Co pay: Value Network Provider, ZONE WISE, AGE WISE & PORTABILITY ,,, ROOM CATEGORY – SINGLR PRIVATE ROOM
Tata AIG MediCare LITE Policy Wordings :
Tata AIG General Insurance Company Limited (We, Our or Us) will provide the insurance, described in this Policy and any endorsements thereto, for the Policy Period, as defined in the Policy to the Insured Person(s) named in the Policy Schedule based on the Disclosure to Information Norm, including in reliance upon the statements contained in the Proposal Form or any other mode of communication which shall be the basis of this Policy and are deemed to be incorporated herein in return for the receipt of the required premium in full and compliance with all the applicable terms, conditions and exclusions of this Policy. The insurance provided under this Policy is only in force for the Insured Person with respect to such and so many of the benefits as indicated by the Sum Insured set opposite such benefit in the Policy Schedule.
Your Obligations:
Please disclose all pre-existing disease/s or condition/s before buying a policy. Non-disclosure may result in claim not being paid and termination of Your policy.
Suitability:
a. This policy covers persons in the age group 91 days onwards (Dependent children between 91 days and 5 years can be insured only when both parents are getting insured). The maximum entry age is 65 years.
b. There is no maximum cover ceasing age under this policy.
c. The policy will be issued for a period 1/2/3 years.
d. This policy can be issued to an individual and/or to a family on family floater basis.
e. The family includes spouse and economically dependent children and up to 2 parents and up to 2 parent-in-laws.
Relationships covered: Self, spouse, upto 3 dependent children , upto 2 parents & upto 2 parents-in-laws. In case of family floater, where the dependent child(ren) attains 26 years of age at renewal, the child(ren) can be covered under a separate policy with eligible continuity benefit.
Sum Insured options (in ₹):
• 5 Lacs
• 7.5 Lacs
• 10 Lacs
• 15 Lacs
• 20 Lacs
Zone(s)
For the purpose of premium computation, the country is categorized in three Zones and premium payable under the policy will be calculated based on the residential location/address as provided by the proposer/insured person in the proposal form:
• Zone A: Mumbai (including Mumbai Metropolitan Region), Delhi (including National Capital Region, Faridabad, Ghaziabad), Ahmedabad, Surat & Baroda
• Zone B: Hyderabad (including Secunderabad), Bengaluru, Kolkata, Indore, Chennai, Chandigarh (including, Mohali, Punchkula, Zirakpur), Pune (including Pimpri Chinchwad) and Rajkot
• Zone C: Rest of India
Lifelong renewal:
We offer you a lifelong renewal for your policy provided premium is paid without any break. Your premiums will be basis the age, sum insured, plan, zone and optional cover. Your renewal premium will be basis your age on renewal and there will be no extra loadings based on your individual claim.
Terms and Conditions
Free look cancellation – Free Look cancellation of 30 days is available after receipt of the policy document to review the policy terms and conditions. In case of any policy related objections, you have the option to cancel the policy and premium would be refunded as per the free look cancellation clause mentioned in the policy.
Risk Loading – We may apply risk loading based on individual’s health status.
Cancellation – There will be no premium refund in case of cancellation due to established fraud, misrepresentation or non-disclosure of material facts.
Grace Period – Grace period of 30 days as per regulation laid down by IRDAI is available for renewal post policy expiry.
Portability – In case you want to port your policy to Us, apply at least 45 days prior to policy renewal date and IRDAI portability guidelines shall apply.
Possibility of Revision – The Company, may revise or modify the terms of the Policy including the premium rates. The Policyholder shall be notified three months before the changes are effected.
Possibility of Withdrawal – In the likelihood of this product being withdrawn in future, the Company will intimate the Insured Person about the same 90 days prior to expiry of the Policy. Insured Person will have the option to migrate to similar health insurance product.
Renewal – The policy is renewable except in case of established fraud or non-disclosure or misrepresentation by the Insured Person.
Section 1 – Definitions
The terms defined below and at other junctures in the Policy Wording have the meanings ascribed to them wherever they appear in this Policy and where appropriate, references to the singular include references to the plural; references to the male includes other genders and references to any statutory enactment includes subsequent changes to the same.
i. Standard Definitions
1. Accident
An Accident means sudden, unforeseen and involuntary event caused by external, visible and violent means.
2. Any one illness
Any one illness means continuous period of illness and includes relapse within 45 days from the date of last consultation with the Hospital/Nursing Home where treatment was taken.
3. AYUSH Day Care Centre
AYUSH Day Care Centre means and includes Community Health Centre (CHC), Primary Health Centre (PHC), Dispensary, Clinic, Polyclinic or any such health centre which is registered with the local authorities, wherever applicable and having facilities for carrying out treatment procedures and medical or surgical/para-surgical interventions or both under the supervision of registered AYUSH Medical Practitioner (s) on day care basis without in-patient services and must comply with all the following criterion:
i. Having qualified registered AYUSH Medical Practitioner(s) in charge;
ii. Having dedicated AYUSH therapy sections as required and/or has equipped operation theatre where surgical procedures are to be carried out;
iii. Maintaining daily records of the patients and making them accessible to the insurance company’s authorized representative.
4. AYUSH Hospital
An AYUSH Hospital is a healthcare facility wherein medical/surgical/para-surgical treatment procedures and interventions are carried out by AYUSH Medical Practitioner(s) comprising of any of the following:
a. Central or State Government AYUSH Hospital or
b. Teaching Hospital attached to AYUSH college recognized by the Central Government/ Central Council of Indian Medicine/ Central Council for Homeopathy, or
c. AYUSH Hospital, standalone or co-located with in-patient healthcare facility
of any recognized system of medicine, registered with the local authorities, wherever applicable, and is under the supervision of a qualified registered AYUSH Medical Practitioner and must comply with all the following criterion :
i. Having atleast 5 in-patient beds;
ii. Having qualified AYUSH Medical Practitioner round the clock;
iii. Having dedicated AYUSH therapy sections as required and/or has equipped operation theatre where Surgical Procedure are to be carried out;
iv. Maintaining daily records of the patients and making them accessible to the insurance company’s authorized representative.
5. AYUSH Treatment
AYUSH treatment refers to the medical and / or hospitalization treatments given under Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy systems.
6. Break in policy
Break in policy means the period of gap that occurs at the end of the existing policy term/installment premium due date, when the premium due for renewal on a given policy or installment premium due is not paid on or before the premium renewal date or grace period.
7. Cashless facility
Cashless Facility means a facility extended by the Insurer to the insured where the payments, of the costs of treatment undergone by the insured in accordance with the Policy terms and conditions, are directly made to the Network Provider by the Insurer to the extent pre-authorization is approved.
8. Condition Precedent
Condition Precedent means a Policy terms or condition upon which the Insurer’s liability under the
Policy is conditional upon.
9. Congenital Anomaly:
Congenital Anomaly means a condition which is present since birth, and which is abnormal with reference to form, structure or position.
a) Internal Congenital Anomaly
Congenital anomaly which is not in the visible and accessible parts of the body.
b) External Congenital Anomaly
Congenital anomaly which is in the visible and accessible parts of the body.
10. Co-Payment
Co-Payment means a cost sharing requirement under a health insurance Policy that provides that the policyholder/insured will bear a specified percentage of the admissible claims amount. A Co- Payment does not reduce the Sum Insured.
11. Cumulative Bonus
Cumulative Bonus means any increase or addition in the Sum Insured granted by the Insurer without an associated increase in premium.
12. Day Care Centre
A Day Care Centre means any institution established for Day Care Treatment of Illness and/or injuries or a medical setup with a Hospital and which has been registered with the local authorities, wherever applicable, and is under supervision of a registered and qualified Medical Practitioner AND must comply with all minimum criterion as under –
i. has qualified nursing staff under its employment;
ii. has qualified Medical Practitioner/s in charge;
iii. has fully equipped operation theatre of its own where Surgical Procedure are carried out;
iv. maintains daily records of patients and will make these accessible to the insurance company’s authorized personnel.
13. Day Care Treatment
Day Care Treatment means medical treatment, and/or Surgical Procedure which is:
i. undertaken under General or Local Anesthesia in a Hospital/Day Care Centre in less than 24 hrs because of technological advancement, and
ii. which would have otherwise required Hospitalization of more than 24 hours.
Treatment normally taken on an out-patient basis is not included in the scope of this definition.
14. Dental Treatment
Dental treatment means a treatment related to teeth or structures supporting teeth including examinations, fillings (where appropriate), crowns, extractions and Surgery.
15. Domiciliary Hospitalization
Domiciliary Hospitalization means medical treatment for an Illness/disease/Injury which in the normal course would require care and treatment at a Hospital but is actually taken while confined at home under any of the following circumstances:
i. the condition of the patient is such that he/she is not in a condition to be removed to a Hospital, or
ii. the patient takes treatment at home on account of non-availability of room in a Hospital.
16. Grace Period
“Grace period” means the specified period of time, immediately following the premium due date during which premium payment can be made to renew or continue a policy in force without loss of continuity benefits pertaining to waiting periods and coverage of pre-existing diseases. For single premium payment policies, coverage is not available during the period for which no premium is received. However, If the premium is paid in instalments during the policy period, coverage will be available during the grace period, within the Policy Period . The grace period for payment of the premium shall be: fifteen days where premium payment mode is monthly and thirty days in all other cases.
17. Hospital
A Hospital means any institution established for in-patient care and Day Care Treatment of Illness and/or injuries and which has been registered as a Hospital with the local authorities under Clinical Establishments (Registration and Regulation) Act 2010 or under enactments specified under the Schedule of Section 56(1) and the said act Or complies with all minimum criteria as under:
i. has qualified nursing staff under its employment round the clock;
ii. has at least 10 in-patient beds in towns having a population of less than 10,00,000 and at least 15 in-patient beds in all other places;
iii. has qualified Medical Practitioner(s) in charge round the clock;
iv. has a fully equipped operation theatre of its own where Surgical Procedure are carried out;
v. maintains daily records of patients and makes these accessible to the insurance company’s authorized personnel;
18. Hospitalization
Hospitalization means admission in a Hospital for a minimum period of 24 consecutive ‘In-patient Care’ hours except for specified procedures/ treatments, where such admission could be for a period of less than 24 consecutive hours.
19. Illness
Illness means a sickness or a disease or pathological condition leading to the impairment of normal physiological function and requires medical treatment.
(a) Acute condition
Acute condition is a disease, illness or Injury that is likely to respond quickly to treatment which aims to return the person to his or her state of health immediately before suffering the disease/ illness/ Injury which leads to full recovery
(b) Chronic condition
A chronic condition is defined as a disease, illness, or Injury that has one or more of the following characteristics:
i. it needs ongoing or long-term monitoring through consultations, examinations, check-ups, and /or tests
ii. it needs ongoing or long-term control or relief of symptoms
iii. it requires rehabilitation for the patient or for the patient to be specially trained to cope with it
iv. it continues indefinitely
v. it recurs or is likely to recur
20. Injury
Injury means accidental physical bodily harm excluding Illness or disease solely and directly caused by external, violent, visible and evident means which is verified and certified by a Medical Practitioner.
21. Inpatient Care
Inpatient Care means treatment for which the Insured Person has to stay in a Hospital for more than 24 hours for a covered event.
22. Intensive Care Unit:
Intensive Care Unit means an identified section, ward or wing of a Hospital which is under the constant supervision of a dedicated Medical Practitioner(s), and which is specially equipped for the continuous monitoring and treatment of patients who are in a critical condition, or require life support facilities and where the level of care and supervision is considerably more sophisticated and intensive than in the ordinary and other wards.
23. ICU Charges:
ICU (Intensive Care Unit) Charges means the amount charged by a Hospital towards ICU expenses which shall include the expenses for ICU bed, general medical support services provided to any ICU patient including monitoring devices, critical care nursing and intensivist charges.
24. Medical Advice
Medical Advice means any consultation or advice from a Medical Practitioner including the issuance of any prescription or follow-up prescription.
25. Medical Expenses:
Medical Expenses means those expenses that an Insured Person has necessarily and actually incurred for medical treatment on account of Illness or Accident on the advice of a Medical Practitioner, as long as these are no more than would have been payable if the Insured Person had not been insured and no more than other Hospital(s) or doctors in the same locality would have charged for the same medical treatment.
26. Medical Practitioner
Medical Practitioner means a person who holds a valid registration from the Medical Council of any State or Medical Council of India or Council for Indian Medicine or for Homeopathy set up by the Government of India or a State Government and is thereby entitled to practice medicine within its jurisdiction; and is acting within its scope and jurisdiction of license.
