Policy Wordings

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 contained in the Proposal signed by the Policyholder (You) 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.

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

Your Obligations

Please disclose all pre-existing disease/s or condition/s before buying a policy. Non-disclosure may result in claim not being paid and termination of Your policy.

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 in aggregate 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 individual policy, the sum insured for all or any of the benefits shall be on 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.

Suitability:

Entry Age: Minimum	Child– 91 days (Dependent children between 91 days and 5 years can be insured only when both parents are getting insured.) Adult- 18 years
Entry Age: Maximum	Child– 25 years Adult– 65
Cover Ceasing age	There is no maximum cover ceasing age under this policy.
Policy Term	1 Year/ 2 Years/ 3 Years
Coverage Options	Individual/Family floater
Age of Proposer	18 years or above
Relationships Covered	This policy can be issued to an individual and/or family. The        family    includes spouse and        economically      dependent         children and parents/parents-in-laws. The policy offers coverage on family floater basis. Maximum 7 members of a family are covered in one Individual Plan Policy (Self, spouse, 3 dependent children , 2 parents & 2 parents-in-laws).  Maximum 7 members are covered in one Family Floater Plan policy (Self, spouse, 3 dependent children (Up to the age of 25 Years) , 2 parents & 2 parents-in-law. In case of family floater, where age of the dependent child is crossing 25 years, the child can be covered under a separate policy with eligible continuity benefit.

This policy covers persons in the age group 5 years onwards (Dependent children between 91 days and 5 years can be insured only when both parents are getting insured). The maximum entry age is 65 years which is relaxed subject to following conditions:

a.            Parent/Parents-in-law above the age of 65 years will become eligible for this product provided

i.  the proposer is also an existing policyholder under any other indemnity Health Insurance of company where lives below 65years are covered.

ii.             If under the same proposal lives below age of 65 years are also proposed and get accepted post underwriting

3. Sum Insured options (₹):

• 3 Lacs
• 4 Lacs
•  5 Lacs
• 7.5 Lacs
•  10 Lacs
•  15 Lacs
• 20 Lacs

Zone(s)

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:

a.            Zone A:  Mumbai  including  MMR/  Thane,  Delhi  NCR/Faridabad/Ghaziabad, Ahmedabad, Surat and Baroda

b.            Zone B: Hyderabad, Bengaluru, Kolkata, Indore, Chennai, Chandigarh/ Mohali/ Punchkula/Zirakpur, Pune/Pimpri Chinchwad and Rajkot

c.             Zone C: Rest of India

Note:

i.              No co-payment shall apply due to change in zone and insured person can avail treatment in any of the zones

Co-payment:

10% copayment shall be applicable in case you are admitted in a hospital room where the room category opted is higher than the eligible category as specified in the policy schedule.

Lifelong renewal:

We offer you a lifelong renewal for your policy provided premium is paid without any break. Your premiums will be basis the age, sum insured and plan. Your renewal premium will be basis your age on renewal and there will be no extra loadings based on your individual claim.

The policy is renewable except in the case of established fraud or non-disclosure or misrepresentation by the Insured Person.

Pre-policy medical check-up:

Pre-Policy Check-up at our network may be required based upon the age and/or 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 Checkup.

Pre-policy medical examination gird:

Age(Yrs)/Sum Insured	All Sum Insured Options
Upto age 45	No medicals/No Tele- Medical Examination Report
46 years and above	Tele- Medical Examination Report (TeleMER)

Note: In case of adverse medical declaration, we may call for TeleMER/additional medical tests at our diagnostic centre.

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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Section 1 – Definitions

The terms defined below and at other junctures in the Policy Wording have the meanings ascribed to them wherever they appear in this Policy and, where appropriate, references to the singular include references to the plural; references to the male include the female and references to any statutory enactment include subsequent changes to the same:

i.  Standard Definitions

1. Accident

An accident means sudden, unforeseen and involuntary event caused by external, visible and violent means.

2.  Any one illness

Any one illness means continuous period of illness and includes relapse within 45 days from the date of last consultation with the Hospital/Nursing Home where treatment was taken.

3. AYUSH Day Care Centre

AYUSH Day Care Centre means and includes Community Health Centre (CHC), Primary Health Centre (PHC), Dispensary, Clinic, Polyclinic or any such health centre which is registered with the local authorities, wherever applicable and having facilities for carrying out treatment procedures and medical or surgical/para-surgical interventions or both under the supervision of registered AYUSH Medical Practitioner (s) on day care basis without in-patient services and must comply with all the following criterion:

i. Having qualified registered AYUSH Medical Practitioner(s) in charge;

ii. Having dedicated AYUSH therapy sections as required and/or has equipped operation theatre where surgical procedures are to be carried out;

iii. Maintaining daily records of the patients and making them accessible to the insurance company’s authorized representative.

