TATHLGP21248V022021

Group MediCare
UIN: TATHLGP21248V022021
POLICY WORDINGS
Tata AIG General Insurance Co. Ltd.

Registered Office:
Peninsula Business Park, Tow er A, 15th Floor,
G.K. Marg, Low er Parel, Mumbai – 400013
24X7 Toll Free No: 1800 266 7780 or 1800 22 9966 (Senior Citizen)
Fax: 022 6693 8170
Email: [email protected] Website: www.tataaig.com
IRDA of India Registration No: 108 CIN:U85110MH2000PLC128425
Group MediCare
Preamble Hospital w hich follow differential billing or for those

expenses in respect of which differential billing is
We w ill provide the insurance cover detailed in the Policy to the
adopted based on the Room Category.
Insured Persons up to the Sum Insured subject to:
b. If the Insured Person is admitted in a hospital room
i. The terms, conditions and exclusions of this Policy.
where the room category opted is higher than the
ii. Statements in the proposal/enrolment form and information category specified in the Policy Schedule/Certificate of
disclosed to Us by You or on Your behalf and on behalf of all Insurance, then the Insured Person shall bear 10% of
persons to be insured whic h is incorporated into the Policy and is admissible claim amount
the basis of it.
In case of unavailability of specif ied room category,
Commencement of risk cover under the policy is subject to receipt of the Insured Person is eligible for next immediate
premium by Us. available hospital room provided that necessary
documented proof for unavailability of such hospital
While the policy is in force, and if the claim is admissible under the
room is furnished to us.
policy, then We shall pay You such Reasonable and Customary
Medical Expenses incurred on treatment or pay for the listed benefit iii. Lim it on Treatment / Illness/ Surgery/ Medical Condition
sum insured. The said treatment must be on the advice of a qualif ied
Medical Practitioner.
We w ill cover the Medical Expenses incurred towards claim
Our liability at any time shall not exceed the maximum sum insured for a specif ied treatment of an Illness/procedure upto the
applicable for the benefit as specified in Your policy schedule or amount of Sub-Limit applicable per claim during the Policy
Certificate of insurance. In case of family floater, the sum insured shall Year as specified in the Policy Schedule/ Certif icate of
be applicable for all the claims made by any or all the insured persons Insurance.
in the family w hereas in case of individual, this shall be applicable for
B2. Pre-Hospitalization expenses
all the claims made by an individual insured person.
We w ill cover the Pre-Hospitalization expenses for consultations,
In case of any other sum insured restric tions, the same shall be
investigations and medicines incurred upto the number of days as
clearly specified in Your Policy schedule/Certif icate of Insurance.
specif ied in your policy schedule/Certific ate of Insurance.
Section 1: Base Covers

The benefit is payable if We have admitted a claim under In-
The follow ing benefits are payable subject to Terms and Conditions of patient Treatment/Day Care Procedures/Domiciliary treatment.
the policy:
B3. Post-Hospitalization expenses
B1. In-Patient Treatment
We w ill cover the Post-Hospitalization expenses for consultations,
We w ill cover for expenses for hospitalization due to investigations and medicines incurred upto the number of days,
disease/illness/Injury during the policy period that requires an as specif ied in your policy schedule/Certific ate of Insurance.
Insured Person’s admission in a hospital as an inpatient.
Medical expenses directly related to the hospitalization would be The benefit is payable if We have admitted a claim under In-
payable provided: patient Treatment/Day Care Procedures /Domiciliary treatment.
i. Lim it on Room Rent/Room Category:
B4. Day Care Procedures
We w ill, limit Room Rent up to the amount/percentage of
Sum Insured or room category as specified in the Policy We w ill cover expenses for listed Day Care treatment due to
Schedule/ Certificate of Insurance. disease/illness/Injury during the policy period taken at a hospital
or a Day Care Centre. The list of such day care procedures
ii. Associated Medical Expenses:
covered is available on our website (www.tataaig.com).
a. If the Insured Person is admitted in a room w here the
Room Rent expenses incurred is higher than limit
This benefit under the policy w ill be limited to the amount
specif ied in the Policy Schedule/ Certificate of
specif ied in the Policy Schedule/ Certific ate of Insurance.
Insurance, then the Insured Person shall bear a
Treatment normally taken on out-patient basis is not included in
rateable proportion of the total Associated Medical
the scope of this cover.
Expenses (including surcharge or taxes thereon),
except pharmacy charges, diagnostic costs, costs of B5. Dom iciliary Treatment
implants & medical devices and consumables
We w ill cover for expenses related to Domiciliary Hospitalization
expenses, in the proportion of the difference between
of the insured person if the treatment exceeds beyond three
the eligible Room Rent expenses to the Room Rent
days. The treatment must be for management of an illness and
expenses actually incurred. Proportionate Expenses is
not for enteral feedings or end of life care.
applied in respect of the
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Tata AIG General Insurance Company Limited - Registered Off ice: Peninsula Business Park, Tower A, 15th Floor, G.K. Marg, Lower Parel, Mumb ai – 400013
24 X7 Toll Free No: 1800 266 7780 or 180 0 22 9966 (Senio r Citizen) Fax: 022 6693 8170 Email: [email protected] Website: www.tataaig.com
IRDA of India Registration No: 108 CIN: U85110MH2000 PLC12842 5
Group MediCare
At the time of claiming under this benefit, we shall require i. This Benefit is opted,
certif ication from the treating doctor fulf illing the conditions as
ii. The maternity claim is admissible by Us under B8, and
mentioned under the general definitions (Section 2-11) of this
policy. iii. Date of delivery is w ithin policy period
This benefit under the policy w ill be limited to the amount The sum insured applicable for pre/post natal cover on out-
specif ied in the Policy Schedule/ Certific ate of Insurance. patient basis shall be part of Maternity limit.
B6. Organ Donor We w ill not be liable to make any payment in respect of any Pre-
hospitalization Expenses or Post – hospitalization Expenses paid
We w ill cover for Medical and surgical Expenses of the organ
under the Base Cover.
donor for harvesting the organ where an Insured Person is the
recipient provided that: B10. Baby day one Cover
i. The organ donor is any person whose organ has been We w ill cover for Medical Expenses incurred during the Policy
made available in accordance and in compliance w ith The Year, towards the Treatment of the New Born Baby from the
Transplantation of Human Organs Act (Amended) , 1994 date of bir th of baby up to the Sub Limit, as specif ied in the
and other applicable laws and rules and the organ donated Policy Schedule/ Certif icate of Insurance, provided that You
is for the use of the Insured Person, and have paid requis ite premium for inclusion of the newborn baby
ii. We have accepted an inpatient Hospitalization claim for the in to the policy.
insured member under In-Patient Hospitalization Treatment New Born Baby older than 90 days can be covered under the
(section B1). Policy as an Insured Person only by way of an endorsement or at
the next Renew al, whichever is earlier, on payment of the
This benefit under the policy w ill be limited to the amount
requisite premium.
specif ied in the Policy Schedule/ Certific ate of Insurance.
B11. Fam ily Transportation Benefit
B7. Ambulance Cover
If We have accepted a claim under Benefit B1, then We will
We w ill cover for expenses incurred on transportation of Insured
reimburse the actual expenses incurred in transporting one
Person in a registered ambulance to a Hospital for admission in
Immediate Family Member from the Insured Person’s residence
case of an Emergency or from one hospital to another hospital for
to the Hospital where the Insured Person is admitted, provided
better medical facilities and treatment, subject to amount as
that such Hospital is located at least 200 kms aw ay from the
specif ied on the policy schedule/Certificate of Insurance.
Insured Person’s residence up to the limit as specif ied in the
policy schedule/Certif icate of Insurance.
For this claim to be paid, the claim must be admissible under
For the purpose of this benefit, Immediate Family Member means
section In-patient Treatment or Day Care Procedures of this
the Insured Person’s legal spouse, children, parents, parents-in-
policy.
law , legal guardian, ward, step child or adopted child.
B8. Maternity Cover
We w ill cover for Maternity Expenses for the delivery of a child Section 2 – General Definitions
and/or Maternity Expenses related to a Medically Necessary
The terms defined below and at other junctures in the Policy Wording
Treatment and lawful medical termination of pregnancy, during
have the meanings ascribed to them w herever they appear in this
the Policy Year, subject to the Sub-Limits and maternity w aiting
Policy and, where appropriate, references to the singular include
period as specified in the Policy Schedule/ Certif icate of
references to the plural; references to the male include the f emale and
Insurance. Medical expenses incurred for resuscitation of
references to any statutory enactment include subsequent changes to
new born baby shall form part of the maternity sub imit.
the same:
We w ill not cover ectopic pregnancy under this benefit (although
1. Accident
it shall be covered under section In-patient Treatment).
An accident means sudden, unforeseen and involuntary event
caused by external, visible and violent means.
Expenses incurred for pre/post natal care shall be excluded from
the scope of this coverage. 2. Age
B9. Pre/Post Natal Cover Means the completed age of the Insured Person on his / her most
recent birthday as per the English calendar, regardless of the
We w ill cover for Medical Expenses incurred during the Policy
actual time of birth.
Year on out-patient basis, in respect of pre- natal check-ups,
since confir mation of pregnancy, post-natal check-ups for a 3. Any one illness
period up to six weeks from date of loss, prescribed pre- natal
Any one illness means continuous period of illness and includes
medicines and diagnostic tests up to the limit specified in the
relapse w ithin 45 days from the date of last consultation with the
Policy Schedule/ Certif icate of Insurance provided that:
Hospital/Nursing Home w here treatment was taken.
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Group MediCare
4. Associated Medical Expenses ii. whic h would have otherw is e required hospitalization of
more than 24 hours.
Associated Medical Expenses shall include Room Rent, nursing
charges, operation theatre charges, fees of Medical Treatment normally taken on an out-patient basis is not
Practitioner/surgeon/ anesthetis t/ Specialist conducted w ithin the included in the scope of this definition
same Hospital w here the Insured Person has been admitted.
10. Dental Treatment
Dental treatment means a treatment related to teeth or structures

