Need for health Insurance:

Changing Life Style:

Due to sedentary life style and lack of physical activity, we are prone to all serious ailments, irrespective of age.

Skyrocketing Medical care cost:

• Good Quality medical treatment comes with a high price tag.
• medical problems eat away savings planned for long term financial objectives.

Preventive Care:

The latest research shows that people with health insurance are found to be mentally and physically healthier.

Access to better medical care:

Expensive healthcare procedures and medicines may be beyond your reach without the security of health insurance

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Customer 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.

The premiums are calculated after taking into account your age, your location (zonal), your medical condition, (any pre-existing diseases), and lifestyle habits (smoking, drinking, etc.)

Do any member(s) have any existing illnesses for which they take regular medication?

• Diabetes
• Blood Pressure
• Heart disease
• Any Surgery
• Thyroid
• Asthma
• Other disease

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Key Benefits:

Medicare Premier is made available for those aged between 18 years and 65 years. However, it provides coverage for dependent children from the age of 3 months to 25 years.

• SI from 5L – 3 Crore (5, 10, 15, 20, 25, 50, 75, 100, 200, 300)
• This policy has no co-payment.
• You can pick any room you like
  • Shared room, single room, deluxe room or any room that’s available.
• You always have full cover irrespective of the disease
  • Meaning this policy doesn’t impose any disease wise sub-limits.
•  The insurer will cover all costs arising out of these pre-existing problems after just 2 years.
• Pre & Post hospitalization expenses covered
• Day Care treatments covered
  • dialysis, chemotherapy, Cataractor minor surgeries.
• Renewal Bonus (NCB): sum insured increases by 50% each year, so long as you make no claims during this period upto sum insured increases by 100%. Also, the bonus amount will reduce at same rate each time you make a claim.
• Free Health Checkups every year Up to Rs 10,000 per policy covered.
• OPD Cover (USP) cover the costs, up to a certain limit. In this case, it’s ₹5,000 annually.
• Maternity benefits offered
  • you wait 4 years before covering this expense. Also, you’ll only get the benefits if both, you and your spouse are enrolled in a single-family floater plan.
• OPD dental (USP) treatments after a waiting period of 2 years up to Rs. 10,000.
• High end diagnostics (USP) Upto Rs 25,000 for listed diagnostics.
• Emergency evacuation (worldwide)
• E-consultation: Unlimited e – consultation.
• Discount on Renewal: An additional discount for staying active and fit. Can be availed at the time of renewal.
• Daily cash allowance: Up to Rs 2,000 per day only in case you opted for Shared accomodation for expenses such as meals, transport etc. of the attendant.

Premium Calculations:

• The premium will be charged on the completed age of the Insured Person.
• The premium for the policy will remain the same for the policy period as mentioned in the policy schedule.
• For family floater, premium is calculated by adding the premium of respective individual members and applying family floater discount.

Terms and Conditions

• Minimum entry age – 91 days and Maximum entry age – 65 years
  • Additionally, Children from 91days to 5 years are covered if both parents are included in the policy.
  • Dependent children up to the age of 25 will be covered as well.
    • from 26 years onwards child can be covered under a separate policy with an eligible continuity benefit.
• No maximum coverage ceasing age under this policy.
• Policy Tenure Options-1/2/3 Years
• Policy can be issued for individual and family floater.
• Covers upto 7 members (Self, Spouse, upto 3 dependent children and parents/parents-in-law).
• 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.
• We may apply risk loading based on individual’s health status.
• There will be no premium refund in case of cancellation due to established fraud, misrepresentation and/or non-disclosure of material facts.
• Grace period of 30 days is available for renewal.
• Sum insured can be enhanced only at the time of renewal subject to our underwriting guidelines
• 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.
• The Company, may revise or modify the terms of the Policy including the premium rates or product withdrawal. The Policyholder shall be notified three months before the changes are effected and shall be provided with an option to migrate to similar products offered by Us.
• The policy is renewable except in case of established fraud or non-disclosure or misrepresentation by the Insured Person.
• Type   of Insurance Policy:
  • Both indemnity & benefit, Policy has elements of both,
    • Indemnity (which cover insured loses) and
    • Benefit (which pays a fix amount under the policy on the occurrence of a covered event).

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Policy Wordings

TATA AIG Medicare Premier is a simplified and comprehensive Health Insurance plan.

Tata AIG General Insurance Company Limited (We, Our or Us) will provide the insurance cover, described in this Policy and any endorsements thereto, for the Insured Period, as defined in the Policy schedule. The insurance cover provided under this Policy is only with respect to such and so many of the benefits upto the Sum Insured as mentioned in the Policy Schedule. Commencement of risk cover under the policy is subject to receipt of premium by us.

The statements and declarations contained in the Proposal signed by the Policyholder (You) and/or medical reports shall be the basis of this Policy and are deemed to be incorporated herein. The insurance cover is governed by and subject to, the terms, conditions and exclusions of this Policy.

Preamble

While the policy is in force, if the Insured Person contracts any disease or suffers from any illness or sustains bodily injury through accident and if such event requires the insured Person to incur expenses for Medically Necessary Treatment, We will indemnify You 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. Each Benefit is subject to its Sum Insured, but Our liability to make payment in respect of any and all Benefits shall be limited to the Sum Insured unless expressly stated to the contrary.

In case of family floater policy, the sum insured for all or any of the benefits shall be on a per policy per year basis unless explicitly stated to the contrary.

In case of an individual policy, the sum insured for all or any of the benefits shall be on a per insured per year basis unless explicitly stated to the contrary.

The said Medically Necessary Treatment must be on the advice of a qualified Medical Practitioner.

Section 1 – General 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 include the female and third gender, references to any statutory enactment include subsequent changes to the same:

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 (the return of a disease) 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:

1. Having qualified registered AYUSH Medical Practitioner(s) in charge;
2. Having dedicated AYUSH therapy sections as required and/or has equipped operation theatre where surgical procedures are to be carried out;
3. 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:

1. Central or State Government AYUSH Hospital or
2. Teaching hospital attached to AYUSH college recognized by the Central Government/ Central Council of Indian Medicine/ Central Council for Homeopathy, or
3. 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:
   • Having atleast 5 in-patient beds;
   • Having qualified AYUSH Medical Practitioner round the clock;
   • Having dedicated AYUSH therapy sections as required and/or has equipped operation theatre where surgical procedures are to be carried out
   • 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/instalment premium due date, when the premium due for renewal on a given policy or instalment 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 term 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. Cumulative Bonus

Cumulative Bonus means any increase or addition in the Sum Insured granted by the insurer without an associated increase in premium.

11. 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 –

1. has qualified nursing staff under its employment;
2. has qualified medical practitioner/s in charge;
3. has fully equipped operation theatre of its own where surgical procedures are carried out;
4. maintains daily records of patients and will make these accessible to the insurance company’s authorized personnel.

12. Day Care Treatment

Day care treatment means medical treatment, and/or surgical procedure which is:

1. undertaken under General or Local Anesthesia in a hospital/day care centre in less than 24 hrs because of technological advancement, and
2. 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

13. Dental Treatment

Dental treatment means a treatment related to teeth or structures supporting teeth including examinations, fillings (where appropriate), crowns, extractions and surgery.

14. 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:

1. the condition of the patient is such that he/she is not in a condition to be removed to a hospital, or
2. the patient takes treatment at home on account of non-availability of room in a hospital.

15. 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.

16. 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:

1. has qualified nursing staff under its employment round the clock;
2. 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;
3. has qualified medical practitioner(s) in charge round the clock;
4. has a fully equipped operation theatre of its own where surgical procedures are carried out;
5. maintains daily records of patients and makes these accessible to the insurance company’s authorized personnel;

17. 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.

18. 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:

1. it needs ongoing or long-term monitoring through consultations, examinations, check- ups, and /or tests
2. it needs ongoing or long-term control or relief of symptoms
3. it requires rehabilitation for the patient or for the patient to be specially trained to cope with it
4. it continues indefinitely
5. it recurs or is likely to recur

19. 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.

20. 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.

21. Maternity expenses

Maternity expenses means;

• medical treatment expenses traceable to childbirth (including complicated deliveries and caesarean sections incurred during hospitalization);
• expenses towards lawful medical termination of pregnancy during the policy period.

22. Medical Advice

Medical Advice means any consultation or advice from a Medical Practitioner including the issuance of any prescription or follow-up prescription.

23. 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 hospitals or doctors in the same locality would have charged for the same medical treatment.

24. 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.

25. Medically Necessary Treatment

Medically necessary treatment means any treatment, tests, medication, or stay in hospital or part of a stay in hospital which:

1. is required for the medical management of the illness or injury suffered by the insured;
2. must not exceed the level of care necessary to provide safe, adequate and appropriate medical care in scope, duration, or intensity;
3. must have been prescribed by a medical practitioner;
4. must conform to the professional standards widely accepted in international medical practice or by the medical community in India.

26. 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.

27. Network Provider

Network Provider means hospitals 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).

28. New Born Baby

Newborn baby means baby born during the Policy Period and is aged upto 90 days

29. 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.

30.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.

31. Pre-Existing Disease

“Pre-existing disease (PED)” means any condition, ailment, injury or disease:

1. 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
2. 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.

32. 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:

1. Such Medical Expenses are incurred for the same condition for which the Insured Person’s Hospitalization was required, and
2. The In-patient Hospitalization claim for such Hospitalization is admissible by the Insurance Company.

33. 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.

34. 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:

1. Such Medical Expenses are for the same condition for which the insured person’s hospitalization was required, and
2. The inpatient hospitalization claim for such hospitalization is admissible by the insurance company

35. 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.

36. 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.

37. 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 diseases, time-bound exclusions and for all waiting periods.

38. Room Rent

Room Rent means the amount charged by a Hospital towards Room and Boarding expenses and shall include the associated medical expenses.

39. 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.

40. 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.

Specific Definitions (Definitions other than as mentioned under Section 1 (i) above)

1. Age

Means the completed age of the Insured Person on his / her most recent birthday as per the English calendar, regardless of the actual time of birth.

2. Policy

Policy means the contract of insurance including but not limited to Policy Schedule, Endorsements and Policy Wordings.

3. 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.

4. Policy Schedule

Policy Schedule means the Policy Schedule attached to and forming part of Policy

5. Policy year

Policy Year means a period of twelve 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, till the Policy Expiry date

6. Shared Accommodation

Shared Accommodation means a hospital room with two or more patient beds. This definition does not apply to ICU or ICCU.

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Section 2 – Benefits

Below listed benefits are payable subject to Terms and Conditions of the policy.

The company’s maximum liability in aggregate for payment of any claim under Section B1, B2, B3, B4 and B7 shall not exceed the opted sum insured. However, any payment under cumulative bonus shall be over and above.

The sequence of utilization of benefits for a claim shall be as per the following:

1. Sum Insured,
2. Any accrued Cumulative Bonus, if applicable
3. Restore benefit amount, if applicable

B1. In-Patient Treatment

We will cover for expenses for hospitalization due to disease/illness/Injury during the policy period that requires an Insured Person’s admission in a hospital as an inpatient for period more than 24 hrs.

Medical expenses directly related to the hospitalization would be payable.

B2. Pre-Hospitalization expenses

We will cover for expenses for Pre-Hospitalization consultations, investigations and medicines incurred upto 60 days before the date of admission to the hospital.

The benefit is payable if We have admitted a claim under section B1 or B4 or B6 or B31 of this policy.

B3. Post-Hospitalization expenses

We will cover for expenses for Post-Hospitalization consultations, investigations and medicines incurred after discharge from the hospital, upto number of days as specified in the table below.

Basic Sum insured	Number of days
Upto Rs. 50 Lacs	90 days
Rs.75 Lacs to Rs.3 Crore	200 days

In case the insured person has opted sum insured Rs. 75 Lacs and above, then We will arrange up to 15 physiotherapy sessions at home within India, wherever available, within the city in which you reside through our empanelled service provider subject to following conditions:

• This limit on physiotherapy sessions is applicable to each insured person, per post- hospitalization event
• Availing the services for physiotherapy at home under this Benefit is at insured person’s sole discretion and risk. We do not assume any liability towards quality of service rendered, any immediate or consequential loss arising out of or in relation to these services rendered by the empanelled service provider.
• The said physiotherapy must be advised in writing by the treating medical practitioner.
• The above services may be provided by the company /network providers or other empaneled hospitals / service providers. Any additional expenses other than the eligible expenses shall be borne by the insured person which shall not be covered under this policy unless specified otherwise
• This facility 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)
• In case we or the empanelled 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 service provider services suspended, curtailed or limited performance shall not constitute breach of contract and the company or the empanelled service provider shall have no liability whatsoever including but not limited to any immediate or consequential loss resulting therefrom.

The benefit is payable if We have admitted a claim under section B1 or B4 or B6 or B31 of this policy.

B4. Day Care Procedures

Day care treatment means medical treatment, and/or surgical procedure which is:

1. undertaken under General or Local Anesthesia in a hospital/day care centre in less than 24 hrs because of technological advancement, and
2. which would have otherwise required hospitalization of more than 24 hours.

We will cover expenses for Day Care Treatment (541) due to disease/illness/Injury during the policy period taken at a hospital or a Day Care Centre.

Treatment normally taken on out-patient basis is not included in the scope of this cover.

B5. Organ Donor

We will cover for Medical and surgical Expenses of the organ donor for harvesting the organ where an Insured Person is the recipient provided that:

1. The organ donor is any person whose organ has been made available in accordance and in compliance with The Transplantation of Human Organs (Amendment) Bill, 2011 and the organ donated is for the use of the Insured Person, and
2. We have accepted an inpatient Hospitalization claim for the insured member under section B1 of this policy.

B6. Domiciliary Treatment

Medical Expenses incurred for availing medical treatment at home which would otherwise have required hospitalization. We will also cover pre and post hospitalization expenses in case of domiciliary hospitalization.

We will cover for expenses related to Domiciliary Hospitalization of the insured person if the treatment exceeds beyond three days. 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.

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:

1. the condition of the patient is such that he/she is not in a condition to be removed to a hospital, or
2. the patient takes treatment at home on account of non-availability of room in a hospital.

B7.  Restore Benefit

We will automatically restore the Basic Sum Insured if the Sum Insured and accrued Cumulative Bonus is insufficient to pay a claim during the policy year. This benefit can be availed once during the policy year subject to the following conditions:

1. The restored sum insured can be used for any admissible claim under Sections B1 to B4, for the insured person(s) who have not claimed earlier under these Sections. In case the insured has claimed under these sections, then this automatic restoration benefit is available for admissions due to unrelated illness/diseases. However, this benefit for related illness/diseases would be available, in case of claimed insured person(s), for admissions after 45 days from the date of discharge of the earlier claim. (now this 45 days not applicable)
2. In case of Family Floater policy, Reinstatement of Sum Insured will be available for all Insured Persons in the Policy on floater basis.
3. For policy with Basic Sum Insured less than or Equal to Rs. 50 Lacs: This benefit shall be applicable annually for policies with tenure of more than 1 year.
4. For policy with Basic Sum Insured Rs. 75 Lacs and above: This benefit shall be applicable annually for multiyear policies. However, for single premium multiyear policies, the insured shall have the right to utilize the available restorations anytime during the policy period, except for the first claim, for

e.g. a policy with tenure of 2 years where entire premium is paid upfront, the insured is eligible for a total of 2 restorations anytime during the policy period except for the first claim in each policy year.

• d. The unutilized restored sum insured cannot be carried forward to the next policy year.
• e. Restore will not trigger for the first claim under each policy year.
• f. The maximum liability under a single claim under this benefit shall be the sum Insured.

This benefit shall not be available for section B13 and B31 of this policy.

Restore — full and partial but TATA is partially which is best ….most of the companies are giving Full restoration..

B8. AYUSH Benefit

We will cover Medical Expenses incurred for treatment as In-Patient or Day Care Treatment costs incurred under Ayurveda, Yoga and Naturopathy, Unani, Sidha or Homoeopathy will be covered in an AYUSH Hospital/ AYUSH day care centre.

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 number of days as specified in the table below, subject to AYUSH In-Patient hospitalization or AYUSH day care treatment claim being admissible under this benefit.

Basic Sum insured	Number of days
Upto Rs. 50 Lacs	90 days
Rs.75 Lacs to Rs.3 Crore	200 days

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).

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 limited as specified in the table below.

Basic Sum Insured	Sub Limit (not for whole year)
Up to Rs. 50 Lacs	Upto Rs. 5000 per hospitalization
Rs. 75 Lacs	Upto Rs. 7500 per hospitalization
Rs. 1 Crore	Upto Rs. 10000 per hospitalization
Rs. 2 Crore	Upto Rs. 20000 per hospitalization
Rs. 3 Crore	Upto Rs. 30000 per hospitalization

For this claim to be paid, the claim must be admissible under section B1 or B4 of this policy.

B10.    Health Checkup (must use)

We will cover for expenses for a Preventive Health Check-up upto 1% of policy sum insured subject to a maximum limit as specified in the table below. The limit is the maximum per policy in case of floater policy and per insured person in case of individual policy

The benefit is payable every year irrespective of claims under the policy. This benefit has a separate limit (over and above base sum insured) and does not affect cumulative bonus.

