemed to enhance any
Insured Person during that Policy Year. Conditions as prescribed under Clause 2.1(c).
iv) The Recharge shall not be considered while calculating the No Claims Bonus. iii) For a Floater policy, the No Claims Bonus, shall be available only on Floater
basis and shall accrue only if no Claim has been made in respect of any
v) The total amount of Recharge shall not exceed the Sum Insured for that
Insured Person during the expiring Policy Year. The No Claims Bonus which
Policy Year.
is accrued during the claim-free Policy Year will only be available to those
vi) Any unutilized Recharge cannot be carried forward to any subsequent Insured Persons who were insured in such claim-free Policy Year and
Policy Year. continue to be insured in the subsequent Policy Year.
vii) If the Policy is issued on a Floater basis, then the Recharge will also be iv) The No Claims Bonus is provisional and is subject to revision if a Claim is
available only on Floater basis. made in respect of the expiring Policy Year.
viii) For any single Claim during a Policy Year the maximum Claim amount v) The entire No Claims Bonus will be forfeited if the Policy is not continued /
payable shall be sum of: renewed on or before Policy Period End Date or the expiry of the Grace
Period whichever is later.
I. The Sum Insured
vi) The No Claims Bonus shall be applicable on an annual basis subject
II. No Claims Bonus
to continuation of the Policy.
ix) During a Policy Year, the aggregate Claim amount payable, subject to
vii) If the Insured Persons in the expiring policy are covered on individual basis
admissibility of the Claim, shall not exceed the sum of:
and thus have accumulated the No Claims Bonus for each member in the
I. The Sum Insured expiring policy, and such expiring policy is renewed with the Company on a
Floater basis, then the No Claims Bonus to be carried forward for credit in
II. No Claims Bonus
3
this Policy would be the least No Claims Bonus amongst all the Package No. List of Medical Tests covered in Age Plan
Insured Persons. Annual Health Check-up
viii) If the Insured Persons in the expiring policy are covered on a Floater basis 1 Complete Blood Count, Urine Routine, 18 years & Care 2
and such Insured Persons renew their expiring Policy with the Company by Blood Group, ESR, Fasting Blood above
splitting the Floater Sum Insured in to 2 or more Floater / individual covers, Glucose, ECG, S Cholesterol, SGPT,
then the No Claims Bonus of the expiring Policy shall be apportioned to Creatinine
such renewed Policy in the proportion of the Sum Insured of each of the
renewed Policy. 2 Complete Blood Count, Urine Routine, 18 years & Care 3
ix) This clause does not alter the Company's right to decline renewal or Blood Group, ESR, Fasting Blood above
cancellation of the Policy for reasons as specified in Clause 6.1. Glucose, Lipid Profile, Kidney Function
Test, Complete Physical Examination
x) In the event of a Claim occurring during any Policy Year, the accrued No by Physician
Claims Bonus will be reduced by 20% of the expiring Sum Insured at the
commencement of next Policy Year, but in no case shall the Sum Insured be 3 Complete Blood Count, Urine Routine, 18 years & Care 4 &
reduced. Blood Group, ESR, Fasting Blood above Care 5
xi) In case Sum Insured under the Policy is reduced at the time of renewal, the Glucose , Lipid Profile, Stress Test (TMT)
applicable No Claims Bonus shall also be reduced in proportion to the Sum or 2D echo, Kidney Function Test,
Insured. Complete Physical Examination
by Physician
xii) In case Sum Insured under the Policy is increased at the time of renewal, the
No Claim Bonus shall be calculated on the Sum Insured applicable on the iii) It is agreed and understood that details in the table above, including the
last completed Policy Year. list of medical tests is indicative only and the Company reserves the right
to add to, modify or amend these details.
b. Any Claim under this Benefit can be made under Clause 5.2(a) & (b).
b. Any Claim under this Benefit can be made under Clause 5.2(a).
2.9 Benefit 9 : Domiciliary Hospitalization
2.11 Benefit 11 : Second Opinion
a. The Company will indemnify for the Medical Expenses incurred during Policy Year
for Domiciliary Hospitalization of the Insured Person up to the amount specified a. If the Insured Person is diagnosed with any Major Illness during the Policy Year,
against this Benefit in the Policy Certificate, provided that: then at the Policyholder's/Insured Person's request, the Company shall
arrange for a Second Opinion from a Medical Practitioner.
i) The condition of the Insured Person is such that the Insured Person is not
in a condition to be removed to a hospital; or b. It is agreed and understood that the Second Opinion will be based only on the
information and documentation provided to the Company which will be
ii) The Insured Person takes treatment at home on account of non-availability
shared with the Medical Practitioner and is subject to the following:
of room in a hospital.
i) This Benefit can be availed a maximum of one time by an Insured Person
b. For the purpose of this Benefit only, Domiciliary Hospitalization means medical
during the Policy Year for each Major Illness.
treatment for a period exceeding 3 consecutive days, for an Illness / Injury, which in
the normal course would require care and treatment at a Hospital but is actually ii) The Insured Person is free to choose whether or not to obtain the
taken while confined at home. Second Opinion and, if obtained under this Benefit, then whether or not
to act on it.
c. Any Medical Expenses incurred under Benefit 2 shall not be payable under this
Benefit. iii) This Benefit is for additional information purposes only and does not and
should not be deemed to substitute the Insured Person's visit or
d. Any Medical Expenses incurred for the treatment in relation to any of the
consultation to an independent Medical Practitioner.
following diseases shall not be payable under this Benefit :
iv) The Company does not provide a Second Opinion or make any
i) Asthma
representation as to the adequacy or accuracy of the same, the Insured
ii) Bronchitis Person's or any other person's reliance on the same or the use to which the
Second Opinion is put.
iii) Chronic Nephritis and Chronic Nephritic Syndrome