5. Cashless facility
supporting teeth including examinations, fillings (where
Cashless facility means a facility extended by the insurer to the appropriate), crowns, extractions and surgery.
insured where the payments, of the costs of treatment undergone
11. Dom iciliary Hospitalization
by the insured in accordance with the policy terms and
conditions, are directly made to the netw ork provider by the Domiciliary hospitalization means medical treatment for an
insurer to the extent pre-authoriz ation is approved. illness/disease/injury whic h in the normal course would require
care and treatment at a hospital but is actually taken while
6. Congenital Anomaly
confined at home under any of the follow ing circumstances:
Congenital Anomaly means a condition w hic h is present since
i. the condition of the patient is such that he/she is not in a
birth, and which is abnormal w ith reference to form, structure
condition to be removed to a hospital, or
or position.
ii. the patient takes treatment at home on account of non-
a) Internal Congenital Anomaly
availability of room in a hospital.
Congenital anomaly w hich is not in the visible and
12. Grace Period
accessible parts of the body.
Grace period means the specif ied period of time immediately
b) External Congenital Anomaly
follow ing the premium due date during w hic h a payment can be
Congenital anomaly w hich is in the vis ible and accessible made to renew or continue a policy in force w ithout loss of
parts of the body continuity benefits such as waiting periods and coverage of pre-
existing diseases. Coverage is not available for the period for
7. Co-Payment
whic h no premium is received.
Co-payment means a cost sharing requirement under a health
13. Hospital
insurance policy that provides that the policyholder/insured will
bear a specified percentage of the admissible claims amount. A A hospital means any institution established for in-patient care
co-payment does not reduce the Sum Insured. and day care treatment of illness and/or injuries and whic h has
been registered as a hospital w ith the local authorities under
8. Day Care Centre
Clinical Establishments (Registration and Regulation) Act 2010 or
A day care centre means any institution established for day care under enactments specif ied under the Schedule of Section 56(1)
treatment of illness and/or injuries or a medical setup with a and the said act Or complies w ith all minimum criteria as under:
hospital and whic h has been registered with the local authorities,
wherever applicable, and is under supervision of a regis tered and
i. has qualified nursing staff under its employment round the
qualified medical practitioner AND must comply w ith all minimum
clock;
criterion as under –
ii. has at least 10 in-patient beds in towns having a population
i. has qualified nursing staff under its employment;
of less than 10,00,000 and at least 15 in-patient beds in all
ii. has qualified medical practitioner/s in charge; other places;
iii. has fully equipped operation theatre of its own where iii. has qualified medical practitioner(s) in charge round the
surgic al procedures are carried out; clock;
iv. maintains daily records of patients and w ill make these iv. has a fully equipped operation theatre of its own where
accessible to the insurance company’s authoriz ed surgic al procedures are carried out;
personnel.
v. maintains daily records of patients and makes these
9. Day Care Treatment accessible to the insurance company’s authoriz ed
personnel;
Day care treatment means medical treatment, and/or surgical
procedure whic h is: 14. Hospitalization
i. undertaken under General or Local Anesthesia in a Hospitalization means admission in a Hospital for a minimum
hospital/day care centre in less than 24 hrs because of period of 24 consecutive ‘In-patient Care’ hours except for
technological advancement, and specif ied procedures/ treatments, where such admission could be
for a period of less than 24 consecutive hours.
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Group MediCare
15. Illness Medical Practitioner, as long as these are no more than would
have been payable if the Insured Person had not been insured
Illness means a sickness or a disease or pathological condition
and no more than other hospitals or doctors in the same locality
leading to the impair ment of normal physiological function and
would have charged for the same medical treatment.
requires medical treatment.
21. Medical Practitioner
(a) Acute condition
Medical Practitioner means a person who holds a valid
Acute condition is a disease, illness or injury that is likely to
registration from the Medical Council of any State or Medical
respond quic kly to treatment w hic h aims to return the
Council of India or Council for Indian Medicine or for Homeopathy
person to his or her state of health immediately before
set up by the Government of India or a State Government and is
suffering the disease/ illness/ injury whic h leads to full
thereby entitled to practice medicine within its jurisdic tion; and is
recovery
acting w ithin its scope and jurisdiction of license.
(b) Chronic condition
A chronic condition is defined as a disease, illness, or injury 22. Medically Necessary Treatment
that has one or more of the follow ing characteristic s: Medically necessary treatment means any treatment, tests,
medication, or stay in hospital or part of a stay in hospital which:
i. it needs ongoing or long-term monitoring through
consultations, examinations, check-ups, and /or tests i. is required for the medical management of the illness or
injury suffered by the insured;
ii. it needs ongoing or long-term control or relief of
ii. must not exceed the level of care necessary to provide
symptoms
safe, adequate and appropriate medical care in scope,
iii. it requires rehabilitation for the patient or for the duration, or intensity;
patient to be specially trained to cope with it
iii. must have been prescribed by a medical practitioner;
iv. it continues indefinitely
iv. must conform to the professional standards widely accepted
v. it recurs or is likely to recur in international medical practice or by the medical
community in India.
16. Injury
23. Network Provider
Injury means accidental physical bodily harm excluding illness or
disease solely and directly caused by external, violent, vis ible and Netw ork Provider means hospitals or health care providers
evident means w hic h is verif ied and certified by a Medical enlisted by an insurer, TPA or jointly by an Insurer and TPA to
Practitioner. provide medical services to an insured by a cashless facility.
17. In-patient Care 24. OPD treatment
Inpatient care means treatment for which the insured person has OPD treatment means the one in w hic h the Insured visits a clinic /
to stay in a hospital for more than 24 hours for a covered event. hospital or associated facility like a consultation room for
diagnosis and treatment based on the advice of a Medical
Practitioner. The Insured is not admitted as a day care or in-
18. Maternity expenses
patient.
Maternity expenses means;
25. Pre-Existing Disease
a. medical treatment expenses traceable to childbirth
Pre-Existing Disease means any condition, ailment , injury or
(including complicated deliveries and caesarean sections
disease
incurred during hospitalization);
o That is/are diagnosed by a Physician within 48 months prior to
b. expenses towards lawful medical termination of pregnancy
the effective date of the Policy issued by the Insurer or its
during the policy period.
reinstatement; or
19. Medical Advice
o For w hic h medical advice or treatment w as recommended by,
Medical Advice means any consultation or advice from a Medical or received from, a Physician w ithin 48 months prior to the
Practitioner including the issuance of any prescription or follow -up effective date of the Policy issued by the Insurer; or its
prescription. reinstatement.
20. Medical Expenses 26. Pre-hospitalization Medical Expenses
Medical Expenses means those expenses that an Insured Person Pre-hospitalization Medical Expenses means medical expenses
has necessarily and actually incurred for medical treatment on incurred during predefined number of days preceding the
account of Illness or Accident on the advic e of a hospitalization of the Insured Person, provided that:
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Group MediCare
i. Such Medical Expenses are incurred for the same condition 34. Room Category
for which the Insured Person’s Hospitalization w as required,
Room Category shall mean one of the following:
and
a. Single Private Room means a hospital room w ith one
ii. The In-patient Hospitalization claim for such Hospitalization
patient bed and such room must be the most economical of
is admissible by the Insurance Company.
all accommodations available in that hospital as single
27. Policyholder occupancy.
The Policyholder shall be the Employer who has taken the group b. Shared Accommodation means a hospital room w ith tw o or
insurance policy as a service benefit to his Employees or a Group more patient beds.
Manager of a homogeneous group of persons who assemble
c. Economy Ward means a hospital room w ith more than three
together for a commonality of purpose and there is a clearly
patient beds.
evident relationship between the member and group manager for
services other than insurance. This definition does not apply to ICU or ICCU.
28. Post-hospitalization Medical Expenses 35. Surgery or Surgical Procedure
Post-hospitalization Medical Expenses means medical expenses Surgery or Surgical Procedure means manual and / or operative
incurred during predefined number of days immediately after the procedure (s) required for treatment of an illness or injury,
insured person is discharged from the hospital provided that: correction of deformities and defects, diagnosis and cure of
diseases, relief from suffering and prolongation of life, performed
i. Such Medical Expenses are for the same condition for in a hospital or day care centre by a medical practitioner.
whic h the insured person’s hospitalization was required,