Basic Sum Insured (Rs.)	Sub Limit
Up to Rs. 50 Lacs	Upto Rs. 10000
Rs. 75 Lacs	Upto Rs. 15000
Rs. 1 Crore	Upto Rs. 20000
Rs. 2 Crore	Upto Rs. 25000
Rs. 3 Crore	Upto Rs. 25000

General Note: Preventive health check only cashless from first year onwards….1 MG team will come and collect samples at home…

For the purpose of this benefit, Preventive Health Check-up means 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.

B11.    Compassionate travel

a. Domestic (During any Visit to other place)

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 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.

The benefit shall be payable if an inpatient Hospitalization claim for the insured member is admissible under section B1 of this Policy.

b. Global (Applicable for sum insured above Rs. 50 Lacs):

In the event the Insured person is hospitalized outside India and claim is admissible under section B13 (Global cover for Planned Hospitalization) of this policy, We will cover expenses related to round trip economy class air ticket, to allow the Immediate Family Member to accompany the Insured person for the purpose of planned treatment outside India.

Note: insured person expenses will be coverd in B13, here only for family member.

This benefit has a separate limit (over and above base sum insured) as specified in the policy schedule and does not affect cumulative bonus. We shall require the following additional documents (proof of travel) supporting the claim under this benefit:

• Copy of Passport (in case of Global),
• Boarding Pass, or Railway ticket or any other document to show proof of travel.

Basic Sum Insured (Rs.)	sub Limit
Up to Rs. 50 Lacs	Upto Rs.20,000 per policy year
Rs. 75 Lacs to Rs. 3 Crore	Upto Rs.50,000 per policy year

B12. Consumables Benefit

We will pay for expenses incurred, for specified consumables listed in ‘Annexure I – List I- Optional Items’ which are consumed during the period of hospitalization directly related to the insured’s medical or surgical treatment of illness/disease/injury. Details of Annexure I- List I-Optional items are available on our website (www.tataaig.com)

However, the following items shall be excluded from scope of this coverage:

• Items of personal comfort, toiletries, cosmetics and convenience shall be excluded from scope of this coverage.
• External durable devices like Bilevel Positive Airway Pressure (BIPAP) machine, Continuous Positive Airway Pressure (CPAP) machine, Peritoneal Dialysis (PD) equipment and supplies, Nimbus/water/air bed, dialyzer and other medical equipments.
• Any item which is neither medical consumable nor medically necessary nor prescribed by Doctor.

For this claim to be paid, the main claim must be admissible under section B1 or B4 or B31 of this policy.

B13. Global Cover for Planned Hospitalization

a. Global Cover for Planned Hospitalization (Medical Expenses)

We will cover for Medical Expenses (in patient & day care) of the Insured Person incurred outside India, upto the sum insured, provided that the diagnosis was made in India and the insured travels abroad for treatment.

The Medical Expenses payable shall be limited to Inpatient and daycare Hospitalization. Any claim under this cover can be made only on reimbursement basis. Cashless facility may be arranged on case to case basis. Insured person can contact us for claim assistance.

The payment of claim under this benefit will be in Indian Rupees based on the rate of exchange published by Reserve Bank of India (RBI), as on the date of invoice and shall be used for conversion of foreign currency into Indian Rupees for claims payment. If these rates are not published on the date of invoice, the exchange rate next published by RBI shall be considered for conversion.

Only the balance basic sum insured along with Cumulative Bonus can be used for this and not the restored sum insured.

We shall require the following additional documents supporting the claim under this benefit:

• Proof of diagnosis in India
• Insured’s Passport and Visa

b. Visa Services Fees (Applicable only for Sum Insured above Rs.50 Lacs i.e 75lakh)

We will cover for reasonable and customary expenses incurred towards obtaining visa for medical treatment of the insured person (Only) travelling abroad upto the sum insured subject to claim being admissible under section B13 (a – Global Cover for Planned Hospitalization (Medical Expenses)) of this policy.

• We shall require valid receipts/bills of visa fee services supporting the claim under this benefit.

Special condition applicable for cover B13 (a) & (b):

Please note that, B13. ‘Global Cover for Planned Hospitalization’ as a Benefit is:

a. not available under this policy and no claim shall be admissible under this section where either the policyholder or any of the Insured Person(s) is a Foreign National or their Residence Status at the time of proposal or anytime during the policy period/ renewal is:

• Non-Resident Indian (NRI); or
• Overseas Citizen of India (OCI)

b. not available under this Policy and no claim shall be admissible under this section, if the Policyholder or any of the Insured Person(s), as a Resident Indian National, has agreed to opt out of this Benefit at the time of proposal or at renewal.

If the coverage under B13. ‘Global Cover for Planned Hospitalization’ is once opted out, then neither the policyholder nor the Insured Person can take coverage under this benefit.

You are eligible for a premium discount @ 2% (once opted out) as specified in the prospectus in case this special condition, as mentioned above, is applicable to You/ Insured Person(s).

B14. Bariatric Surgery Cover

We’ll cover the cost of bariatric surgery to help deal with obesity and weight issues.

We will cover for reasonable and customary expenses for Bariatric Surgery if the insured fulfills all of the following conditions:

1. Surgery to be conducted is upon the advice of the Doctor
2. The member has to be 18 years of age or older and
3. Body Mass Index (BMI) greater than or equal to 40 or
4. BMI is greater than or equal to 35 in conjunction with any of the following severe co- morbidities following failure of less invasive methods of weight loss:
   • Obesity-related cardiomyopathy (a disease of the heart muscle)
   • Coronary heart disease
   • Severe sleep apnea
   • Uncontrolled Type2 Diabetes

In view of this coverage getting extended, exclusion code (Code-Excl06) of this policy stands deleted.

B15. 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.

B16. Vaccination cover (must use)

We will cover for expenses related to the cost of the following vaccines only:

Basic Sum Insured	Vaccines covered
Up    to    Rs.    50 Lacs	Without any waiting period: 1. Anti-rabies vaccine following an animal bite 2. Typhoid vaccination After 2 years of continuous coverage with Us: 1. Human Papilloma Virus (HPV) vaccine 2. Hepatitis B Vaccine
Rs. 75 Lacs to Rs. 3 Crore.	Without any waiting period: 1. Anti-rabies vaccine following an animal bite 2. Typhoid vaccination After 2 years of continuous coverage with Us: 1. Human Papilloma Virus (HPV) vaccine 2. Hepatitis A Vaccine 3. Hepatitis B Vaccine 4. Tetanus, Diphtheria, Pertussis 5. Pneumococcal

Expenses related to the doctor, nurse or any incidental expenses are not payable. This benefit has a separate limit (over and above base sum insured) and does not affect cumulative bonus.

B17.    Hearing Aid

The items must be prescribed by a specialized Medical Practitioner as medically necessary. This benefit has a separate limit (over and above base sum insured) and does not affect cumulative bonus.

We will cover for reasonable charges for a hearing aid every third year. The maximum amount (Sub Limit) payable is 50% of actual cost or Rs. 10,000/- per policy, whichever is lower.

B18.    Daily Cash for choosing Shared Accommodation

We will pay a fixed amount per day as mentioned in the policy schedule if the Insured Person is Hospitalized in Shared Accommodation in a Network Hospital for each continuous and completed period of 24 hours. The benefit payable per day would be (sub limit) 0.25% of base sum insured and a maximum of Rs. 2000 per day. (i.e 8lakhs above Rs.2000)

For this claim to be paid, the main claim must be admissible under section B1 of this policy. This benefit has a separate limit (over and above base sum insured) and does not affect cumulative bonus.

B19. Daily Cash for Accompanying an Insured Child

We will pay a fixed amount per day, as mentioned in the policy schedule, if the Insured Person Hospitalized is a child Aged 12 years or less, for one accompanying adult for each complete period of 24 hours. The benefit payable per day would be (sub limit) 0.25% of base sum insured and a maximum of Rs.2000 per day. (i.e 8lakhs above Rs.2000)

For this claim to be paid, the main claim must be admissible under section B1 of this policy. This benefit has a separate limit (over and above base sum insured) and does not affect cumulative bonus.

B20. Second Opinion

We will provide You a second opinion from Network Provider or Medical Practitioner, 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. (by sharing all the test report you can talk with a our doctors)

1. Cancer
2. Kidney Failure
3. Myocardial Infarction
4. Angina
5. Coronary bypass surgery
6. Stroke/Cerebral hemorrhage
7. Organ failure requiring transplant
8. Heart Valve replacement
9. Brain tumors

This benefit can be availed by an insured person once during a Policy Year.

B21. Maternity Cover (only delivery expenses – Must Use)

We will cover for Maternity Expenses, upto limits as specified in the table below, per policy subject to a waiting period of 4 years of continuous coverage under this policy .

Basic Sum Insured	Sub Limit
Up to Rs. 50 Lacs	A maximum of upto Rs 50,000/-. In case of birth of a girl child, the maximum limit under this coverage would be upto Rs 60,000/- per policy
Rs.75    Lacs    to    Rs.3 Crore	A maximum of upto Rs 1,00,000/-. In case of birth of a girl child, the maximum limit under this coverage would be upto Rs 1,20,000/- per policy

We will not cover ectopic pregnancy (fertilised egg implants itself outside of the womb, usually in one of the fallopian tubes) under this benefit (although it shall be covered under section B1).

Expenses incurred for following shall be excluded from the scope of this coverage:

• Expenses incurred for pre/post natal care (during Pregnancy period)
• Pre/Post hospitalization benefit (Section B2 and B3 of this policy)

In view of this coverage getting extended, maternity exclusion code 18 stands deleted. However, no coverage is available for voluntary termination of pregnancy during the policy period under this policy.

Note:

1. No limit on No of deliveries..
2. No need that husband & Wife must be covered under same policy. this benefit is applicable for female Insured.

B22.    Delivery Complications Cover

We will cover for medical expenses incurred for the medically necessary treatment of the new born baby upto limits as specified in the table below, for complications related to delivery if claim is admitted under the maternity benefit (B21) of this policy.

Basic Sum Insured	Sub Limit
Up to Rs.50 Lacs	Upto Rs. 10000
Rs. 75 Lacs to Rs. 3 Crore	Upto Rs. 25000

B23.    First year Vaccinations

We will pay for vaccination expenses for up to one year after the birth of the child subject to a limit (sub limit) of Rs. 10,000/- provided the child is covered with Us. In case of girl child, applicable limit under this coverage would be Rs.15,000/-.

For the claim to be paid under this benefit, the expenses related to maternity should be admissible under section B21 of this policy. The limit of Rs.10,000 (Rs.15,000 in case of girl child) is a lifetime limit and not a policy limit which will be applicable for each child.

B24. Prolonged Hospitalization Benefit

We will pay a fixed amount of 1% of sum insured, (sub limit) in the event of insured hospitalized for a disease/illness/injury for a continuous period exceeding 10 days.

This benefit will be triggered provided that the hospitalization claim is accepted under section B1 of this policy.

This benefit shall not be applicable for section B6 / B 31 of this policy.

This benefit has a separate limit (over and above base sum insured) and does not affect cumulative bonus.

B25. High End Diagnostics

 Feature Exclusive for Medicare Premier

We will cover for reasonable charges incurred for the following diagnostic tests only on OPD basis if required as part of a medically necessary treatment subject to limits as specified in the table below, per policy year:

1. Brain Perfusion imaging
2. Computed Tomography (CT) guided Biopsy
3. Computed Tomography (CT) Urography
4. Digital Subtraction Angiography (DSA)
5. Liver Biopsy
6. Magnetic Resonance Cholangiography Scan
7. Positron Emission Tomography Computed Tomography (PET CT)
8. Positron emission tomography Magnetic Resonance Imaging (PET MRI)
9. Renogram

Basic Sum Insured	Sub Limit
Up to Rs.50 Lacs	Up to Rs. 25,000 per policy year
Rs. 75 Lacs to Rs. 3 Crore	Up to Rs. 50,000 per policy year

This benefit has a separate limit (over and above base sum insured) and does not affect cumulative bonus.

B26. OPD Treatment (Must Use)

Feature Exclusive for Medicare Premier

Once the insured has completed two years of continuous coverage with Us, We will pay for expenses related to consultations and pharmacy up to limits specified in the table below, per policy year annually subject to policy terms and conditions.

Basic Sum Insured	Sub Limit
Up to Rs.50 Lacs	Upto Rs. 5,000/-
Rs.75 Lacs	Upto Rs. 7,500/-
Rs. 1 Crore	Upto Rs. 10,000/-
Rs. 2 Crore	Upto Rs. 15,000/-
Rs. 3 Crore	Upto Rs. 20,000/-

This benefit has a separate limit (over and above base sum insured) and does not affect cumulative bonus.

B27. OPD Treatment – Dental

Once the Insured has completed two years of continuous coverage with Us, we will pay for expenses related to the following dental treatments only subject to a maximum of limit specified in the table below, per policy year annually:

• Root Canal Treatment (single or multiple sittings)
• Tooth extraction(s)
• Filling

Basic Sum Insured	Sub Limit
Up to Rs. 50 Lacs	Upto Rs. 10,000/-
Rs. 75 Lacs	Upto Rs. 12,500/-
Rs.1 Crore	Upto Rs. 15,000/-
Rs.2 Crore	Upto Rs. 20,000/-
Rs.3 Crore.	Upto Rs. 25,000/-

This benefit has a separate limit (over and above base sum insured) and does not affect Cumulative Bonus.

In view of this coverage getting extended, dental exclusion (General Exclusions ii. 1. ix) is not applicable for this particular coverage.

B28. Emergency Air Ambulance Cover

We will pay for ambulance transportation of the Insured Person in an airplane or helicopter subject to maximum of limit specified in the table below, for emergency life threatening health conditions which require immediate and rapid ambulance transportation to the hospital/medical centre for further medical management.

The Medical Evacuation should be prescribed by a Medical Practitioner and should be Medically Necessary.

This benefit shall only be payable if We have accepted an inpatient Hospitalization claim for the Insured member under section B1 of this policy.

Basic Sum Insured	Sub Limit
Up to Rs.50 Lacs	Up to Rs. 500,000
Rs.75 Lacs to Rs. 3 Crore	Up to Rs. 500,000 for Non Network; Upto Sum Insured for Network Provider

This benefit has a separate limit (over and above base sum insured) and does not affect Cumulative Bonus.

B29. 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 a fixed amount of 100% of the base Sum Insured, maximum up to Rs 50 Lacs (Sub Limit).

Note: it is fixed amount for each died person.

This benefit is not applicable for dependent children covered in the policy.

B30. Cumulative Bonus/ No Claim Discount

1. 50% cumulative bonus will be applied on the Sum Insured for next policy year under the Policy after every claim free Policy Year, provided that the Policy is renewed with Us and without a break. The maximum cumulative bonus shall not exceed 100% of the Sum Insured in any Policy Year.
2. If a Cumulative Bonus has been applied and a claim is made, then in the subsequent Policy Year We will automatically decrease the Cumulative Bonus by 50% of the Sum Insured in that following Policy Year. There will be no impact on the Inpatient Sum Insured, only the accrued Cumulative Bonus will be decreased.
3. In policies with a tenure of more than one year, the above guidelines of Cumulative Bonus shall be applicable post completion of each policy year
4. In relation to a Family Floater, the Cumulative Bonus so applied will only be available in respect of those Insured Persons who were Insured Persons in the claim free Policy Year and continue to be Insured Persons in the subsequent Policy Year.
5. For purpose of computation of Cumulative Bonus, the percentage (%) of Cumulative Bonus will be applied on the base Sum Insured only. Restored sum insured will not be taken into consideration.
6. Cumulative Bonus shall be provided only if No Claim Discount has not been availed for the claim free previous Policy Year.

B31.  Home Care Treatment Cover (Applicable only for Sum Insured Rs.75 Lacs and above)

We will cover for reasonable and customary medical expenses incurred for treatment taken at home, which are “Equivalent Medical charges” as defined in this policy, for below specified conditions/illness upto the sum insured (excluding accrued cumulative bonus) for the Insured Person’s medically necessary treatment at home. Restore benefit sum insured is not applicable for this benefit.

Basic Sum Insured (Rs.)	sub Limit
Up to Rs. 50 Lacs	NA
Rs. 75 Lacs to Rs. 3 Crore	Upto Sum Insured for 1. Dialysis at home 2. Cancer care at home 3. Up to 25% of Sum Insured for Pandemic Care at home, max up to 15 days  in  a  policy year

Home Care Treatment means treatment availed by the Insured Person at home for below listed conditions/ illness/ procedures, which in normal course would require hospitalization of more than 24 hours or would have been admissible under Day Care Procedures but is actually taken at home provided that:

1. The medical practitioner advices the insured person to undergo treatment at home.
2. There is a continuous active line of treatment with monitoring of the health status by a medical practitioner for each day through the duration of the home care treatment.
3. Daily monitoring chart including records of treatment administered duly signed by the treating doctor is maintained
4. Home care treatment is availed in India.
5. Home treatment services may be provided through network service provider/ empanelled service provider in select cities for select treatment procedures only. Please contact us or visit our website (www.tataaig.com) for updated list of treatment procedures and cities where home treatment service is provided.
6. Insured shall be permitted to avail the services as prescribed by the medical practitioner.
7. In case the insured intends to avail the services of non-network provider, claim shall be subject to reimbursement, a prior approval from the insurer needs to be taken before availing such services from a registered home care provider. Insurer shall respond to approval request within 4 working hours of receiving the last necessary requirement.