v) The Company does not assume any liability for and shall not be responsible
iv) Diarrhoea and all types of Dysenteries including Gastro-enteritis
for any actual or alleged errors, omissions or representations made by any
v) Diabetes Mellitus and Insipidus Medical Practitioner or in any Second Opinion or for any consequences of
actions taken or not taken in reliance thereon.
vi) Epilepsy
vi) The Policyholder or Insured Person shall indemnify the Company and hold
vii) Hypertension
the Company harmless for any loss or damage caused by or arising out of
viii) Influenza, cough or cold or in relation to any opinion, advise, prescription, actual or alleged errors,
omissions or representations made by the Medical Practitioner or for any
ix) All Psychiatric or Psychosomatic Disorders
consequences of any action taken or not taken in reliance thereon.
x) Pyrexia of unknown origin
vii) Any Second Opinion provided under this Benefit shall not be valid for any
xi) Tonsillitis and Upper Respiratory Tract Infection including Laryngitis and medico-legal purposes.
Pharyngitis
viii) The Second Opinion does not entitle the Insured Person to any
xii) Arthritis, Gout and Rheumatism consultation from or further opinions from that Medical Practitioner.
e. Any Claim under this Benefit can be made under Clause 5.2 (b). c. For the purposes of this Benefit only:
2.10 Benefit 10 : Health Check-up i) Second Opinion means an additional medical opinion obtained by the
Company from a Medical Practitioner solely on the Policyholder or Insured
a. On the Insured Person's request, the Company shall arrange for the Insured
Person's express request in relation to a Major Illness which the Insured
Person's Health Check-up in accordance with the table below at its Network
Person has been diagnosed with during the Policy Year.
Hospitals, provided that:
ii) Major Illness means one of the following only:
i) This Benefit shall be available only to those Insured Persons that are Age 18
or above on the Policy Period Start Date provided further that this Benefit I. Benign Brain Tumour
shall not be available to any Insured Person who is covered under the
II. Cancer
Policy as the Policyholder's child.
III. End Stage Lung Failure
ii) This Benefit shall only be available once in every year during the Policy Year.
IV. Heart Attack
V. Open Chest Coronary Artery Bypass Graft
VI. Heart Valve Replacement
VII. Coma
4 8
VIII. End Stage Renal Failure VIII. All types of Hernia, Hydrocele;
IX. Stroke IX. Hysterectomy for menorrhagia or fibromyoma or prolapse of uterus
unless necessitated by malignancy;
X. Major Organ Transplant
X. Internal tumors, skin tumors, cysts, nodules, polyps including breast
XI. Paralysis
lumps (each of any kind) unless malignant;
XII. Motor Neuron Disease
XI. Kidney Stone/Ureteric Stone/Lithotripsy/Gall Bladder Stone;
XIII. Multiple Sclerosis
XII. Myomectomy for fibroids;
XIV. Major Burns
XIII. Varicose veins and varicose ulcers
XV. End Stage Liver Disease
ii) If an Insured Person is suffering from any of the above Illnesses, conditions
d. Any Claim under this Benefit can be made under Clause 5.2(a). or Pre-existing Diseases at the time of commencement of first policy with
the Company, any Claim in respect of that Illness, condition or Pre-existing
Disease shall not be covered until the completion of 48 months of
3. Special Conditions continuous insurance coverage with the Company from the first Policy
Period Start Date.
Special Conditions shall be applicable only if the same is specifically mentioned in the Policy
Certificate. c. Pre-existing Disease: Claims will not be admissible for any Medical Expenses
incurred as Hospitalization Expenses for diagnosis/treatment of any Pre-existing
3.1 Special Condition 1 : Floater Cover Disease until 48 months of continuous coverage has elapsed, since the inception
a. The Company's maximum, total and cumulative liability, for any and all Claims of the first Policy with the Company.
incurred during the Policy Year in respect of all Insured Persons, shall not exceed d. If the Sum Insured is enhanced on any renewal of this Policy, the waiting periods as
the Sum Insured. defined above in Clauses 4.1(a), 4.1(b) and 4.1(c) shall be applicable afresh to the
b. Definition 1.40 is deleted entirely and replaced with the following: incremental amount of the Sum Insured only.
Sum Insured : The amount specified in the Policy Certificate which e. If the Sum Insured is reduced on any renewal of this Policy, the credit for waiting
represents the Company's maximum, total and cumulative liability for all Insured periods as defined above in Clauses 4.1(a), 4.1(b) and 4.1(c) shall be restricted to
Persons for any and all Claims incurred during the Policy Year. the lowest Sum Insured under the previous Policy.
3.2 Special Condition 2 : Co-payment f. The Waiting Periods as defined in Clauses 4.1(a), 4.1(b) and 4.1(c) shall be
applicable individually for each Insured Person and Claims shall be assessed
a. The Policyholder shall bear 20% of the Final Claim Amount assessed by the accordingly.
Company in accordance with Clause 5.5 in accordance with the table below and
the Company's liability shall be restricted to the balance amount payable : 4.2 Portability
a. If the Policyholder and/or Insured Person applies to the Company for a health
Cover Type Entry Age* of Insured Person Applicable To
insurance policy, provided that
or Eldest Insured Person
(in case of Floater) i) The proposed Insured Person has to be covered without any break under
any similar individual indemnity health insurance policy from any non-life
Individual >=61 years Individual Insured Person insurance company registered with the IRDA or any similar group
Floater >=61 years All Insured Person's indemnity health insurance policy from the Company; and
* Entry Age means the age of the Insured Person at the time of issue of the first Policy with the Company. ii) The Sum Insured opted for with the Company should be equal to or higher
than the Sum Insured of the expiring health policy, then
b. The Co-payment shall be applicable to each and every Claim, for each Insured Person.
The Waiting Periods as defined in Clauses 4.1(a), 4.1(b) and 4.1(c) of this
Policy shall be reduced by the number of months of continuous coverage
under such health insurance policy with the previous insurer to the extent of the
4. Exclusions Sum Insured and the Eligible Cumulative Bonus under the expiring health
insurance policy.
4.1. Waiting Period
The Waiting Periods under Clauses 4.1(a), 4.1(b) and 4.1(c) shall be applicable
a. 30-Day waiting period
afresh to the amount by which the Sum Insured under this Policy exceeds the total
i) Claim for any Medical Expenses incurred for treatment of any Illness during of sum insured and Eligible Cumulative Bonus under the terms of the expiring
the first 30 days of Policy Period Start Date shall not be admissible, except policy.
those Medical Expenses incurred as a result of an Injury.
b. The Waiting Periods as defined in Clauses 4.1(a), 4.1(b) and 4.1(c) shall be
ii) This exclusion shall not apply for subsequent Policy Years provided that applicable individually for each Insured Person and Claims shall be assessed
there is no break in insurance cover for that Insured Person and that the accordingly.
Policy has been renewed with the Company for that Insured Person on
c. Credit for the sum insured and the Eligible Cumulative Bonus of the expiring
time and for the same or lower Sum Insured.
policy shall additionally be available as under:
b. Specific waiting period
i) If the Insured Person was covered on a Floater basis under the expiring
i) Any Claim for or arising out of any of the following Illnesses or Surgical policy and is proposed to be covered on a Floater basis with the Company,
Procedures shall not be admissible during the first 24 (twenty then the Eligible Cumulative Bonus to be carried forward for credit under
four)consecutive months of coverage of the Insured Person by the this Policy would also be applied on a Floater basis only.
Company from the first Policy Period Start Date:
ii) In all other cases the Eligible Cumulative Bonus to be carried forward for
I. Arthritis (if non-infective), Osteoarthritis and Osteoporosis, Gout, credit in this Policy would be applied on an individual basis only.
Rheumatism and Spinal Disorders, Joint Replacement Surgery;
For the purpose of this provision the “Eligible Cumulative Bonus” shall mean the additional
II. Benign ear, nose and throat (ENT) disorders and surgeries (including sum insured and cumulative bonus which the Insured Person would have been eligible for,
but not limited to Adenoidectomy, Mastoidectomy, Tonsillectomy had the same policy been renewed with the same insurance company.
and Tympanoplasty), Nasal Septum Deviation, Sinusitis and related
d. In case the Policyholder has opted to switch to any other insurer under portability
disorders;
and the outcome of acceptance of the portability is awaited from the new insurer
III. Benign Prostatic Hypertrophy; on the date of renewal:
IV. Cataract; i) The Company may at the request of the Policyholder, extend the Policy for
a period not less than 1 month at an additional premium to be paid on a
V. Dilatation and Curettage;
pro-rated basis.
VI. Fissure/Fistula in anus, Hemorrhoids/Piles, Pilonidal Sinus, Gastric
ii) In case any Claim is reported during the extended Policy Period, the
and Duodenal Ulcers;
Policyholder shall first pay the premium so as to make the Policy Period of
VII. Surgery of Genito urinary system unless necessitated by malignancy; 12 full calendar months. The Company's liability for the payment of the
Claim shall commence only once such premium is received. Alternately,
9 5
the Company may deduct the premium payable by the Policyholder xix) Non-allopathic treatment.
and pay the balance Claim amount, if any and issue Policy for the balance
xx) Any out-patient treatment.
Policy Period.
Note: Portability provisions will apply even if the Insured Person migrates to any other xxi) Treatment received outside India.
health insurance policy.
xxii) Charges incurred at Hospital primarily for diagnostic, X-ray or laboratory
4.3 Permanent Exclusions examinations not consistent with or incidental to the diagnosis and
treatment of the positive existence or presence of any Illness or Injury, for
a. Any Claim in respect of any Insured Person for, arising out of or directly or
which In-patient Care/ Day Care Treatment is required.
indirectly due to any of the following shall not be admissible unless expressly stated
to the contrary elsewhere in the Policy terms and conditions: xxiii) War (whether declared or not) and war like occurrence or invasion, acts of
foreign enemies, hostilities, civil war, rebellion, revolutions, insurrections,
i) Any condition directly or indirectly caused by or associated with any
mutiny, military or usurped power, seizure, capture, arrest, restraints and
sexually transmitted disease, including Genital Warts, Syphilis,
detainment of all kinds.
Gonorrhoea, Genital Herpes, Chlamydia, Pubic Lice and Trichomoniasis,
Acquired Immuno Deficiency Syndrome (AIDS) whether or not arising out xxiv) Any Illness or Injury directly or indirectly resulting or arising from or
of HIV, Human T-Cell Lymphotropic Virus Type III (HTLV–III or IITLB-III) or occurring during commission of any breach of any law by the Insured
Lymphadinopathy Associated Virus (LAV) or the mutants derivative or Person with any criminal intent.
Variations Deficiency Syndrome or any Syndrome or condition of a similar
xxv) Act of self-destruction or self-inflicted Injury, attempted suicide or suicide
kind.
while sane or insane or Illness or Injury attributable to consumption, use,
ii) Any treatment arising from or traceable to pregnancy (including voluntary misuse or abuse of tobacco, intoxicating drugs and alcohol or hallucinogens.
termination), miscarriage (unless due to an Accident), childbirth, maternity
xxvi) Any charges incurred to procure any medical certificate, treatment or
(including caesarian section), abortion or complications of any of these.
Illness related documents pertaining to any period of Hospitalization or
This exclusion will not apply to ectopic pregnancy.
Illness.
iii) Any treatment arising from or traceable to any fertility, infertility, sub
xxvii) Personal comfort and convenience items or services including but not
fertility or assisted conception procedure or sterilization, birth control
limited to T.V. (wherever specifically charged separately), charges for access
procedures, hormone replacement therapy, contraceptive supplies or
to telephone and telephone calls (wherever specifically charged
services including complications arising due to supplying services or
separately), foodstuffs (except patient's diet), cosmetics, hygiene articles,
Assisted Reproductive Technology.
body or baby care products and bath additive, barber or beauty service,
iv) Any dental treatment or surgery unless necessitated due to an Injury. guest service as well as similar incidental services and supplies.
v) Treatment taken from anyone who is not a Medical Practitioner or from a xxviii) Stem Cell implantation, harvesting, storage or any kind of treatment using
Medical Practitioner who is practicing outside the discipline for which he is stem cells.
licensed or any kind of self-medication.
xxix) Expenses related to any kind of RMO charges, service charge, surcharge,
vi) Charges incurred in connection with cost of spectacles and contact lenses, admission fees, registration fees, night charges levied by the hospital under
hearing aids, routine eye and ear examinations, laser surgery for correction whatever head.
of refractory errors, dentures, artificial teeth and all other similar external
xxx) Any Hospitalization primarily for investigation and/or diagnosis purpose.
appliances and/or devices whether for diagnosis or treatment.
xxxi) Nuclear, chemical or biological attack or weapons, contributed to, caused
vii) Experimental, investigational or unproven treatments which are not
by, resulting from or from any other cause or event contributing
consistent with or incidental to the diagnosis and treatment of the positive
concurrently or in any other sequence to the loss, claim or expense. For the
existence or presence of any Illness for which confinement is required at a
purpose of this exclusion:
Hospital. Any Illness or treatment which is a result or a consequence of
undergoing such experimental or unproven treatment. I. Nuclear attack or weapons means the use of any nuclear weapon or
device or waste or combustion of nuclear fuel or the emission,
viii) Any expenses incurred on prosthesis, corrective devices, external durable
discharge, dispersal, release or escape of fissile/fusion material
medical equipment of any kind, like wheelchairs, walkers, belts, collars, caps,
emitting a level of radioactivity capable of causing any Illness,
splints, braces, stockings of any kind, diabetic footwear,
incapacitating disablement or death.
glucometer/thermometer, crutches, ambulatory devices, instruments used