and 36. Unproven/Experimental treatment
ii. The inpatient hospitalization claim for such hospitalization is Unproven/Experimental treatment means the treatment including
admissible by the insurance company drug experimental therapy whic h is not based on established
medical practice in India, is treatment experimental or unproven.
29. Migration
Migration” means, the right accorded to health insurance

37. We/Us/Our means TATA AIG General Insurance Company
policyholders (including all members under family cover and
Limited.
members of group health insurance policy), to transfer the credit
gained for pre-existing conditions and time bound exclusions, 38. You/Your/Yourself means the Policy Holder and/or Insured
with the same insurer. Person(s) who is named in the Policy Schedule.
30. Qualified Nurse Section 3 – General Exclusions
Qualified nurse means a person who holds a valid registration 1. Waiting Period
from the Nursing Council of India or the Nursing Council of any
i. 30 days waiting (Code- Excl 03) shall be waived off
state in India.
ii. Specified disease / procedure Waiting period: (Code- Excl
31. Reasonable and Customary Charges
02)shall be waived off
Reasonable and Customary charges means the charges for
iii. Pre-Existing Diseases(Code- Excl 01)shall be waived off
services or supplies, which are the standard charges for the
specif ic provider and consis tent w ith the prevailing charges in the iv. Nine months maternity waiting period shall be waived off
geographical area for identical or similar services, taking into
2. Medical Exclusions
account the nature of the illness / injury involv ed.
We w ill neither be liable nor make any payment for any claim in
32. Renewal
respect of any Insured Person whic h is caused by, aris ing from or
Renew al means the terms on which the contract of insurance can in any way attributable to any of the follow ing exclusions, unless
be renewed on mutual consent w ith a provision of grace period expressly stated to the contrary in this Policy connection with or in
for treating the renewal continuous for the purpose of gaining respect of:
credit for pre-exis ting diseases, time-bound exclusions and for all
1. Investigation & Evaluation(Code- Excl 04)
waiting periods.
a) Expenses related to any admission primarily for
33. Room Rent
diagnostics and evaluation purposes only are
Room Rent means the amount charged by a Hospital towards excluded.
Room and Boarding expenses and shall include the associated
b) Any diagnostic expenses which are not related or not
medical expenses.
incidental to the current diagnosis and treatment are
excluded.
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Group MediCare
2. Rest Cure, rehabilitation and respite care(Code - Excl 05) 7. Treatments received in heath hydros, nature cure clinics,
spas or similar establishments or priv ate beds regis tered as
a nursing home attached to such establishments or where
Expenses related to any admission primarily for enforced
admission is arranged wholly or partly for domestic reasons.
bed rest and not for receiving treatment. This also includes:
(Code- Excl 13)
8. Dietary supplements and substances that can be purchased

i. Custodial care either at home or in a nursing facility
without prescription, including but not limited to Vitamins,
for personal care such as help w ith activities of daily
minerals and organic substances unless prescribed by a
living such as bathing, dressing, moving around either
medical practitioner as part of hospitalization claim or day
by skilled nurses or assistant or non-skilled persons.
care procedure (Code- Excl 14)
ii. Any services for people who are terminally ill to