Specified conditions/ illness covered under Home care treatment:

1. Dialysis at home (for kidney patient)
2. Chemotherapy at home (for cancer)
3. Pandemic Care at home (COVID-19) for a maximum period of 15 days and maximum upto 25% of the base sum insured excluding cumulative bonus (Pandemic as defined and declared by World Health Organization (WHO) or any equivalent healthcare authority)

In this benefit, the following shall be covered if prescribed by the treating medical practitioner and is related to treatment covered under the policy,

1. Diagnostic tests undergone at home or at diagnostics center
2. Medicines prescribed in writing
3. Consultation charges of the medical practitioner
4. Nursing charges related to medical staff
5. Medical procedures limited to parenteral administration of medicines.
6. Including but not limited to cost of Pulse Oximeter, Oxygen cylinder and nebulizer wherever applicable

For the purpose of this cover, “Equivalent Medical charges” shall mean the charges for services or supplies, which are the standard/equivalent charges for the specific provider and not more than the prevailing charges in the geographical area for identical or similar services taken on inpatient/day care basis, considering the nature of the illness / injury involved.

B32. Wellness Services (practically not applicable but Must use)

We / our Empanelled Service Provider will provide below mentioned wellness services designed to assist insured persons in maintaining and improving good health and fitness. These Wellness Services will be available for the insured person during the policy period and as specified in the Policy schedule.

1.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, as per the limit specified in your Policy Schedule.

This service can only be availed subject to condition below:

– Consultation will be provided through various specified modes of communication (including but not limited to) like audio, video, online portal, chat, digital customer application or any other digital mode.

2. Teleconsultation – Speciality

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 & specialist Medical Practitioner/ Health Care Professional, as per the limit/speciality specified in your Policy Schedule.

This service can only be availed subject to conditions below:

– Consultation will be provided through various specified modes of communication (including but not limited to) like audio, video, online portal, chat, digital customer application or any other digital mode.

3. Ambulance Booking facility

We / Our empanelled Service Provider will provide a facility to book a road ambulance in India, for transportation of an Insured Person to a Hospital for admission or from one hospital to another hospital for better medical facilities and treatment.

This booking service can be availed at Our Network subject to the transportation of the Insured Person will be offered to the nearest Hospital

4. Emergency – Help me feature

In case of an emergency, insured person will have an option to share his/her location with the ‘designated caregiver’ through our customer application provided the insured person has registered on our App.

The app will trigger a message and call to the designated caregiver informing about the emergency and sharing the location of the Insured Person.

For the purpose of this benefit, ‘designated caregiver’ shall mean that individual who has been specified as a caregiver at the time of registration in the customer App.

Please note

–     This service will be available subject to suitable infrastructure, connectivity, device restrictions and device functionality.

5. Redeemable voucher/Discount on services

We / our empanelled service provider will provide redeemable vouchers/ discount (as approved by the regulator from time to time) on certain specified products/ services to promote wellness and fitness, Discounts on Pharmacy & Diagnostics of the insured person.

6. Health Condition Management

We / our empanelled service provider will provide consultative services related to health conditions/ illnesses with the objective of maintaining good health and improving it through various health condition management programmes including but not limited to nutrition management, weight management, chronic condition management, stress management, health coach (as approved by the regulator from time to time) and offered by us.

Consultative services will be provided through various specified modes of communication (including but not limited to) audio, video, online portal, chat, digital customer application or any other digital mode.

Definition:

For the purpose of section B 32 of this policy, a Health Care 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.

B33. Wellness Program (practically not applicable but must use)

We / our empanelled service provider will provide a wellness program designed to promote wellness and fitness amongst the insured persons. This wellness program is structured to reward the insured person in the form of measurable wellness score for the prescribed physical efforts/fitness activity undertaken by such insured person during the policy period. This is a voluntary program available for insured with age above 18 years, at the start of the policy year. It is advisable to the insured person to consult his/her physician before starting any physical exercise/ activity.

It is a pre-condition for enrolment under this wellness programme, that the insured person should have undergone the health risk assessment as specified below and depending on the outcome from health risk assessment, the wellness reward and its scoring should be administered. The earnings under the wellness program is linked to your wellness category and shall be valid for one year from the date of credit of daily score in insured person’s wellness account, provided the policy is renewed within the grace period. Daily score will be credited after the completion of a healthy day.

For the purpose of understanding if the daily score is credited on 1st Jan 2024 it will be valid up to 31st Dec 2024.

1. Health risk assessment

We / our empanelled service provider will provide a health risk assessment (HRA) questionnaire, which is an online tool for evaluation of status of health and quality of the insured person’s life. This tool helps insured persons to review their lifestyle practises which may impact their health status.

To undertake the health risk assessment, you can log into your account on our customer application. This can be undertaken once a policy year.

On completion of the health risk assessment and based on the insured person’s assessment results, we / our empanelled service provider will identify the wellness category in which the insured person falls in.

Wellness categories for this purpose are defined as below:

• Green – low risk for developing lifestyle disease as compared to peers in the same age and gender group.
• Yellow – moderate risk for developing lifestyle disease as compared to peers in the same age and gender group.
• Red – higher risk for developing lifestyle disease as compared to peers in the same age and gender group.

The overall wellness category is valid till the expiry of the policy year in which the insured undergoes the assessment and will be updated based on HRA results of subsequent assessment undergone by the insured person in each consecutive policy year, subject to renewal of the policy within the grace period. In the event of a long- term policy (greater than 1 year) the insured has to undergo HRA in each policy year to be eligible for wellness rewards. If the insured does not undergo assessment in the consecutive policy year, henceforth no rewards will be earned for any physical activity undertaken. However, earned rewards will be carried forward till its validity and will be available for utilization.

2. Wellness Rewards

Mechanism to earn Wellness Reward:

We will encourage physical exercise and fitness and recognise the effort by rewarding the insured person on daily basis for each healthy day.

A healthy day can be earned by undertaking below activity on a calendar day:

1. Recording 10, 000 steps / day# in the activity tracking apps or fitness tracker devices as prescribed by the company or our empanelled service provider: or
2. Burning 500 calories or more in a day through activity as measured by fitness tracker devices.

The company may at its discretion change the above criteria and the same would be mentioned in the policy schedule/ customer application.

Wellness reward will be earned depending on the wellness category of the insured person and as per the grid below:

	Wellness category
	Green	Yellow	Red
Rewards               per Healthy Day	10	7	5

Note:

• HRA registration will be allowed anytime during the policy year and healthy activities will be tracked throughout the policy year, however, for each policy year, activities completed in first 300 days of the policy year will be considered for reward in the same year, activities completed on or after 301st day of the policy year will be carried forward to the next policy year and will be available for utilization in the next year provided the policy has been inforce or renewed with us without any break within the grace period.
• In case of individual policy, each insured person would be tracked separately and shall earn wellness reward based on one’s own individual performance/physical activity as per the grid above
• In case of family floater policy, each insured person, with age above 18 years, at the start of the policy year, would be tracked separately and shall earn wellness reward based on one’s own individual performance/physical activity as per the grid above. In order to compute the wellness reward for such policies, average of individual performance rewards would be considered for computation of wellness reward.
• # The company may also use alternative measurement criteria in lieu of steps and calories burnt and the same shall be mentioned on the policy schedule
• Data entered manually in the fitness tracking apps or devices will not be considered for tracking healthy day
• Calories burnt during basic metabolism shall not be considered for tracking healthy day (here basic metabolism refers to activities done while at rest to maintain vital functions such as breathing and keeping warm etc.)

Mechanism to Utilise Wellness Reward:

Wellness Reward accumulated through fitness activities can be converted into monetary value as per method defined below and can be utilized towards the payment of services/items under below categories, available through our Network/ empanelled service provider:

• OPD consultation/ treatment
• Pharmaceuticals
• Health-check-ups/ diagnostics
• Health Supplements
• Coverage of cost of treatment of any admissible claim in respect of non-payable items that are specified under the terms and conditions of the base policy
• Or any other items as prescribed by the company or our empanelled service provider as approved by the Regulator as a redeemable item from time to time.

Note:

• Wellness Reward can be converted into a monetary value after every Healthy Day, during the Cover Period
• Monetary value of the Wellness score earned is equivalent to the:
  • Wellness score earned X (Per year Policy Premium without Taxes/ 10,000).
    • In case of policy with tenure more than one year, ‘per year policy Premium without Taxes’ = (Total Policy premium without tax, for the tenure/ policy tenure).
    • In case of family floater policy, reward will be calculated on average premium per person which is equivalent to the Total Policy premium without tax/ number of Insured persons covered in the policy on floater basis

Illustration

Age of the Insured Person (Years)	40
Sum Insured opted under the Policy (Rs.)	5 Lacs
Plan Type	Individual
Policy Tenure (years)	1
Total number of members covered under the policy	1
Net Premium paid (without Tax)	7931
Wellness     Category     (post     Health     Risk Assessment)	Green

Healthy Day	Wellness Reward earned (per day)	Wellness Reward converted to Monetary Value (per day)	Wellness Reward credited after        Healthy Day	Wellness Reward valid up to 365 days (provided the policy is active and insured is covered)
1    to    300 day	10	7.931	Date of credit of Wellness score	365 days from the Date of credit of Wellness score
301       day onwards	10	7.931	Date of Policy Anniversary – in case of Multi year policy Date of renewal – in case of 1 yr policy	365 days from: Date of Policy Anniversary – in case of Multi year policy – Date of renewal – in case of 1 yr policy, as applicable
Maximum Total in a Policy Year		2894.82

Steps to register for Wellness Program and earn & spend Wellness Rewards

Step 1. Register yourself on customer application

• The insured person will download Tata AIG customer application on your device and complete registration process by providing policy and insured person’s details.

Step 2. Complete health risk assessment

• Submit response to the online health questionnaire on your device.
• On completion of the health risk assessment, a Wellness category will be assigned to the insured person for the policy year and will be updated based on the latest health risk assessment in next policy year.

Step 3. Comply with mechanism to earn Wellness Rewards

• We will track the physical exercise and fitness activities completed by the insured person, through the customer app.
• Activities completed on a calendar day will be considered as a Healthy Day and reward will be credited to insured person’s wellness account.

Step 4. Convert Healthy Day into monetary value and spend

• Insured person will have an option to convert the accumulated rewards into the monetary value and spend it on items/ services offered under the policy
• The unutilized rewards will be carried forward to next Policy year till this policy is renewed with us within grace period and is inforce subject to validity period of the reward point)

Disclaimer (applicable to section B32 & B33)

• Availing the services under this benefit is purely upon the Insured’s sole discretion and risk.

• For services that are provided through empanelled Service Providers, we are acting as a facilitator; hence 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 schedule, shall not be covered under this policy and all expenses incurred shall be borne by the insured person.
• 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/network provider under this policy.
• Insured person may consult any medical professional at any network provider/empanelled service provider at its sole discretion. The cost of service arising out of insured person choice of medical professional at any network provider/emplaned service provider shall be completely 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
• 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.
• The insured person is free to choose whether or not to act on the recommendation after seeking consultation.
• 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.
• We at our discretion may provide discounts on any of the above services
• Any discount offered under redeemable voucher/discount on services by our empanelled service providers are subject to modification or withdrawal. We do not assume any liability towards the quantum of discount, quality of product/services and timeline within which the product/service is rendered.
• For Ambulance Booking facility–
  • These services are provided through our empanelled service provider in select cities. Please contact us / refer to our digital customer application for more details on this service.
  • We do not assume any liability towards quality and turnaround times of service rendered, any loss or damage arising out of or in relation to these services rendered by the empanelled service provider.
  • This facility may be availed through Our digital customer application or through calling Our call centre on the tollfree number specified in the Policy Schedule.
• 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.
• 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)
• Any service availed by the Insured Person under this Benefit will not impact Cumulative Bonus if applicable.
• We reserve the right to change any 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. During such change, all the credits earned by the insured person shall be transferred to the new service provider.
• 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.

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Section 3 –Exclusions (Must Read)

General 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, unless expressly stated to the contrary in this Policy.

1. Standard Exclusions

A. Exclusions with waiting periods (5 kinds of waiting periods)

1. 30 Days Waiting Period (Code-Excl03):

• 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.
• This exclusion shall not, however, apply if the Insured Person has Continuous Coverage for more than twelve months.
• The within referred waiting period is made applicable to the enhanced sum insured in the event of granting higher sum insured subsequently.

2. Specified Disease/Procedure Waiting Period (Code-Excl02): excluded until the expiry of 24 months

• Expenses related to the treatment of the listed Conditions, surgeries/treatments (40) 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.
• In case of enhancement of sum insured the exclusion shall apply afresh to the extent of sum insured increase.
• If any of the specified disease/procedure falls under the waiting period specified for pre-Existing diseases, then the longer of the two waiting periods shall apply.
• The waiting period for listed conditions shall apply even if contracted after the policy or declared and accepted without a specific exclusion.
• 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 Diseases/procedures (40) as furnished below:

1. Tumors, Cysts, polyps including breast lumps (benign)
2. Polycystic ovarian disease
3. Fibromyoma
4. Adenomyosis
5. Endometriosis
6. Prolapsed Uterus
7. Non-infective arthritis
8. Gout and Rheumatism
9. Osteoporosis
10. Ligament, Tendon or Meniscal tear
11. Prolapsed Inter Vertebral Disc
12. Cholelithiasis
13. Pancreatitis
14. Fissure/fistula in anus, haemorrhoids, pilonidal sinus
15. Ulcer & erosion of stomach & duodenum
16. Gastro Esophageal Reflux Disorder (GERD)
17. Liver Cirrhosis
18. Perineal Abscesses
19. Perianal / Anal Abscesses
20. Calculus diseases of Urogenital system Example: Kidney stone, Urinary bladder stone.
21. Benign Hyperplasia of prostate
22. Varicocele
23. Cataract
24. Retinal detachment
25. Glaucoma
26. Congenital Internal Diseases

The following treatments are covered after a waiting period of two years irrespective of the illness for which it is done:

• Adenoidectomy
• Mastoidectomy
• Tonsillectomy
• Tympanoplasty
• Surgery for nasal septum deviation
• Nasal concha resection
• Surgery for Turbinate hypertrophy
• Hysterectomy
• Joint replacement surgeries Eg: Knee replacement, Hip replacement
• Cholecystectomy
• Hernioplasty or Herniorraphy
• Surgery/procedure for Benign prostate enlargemen
• Surgery for Hydrocele/ Rectocele
• Surgery of varicose veins and varicose ulcers

3. Pre – Existing Diseases Waiting Period (Code-Excl01) (excluded until the expiry of 24 months)

• Expenses related to the treatment of a pre-existing Disease (PED) and its direct complications shall be excluded until the expiry of 24 months of continuous coverage after the date of inception of the first policy with us
• In case of enhancement of sum insured the exclusion shall apply afresh to the extent of sum insured increase.
• 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.
• Coverage under the policy after the expiry of 24 months for any pre-existing disease is subject to the same being declared at the time of application and accepted by us.

4. OPD Treatment & OPD Treatment-Dental

will be covered after a waiting period of 24 months of continuous coverage under this policy.

5. Maternity

will be covered after a waiting period of 48 months of continuous coverage under this policy with us.

B. Medical Exclusions (life time Not Covered)

1. Treatment for, Alcoholism, drug or substance abuse or any addictive condition and consequences thereof .(Code-Excl12)
2. Expenses related to surgical treatment of obesity that does not fulfil the below conditions (Code-Excl06)
   • Surgery to be conducted is upon the advice of the Doctor
   • The surgery/Procedure conducted should be supported by clinical protocols
   • The member has to be 18 years of age or older and
   • Body Mass Index (BMI);
     • greater than or equal to 40 or
     • greater than or equal to 35 in conjunction with any of the following severe co-morbidities following failure of less invasive methods of weight loss:
       • Obesity-related cardiomyopathy
       • Coronary heart disease
       • Severe Sleep Apnea
       • Uncontrolled Type2 Diabetes

iii. Investigation and evaluation (Code-Excl04): (Deductions list)

• Expenses related to any admission primarily for diagnostics and evaluation purposes only are excluded.
• Any diagnostic expenses which are not related or not incidental to the current diagnosis (i.e other tests that are not required for the current treatment) and treatment are excluded.

iv. Expenses related to Sterility and infertility (Code-Excl17). This includes: (i.e Pregnancy Related)

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

v. Refractive error (Code -Excl15):

Expenses related to the treatment for correction of eye sight due to refractive error less than 7.5 dioptres.

vi. Change-of-Gender treatments (Code- Excl 07):

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

vii. Cosmetic or Plastic Surgery (Code – Excl08) : Expenses for cosmetic or plastic surgery or any treatment to change appearance unless for reconstruction following an Accident, Burn(s) or Cancer or as part of medically necessary treatment to remove a direct and immediate health risk to the insured. For this to be considered a medical necessity, it must be certified by the attending Medical Practitioner.

viii. Rest cure, rehabilitation and respite care (Code-Excl05):

1. Expenses related to any admission primarily for enforced bed rest and not for receiving treatment. This also includes:
   • Custodial care either at home or in a nursing facility for personal care such as help with activities of daily living such as bathing, dressing, moving around either by skilled nurses or assistant or non-skilled persons.
   • Any services for people who are terminally ill to address physical, social, emotional and spiritual needs.

ix. Unproven treatments (Code-Excl16) : Expenses related to any unproven treatment, services and supplies for or in connection with any treatment. Unproven treatments are treatments, procedures or supplies that lack significant medical documentation to support their effectiveness.

x. Maternity (Code – Excl18):

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

xi. Treatments received in health 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)

xii. 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)

C. Non-Medical Exclusions ((life time Not Covered))

1. Hazardous or Adventure Sports (Code Excl09) : Expenses related to any treatment necessitated due to participation as a professional in hazardous or adventure sports, including but not limited to, para-jumping, rock climbing, mountaineering, rafting, motor racing, horse racing or scuba diving, hand gliding, sky diving, deep-sea diving
2. Breach of law (Code Excl10): Expenses for treatment directly arising from or consequent upon any Insured Person committing or attempting to commit a breach of law with criminal intent.
3. Excluded Providers (Blacklist Hospitals) (Code-Excl11):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 .