27. Medically Necessary Treatment
Medically Necessary Treatment means any treatment, tests, medication, or stay in Hospital or part of a stay in Hospital which:
i. is required for the medical management of the Illness or Injury suffered by the insured;
ii. must not exceed the level of care necessary to provide safe, adequate and appropriate medical care in scope, duration, or intensity;
iii. must have been prescribed by a Medical Practitioner;
iv. must conform to the professional standards widely accepted in international medical practice or by the medical community in India.
28. Migration
“Migration” means a facility provided to policyholders (including all members under family cover and group policies), to transfer the credits gained for pre-existing diseases and specific waiting periods from one health insurance policy to another with the same insurer.
29. Network Provider
Network Provider means Hospital(s) or health care providers enlisted by an Insurer, TPA or jointly by an Insurer and TPA to provide medical services to an insured by a Cashless Facility.
The updated list of Network Provider is available on Our website (www.tataaig.com).
30. Notification of Claim
Notification of Claim means the process of intimating a claim to the Insurer or TPA through any of the recognized modes of communication.
31. OPD treatment
OPD treatment means the one in which the Insured visits a clinic / 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-patient.
32. Pre-Existing Disease
i. “Pre-existing disease (PED)” means any condition, ailment, injury or disease:
a. that is/are diagnosed by a physician not more than 36 months prior to the date of commencement of the policy issued by the insurer; or
b. for which medical advice or treatment was recommended by, or received from, a physician, not more than 36 months prior to the date of commencement of the policy
33. Pre-Hospitalization Medical Expenses
Pre-Hospitalization Medical Expenses means Medical Expenses incurred during predefined number of days preceding the Hospitalization of the Insured Person, provided that:
i. Such Medical Expenses are incurred for the same condition for which the Insured Person’s Hospitalization was required, and
ii. The In-patient Hospitalization claim for such Hospitalization is admissible by the Insurance Company.
34. Portability
“Portability” means a facility provided to the health insurance policyholders (including all members under family cover), to transfer the credits gained for, pre-existing diseases and specific waiting periods from one insurer to another insurer.
35. Post-Hospitalization Medical Expenses
Post-Hospitalization Medical Expenses means Medical Expenses incurred during predefined number of days immediately after the Insured Person is discharged from the Hospital provided that:
i. Such Medical Expenses are for the same condition for which the Insured Person’s Hospitalization was required, and
ii. The inpatient Hospitalization claim for such Hospitalization is admissible by the insurance company.
36. Qualified Nurse
Qualified Nurse means a person who holds a valid registration from the Nursing Council of India or the Nursing Council of any state in India.
37. Reasonable and Customary Charges
Reasonable and Customary Charges means the charges for services or supplies, which are the standard charges for the specific provider and consistent with the prevailing charges in the geographical area for identical or similar services, taking into account the nature of the Illness / Injury involved.
38. Renewal
Renewal means the terms on which the contract of insurance can be renewed on mutual consent with a provision of Grace Period for treating the Renewal continuous for the purpose of gaining credit for Pre-Existing Disease(s), time-bound exclusions and for all waiting periods.
39. Room Rent
Room Rent means the amount charged by a Hospital towards Room and Boarding expenses and shall include the associated Medical Expenses.
40. Surgery or Surgical Procedure
Surgery or Surgical Procedure means manual and / or operative procedure (s) required for treatment of an Illness or Injury, correction of deformities and defects, diagnosis and cure of diseases, relief from suffering and prolongation of life, performed in a Hospital or Day Care Centre by a Medical Practitioner.
41. Unproven/Experimental treatment
Unproven/Experimental treatment means the treatment including drug experimental therapy which is not based on established medical practice in India, is treatment experimental or unproven.
ii. Specific Definitions (Definitions other than as mentioned under Section 1 (i) above)
42. Age
Means the completed Age of the Insured Person on his / her last birthday as on date of commencement of the Policy and as per the English calendar.
43. Policy
Policy means the contract of insurance including but not limited to Policy Schedule, Endorsements, Policy Wordings (inbuilt covers & optional covers, if opted) and Riders etc., as applicable.
44. Policy Period
Policy Period means the time during which this Policy is in effect. Such period commences from Commencement Date and ends on the Expiry Date and specifically appears in the Policy Schedule.
45. Policy Schedule
Policy Schedule means the Policy Schedule attached to and forming part of Policy.
46. Policy Year
Policy Year means a period of twelve consecutive months beginning from the date of commencement of the Policy Period and ending on the last day of such twelve-month period. For the purpose of subsequent years, Policy Year shall mean a period of twelve months commencing from the end of
the previous Policy Year and lapsing on the last day of such twelve-month period, or the Policy Expiry date whichever is earlier.
47. Shared Accommodation
Shared Accommodation means a Hospital room with two or more in-patient beds. This definition does not apply to ICU or ICCU.
48. Single Private Room
Single Private Room means an air-conditioned room in a Hospital where a single patient is accommodated and which has an attached toilet (lavatory and bath). Such room type shall be the most basic and the most economical of all accommodations available as a single occupancy room in that Hospital. This does not include a deluxe room or a suite or a VIP room.
49. Sum Insured
“Sum Insured” refers to the amount specified in the Policy Schedule at the inception of a Policy Year, excluding any Bonus. Sum Insured represents Our maximum, total and cumulative liability under the Policy, for all the Insured Person(s) covered in aggregate, for the respective Policy Year.
• Upon the successful admission of a claim, the Sum Insured for the remaining Policy Year shall be accordingly reduced by the amount of the claim settled (inclusive of ‘taxes’) or admitted.
• In cases where the Policy Period is 2/3 years, the specified Sum Insured in the Policy Schedule signifies the limit for the initial Policy Year. This limit shall expire at the conclusion of the first year, and fresh limit up to the opted Sum Insured will become available for the subsequent second/third year.
50. Valued Provider – Pan India
‘Valued Provider – Pan India’ is a specific network of Hospital(s), designated as such and mentioned in the Policy Schedule. It consists of a defined list of Hospital(s) or health care providers enlisted by Us, and/or TPA to provide medical services to an Insured Person by a Cashless Facility. Reference made to ‘Network Provider’ in the Policy wordings shall be substituted with ‘Valued Provider – Pan India’, except for Section 5(e) Claim Assessment and Payment, sub section iii (b). The updated list of Valued Provider – Pan India is available on Our website (www.tataaig.com).
51. We, Us, Our, Insurer
means The TATA AIG General Insurance Company Limited that has provided Insurance Cover under this Policy.
52. You, Your, Insured Person
means the person whose name specifically appears in the Policy Schedule as an Insured Person/ Policyholder.
53. Zone(s)
For the purposes of Premium calculation and payment, India has been categorized in 3 different Zone(s):
i. Zone A: Mumbai (including Mumbai Metropolitan Region), Delhi (including National Capital Region, Faridabad, Ghaziabad), Ahmedabad, Surat & Baroda
ii. Zone B: Hyderabad (including Secunderabad), Bengaluru, Kolkata, Indore, Chennai, Chandigarh (including, Mohali, Punchkula, Zirakpur), Pune (including Pimpri Chinchwad) and Rajkot
iii. Zone C: Rest of India
Please note that the above-mentioned categorization of Zone(s) is subject to change at Our sole discretion. Any such change made which shall impact an existing policyholder, shall be intimated under 3 months’ notice and shall be applicable from the immediate next Renewal.
Section 2 – Benefits
If during the Policy Period one or more Insured Person(s) is required to be hospitalized for treatment of an Illness or Injury at a Hospital / Day Care Centre, following Medical Advice of a duly qualified Medical Practitioner, the Company shall indemnify Medically Necessary expenses towards the Coverage mentioned in the Policy Schedule for the amount of such Reasonable and Customary Charges or compensate to the extent agreed, upto the limits mentioned, subject to terms and conditions of the Policy. Provided further that, any amount payable under the Policy shall be subject to the terms of coverage (including any Co-Payment), exclusions, conditions and definition contained herein. Maximum liability of the Company under all such Claims during each Policy Year shall be the Sum Insured opted and Cumulative Bonus (if accrued) specified in the Policy Schedule. The coverages available to a specific Insured Person/ Policy shall be as per the benefits mentioned in the Policy Schedule.
In case of family floater Policy, the sum insured for all or any of the benefits shall be on a per Policy Year basis unless explicitly stated to the contrary. In case of individual Policy, the sum insured for
all or any of the benefits shall be on per Insured Person per Policy Year basis unless explicitly stated to the contrary.
Our maximum liability under the Policy for payment of all claims arising out of Any one illness in aggregate under Sections B1, B2, B3, B4, B5, B6, B7, B8, B9, B12, B13 shall not exceed the opted sum insured and accrued Cumulative Bonus, subject to the balance sum insured.
B1. In-Patient Treatment
We will cover Medical Expenses for Medically Necessary Treatment in a Hospital, due to disease/Illness/Injury, that requires an Insured Person’s admission in a Hospital for an Inpatient Care for period more than 24 hrs., during the Policy Period.
Medical expenses directly related to the hospitalization would be payable.
The Company shall indemnify Medical Expenses as listed below:
i. Room Rent, Boarding, Nursing Expenses as provided by the Hospital / Nursing Home upto the Single Private Room category.
ii. Intensive Care Unit (ICU) / Intensive Cardiac Care Unit (ICCU) expenses
iii. Surgeon, Anesthetist, Medical Practitioner, Consultants, Specialist Fees whether paid directly to the treating doctor / surgeon or to the Hospital.
iv. Anesthesia, blood, oxygen, operation theatre charges, surgical appliances, medicines and drugs, costs towards diagnostics, diagnostic imaging modalities and such similar other expenses.
If the Insured Person is admitted in a room category that is higher than the Single Private Room, then the Insured Person shall bear a rateable proportion of the Room Rent and the total Associated Medical Expenses, including surcharge or taxes thereon in the proportion of the ‘difference between the Room Rent actually incurred & the Room Rent of the Single Private Room category’ to ‘the Room Rent actually incurred’.
• For the purpose of this Benefit “Associated Medical Expenses” shall include the applicable nursing charges, operation theatre charges, fees of Medical Practitioner including surgeon/ anesthetist/ specialist within the same Hospital where the Insured Person has been admitted. “Associated Medical Expenses” does not include cost of pharmacy & consumables, cost of implants & medical devices and cost of diagnostics.
• Proportionate deductions are not applicable for ICU Charges.
• Such proportionate deductions, if any, will not be applied in respect of the Hospital(s) which do not follow differential billing or for those Associated Medical Expenses in respect of which differential billing is not adopted based on the room category.
Benefit Specific Sub-limit: Room category- Upto Single private room
limit for In-Patient Treatment: Upto Sum Insured
B2. Pre-Hospitalization expenses
We will cover for expenses for Pre-Hospitalization consultations, investigations and medicines incurred upto 60 days prior to the date of admission to the Hospital. Any pre-Hospitalization expenses incurred prior to Policy Period shall not be covered.
The benefit is payable if We have admitted a claim under B1 or B4 or B6.
Limit for Pre-Hospitalisation expenses: Upto 60 days, Upto Sum Insured
B3. Post-Hospitalization expenses
We will cover for expenses for Post-Hospitalization consultations, investigations and medicines incurred upto 180 days after discharge from the Hospital.
The benefit is payable if We have admitted a claim under B1 or B4 or B6.
Limit for Post-Hospitalisation Expenses: Upto 180 days, Upto Sum Insured
B4. Day Care Treatment
We will cover expenses for Day Care Treatment, due to disease/Illness/Injury, taken in a Hospital or a Day Care Centre, during the Policy Period.
Limit for Day Care Procedures: Upto Sum Insured
B5. Organ Donor
We shall cover the Medical Expenses, up to the limits as specified in the Policy Schedule, incurred by or in respect of the organ donor, for an organ transplant Surgery, solely towards the harvesting of the organ donated subject to the following conditions:
Conditions
i. The organ donation conforms to the Transplantation of Human Organs (Amendment) Bill, 2011 and the organ is for the use of the Insured Person;
ii. The Insured Person is the recipient of the organ so donated by the organ donor and the claim of such Surgery is accepted by Us under B1 of this Policy;
iii. The organ transplant is medically necessary for the Insured Person as certified by a Medical Practitioner;
iv. Claim under this section shall be assessed as per the claim of the recipient Insured Person.