9. Refractive Error:(Code- Excl 15)
address physical, social, emotional and spiritual
needs. Expenses related to the treatment for correction of eye sight
due to refractive error less than 7.5 dioptres.
3. Obesity/ Weight Control(Code- Excl 06)
10. Unproven Treatments:(Code - Excl 16)
Expenses related to the surgical treatment of obesity that
does not fulf ill all the below conditions: Expenses related to any unproven treatment, services and
supplies for or in connection with any treatment. Unproven
1) Surgery to be conducted is upon the advic e of the
treatments are treatments, procedures or supplies that lack
Doctor
significant medical documentation to support their
2) The surgery/Procedure conducted should be effectiveness.
supported by clinical protocols
11. Sterility and Infertility: (Code- Excl 17)
3) The member has to be 18 years of age or older and
Expenses related to sterility and infertility. This includes:
4) Body Mass Index (BMI);
i. Any type of contraception, sterilization
a) greater than or equal to 40 or
ii. Assis ted Reproduction services including artif icial
b) greater than or equal to 35 in conjunction with insemination and advanced reproductive technologies
any of the following severe co-morbidities such as IVF, ZIFT, GIFT, ICSI
follow ing failure of less invasiv e methods of
iii. Gestational Surrogacy
weight loss:
iv. Reversal of sterilization
I. Obesity-related cardiomyopathy
12. Maternity (Code - Excl 18):
II. Coronary heart disease
i. Medical treatment expenses traceable to childbirth
III. Severe Sleep Apnea
(including complicated deliveries and caesarean
IV. Uncontrolled Type2 Diabetes sections incurred during hospitalization) except ectopic
pregnancy;
4. Change-of-Gender treatments: (Code - Excl 07)
ii. expenses towards miscarriage (unless due to an
Expenses related to any treatment, including surgical
accident) and lawful medical termination of pregnancy
management, to change characteristic s of the body to those
during the policy period.
of the opposite sex.
13. Congenital External Diseases, defects or anomalies.
5. Cosmetic or plastic Surgery: (Code- Excl 08)
14. Stem cell therapy, however Hematopoietic stem cells for
Expenses for cosmetic or plastic surgery or any treatment to
bone marrow transplant for haematological conditions will
change appearance unless for reconstruction follow ing an
be covered under Benefit B1 and B4 of this Policy.
Accident, Burn(s) or Cancer or as part of medically
necessary treatment to remove a dir ect and immediate 15. Growth hormone therapy.
health risk to the insured. For this to be considered a
16. Sleep-apnoea.
medical necessity, it must be certif ied by the attending
Medical Practitioner. 17. Admission primarily for administration of Intra-artic ular or
intra-lesional injections or Intravenous immunoglobulin
6. Treatment for, Alc oholism, drug or substance abuse or any
infusion or supplementary medications like Zolendronic
addictive condition and consequences thereof. (Code-
Acid.
Excl 12)
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Group MediCare
18. Venereal disease, sexually transmitted disease or illness. xii. Crutches or any other external appliance and/or devic e used
for diagnosis or treatment (except when used intra-
19. All preventive care, vaccination including inoculation and
operatively and explicitly stated and covered in the policy.
immunisations (except in case of post- bite treatment and
other vaccines explicitly covered). xiii. Any claim incurred after date of proposal/enrolment form
and before issuance of policy/Certif icate of Insurance where
20. Dental treatment or surgery of any kind unless as a result of
there is change in health status of the member and the
Illness/Accidental Bodily Injury to natural teeth and also
same is not communicated to us.
requiring hospitalization.
xiv. Expenses incurred towards treatment in any hospital or by
21. Any non-allopathic treatment.
any Medical Practitioner or any other provider specif ically
3. Non-Medical Exclusions excluded by the Insurer and disclosed in its website /
notified to the policyholders are not admissible. How ever, in
i. War or any act of war, invasion, act of foreign enemy, war
case of life threatening situations or follow ing an accident,
like operations (whether war be declared or notor caused
expenses up to the stage of stabilization are payable but
during service in the armed forces of any country),, civ il w ar,
not the complete claim (Code – Excl11)
public defence, rebellion, revolution, insurrection, military or
usurped acts, nuclear weapons/materials, chemical and Section 4 – General Conditions
biological w eapons, ionising radiation.
1. Condition Precede nt
ii. Any Insured Person’s partic ipation or involvement in naval,
i. The premium for the policy will remain the same for the
military or air force operation.
policy period as mentioned in the policy schedule.
iii. Hazardous or Adventure Sports (Code Excl09) : Expenses
ii. No change in this Policy shall be valid unless a valid
related to any treatment necessitated due to partic ipation as
endorsement is passed in the policy.
a professional in hazardous or adventure sports, including
but not limited to, para-jumping, rock climbing, iii. In case of master policy, the policy period would be 1 year
mountaineering, rafting, motor racing, horse racing or scuba how ever the period of certific ate of insurance would be from
diving, hand gliding, sky diving, deep-sea diving 1 year to 5 years (in case of credit linked). Details of the
policy term applicable to individual certif icate of insurance
iv. Breach of law (Code Excl10): Expenses for treatment
would be clearly stated in Your certif icate of insurance.
directly arising from or consequent upon any Insured
Person committing or attempting to commit a breach of law
with criminal intent. 2. Condition Precedent to Admission of Liability
v. Intentional self-injury or attempted suicide while sane or The terms and conditions of the policy must be fulf illed by the
insane. Insured Person for the Company to make any payment for
claim(s) arising under the Policy.
vi. Items of personal comfort and convenience like television
(wherever specif ically charged for), charges for access to 3. Disclosure of Inform ation
telephone and telephone calls, internet, foodstuffs (except
The policy shall be void and all premium paid thereon shall be
patient’s diet), cosmetics, hygiene artic les, body care
forfeited to the Company in the event of mis-representation, mis-
products and bath additive, barber or beauty servic e, guest
description or non-dis closure of any material fact by the
service.
Policyholder
vii. Treatment rendered by a Medical Practitioner w hic h is
(Explanation: “Material facts” for the purpose of this policy shall
outside his discipline
mean all relevant information sought by the company in the
viii. Doctor’s fees charged by the Medical Practitioner sharing proposal form and other connected documents to enable it to
the same residence as an Insured Person or who is an take informed decision in the context of underwriting the ris k)
immediate relative of an Insured Person’s family.
4. Insured Person
ix. Provision or fitting of hearing aids, spectacles or contact
i. Only those persons named as an Insured Person in the
lenses including optometric therapy unless explicitly stated
Policy Schedule/Certif icate of insurance shall be covered
and covered in the policy.
under this Policy.
x. Any treatment and associated expenses for alopecia,
ii. Mid-term addition of Primary Insured and Dependents:
baldness, wigs, or toupees, medical supplies including
elastic stockings, diabetic test strips, and similar products. Mid-term addition of Primary insured and dependents shall
xi. Any treatment or part of a treatment that is not of a be allow ed in the event of follow ing:
reasonable charge, not medically necessary; drugs or 1. Intimation is given to Us by a defined & agreed date
treatments which are not supported by a prescription. and shall be subject to Guidelines on Group Insurance
Policies, dated 14th July 2005 issued by
8
Group MediCare
Insurance Regulatory and Development Authority of claim, w ho shall be jointly and severally liable for such repayment
India and any subsequent amendments as published to the Insurer.
from time to time
For the purpose of this clause, the expression “fraud” means any
2. Requisite premium has been paid to Us. of the follow ing acts committed by the insured person or by his
agent or the Hospital / Doctor, any other party acting on behalf of
3. All existing dependents must be covered along w ith
the Insured Person w ith intent to deceive the insurer or to induce
the Primary Insured and the addition of Dependents
the insurer to issue an insurance policy:
shall be allow ed only in the event of:
a) the suggestion, as a fact of that which is not true and whic h
• Children in the event of childbirth
the insured person does not believe to be true;
• Spouse in the event of marriage
b) the active concealment of a fact by the insured person
If any of the conditions (1) & (2) above are not met, having know ledge or belief of the fact;
coverage w ill commence only from the date of
c) any other act fitted to deceiv e; and
intimation to Us or premium remittance w hic hever is
later. d) any such act or omission as the law specially declares to be
fraudulent
iii. Mid-term deletion of Primary Insured and Dependents:
The Company shall not repudiate the claim and / or forfeit the
a. In case of Employer-Employee Policies:
policy benefits on the ground of Fraud, if the insured person /
• The coverage for exis ting Primary Insured and benefic iary can prove that the misstatement was true to the best
his dependents w ill automatically expire from of his knowledge and there was no deliberate intention to
date of cessation of employment. suppress the fact or that such mis-statement of or suppression of
material fact are w ithin the know ledge of the insurer.
• Pro-rata refund of premium w ould be made on
intimation provided such intimation is made by a 7. Multiple Policies
defined date and no claim is made by the
i. In case of multiple policies taken by an insured person
Primary Insured or his dependents.
during a period from one or more insurers to indemnify
b. In case of non Employer-Employee Policies, the treatment costs, the insured person shall have the right to
coverage shall automatically expire from the date the require a settlement of his/her claim in terms of any of
insured person exits the scheme. his/her policies. In all such cases the insurer chosen by the
Insured Person shall be obliged to settle the claim as long
c. In case of refund of premium being generated on the
as the claim is w ithin the limits of and according to the terms
Policy due to deletion of Insured Persons, the same
of the chosen Policy.
will be refunded or adjusted accordingly against the
future premium installments due on the Policy. ii. Insured person having multiple policies shall also have the
right to prefer claims under this policy for the amounts
5. Entire Contract
disallow ed under any other policy / policies even if the sum