Specific Exclusions (Exclusions other than as mentioned under Section 3 (1, 2 & 3) above)—-(life time Not Covered)

1. Medical Exclusions

1. Alcoholic pancreatitis (i.e caused by heavy alcohol consumption)
2. Congenital External Diseases, defects or anomalies; (i.e birth defects)
3. Stem cell therapy (i,e uses stem cells to repair damaged tissue) ; however hematopoietic stem cells for bone marrow transplant for hematological conditions will be covered under benefit B1 or B4 of this policy;
4. Growth hormone therapy; (i.e treat growth hormone deficiency)
5. Sleep-apnoea (i.e sleep disorder, Snoring, obesity)
6. Admission primarily for administration of Intra-articular or intra-lesional injections or Intravenous immunoglobulin infusion or supplementary medications like Zolendronic Acid (i.e a drug treatment for osteoporosis eg: strengthen bones)
7. Venereal disease, sexually transmitted disease or illness;
8. All preventive care, vaccination including inoculation and immunisations (except in case of post- bite treatment and other vaccines explicitly covered);
9. Dental treatment or surgery of any kind except as specified in ‘Inpatient Treatment – Dental’.
10. Any existing disease specifically mentioned as Permanent exclusion in the Policy Schedule.

2. Non-Medical Exclusions

1. 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 (తిరుగుబాటు) , revolution (విప్లవం), insurrection (గొడవ), military or usurped acts (అక్రమ చర్యలు), nuclear weapons/materials, chemical and biological weapons, ionising radiation.
2. Any Insured Person’s participation or involvement in naval, military or air force operation,
3. Intentional self-injury or attempted suicide while sane or insane.
4. 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
5. Treatment rendered by a Medical Practitioner which is outside his discipline.
6. 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.
7. Provision or fitting of hearing aids, spectacles or contact lenses including optometric therapy unless explicitly stated and covered in the policy,
8. Any treatment and associated expenses for alopecia, baldness, wigs, or toupees, medical supplies including elastic stockings, diabetic test strips, and similar products.
9. Any treatment or part of a treatment that is not of a reasonable charge, not medically necessary; drugs or treatments which are not supported by a prescription.
10. Crutches or any other external appliance and/or device used for diagnosis or treatment (except when used intra-operatively and explicitly stated and covered in the policy).
11. 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

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Section 4 – General Terms and Clauses

Standard General Terms and 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)

• The Company shall settle or reject a claim, as the case may be, within 30 days from the date of receipt of last necessary document.
• 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.
• 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.
• 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).The Clause shall be suitably modified by the insurer based on the amendment(s), if any to the relevant provisions of Protection of Policyholder’s Interests Regulations, 2024)

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 (Tata, HDFC, ICICI, Care)

• 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.
• 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.
• 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.
• 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:

1. the suggestion, as a fact of that which is not true and which the insured person does not believe to be true;
2. the active concealment of a fact by the insured person having knowledge or belief of the fact;
3. any other act fitted to deceive; and
4. 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

1. The policyholder may cancel this policy by giving 7 days written notice and in such an event, the Company shall refund proportionate premium for the unexpired policy period provided 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 under the Policy.
2. The Company may cancel the policy at any time on grounds of established fraud, misrepresentation or non-disclosure of material facts by the 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

1. 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.
2. 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.

• Renewal shall not be denied on the ground that the insured person had made a claim or claims in the preceding policy years.
• Request for renewal along with requisite premium shall be received by the Company before the end of the policy period.
• 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.
• 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 (Annually (for multi-year policy)/ Half-yearly / quarterly).
• Coverage during such grace period (in case of instalment premium):
  • 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.
  • 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.
• 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 renewals based on individual claims experience.

11. Withdrawal of Policy

• 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 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 under the policy no look back to be applied. This period of five years is called as moratorium period. The moratorium would be applicable for the sums insured of the first policy and subsequently completion of five continuous years would be applicable from date of enhancement of sums insured only on the enhanced limits. After the expiry of Moratorium Period no health insurance claim shall be contestable except for proven fraud and permanent exclusions specified in the policy contract. The 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 renewals 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 (Must Read)

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 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.

Specific  terms and clauses (terms and clauses other than those mentioned under Section 4 (i) above)

17. Premium Payment

• Premium to be paid for the Policy Period before Policy Commencement date as opted by You in the proposal form.
• If you have opted to pay premium in full (lumpsum) upfront then the entire premium for the policy period shall be paid before the policy commencement date with an option of policy tenure 1/2/3 years.
• Long term premium discount of 5% and 10% is applicable for policy with tenure of 2 and 3 years respectively.

18. Insured Person

• Only those persons named as an Insured Person in the Schedule shall be covered under this Policy.

• Any person may be added during the Policy Period after his application 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.
• We will be offering continuous renewal with no exit age subject to regular premium payment and compliance with all provisions and terms & conditions of this policy by the Insured Person.

19. Loadings

• We may apply a risk loading on the premium payable (based upon the declarations made in the proposal form and the health status of the persons proposed for insurance).
• The maximum risk loading applicable for an individual shall not exceed 100% of premium per diagnosis / medical condition and an overall risk loading of over 150% of premium per person.
• The loading shall only be applied basis an outcome of Our medical underwriting.
• 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).
  • We will inform You about the applicable risk loading through a counter offer letter.
  • You need to revert to Us with consent and additional premium (if any), within 15 days of the issuance of such counter offer letter.
  • 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.
• Please note that We will issue Policy only after getting Your consent.

Pre-Policy Check-up (PPC)

Pre-Policy Check-up at our network is required. The medical reports are valid for a period of 90 days from the date of the Pre-Policy Check-up. The company may conduct Tele MER/Video, MER/Pre-Policy Check-up based on age/Sum Insured medical declaration or any other underwriting criteria.

In case of an adverse medical declaration, we may call for additional medical tests. We may conduct medical tests at diagnostic centres based on medical disclosure wherever applicable. At least 50% of the Pre-Policy medical Check-up cost would be borne by TATA AIG in case a Pre-Policy Check-up (PPC) is conducted and the proposal is accepted.

20.Entire Contract

1. 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.
2. 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.

21. Change of Policyholder

1. The change of Policyholder is permitted only at the time of renewal.
2. If the Insured Person is no longer eligible on grounds of age or dependency, the insured member will be eligible to apply for a new policy and enjoy continuity benefits upto Sum Insured.

22. Notices

1. Any notice, direction or instruction under this Policy shall be in writing and if it is to:
   • 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 Persons for these purposes.
   • 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.

23. Premium Payment Zone

For the purpose of premium computation, the country is divided into following three Zones and 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:

1. Zone A: Mumbai (including Mumbai Metropolitan Region), Delhi (including National Capital Region, Faridabad, Ghaziabad), Ahmedabad, Surat & Baroda
2. Zone B: Hyderabad (including Secunderabad), Bengaluru, Kolkata, Indore, Chennai, Chandigarh (including, Mohali, Punchkula, Zirakpur), Pune (including Pimpri Chinchwad) and Rajkot
3. Zone C: Rest of India

Please note that the above-mentioned categorization of zones 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.

24. 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 Persons till the end of Policy Period. The other insured persons may also apply to renew the policy. In case, the other insured person is minor, the policy shall be renewed only through any one of his/her natural guardian or guardian appointed by court. 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. Provided no claim has been made, and termination takes place on account of death of the insured person, 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 Policy holder or the nominee in case of demise of the Policy holder. We would require death certificate of the Deceased Insured Person for processing of the refund amount.

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Section 5 – Claims Procedure and Claims Payment (Must Read)

This section explains about the procedures involved to file a valid claim by the insured member and processes related in managing the claim by TPA or Us. 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.

1. Notification of Claim

	Treatment,         Consultation         or Procedure:	We    or    Our    TPA*   must    be informed:
1	If any treatment for which a claim may be made and that treatment requires planned Hospitalisation:	At least 48 hours prior to the Insured Person’s admission.
2	If any treatment for which a claim may be made and that treatment requires emergency Hospitalisation	Within 24 hours of the Insured Person’s admission to Hospital.

*TPA as mentioned in the policy schedule, if any

• Claim Related Information: For any claim related query, intimation of claim and submission of claim related documents, You can contact Us through:
• Name: TAGIC Health Claims
• Email:  healthclaimsupport@tataaig.com
• Toll Free: 1800 266 7780 or 1800 229 966 (For Senior Citizens)
• Website: www.tataaig.com
• Submit claim: 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. For list of network hospitals, please visit our website.

2. Cashless Service

	Treatment, Consultation     or Procedure:	Treatment, Consultation     or Procedure Taken at:	Cashless Service              is Available:	We must be given notice that the Insured Person wishes to take advantage of the cashless service accompanied by full particulars:
	If     any    planned treatment, consultation      or procedure for which a claim may be made:	Network Hospital	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 treatment or Hospitalisation
	If any treatment, consultation      or procedure         for which a claim may be                made, requiring emergency hospitalisation	Network Hospital	We will provide cashless service by             making payment to the extent of Our liability directly to the Network Hospital.	Within 24 hours after the treatment or Hospitalisation

3. Procedure for Cashless Service

• Cashless Service is only available at Network Hospitals.
• In order to avail of cashless treatment, the following procedure must be followed by You:
  • Prior to taking treatment and/or incurring Medical Expenses at a Network Hospital, You must notify our designated TPA/Us and request pre-authorization.
  • For any emergency Hospitalisation, our designated TPA/We must be informed no later than 24 hours of the start of Your hospitalization/ treatment.
  • For any planned hospitalization, our designated TPA/We must be informed atleast 48 hours prior to the start of your hospitalization/treatment.
  • 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.
  • 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.
  • In case the ailment /treatment is not covered under the policy or cashless is rejected due to insufficient documents submitted, a rejection letter would be sent to the Hospital/You by TPA/Us.
  • 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.
  • 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.
  • If the cashless is approved, the original bills and evidence of treatment in respect of the same shall be left with the Network Hospital.
  • 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.

3A. For Reimbursement of Claim:

• Please intimate our TPA/Us within 7 days of completion of treatment, consultation or procedure.
• Please submit claim documents to our TPA/Us within 15 days of occurrence of incident.

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:

Assistance:

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:

1. 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.
2. Helpline number: Toll Free: <1800 266 7780> or <1800 22 9966> (only for Senior Citizen policyholders).
3. Please refer our website www.tataaig.com to download claim form.

4. Supporting Documentation & Examination

• 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.

• 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.
• 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.
• Such documentation will include the following:

1. 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 Web site.
2. 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.
3. All medical reports, case histories, investigation reports, indoor case papers/ treatment papers (in reimbursement cases, if available), discharge summaries.
4. A precise diagnosis of the treatment for which a claim is made.
5. 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.
6. 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.
7. 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.
8. 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
9. Copy of settlement letter from other insurance company or TPA
10. Stickers and invoice of implants used during surgery
11. 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.
12. 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
13. Legal heir/succession certificate, if required
14. PM report (wherever applicable)
15. The company reserves the right to call for additional documents wherever required.

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.

We at our own expense, shall have the right and opportunity to examine insured persons 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.

5. Claims Payment

1. We shall be under no obligation to make any payment under this Policy unless We have received all premium payments in full in time and We have been provided with the documentation and information We or Our TPA has requested to establish the circumstances of the claim, its quantum or Our liability for it, and unless the Insured Person has complied with his obligations under this Policy.
2. This Policy only covers claims incurred within India (except in case of benefit B13- Global cover for Planned Hospitalization, wherever applicable), and payments under this Policy shall only be made in Indian Rupees within India.
3. 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.
4. The benefits/services/claims offered/payable under this policy including but not limited to Section B10, B32 & B33 can be availed within India only.

6. Claim procedure and management of Wellness Services & Wellness Program (Section B32 & B33)

i. Utilise Wellness Points:

Utilisation of Wellness points is only available at network service providers. To avail products or services, Insured Person must visit our Customer application and buy the required product/ services. On successful purchase, an amount equivalent to the monetary value of the Earned Wellness points will be deducted from Your policy.

ii. Avail services under Benefits:

Services are only available at network. To avail the same, following procedure must be followed:

Teleconsultation:

Insured person can gain access to tele/video/digital consultation with a general physician/ specialist/psychiatrist, using our digital customer application.

Ambulance booking facility:

Insured person can use our digital customer application to book an ambulance. This service will be offered on best effort basis and does not have a legal binding on us.

Emergency – Help me feature:

In case of an emergency, insured person can use Our Customer application to alert designated caregiver, at a push of a button. An alert message will be sent to the designated caregiver, informing him/her about the emergency. By opting this feature, the insured person authorizes us/our empanelled service provider to share their geo- location with the designated caregiver.

This service will be offered on best effort basis and does not have a legal binding on us.

iii. 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.

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Section 6 – Dispute Resolution

1. 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

For updated list and details of Insurance Ombudsman Offices, please visit website http://www.cioins.co.in/ombudsman.html

Sr.No .	Centre	Address & Contact	Jurisdiction of Office Union Territory, District
1	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.i n	Gujarat, Dadra & Nagar Haveli, Daman and Diu
2	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
3	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
4	BHUBHANESHWA R	Office          of          the          Insurance Ombudsman, 62,                     Forest                     park, Bhubaneswar        –         751         009. Tel.:    0674     –     2596461    /2596455 Email: bimalokpal.bhubaneswar@cioins.c o.in	Odisha

5	CHANDIGARH	Office Of The Insurance Ombudsman, Jeevan Deep Building SCO 20-27, Ground Floor Sector- 17 A, Chandigarh    –    160    017. Tel.:  0172  –  4646394  /  2706468 Email: bimalokpal.chandigarh@cioins.co.i n	Punjab, Haryana (excluding Gurugram, Faridabad, Sonepat         and Bahadurgarh), Himachal Pradesh,    Union Territories        of Jammu               & Kashmir,Ladakh & Chandigarh.
6	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, PuducherryTow n    and   Karaikal (which are part of Puducherry)
7	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
8	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
9	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 Sravasti, Gonda, Faizabad, Amethi, Kaushambi, Balrampur, Basti, Ambedkarnagar, Sultanpur, Maharajgang, Santkabirnagar, Azamgarh, Kushinagar, Gorkhpur, Deoria,         Mau, Ghazipur, Chandauli, Ballia, Sidharathnagar

14	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)
15	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.

16	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
17	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)

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.

Tata AIG General Insurance Company Limited

Registered Office: Peninsula Business Park, Tower A, 15th Floor, G.K. Marg, Lower Parel, Mumbai 400013, Maharashtra, India

24X7 Toll Free No: 1800 266 7780 or 1800 22 9966 (For Senior Citizens)

Email:customersupport@tataaig.com Website: www.tataaig.com IRDA of India Registration No: 108

CIN: U85110MH2000PLC128425

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Riders You should get these additional benefits to enhance your current plan

Note: Terms and conditions of the Rider are to be read in conjunction with the terms and
conditions of the Base Policy.

1. Cancer Benefit (25% – 40%) (UIN: TATHLIA25038V012425)

If an insured person is diagnosed with “Cancer of Specified Severity” as defined herein during the Policy Period, then we will pay the sum insured as specified.

Section 1:

1.Suitability:

• This Rider covers persons in the age group 18 Years onwards. This Rider is not applicable for dependent children covered in the Policy.
• This Policy can be issued to an individual and/or family. However, in case of family, the coverage shall be available on individual basis only.
• All the other eligibility conditions, relationships covered under this Rider will be applicable as per the base Policy.

2. Rider Conditions:

• Rider can only be opted along with the base Policy and cannot be opted in isolation or as a separate product.
• The Riders are provided in lieu of additional premium and subject to the terms, conditions and exclusions as stated in the Rider wordings in addition to the Policy Terms, Conditions and Exclusions.
• This Rider, if selected, shall be mentioned in the Policy Schedule and will be available up to the limit specified therein, for all Insured Person(s) covered under the underlying base Policy, unless stated otherwise.
• Cover(s) provided under this Rider and their limits are only with respect to such and so many as indicated in the Policy Schedule.
• The Rider shall offer coverage subject to below conditions:
  • Terms and conditions of the Rider are to be read in conjunction with the terms and conditions of the Base Policy.
  • The continuance of risk cover under the Base Policy is a necessary precondition for continuance of cover under Rider.
  • Admission of liability under any cover in this Rider shall not have any bearing on admissibility of a claim under the Base Policy on any ground including non-disclosure of material fact or pre-existing disease.

3. Sum Insured Options:

• 5 Lakhs
• 10 Lakhs
• 15 Lakhs
• 20 Lakhs
• 25 Lakhs
• 50 Lakhs
• 75 Lakhs
• 100 Lakhs

Section 2: General Definitions

All Standard and Specific Definitions as defined in the respective base Policy shall also apply for Riders, wherever applicable.