in treatment of sleep apnea syndrome (C.P.A.P) or continuous ambulatory II. Chemical attack or weapons means the emission, discharge,
peritoneal dialysis (C.A.P.D.) and oxygen concentrator for asthmatic dispersal, release or escape of any solid, liquid or gaseous chemical
condition, cost of cochlear implants. compound which, when suitably distributed, is capable of causing any
Illness, incapacitating disablement or death.
ix) Weight management services and treatment, services and supplies
including treatment of obesity (including morbid obesity) III. Biological attack or weapons means the emission, discharge,
dispersal, release or escape of any pathogenic (disease producing)
x) Any treatment related to sleep disorder or sleep apnea syndrome, general
micro-organisms and/or biologically produced toxins (including
debility convalescence, cure, rest cure, health hydros, nature cure clinics,
genetically modified organisms and chemically synthesized toxins)
sanatorium treatment, Rehabilitation measures, private duty nursing,
which are capable of causing any Illness, incapacitating disablement or
respite care, long-term nursing care, custodial care or any treatment in an
death.
establishment that is not a Hospital.
In addition to the foregoing, any loss, claim or expense of whatsoever
xi) Treatment of any Congenital Anomaly or Illness or defects or anomalies or
nature directly or indirectly arising out of, contributed to, caused by,
treatment relating to birth defects.
resulting from, or in connection with any action taken in controlling,
xii) Treatment of mental illness, stress, psychiatric or psychological disorders. preventing, suppressing, minimizing or in any way relating to the above shall
also be excluded.
xiii) Aesthetic treatment, cosmetic surgery or plastic surgery or related
treatment of any description, including any complication arising from these xxxii) Impairment of an Insured Person's intellectual faculties by abuse of
treatments, other than as may be necessitated due to an Injury, cancer or stimulants or depressants.
burns.
xxxiii) Alopecia, wigs and/or toupee and all hair or hair fall treatment and
xiv) Any treatment/surgery for change of sex or gender reassignments products.
including any complication arising from these treatments.
xxxiv) Any treatment taken in a clinic, rest home, convalescent home for the
xv) Circumcision unless necessary for treatment of an Illness or as may be addicted, detoxification center, sanatorium, home for the aged, mentally
necessitated due to an Accident. disturbed, remodeling clinic or similar institutions.
xvi) All preventive care, vaccination, including inoculation and immunizations
(except in case of post-bite treatment), vitamins and tonics.
5. Claims Intimation, Assessment and Management
xvii) Artificial life maintenance, including life support machine use, where such
treatment will not result in recovery or restoration of the previous state of 5.1 Upon the occurrence of any Illness or Injury that may give rise to a Claim under
health. this Policy, then as a condition precedent to the Company's liability under the
xviii) All expenses related to donor screening, treatment, including surgery to Policy, the Policyholder or Insured Person shall undertake all of the following:
remove organs from the donor, in case of transplant surgery. a. Claims Intimation
6 01
i) If any Illness is diagnosed or discovered or any Injury is suffered or any other b. Re-imbursement
contingency occurs which has resulted in a Claim or may result in a Claim
The Company shall be given intimation of Hospitalization at its call center or in
under the Policy, the Policyholder or Insured Person, shall notify the
writing at least 48 hours before the commencement of a planned Hospitalization
Company either at the Company's call center or in writing immediately.
or within 24 hours of admission to Hospital, if the Hospitalization is required in an
ii) If the Insured Person is to undergo planned Hospitalization, the Emergency. It is agreed and understood that in all cases where intimation of a
Policyholder or Insured Person shall give written intimation to the Claim has been provided under this provision, all the information and
Company of the proposed Hospitalization at least 48 hours prior to the documentation specified in Clause 5.4 below shall be submitted (at the
planned date of admission to Hospital. Policyholder or Insured Person's expense) to the Company immediately and in
any event within 15 days of Insured Person's discharge from Hospital.
iii) It is agreed and understood that the following details are to be provided to
the Company at the time of intimation of Claim: 5.3 Policyholder's or Insured Person's duty at the time of Claim
I. Policy Number; a. The Policyholder or Insured Person shall check the updated list of Network
Hospitals before submission of a pre-authorisation request for cashless facility;
II. Name of the Policyholder;
and
III. Name of the Insured Person in respect of whom the Claim is being
b. It is agreed and understood that as a condition precedent for a Claim to be
made;
considered under this Policy:
IV. Nature of Illness or Injury;
i) All reasonable steps and measures must be taken to avoid or minimize the
V. Name and address of the attending Medical Practitioner and quantum of any Claim that may be made under this Policy.
Hospital;
ii) The Insured Person shall follow the directions, advice or guidance provided
VI. Date of admission to Hospital or proposed date of admission to by a Medical Practitioner and the Company shall not be obliged to make
Hospital for planned Hospitalization; payment that is brought about or contributed to by the Insured Person
failing to follow such directions, advice or guidance.
VII. Any other information, documentation or details requested by the
Company. iii) Intimation of the Claim, notification of the Claim and submission or
provision of all information and documentation shall be made promptly
5.2 Claims Procedure
and in any event in accordance with the procedures and within the
a. Cashless timeframes specified in Clause 5 of the Policy.
i) Cashless facility is available only at Network Hospitals. The Insured Person iv) The Insured Person will, at the request of the Company, submit himself for
can avail of this cashless facility at the time of admission into a Network a medical examination by the Company's nominated Medical Practitioner
Hospital, by presenting the health card provided by the Company under as often as the Company considers reasonable and necessary. The cost of
this Policy along with a valid photo identification document (Voter such examination will be borne by the Company.
ID card/Driving License/Passport/PAN Card or any other identification
v) The Company's Medical Practitioner and representatives shall be given
documentation as approved by the Company).
access and co-operation to inspect the Insured Person's medical and
ii) In addition to the foregoing, in order to avail of the cashless facility, the Hospitalization records and to investigate the facts and examine the
following procedure must be followed: Insured Person.
I. Pre-authorization: The Policyholder or Insured Person must call the vi) The Company shall be provided with complete documentation and
Company's call center and request authorization for the proposed information which the Company has requested to establish its liability for
treatment by way of submission of a completed pre-authorization the Claim, its circumstances and its quantum.
form at least 48 hours before the commencement of planned
5.4 Claim Documents
Hospitalization or within 24 hours of admission to Hospital, if the
Hospitalization is required in an Emergency. a. The following information and documentation shall be submitted in accordance
with the procedures and within the timeframes specified in Clause 5 in respect of
II. The Company will process the request for authorization after having
all Claims:
obtained accurate and complete information in respect of the Illness
or Injury for which cashless facility is sought to be availed. The i) Duly completed and signed Claim form, in original;
Company will confirm in writing authorization or rejection of the