What is not covered
i. Pre-Hospitalization Medical Expenses or Post-Hospitalization Medical Expenses of the organ donor
ii. Screening Expenses of the organ donor
iii. Any other medical expense as a result of harvesting from the organ donor
iv. Costs directly or indirectly associated with the acquisition of the donor’s organ
v. Transplant of any organ/tissue where the transplant is experimental or investigational
vi. Expenses related to organ transportation or preservation
vii. Any other medical treatment or complication in respect of the donor, consequent to harvesting.
Limit for Organ Donor: Upto Sum Insured
B6. Domiciliary Treatment
We will cover for expenses related to Domiciliary Hospitalization of the Insured Person if the treatment exceeds beyond three consecutive days and is availed during the Policy Period. The treatment must be for management of an Illness and not for enteral feedings or end of life care.
At the time of claiming under this benefit, We shall require certification from the treating doctor fulfilling the conditions as mentioned under the general definitions (Section 1) of this Policy.
Limit for Domiciliary Treatment: Upto Sum Insured
B7. Restore Benefit
We will automatically reinstate 100% of the Sum Insured, if the balance Sum Insured and accrued Cumulative Bonus is insufficient to pay an admissible claim under B1 to B6 In-Patient Treatment, Pre-Hospitalization Expenses, Post- Hospitalization Expenses, Day Care Treatment, Organ Donor cover or Domiciliary Treatment cover, of this Policy. The Restore Benefit will be available once during the Policy Year but shall not be available for the first admissible Hospitalization / Domiciliary Hospitalization claim in each Policy Year. Notwithstanding the above, Our maximum liability in aggregate for all claims during a Policy Year under B7 ‘Restore benefit’ shall not exceed the Sum Insured.
Restore Benefit will be available once during the Policy Year subject to the following conditions:
a. The reinstated sum insured can be used by the Insured Person(s) for any claim (related or unrelated Illness/ Injury) under B1 to B6 of the Policy.
b. However, in case of Any one illness, this benefit for related Illness/ Injury would be available to the Insured Person(s), who have claimed earlier, only for Hospitalization/ Domiciliary Hospitalization where date of admission is beyond 45 days from the date of discharge of the immediately preceding Hospitalization/ date of end of Domiciliary Hospitalization, for which claim has been paid.
c. In a floater Policy, the Reinstated Sum Insured will be available for all Insured Person(s) in the Policy on floater basis.
d. The unutilized restored sum insured cannot be carried forward to the next Policy Year.
e. This benefit shall also be applicable annually for policies with tenure of more than 1 year
f. Restore will not trigger or be available for utilization for the first claim under each Policy Year.
g. Accrued Bonus, if any, will not be reinstated.
B8. AYUSH Benefit
We will cover for Medical Expenses incurred for treatment as In-Patient or Day Care Treatment in an AYUSH Hospital/ AYUSH day care centre, for a room category maximum up to Single Private Room and applicability of Associated Medical Expenses.
This benefit shall also cover Pre-Hospitalization medical expenses for a period of upto 60 days before the date of admission to the AYUSH hospital/ AYUSH day care centre and Post- Hospitalization Medical Expenses for a period upto 180 days, subject to AYUSH In-Patient hospitalization or AYUSH day care treatment claim being admissible under this benefit.
Claims under this section shall be assessed as per the applicable insurance guidelines related to AYUSH and benchmark rates as available on Ministry of AYUSH website (https://ayushnext.ayush.gov.in/site/insurance-guidelines-related-to-ayush).
For your reference, the document has been uploaded on Our website under “Annexure B for AYUSH Benefit” (www.tataaig.com).
Limit for AYUSH Benefit: Upto Sum Insured
B9. Ambulance Cover
We will cover for expenses incurred on transportation of Insured Person in a registered ambulance to a Hospital for admission in case of an Emergency or from one Hospital to another Hospital for better medical facilities and treatment, subject to a maximum limit as specified in the Policy Schedule per Hospitalization.
For this claim to be paid, the claim must be admissible under B1 or B4 of this Policy.
Benefit Specific Sub-limit: Ambulance Cover Upto Rs. 3000 per Hospitalization.
B10. Health Checkup
At the request of the Insured Person, We/ Our empaneled service provider will arrange for below listed medical tests every Policy Year provided the Policy is in force with Us. The health check- ups shall be arranged by Us only on cashless basis at Our empanelled service providers or at Insured Person’s residence, as per availability.
Health Check Up will be available for all Insured Person(s) covered under the Policy irrespective of claim. Check-ups under this benefit can be availed once in a Policy Year.
List of tests:
a. Complete Blood Count with Erythrocyte Sedimentation Rate (CBC with ESR) test
b. Fasting Blood Sugar Test
c. Hemoglobin A1C Test (Hba1c)
d. Lipid Profile Test
e. Liver Function Test
f. Electrocardiogram (ECG) Test
g. Urine Routine Analysis
For the purpose of this benefit, Preventive Health Check-up means the above medical test(s) undertaken for general assessment of health status and does not include any diagnostic or investigative medical tests for evaluation of Illness or a disease.
Utilization of this benefit by Insured Person shall not affect Cumulative Bonus.
B11. Compassionate Travel
In the event the Insured Person is Hospitalized in India for more than Five consecutive days in a place where no adult member of his immediate family is present, We will cover for expenses related to a round trip economy class domestic air ticket, or first-class railway ticket, to allow the Immediate Family Member be at his bedside for the duration of his stay in the Hospital, subject to a maximum limit as specified in the Policy Schedule during a Policy Year.
This benefit shall be payable if We have accepted an inpatient Hospitalization claim for the Insured Person(s) under In Patient Treatment (B1).
This benefit has a separate limit (over and above base sum insured).
We shall require additional documents as proof of travel for supporting the claim under this benefit.
Limit for Compassionate Travel: Upto ₹20,000 per policy year (over and above base sum insured)
B12. Bariatric Surgery Cover
We will cover for reasonable and customary expenses for Bariatric Surgery if the insured fulfills all of the following conditions:
i. Surgery to be conducted is upon the advice of the Doctor.
ii. The Surgery/Procedure conducted should be supported by clinical protocols.
iii. The member has to be 18 years of Age or older and
iv. Body Mass Index (BMI) greater than or equal to 40 or
v. BMI greater than or equal to 35 in conjunction with any of the following severe comorbidities following failure of less invasive methods of weight loss:
a. Obesity-related cardiomyopathy
b. Coronary heart disease
c. Severe sleep apnea
d. Uncontrolled Type2 Diabetes
The coverage and claim assessment and terms & conditions applicable shall be as per the Section 2 Benefit B1 of this Policy.
Limit for Bariatric Surgery Cover: Upto Sum Insured
B13. In-Patient Treatment – Dental
We will cover for Medical Expenses incurred towards Hospitalization for Dental Treatment under anesthesia necessitated due to an Accident/Injury/Illness.
The benefit is payable (notwithstanding exclusion under Section 3.ii.sub-section 1.ix).
The coverage and claim assessment and terms & conditions applicable shall be as per the Section 2 Benefit B1 of this Policy.
Limit for In-Patient Treatment – Dental: Upto Sum Insured
B14. Vaccination cover
We will cover the cost of the following vaccines if the Insured Person(s) is vaccinated during the Policy Year:
– Anti-rabies vaccine following an animal bite
– Typhoid vaccine
After 2 years of continuous coverage with Us:
– Human Papilloma Virus (HPV) vaccine
– Hepatitis B Vaccine
The benefit is payable (notwithstanding the exclusion as per Section 3.ii.sub-section 1.viii) subject to a maximum limit as specified in the Policy Schedule per Policy Year and this benefit has a separate limit (over and above the base sum insured) and does not affect Cumulative Bonus. Expenses related to the doctor, nurse or any incidental expenses are not payable.
Limit for Vaccination cover: Upto ₹5,000 per policy (over and above base sum insured)
B15. Hearing Aid
We will cover for reasonable charges for a hearing aid for the Insured Person, every third year provided there is continuous coverage under this Policy, without any break and is subject to a maximum limit as specified in the Policy Schedule per Policy. This benefit has a separate limit (over and above the base sum insured) and does not affect Cumulative Bonus.
The items must be prescribed by a specialized Medical Practitioner as medically necessary.
Limit for Hearing Aid: Upto 50% of actual cost or ₹10,000/- per policy, whichever is lower (over and above base sum insured)
B16. Daily Cash for choosing Shared Accommodation
We will pay a fixed amount per day, if the Insured Person is Hospitalized in Shared Accommodation in a Hospital in Our network of Valued Provider – Pan India, for each continuous and completed period of 24 hours of Hospitalization. The benefit payable per day would be subject to a maximum limit as specified in the Policy Schedule.
For this claim to be paid, the main claim must be accepted under B1 of this Policy. This benefit has a separate limit (over and above base sum insured).
Limit for Daily Cash for choosing Shared Accommodation: Upto 0.25% of base sum insured and a maximum of ₹2000 per day (over and above base sum insured).
B17. Daily Cash for Accompanying an Insured Child
We will pay a fixed amount per day, if the Insured Person Hospitalized is a child Aged 12 years or less, for one accompanying adult for each completed period of 24 hours of Hospitalization in Our network of Valued Provider – Pan India – Pan India. The benefit payable per day would be subject to a maximum limit as specified in the Policy Schedule.
For this claim to be paid, the main claim must be accepted under B1 of this Policy. This benefit has a separate limit (over and above base sum insured).
Limit for Daily Cash for Accompanying an Insured Child: Upto 0.25% of base sum insured and a maximum of ₹2000 per day (over and above base sum insured).
B18. Second Opinion
At Your request, We will provide You a second medical opinion in India from Our Empaneled Service Provider, if an Insured Person is diagnosed with the below mentioned Illnesses during the Policy Period. The expert opinion would be directly sent to the Insured Person.
i. Cancer
ii. Kidney Failure
iii. Myocardial Infarction
iv. Angina
v. Coronary bypass Surgery
vi. Stroke/Cerebral hemorrhage
vii. Organ failure requiring transplant
viii. Heart Valve replacement
ix. Brain tumors
This benefit can be availed by an Insured Person once during a Policy Year.
Second Opinion will be based only on the information and documentation provided to Us which will be shared with Our empaneled service provider. Conditions as mentioned under Disclaimer Clause (applicable to B18 & B21) in the Policy shall apply.
B19. Accidental Death Benefit (Optional Cover)
If an Insured Person suffers an Accident during the Policy Period and this is the sole and direct cause of his death within 365 days from the date of Accident, then We will pay the Sum Insured as mentioned against the respective Insured Person in the Policy Schedule.
This benefit is not applicable for insured children or Insured Person less than 18 years of Age as on Policy commencement date.
Benefit under optional cover (if opted) shall be available to the Insured Person, only
if the particular benefit/optional cover is specifically mentioned in the Policy Schedule. This benefit has a separate limit (over and above base sum insured).
Limit for Accidental Death Benefit Add on : 100% of the base Sum insured.
B20. Cumulative Bonus / No Claim Discount:
You have the option to choose between Cumulative Bonus and No Claim Discount.
i. We will provide Cumulative Bonus in the form of 50% of the base Sum Insured of the expiring Policy, on each Renewal of the Policy, after every claim free Policy Year, provided that the Policy is renewed with Us without a break. The total accrued Cumulative Bonus shall not exceed 100% of the base Sum Insured in any Policy Year.
ii. If a Cumulative Bonus has been applied and a claim is made, then in the subsequent Policy Year We will automatically decrease the accrued Cumulative Bonus by 50% of the Base Sum Insured in that following Policy Year.
iii. In policies with a tenure of more than one year, Bonus shall accrue post completion of each Policy Year.
iv. In relation to a Family Floater, the Cumulative Bonus so applied will only be available in respect of those Insured Person(s) who were Insured Person(s) in the claim free Policy Year and continue to be Insured Person(s) in the subsequent Policy Year.
v. For purpose of computation of Cumulative Bonus, the percentage (%) of Cumulative Bonus will be applied on the base Sum Insured of the expiring Policy only. Restore Benefit amount will not be taken into consideration for such computation.
vi. Any accrued Cumulative Bonus can only be utilized for an admissible claim under B1, B2, B3, B4, B5, B6, B8, B9, B12 & B13 of this Policy.
vii. In case the Sum Insured under the Policy is reduced at the time of Renewal then the accrued Cumulative Bonus under this benefit shall be reduced in proportion to the reduced sum insured.
viii. Cumulative Bonus will lapse if the Policy is not renewed before Policy expiry (including the Grace Period).
ix. Cumulative Bonus shall be provided only if No Claim Discount has not been availed for the claim free previous Policy Year.
If you Choose No Claim Discount, We will allow 1% discount on renewal premium for every claim free Policy Year, provided that the Policy is renewed with Us without break.