Additional Specific Definitions:

1. Cancer of Specified Severity
‘Cancer of Specified Severity’ is defined as the following:
I. A malignant tumor characterized by the uncontrolled growth and spread of malignant cells with invasion and destruction of normal tissues. This diagnosis must be supported by histological evidence of malignancy. The term cancer includes leukemia, lymphoma and sarcoma.

II. The following are excluded –

i. All tumors which are histologically described as carcinoma in situ, benign, pre-malignant,
borderline malignant, low malignant potential, neoplasm of unknown behavior, or
noninvasive, including but not limited to: Carcinoma in situ of breasts, Cervical dysplasia CIN1,
CIN – 2 and CIN-3.
ii. Any non-melanoma skin carcinoma unless there is evidence of metastases to lymph nodes or
beyond;
iii. Malignant melanoma that has not caused invasion beyond the epidermis;
iv. All tumors of the prostate unless histologically classified as having a Gleason score greater
than 6 or having progressed to at least clinical TNM classification T2N0M0.

V. All Thyroid cancers histologically classified as T1N0M0 (TNM Classification) or below;

vi. Chronic lymphocytic leukaemia less than RAI stage 3
vii. Non-invasive papillary cancer of the bladder histologically described as TaN0M0 or of a lesser classification,
viii. All Gastro-Intestinal Stromal Tumors histologically classified as T1N0M0 (TNM Classification) or below and with mitotic count of less than or equal to 5/50 HPFs.

R1. Cancer Benefit: (Fixed Amount)

In consideration of additional premium paid if an insured person is diagnosed with “Cancer of Specified Severity” as defined herein during the Policy Period, then we will pay the sum insured specified in the policy schedule provided:

1. “Cancer of Specified Severity” which the Insured Person is suffering from occurs or first manifest itself during the Policy Period, post initial waiting period of 30 days, as a first incidence.
2. The person survives for a period of at least 30 days from the diagnosis of the “Cancer of Specified Severity”.
3. On our admission of claim under this section in respect of an Insured Person, the cover under this section terminates in respect to that Insured Person.
4. Our liability for a lifetime of an Insured Person under this cover will be limited to the Sum Insured specified against this cover in the Policy Schedule.
5. Initial waiting period of 30 days shall also be applicable on the amount by which Sum Insured is increased in case of enhancement of Sum Insured at renewal.
6. Cancer arising due to Pre-Existing Disease shall not be covered under this Rider.

This benefit has a separate limit (over and above base Sum Insured).

– Upto Sum Insured (Sum Insured Options (₹ Lacs) 5 / 10 / 15 / 20 / 25 / 50 / 75 / 100)
⁻ As diagnosed with “Cancer of Specified Severity” as defined.
⁻ Post initial waiting period of 30 days, as a first incidence.
⁻ Survival Period of 30 Days.
⁻ This benefit has a separate individual limit (over and above base Sum Insured).

• This Rider covers persons in the age group 18 Years onwards. This Rider is not applicable for dependent children covered in the policy.

R2. CanCare Booster: (Not Available)

In consideration of additional premium paid, if an insured person is diagnosed with “Cancer of Specified Severity” as defined herein during the Policy Period, then we will pay the Sum Insured applicable in the Policy Year. The Sum Insured under this cover will be increased by 10% every year subject to below conditions:

1. CanCare Booster Sum Insured increase % will be applied on the CanCare Booster benefit Sum Insured opted for the first time under this rider. The maximum accrued increased Sum Insured shall not exceed 100% of the initial CanCare Booster Sum Insured opted, in any Policy Year.
2. “Cancer of Specified Severity” which the Insured Person is suffering from occurs or first manifest itself during the Policy Period, post initial waiting period of 30 days, as a first incidence.
3. The person survives for a period of at least 30 days from the diagnosis of the “Cancer of Specified Severity”.
4. In case of Policies with a tenure of one year, the above mentioned increase in Sum Insured shall be applicable at renewal of the Policy along with this cover, without any break.
5. In policies with a tenure of more than one year, the above mentioned increase in Sum Insured shall be applicable post completion of each Policy Year.
6. On our admission of claim under this cover in respect of an Insured Person, the cover will terminate in respect to that Insured Person.
7. Cancer arising due to Pre-Existing Disease shall not be covered under this Rider.
8. This benefit has a separate limit (over and above base Sum Insured).
9. Revision in Sum Insured shall not be allowed any time post inception of the Policy including subsequent renewal of the Policy.

Illustration:

Policy Year	1st Year	2nd Year	3rd Year	4th Year
CanCare Booster %	–	10%	10%	10%
Sum Insured under CanCare Booster	₹10,00,000 (Initial Sum Insured Opted)	₹11,00,000	₹12,00,000	₹13,00,000

Note1: Pre-Policy Medical Check up:

Pre-Policy Check up at our network may be required based upon the age, gender and Sum Insured. 100% of the expenses incurred per Insured Person will be payable by TATA AIG only on the acceptance of the Proposal. The Medical Reports are valid for a period of 90 days from the date of Pre-Policy Check up.

Gender	Age	Sum Insured	Pre-Policy Check up Tests*
Male	Above 45 years	₹50 Lakhs and above	1. Prostate Specific Antigen (PSA) 2. Test Carcinoembryonic Antigen (CEA) Test
Female	Above 45 years	₹50 Lakhs and above	1. Cancer Antigen – 125 (CA – 125) Test 2.Carcinoembryonic Antigen (CEA) Test

• In case of adverse medical declaration, we may call for Tele-MER/additional medical tests.
• Tele-MER means Tele Medical Examination Reporting.
• 100% of Tele-MER 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 the Company in case where Proposal is accepted.
• Financial underwriting may be done in case of higher Sum Insured options.

Note2. Premium Rates (Rate Per Lakh):

a. Cancer Benefit:

Age Band	Premium (In ₹)
18-35	99
36-45	265
46-55	566
56+	1,240

b. CanCare Booster:

Age Band	Premium (In ₹)
18-35	158
36-45	419
46-55	880
56+	1,862

Note 3. Terms and Conditions:

All the general terms and conditions, waiting periods, exclusions and claim procedure shall be applicable as per the base Policy.

2. Women suraksha (up to 10%)(UIN: TATHLIA25036V012425)

Section 1:

1. Suitability:

• This Policy can be issued to an individual and/or family. However, in case of family, the coverage shall be available on individual basis only.
• All the other eligibility conditions, entry age limits, relationships covered under this Rider will be applicable as per the base Policy.
• Minimum one benefit from the Rider has to be opted by the Policyholder.

2. Rider Conditions:

• Rider can only be opted along with the base Policy and cannot be opted in isolation or as a separate product.
• The Riders are provided in lieu of additional premium and subject to the terms, conditions and exclusions as stated in the Rider Wordings in addition to the base Policy terms, conditions and Exclusions.
• These Rider(s), if selected, shall be mentioned in the Policy Schedule and will be available up to the limit specified therein, for female Insured Person(s) covered under the underlying base Policy, unless stated otherwise.
• Terms and conditions of the Riders are to be read in conjunction with the terms and conditions of the base Policy.
• The continuance of risk cover under the base Policy is necessary precondition for continuance of cover under Riders.
• The scope of coverage under these Riders are restricted to the geography of India.
• Admission of liability under any cover in this Rider shall not have any bearing on admissibility of a claim under the base Policy on any ground including non-disclosure of material fact or pre-existing disease.
• Coverage under this Rider shall be availed during the Policy Period only.
• Benefits under this Rider have separate limits (Over and above the base Sum Insured), as specified in the Policy Schedule, and does not affect Cumulative Bonus in the base Policy, if applicable.

Section 2: General Definitions

All Standard and Specific Definitions as defined in the respective base Policy shall also apply for Riders, wherever applicable.

Additional Specific Definitions:

1. Health Care Professional:

A Health Care 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.

2. Service Provider:

Service Provider means the providers empanelled and engaged by Us for arranging/providing services under Riders mentioned in the base Policy Schedule.

A. Women Suraksha Package 1

R1. She Care+

We/Our empanelled service provider will arrange for the specified Consultations at the request of the female insured person(s), at our empanelled service provider in India.

In consideration of additional premium paid and notwithstanding the exclusion mentioned under base Policy with respect to Sterility and Infertility (Code-Excl 17) and Maternity (Code-Excl 18), We/Our empanelled service provider will arrange for the below mentioned consultations at Your request, at our empanelled service provider in India.

1. Gynaecologist Consultation
2. Premenstrual Syndrome (PMS) Counseling
3. Menarche Counseling
4. Menopause Counseling
5. Infertility Counseling
6. Dermatologist Consultation

Sum Insured (₹)	No. of consultations
Less than 20 Lacs	Upto 10
20 Lacs – 50 Lacs	Upto 15
More than 50 Lacs	Upto 20

These consultations will be provided through various specified modes of communications (including but not limited to) like In-person, audio, video, online portal, chat, digital customer application or any other digital mode.

R2. Polycystic Ovarian Cover

We will cover the Reasonable and Customary Charges for Evaluation of irregular menstrual cycles as prescribed by the treating Medical practitioner and towards the treatment of Polycystic ovarian disease/syndrome, as prescribed by the treating a Medical practitioner.

We/Our empanelled Service Provider will arrange for the specified cancer screening in India and We will also cover the Reasonable and Customary Charges for the Cervical Cancer Vaccination.

In consideration of additional premium paid and notwithstanding the exclusion mentioned under base Policy with respect to Specified Disease/Procedure Waiting Period (Code-Excl 02), We/Our empanelled Service Provider will:

1. Arrange for the below mentioned covers in India:
   • In     person      consultation      with     a     Medical     Practitioner      for     Polycystic        Ovarian Disease/Syndrome.
   • Following diagnostic tests as prescribed by the treating Medical Practitioner:
     • Prolactin, Serum
     • Testosterone
     • Thyroid Function Test
     • HbA1c
     • CBC ESR
     • Luteinizing Hormone (LH)
     • Follicular Stimulating Hormone (FSH)
     • LH: FSH Ratio
2. Cover the Reasonable and Customary Charges towards the treatment of Polycystic Ovarian Disease/Syndrome, as prescribed by the treating Medical practitioner.

Sum Insured (₹)	Consultation & Listed diagnostic Tests (₹)	Treatment for Polycystic ovarian disease/syndrome (₹)
Less than 20 Lacs	Upto 2500	Upto 5000
20 Lacs – 50 Lacs	Upto 3000	Upto 8000
More than 50 Lacs	Upto 3500	Upto 10000

B. Women Suraksha Package 2

R3. Women+ Screening & Vaccination Cover:

In consideration of additional premium paid and notwithstanding the exclusion mentioned under base Policy with respect to all preventive care including Health Check-Ups, vaccination including inoculation and immunizations, We/Our empanelled Service Provider will:

1. Arrange for the below mentioned cancer screening in India, at Your request:
   • Breast cancer Screening – Mammography
   • Ovarian Cancer Screening – Ultrasound and CA 125
   • Cervical Cancer Screening – Pap Smear
2. Cover the Reasonable and Customary Charges for the Cervical Cancer Vaccination including the cost of vaccine, provided the vaccination is availed at our network of empanelled service provider. However, the expenses related to the doctor, nurse or any other incidental expenses shall not be payable if the cancer vaccination has been availed.

Sum Insured (₹)	Cancer Screening	Cervical cancer Vaccination Cost (₹)
Less than 20 Lacs	Annually	Upto 5000
20 Lacs – 50 Lacs	Annually	Upto 5000
More than 50 Lacs	Bi-annually	Upto 5000

R4. Maternity Protect:

In consideration of additional premium paid, this benefit shall offer below covers:

a. Infertility Treatment:

Notwithstanding the exclusion mentioned under base Policy with respect to Sterility and Infertility (Code – Excl 17), We will cover the Reasonable and Customary Charges for the cost of the following Treatment(s), if the Insured Person(s) is medically prescribed by the treating Medical Practitioner to procure the same for the treatment of infertility:

• Intrauterine Insemination (IUI)
• In-Vitro Fertilization (IVF)
• Embryo Transfer

The benefit is payable only for one such treatment cycle for each female insured person(s) per Policy Year.

Sum Insured (₹)	Less than 20 Lacs	20 Lacs – 50 Lacs	More than 50 Lacs
Infertility Treatment(₹)	Upto 1,00,000	Upto 1,00,000	Upto 3,00,000

b. Sterilization Treatments:

Google: Sterilization treatments refer to processes that eliminate or destroy all forms of microbial life, including bacteria, spores, and viruses, on surfaces or in fluids, ensuring a sterile environment. 

Notwithstanding the exclusion mentioned under base Policy with respect to Sterility and Infertility (Code-Excl 17), We will cover the Reasonable and Customary Charges for Medical Expenses towards the voluntary sterilization of a female adult Insured Person(s) after a Waiting Period of two continuous years with Us under this cover.

For availing this benefit, the Female Insured must be a married person and her age should be22 years or above during the treatment.

The treatment is covered once in the lifetime of the Insured Person under this cover. We shall not pay for the expenses incurred towards reversal treatments of such sterilization, under this cover.

• Once in the policy lifetime
• Waiting period 2 years
• For availing this benefit, the female insured must be a married person and her age should be 22 years or above during the treatment
• We shall not pay for the expenses incurred towards reversal treatments of such sterilization

Sum Insured (₹)	Less than 20 Lacs	20 Lacs – 50 Lacs	More than 50 Lacs
Sterilization Treatments (₹)	Upto 25,000	Upto 25,000	Upto 25,000

c. Ante-Natal & Post-Natal Care:

Notwithstanding the exclusion mentioned under base Policy with respect to Maternity (Code-Excl 18), We will arrange for the following Ante-Natal & Post-Natal Check-Ups, on an outpatient basis. Ante-Natal consultation shall be covered since the date of confirmation of pregnancy and Post-Natal consultation shall be covered for a period up to six weeks post delivery.

1. Ante-Natal check up shall include:
   • 5 in-person consultations with gynecologist
   • One Ultrasound
   • Evaluation of Hypertension
   • One Blood Test
     • Blood Group Antibodies
     • HIV, Syphilis, Rubella, Hepatitis
     • Rhesus Negative Status
     • Anaemia
     • Vitamin D
     • HbA1c
   • Urine Culture
2. Post-Natal Checkup shall include:
   • 5 In person consultations with gynaecologist
   • Lactation Consultation
   • Up to two in-person consultation for post-partum depression with psychiatrist

Consultations & Listed Diagnostics Tests

Sum Insured (₹)	Less than 20 Lacs	20 Lacs – 50 Lacs	More than 50 Lacs
Ante-Natal Care & Post Natal Care (₹)	Upto 3000	Upto 5000	Upto 10,000

d. Maternity Buddy Program:

We/Our empanelled Service Provider will arrange for Health Care Professional who will advise and conduct sessions on matters related to pregnancy and child birth for the Insured Person provided you are covered for Maternity benefit under the base Policy.

This program will be provided through various specified modes of communications (including but not limited to) like audio, video, online portal, chat, digital customer application or any other digital mode.

Sum Insured (₹)	Less than 20 Lacs	20 Lacs – 50 Lacs	More than 50 Lacs
Maternity Buddy Program	Available	Available	Available

e. Home Assessment and Modification for Baby Care/Infant Care:

We/Our empanelled service provider will arrange for a home assessment to evaluate and recommend the modifications required in home to suit the safety and mobility needs for an infant.

In addition, We will pay a fixed amount as mentioned in the Policy Schedule to undertake home alteration, if recommended by the home assessor arranged by Us. Coverage under this Rider is available subject to request for assessment received within 24 months post-delivery. However, under this benefit claim will be paid only once in the policy lifetime for similar type of modification recommended by our assessor.

This benefit becomes payable only if a claim is admissible under Maternity Cover under the base Policy.

Sum Insured (₹)	Less than 20 Lacs	20 Lacs – 50 Lacs	More than 50 Lacs
Home Assessment and Modification for Baby Care/Infant Care (₹)	Upto 5,000	Upto 8,000	Upto 10,000

R5. Personalized Health Care Manager:

In consideration of additional premium paid, We/Our empanelled service provider will offer telephonic assistance of a personalized health care manager, who will assist in booking appointments of the Insured Person and coordinating with providers for below listed services in India, as per Insured Person’s requirement.

Personalized Health Care Manager shall only be responsible for booking and coordination on call, whereas, booking fees, cost of items or service charges, if any, shall be borne by the Insured Person. Coverage under this benefit will be subject to below conditions:

1. Services of Personalized Health Care Manager will be available only during the Post Hospitalization period after a claim.
2. A Hospitalization claim under the base Policy is admissible by Us for medically necessary surgery under In-Patient Treatment and Day Care Treatments/Procedures cover of the base Policy.

Personalized Health Care Manager will help in arranging and coordinating below services:

• Assistance on availing consultations, booking screening test etc.
• Appointment at Hospital / Diagnostic Center
• Claim Assistance
• Ambulance Booking
• Vaccination Appointment
• Availing any Home Care Services

R6. Loss of Pay – Bereavement:

In consideration of additional premium paid and in case of death of an immediate family member (spouse/ child/ parent, covered under the base Policy), due to an accident or illness, requires leave by one of the Insured Persons from work which results in Leave Without Pay (LWP), We will pay a daily cash benefit towards loss of pay as specified in the Policy Schedule. The claim under this cover is payable subject to the following condition:

1. Bereavement leave is availed within first thirty days from the death of the immediate family member (spouse/child/parent);
2. The Insured Person has suffered loss of pay for the bereavement leave availed;
3. Daily cash (Fixed pay(₹) 800 per day) under this cover is payable only within first thirty days from the death of the immediate family member (spouse/child/parent) and for a maximum of up to thirty days.