ii) Medical Practitioner's referral letter advising Hospitalization;
request to avail cashless facility for the Insured Person's
Hospitalization. iii) Medical Practitioner's prescription advising drugs/diagnostic tests/
consultation;
III. If the request for availing cashless facility is authorized by the
Company, then payment for the Medical Expenses incurred in iv) Original bills, receipts and discharge card from the Hospital/
respect of the Insured Person shall not have to be made to the extent Medical Practitioner;
that such Medical Expenses are covered under this Policy and fall
v) Original bills from pharmacy/chemists;
within the amount authorized in writing by the Company for availing
cashless facility. Payment in respect of co-payments (if applicable) or vi) Original pathological/diagnostic test reports/radiology reports
any other costs and expenses not authorized under the cashless and payment receipts;
facility shall be made directly by the Policyholder or Insured Person to
vii) Indoor case papers;
the Network Hospital. All original bills and evidence of treatment for
the Medical Expenses incurred in respect of the Hospitalization of viii) First Information Report, final police report, if applicable;
the Insured Person and all other information and documentation
ix) Post mortem report, if conducted;
specified at Clause 5.4 shall be submitted to the Network Hospital
immediately and in any event before the Insured Person's discharge x) Any other document as required by the Company to assess the Claim
from Hospital.
b. Only in the event that original bills, receipts, prescriptions, reports or other
IV. If the Company does not authorize the cashless facility due to documents have already been given to any other insurance company or to a
insufficient Sum Insured or if insufficient information is provided to reimbursement provider the Company will accept properly verified photocopies
the Company to determine the admissibility of the Claim, payment of such documents attested by such other insurance company/reimbursement
for the treatment will have to be made by the Policyholder or Insured provider along with an original certificate of the extent of payment received from
Person to the Network Hospital, following which a Claim for such insurance company/reimbursement provider.
reimbursement may be made to the Company and the same will be
c. The Company will only accept bills/invoices which are made in the Insured
considered by the Company subject to the Policy.
Person's name.
iii) It is agreed and understood that the Company may, in its sole discretion,
d. The Company shall condone delay on merit for delayed Claims where delay is proved
modify or add to the list of Network Hospitals or modify or restrict the
to be for reasons beyond the control of the Policyholder or the Insured Person.
extent of cashless facilities that may be availed at any particular Network
Hospital. For an updated list of Network Hospitals and the extent of 5.5 Claim Assessment
cashless facilities available at each Network Hospital, the Policyholder or
a. All admissible Claims under this Policy shall be assessed by the Company in the
Insured Person can refer to the list of Network Hospitals available on the
following progressive order:
Company's website or at the call centre.
i) If the provisions of the Contribution Clause in Clause 6.9 are applicable, the
11 7
Company's liability to make payment under that Claims shall first 6.6 No constructive Notice
be apportioned accordingly.
Any knowledge or information of any circumstance or condition in relation to the
ii) If a room/ICU accommodation has been opted for where the rent or Policyholder or Insured Person which is in possession of the Company other than
category is higher than the eligible limit as applicable in accordance with Clause that information expressly disclosed in the Proposal Form or otherwise in writing
2.1(c)(i) & (ii) for that Insured Person under the Policy, then, the Variable to the Company, shall not be held to be binding or prejudicially affect the
Medical Expenses payable shall be pro-rated as per the applicable limits. Company.
iii) If any sub-limits on Medical Expenses are applicable in accordance with 6.7 Complete discharge
Clause 2.1(c)(iii), the Company's liability to make payment shall be limited
Payment made by the Company to the Policyholder or Insured Person or the
to such extent as applicable.
nominee of the Policyholder or the legal representative of the Policyholder or to
iv) Co-payment, if any, shall be applicable on the amount payable by the the Hospital, as the case may be, of any Medical Expenses or compensation or
Company after applying Clause 5.5(a)(i), (ii) and (iii). benefit under the Policy shall in all cases be complete and construe as an effectual
discharge in favor of the Company.
b. The Claim amount assessed in Clause 5.5(a) above would be deducted from the
following amounts in the following progressive order: 6.8 Subrogation
i) Sum Insured; The Policyholder and Insured Person shall at his own expense do or concur in
doing or permit to be done all such acts and things that may be necessary or
ii) No Claims Bonus;
reasonably required by the Company for the purpose of enforcing and/or
iii) Recharge of Sum Insured (if applicable). securing any civil or criminal rights and remedies or obtaining relief or indemnity
from any other party to which the Company is or would become entitled upon
5.6 Payment Terms
the Company paying for a Claim under this Policy, whether such acts or things shall
a. This Policy covers only medical treatment taken entirely within India. All payments be or become necessary or required before or after its payment. Neither the
under this Policy shall be made in Indian Rupees and within India. Policyholder nor any Insured Person shall prejudice these subrogation rights in any
manner and shall at his own expense provide the Company with whatever
b. The Sum Insured of the Insured Person shall be reduced by the amount payable or
assistance or cooperation is required to enforce such rights. Any recovery the
paid under the Policy Terms and Conditions and only the balance amount shall be
Company makes pursuant to this clause shall first be applied to the amounts paid
available as the Sum Insured for the unexpired Policy Year.
or payable by the Company under this Policy and any costs and expenses incurred
c. The Company shall have no liability to make payment of a Claim under the Policy in by the Company of effecting a recovery, where after the Company shall pay any
respect of an Insured Person, once the Sum Insured for that Insured Person is balance remaining to the Policyholder. This clause shall not apply to any Benefit
exhausted. offered on a fixed benefit basis.
d. If the Policyholder or Insured Person suffers a relapse within 45 days of the date of 6.9 Contribution
discharge from the Hospital for which a Claim has been made, then such relapse
If at the time when any Claim arises under this Policy, there is any other insurance
shall be deemed to be part of the same Claim and all the limits for Any One Illness
which covers (or would have covered but for the existence of this Policy), the
under this Policy shall be applied as if they were under a single Claim.
same Claim (in whole or in part), then the Company shall not be liable to pay or
e. For cashless Claims, the payment shall be made to the Network Hospital whose contribute more than its ratable proportion of any Claim. This clause shall not
discharge would be complete and final. apply to any Benefit offered on a fixed benefit basis.
f. For the Reimbursement Claims, the Company will pay the Policyholder. In the 6.10 Policy Disputes
event of death of the Policyholder, the Company will pay the nominee (as named
Any and all disputes or differences under or in relation to the validity, construction,
in the Policy Certificate) and in case of no nominee at its discretion to the legal
interpretation and effect to this Policy shall be determined by the Indian Courts
heirs of the Policyholder whose discharge shall be treated as full and final
and in accordance with Indian law. The disputes on quantum on payment of losses
discharge of its liability under the Policy.
or any other dispute explained in the paragraph shall be preferred to be dealt and
resolved under the alternative dispute resolutions system including Arbitration
and Conciliation Act of India.
6. General Terms and Conditions
6.11 Free Look Period
6.1 Duty of disclosure & Fraud a. The Policyholder may, within 15 days from the receipt of the Policy document,
If any untrue or incorrect statements are made or there has been a return the Policy stating reasons for his objection, if the Policyholder disagrees
misrepresentation, mis-description or non-disclosure of any material particulars with any Policy terms and conditions. If no Claim has been made under the Policy,
or any material information having been withheld or if a Claim is fraudulently the Company will refund the premium received after deducting proportionate
made or any fraudulent means or devices are used by the Policyholder or the risk premium for the period on cover, expenses for medical examination (as per
Insured Person or any one acting on his/their behalf, the Company shall have no the below mentioned grid) and stamp duty charges. If only part of the risk has
liability to make payment of any Claims and the premium paid shall be forfeited to commenced, such proportionate risk premium shall be calculated as
the Company. commensurate with the risk covered during such period.
6.2 Observance of Terms and Conditions Age/Sum Insured Sum Insured upto Sum Insured 7 Lac Sum Insured above
The due observance and fulfillment of the terms and conditions of this Policy 5 Lac & 10 Lac 10 Lac
(including the realization of premium by their respective due dates and 6 years to 18 years Nil Nil `2,200
compliance with the specified procedure on all Claims) in so far as they relate to
anything to be done or complied with by the Policyholder or any Insured Person, 19 years to 45 years Nil `825 `2,200
shall be condition precedent to the Company's liability under the Policy. 46 years & above `825 `2,200 `2,200
6.3 Reasonable Care
b. It is agreed and understood that this clause cannot be exercised on any renewal
Insured Persons shall take all reasonable steps to safeguard the interests against of this Policy, if the Policy terms and conditions remain unchanged.
any Illness or Injury that may give rise to a Claim.
6.12 Renewal Terms
6.4 Material Change
a. This Policy will automatically terminate on the Policy Period End Date. All
It is a condition precedent to the Company's liability under the Policy that the
renewal applications should reach the Company on or before the Policy Period
Policyholder shall immediately notify the Company in writing of any material
End Date.
change in the risk on account of change in nature of occupation or business at his
own expense. The Company may, in its discretion, adjust the scope of cover and/ b. The Company may, in its sole discretion, revise the renewal premium payable
or the premium paid or payable, accordingly. under the Policy provided that revisions to the renewal premium are in
accordance with the IRDA rules and regulations as applicable from time to
6.5 Records to be maintained
time. The premium payable on renewal shall be paid to the Company on or
The Policyholder and Insured Person shall keep an accurate record containing all before the Policy Period End Date and in any event before the expiry of the
relevant medical records and shall allow the Company or its representatives to Grace Period.
inspect such records. The Policyholder or Insured Person shall furnish such
c. For the purpose of this provision, Grace Period means a period of 30 days
information as the Company may require under this Policy at any time during the
immediately following the Policy Period End Date during which a payment can be
Policy Period and up to three years after the Policy Period End Date, or until final
made to renew this Policy without loss of continuity benefits such as Waiting
adjustment (if any) and resolution of all Claims under this Policy.
8 21
Periods and coverage of Pre-existing Diseases. Coverage is not available for the increase/decrease of the Sum Insured shall be permissible only at the time of
period for which premium is not received by the Company and the Company shall renewal of the Policy.
not be liable for any Claims incurred during such period. The provisions of Section
6.17 Overriding effect of Policy Certificate
64VB of the Insurance Act shall be applicable.
In case of any inconsistency in the terms and conditions in this Policy vis-a-vis the
d. The Company will ordinarily not refuse to renew the Policy except on ground
information contained in the Policy Certificate, the information contained in the
of fraud, moral hazard or misrepresentation.
Policy Certificate shall prevail.
e. If the Policy Certificate specifies that the Policy has been issued on an auto
6.18 Electronic Transactions
renewal basis, the conditions specified above shall apply only on the expiry of
the entire auto renewal period as specified in the Policy Certificate. The Policyholder and Insured Person agree to adhere to and comply with all such
terms and conditions as the Company may prescribe from time to time, and
f. The Company reserves the right to carry out underwriting in relation to any
hereby agrees and confirms that all transactions effected by or through facilities
request for increase of the Sum Insured at the time of renewal of the Policy.
for conducting remote transactions including the Internet, World Wide Web,
6.13 Cancellation/Termination electronic data interchange, call centers, tele-service operations (whether voice,
video, data or combination thereof) or by means of electronic, computer,
a. The Company may at any time, cancel this Policy on grounds as specified in Clause automated machines network or through other means of telecommunication,
6.1, by giving 15 days' notice in writing by Registered Post Acknowledgment Due / established by or on behalf of the Company, for and in respect of the Policy or its
recorded delivery to the Policyholder at his last known address. terms, or the Company's other products and services, shall constitute legally
binding and valid transactions when done in adherence to and in compliance with
b. The Policyholder may also give 15 days' notice in writing, to the Company, for the the Company's terms and conditions for such facilities, as may be prescribed from
cancellation of this Policy, in which case the Company shall from the date of receipt time to time.
of the notice, cancel the Policy and refund the premium for the unexpired period
of this Policy at the short period scales as mentioned below, provided no Claim has 6.19 Grievances
been made under the Policy. a. The Company has developed proper procedures and effective mechanism to
c. Refund % to be applied on premium received address complaints, if any of the customers. The Company is committed to
comply with the Regulations, standards which have been set forth in the
Cancellation date up to (x months) from 1 Year 2 Year 3 Year Regulations, Circulars issued from time to time in this regard.
Policy Period Start Date
b. If the Policyholder has a grievance that the Policyholder wishes the Company to
Upto 1 month 75.0% 87.0% 91.0% redress, the Policyholder may contact the Company with the details of his
grievance through:
Upto 3 months 50.0% 74.0% 82.0%
Website : www.religarehealthinsurance.com
Upto 6 months 25.0% 61.5% 73.5%
E-mail : [email protected]
Upto 12 months 0.0% 48.5% 64.5% Contact No.: 1800-200-4488
Upto 15 months N.A. 24.5% 47.0% Fax : 1800-200-6677
Upto 18 months N.A. 12.0% 38.5% Post/Courier : Any branch office or the correspondence address, during normal
business hours
Upto 24 months N.A. 0.0% 30.0%
c. If the Policyholder is not satisfied with the Company's redressal of the
Upto 30 months N.A. N.A. 8.0% Policyholder's grievance through one of the above methods, the Policyholder may
Beyond 30 months N.A. N.A. 0.0% contact the Company's Head of Customer Service at:
d. In case of demise of the Policyholder, The Grievance Cell,