B21. Wellness Services
Teleconsultation – General
We /Our empanelled service provider will arrange for teleconsultations upon Insured Person’s request through telecommunications and digital communication technologies for Insured Person’s health related complaints or preventive health care by a qualified Medical Practitioner/ Health Care Professional.
This service can only be availed subject to condition below:
– Consultation will be provided through various specified modes of communication like audio, video, online portal, chat, digital customer application or any other digital mode.
Definition: For the purpose of section B 21 of this Policy, a Healthcare Professional is a person who holds a valid qualification from regulatory body as set up by the Government of India or a State Government or any other relevant authority and is engaged in actions with an objective of maintaining and improving individual’s good health.
Disclaimer Clause (applicable to B18 & B21)
1. Availing the services under this benefit is purely upon the Insured’s sole discretion and risk.
2. For services that are provided through empanelled service providers, We are acting as a facilitator; hence We would not be liable for any incremental costs or the services. Any additional services availed, or expenses incurred on such services or benefits which are other than those covered under this Policy and explicitly excluded by this Policy, shall not be covered under this Policy and all expenses incurred shall be borne by the Insured Person.
3. We shall not be responsible for or liable for, any actions, claims, demands, losses, damages, costs, charges and expenses which Insured Person claims to have suffered, sustained or incurred, by way of and / or on account of the benefit. We shall not be liable for any deficiency or discrepancy in the services provided by empanelled service provider under this Policy.
4. Insured Person may consult any medical professional at any empanelled service provider at its sole discretion. The cost of service arising out of Insured Person choice of medical professional at any empanelled service provider shall completely be borne by the Insured Person unless covered otherwise. However, the services under this Policy should not be construed to constitute Medical Advice and/or substitute the Insured Person’s visit/ consultation to an independent Medical Practitioner/Healthcare professional.
5. The Medical Practitioner may suggest/recommend/prescribe over the counter medications based on the information provided, if required on a case-to-case basis. Provided that any recommendation under this Policy shall not be valid for any medico legal purposes.
6. The Insured Person is free to choose whether or not to act on the recommendation after seeking consultation.
7. Any advice, recommendations or suggestions made by any medical professional shall be solely based on the information and documentation provided by the Insured Person to such medical professional. We shall not be liable towards any loss or damage (immediate or consequential) arising out of or in relation to any opinion, advice, prescription, actual or alleged errors, omissions and representations made by the medical professional from whom We have availed services or taken benefit or for any consequence of any act or omission in reliance thereon.
8. Above mentioned services are non-portable, annual contracts, independent of Policy contract and not lifelong renewable. The Services provided may be added / deleted / modified at Our discretion and the same shall be notified to the policyholders in advance prior to change effective date.
9. Provision of these services is subject to availability as per the duration specified by Us/the empanelled service provider. Details are available on Our website (www.tataaig.com)
10. Any service availed by the Insured Person under this Benefit will not impact Cumulative Bonus if applicable.
11. We reserve the right to change any empanelled service provider during the currency of the Policy or at Renewal. The same shall be intimated to the insured atleast 15 days prior to the effective date of change.
12. In case We or the assistance service provider fails to provide any of the services as mentioned in this Policy or is unable to implement, in whole or in part due to force majeure, non-availability of services, change in law, rule or regulations which affects the services, or if any regulatory or governmental agency having jurisdiction over a party takes a position which affects the services , then the assistance services’ suspended, curtailed or limited performance shall not constitute breach of contract and the company or the assistance service provider shall have no liability whatsoever including but not limited to any loss or damage resulting therefrom.
13. We shall not accept any liability towards quality of the services made available by service provider. The service provider is responsible for providing the availed services and We are not liable for any defects or deficiencies on the part of the service provider.
Tax Benefit:
The premium amount paid under this policy qualifies for deduction under Section 80D of the Income Tax Act. This benefit is not applicable for premium amount paid towards accidental death benefit.
Optional Covers:
You can choose below mentioned optional cover by paying an additional premium.
• Accidental Death Benefit:
If an Insured Person suffers an accident during the policy period and this is the sole and direct cause of his death within 365 days from the date of accident, then we will pay the Sum Insured as mentioned in the ‘Benefit Table’. This benefit is not applicable for insured children or Insured Person less than 18 years of Age as on Policy commencement date.
Discounts on premium:
i. 10% long term discount on premium in case insured opts policy term of 3 years
ii. 5% long term discount on premium in case insured opts policy term of 2 years
iii. Family floater discount on the base premium:
• 2 members -20%
• 3 members -28%
• 3+ members-32%
iv. 10% discount to all TATA Group employees
TATA AIG Consumables Benefit Add on (UIN:TATHLIA24177V012324)
(For Add On applicable to you, please refer your Policy Schedule)
If this Add On is opted, then notwithstanding the exclusion “Non payable items as mentioned in Annexure I – List I of optional items available on Our website (www.tataaig.com)”, We will pay for expenses incurred towards specified consumables, as listed in Annexure I – List I of optional items, available on Our website (www.tataaig.com), which are consumed during the period of Hospitalization directly related to the Insured Person’s medical or surgical treatment of Illness/disease/Injury.
Loading of 4% of the Base Policy premium shall be applicable for this Add On. No Base Policy loading or discount shall be applicable to this Add On. This premium rate is exclusive of taxes.
Limit for Consumables Benefit Add on: We will pay for expenses incurred towards specified consumables, as listed in Annexure I – List I of optional items.
Section 3 – Exclusions
We will neither be liable nor make any payment for any claim in respect of any Insured Person
which is caused by, arising from or in any way attributable to any of the following exclusions.
i. Standard Exclusions
1. Exclusions with waiting periods
i. Pre-Existing Diseases Waiting Period(Code- Excl 01):
a. Expenses related to the treatment of a Pre-Existing Disease (PED) and its direct complications shall be excluded until the expiry of 36 months of continuous coverage after the date of inception of the first Policy with Us.
b. In case of enhancement of sum insured the exclusion shall apply afresh to the extent of sum insured increase.
c. If the Insured Person is continuously covered without any break as defined under the Portability norms of the extant IRDAI (Health Insurance) Regulations, then waiting period for the same would be reduced to the extent of prior coverage.
d. Coverage under the Policy after the expiry of 36 months for any Pre-Existing Disease is subject to the same being declared at the time of application and accepted by Us.
ii. Specified Disease/Procedure Waiting Period (Code- Excl 02):
a. Expenses related to the treatment of the listed Conditions, surgeries/treatments shall be excluded until the expiry of 24 months of continuous coverage after the date of inception of the first Policy with Us. This exclusion shall not be applicable for claims arising due to an Accident.
b. In case of enhancement of sum insured the exclusion shall apply afresh to the extent of sum insured increase.
c. If any of the specified disease/procedure falls under the waiting period specified for Pre-Existing Disease(s), then the longer of the two waiting periods shall apply.
d. The waiting period for listed conditions shall apply even if contracted after the Policy or declared and accepted without a specific exclusion.
e. If the Insured Person is continuously covered without any break as defined under the applicable norms on Portability stipulated by IRDAI, then waiting period for the same would be reduced to the extent of prior coverage.
List of Specific disease/conditions/treatments: (34)
I. Tumors, Cysts, polyps including breast lumps (benign)
II. Polycystic ovarian disease, Fibromyoma, Adenomyosis, Endometriosis
III. Prolapsed Uterus
IV. Rheumatism
V. Ligament, Tendon or Meniscal tear
VI. Prolapsed Inter-Vertebral Disc
VII. Cholelithiasis
VIII. Pancreatitis
IX. Fissure/fistula in anus, haemorrhoids, pilonidal sinus
X. Ulcer & erosion of stomach & duodenum
XI. Gastro Esophageal Reflux Disorder (GERD)
XII. Liver Cirrhosis
XIII. Perineal Abscesses
XIV. Perianal / Anal Abscesses
XV. Calculus diseases of Urogenital system Example: Kidney stone, Urinary bladder stone.
XVI. Benign Hyperplasia of prostate
XVII. Varicocele
XVIII. Cataract, Retinal detachment, Glaucoma
XIX. Congenital Internal Diseases
List of procedure/surgeries/treatments:
XX. Adenoidectomy
XXI. Mastoidectomy
XXII. Tonsillectomy
XXIII. Tympanoplasty
XXIV. Surgery for nasal septum deviation
XXV. Nasal concha resection
XXVI. Surgery for Turbinate hypertrophy
XXVII. Hysterectomy
XXVIII. Osteoarthritis, joint replacement, osteoporosis,
XXIX. Systemic connective tissue disorders, inflammatory polyarthropathies, Rheumatoid, Gout
XXX. Cholecystectomy
XXXI. Hernioplasty or Herniorraphy
XXXII. Surgery/procedure for Benign prostate enlargement
XXXIII. Surgery for Hydrocele/ Rectocele/Spermatocele
XXXIV. Surgery of varicose veins and varicose ulcers
iii. 30 Days Waiting Period (Code- Excl 03):
a. Expenses related to the treatment of any Illness within 30 days from the first Policy commencement date shall be excluded except claims arising due to an Accident, provided the same are covered.
b. This exclusion shall not, however, apply if the Insured Person has Continuous Coverage for more than twelve months.
c. The within referred waiting period is made applicable to the enhanced sum insured in the event of granting higher sum insured subsequently.
2. Medical Exclusions (12 + 11 = 23)
i. Investigation and evaluation (Code- Excl 04):
a. Expenses related to any admission primarily for diagnostics and evaluation purposes only are excluded.
b. Any diagnostic expenses which are not related or not incidental to the current diagnosis and treatment are excluded.
ii. Rest cure, rehabilitation and respite care (Code- Excl 05):
a. Expenses related to any admission primarily for enforced bed rest and not for receiving treatment. This also includes:
i. Custodial care either at home or in a nursing facility for personal care such as help with activities of daily living such as bathing, dressing, moving around either by skilled nurses or assistant or non-skilled persons.
ii. Any services for people who are terminally ill to address physical, social, emotional and spiritual needs.
iii. Obesity/ Weight Control (Code- Excl 06):
Expenses related to surgical treatment of obesity that does not fulfil the below conditions:
a. Surgery to be conducted is upon the advice of the Doctor.
b. The Surgery/Procedure conducted should be supported by clinical protocols.
c. The member has to be 18 years of Age or older and
d. Body Mass Index (BMI);
i. greater than or equal to 40 or
ii. greater than or equal to 35 in conjunction with any of the following severe co- morbidities following failure of less invasive methods of weight loss:
1. Obesity-related cardiomyopathy
2. Coronary heart disease
3. Severe Sleep Apnea
4. Uncontrolled Type2 Diabetes
iv. Change-of-Gender treatments: Code- Excl07:
Expenses related to any treatment, including surgical management, to change characteristics of the body to those of the opposite sex.
v. Cosmetic or Plastic Surgery (Code- Excl 08):
Expenses for cosmetic or plastic Surgery or any treatment to change appearance unless for reconstruction following an Accident, Burn(s) or Cancer or as part of Medically Necessary Treatment to remove a direct and immediate health risk to the insured. For this to be considered a medical necessity, it must be certified by the attending Medical Practitioner.
vi. Treatment for, Alcoholism, drug or substance abuse or any addictive condition and consequences thereof (Code- Excl 12).
vii. Treatments received in heath hydros, nature cure clinics, spas or similar establishments or private beds registered as a nursing home attached to such establishments or where admission is arranged wholly or partly for domestic reasons. (Code- Excl13)
viii. Dietary supplements and substances that can be purchased without prescription, including but not limited to Vitamins, minerals and organic substances unless prescribed by a Medical Practitioner as part of Hospitalization claim or day care procedure. (Code-Excl14)
ix. Refractive error (Code- Excl 15): Expenses related to the treatment for correction of eye sight due to refractive error less than 7.5 dioptres.
x. Unproven treatments (Code- Excl 16):
Expenses related to any Unproven Treatment, services and supplies for or in connection with any treatment. Unproven Treatments are treatments, procedures or supplies that lack significant medical documentation to support their effectiveness.
xi. Sterility and Infertility (Code- Excl 17): Expenses related to Sterility and infertility. This includes:
i. Any type of contraception, sterilization
ii. Assisted Reproduction services including artificial insemination and advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI
iii. Gestational Surrogacy
iv. Reversal of sterilization
xii. Maternity (Code – Excl 18):
a. Medical treatment expenses traceable to childbirth (including complicated deliveries and caesarean sections incurred during Hospitalization) except ectopic pregnancy;
b. Expenses towards miscarriage (unless due to an Accident) and lawful medical termination of pregnancy during the Policy Period.