i. This Policy, its Schedule, endorsement(s), proposal/ insured is not exhausted. Then the Insurer shall
enrolment form constitutes the entire contract of insurance. independently settle the claim subject to the terms and
No change in this policy shall be valid unless approved by conditions of this Policy.
Us and such approval be endorsed hereon.
iii. If the amount to be claimed exceeds the sum insured under
ii. This Policy and the Policy Schedule/Certificate of insurance a single Policy, the Insured person shall have the right to
shall be read together as one contract and any word or choose insurer from whom he/she wants to claim the
expression to which a specific meaning has been attached balance amount.
in any part of this Policy or of the Schedule shall bear such
iv. Where an insured person has policies from more than one
meaning w herever it may appear.
insurer to cover the same ris k on indemnity basis, the
6. Fraud insured person shall only be indemnified the hospitalization
costs in accordance w ith the terms and conditions of the
If any claim made by the Insured Person, is in any respect
chosen Policy.
fraudulent, or if any fals e statement, or declaration is made or
used in support thereof, or if any fraudulent means or devices are 8. Renewal of Policy
used by the Insured Person or anyone acting on his/her behalf to
The Policy shall ordinarily be renewable except on grounds of
obtain any benefit under this policy, all benefits under this policy
fraud, misrepresentation by the insured person.
and the premium paid shall be forfeited.
i. The Company shall endeavor to give notice for renewal.
Any amount already paid against claims made under this Policy
How ever, the Company is not under obligation to give any
but w hic h are found fraudulent later shall be repaid by all
notice for renew al.
recipient (s)/ Policyholder(s), who has made that partic ular
9
Group MediCare
ii. Renew al shall not be denied on the ground that the insured b. Us, it shall be delivered to Our address specif ied in
had made a claim or claims in the preceding policy years. the Schedule to this Policy. No insurance agents,
brokers or other person or entity is authorised to
receiv e any notic e, direction or instruction on Our
iii. Request for renewal along w ith requisite premium shall be
behalf unless We have expressly stated to the
receiv ed by the Company before the end of the policy
contrary in writing.
period.
13. Termination
iv. At the end of the policy period, the policy shall terminate
and can be renewed within the Grace Period of 30 days to i. You may terminate this Policy / Certific ate of Insurance at
maintain continuity of benefits without Break in Policy. any time by giving Us written notice, and the
Coverage is not available during the grace period. Policy/Certificate of Insurance shall terminate w hen such
written notice is received.
v. No loading shall apply on renewals based on individual
claims experience. In case of master policy, each Certific ate of Insurance will
get terminated on the earliest of the follow ing dates:
9. Possibility of Revision of Terms of the Policy Including the
Prem ium Rates a. The date You or We cancel the Certific ate of
Insurance
The Company, w ith prior approval of IRDAI, may revise or modify
the terms of the Policy including the premium rates. The Insured b. The member opts out of the scheme
Person shall be notified three months before the changes are
c. Foreclosure/closure of loan availed (wherever
effected.
applicable)
10. Migration
14. Cancellation
The insured person will have the option to migrate the policy to
i. The Policyholder may cancel this policy by giving 15 days
other health insurance products/plans offered by the company
written notice and in such an event, the Company shall
policy by applying for migration of the policy atleast 30 days
refund premium for the unexpired policy period as detailed
before the policy renewal date as per IRDAI guidelines on
below .
Migration. If such person is presently covered and has been
continuously covered without any lapses under any health Short Rate Table:
insurance product/plan offered by the company, the insured
Year
person w ill get the accrued continuity benefits in waiting periods
Length of 1 2 3 4 5
as per IRDAI guidelines on Migration.
time Policy in
For Detailed Guidelines on Migration, kindly refer Guidelines force
issued by IRDAI(Insurance Regulatory and Development Upto 1 Month 85.00% 87.50% 91.50% 96% 98%
Authority of India) on Migration and Portability of Health >1 month & 70.00% 75.00% 88.50% 93% 95%
Insurance policies – Ref: IRDAI/HLT/REG/CIR/194/07/2020) Upto 3
dated 22nd July 2020 and subsequent amendments thereof. Months
11. Withdrawal of Policy >3 months & 50.00% 62.50% 75% 78% 80%
Upto 6
i. In the likelihood of this product being withdrawn in future,
Months
the Company w ill intimate the Insured Person about the
>6 months & Nil 50.00% 66.50% 70% 72%
same 90 days prior to expiry of the Policy. Upto 12
ii. Insured Person w ill have the option to migrate to similar Months
health insurance product available w ith the Company at the >12 months NA 30% 50% 52% 54%
time of renewal w ith all the accrued continuity benefits such & Upto 15
as cumulative bonus, waiv er of waiting period as per IRDAI Months
guidelines provided the Policy has been maintained without >15 months NA 20% 41.50% 43% 44%
a break. & Upto 18
Months
12. Notices
>18 months NA Nil 33% 35% 36%
i. Any notice, direction or instruction under this Policy shall be & Upto 24
in w riting and if it is to: months
>24 months NA NA 15% 20% 30%
a. Any Insured Person, then it shall be sent to You at
& Upto 30
Your address specified in the Schedule to this Policy
months
and You shall act for all Insured Person(s) for these
purposes.
10
Group MediCare
> 30 months NA NA Nil 15% 25% 17. Claim settlement (provision of Penal Interest)
& Up to 36 i. The Company shall settle or reject a claim, as the case may
months be, w ithin 30 days from the date of receipt of last necessary
> 36 months NA NA NA Nil 20% document.
& up to 42
Exceeding 42 NA NA NA Nil Nil ii. ln the case of delay in the payment of a claim, the Company
months shall be liable to pay interest to the policyholder from the
date of receipt of last necessary document to the date of
Notw ithstanding anything contained herein or otherwise, no
payment of claim at a rate 2% above the bank rate.
refunds of premium shall be made in respect of Cancellation
where, any claim has been admitted or has been lodged or iii. How ever, where the circumstances of a claim w arrant an
any Benefit has been availed by the Insured Person under investigation in the opinion of the Company, it shall initiate
the Policy. and complete such investigation at the earliest, in any case
not later than 30 days from the date of receipt of last
ii. The Company may cancel the Policy at any time on necessary document- ln such cases, the Company shall
grounds of mis-representation, non-dis closure of material
settle or reject the claim w ithin 45 days from the date of
facts, fraud by the Insured Person by giving 15 days written
receipt of last necessary document.
notice. There would be no refund of premium on
cancellation on grounds of mis-representation, non- iv. ln case of delay beyond stipulated 45 days, the Company
disclosure of material facts or fraud. shall be liable to pay interest to the policyholder at a rate
2% above the bank rate from the date of receipt of last
15. Free look period
necessary document to the date of payment of claim.
The Free Look Period shall be applicable on new indiv idual (“Bank rate” shall mean the rate fixed by the Reserve Bank
health insurance policies and not on renewals or at the time of of lndia (RBl) at the beginning of the financial year in whic h
porting/migrating the policy. claim has fallen due)
The insured person shall be allow ed free look period of fif teen 18. Complete Discharge
days from date of receipt of the policy document to review the
terms and conditions of the policy, and to return the same if not Any payment to the Policyholder, Insured Person or his/ her
acceptable. nominees or his/ her legal representative or assignee or to the
Hospital, as the case may be, for any benefit under the policy
If the insured has not made any claim during the Free Look shall be a valid discharge towards payment of claim by the
Period, the insured shall be entitled to Company to the extent of that amount for the particular claim.
i. a refund of the premium paid less any expenses incurred by 19. Arbitration
the Company on medical examination of the insured person
and the stamp duty charges or If any dispute or difference shall aris e as to the quantum to be
paid by the Policy, (liability being otherw ise admitted) such
ii. where the risk has already commenced and the option of difference shall independently of all other questions, be referred
return of the policy is exercised by the insured person, a to the decision of a sole arbitrator to be appointed in w riting by
deduction towards the proportionate risk premium for period the parties here to or if they cannot agree upon a single arbitrator
of cover or within thirty days of any party invoking arbitration, the same shall
iii. Where only a part of the insurance coverage has be referred to a panel of three arbitrators, comprising two
commenced, such proportionate premium commensurate arbitrators, one to be appointed by each of the parties to the
with the insurance coverage during such period dispute/difference and the third arbitrator to be appointed by such
tw o arbitrators and arbitration shall be conducted under and in
accordance w ith the provisions of the Arbitration and Conciliation
16. Nom ination:
Act 1996, as amended by Arbitration and Conciliation
The Policyholder is required at the inception of the Policy to make (Amendment) Act, 2015 (No. 3 of 2016).
a nomination for the purpose of payment of claims under the
Policy in the event of death of the Policyholder. A ny change of It is clearly agreed and understood that no difference or dispute
nomination shall be communicated to the company in w riting and shall be preferable to arbitration as herein before provided, if the
such change shall be effective only when an endorsement on the Company has dis puted or not accepted liability under or in
Policy is made. In the event of death of the Policyholder, the respect of the policy.
Company will pay the nominee {as named in the Policy
Schedule/Policy Certificate/Endorsement (if any)} and in case It is hereby expressly stipulated and declared that it shall be a
there is no subsis ting nominee, to the legal heirs or legal condition precedent to any right of action or suit upon the policy
representatives of the Policyholder whose discharge shall be that award by such arbitrator/arbitrators of the amount of
treated as full and final discharge of its liability under the Policy. expenses shall be first obtained.
11
Tata AIG General Insurance Company Limi ted - Registered Off ice: Peninsula Business Park, Tower A, 15th Floor, G.K. Marg, Lower Parel, Mumb ai – 400013
Group MediCare
20. Dispute Resolution Clause by full