Religare Health Insurance Company Limited
i) Where the Policy covers only the Policyholder, this Policy shall stand null
and void from the date and time of demise of the Policyholder. GYS Global,
Plot No. A3, A4, A5,
ii) Where the Policy covers other Insured Members, this Policy shall
Sector - 125,
continue till the end of Policy Period. If the other Insured Persons wish to
continue with the same Policy, the Company will renew the Policy subject Noida, U.P. - 201301
to the appointment of a Policyholder provided that: d. If the Policyholder is not satisfied with the Company's redressal of the
I. Written notice in this regard is given to the Company before the Policyholder's grievance through one of the above methods, the Policyholder may
Policy Period End Date; and approach the nearest Insurance Ombudsman for resolution of the grievance. The
contact details of Ombudsman offices are mentioned below:
II. A person over Age 18 who satisfies the Company's criteria to
become a Policyholder.
6.14 Limitation of Liability
Any Claim under this Policy for which the notification or intimation of Claim is
received 12 calendar months after the event or occurrence giving rise to the
Claim shall not be admissible, unless the Policyholder proves to the Company's
satisfaction that the delay in reporting of the Claim was for reasons beyond his
control.
6.15 Communication
a. Any communication meant for the Company must be in writing and be delivered
to its address shown in the Policy Certificate. Any communication meant for the
Policyholder will be sent by the Company to his last known address or the address
as shown in the Policy Certificate.
b. All notifications and declarations for the Company must be in writing and sent to
the address specified in the Policy Certificate. Agents are not authorized to
receive notices and declarations on the Company's behalf.
c. Notice and instructions will be deemed served 10 days after posting or
immediately upon receipt in the case of hand delivery, facsimile or e-mail.
6.16 Alterations in the Policy
This Policy constitutes the complete contract of insurance. No change or
alteration shall be valid or effective unless approved in writing by the Company,
which approval shall be evidenced by a written endorsement signed and stamped
by the Company. However, change or alteration with respect to
31 9
Office of the Ombudsmen Name of the Ombudsmen Contact Details Area of Jurisdiction
AHMEDABAD Shri P. Ramamoorthy Insurance Ombudsman, Gujarat , UT of Dadra & Nagar Haveli,
Office of the Insurance Ombudsman, 2nd Floor, Ambica House, Daman and Diu
Nr. C.U. Shah College, Ashram Road, AHMEDABAD - 380 014.
Tel : 079-27546840, Fax : 079-27546142
BHOPAL Insurance Ombudsman, Madhya Pradesh & Chhattisgarh
Office of the Insurance Ombudsman, Janak Vihar Complex,
2nd Floor, 6, Malviya Nagar, Opp. Airtel, Near New Market,
BHOPAL(M.P.) - 462 023.
Tel : 0755-2569201, Fax : 0755-2769203
BHUBANESHWAR Shri B. P. Parija Insurance Ombudsman, Orissa
Office of the Insurance Ombudsman, 62, Forest Park,
BHUBANESHWAR - 751 009.
Tel : 0674-2596455, Fax : 0674-2596429
CHANDIGARH Insurance Ombudsman, Punjab , Haryana, Himachal Pradesh,
Office of the Insurance Ombudsman, S.C.O. No.101-103, Jammu & Kashmir , UT of Chandigarh
2nd Floor, Batra Building, Sector 17-D, CHANDIGARH - 160 017.
Tel : 0172-2706468, Fax : 0172-2708274
CHENNAI Shri V. Ramasaamy Insurance Ombudsman, Tamil Nadu, UT - Pondicherry Town
Office of the Insurance Ombudsman, Fathima Akhtar Court, and Karaikal (which are part of UT of
4th Floor, 453 (old 312), Anna Salai, Teynampet, CHENNAI - 600 018. Pondicherry)
Tel : 044-24333668/5284, Fax : 044-24333664
NEW DELHI Shri Surendra Pal Singh Insurance Ombudsman, Delhi & Rajasthan
Office of the Insurance Ombudsman, 2/2 A, Universal Insurance Bldg.,
Asaf Ali Road, NEW DELHI - 110 002.
Tel : 011-23239633, Fax : 011-23230858
GUWAHATI Shri D. C. Choudhury Insurance Ombudsman, Assam , Meghalaya, Manipur, Mizoram,
Office of the Insurance Ombudsman, “Jeevan Nivesh”, 5th Floor, Arunachal Pradesh, Nagaland
Near Panbazar Overbridge, S.S. Road, GUWAHATI - 781 001 (ASSAM). and Tripura
Tel : 0361-2132204/5, Fax : 0361-2732937
HYDERABAD Shri K. Chandrahas Insurance Ombudsman, Andhra Pradesh, Karnataka and
Office of the Insurance Ombudsman, 6-2-46, 1st Floor, Moin Court, UT of Yanam - a part of the UT
A.C. Guards, Lakdi-Ka-Pool, HYDERABAD - 500 004. of Pondicherry
Tel : 040-65504123, Fax : 040-23376599
KOCHI Shri R. Jyothindranathan Insurance Ombudsman, Kerala, UT of (a) Lakshadweep,
Office of the Insurance Ombudsman, 2nd Floor, CC 27/2603, (b) Mahe - a part of UT
Pulinat Bldg., Opp. Cochin Shipyard, M.G. Road, ERNAKULAM - 682 015. of Pondicherry
Tel : 0484-2358759, Fax : 0484-2359336
KOLKATA Ms. Manika Datta Insurance Ombudsman, West Bengal, Bihar, Jharkhand and
Office of the Insurance Ombudsman, 4th Floor, UT of Andeman & Nicobar Islands,
Hindusthan Bldg. Annexe, 4, C.R.Avenue, Kolkatta - 700 072. Sikkim
Tel : 033-22124346/(40), Fax : 033-22124341
LUCKNOW Shri G. B. Pande Insurance Ombudsman, Uttar Pradesh and Uttaranchal
Office of the Insurance Ombudsman, Jeevan Bhawan, Phase-2,
6th Floor, Nawal Kishore Road, Hazaratganj, LUCKNOW - 226 001.
Tel : 0522-2231331, Fax : 0522-2231310
MUMBAI Shri S. Viswanathan Insurance Ombudsman, Maharashtra, Goa
Office of the Insurance Ombudsman, 3rd Floor, Jeevan Seva Annexe,
S.V. Road, Santacruz(W), MUMBAI - 400 054.
Tel : 022-26106928, Fax : 022-26106052
The details of Insurance Ombudsman are available on IRDA website : www.irda.gov.in, on the website of General Insurance Council : www.generalinsurancecouncil.org.in, the Company's website
www.religarehealthinsurance.com or from any of the Company's offices.
Address and contact number of Governing Body of Insurance Council -
Shri M.V.V. Chalam, Secretary General The Secretary
3rd Floor, Jeevan Seva Annexe, 3rd Floor, Jeevan Seva Annexe,
S.V. Road, Santacruz(W), S.V. Road, Santacruz (W),
MUMBAI - 400 021 MUMBAI - 400 021.
Tel : 022-26106245 Tel : 022 26106980
Fax : 022-26106949 Fax : 022-26106949
10 41
Annexure A - List of Day Care Treatments
1. Microsurgical operations on the middle ear 45. Laser Photocoagulation to treat Ratinal Tear
1. Stapedotomy to treat various lesions in middle ear
5. Operations on the skin & subcutaneous tissues
2. Revision of a stapedectomy
46. Incision of a pilonidal sinus
3. Other operations on the auditory ossicles
47. Other incisions of the skin and subcutaneous tissues
4. Myringoplasty (post-aura/endaural approach as well as simple Type - I
48. Surgical wound toilet (wound debridement) and removal of diseased tissue
Tympanoplasty)
of the skin and subcutaneous tissues
5. Tympanoplasty (closure of an eardrum perforation/reconstruction
49. Local excision of diseased tissue of the skin and subcutaneous tissues
of the auditory ossicles)
50. Other excisions of the skin and subcutaneous tissues
6. Revision of a tympanoplasty
51. Simple restoration of surface continuity of the skin and subcutaneous
7. Other microsurgical operations on the middle ear
tissues
2. Other operations on the middle & internal ear 52. Free skin transplantation, donor site
8. Myringotomy 53. Free skin transplantation, recipient site
9. Removal of a tympanic drain 54. Revision of skin plasty
10. Incision of the mastoid process and middle ear 55. Other restoration and reconstruction of the skin and subcutaneous tissues.
11. Mastoidectomy 56. Chemosurgery to the skin.
12. Reconstruction of the middle ear 57. Destruction of diseased tissue in the skin and subcutaneous tissues
13. Other excisions of the middle and inner ear 58. Reconstruction of Deformity/Defect in Nail Bed
14. Fenestration of the inner ear
6. Operations on the tongue
15. Revision of a fenestration of the inner ear
59. Incision, excision and destruction of diseased tissue of the tongue
16. Incision (opening) and destruction (elimination) of the inner ear
60. Partial glossectomy
17. Other operations on the middle and inner ear
61. Glossectomy
18. Removal of Keratosis Obturans
62. Reconstruction of the tongue
3. Operations on the nose & the nasal sinuses 63. Other operations on the tongue
19. Excision and destruction of diseased tissue of the nose
7. Operations on the salivary glands & salivary ducts
20. Operations on the turbinates (nasal concha)
64. Incision and lancing of a salivary gland and a salivary duct
21. Other operations on the nose
65. Excision of diseased tissue of a salivary gland and a salivary duct
22. Nasal sinus aspiration Foreign body removal from nose
66. Resection of a salivary gland
4. Operations on the eyes 67. Reconstruction of a salivary gland and a salivary duct
23. Incision of tear glands 68. Other operations on the salivary glands and salivary ducts
24. Other operations on the tear ducts
8. Other operations on the mouth & face