3. Non-Medical Exclusions (3 + 13 = 16)
i. Hazardous or Adventure Sports (Code- Excl 09):
Expenses related to any treatment necessitated due to participation as a professional in hazardous or adventure sports, including but not limited to, para-jumping, rock climbing, mountaineering, rafting, motor racing, horse racing or scuba diving, hand gliding, sky diving, deep-sea diving.
ii. Breach of law (Code- Excl 10):
Expenses for treatment directly arising from or consequent upon any Insured Person
committing or attempting to commit a breach of law with criminal intent.
iii. Excluded Providers: (Code-Excl 11):
Expenses incurred towards treatment in any Hospital or by any Medical Practitioner or any other provider specifically excluded by the Insurer and disclosed in its website / notified to the policyholders are not admissible. However, in case of life threatening situations or following an Accident, expenses up to the stage of stabilization are payable but not the complete claim.
ii. Specific Exclusions (Exclusions other than as those mentioned under Section 3 (i) subsection 1, 2 &3 above)
We will neither be liable nor make any payment for any claim in respect of any Insured Person which is caused by, arising from or in any way attributable to any of the following exclusions.
1. Medical Exclusions
i. Alcoholic pancreatitis or Alcoholic liver disease;
ii. Congenital External Diseases, defects or anomalies;
iii. Stem cell therapy; however hematopoietic stem cells for bone marrow transplant for haematological conditions will be covered under this Policy
iv. Growth Hormone Therapy
v. Sleep-apnoea and Sleeping disorder;
vi. Admission primarily for administration (via any form or mode) of immunoglobulin infusion or supplementary medications like Zolendronic Acid, etc;
vii. Venereal disease, sexually transmitted disease or Illness;
viii. All preventive care, vaccination including inoculation and immunisations;
ix. Dental Treatment or Dental Surgery of any kind unless incidental to an admissible Hospitalization claim where the cause of admission is Accident/ Illness; cost of dentures, dental implants and braces
x. Any existing disease specifically mentioned as Permanent exclusion in the Policy Schedule.
xi. Non payable items as mentioned in Annexure I – List I of optional items available on Our website (www.tataaig.com)
2. Non-Medical Exclusions
i. War or any act of war, invasion, act of foreign enemy, war like operations (whether war be declared or not or caused during service in the armed forces of any country), civil war, public defence, rebellion, revolution, insurrection, military or usurped acts, nuclear weapons/materials, chemical and biological weapons, ionising radiation.
ii. Nuclear, chemical or biological attack or weapons, contributed to, caused by, resulting from or from any other cause or event contributing concurrently or in any other sequence to the loss, claim or expense. For the purpose of this exclusion:
• Nuclear attack or weapons means the use of any nuclear weapon or device or waste or combustion of nuclear fuel or the emission, discharge, dispersal, release or escape of fissile/ fusion material emitting a level of radioactivity capable of causing any Illness, incapacitating disablement or death
• Chemical attack or weapons means the emission, discharge, dispersal, release or escape of any solid, liquid or gaseous chemical compound which, when suitably distributed, is capable of causing any Illness, incapacitating disablement or death.
• Biological attack or weapons means the emission, discharge, dispersal, release or escape of any pathogenic (disease producing) micro-organisms and/or biologically produced toxins (including genetically modified organisms and chemically synthesized toxins) which are capable of causing any Illness, incapacitating disablement or death.
iii. Any Insured Person’s participation or involvement in naval, military or air force operation.
iv. Intentional self-Injury or attempted suicide while sane or insane.
v. Items of personal comfort and convenience like television (wherever specifically charged for), charges for access to telephone and telephone calls, internet, foodstuffs (except patient’s diet), cosmetics, hygiene articles, body care products and bath additive, barber or beauty service, guest service.
vi. Treatment rendered by a Medical Practitioner which is outside his discipline.
vii. Doctor’s fees charged by the Medical Practitioner sharing the same residence as an Insured Person or who is an immediate relative of an Insured Person’s family.
viii. Fitting of hearing aids, Provision/fitting of spectacles or contact lenses including optometric therapy.
ix. Any treatment and associated expenses for alopecia, baldness, wigs, or toupees, medical supplies including elastic stockings, diabetic test strips, and similar products.
x. Any treatment or part of a treatment that does not form part of ‘Reasonable and Customary Charges’ nor is Medically Necessary.
xi. Expenses which are either not supported by a prescription of a Medical Practitioner or are not related to Illness or disease for which claim is admissible under the Policy.
xii. Any external appliance and/or device used for diagnosis or treatment except when used intra- operatively.
xiii. Any Illness diagnosed or Injury sustained or where there is change in health status of the member after date of proposal and before commencement of Policy and the same is not communicated and accepted by Us.
Section 4 – General Terms and Clauses
i. Standard General Terms & Clauses
1. Disclosure of Information
The Policy shall be void and all premium paid thereon shall be forfeited to the Company in the event of established fraud, misrepresentation, misdescription or non-disclosure of any material fact by the policyholder.
(Explanation: “Material facts” for the purpose of this Policy shall mean all relevant information sought by the company in the proposal form and other connected documents to enable it to take informed decision in the context of underwriting the risk)
2. Condition Precedent to Admission of Liability
The terms and conditions of the Policy must be fulfilled by the Insured Person for the Company to make any payment for claim(s) arising under the Policy.
3. Claim Settlement (provision for Penal Interest)
i. The Company shall settle or reject a claim, as the case may be, within 15 days from the date of receipt of last necessary document.
ii. In the case of delay in the payment of a claim, the Company shall be liable to pay interest to the policyholder from the date of receipt of last necessary document to the date of payment of claim at a rate 2% above the bank rate.
iii. However, where the circumstances of a claim warrant an investigation in the opinion of the Company, it shall initiate and complete such investigation at the earliest, in any case not later than 30 days from the date of receipt of last necessary document. In such cases, the Company shall settle or reject the claim within 45 days from the date of receipt of last necessary document.
iv. In case of delay beyond stipulated 45 days, the Company shall be liable to pay interest to the policyholder at a rate 2% above the bank rate from the date of receipt of last necessary document to the date of payment of claim.
(Explanation: “Bank rate” shall mean the rate fixed by the Reserve Bank of India (RBl) at the beginning of the financial year in which claim has fallen due).
4. Complete Discharge
Any payment to the policyholder, Insured Person or his/ her nominees or his/ her legal representative or assignee or to the Hospital, as the case may be, for any benefit under the Policy shall be a valid discharge towards payment of claim by the Company to the extent of that amount for the particular claim.
5. Multiple Policies
i. In case of multiple policies taken by an Insured Person during a period from one or more Insurers to indemnify treatment costs, the Insured Person shall have the right to require a settlement of his/her claim in terms of any of his/her policies. In all such cases the
Insurer chosen by the Insured Person shall be obliged to settle the claim as long as the claim is within the limits of and according to the terms of the chosen Policy.
ii. Insured Person having multiple policies shall also have the right to prefer claims under this Policy for the amounts disallowed under any other Policy / policies even if the sum insured is not exhausted. Then the Insurer shall independently settle the claim subject to the terms and conditions of this Policy.
iii. If the amount to be claimed exceeds the sum insured under a single Policy, the Insured Person shall have the right to choose Insurer from whom he/she wants to claim the balance amount and we will assist the insured person in facilitating the same
iv. Where an Insured Person has policies from more than one Insurer to cover the same risk on indemnity basis, the Insured Person shall only be indemnified the treatment costs in accordance with the terms and conditions of the chosen Policy.
6. Fraud
If any claim made by the Insured Person, is in any respect fraudulent, or if any false statement, or declaration is made or used in support thereof, or if any fraudulent means or devices are used by the Insured Person or anyone acting on his/her behalf to obtain any benefit under this Policy, all benefits under this Policy and the premium paid shall be forfeited.
Any amount already paid against claims made under this Policy but which are found fraudulent later shall be repaid by all recipient(s)/policyholder(s), who has made that particular claim, who shall be jointly and severally liable for such repayment to the Insurer.
For the purpose of this clause, the expression “fraud” means any of the following acts committed by the Insured Person or by his agent or the Hospital/doctor/any other party acting on behalf of the Insured Person, with intent to deceive the Insurer or to induce the Insurer to issue an insurance Policy:
a) the suggestion, as a fact of that which is not true and which the insured person does not believe to be true;
b) the active concealment of a fact by the Insured Person having knowledge or belief of the fact;
c) any other act fitted to deceive; and
d) any such act or omission as the law specially declares to be fraudulent.
The Company shall not repudiate the claim and / or forfeit the Policy benefits on the ground of Fraud, if the Insured Person / beneficiary can prove that the misstatement was true to the best of his knowledge and there was no deliberate intention to suppress the fact or that such misstatement of or suppression of material fact are within the knowledge of the Insurer.
7. Cancellation
i. The policyholder may cancel this Policy by giving 7 days written notice and in such an event, the Company shall refund proportionate premium for unexpired policy period. No refunds of premium shall be made in respect of Cancellation where, any claim has been admitted or has been lodged or any benefit under this Policy has been availed by the Insured Person.
ii. The Company may cancel the Policy at any time on grounds of established fraud, misrepresentation or non-disclosure of material facts, fraud by the Policyholder/ Insured Person by giving 15 days’ written notice. There would be no refund of premium on cancellation on grounds of established fraud, misrepresentation or non-disclosure of material facts.
8. Migration
The Insured Person will have the option to migrate the Policy to other health insurance products/plans offered by the company by applying for Migration of the Policy at least 30 days before the Policy Renewal date as per IRDAI guidelines. lf such person is presently covered and has been continuously covered without any lapses under any health insurance product/plan offered by the company, the Insured Person will get the accrued continuity benefits in waiting periods as per IRDAI guidelines on Migration.
For Detailed Guidelines on Migration, kindly refer
Insurance Regulatory and Development Authority of India (Insurance Products) Regulations, 2024 F. No. IRDAI/Reg/8/202/2024 dated 20th March, 2024 and Master Circular on IRDAI (Insurance Products) Regulations 2024- Health Insurance Ref: IRDAI/HLT/CIR/PRO/84/5/ 2024 dated 29th May 2024 and subsequent amendments thereof
9. Portability
The Insured Person will have the option to port the Policy to other Insurers by applying to such Insurer to port the entire Policy along with all the members of the family, if any, at least 30 days before, but not earlier than 60 days from the Policy Renewal date as per IRDAI guidelines. If such person is presently covered and has been continuously covered without any lapses under any health insurance Policy with an Indian General/Health Insurer, the proposed Insured Person will get the accrued continuity benefits in waiting periods as per IRDAI guidelines on Portability.
For Detailed Guidelines on Portability, kindly refer
Insurance Regulatory and Development Authority of India (Insurance Products) Regulations, 2024 F. No. IRDAI/Reg/8/202/2024 dated 20th March, 2024 and Master Circular on IRDAI (Insurance Products) Regulations 2024- Health Insurance Ref: IRDAI/HLT/CIR/PRO/84/5/ 2024 dated 29th May 2024 and their subsequent amendments thereof
10. Renewal of Policy
The Policy shall ordinarily be renewable except on grounds of established fraud, non- disclosure or misrepresentation by the Insured Person.
i. Renewal shall not be denied on the ground that the Insured Person had made a claim or claims in the preceding Policy Years.
ii. Request for Renewal along with requisite premium shall be received by the Company before the end of the Policy Period.
iii. Single premium payment mode Policy can be renewed within the Grace Period of 30 days to maintain continuity of benefits without break in policy. Coverage is not available during the grace period after the end of the policy period. If not renewed under the Grace Period, the Policy shall terminate at the end of the Grace period.
iv. The grace period for payment of the premium during the Policy Period, for instalment premium shall be fifteen days where premium payment mode is monthly and thirty days in all other cases (Annual/Half-Yearly/Quarterly/Limited Premium paying term).
v. Coverage during such grace period (in case of instalment premium):
a. Within the policy period – coverage will be available from the due date of instalment premium till the date of receipt of premium by Company within the grace period.
b. At the end of the policy period – the policy shall terminate and can be renewed within the Grace Period of 30 days to maintain continuity of benefits without break in policy. Coverage is not available during the grace period after the end of the policy period.
vi. The insured person will get the accrued continuity benefit in respect of the “Waiting Periods”, “Specific Waiting Periods” in the event of payment of premium within the stipulated grace Period. No loading shall apply on Renewal(s) based on individual claims experience.
Change in Sum Insured
Sum Insured can be enhanced only at the time of renewal subject to underwriting guidelines of the company.