Any and all disputes or differences under or in relation to this particulars:
Policy shall be determined by the Indian Courts and subject to If any planned Netw ork We w ill At least 48
Indian law . treatment, Hospital provide hours before
21. Moratorium Period consultation or cashless the planned
procedure for service by treatment or
After completion of eight continuous years under this policy no whic h a claim making Hospitalisation
look back w ould be applied. This period of eight years is called as may be made: payment to
moratorium period. The moratorium w ould be applicable for the the extent of
sums insured of the first policy and subsequently completion of Our liability
eight continuous years would be applicable from date of directly to the
enhancement of sums insured only on the enhanced limits. After Netw ork
the expiry of Moratorium Period no health insurance claim shall Hospital.
be contestable except for proven fraud and permanent exclusions
If any Netw ork We w ill Within 24
specif ied in the policy contract. The policies would however be
treatment, Hospital provide hours after the
subject to all limits, Sub limits, co-payments, deductibles as per
consultation or cashless treatment or
the policy contract.
procedure for service by Hospitalisation
Section 5 – Claims Procedure and Claims Payment whic h a claim making
This section explains about the procedures involv ed to file a valid claim may be made, payment to
by the insured member and processes related in managing the claim requiring the extent of
by TPA or Us. All the procedures and processes such as notif ication of emergency Our liability
hospitalisation directly to the
claim, availing cashless service, supporting claim documents and
Netw ork
related claim terms of payment are explained in this section.
Hospital.
1. Notification of Claim 3. Procedure for Cashless Service
Treatment, Consultation We or Our TPA* must be i. Cashless Service is only available at Netw ork Hospitals.
or Procedure: informed:
ii. In order to avail cashless treatment, the following procedure
1 If any treatment for which a At least 48 hours prior to the must be followed by You:
claim may be made and that Insured Person’s admission.
a. Prior to taking treatment and/or incurring Medical
treatment requires planned
Expenses at a Netw ork Hospital, You must call our
Hospitalisation:
designated TPA/Us and request pre-authorization.
2 If any treatment for which a Within 24 hours of the
b. For any emergency Hospitalization, our designated
claim may be made and that Insured Person’s admission
TPA/We must be informed no later than 24 hours of
treatment requires to Hospital.
the start of Your hospitalization/ treatment.
emergency Hospitalisation
c. For any planned hospitalization, our designated
Failure to furnish such intimation w ithin the time required shall not
TPA/We must be informed atleast 48 hours prior to
invalidate nor reduce any claim if You can satisfy us that it was not
the start of your hospitalization/treatment.
reasonably possible for You to giv e proof of such delay w ithin such
time. The Company may relax these timelines only in special d. Our designated TPA/We w ill check your coverage as
circumstances and for the reasons beyond the control of the insured. per the eligibility and send an authorization letter to
the provider. You have to provide the ID card issued
*TPA as mentioned in the policy schedule
to You along w ith any other information or
2. Cashless Service documentation that is requested by the TPA/Us to the
Netw ork Hospital.
Treatment, Treatment, Cashless We must be
Consultation or Consultatio Service is given notice e. In case of defic iency in the documents sent to TPA/Us
Procedure: n or Available: that the for cashless authoriz ation, the same shall be
Procedure Insured Person communicated to the hospital by TPA/Us w ithin 6
Taken at: wis hes to take hours of receipt of the documents.
advantage of
f. In case the ailment /treatment is not covered under
the cashless
the policy or cashless is rejected due to insuffic ient
service
documents submitted, a rejection letter would be sent
accompanied
to the hospital within 6 hours.
12
Group MediCare Base
g. Rejection of cashless in no way indicates rejection of hospitalization claim Prescriptions must be submitted
the claim. You are required to submit the claim along with the corresponding Doctor/hospital invoice.
with required documents for us to decide on the
admissibility of the claim.
g. All pre and post investigation, treatment and follow up
h. If the cashless is approved, the original bills and (consultation) records pertaining to the present
evidence of treatment in respect of the same shall be ailment for which claim is being made, if and where
left with the Network Hospital. applicable.
i. Pre-authorization does not guarantee that all costs h. Treating doctor’s certific ate regarding missing
and expenses will be covered. We reserve the right to information in case his tories e.g. Circumstance of
review each claim for Medical Expenses and injury and Alcohol or drug influence at the time of
accordingly coverage will be determined according to accident, if available
the terms and conditions of this Policy.
i. Copy of settlement letter from other insurance
4. Supporting Documentation & Exam ination company or TPA
i. You or someone claiming on Your behalf shall provide Us j. Stickers and invoice of implants used during surgery
with documentation, medical records and information We or
k. Copy of MLC (Medico legal case) records, if carried
Our TPA may request to establish the circumstances of the
out and FIR (First information report) if regis tered, in
claim, its quantum or Our liability for the claim w ithin
case of claims arising out of an accident and available
15 days or earlier of Our request or the Insured Person’s
with the claimant.
discharge from Hospitalisation or completion of treatment.
l. Regulatory requirements as amended from time to
time, currently mandatory NEFT (to enable direct
ii. Failure to furnish such evidence within the time required
credit of claim amount in bank account) and KYC
shall not invalidate nor reduce any claim if you can satisfy
(recent ID/Address proof and photograph)
us that it was not reasonably possible for you to give proof
requirements
within such time.
m. Legal heir/succession certific ate , if required
iii. We may accept claims w here documents have been
provided after a delayed interval only in special n. PM report (wherever applicable and conducted)
circumstances and for the reasons beyond the control of the
v. Note: In case You are claiming for the same event under an
Insured Person.
indemnity based policy of another insurer and are required
iv. Such documentation will include the follow ing: to submit the original documents related to Your treatment
with that particular insurer, then You may provide Us with
a. Our claim form, duly completed and signed for on
the attested copies of such documents along w ith a
behalf of the Insured Person. We, upon receipt of a
declaration from the particular insurer specif ying the
notice of claim, w ill furnish Your representativ e w ith
availability of the original copies of the specif ied treatment
such forms as We may require for filing proofs of loss
documents with it.
or you may download the claim form from our Web
site. We at our own expense, shall have the right and opportunity
to examine Insured Person(s) through Our Authorised
b. Original Bills (pharmacy purchase bill, consultation bill,
Medical Practitioner w hose details w ill be notified to Insured
diagnostic bill) and any attachments thereto like
Person w hen and as often as We may reasonably require
receipts or prescriptions in support of any amount
during the pendency of a claim hereunder.
claimed w hich will then become Our property.
c. All medical reports, case histories, investigation