4. AYUSH Hospital

An AYUSH Hospital is a healthcare facility wherein medical/surgical/para-surgical treatment procedures and interventions are carried out by AYUSH Medical Practitioner(s) comprising of any of the following:

a.            Central or State Government AYUSH Hospital or

b.            Teaching hospital attached to AYUSH college recognized by the Central Government/ Central Council of Indian Medicine/ Central Council for Homeopathy, or

c.             AYUSH Hospital, standalone or co-located with in-patient healthcare facility of any recognized system of medicine, registered with the local authorities, wherever applicable, and is under the supervision of a qualified registered AYUSH Medical Practitioner and must comply with all the following criterion :

i.              Having atleast 5 in-patient beds;

ii.             Having qualified AYUSH Medical Practitioner round the clock;

iii.            Having dedicated AYUSH therapy sections as required and/or has equipped operation theatre where surgical procedures are to be carried out;

iv.           Maintaining daily records of the patients and making them accessible to the insurance company’s authorized representative.

5. AYUSH Treatment

AYUSH treatment refers to the medical and / or hospitalization treatments given under Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy systems.

6. Break in Policy

Break in policy means the period of gap that occurs at the end of the existing policy term/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 terms or condition upon which the insurer’s liability under the policy is conditional upon.

9. Congenital Anomaly:

Congenital Anomaly means a condition which is present since birth, and which is abnormal with reference to form, structure or position.

a) Internal Congenital Anomaly

Congenital anomaly which is not in the visible and accessible parts of the body.

b) External Congenital Anomaly

Congenital anomaly which is in the visible and accessible parts of the body.

10.Co-Payment

Co-payment means a cost sharing requirement under a health insurance policy that provides that the policyholder/insured will bear a specified percentage of the admissible claims amount. A co- payment does not reduce the Sum Insured.

11.  Cumulative Bonus

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

12.   Day Care Centre

A day care centre means any institution established for day care treatment of illness and/or injuries or a medical setup with a hospital and which has been registered with the local authorities, wherever applicable, and is under supervision of a registered and qualified medical practitioner AND must comply with all minimum criterion as under –

i.  has qualified nursing staff under its employment;

ii.  has qualified medical practitioner/s in charge;

iii. has fully equipped operation theatre of its own where surgical procedures are carried out;

iv. maintains daily records of patients and will make these accessible to the insurance company’s authorized personnel.

13. Day Care Treatment

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

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

ii.   which would have otherwise required hospitalization of more than 24 hours.

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

14. Dental Treatment

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

15.Domiciliary Hospitalization

Domiciliary hospitalization means medical treatment for an illness/disease/injury which in the normal course would require care and treatment at a hospital but is actually taken while confined at home under any of the following circumstances:

i.  the condition of the patient is such that he/she is not in a condition to be removed to a hospital, or

ii.  the patient takes treatment at home on account of non-availability of room in a hospital.

16. Grace Period

“Grace period” means the specified period of time, immediately following the premium due date during which premium payment can be made to renew or continue a policy in force without loss of continuity benefits pertaining to waiting periods and coverage of pre-existing diseases.

For single premium payment policies, coverage is not available during the period for which no premium is received. However, If the premium is paid in instalments during the policy period, coverage will be available during the grace period, within the policy period.

The grace period for payment of the premium shall be: fifteen days where premium payment mode is monthly and thirty days in all other cases.

17. Hospital

A hospital means any institution established for in-patient care and day care treatment of illness and/or injuries and which has been registered as a hospital with the local authorities under Clinical Establishments (Registration and Regulation) Act 2010 or under enactments specified under the Schedule of Section 56(1) and the said act Or complies with all minimum criteria as under:

i.              has qualified nursing staff under its employment round the clock;

ii.             has at least 10 in-patient beds in towns having a population of less than 10,00,000 and at least 15 in-patient beds in all other places;

iii.            has qualified medical practitioner(s) in charge round the clock;

iv.           has a fully equipped operation theatre of its own where surgical procedures are carried out;

v.            maintains daily records of patients and makes these accessible to the insurance company’s authorized personnel;

18. Hospitalization

Hospitalization means admission in a Hospital for a minimum period of 24 consecutive ‘In-patient Care’ hours except for specified procedures/ treatments, where such admission could be for a period of less than 24 consecutive hours.