11. Withdrawal of Policy
i. In the likelihood of this product being withdrawn in future, the Company will intimate the Insured Person about the same 90 days prior to expiry of the Policy.
ii. Insured Person will have the option to migrate to similar health insurance product available with the Company at the time of Renewal with all the accrued continuity benefits such as Cumulative Bonus, waiver of waiting period as per IRDAI guidelines, provided the Policy has been maintained without a break.
12. Moratorium Period
After completion of five continuous years of coverage (including portability and migration) in health insurance policy, no policy and claim shall be contestable by the insurer on grounds of non-disclosure, misrepresentation, except on grounds of established fraud. This continuous period of five years is called as moratorium period. The moratorium would be applicable for the sums insured of the first policy. Wherever the sum insured is enhanced, completion of five continuous years would be applicable from the date of enhancement of sums insured only on the enhanced limits. The policies would however be subject to all limits, sub limits, Co-Payments, deductibles as per the Policy contract.
13. Possibility of Revision of Terms of the Policy Including the Premium Rates
The Company may revise or modify the terms of the Policy including the premium rates. The Insured Person shall be notified three months before the changes are effected.
14. Free look period
The Free Look Period shall be applicable on new individual health insurance policies and not on Renewal(s) or at the time of porting/migrating the Policy.
The Insured Person shall be allowed free look period of thirty days from date of receipt of the Policy document, whether received electronically or otherwise, to review the terms and conditions of the Policy, and to return the same if not acceptable.
If the insured has not made any claim during the Free Look Period, the insured shall be entitled to a refund of the premium paid subject to deduction of proportionate risk premium for the period of cover and the expenses, if any, incurred by Us on medical examination of the proposer and stamp duty charges
15. Redressal of Grievance
At TATA AIG, we strive to provide the best service to our customers. If you’re not satisfied and wish to lodge a complaint, please call our 24/7 toll-free number 1800-266-7780/1800 22 9966 (For Senior Citizens) or 022-66939500 (toll charges apply), or email us at customersupport@tataaig.com. We will investigate and respond within the regulatory turnaround time (TAT).
Escalation Level 1
If you do not receive a response or are not satisfied with the resolution, please contact us at manager.customersupport@tataaig.com.
Escalation Level 2
If you still need assistance, reach out to the Head of Customer Services at head.customerservices@tataaig.com. We will provide our final response within the regulatory TAT.
If you’re still not satisfied after this process, you may approach the Insurance Ombudsman of concerned jurisdiction.
You can also lodge a grievance on the Bima Bharosa Grievance Redressal Portal: https://bimabharosa.irdai.gov. in
The name and address of the Insurance Ombudsman of competent jurisdiction is provided under Annexure A of this Policy.
16. Nomination
The policyholder is required at the inception of the Policy to make a nomination for the purpose of payment of claims under the Policy in the event of death of the policyholder. Any change of nomination shall be communicated to the company in writing and such change shall be effective only when an endorsement on the Policy is made. In the event of death of the policyholder, the Company will pay the nominee {as named in the Policy Schedule/
/Endorsement (if any)} and in case there is no subsisting nominee, to the legal heirs or legal
representatives of the policyholder whose discharge shall be treated as full and final discharge of its liability under the Policy.
ii. Specific terms and clauses (terms and clauses other than those mentioned under Section 4 (i) above)
17. Insured Person
i. Only those persons named as an Insured Person in the Schedule shall be covered under this Policy.
ii. Any eligible person may be added during the Policy Period after his proposal has been accepted by Us, additional premium has been paid and We have issued an endorsement confirming the addition of such person as an Insured Person.
18. Risk Loadings
i. We may apply a risk loading on the premium payable (based upon the declarations made in the proposal and the health status of the persons proposed for insurance).
ii. The loading shall be applied basis outcome of Our underwriting.
iii. These loadings are applied from Commencement Date of the Policy including subsequent Renewal(s) with Us or on the receipt of the request of increase in Sum Insured (for the increased Sum Insured).
a. We will inform You about the applicable risk loading through a counter offer letter.
b. You need to revert to Us with consent and additional premium (if any), within 15 days of the issuance of such counter offer letter.
c. In case, You neither accept the counter offer nor revert to Us within 15 days, We shall cancel Your application and refund the premium paid within next 10 days subject to deduction of the Pre-Policy Check up charges, as applicable.
iv. Please note that We will issue Policy only after getting Your consent.
19. Entire Contract
i. This Policy, its Schedule, endorsement(s), proposal constitutes the entire contract of insurance. No change in this Policy shall be valid unless approved by Us and such approval be endorsed hereon.
ii. This Policy and the Schedule shall be read together as one contract and any word or expression to which a specific meaning has been attached in any part of this Policy or of the Schedule shall bear such meaning wherever it may appear.
20. Notices
i. Any notice, direction or instruction under this Policy shall be in writing and if it is to:
a. Any Insured Person, then it shall be sent to You at Your address specified in the Schedule to this Policy and You shall act for all Insured Person(s) for these purposes.
b. Us, it shall be delivered to Our address specified in the Schedule to this Policy. No insurance agents, brokers or other person or entity is authorised to receive any notice, direction or instruction on Our behalf unless We have expressly stated to the contrary in writing.
21. Zone
Premium payable under the Policy will be computed based on the residential location/address as provided by the proposer/Insured Person in the proposal form.
Premium to be received by Company before Policy Commencement date.
22. Premium Refund in case of demise of the Insured Person
The coverage for the Insured Person(s) shall automatically terminate in case of his/ her (Insured Person) demise. However, the cover shall continue for the remaining Insured Person(s) till the end of Policy Period.
Provided no claim has been made and deletion from Policy takes place on account of death of the Insured Person during the Policy Period, pro-rata refund of premium of the deceased Insured Person for the balance period of the Policy will be made. Refund will be made to the Policyholder or the nominee as the case may be in case of demise of the Policyholder. We would require death certificate of the Deceased Insured Person for processing of the refund amount.
The other Insured Person(s) may also apply to renew the Policy. In the event of change of Proposer, all relevant particulars in respect of such person (including his/her relationship with the Insured Person) must be submitted to the company along with the application.
Pre-policy medical check-up:
Pre-policy medical examination gird:
| Age/Sum Insured | All Sum Insured Options |
| Upto 17 Years | Tele MER/ Video MER (only if positive medical declaration) |
| 18 Years – 45 Years | Individual: Tele MER/ Video MER Family Floater: Tele MER / Video MER (only if positive medical declaration) |
| 46 Years and above | Tele MER/ Video MER/PPC |
- In case of adverse medical declaration, we may call for additional medical tests. We may conduct medical tests at diagnostic centre based on medical disclosure wherever applicable.
- 100% of TeleMER cost would be borne by the Company, in case of proposal acceptance.
- At least 50% of pre-policy medical checkup cost would be borne by Tata AIG in case where proposal is accepted.
- Pre-Policy Check-up(PPC) at our network, if required. The medical reports are valid for a period of 90 days from the date of Pre-Policy Checkup.
The Company may conduct Tele MER / Video MER / Pre – Policy Check – up based on age / Sum Insured medical declaration or any other underwriting criteria.
Section 5 – Claims Procedure and Claims Payment
This section explains about the procedure involved to file a valid claim by the Insured Person and processes related to assessment, cost sharing and management of the claim. All the procedures and processes such as Notification of Claim, availing cashless service, supporting claim documents and related claim terms of payment are explained in this section.
a. Notification of Claim & Assistance:
Every claim needs to be notified to Us either in writing or email or through a call to Our tollfree number, as mentioned in the Policy Schedule, within the stipulated timelines as mentioned below:
| Event | We or Our TPA* must be informed: | |
| 1 | If any treatment for which a claim may be made and that treatment requires planned Hospitalization/ Day Care Treatment/ AYUSH/ Domiciliary Treatment: | At least 48 hours prior to the Insured Person’s admission/ start of treatment. |
| 2 | If any treatment for which a claim may be made and that treatment requires emergency Hospitalization/ Day Care Treatment | Within 24 hours of the Insured Person’s admission to Hospital or at the time of discharge, whichever is earlier. |
*TPA as mentioned in the Policy Schedule, if applicable.
Timely intimation of claim in Our prescribed format is a pre-condition for admission of liability.
We may waive off this condition in extreme cases of hardship where it is proved to Our satisfaction that under the circumstances in which You were placed, it was not possible for You or any other person to give notice or file claim within the prescribed time limit.
Claim Related Information:
For any claim related query, intimation of claim and submission of claim related documents, the Policyholder/Insured Person can contact us through:
| Claims Servicing Details | |
| Name | TAGIC Health Claims |
| Claims Administrator Address | TATA AIG General Insurance Company Limited, 5th and 6th Floor, Imperial Towers, H.No 7-1-6-617/A, GHMC No – 615,616, Ameerpet, Hyderabad – 500016, Telangana, Phone: 040- 66864900 |
| Email ID | healthclaimsupport@tataaig.com |
| Toll-Free No.: | 1800 266 7780 or 1800 229 966 (For Senior Citizens) |
| Website | www.tataaig.com |
b. Cashless Service
| Treatment, Consultation or Procedure: | Taken at: | Cashless Service is Available: | We must be given notice that the Insured Person wishes to avail cashless service accompanied by full particulars: |
| If any planned treatment, consultation or procedure for which a claim may be made: | Our network of Valued Provider – Pan India | We will provide cashless service by making payment to the extent of Our liability directly to the Network Hospital. | At least 48 hours before the planned Hospitalization |
| If any treatment, consultation or procedure for which a claim may be made, requiring emergency Hospitalization | Our network of Valued Provider – Pan India | We will provide cashless service by making payment to the extent of Our liability directly to the Network Hospital. | Within 24 hours of the Hospitalization and prior to discharge |
c. Procedure for reimbursement claims:
• Please intimate our TPA/Us within 7 days of completion of treatment, consultation or procedure.
• Please send the duly signed claim form and all the information/documents mentioned therein to our TPA/Us within 15 days of the occurrence of the Incident.
• Please refer to claim form for complete documentation.
• If there is any deficiency in the documents/information submitted by the Policyholder/Insured Person, our TPA/We will send the deficiency letter within 7 working days of receipt of the claim documents.
• On receipt of the complete set of claim documents, We will send the payment for the admissible amount, along with a settlement statement within 30 days.
• The payment will be sent in the name of the proposer/ Nominee in case of death of Proposer
• Kindly send the claim documents to:
Tata AIG General Insurance Company Limited, 5th and 6th Floor, Imperial Towers, H.No 7-1-6- 617/A, GHMC No – 615,616, Ameerpet, Hyderabad – 500016, Telangana, Phone-040- 66864900
Turn Around Time (TAT) for claims settlement:
TAT for preauthorization of cashless facility and for cashless final bill authorization shall be as prescribed by the Regulator under the
Master Circular on IRDAI (Insurance Products) Regulations 2024- Health Insurance Ref: IRDAI/HLT/CIR/PRO/84/5/ 2024 and its subsequent amendments thereof.
Assistance:
- Please refer to our website www.tataaig.com or call us on our toll free number at <1800- 266-7780> to get details on our empanelled hospitals and list of Excluded providers/
Blacklisted Hospitals. - Helpline number: Toll Free: <1800 266 7780> or <1800 22 9966> (only for Senior Citizen policyholders)
- Please refer our website www.tataaig.com to download claim form
c. Procedure for Cashless Service at Our network of Valued Provider – Pan India
i. Cashless Service is only available at Our network of Valued Provider – Pan India .
ii. In order to avail cashless treatment, the following procedure must be followed by You:
a. Prior to taking treatment and/or incurring Medical Expenses at a Network Hospital, You
must notify Our designated TPA/Us and request pre-authorization.
b. Our designated TPA/We will check Your coverage as per the eligibility and send an authorization letter to the provider. You have to provide the ID card issued to You along with any other information or documentation that is requested by the TPA/Us to the Network Hospital.
c. In case of deficiency in the documents sent to TPA/Us for cashless authorization or the ailment /treatment is not covered under the policy, the same shall be communicated to the Hospital/You by TPA/Us..
d. We/TPA will respond within TAT as prescribed by the Regulator under the Master Circular on IRDAI (Insurance Products) Regulations 2024- Health Insurance Ref: IRDAI/HLT/CIR/PRO/84/5/ 2024 and its subsequent amendments thereof.
e. Rejection of cashless in no way indicates rejection of the claim. You are required to submit the claim along with required documents for Us to decide on the admissibility of the claim.
f. If the cashless is approved, the original bills and evidence of treatment in respect of the same shall be left with the Network Hospital.
g. Pre-authorization does not guarantee that all costs and expenses will be covered. We reserve the right to review each claim for Medical Expenses and accordingly coverage will be determined according to the terms and conditions of this Policy.
d. Supporting Documentation & Examination
i. We or Our TPA may require documentation, medical records and information to establish the circumstances of the claim, its quantum or Our liability for the claim within 15 days or earlier of Our request or the Insured Person’s discharge from Hospitalization or completion of treatment.
ii. In case the delay is at Your end, failure to furnish such evidence within the time required shall not invalidate nor reduce any claim if You can satisfy Us that it was not reasonably possible for You to give proof within such time.
iii. We may accept claims where documents have been provided after a delayed interval only in special circumstances and for the reasons beyond the control of the Insured Person.
iv. Such documentation will include the following:
a. Our claim form, duly completed and signed for on behalf of the Insured Person.