Disclaimers:

1. Any service under this Rider will only be provided on the request of the insured person through our empanelled service providers on cashless basis only.
2. Availing the services under this Rider is upon the Insured Person’s sole discretion and risk.
3. For services that are provided through empanelled Service Providers, we are acting as a facilitator; hence 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.
4. We shall not be responsible for or liable for, any action, claim, demand, loss, damage, cost, 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/network provider under this Policy.
5. Insured Person may consult any medical/service professional at any network provider/empanelled service provider at his/her sole discretion. The cost of service arising out of insured Person choice of medical professional at any network provider/empanelled service provider shall be completely 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.
6. The Medical/service 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.
7. The Insured Person is free to choose whether or not to act on the recommendation after seeking consultation.
8. Any advice, recommendation or suggestion made by any medical/service professional shall be solely based on the information and documentation provided by the Insured Person to such medical/service 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/service professional from whom we have availed services or taken benefit or for any consequence of any act or omission in reliance thereon.
9. 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.
10. 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).
11. Any service availed by the Insured Person under these Benefits will not impact Cumulative Bonus under the Base Policy, if applicable.
12. We reserve the right to change any service provider during the currency of the Policy or at renewal. The same shall be intimated to the Insured Person atleast 15 days prior to the effective date of change. During such change, all the credits earned by the insured Person shall be transferred to the new service provider.
13. In case We or the Assistance/empanelled 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/empanelled Service Provider shall have no liability whatsoever including but not limited to any loss or damage resulting therefrom
14. 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.
15. The above-mentioned assistance services, as applicable, are purely on referral or arrangement basis, We/Our empanelled service provider shall not be responsible for any third-party expenses incurred and it shall be the responsibility of the Insured Person.

3. Pocket Saver (upto 10%)(UIN:TATHLIA25035V012425)

Section 1:

1. Suitability:

• This Policy can be issued to an individual and/or family. However, in case of family, the coverage shall be available on individual basis only.
• All the other eligibility conditions, entry age limits, relationships covered under this Rider will be applicable as per the base Policy.
• Minimum one benefit from the Rider has to be opted by the Policyholder.

2. Rider Conditions:

• Rider can only be opted along with the base Policy and cannot be opted in isolation or as a separate product.
• The Riders are provided in lieu of additional premium and subject to the terms, conditions and exclusions as stated in the Rider wordings in addition to the Policy terms, conditions and exclusions.
• These Rider(s), if selected, shall be mentioned in the Policy Schedule and will be available up to the limit specified therein, for all Insured Person(s) covered under the underlying base Policy, unless stated otherwise.
• Terms and conditions of the Riders are to be read in conjunction with the terms and conditions of the base Policy.
• The continuance of risk cover under the base Policy is necessary precondition for continuance of cover under Riders.
• The scope of coverage under these Riders are restricted to the geography of India.
• Admission of liability under any cover in this Rider shall not have any bearing on admissibility of a claim under the base Policy on any ground including non-disclosure of material fact or pre-existing disease.
• Coverage under this Rider shall only be offered if prescribed by the treating Medical Practitioner except for doctor consultations.
• Coverage/Services under this Rider can be availed only during the Policy Period, subject to the condition that the Insured Person contracts any disease or suffers from any illness or sustains bodily injury through accident, within the Policy Period.
• Benefits under this Rider have separate limits (over and above the base Sum Insured), as specified in the Policy Schedule, and does not affect Cumulative Bonus in the base Policy, if applicable.

Section 2: General Definitions

All Standard and Specific Definitions as defined in the respective base Policy shall also apply for Riders, wherever applicable.

Additional Specific Definitions:

1. Health Care Professional:

A Health Care 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.

2. Service Provider:

Service Provider means the providers empanelled and engaged by Us for arranging/providing services under Riders mentioned in the base Policy Schedule.

Section 3: Rider Benefit

At least one benefit has to be opted to avail.

R1. Out-patient Treatment and Consultation:

In consideration of additional premium paid, We will cover the Reasonable and Customary Charges for in-person consultations and diagnostic tests subject to below conditions:

1. The Insured Person is suffering from any illness or injury and is not availing the services for preventive consultations;
2. Diagnostic test is prescribed by the treating Medical Practitioner.

R2. Out-patient Treatment – Dental:

In consideration of additional premium paid, We will cover:

1. Reasonable and Customary Charges for expenses related to in-person consultations with Dental Specialist on an Out-patient basis.
2. Reasonable and Customary Charges for expenses related to following dental treatments/procedures as prescribed by the treating Medical Practitioner and availed by the Insured Person, subject to limits and waiting period as specified in the Policy Schedule.
   • Root Canal Treatment (Single or multiple sittings)
   • Tooth Extraction(s)
   • Restoration/Filling
   • All Forms of Dental X-ray
   • Crown
   • Pulpectomy
   • Therapeutic Pulpotomy

In view of this coverage getting extended, dental exclusion (Dental treatment or surgery of any kind) of the base Policy will not be applicable for this particular Rider.

In case of Accidental Damage to natural teeth following the accident, the claim under this Rider will be admissible only if the treatment for the same shall be taken immediately within thirty (30) days following damage.

The claim under this Rider shall not be payable:

• If the damage was caused as a result of consumption of pan masala, gutka, tambaku, alcohol, or any substance use/abuse;
• Towards scaling/polishing, bleaching, cap of teeth, braces, aligner, tooth replacement or any other cosmetic or aesthetic treatment.

R3. OPD – Vision Care:

In consideration of additional premium paid, We will cover:

i. Reasonable and Customary Charges for expenses related to in person consultations with Ophthalmologist on an Out-patient basis, including Medically necessary procedures and Medically Prescribed diagnostic tests associated to eye/vision, subject to limits and waiting period as specified in the Policy Schedule.

ii. Reasonable and Customary Charges for corrective spectacle lenses as prescribed by the Ophthalmologist or Optometrist once after every block of two continuous Policy Year with Us under this Rider, irrespective of claim in the base Policy.

This cover excludes cost of tinted / reactive lenses, sunglasses, non-corrective contact lenses, and/or similar expenses, whether medically prescribed or not, under this cover.

R4. OPD – Pharmacy:

In consideration of additional premium paid, We will cover the Reasonable and Customary Charges for expenses related to purchase of medicines, drugs and medical consumables, as prescribed by the treating Medical Practitioner under the following cover(s) and availed by the Insured Person on an Out-patient basis.

1. Out-patient Treatment and Consultation
2. Out-patient Treatment – Dental
3. OPD – Vision Care
4. Teleconsultation – General
5. Teleconsultation – Specialty

Under this cover, amount for below listed products shall be restricted to 50% of the OPD Pharmacy Sum Insured, as specified in the Policy Schedule:

• Health supplements,
• Nutraceuticals,
• Foods for special dietary use/special medical purpose/ with added probiotics and/or foods with added prebiotics,
• Vaccinations,
• Vitamins, tonics or other related products.

For the purpose of this Benefit, the exclusion mentioned under Code-Excl 14 (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) shall not be applicable.

R5. High End Diagnostics Rider:

In consideration of additional premium paid, We will cover for the Reasonable and Customary Charges incurred for the following diagnostic tests only on OPD basis if required as part of a medically necessary treatment subject to the limits as specified in the Policy Schedule:

1. Brain Perfusion Imaging
2. Computed Tomography (CT) Guided Biopsy
3. Computed Tomography (CT) Urography
4. Digital Subtraction Angiography (DSA)
5. Liver Biopsy
6. Magnetic Resonance Cholangiography Scan
7. Positron Emission Tomography Computed Tomography (PET CT)
8. Positron Emission Tomography Magnetic Resonance Imaging (PET MRI)
9. Renogram

R6. OPD Physiotherapy:

In consideration of additional premium paid, We/Our empanelled service provider will arrange for physiotherapy sessions from qualified Physiotherapist to treat illness/injury or deformity suffered by the Insured Person during the Policy Period, on an Out-patient basis, subject to the following conditions:

• Physiotherapy being advised in writing by the treating Medical Practitioner.
• The limit on physiotherapy sessions is applicable to each Insured Person, per Policy Year.

R7. Teleconsultation – General Rider:

In consideration of additional premium paid, 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, as per the limit specified in Your base Policy Schedule.

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.

R8. Teleconsultation – Specialty Rider:

In consideration of additional premium paid, 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 & specialist Medical Practitioner/Health Care Professional, as per the limit/ speciality specified in your Policy Schedule.

This service can only be availed subject to conditions 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.

R9. Medical Devices Cover Rider:

In consideration of additional premium paid, We will cover reasonable and customary expenses incurred by the Insured Person towards renting or purchase of below mentioned medical devices during the Policy Year only if the same is prescribed by the treating Medical Practitioner under OPD Consultation , where OPD Consultation is admissible under the Out-patient treatment Rider.

List of medical devices:

1. Wheel Chair
2. Air Mattress
3. Walker
4. Belts
5. Collar
6. Caps
7. Splints
8. Braces
9. Stockings
10. Crutches
11. Commode Chair
12. Walking Stick

The benefit to the extent covered here shall supersede the exclusion for external appliance and/or device (“Any external appliance and/or device used for diagnosis or treatment except when used intra-operatively”) mentioned in the base Policy.

Section 4 – 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.

A. Standard Exclusions:

1. Exclusions with Waiting Periods:

a. 30 Days Waiting Period (Code-Excl 03):

• 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.
• This exclusion shall not, however, apply if the Insured Person has Continuous Coverage for more than twelve months.
• The within referred waiting period is made applicable to the enhanced Sum Insured in the event of granting higher Sum Insured subsequently.

b. Pre-Existing Diseases Waiting Period (Code-Excl 01):

• Expenses related to the treatment of a Pre-Existing Disease (PED) and its direct complications shall be excluded until the expiry of months of continuous coverage as mentioned in the Policy Schedule after the date of inception of the first Policy with us.
• In case of enhancement of Sum Insured/change of plan/ the Exclusion shall apply afresh to the extent of Sum Insured increase.
• If the Insured Person is continuously covered without any break as defined under the portability norms of the extant IRDAI Regulations, then Waiting Period for the same would be reduced to the extent of prior coverage.
• Coverage under the Policy after the expiry of months as mentioned in the Policy Schedule for any Pre-Existing disease is subject to the same being declared at the time of application and accepted by us.

B. General 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.

2. Medical Exclusions:

• Change-of-Gender Treatments (Code-Excl 07):

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

• Cosmetic or Plastic Surgery (Code-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 Person. For this to be considered a medical necessity, it must be certified by the attending Medical Practitioner.

• Treatment for, Alcoholism, drug or substance abuse or any addictive condition and consequences thereof (Code-Excl 12).
• Treatments received in health 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-Excl 13).
• 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-Excl 14).
• 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.

• Sterility and Infertility (Code-Excl 17):

Expenses related to Sterility and Infertility. This includes:

1. Any type of contraception, sterilization
2. Assisted Reproduction services including artificial insemination and advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI
3. Gestational Surrogacy
4. Reversal of Sterilization

• Maternity (Code-Excl 18):

1. Medical treatment expenses traceable to childbirth (including complicated deliveries and caesarean sections incurred during Hospitalization) except ectopic pregnancy;
2. Expenses towards miscarriage (unless due to an Accident) and lawful medical termination of pregnancy during the Policy Period.

3. Non-Medical Exclusions:

• 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.
• 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.

Specific Exclusions (Exclusions other than as those mentioned under Section 4 (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:

1. Alcoholic pancreatitis or alcoholic liver disease;
2. Congenital External Diseases, defects or anomalies;
3. Venereal disease, sexually transmitted disease or Illness;
4. Any existing disease specifically mentioned as Permanent exclusion in the Policy Schedule.
5. Circumcision unless necessary for treatment of an Illness or as may be necessitated due to an Accident.
6. Hydrotherapy, Acupuncture, Reflexology, Chiropractic treatment or treatment related to any unrecognized systems of medicine.
7. Expenses related to rest cure, rehabilitation and respite care:
   • Expenses incurred primarily towards enforced bed rest and not for receiving treatment. This also includes:
     • Custodial care either at home or in a nursing facility for personal care such as help with activities of daily living such as bathing, dressing, moving around either by skilled nurses or assistant or non-skilled persons.
     • Any services for people who are terminally ill to address physical, social, emotional and spiritual needs.

2. Non-Medical Exclusions:

1. 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.
2. 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.
3. Any Insured Person’s participation or involvement in naval, military or air force operation.
4. Intentional self-Injury or attempted suicide while sane or insane.
5. Charges for, cosmetics, hygiene articles, body care products and bath additive, barber or beauty service, guest service.
6. Doctor’s/Physiotherapist’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.
7. Any treatment and associated expenses for alopecia, baldness, wigs or toupees, medical supplies including diabetic test strips and similar products.
8. Any treatment or part of a treatment that does not form part of ‘Reasonable and Customary Charges’, nor is medically necessary.
9. Expenses which are either not supported by a prescription of a Medical Practitioner or are not related to Illness/injury or disease.
10. Any external appliance and/or device used for diagnosis or treatment except when used intra-operatively.
11. 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.
12. Any treatment taken in a clinic, rest home, convalescent home for the addicted, detoxification center, sanatorium, home for the aged, remodeling clinic or similar institutions.

Option 1:

Rider Name	Base Sum Insured (In ₹)
	5 Lakhs	7.5 Lakhs	10 Lakhs	15 Lakhs	20 Lakhs	25 Lakhs	50 Lakhs	75 Lakhs	1 Cr	2 Cr	3 Cr
Out-patient Treatment and Consultation (In ₹)	Up to 5,000	Up to 6,000	Up to 8,000	Up to 15,000	Up to 22,000	Up to 25,000	Up to 50,000	Up to 70,000	Up to 1,00,000	Up to 1,00,000	Up to 1,00,000
Out-patient Treatment – Dental (In ₹)	Up to 7,500	Up to 10,000	Up to 15,000	Up to 20,000	Up to 32,000	Up to 50,000	Up to 70,000	Up to 90,000	Up to 1,00,000	Up to 1,00,000	Up to 1,00,000
OPD – Vision Care (In ₹)	Up to 1,500	Up to 2,500	Up to 5,000	Up to 12,000	Up to 12,000	Up to 20,000	Up to 20,000	Up to 25,000	Up to 30,000	Up to 30,000	Up to 30,000
OPD – Pharmacy (In ₹)	Up to 1,000	Up to 1,500	Up to 2,000	Up to 3,000	Up to 4,000	Up to 5,000	Up to 10,000	Up to 15,000	Up to 20,000	Up to 20,000	Up to 20,000
OPD Physiotherapy	Up to 5 Sessions	Up to 5 Sessions	Up to 5 Sessions	Up to 10 Sessions	Up to 10 Sessions	Up to 10 Sessions	Up to 10 Sessions	Up to 10 Sessions	Up to 20 Sessions	Up to 20 Sessions	Up to 20 Sessions
High End Diagnostics Rider (In ₹)	Up to 10,000	Up to 10,000	Up to 10,000	Up to 25,000	Up to 25,000	Up to 25,000	Up to 25,000	Up to 50,000	Up to 50,000	Up to 50,000	Up to 50,000
Medical Devices Cover Rider (In ₹)	Up to 5,000	Up to 5,000	Up to 5,000	Up to 10,000	Up to 10,000	Up to 10,000	Up to 10,000	Up to 20,000	Up to 20,000	Up to 20,000	Up to 20,000
Teleconsult- ation – General Rider	Unlimited
Teleconsult- ation – Specialty Rider	Unlimited

Option 2:

Rider Name	Base Sum Insured (In ₹)
	5 Lakhs	7.5 Lakhs	10 Lakhs	15 Lakhs	20 Lakhs	25 Lakhs	50 Lakhs	75 Lakhs	1 Cr	2 Cr	3 Cr
Out-patient Treatment and Consultation (In ₹)	Up to 2,500	Up to 3,750	Up to 4,000	Up to 6,500	Up to 8,500	Up to 12,500	Up to 25,000	Up to 37,500	Up to 50,000	Up to 50,000	Up to 50,000
Out-patient Treatment – Dental (In ₹)	Up to 3,500	Up to 5,000	Up to 8,000	Up to 10,000	Up to 17,500	Up to 25,000	Up to 40,000	Up to 50,000	Up to 50,000	Up to 50,000	Up to 50,000
OPD – Vision Care (In ₹)	Up to 1,500	Up to 2,500	Up to 5,000	Up to 12,000	Up to 12,000	Up to 20,000	Up to 20,000	Up to 25,000	Up to 30,000	Up to 30,000	Up to 30,000
OPD – Pharmacy (In ₹)	Up to 500	Up to 750	Up to 1,000	Up to 1,500	Up to 2,000	Up to 2,500	Up to 5,000	Up to 7,500	Up to 10,000	Up to 10,000	Up to 10,000
OPD Physiotherapy	Up to 5 Sessions	Up to 5 Sessions	Up to 5 Sessions	Up to 10 Sessions	Up to 10 Sessions	Up to 10 Sessions	Up to 10 Sessions	Up to 10 Sessions	Up to 20 Sessions	Up to 20 Sessions	Up to 20 Sessions
High End Diagnostics Rider (In ₹)	Up to 10,000	Up to 10,000	Up to 10,000	Up to 25,000	Up to 25,000	Up to 25,000	Up to 25,000	Up to 50,000	Up to 50,000	Up to 50,000	Up to 50,000
Medical Devices Cover Rider (In ₹)	Up to 5,000	Up to 5,000	Up to 5,000	Up to 10,000	Up to 10,000	Up to 10,000	Up to 10,000	Up to 20,000	Up to 20,000	Up to 20,000	Up to 20,000
Teleconsult- ation – General Rider	Unlimited
Teleconsult- ation – Specialty Rider	Unlimited

Section 5: Process for Availing the Benefits

Step 1: Register Yourself on Customer Application

Please download TATA AIG customer application on your device and complete registration process by providing Policy and Insured Person’s details.