19.  Illness

Illness means a sickness or a disease or pathological condition leading to the impairment of normal physiological function and requires medical treatment.

(a)          Acute condition

Acute condition is a disease, illness or injury that is likely to respond quickly to treatment which aims to return the person to his or her state of health immediately before suffering the disease/ illness/ injury which leads to full recovery

(b)          Chronic condition

A chronic condition is defined as a disease, illness, or injury that has one or more of the following characteristics:

i.              it needs ongoing or long-term monitoring through consultations, examinations, check-ups, and /or tests

ii.             it needs ongoing or long-term control or relief of symptoms

iii.            it requires rehabilitation for the patient or for the patient to be specially trained to cope with it

iv.           it continues indefinitely

v.            it recurs or is likely to recur

20.          Injury

Injury means accidental physical bodily harm excluding illness or disease solely and directly caused by external, violent, visible and evident means which is verified and certified by a Medical Practitioner.

21.          Inpatient Care

Inpatient care means treatment for which the insured person has to stay in a hospital for more than 24 hours for a covered event.

22.          Intensive Care Unit:

Intensive care unit means an identified section, ward or wing of a hospital which is under the constant supervision of a dedicated medical practitioner(s), and which is specially equipped for the continuous monitoring and treatment of patients who are in a critical condition, or require life support facilities and where the level of care and supervision is considerably more sophisticated and intensive than in the ordinary and other wards.

23.          Medical Advice

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

24.          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.

25.          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.

26.          Medically Necessary Treatment

Medically Necessary Treatment means any treatment, tests, medication, or stay in Hospital or part of a stay in Hospital which:

i.              is required for the medical management of the Illness or Injury suffered by the insured;

ii.             must not exceed the level of care necessary to provide safe, adequate and appropriate medical care in scope, duration, or intensity;

iii.            must have been prescribed by a Medical Practitioner;

iv.           must conform to the professional standards widely accepted in international medical practice or by the medical community in India.

27.          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.

28.          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).

29.          Notification of Claim

Non-Network means any Hospital, Day Care Centre or other provider that is not part of the network.

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:

a.            that is/are diagnosed by a physician not more than 36 months prior to the date of commencement of the Policy issued by the Insurer; or

b.            for which Medical Advice or treatment was recommended by, or received from, a physician, not more than 36 months prior to the date of commencement of the Policy.

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:

i.              Such Medical Expenses are incurred for the same condition for which the Insured Person’s Hospitalization was required, and

ii.             The In-patient Hospitalization claim for such Hospitalization is admissible by the Insurance Company.

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:

i.              Such Medical Expenses are for the same condition for which the Insured Person’s Hospitalization was required, and

ii.             The inpatient Hospitalization claim for such Hospitalization is admissible by the insurance company.

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.

General Note: to avoid unnecessary stress better go to network hospitals)

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.

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

41.          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.

42.          Policy

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

43.          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.

44.          Policy Schedule

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

45.          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.

46.          Shared Accommodation

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

Section 2 – Benefits

The following benefits are payable subject to Terms and Conditions of the policy:

B1.In-Patient Treatment

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

Medical expenses directly related to the hospitalization would be payable.

Specific Sub-limit: In-Patient Treatment: Upto Sum Insured

B2.Pre-Hospitalization expenses

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

The benefit is payable if We have admitted a claim under B1 or B4 or B6.

Specific Sub-limit: Pre-Hospitalisation expenses: Upto 60 days, Upto Sum Insured

B3.Post-Hospitalization expenses

We will cover for expenses for Post-Hospitalization consultations, investigations and medicines incurred upto 90 days after discharge from the hospital.

The benefit is payable if We have admitted a claim under B1 or B4 or B6.

Specific Sub-limit: Post-Hospitalisation Expenses: Upto 90 days, Upto Sum Insured

B4.Day Care Procedures

We will cover expenses for listed Day Care Treatment due to disease/illness/Injury during the policy period taken at a hospital or a Day Care Centre. The list of such day care procedures covered is available on our website (www.tataaig.com).

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

Specific Sub-limit: Day   Care  Procedures: Upto    Sum Insured

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:

i.              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

ii.             We have accepted an inpatient Hospitalization claim for the insured member under In Patient Hospitalization Treatment (section B1).

Specific Sub-limit: Organ Donor: Upto Sum Insured

B6.Domiciliary Treatment

We will cover for expenses related to Domiciliary Hospitalization of the insured person if the treatment exceeds beyond three days. The treatment must be for management of an illness and not for enteral feedings or end of life care.

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

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.