We, upon receipt of a notice of claim, will furnish Your representative with such forms as We may require for filing proofs of loss or You may download the claim form from Our Website.
b. Original Bills (pharmacy purchase bill, consultation bill, diagnostic bill) and any attachments thereto like receipts or prescriptions in support of any amount claimed which will then become Our property.
c. All medical reports, case histories, investigation reports, indoor case papers/ treatment papers (in reimbursement cases, if available), discharge summaries.
d. A precise diagnosis of the treatment for which a claim is made.
e. A detailed list of the individual medical services and treatments provided and a unit price for each in case not available in the submitted Hospital bill..
f. Prescriptions that name the Insured Person and in the case of drugs: the drugs prescribed, their price and a receipt for payment. In case of pre/post Hospitalization claim Prescriptions must be submitted with the corresponding Doctor/Hospital invoice.
g. All pre and post investigation, treatment and follow up (consultation) records pertaining to the present ailment for which claim is being made, if and where applicable.
h. Treating doctor’s certificate regarding missing information in case histories e.g. Circumstance of Injury and Alcohol or drug influence at the time of Accident, if available.
i. Copy of settlement letter from other insurance company or TPA.
j. Stickers and invoice of implants used during Surgery.
k. Copy of MLC (Medico legal case) records, if carried out and FIR (First information report), if registered, in case of claims arising out of an Accident and available with the claimant.
l. Regulatory requirements as amended from time to time, currently mandatory NEFT (to enable direct credit of claim amount in bank account) and KYC (recent ID/Address proof and photograph) requirements.
m. Legal heir/succession certificate, if required
n. PM report (wherever applicable)
o. The Company reserves the right to call for additional documents wherever required.
v. Note: In case You are claiming for the same event under an indemnity-based Policy with Us and with another Insurer and are required to submit the original documents related to Your treatment with that particular Insurer, then We will require the attested copies of such documents along with a declaration from the particular Insurer specifying the availability of the original copies of the specified treatment documents with it.
vi. We at Our own expense, shall have the right and opportunity to examine Insured Person(s) through Our Authorised Medical Practitioner whose details will be notified to Insured Person when and as often as We may reasonably require during the pendency of a claim hereunder.
e. Claims Assessment and Payment
i. General
a. We shall be under no obligation to make any payment under this Policy unless:
– We have received all premium payments in full and in time and
– We have been provided with the documentation and information which We
or Our TPA has requested to establish the circumstances of the claim, its quantum or Our liability for it, and
– Unless You have complied with Your obligations under this Policy.
b. This Policy only covers claims incurred within India (except B19, wherever applicable), and payments under this Policy shall only be made in Indian Rupees within India.
c. Medical Expenses incurred for AYUSH treatment shall be assessed only under benefit B8 of this policy and shall be admissible only if incurred within India.
d. Where an ailment/ Illness/ disease is excluded under both exclusions with waiting Periods (as specified under Section 3 (i) Sub section (1) and under any other Policy exclusion, then for assessment of liability, any expense related to that ailment/ Illness/ disease shall not be covered under this Policy.
ii. Sequence of applicability & Utilization:
a. The sequence of assessment of claim shall be as per table given below:
| Steps | Assessment | Where Age specific Co-Payment is applicable | Where Age specific Co- Payment is not applicable |
| 1 | Amount of Claim Intimated | √ | √ |
| 2 | Less Non-Payable expenses | √ | √ |
| 3 | =Admissible Expenses | √ | √ |
| 4 | Less Associated Medical Expenses as defined under the Policy (if applicable) | √ | √ |
| 5 | =Admissible Claim | √ | √ |
| 6 | Less (Out of Our network of Valued Provider – Pan India Co-Payment* as defined in Policy + Age Linked Co-Payment) OR Age linked Co-Payment | (30%*+20%) OR 20% | 30%* OR 0% |
| 7 | =Final Assessed Liability | √ | √ |
| 8 | Claim Payable subject to applicable | Balance Sum Insured (including accrued Cumulative Bonus)/ Benefit Limit |
* If admission is outside Our network of Valued Provider – Pan India
The payment of any claim under this Policy shall be subject to benefit limits, balance sum insured and accrued Cumulative Bonus, as available
b. The sequence of utilization of benefit for a claim shall be in the following order:
1. Balance Sum Insured/Sum Insured (as applicable),
2. Any accrued Cumulative Bonus, if applicable (B20)
3. Restore benefit amount, if applicable (B7)
Accidental Death Benefit (B19) shall be assessed as per the Sum Insured of the Optional Cover.
iii. Cost Sharing
a. Age linked Co-Payment
If the entry Age of the Insured Person is 61 years or above at the time of first coverage under this Policy, then such Insured Person shall bear 20% of each admissible claim (over and above any other Co-Payment, if applicable). This shall be applicable even in Portability cases, irrespective of previous coverage.
This Co-Payment shall be applicable for all claims admitted under
• B1, B2, B3, B4, B5, B6, B8, B9, B12 and B13 of this Policy; and
• if B7 and B20 of this Policy is utilized for payment of claim under aforementioned sections.
Exception to this clause:
This Co-Payment shall not be applicable in case of Migration from any active Tata AIG indemnity health Policy to this product provided, entry Age of the Insured Person was less than 61 years at the time of first coverage under the first indemnity health Policy with Us, subject to continuous coverage without any break in the Policy.
b. Co-Payment for treatment availed out of Our Network of Valued Provider – Pan India
“Valued Provider – Pan India” network list is different from Our standard list of “Network Provider”. Cashless services shall be available only in those Hospitals or health care providers which have been specifically enlisted under ‘Valued Provider – Pan India’.
The standard list of Network Provider shall not be available to the Insured Person under this Policy. List of Valued Provider – Pan India will be updated from time to time and will be available on Our website www.tataaig.com
Note: ‘Valued Provider – Pan India’ is a specific network of Hospital(s), designated as such. It consists of a defined list of Hospital(s) or health care providers enlisted by Us, and/or TPA to provide medical services to an Insured Person by a Cashless Facility. The updated list of Valued Provider – Pan India is available on Our website (www.tataaig.com).
If the Insured Person avails treatment outside Our network of “Valued Provider-Pan India”, then a Co-Payment of 30% will be applicable for each such claim resulting from admission of the Insured Person in a Hospital/ Day Care Centre/ AYUSH Hospital/ AYUSH Day Care Centre. However, no Co-Payment under this sub section shall be applicable if Hospitalization is for an Injury arising from an Accident.
For Clarity: This Co-Payment shall be applicable on claims admitted under
• B1, B4, B5, B8, B12 & B13 of this Policy; and
• if B7 and B20 of this Policy is utilized for payment of claim under aforementioned sections.
iv. Claims Procedure and management of Wellness Services (Section B10 & B21)
Service may be availed through Our website or Our mobile application or through calling Our call centre on the toll free number specified in the Policy Schedule. Alternatively, details of Our empanelled service provider are available on Our website (www.tataaig.com).
Supporting Documentation & Examination
Insured Person or someone booking services on Your behalf shall provide Us with identification documentation, medical records and information We may request to establish the circumstances of the claim.
Your claim will be processed including cashless and final bill authorization as prescribed by the Regulator under the Master Circular on IRDAI (Insurance Products) Regulations 2024- Health Insurance Ref: IRDAI/HLT/CIR/PRO/84/5/ 2024 and its subsequent amendments thereof.
Section 6 – Dispute Resolution
Dispute Resolution Clause
Any and all disputes or differences under or in relation to this Policy shall be determined by the Indian Courts and subject to Indian law.
Annexure A
NAMES OF OMBUDSMAN AND ADDRESSES OF OMBUDSMAN CENTRES
| Centre | Address & Contact | Jurisdiction of Office Union Territory, District |
| AHMEDABAD | Office of the Insurance Ombudsman, Jeevan Prakash Building, 6th floor, Tilak Marg, Relief Road, AHMEDABAD – 380 001. Tel.: 079 – 25501201/02/05/06 Email: bimalokpal.ahmedabad@cioins.co.in | Gujarat, Dadra & Nagar Haveli, Daman and Diu |
| BENGALURU | Office of the Insurance Ombudsman, Jeevan Soudha Building,PID No. 57-27- N-19 Ground Floor, 19/19, 24th Main Road, JP Nagar, Ist Phase, Bengaluru – 560 078. Tel.: 080 – 26652048 / 26652049 Email: bimalokpal.bengaluru@cioins.co.in | Karnataka |
| BHOPAL | Office of the Insurance Ombudsman, 1st floor,”Jeevan Shikha”, 60-B,Hoshangabad Road, Opp. Gayatri Mandir, Bhopal – 462 011. Tel.: 0755 – 2769201 / 2769202 Email: bimalokpal.bhopal@cioins.co.in | Madhya Pradesh, Chhattisgarh |
| BHUBHANES HWAR | Office of the Insurance Ombudsman, 62, Forest park, Bhubaneswar – 751 009. Tel.: 0674 – 2596461 /2596455 Email: bimalokpal.bhubaneswar@cioins.co.in | Odisha |
| CHANDIGAR H | Office Of The Insurance Ombudsman, Jeevan Deep Building SCO 20-27, Ground Floor Sector- 17 A, | Punjab, Haryana (excluding Gurugram, Faridabad, Sonepat and Bahadurgarh), Himachal Pradesh, Union Territories of |
| Chandigarh – 160 017. Tel.: 0172 – 4646394 / 2706468 Email: bimalokpal.chandigarh@cioins.co.in | Jammu & Kashmir,Ladakh & Chandigarh. | |
| CHENNAI | Office of the Insurance Ombudsman, Fatima Akhtar Court, 4th Floor, 453, Anna Salai, Teynampet, CHENNAI – 600 018. Tel.: 044 – 24333668 / 24333678 Email: bimalokpal.chennai@cioins.co.in | amil Nadu, PuducherryTown and Karaikal (which are part of Puducherry) |
| DELHI | Office of the Insurance Ombudsman, 2/2 A, Universal Insurance Building, Asaf Ali Road, New Delhi – 110 002. Tel.: 011 – 23237539 Email: bimalokpal.delhi@cioins.co.in | Delhi & following Districts of Haryana – Gurugram, Faridabad, Sonepat & Bahadurgarh |
| GUWAHATI | Office of the Insurance Ombudsman, Jeevan Nivesh, 5th Floor, Nr. Panbazar over bridge, S.S. Road, Guwahati – 781001(ASSAM). Tel.: 0361 – 2632204 / 2602205 Email: bimalokpal.guwahati@cioins.co.in | Assam, Meghalaya, Manipur, Mizoram, Arunachal Pradesh, Nagaland and Tripura |
| HYDERABAD | Office of the Insurance Ombudsman, 6-2-46, 1st floor, “Moin Court”, Lane Opp. Saleem Function Palace, A. C. Guards, Lakdi-Ka-Pool, Hyderabad – 500 004. Tel.: 040 – 23312122 Email: bimalokpal.hyderabad@cioins.co.in | Andhra Pradesh, Telangana, Yanam and part of Union Territory of Puducherry |
| JAIPUR | Office of the Insurance Ombudsman, Jeevan Nidhi – II Bldg., Gr. Floor, Bhawani Singh Marg, Jaipur – 302 005. Tel.: 0141- 2740363/2740798 Email: bimalokpal.jaipur@cioins.co.in | Rajasthan |
| KOCHI | Office of the Insurance Ombudsman, 10th Floor, Jeevan Prakash,LIC Building, Opp to Maharaja’s College Ground,M.G.Road, Kochi – 682 011. Tel.: 0484 – 2358759 Email: bimalokpal.ernakulam@cioins.co.in | Kerala, Lakshadweep, Mahe-a part of Union Territory of Puducherry |
| KOLKATA | Office of the Insurance Ombudsman, Hindustan Bldg. Annexe, 7th Floor, 4, C.R. Avenue, KOLKATA – 700 072. Tel.: 033 – 22124339 / 22124341 Email: bimalokpal.kolkata@cioins.co.in | West Bengal, Sikkim, Andaman & Nicobar Islands |
| LUCKNOW | Office of the Insurance Ombudsman, 6th Floor, Jeevan Bhawan, Phase-II, Nawal Kishore Road, Hazratganj, Lucknow – 226 001. Tel.: 0522 – 4002082 / 3500613 Email: bimalokpal.lucknow@cioins.co.in | Districts of Uttar Pradesh : Lalitpur, Jhansi, Mahoba, Hamirpur, Banda, Chitrakoot, Allahabad, Mirzapur, Sonbhabdra, Fatehpur, Pratapgarh, Jaunpur,Varanasi, Gazipur, Jalaun, Kanpur, Lucknow, Unnao, Sitapur, Lakhimpur, Bahraich, Barabanki, Raebareli, Sravasti, Gonda, Faizabad, Amethi, Kaushambi, Balrampur, Basti, Ambedkarnagar, Sultanpur, Maharajgang, Santkabirnagar, Azamgarh, Kushinagar, Gorkhpur, Deoria, Mau, Ghazipur, Chandauli, Ballia, Sidharathnagar |
| MUMBAI | Office of the Insurance Ombudsman, 3rd Floor, Jeevan Seva Annexe, S. V. Road, Santacruz (W), Mumbai – 400 054. Tel.: 022 – 69038800/27/29/31/32/33 Email: bimalokpal.mumbai@cioins.co.in | Goa, Mumbai Metropolitan Region (excluding Navi Mumbai & Thane) |
| NOIDA | Office of the Insurance Ombudsman, Bhagwan Sahai Palace 4th Floor, Main Road, Naya Bans, Sector 15, Distt: Gautam Buddh Nagar, U.P- 201301. Tel.: 0120-2514252 / 2514253 Email: bimalokpal.noida@cioins.co.in | State of Uttarakhand and the following Districts of Uttar Pradesh: Agra, Aligarh, Bagpat, Bareilly, Bijnor, Budaun, Bulandshehar, Etah, Kannauj, Mainpuri, Mathura, Meerut, Moradabad, Muzaffarnagar, Oraiyya, Pilibhit, Etawah, Farrukhabad, Firozbad, Gautam Buddh nagar, Ghaziabad, Hardoi, Shahjahanpur, Hapur, Shamli, Rampur, Kashganj, Sambhal, Amroha, Hathras, Kanshiramnagar, Saharanpur. |
| PATNA | Office of the Insurance Ombudsman, 2nd Floor, Lalit Bhawan, Bailey Road, Patna 800 001. Tel.: 0612-2547068 Email: bimalokpal.patna@cioins.co.in | Bihar, Jharkhand |
| PUNE | Office of the Insurance Ombudsman, Jeevan Darshan Bldg., 3rd Floor, C.T.S. No.s. 195 to 198, N.C. Kelkar Road, Narayan Peth, Pune – 411 030. Tel.: 020-24471175 Email: bimalokpal.pune@cioins.co.in | Maharashtra, Areas of Navi Mumbai and Thane (excluding Mumbai Metropolitan Region) |
For updated list and details of Insurance Ombudsman Offices, please visit website http://www.cioins.co.in/ombudsman.html
Section 64VB of the Insurance Act, 1938 – Commencement of risk cover under the Policy is subject to receipt of premium by Tata AIG General Insurance Company Limited.