5. Claims Payment
reports, indoor case papers/ treatment papers (in
reimbursement cases, if available), discharge i. We shall be under no obligation to make any payment under
summaries. this Policy unless We have receiv ed all premium payments
in full and on time and We have been provided with the
d. A precise diagnosis of the treatment for which a claim
documentation and information We or Our TPA has
is made.
requested to establish the circumstances of the claim, its
e. A detailed list of the individual medical services and quantum or Our liability for it, and unless the Insured Person
treatments provided and a unit pric e for each in case has complied w ith his obligations under this Policy.
not available in the submitted hospital bill.
f. Prescriptions that name the Insured Person and in the ii. All claims w ill be settled in accordance w ith the applicable
case of drugs: the drugs prescribed, their price and a regulatory guidelines, including IRDAI (Protection of
receipt for payment. In case of pre/post Policyholders Interests Regulation), 2017.
13
Group MediCare
Section 6 – Redressal of Grievance BHOPAL Office of the Insurance Madhya

Ombudsman, Janak Pradesh,
In case of any grievance the Insured Person may contact through
Vihar Complex, 2nd Chattisgarh
Website: www.tataaig.com Floor, 6, Malviya Nagar,
Opp. Airtel Offic e,Near
Call us 24X 7 toll free helpline 1800 266 7780 or 1800 22 9966 New Market, Bhopal –
(Senior Citizen) Email us at [email protected] 462 003. Tel.: 0755 -
2769201 / 2769202 Fax:
Write to us at: Customer Support, Tata AIG General Insurance 0755 - 2769203 Email:
Company Limited bimalokpal.bhopal@eco
i.co.in
BHUBANESHWAR Office of the Insurance Orissa

A-501 Building No. 4 IT Infinity Park, Dindoshi, Malad (E), Mumbai -
Ombudsman,62, Forest
400097 park, Bhubneshwar –
Visit the Servicing Branch mentioned in the policy document 751 009. Tel.: 0674 -
2596461 /2596455 Fax:
The insured person may also approach the grievance cell at any of the 0674 - 2596429 Email:
Company’s branches with details of grievance. bimalokpal.bhubanesw
[email protected]
lf lnsured person is not satisfied with the redressal of grievance through
one of the above methods, Insured person may contact the grievance CHANDIGARH Office of the Insurance Punjab,
officer at [email protected]. For updated details Ombudsman, S.C.O. No. Haryana,
101, 102 & 103, 2nd Himachal
of grievance offic er, kindly refer the link
Floor, Batra Building, Pradesh,
(https://www.tataaig.com/grievance-redressal-policy) Sector 17 – D, Jammu &
lf lnsured person is not satisfied with the redressal of grievance through Chandigarh – 160 017. Kashmir,
above methods, the Insured Person may also approach the office of Tel.: 0172 - 2706196 / Chandigarh
2706468 Fax: 0172 -
lnsurance Ombudsman of the respective area/region for redressal of
2708274 Email:
grievance as per lnsurance Ombudsman Rules 2017. Grievance may
bimalokpal.chandigarh
also be lodged at IRDAI lntegrated Grievance Management System - @ecoi.co.in
https://igms. irda.gov.in/
CHENNAI Office of the Insurance Tamil Nadu,
LIST OF INSURANCE OMBUDSMAN Ombudsman, Fatima Pondicherry
Akhtar Court, 4th Floor, Tow n and
Office of the Address & Contact Jurisdiction of
453,Anna Salai, Karaikal (w hic h
Ombudsm an details Office Union
Teynampet, CHENNAI – are part of
Territory,
600 018. Tel.: 044 - Pondicherry).
District
24333668 / 24335284
AHMEDABAD Office of the Insurance Gujarat,Dadra Fax: 044 - 24333664
Ombudsman & Nagar Haveli, Email: bimalokpal.
,Jeevan Prakash Daman and [email protected]
Building, 6th floor, Tilak Diu. DELHI Office of the Insurance Delhi
Marg, Relief Road, Ombudsman, 2/2 A,
Ahmedabad – 380 Universal Insurance
001.Tel.: 079 - Building, Asaf Ali Road,
25501201/02/05/06 New Delhi – 110 002.
Email: Tel.: 011 - 23239633 /
bimalokpal.ahmedabad 23237532 Fax: 011 -
@ecoi.co.in 23230858
Email: bimalokpal.
BENGALURU Office of the Insurance Karnataka [email protected]
Ombudsman,
GUWAHATI Office of the Insurance Assam,
Jeevan Soudha
Ombudsman, Jeevan Meghalaya,
Building,PID No. 57-27-
Nivesh, 5th Floor, Nr. Manipur,
N-19 Ground Floor,
Panbazar over bridge, Mizoram,
19/19, 24th Main
S.S. Road, Guwahati – Arunachal
Road,JP Nagar, Ist
781001(ASSAM). Tel.: Pradesh,
Phase, Bengaluru – 560
0361 - 2132204 / Nagaland and
078. Tel.: 080 - 2132205 Fax: 0361 -
26652048 / 26652049 Tripura
2732937
Email: Email: bimalokpal.
bimalokpal.bengaluru@ guw [email protected]
ecoi.co.in
14
Group MediCare
HYDERABAD Office of the Insurance Andhra Sravasti,