25. Incision of diseased eyelids
69. External incision and drainage in the region of the mouth, jaw and face
26. Correction of Eyelid Ptosis by Levator Palpebrae Superioris Resection
70. Incision of the hard and soft palate
(bilateral)
71. Excision and destruction of diseased hard and soft palate
27. Correction of Eyelid Ptosis by Fascia Lata Graft (bilateral)
72. Incision, excision and destruction in the mouth
28. Excision and destruction of diseased tissue of the eyelid
73. Palatoplasty
29. Operations on the canthus and epicanthus
74. Other operations in the mouth
30. Corrective surgery for entropion and ectropion
31. Corrective surgery for blepharoptosis 9. Operations on tonsils and adnoids
32. Removal of a foreign body from the conjunctiva 75. Transoral incision and drainage of a pharyngeal abscess
33. Removal of a foreign body from the cornea 76. Tonsillectomy without adenoidectomy
34. Incision of the cornea 77. Tonsillectomy with adenoidectomy
35. Operations for pterygium 78. Excision and destruction of a lingual tonsil
36. Other operations on the cornea 79. Other operations on the tonsils and adenoids
37. Removal of a foreign body from the lens of the eye 80. Trauma surgery and orthopaedics
38. Removal of a foreign body from the posterior chamber of the eye 81. Incision on bone, septic and aseptic
39. Removal of a foreign body from the orbit and eyeball 82. Closed reduction on fracture, luxation or epiphyseolysis with
osteosynthesis
40. Operation of cataract
83. Suture and other operations on tendons and tendon sheath
41. Diathermy/Cryotherapy to treat retinal tear
84. Reduction of dislocation under GA
42. Anterior chamber Paracentesis/Cyclodiathermy/Cyclocryotherapy/
Goniotomy/Trabeculotomy and Filtering and Allied Operations to treat 85. Adenoidectomy
glaucoma
10. Operations on the breast
43. Enucleation of Eye without Implant
86. Incision of the breast abscess
44. Dacryocystorhinostomy for various lesions of Lacrimal Gland
87. Operations on the nipple
71 11
88. Excision of single breast lump 15. Operations on the testes
132. Incision of the testes
11. Operations on the digestive tract, Kidney and Bladder
133. Excision and destruction of diseased tissue of the testes
89. Incision and excision of tissue in the perianal region
134. Unilateral orchidectomy
90. Surgical treatment of anal fistulas
135. Bilateral orchidectomy
91. Surgical treatment of hemorrhoids
136. Orchidopexy
92. Division of the anal sphincter (sphincterotomy)
137. Abdominal exploration in cryptorchidism
93. Other operations on the anus
138. Surgical repositioning of an abdominal testis
94. Ultrasound guided aspirations
139. Reconstruction of the testis
95. Sclerotherapy, etc.
140. Implantation, exchange and removal of a testicular prosthesis
96. Laparotomy for grading Lymphoma with Splenectomy/Liver/Lymph Node
Biopsy 141. Other operations on the testis
97. Therapeutic Laparoscopy with Laser
16. Operations on the spermatic cord, epididymis and ductus
98. Cholecystectomy and Choledocho-Jejunostomy/Duodenostomy/ deferens
Gastrostomy/Exploration Common Bile Duct
142. Surgical treatment of a varicocele and a hydrocele of the spermatic cord
99. Esophagoscopy, gastroscopy, duodenoscopy with polypectomy/ removal of
143. Excision in the area of the epididymis
foreign body/diathermy of bleeding lesions
144. Epididymectomy
100. Lithotripsy/Nephrolithotomy for renal calculus
101. Excision of renal cyst 17. Operations on the penis
102. Drainage of Pyonephrosis/Perinephric Abscess 145. Operations on the foreskin
103. Appendicectomy with/without Drainage 146. Local excision and destruction of diseased tissue of the penis
12. Operations on the female sexual organs 147. Amputation of the penis
104. Incision of the ovary 148. Other operations on the penis
105. Insufflations of the Fallopian tubes
18. Operations on the urinary system
106. Other operations on the Fallopian tube
149. Cystoscopical removal of stones
107. Dilatation of the cervical canal
150. Catheterisation of Bladder
108. Conisation of the uterine cervix
19. Other Operations
109. Therapeutic curettage with Colposcopy/Biopsy/Diathermy/Cryosurgery/
151. Lithotripsy
110. Laser Therapy of Cervix for Various lesions of Uterus
152. Coronary angiography
111. Other operations on the uterine cervix
153. Biopsy ofTemporal Artery for Various Lesions
112. Incision of the uterus (hysterectomy)
154. External Arterio-venous Shunt
113. Local excision and destruction of diseased tissue of the vagina and the
pouch of Douglas 155. Haemodialysis