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 risk relating to lives or property in India, any rebate of the whole or part of the commission payable or any rebate of the premium shown on the Policy, nor shall any person taking out or renewing or continuing a Policy accept any rebate, except such rebate as may be allowed in accordance with the published prospectuses or tables of the Insurer.
2. Any person making default in complying with the provisions of this section shall be liable for a penalty which may extend to ten lakh rupees.
Premium Rates:
i. The premium will be charged on the completed age of the Insured Person and as per applicable zone.
ii. For family floater, premium is calculated by adding the premium of respective individual members and applying family floater discount.
iii. Monthly/Quarterly/Half-Yearly instalment options would be allowed and following loadings shall be applicable as per the selected installment option and Policy Tenure:
| Installments | Policy Tenure | ||
| 1 Year | 2 Year | 3 Year | |
| Monthly | 5.00% | 9.00% | 13.00% |
| Quarterly | 4.00% | 8.00% | 11.50% |
| Half-Yearly | 3.00% | 7.00% | 10.50% |
If the insured person has opted for Payment of Premium on an installment basis, as mentioned in the policy Schedule, the following Conditions shall apply (notwithstanding any terms contrary elsewhere in the policy)
I. Grace Period of 15 days would be given to pay the installment premium due for the policy where premium payment mode is monthly and thirty days in all other cases (Half- Yearly/Quarterly), during the policy period. During such grace period, coverage shall be available from the due date of installment premium till the date of receipt of premium by Company.
II. The insured person will get the accrued continuity benefit in respect of the “Waiting Periods”, “Specific Waiting Periods” in the event of payment of premium within the stipulated grace Period.
III. No interest will be charged lf the installment premium is not paid on due date
IV. In case installment premium due is not received within the grace period, the policy will get cancelled.
V. In the event of a claim, all subsequent premium instalments shall immediately become due and payable.
VI. The company has the right to recover and deduct all the pending installments from the claim amount due under the policy.
| Zone A (Annual Per Person Rates in ₹ ) | |||||
| Age (in years)/ Sum Insured | 5 Lakhs | 7.5 Lakhs | 10 Lakhs | 15 Lakhs | 20 Lakhs |
| 91 Days -17 | 5,162 | 5,496 | 5,604 | 6,282 | 6,496 |
| 18-35 | 7,937 | 8,359 | 8,521 | 9,511 | 10,158 |
| 36-40 | 9,642 | 10,044 | 10,440 | 11,549 | 12,210 |
| 41-45 | 10,397 | 10,832 | 11,255 | 12,456 | 13,171 |
| 46-50 | 14,556 | 15,058 | 15,585 | 17,572 | 17,939 |
| 51-55 | 19,222 | 20,173 | 20,715 | 22,989 | 23,517 |
| 56-60 | 23,465 | 24,589 | 24,701 | 27,199 | 28,589 |
| 61-65 | 29,541 | 30,988 | 31,059 | 34,563 | 35,935 |
| 66-70^ | 45,939 | 48,847 | 48,970 | 55,088 | 57,075 |
| 71+^ | 57,384 | 60,484 | 61,848 | 69,472 | 71,197 |
| Zone B | ||||||
| Age (in years)/ Sum Insured | 5 Lakhs | 7.5 Lakhs | 10 Lakhs | 15 Lakhs | 20 Lakhs | |
| 91 Days -17 | 4,812 | 5,236 | 5,276 | 6,007 | 6,219 | |
| 18-35 | 6,851 | 7,330 | 7,990 | 8,998 | 9,417 | |
| 36-40 | 8,267 | 8,816 | 9,761 | 11,081 | 11,413 | |
| 41-45 | 8,912 | 9,507 | 10,520 | 11,949 | 12,308 | |
| 46-50 | 13,342 | 14,186 | 14,683 | 16,530 | 17,029 | |
| 51-55 | 17,017 | 18,057 | 18,367 | 20,496 | 21,379 | |
| 56-60 | 20,767 | 21,943 | 22,068 | 24,959 | 25,659 | |
| 61-65 | 25,918 | 27,940 | 28,101 | 31,021 | 32,676 | |
| 66-70^ | 40,227 | 43,964 | 44,171 | 49,756 | 51,669 | |
| 71+^ | 50,822 | 53,256 | 55,524 | 61,152 | 64,902 | |
| Zone C | ||||||
| Age (in years)/ Sum Insured | 5 Lakhs | 7.5 Lakhs | 10 Lakhs | 15 Lakhs | 20 Lakhs | |
| 91 Days -17 | 4,050 | 4,310 | 4,377 | 4,951 | 5,098 | |
| 18-35 | 6,273 | 6,506 | 6,742 | 7,632 | 7,786 | |
| 36-40 | 7,575 | 7,991 | 8,097 | 9,244 | 9,594 | |
| 41-45 | 8,160 | 8,611 | 8,719 | 9,961 | 10,340 | |
| 46-50 | 11,306 | 11,849 | 12,071 | 13,456 | 14,196 | |
| 51-55 | 15,284 | 15,577 | 15,767 | 17,888 | 18,486 | |
| 56-60 | 18,241 | 19,160 | 19,479 | 21,303 | 22,140 | |
| 61-65 | 22,905 | 24,183 | 24,238 | 27,154 | 28,358 | |
| 66-70^ | 35,391 | 37,360 | 37,552 | 41,610 | 44,115 | |
| 71+^ | 44,959 | 46,577 | 47,759 | 54,191 | 55,598 | |
Accidental Dealth Benefit (Optional Cover) (Annual Per Person Rates in ₹ )
| All Zones | |||||
| Age (in Years)\Sum Insured | 5 Lakh | 7.5 Lakh | 10 Lakh | 15 Lakh | 20 Lakh |
| All Ages | 279 | 418 | 558 | 836 | 1,115 |
^ Premium rates for age above 65 is for renewal.
Benefit Table
| Benefit Name | Coverage Limit |
| In-Patient Treatment | Upto Sum Insured |
| Pre-Hospitalization expenses | Upto 60 Days |
| Post-Hospitalization expenses | Upto 180 Days |
| Day Care Treatment | Upto Sum Insured |
| Organ Donor | Upto Sum Insured |
| Domiciliary Treatment | Upto Sum Insured |
| Restore Benefit | Available, Once in a policy year |
| AYUSH Benefit | Upto Sum Insured |
| Ambulance Cover | Upto ₹3,000 per hospitalization |
| Health Checkup | Once every policy year for listed tests, only on Cashless basis. |
| Compassionate Travel | Upto ₹20,000 per policy year, over and above base Sum Insured |
| Bariatric Surgery Cover | Upto Sum Insured |
| In-Patient Treatment – Dental | Upto Sum Insured |
| Vaccination Cover | Upto ₹5,000 per policy year as per the list, over and above base Sum Insured |
| Hearing Aid | 50% of actuals; maximum ₹10,000 per policy, every third year of continuous coverage under this Policy, over and above base Sum Insured |
| Daily Cash for choosing Shared Accommodation | 0.25% of base Sum Insured; maximum ₹2000 per day, over and above base Sum Insured Benefit applicable only if hospitalization is in Our network of Valued Provider – Pan India |
| Daily Cash for Accompanying an Insured Child | 0.25% of base Sum Insured; maximum ₹2000 per day, over and above base Sum Insured Benefit applicable only if hospitalization is in Our network of Valued Provider – Pan India |
| Second Opinion | Covered for listed illnesses |
| Cumulative Bonus | 50% of the base Sum Insured of the expiring Policy, on each Renewal of the Policy after every claim free Policy Year, maximum upto 100% of the base Sum Insured in any Policy Year. Cumulative bonus shall be provided only if No Claim Discount has not been availed for the claim free previous Policy Year. Alternately, No Claim Discount in premium can be opted, in which case policy will not be entitled for Cumulative Bonus. |
| Accidental Death Benefit (Optional Cover) | 100% of base Sum Insured |
| Consumables Benefit:(Optional Cover) | (Optional Cover) |
| Wellness Services | Teleconsultation – General: Available |
| Room Category | Single Private Room* |
| Cost Sharing | |
| Age Linked Co-Payment | 20% co-payment for each admissible claim applicable if the entry Age of the Insured Person is 61 years or above at the time of first coverage under this Policy |
| Network Applicable | Valued Provider – Pan India ‘Valued Provider – Pan India’ is a specific network of Hospital(s), designated as such and mentioned in the Policy Schedule. It consists of a defined list of Hospital(s) or health care providers enlisted by Us, and/or TPA to provide medical services to an Insured Person by a Cashless Facility. “Valued Provider – Pan India” network list is different from Our standard list of “Network Provider”. The updated list of Valued Provider – Pan India is available on Our website (www.tataaig.com). |
| Co-payment for treatment availed out of Our Network of Valued Provider – Pan India | 30% co-payment for each such admissible claim applicable where the Insured Person avails treatment outside Our network of “Valued Provider-Pan India”. |
*Note: Proportionate deduction of Associated Medical Expenses applicable in case insured person is admitted in a room category that is higher than the Single Private Room