Ombudsman, 6-2-46, Pradesh, Gonda,
1st floor, “Moin Court”, Telangana, Faizabad,
Lane Opp. Saleem Yanam and Amethi,
Function Palace, A. C. part of Kaushambi,
Guards, Lakdi-Ka-Pool, Territory of Balrampur,
Hyderabad - 500 004. Pondicherry. Basti,
Tel.: 040 - 65504123 / Ambedkarnaga
23312122 Fax: 040 - r, Sultanpur,
23376599 Maharajgang,
Email: bimalokpal. Santkabirnagar,
[email protected]
Azamgarh,
JAIPUR Office of the Insurance Rajasthan Kushinagar,
Ombudsman, Jeevan Gorkhpur,
Nidhi – II Bldg., Gr. Deoria, Mau,
Floor, Bhaw ani Singh Ghazipur,
Marg, Jaipur - 302 005. Chandauli,
Tel.: 0141 - 2740363 Ballia,
Email: Bimalokpal. Sidharathnagar
[email protected]
MUMBAI Office of the Insurance Goa, Mumbai
ERNAKULAM Office of the Insurance Kerala,
Ombudsman, 3rd Floor, Metropolitan
Ombudsman, 2nd Floor, Lakshadweep,
Jeevan Seva Annexe, S. Region
Pulinat Bldg., Opp. Mahe-a part of
V. Road, Santacruz (W), excluding Navi
Cochin Shipyard, M. G. Pondicherry
Mumbai - 400 054. Tel.: Mumbai &
Road, Ernakulam - 682
015. Tel.: 0484 - 022 - 26106552 / Thane
2358759 / 2359338 Fax: 26106960Fax: 022 -
0484 - 2359336 26106052 Email:
Email: bimalokpal.mumbai@ec
bimalokpal.ernakulam@ oi.co.in
ecoi.co.in
NOIDA Office of the Insurance State of
KOLKATA Office of the Insurance West Bengal, Ombudsman, Bhagw an Uttaranchal
Ombudsman, Sikkim, Sahai Palace 4th Floor, and the
Hindustan Bldg. Andaman & Main Road, Naya Bans, follow ing
Annexe, 4th Floor, 4, Nicobar Islands Sector 15, Distt: Gautam Districts of
C.R. Avenue, KOLKATA - Buddh Nagar, U.P- Uttar Pradesh:
700 072. Tel.: 033 - 201301. Tel.: 0120- Agra, Aligarh,
22124339 / 22124340 2514250 / 2514252 / Bagpat,
Fax : 033 - 22124341 2514253 Email: Bareilly, Bijnor,
Email: bimalokpal.noida@ecoi. Budaun,
bimalokpal.kolkata@eco co.in Bulandshehar,
i.co.in Etah, Kanooj,
Mainpuri,
LUCKNOW Office of the Insurance Districts of
Mathura,
Ombudsman, 6th Floor, Uttar Pradesh :
Meerut,
Jeevan Bhawan, Phase- Laitpur, Jhansi,
Moradabad,
II, Naw al Kishore Road, Mahoba,
Muzaffarnagar,
Hazratganj, Lucknow - Hamirpur,
Oraiyya,
226 001. Tel.: 0522 - Banda,
Pilibhit, Etaw ah,
2231330 / 2231331 Fax: Chitrakoot,
Farrukhabad,
0522 - 2231310 Email: Allahabad,
Firozbad,
bimalokpal.lucknow@ec Mirzapur,
Gautambodhan
oi.co.in Sonbhabdra,
agar,
Fatehpur,
Ghaziabad,
Pratapgarh,
Hardoi,
Jaunpur,Varana
Shahjahanpur,
si, Gazipur,
Hapur, Shamli,
Jalaun, Kanpur,
Rampur,
Lucknow,
Kashganj,
Unnao, Sitapur,
Sambhal,
Lakhimpur,
Amroha,
Bahraich,
Hathras,
Barabanki,
Raebareli,
15
Group MediCare
Kanshiramnaga
r, Saharanpur
PATNA Office of the Insurance Bihar,

Ombudsman, 1st Jharkhand
Floor,Kalpana Arcade
Building,, Bazar Samiti
Road, Bahadurpur,
Patna 800 006. Tel.:
0612-2680952 Email:
bimalokpal.patna@ecoi.
co.in
PUNE Office of the Insurance Maharashtra,

Ombudsman, Jeevan Area of Navi
Darshan Bldg., 3rd Mumbai and
Floor, C.T.S. No.s. 195 to Thane
198, N.C. Kelkar Road, excluding
Narayan Peth, Pune – Mumbai
411 030. Tel.: 020- Metropolitan
41312555 Email: Region
[email protected]
o.in
For updated list and details of Insurance Ombudsman Offices, please

visit website http://ecoi.co.in/ombudsman.html
Prohibition of Rebates - Section 41 of the Insurance Act, 1938 as

amended by Insurance Laws (Amendment) Act, 2015.
1. No person shall allow or offer to allow, either directly or indirectly,

as an inducement to any person to take out or renew or continue
an insurance in respect of any kind of ris k relating to lives or
property in India, any rebate of the whole or part of the
commission payable or any rebate of the premium show n on the
policy, nor shall any person taking out or renew ing or continuing a
policy accept any rebate, except such rebate as may be allow ed in
accordance with the published prospectuses or tables of the
insurer.
2. Any person making default in complying w ith the provisions of this
section shall be liable for a penalty which may extend to ten lakh
rupees.
Insurance is the subject matter of solicitation. For details on risk factors,

terms and conditions, please read policy document carefully before
concluding a sale.
16

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Group MediCare

Tata AIG General Insurance Co. Ltd.

Preamble Hospital w hich follow differential billing or for those

Section 1: Base Covers

Dental treatment means a treatment related to teeth or structures

17. In-patient Care 24. OPD treatment

20. Medical Expenses 26. Pre-hospitalization Medical Expenses

28. Post-hospitalization Medical Expenses 35. Surgery or Surgical Procedure

whic h the insured person’s hospitalization was required,

Migration” means, the right accorded to health insurance

30. Qualified Nurse Section 3 – General Exclusions

8. Dietary supplements and substances that can be purchased

ii. Any services for people who are terminally ill to

20. Dispute Resolution Clause by full

1. Notification of Claim 3. Procedure for Cashless Service

c. All medical reports, case histories, investigation

Section 6 – Redressal of Grievance BHOPAL Office of the Insurance Madhya

BHUBANESHWAR Office of the Insurance Orissa

HYDERABAD Office of the Insurance Andhra Sravasti,

PATNA Office of the Insurance Bihar,

PUNE Office of the Insurance Maharashtra,

For updated list and details of Insurance Ombudsman Offices, please

Prohibition of Rebates - Section 41 of the Insurance Act, 1938 as

1. No person shall allow or offer to allow, either directly or indirectly,

Insurance is the subject matter of solicitation. For details on risk factors,

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