Link to download TATA AIG Customer Application:

For Android: https://play.google.com/store/apps/detailsid=com.tataaig.android

For iOS: https://apps.apple.com/in/app/tata-aig-insurance/id1586595850

Step 2: Select the Service Required

Please select the desired service from the list of services available on the Home Page of the application.

Step 3: Please provide the required information and follow the prescribed process for availing the services.

Disclaimers:

1. Any service under this Rider will only be provided on the request of the insured person through our empanelled service providers on cashless basis only.
2. Availing the services under this Rider is upon the Insured Person’s sole discretion and risk.
3. For services that are provided through empanelled Service Providers, we are acting as a facilitator; hence 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.
4. We shall not be responsible for or liable for, any action, claim, demand, loss, damage, cost, 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/network provider under this Policy.
5. Insured Person may consult any medical/service professional at any network provider/empanelled service provider at his/her sole discretion. The cost of service arising out of insured Person choice of medical professional at any network provider/empanelled service provider shall be completely 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.
6. The Medical/service 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.
7. The Insured Person is free to choose whether or not to act on the recommendation after seeking consultation
8. Any advice, recommendation or suggestion made by any medical/service professional shall be solely based on the information and documentation provided by the Insured Person to such medical/service 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/service professional from whom we have availed services or taken benefit or for any consequence of any act or omission in reliance thereon.
9. 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.
10. 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).
11. We reserve the right to change any service provider during the currency of the Policy or at renewal. The same shall be intimated to the Insured Person atleast 15 days prior to the effective date of change. During such change, all the credits earned by the insured Person shall be transferred to the new service provider.
12. In case We or the Assistance/Empanelled 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/Empanelled 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.
14. The above-mentioned assistance services are purely on referral or arrangement basis, We/Our empanelled service provider shall not be responsible for any third-party expenses incurred and it shall be the responsibility of the Insured Person.

4 . Mental well being (Nominal Price) (UIN: TATHLIA25037V012425)

Section 1:

1. Suitability

• This Policy can be issued to an individual and/or family. However, in case of family, the coverage shall be available on individual basis only.
• All the other eligibility conditions, entry age limits, relationships covered under this Rider will be applicable as per the base Policy.
• Minimum one benefit from the Rider has to be opted by the Policyholder.

2. Rider Conditions

• Rider can only be opted along with the base Policy and cannot be opted in isolation or as a separate product.
• The Riders are provided in lieu of additional premium and subject to the terms, conditions and exclusions as stated in the Rider wordings in addition to the Policy terms, conditions and exclusions.
• These Rider(s), if selected, shall be mentioned in the Policy Schedule and will be available up to the limit specified therein, for all Insured Person(s) covered under the underlying base Policy, unless stated otherwise.
• Terms and conditions of the Riders are to be read in conjunction with the terms and conditions of the base Policy.
• The continuance of risk cover under the base Policy is necessary precondition for continuance of cover under Riders.
• The scope of coverage under these Riders are restricted to the geography of India.
• Admission of liability under any cover in this Rider shall not have any bearing on admissibility of a claim under the base Policy on any ground including non-disclosure of material fact or pre-existing disease.
• Coverage/services under this Rider can be availed only during the Policy Period.
• Benefits under this Rider have separate limits (over and above the base Sum Insured), as specified in the Policy Schedule, and does not affect Cumulative Bonus in the base Policy, if applicable.

Section 2: General Definitions

All Standard and Specific Definitions as defined in the respective base Policy shall also apply for Riders, wherever applicable.

Additional Specific Definitions:

1. Health Care Professional:

A Health Care 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

2. Service Provider:

Service Provider means the providers empanelled and engaged by Us for arranging/providing services under Riders mentioned in the base Policy Schedule.

Section 3: Rider Covers

R1. Mental Health Screening

In consideration of additional premium paid, We/Our empanelled service provider will arrange for Mental Health Screening of the Insured Person, once in a Policy Year provided the Policy is in force with us. Such screening shall include:

1. One evaluation with psychiatrist
2. An online questionnaire for personality assessment
3. Below mentioned diagnostic tests, if prescribed by the consulting psychiatrist:
   • Thyroid function Test
   • Liver Function Test
   • Kidney Function Test
   • ECG
   • Serum Electrolyte Test
   • Blood Sugar

Once every policy year, only on Cashless basis

R2. Psychological Therapy and Procedures

In consideration of additional premium paid, We/Our empanelled service provider will arrange for psychological therapy/talking therapy session with a registered psychiatric/psychologist for management of mental/behavioural/psychiatric or psychological disorders including but not limited to anxiety, depression, stress, bipolar disorder, substance use/abuse, subject to the below conditions:

1. The  condition  has  been  diagnosed  and  confirmed  by  the  treating  Health  Care Professional/Medical Practitioner.
2. Psychiatric counselling has been prescribed by the treating Medical Practitioner.

Maximum Upto 10 sessions per person with a registered psychiatric/psychologist in a policy year, only on Cashless basis

R3. Vocational Rehabilitation

In consideration of additional premium paid, and notwithstanding the exclusion mentioned under ‘’Rest cure, rehabilitation and respite care (Code- Excl 05)’’ of the base Policy:

If an illness or injury impacts mental health of the Insured Person affecting the career/job performance, then We will cover expenses for vocational rehabilitation of the Insured Person and improve overall mental wellbeing if an illness or injury impacts mental health of the insured person impacting the career/job performance subject to the same being prescribed by the Health Care Professional/Medical Practitioner.

Up to base Sum Insured, Over and above the base Sum Insured, Maximum upto 30 days

R4. Diet Consultation Rider

In consideration of additional premium paid and with an objective of maintaining good health, We/Our empanelled service provider will arrange for a consultation with a nutritionist/dietitian during the Policy Period. if the same has been prescribed by a Mental Health Care Professional during the Policy Period.

Consultation will be provided through various specified modes of communication (including but not limited to) like in person, audio, video, online portal, chat, customer application or any other digital mode.

Maximum Upto 4 sessions per person consultation with a nutritionist/dietitian in a policy year, only on Cashless basis

R5. Stress Management Rider

In consideration of additional premium paid, We/Our empanelled service provider will arrange for consultative services to Insured Person by a Health Care Professional to maintain good health through Stress Management Program including but not limited to sessions on work/life balance, awareness sessions on mental wellbeing, mental health screening and fitness coach.

Consultation will be provided through various specified modes of communication (including but not limited to) like audio, video, online portal, chat, customer application or any other digital mode.

UNLIMITED

R6. Addiction Cessation Program

In consideration of additional premium paid, We/Our empanelled service provider will arrange for consultative services to Insured Person by a Health Care Professional related to controlling substance addiction with the objective of helping quit substance addiction through the cessation program including but not limited to expert counselling, and consultations.

Consultation will be provided through various specified modes of communication (including but not limited to) like audio, video, online portal, chat, customer application or any other digital mode.

UNLIMITED

Cover/ Benefit Name	Coverage Limit
Mental Health Screening	Once every policy year for listed tests, only on Cashless basis
Psychological Therapy and Procedures	Maximum up to 10 sessions per person in a policy year, only on Cashless basis
Diet Consultation Rider	Maximum up to 4 sessions per person in a policy year, only on Cashless basis
Vocational Rehabilitation	Up to base Sum Insured, Over and above the base Sum Insured, Maximum up to 30 days
Stress Management Rider	Unlimited
Addiction Cessation Program	Unlimited

Terms and Conditions

All the general terms and conditions, waiting periods, exclusions and claim procedure shall be applicable as per the base Policy.

Disclaimers

1. Any service under this Rider will only be provided on the request of the Insured Person through our empanelled Service Providers on cashless basis only.
2. Availing the services under this Rider is upon the Insured Person’s sole discretion and risk.
3. For services that are provided through empanelled Service Providers, we are acting as a facilitator; hence 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.
4. We shall not be responsible for or liable for, any action, claim, demand, loss, damage, cost, 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/Network Provider under this Policy.
5. Insured Person may consult any medical/service professional at any network provider/empanelled Service Provider at his/her sole discretion. The cost of service arising out of Insured Person choice of medical professional at any Network Provider/empanelled Service Provider shall be completely 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.
6. The medical/service 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.
7. The Insured Person is free to choose whether or not to act on the recommendation after seeking consultation.
8. Any advice, recommendation or suggestion made by any medical/service professional shall be solely based on the information and documentation provided by the Insured Person to such medical/service 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/service professional from whom we have availed services or taken benefit or for any consequence of any act or omission in reliance thereon.
9. 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.
10. 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).
11. Any service availed by the Insured Person under these Benefits will not impact Cumulative Bonus under the base policy, if applicable.
12. We reserve the right to change any Service Provider during the currency of the Policy or at renewal. The same shall be intimated to the Insured Person atleast 15 days prior to the effective date of change. During such change, all the credits earned by the Insured Person shall be transferred to the new Service Provider.
13. In case We or the Assistance/empanelled 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/empanelled Service Provider shall have no liability whatsoever including but not limited to any loss or damage resulting therefrom.
14. 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.
15. The above-mentioned assistance services, as applicable are purely on referral or arrangement basis, We/Our empanelled Service Provider shall not be responsible for any third-party expenses incurred and it shall be the responsibility of the Insured Person.

Flexi Shield (UIN: TATHLIA25039V012425)

Section 1:

1. Suitability

• This Policy can be issued to an individual and/or family. However, in case of family, the coverage shall be available on individual basis only.
• All the other eligibility conditions, entry age limits, relationships covered under this Rider will be applicable as per the base Policy.
• Minimum one benefit from the Rider has to be opted by the Policyholder.

2. Rider Conditions

• Rider can only be opted along with the base Policy and cannot be opted in isolation or as a separate product.
• The Riders are provided in lieu of additional premium or discount as applicable and subject to the terms, conditions and exclusions as stated in the Rider wordings in addition to the Policy Terms, Conditions and Exclusions.
• These Rider(s), if selected, shall be mentioned in the Policy Schedule and will be available up to the limit specified therein, for all Insured Person(s) covered under the underlying base Policy, unless stated otherwise.
• Cover(s) provided under this Rider and their limits are only with respect to such and so many as indicated in the Policy Schedule.
• The Rider shall offer coverage subject to below conditions:
  • Terms and conditions of the Rider are to be read in conjunction with the terms and conditions of the base Policy.
  • The continuance of risk cover under the base Policy is necessary precondition for continuance of cover under Rider.
  • The scope of coverage under these Riders are restricted to the geography of India, unless specified otherwise in the respective Rider cover.
  • Admission of liability under any Rider shall not have any bearing on admissibility of a claim under the base Policy on any ground including non-disclosure of material fact or Pre-Existing Disease.

Section 2: General Definitions

All Standard and Specific Definitions as defined in the respective base Policy shall also apply for Riders, wherever applicable.

Additional Specific Definitions:

1. Health Care Professional:

A Health Care 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.

2. Service Provider:

Service Provider means the providers empanelled and engaged by Us for arranging/providing services under Riders mentioned in the base Policy Schedule. The name, address and contact particulars of such service providers shall be specified by Us in the base Policy Schedule.

R13 .Voluntary Aggregate Deductible ( 25% – 30% Discount)

In consideration of premium discount availed by You, Our liability under the base Policy shall be subject to Aggregate Deductible as specified (Eg: 50,000 )in the Policy Schedule.

Voluntary Aggregate Deductible, if opted and as specified in the Policy Schedule, shall be applicable on aggregate of final assessed amount of all admissible claims in a Policy Year.

In case of multi-year base Policy (i.e. tenure more than 1 year), such Aggregate Deductible would be applicable per Policy Year.

Aggregate Deductible shall continue for all the subsequent Renewals of the base Policy, provided the base Policy is renewed with Us without any break.

Aggregate Deductible shall be applicable for all indemnity claims under following covers of the base Policy, as applicable:

1. In-Patient Treatment,
2. Pre/Post Hospitalization Expenses,
3. Day Care Procedures/Treatments (as applicable),
4. Domiciliary Treatment,
5. Organ Donor,
6. AYUSH Benefit,
7. Consumables Benefit (if Opted under Base Policy or Rider),
8. Global Cover/Global Cover for Planned Hospitalization/Global Cover,
9. Global Cover for Emergency Hospitalization (if opted under Rider)
10. Bariatric Surgery Cover,
11. In-Patient Treatment- Dental,
12. Home Care Treatment Cover (if opted under Rider)
13. Home Physiotherapy

Aggregate Deductible shall not be applicable for any claim under following covers of the base Policy, as applicable:

a. Ambulance Cover/ Road Ambulance Cover
b. Maternity Cover
c. Delivery Complications Cover
d. First year Vaccinations
e. Mental Wellbeing Rider
f. Additional Sum Insured for Accidental Hospitalization
g. OPD Rider
h. Any cover under the base Policy or any Rider which has Sum Insured over and above the base
Sum Insured.

For the purpose of this Rider, Aggregate Deductible is an irrevocable cost sharing requirement under this Policy which provides that We will not be liable for a specified amount in aggregate for all claims during the Policy Year.

25,000	50,000	1,00,000
soon Available	Available	soon Available

Accident Suraksha (Nominal Price)

R6. Additional Sum Insured for Accidental Hospitalization

In consideration of additional premium paid for this Rider, if the Insured Person suffers an accident during the Policy Period and this accident is the sole and direct cause for the Hospitalization of the Insured Person, then We will provide an additional Sum Insured, as specified in the Policy Schedule against this Rider, for Medical Expenses incurred towards the In-Patient Treatment of the Insured Person during such Hospitalization, subject to the following conditions:

1. For individual as well as family floater policies, this limit is individually available for each Insured Person covered under the Policy.
2. Additional Sum Insured for Accidental Hospitalization, if applicable, shall be utilized before the Sum Insured in the base Policy.
3. Once triggered, the total amount available under this cover shall be available for utilization for In-Patient Hospitalization expenses linked to Accident only, in a Policy Year.
4. Any unutilized ‘Additional Sum Insured for Accidental Hospitalization’, shall not be carried forwarded.
5. The admissibility of claim under this Rider shall be subject to the terms, conditions and exclusions of the base Policy.
6. Specific exclusions applicable to this Rider:

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:

• Where the Insured Person is under the influence of intoxicating liquor or drugs or other intoxicants, except where the Insured Person is not directly responsible for the injury/accident though under influence of intoxication.
• Insured Person committing or attempting to commit an illegal activity or violation of law.

• Upto base Sum Insured;
• Over and above the base sum insured
• For individual as well as family floater policies, this limit is individually available for each insured person covered under the policy.

R36. Permanent Total Disability Benefit Rider

In consideration of additional premium paid, if an Insured Person suffers an Accident during the Policy Period and this accidental injury results in You suffering Permanent Total Disability, then We will pay the 100% of the Sum Insured as mentioned under this Rider against the respective Insured Person in the Policy Schedule provided:

• The Functional Loss is within 365 days from the date of Accident which caused the Injury.
• This clause is however not applicable for immediate Dismemberment cases.
• Permanent Total Disability is certified by a Medical Practitioner and has continued for a period of 365 days and is total, continuous and permanent at the end of this period.

For the purpose of this cover, Permanent Total Disability shall mean either of the following:
• Loss of sight of both eyes
• Loss by physical Separation or ability to use both hands or both feet
• Loss by physical Separation or ability to use one hand and one foot.
• Loss of sight of one eye and the physical separation of or the loss of ability to use either one hand or one foot.

With respect to the above, loss means physical separation of the body part, or the total loss of functional use provided this has continued for at least twelve (12) months from the onset of such disablement and provided further that We are satisfied based on a written confirmation by a Medical Practitioner at the expiry of the twelve (12) months that there is no reasonable medical hope of improvement.

Specific conditions applicable to this benefit:
• Once a claim has been accepted and 100% of the Sum Insured as specified in the Policy Schedule has been paid under this Rider, then this Rider shall immediately and automatically cease in respect of that Insured Person.
• This benefit is not applicable for Insured Children or Insured Person less than 18 years of Age as on base Policy commencement date.
• This benefit has a separate limit (over and above base Sum Insured).