114. Incision of vagina 156. Radiotherapy for Cancer
115. Incision of vulva 157. Cancer Chemotherapy
116. Culdotomy 158. Endoscopic polypectomy
117. Operations on Bartholin's glands (cyst) 20. Operations of bones and joints
118. Salpingo-Oophorectomy via Laparotomy 159. Surgery for ligament tear
13. Operations on the prostate & seminal vesicles 160. Surgery for meniscus tear
119. Incision of the prostate 161. Surgery for hemoarthrosis/pyoarthrosis
120. Transurethral excision and destruction of prostate tissue 162. Removal of fracture pins/nails
121. Transurethral and percutaneous destruction of prostate tissue 163. Removal of metal wire
122. Open surgical excision and destruction of prostate tissue 164. Closed reduction on fracture, luxation
123. Radical prostatovesiculectomy 165. Reduction of dislocation under GA
124. Other excision and destruction of prostate tissue 166. Epiphyseolysis with osteosynthesis
125. Operations on the seminal vesicles 167. Excision of Bursirtis
126. Incision and excision of periprostatic tissue 168. Tennis Elbow Release
127. Other operations on the prostate 169. Excision of Various Lesions in Coccyx
170. Arthroscopic knee aspiration
14. Operations on the scrotum & tunica vaginalis testis
128. Incision of the scrotum and tunica vaginalis testis
129. Operation on a testicular hydrocele
130. Excision and destruction of diseased scrotal tissue
131. Other operations on the scrotum and tunica vaginalis testis
12 81
Annexure B - Exhibit 1: Illustration for Recharge of Sum Insured
For Policy Period 1st Jan. 2012 to 31st Dec. 2012