Specific Exclusions applicable to this Rider
This Rider does not provide benefits for any loss resulting from:
i. An accident that do not occur within the Policy Period
II. Ionizing radiation or contamination by radioactivity from any nuclear waste from combustion of nuclear fuel; or the radioactive, toxic, explosive or other hazardous properties of any explosion nuclear assembly or nuclear component, thereof
iii. Asbestosis (ఊపిరి తిత్తులలో సంభవించు జబ్బు) or other related sickness or disease resulting from the existence, production, handling, processing, manufacture, sale, distribution of asbestos or other products thereof.
iv. Participation in any Professional Sports which remunerates in excess of 50% of the Insured
Person‘s annual income as a means of their livelihood
v. Being under the influence of intoxicating liquor or drugs or other intoxicants except where the
insured is not directly responsible for the injury / accident though under influence of intoxication
vi. Whilst engaging in Adventure Sports, where Adventure Sports means Recreational activities
perceived as involving a high degree of risk. These activities involve speed, height, a high level of
physical exertion, and highly specialized gear.
vii. Whilst engaging in aviation or ballooning, whilst mounting into, dismounting from or traveling in any balloon or aircraft other than as a passenger (fare paying or otherwise) in any duly licensed standard type of aircraft anywhere in the world
viii. Infections (except pyogenic infections which shall occur through an Accidental cut or wound) or any other kind of Disease;
ix. Insured Person committing or attempting to commit an illegal activity or violation of law

Claim Documentation
a. Completed Claim Form.
b. Competent Medical Authority / Doctor like Civil Surgeon, confirming the Disability percentage /
period and prognosis for Permanent Total Disability.
c. Self-attested copy of FIR, if filed / Police Panchnama, if conducted.
d. Self-attested copy of Discharge Summary or all Medical records Self-attested copy of news paper
cutting, if any.
e. Self-attested copy of KYC documents with NEFT details of nominee and KYC form.

• 100% of the Sum Insured or (₹)50,00,000 whichever is lower
• This benefit is not applicable for insured children or Insured Person less than 18 years of Age as on base Policy commencement date.
• Once in a lifetime of an Insured Person.
• Over and above the base sum insured.
• For individual as well as family floater policies, this limit is individually available for each insured person covered under the policy.

R8. Advanced Cover ( 35% – 40% loading)

In consideration of additional premium paid for this Rider, the Pre-Existing Disease Waiting Period as applicable under the base Policy should be read as “30 days” under Pre-existing Diseases Waiting Period (Code- Excl 01) for the Insured Person(s) specified in the Policy Schedule for the following named Pre-Existing Diseases only:

1. Diabetes Mellitus (Type 2),
2. Hypertension,
3. Hyperlipidemia &
4. Asthma

The above substitution shall only be applicable for such specified Insured Person(s) for whom ‘Advanced Cover’ has been opted and additional premium paid, which shall be specified in the base Policy Schedule.

The above would be applicable if the above-named Pre-Existing Diseases have been declared by You for the specific Insured Person for whom this coverage has been opted and the same has been accepted by Us at the time of first coverage under this Policy.

The additional premium charged under this Rider shall be a rate applied on the applicable base Policy premium for that individual at the base Policy inception or on the base Policy renewal date.

In case of portability, the “30 days” as mentioned above should be read as “0 Days” and waiver of waiting period for the above named four illnesses shall be restricted to the lower of the expiring Sum Insured or opted Sum Insured under this Policy, provided the above-named Pre-Existing Diseases had been declared by You at the time of applying for the first Policy and mentioned as accepted under the expiring ported/Our Policy.

If this Rider is availed, then it has to be mandatorily opted for all Insured Persons who have any of the above mentioned Pre-Existing Disease.

R10. Restore Infinity Plus (Inbuilt)

We will provide reinstatement of sum insured unlimited number of times during a Policy Year post exhaustion of the Restore Benefit.

In consideration of additional premium paid, notwithstanding the Restore Benefit/Restore Infinity Cover (if applicable) under the base Policy, We will provide reinstatement of base Policy Sum Insured, if the Sum Insured and Cumulative Bonus or 5X Supercharge Bonus or Supercharge Bonus or Inflation Protect or Carry Forward of Unutilized Sum Insured (if applicable) is insufficient to pay an admissible Hospitalization claim in the underlying base Policy. The reinstatement will be available for unlimited number of times during a Policy Year, subject to below conditions:

This benefit shall not be available for the first admissible Hospitalization / Domiciliary Hospitalization claim in each Policy Year.

1. This benefit shall not be available for the first admissible Hospitalization / Domiciliary Hospitalization Claim in each Policy Year. The Sum Insured will be restored for the subsequent claim in the Policy Year.
2. In case of Family Floater Policy, Reinstatement of Sum Insured will be available for all Insured Persons in the Policy on floater basis.
3. The unutilized restored Sum Insured cannot be carried forward to the next Policy Year.
4. This benefit shall also be applicable annually for policies with tenure of more than 1 year.
5. Any restored Sum Insured can only be utilized for an admissible claim under following indemnity covers of the base Policy, as applicable:
   • In-Patient Treatment,
   • Pre/Post Hospitalization Expenses,
   • Day Care Treatment/Day Care Procedure,
   • Domiciliary Treatment,
   • Organ Donor,
   • AYUSH Benefit,
   • Ambulance Cover / Road Ambulance cover,
   • Consumables Benefit,
   • Bariatric Surgery Cover
   • In-Patient Treatment- Dental
6. Any restored Sum Insured under this benefit cannot be utilized for an admissible claim under:
   • Any cover other than the ones mentioned in the above section or
   • Any cover under the base Policy/Rider which has Sum Insured over and above the base Sum Insured.
7. Our maximum liability in aggregate of all claims arising out of a single Hospitalization shall not exceed the Sum Insured of the underlying base Policy.

• Unlimited Restoration for related & unrelated Illness/Injury;(Even BEFORE 45 days from preceding Hospitalization)
• Upto Base Sum Insured
• In case of Family Floater policy, Our maximum liability in aggregate of all claims arising out of a single Hospitalization shall not exceed the Sum Insured.
• NOEXCLUSION for Cancer Treatment & Dialysis

R5. Inflation Protect (Inbuilt)

In consideration of additional premium paid for this Rider We will provide an additional increase in the Sum Insured on the basis of inflation rate (all India) in the previous calendar year for next Policy Year, irrespective of claims in preceding Policy Years, provided that:

• The Policy is renewed with Us and without a break.
• In policies with a tenure of more than one year, Inflation Protect shall accrue post completion of each Policy Year.
• The inflation rate shall be applied on the base Policy Sum Insured of the expiring Policy. In case the Sum Insured under the Policy is reduced at the time of Renewal then the accrued Inflation Protect under this benefit shall be reduced in proportion to the reduced Sum Insured.
• Unutilized accrued Inflation Protect amount will get carried forward to the next Policy Year provided the Policy is renewed with Us without any break.
• If this Rider is not renewed before Policy expiry (including the Grace Period) then all the accrued and carried forward Inflation Protect amount shall lapse.
• Any accrued Inflation Protect amount shall be utilized after the Sum Insured in the base Policy is exhausted.
• For Floater policies, the accrued Inflation Protect amount shall be available on a floater basis for all Insured Persons, who were covered under the expiring Policy, on a per Policy Year basis

• Additional increase in the sum insured on the basis of inflation rate (all India) in the
  previous calendar year for next policy year.
• Increase as per the average consumer price index (CPI)

Illustration 1: Sum Insured same for subsequent Policy Year.

Base Policy Year	1st Year	2nd Year	3rd Year	4th Year	5th Year
Base Policy Sum Insured	10 Lakhs	10 Lakhs	10 Lakhs	10 Lakhs	10 Lakhs
Inflation Rate	6%	7%	8%	7%	7%
Inflation Protect Amount	60,000	70,000	80,000	70,000	70,000
Total Sum Insured	–	10,60,000	11,30,000	12,10,000	12,80,000

Illustration 2: Sum Insured Enhancement in subsequent Policy Year.

Base Policy Year	1st Year	2nd Year	3rd Year	4th Year	5th Year
Base Policy Sum Insured	10 Lakhs	10 Lakhs	20 Lakhs	20 Lakhs	20 Lakhs
Inflation Rate	6%	7%	8%	7%	7%
Inflation Protect Amount	60,000	70,000	1,60,000	1,40,000	1,40,000
Total Sum Insured	–	10,60,000	21,30,000	22,90,000	24,30,000

Illustration 3: Sum Insured reduction in subsequent Policy Year.

Base Policy Year	1st Year	2nd Year	3rd Year	4th Year	5th Year
Base Policy Sum Insured	10 Lakhs	10 Lakhs	10 Lakhs	5 Lakhs	5 Lakhs
Inflation Rate	6%	7%	8%	7%	7%
Inflation Protect Amount	60,000	70,000	80,000	35,000	35,000
Total Sum Insured	–	10,60,000	11,30,000	6,05,000 (50% * {80K + 130K})	6,40,000

Illustration 4: Rider not Renewed.

Base Policy Year

1st Year

2nd Year

3rd Year

4th Year

5th Year (Rider not Renewed at the end of 4th Policy Year)

Base Policy Sum Insured	10 Lakhs	10 Lakhs	10 Lakhs	10 Lakhs	10 Lakhs
Inflation Rate	6%	7%	8%	7%	7%
Inflation Protect Amount	60,000	70,000	80,000	70,000	– (Total amount Lapse)
Total Sum Insured	–	10,60,000	11,30,000	12,10,000	10,00,000

For the purpose of this cover, the inflation would be computed as the change in average CPI of the entire calendar year published by the National Statistical Office (NSO), Ministry of Statistics and Program Implementation. The average CPI of the previous calendar year shall be applicable only after three months of the release of the CPI of the last month of the previous calendar year. In case inflation rate of previous calendar year is not available then the inflation rate available for penultimate (Last) calendar year shall be considered.

R4. Cumulative Bonus Shield (now available only for Zone C for new & port)

In consideration of additional premium paid for this Rider the Cumulative Bonus accrued under the base Policy shall not be reduced at renewals subject to the total amount of all claims made in a Policy Year, under the base Policy which impacts Cumulative Bonus under the respective base Policy, does not exceed the specified limit in the Policy Schedule for this Rider.

However, if total claims paid in the base Policy for benefits which impacts Cumulative Bonus under the respective base Policy in a Policy Year exceeds the specified limit for this Rider, then the Cumulative Bonus shall reduce at a rate as defined in the base Policy.

In policies with a tenure of more than one year, the above provisions of Cumulative Bonus Shield shall be applicable post completion of each Policy Year.

All other terms and conditions applicable to the Cumulative Bonus of base Policy shall also be applicable to this Rider.

• Cumulative Bonus accrued under the base Policy shall not be reduced, If total amount of all claims made in a Policy year does not exceed 50,000/ 75,000/ 1,00,000 (₹)
• NO IMPACT on Cumulative Bonus for small claims

11. Global Suraksha (available only for Port)

Fixed daily cash amount, subject to deductible of 2 days for each continuous and completed period of 24 hours of Hospitalization, if an Insured Person avails treatment outside India, during the Policy Period maximum up to 30 days of hospitalization. TAGIC will provide You a second medical opinion from Our empaneled service provider or Medical Practitioner located worldwide outside India, if an Insured Person is diagnosed with the listed Illnesses during the Policy Period.

R3. International Second Opinion

In consideration of additional premium paid for this Rider, We will provide You at your request a second medical opinion from Our Network Provider/empanelled Service Provider or Medical Practitioner located worldwide outside India, 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.

1. Cancer
2. Kidney Failure
3. Myocardial Infarction
4. Angina
5. Coronary Bypass Surgery
6. Stroke/Cerebral Hemorrhage
7. Organ failure requiring transplant
8. Heart Valve Replacement
9. Brain Tumors
10. End stage Lung Disease
11. End stage Liver Failure
12. Bone Marrow Transplant
13. Permanent Paralysis of Limbs
14. Motor Neuron Disease
15. Parkinson’s Disease

This benefit can be availed by an Insured Person once for each Illness in a Policy Year.

Once for each illness mentioned for each insured in a policy year

At our empanelled service provider

R38. Worldwide Hospital Cash Benefit Rider

In consideration of additional premium paid if an Insured Person avails treatment outside India, during the Policy Period, We will pay a fixed daily cash amount, subject to deductible (number of days) as specified in the Policy Schedule, for each continuous and completed period of 24 hours of Hospitalization provided that:

1. The In-Patient Hospitalization claim is admissible under Global Cover for Planned Hospitalization/Global Cover (as applicable in the base Policy), for the same Hospitalization.
2. This benefit will be available up to the number of days specified in the Policy Schedule.
3. On the day of discharge, when Insured Person is discharged before completion of consecutive 24 hours of Hospitalization but after the completion of 12 hours, We shall pay 50% of daily cash benefit.
4. This benefit has a separate limit (over and above base Sum Insured).

• For In-patient Hospitalization claim is admissible under Global Cover for Planned Hospitalization/Global Cover (as applicable in the base policy).
• After the completion of 12 hours, we shall pay 50% of daily cash benefit
• This benefit has a separate limit (over and above base Sum Insured)
• This limit is individually available for each insured person covered under the policy.

12. Premier with Plus

60L = 10L Medicare Premier + 50L Medicare Plus

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FAQ:

1. How to claim the tax benefit? How much are the limits and who can claim the benefit?

You can claim tax deduction u/s 80 D of Income Tax Act for premium paid towards health insurance as per the limit below

• For Self and Family (All members below 60 years), the maximum amount that can be saved under section 80D is ₹25,000
• For Self and Family + Parents (All members below 60 years), the maximum amount that can be saved under section 80D is ₹50,000 (₹25,000+₹25,000)
• For Self and Family (all members below 60 years) with Senior Citizen Parents, the maximum amount that can be saved under section 80D is ₹75,000 (₹25,000 + ₹50,000)
• For Self and Family (with eldest member above 60 years) with Senior Citizen Parents, the maximum amount that can be saved under section 80D is ₹1,00,000 (₹50,000 + ₹50,000)

2. How do I claim tax benefit if I opt for a 3 year policy?

You can choose to claim the tax benefit either each year or in one go. Ex. If you have paid ₹24,000/- for 3 years, you can claim ₹8,000/- as tax benefit each year or choose to claim the entire ₹24,000/- in one year. 

3. I am already covered in my Company policy, should I still buy another health insurance policy?

We suggest you should because coverage in most corporate health policies is,

• Limited to only ₹2-3 lakhs, which is quite inadequate given high costs of treatment
• Stops immediately in case of a job switch, job loss or retirement
• Is subject to change as per employer’s discretion

Therefore, one must always have a personal health insurance policy to take care of any medical expenses any time.

4. What are the top reasons an insurer can decline a claim?

There are various reasons for which an insurer can decline a claim. Some of them are:

• Non-disclosure : if a person did not completely disclose any past or present medical condition or lifestyle habit, such as smoking or drinking
• Claim Made in Waiting period : Person files a claim even though the waiting period is not over for the particular disease
• Policy in Grace Period : If a person hasn’t renewed the policy before expiry date, policy enters grace period, where insurer isn’t liable to pay claims

5. I am living outside India, how can I buy health insurance?

If you are an NRI, you are eligible to purchase health insurance plan in India and just need proof of residence, IT returns and other related documents for making the purchase. Please note that most of the health insurance policies come with a clause of ‘geographical restrictions’, which indicates that the policy will not cover any expense of the insured outside India. In that case, if you reside in the USA and seek medical supervision, the insurance company in India will not cover you for the expenses incurred.

6. What if multiple members in my family have to make a claim?

We recommend to look for policies providing Unlimited Auto Restoration of Sum Insured, so that in an unfortunate event of multiple members requiring medical care or hospitalization, they can avail the same under the policy.

7. What is the right age to buy health insurance?

One must buy health insurance as young as possible. Here’s why:

• You can get a policy easily since you are fit and fine
• You complete the waiting periods at a young age
• The premiums are very less

8. Will my premium increase next year once I purchase health insurance?

Health insurance premiums are adjusted as per the rising medical costs. Few insurers increase the premium in a block of 5 years, while others increase marginally each year. Hence it is always advisable to go for multi-year policy to get discounts and save more.

9. Can I include my parents, spouse, children and myself in one policy?

Yes, you can include all the above in one health insurance policy. If you would like to include your in-laws in place of parents, you can do that as well. However, considering the age of your parents and their pre-existing health conditions, you should take one policy for them and a separate one for yourself, spouse and children to get the best premium options.

10. What will my policy not cover?

A general list of exclusions from a health insurance policy are as follows:

• Infertility
• Injuries/illnesses that result from illegal activities
• Injuries suffered as a result of engaging in adventure sports
• Addiction treatments
• Dental treatments (unless the dental injury results from an accident)
• Genetic disease/Congenital conditions
• Cosmetic treatments
• Treatment for self-harm
• Alternative therapies

11. Whether Health Insurance is available lifelong once taken a policy?

Health insurance is required to be renewed each year unless you have taken a multi-year plan in which case the policy needs to be renewed at the end of last year to keep getting all the benefits and continued coverage.

12. What are disease-wise sub limits?

When the insurer puts limits or restrictions on a particular set of illnesses in your health insurance policy, it is referred to as putting sub limits. In case of any claims arising in such a case, only the amount up to the limit will be paid by the insurer for that particular illness. The remaining, if any, needs to be paid by you. Therefore, look for plans that do not have any sublimits. 

13. What is unlimited restoration?

There are also some plans which can be restored unlimited times in the policy year So, it is always advisable to check with your health insurer before opting for this benefit. For most health insurers, the total sum insured is restored only if the entire sum insured is exhausted under a single claim.

14. Are Alternative treatments covered?

A health insurance plan that covers treatment through alternative medicines such as Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy is known as AYUSH cover. It varies from insurer to insurer and mostly offered in comprehensive policies.