Details Scenario 1 Scenario 2 Scenario 3 Scenario 4
Sum Insured at Policy Year Start Date (01-Jan-2012) 3,00,000 3,00,000 3,00,000 3,00,000
No Claims Bonus - - 90,000 90,000
Assuming that policy has 3 claim free years
Total Eligible Sum Insured for Claim 3,00,000 3,00,000 3,90,000 3,90,000
Claim 1 on 01-May-2012 :
Claim made for (Rs.) 2,00,000 2,00,000 3,50,000 4,50,000
Claim Amount Eligible 2,00,000 2,00,000 3,50,000 3,90,000
Sum Insured utilized for Claim 2,00,000 2,00,000 3,00,000 3,00,000
No Claims Bonus available No No Yes Yes
No Claim Bonus amount to be utilized for Claim N.A. N.A. 50,000 90,000
Total Claim Payable 2,00,000 2,00,000 3,50,000 3,90,000
Balance Sum Insured available for the balance policy period 1,00,000 1,00,000 - -
Balance No Claim Bonus available for the balance policy period - - 40,000 -
Recharge Sum Insured available for the balance policy period 3,00,000 3,00,000 3,00,000 3,00,000
Claim 2 on 01-Sep-2012
Claim made for (Rs.) 2,00,000 4,00,000 3,50,000 3,50,000
Claim Amount Eligible 2,00,000 3,00,000 3,40,000 3,00,000
Sum Insured utilized for Claim 1,00,000 1,00,000 - -
No Claims Bonus available No No Yes No
No Claim Bonus amount to be utilized for Claim N.A. N.A. 40,000 N.A.
Recharge available Yes Yes Yes Yes
Recharge Sum Insured utilized 1,00,000 2,00,000 3,00,000 3,00,000
Total Claim Payable 2,00,000 3,00,000 3,40,000 3,00,000
Balance Sum Insured available for the balance policy period - - - -
Recharge Sum Insured available for the balance policy period 2,00,000 1,00,000 - -
Note : It is assumed that Claim Event 1 and Claim Event 2 are not related events
91 13

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Policy Terms and Conditions

1. Definitions b. Does not have his independent sources of income; and

Hospital room where a single patient is accommodated and which

iii) Chronic Nephritis and Chronic Nephritic Syndrome

glucometer/thermometer, crutches, ambulatory devices, instruments used

Company will confirm in writing authorization or rejection of the

d. In case of demise of the Policyholder, The Grievance Cell,

8. Other operations on the mouth & face

pouch of Douglas 155. Haemodialysis

For Policy Period 1st Jan. 2012 to 31st Dec. 2012

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