Specific Sub-limit: Domiciliary    Treatment:     Upto     Sum Insured

B7.Restore benefits

We will automatically restore the Basic Sum Insured upon exhaustion of the Sum Insured and accrued Cumulative Bonus, during the policy period. An additional amount equivalent to the base Sum Insured will be restored once during the policy period subject to the following conditions:

a.            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.

b.            In case of Family Floater policy, Reinstatement of Sum Insured will be available for all Insured Persons in the Policy on floater basis.

c.             This benefit shall be applicable annually for policies with tenure of more than 1 year.

d.            The unutilized restored sum insured cannot be carried forward. This benefit shall not be applicable for Global Cover (section B13).

B8.          AYUSH Benefit

We will cover Medical Expenses incurred for treatment as In-Patient or Day Care Treatment 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 90 days, subject to AYUSH In-Patient hospitalization or AYUSH day care treatment claim being admissible under this benefit.

Claims under this section shall be assessed as per the applicable insurance guidelines related to AYUSH and benchmark rates as available on Ministry of AYUSH website

(https://ayushnext.ayush.gov.in/site/insurance-guidelines-related-to-ayush).

For your reference, the document has been uploaded on Our website under “Annexure B for AYUSH Benefit” (www.tataaig.com).

Limit for AYUSH Benefit: Upto Sum Insured

B9.Ambulance Cover

We will cover for expenses incurred on transportation of Insured Person in a registered ambulance to a Hospital for admission in case of an Emergency or from one hospital to another hospital for better medical facilities and treatment, subject to Rs. 3000 per Hospitalization.

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

Benefit Specific Sub-limit: Ambulance    Cover Upto    Rs.3000   per Hospitalization.

B10.       Health Checkup

We will cover for expenses for a Preventive Health Check-up upto 1% of previous sum insured subject to a maximum of Rs. 10,000/- per policy. The limit is the maximum per policy and more than one insured can utilize the amount.

The benefit is payable once after block of every two continuous claim free policy years with us. This benefit has a separate limit (over and above base sum insured) and does not affect cumulative bonus.

B11.       Compassionate travel

In the event the Insured Person is Hospitalized 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 expenses must be incurred within India and shall not exceed Rs. 20,000 during a policy year.

This benefit shall be payable if We have accepted an inpatient Hospitalization claim for the insured member under In Patient Hospitalization Treatment (Section B1).

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

We shall require the following additional documents (proof of travel) supporting the claim under this benefit: Boarding Pass, or Railway ticket or any other document to show proof of travel.

limit for Compassionate Travel: Upto ₹20,000 per policy year

B12.       Consumables Benefit

We will pay for expenses incurred, for specified consumables listed in ‘Annexure – 1 List 1 as Optional Items (Consumables Benefit)’ 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 (Consumables Benefit) 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 of this policy.

Consumables     Benefit:     Upto     Sum Insured

B13.       Global Cover

We will cover for Medical Expenses 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 only on reimbursement basis. Cashless facility may be arranged on case to case basis. Insured person can contact us for any claim assistance.

The payment of any claim under this benefit will be in Indian Rupees based on the rate of exchange as on the date of invoice, published by Reserve Bank of India (RBI) 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 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

Global Cover: Upto Sum Insured

B14.  Bariatric Surgery Cover

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

i.              Surgery to be conducted is upon the advice of the Doctor.

ii.             The member has to be 18 years of age or older and

iii.            Body Mass Index (BMI) greater than or equal to 40 or

iv.           BMI greater than or equal to 35 in conjunction with any of the following severe comorbidities following failure of less invasive methods of weight loss:

a.            Obesity-related cardiomyopathy

b.            Coronary heart disease

c.             Severe sleep apnea

d.            Uncontrolled Type2 Diabetes

Bariatric Surgery Cover: Upto Sum Insured

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.

In-Patient Treatment – Dental: Upto Sum Insured

B16.       Vaccination cover

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

Without any waiting period:

–              Anti-rabies vaccine following an animal bite

–              Typhoid vaccination

After 2 years of continuous coverage with Us:

–              Human Papilloma Virus (HPV) vaccine

–              Hepatitis B Vaccine

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.

The maximum payable is actuals or Rs. 5,000/- per policy, whichever is lower.

Vaccination cover: Upto ₹5,000 per policy (over and above base sum insured)

B17.       Hearing Aid

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

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

Hearing Aid: Upto 50% of actual cost or ₹10,000/- per policy, whichever is lower (over and above base sum insured)

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 0.25% of base sum insured and a maximum of Rs. 2000 per day. This benefit is applicable only for those cases where shared accommodation category is not opted by the policy holder in the policy.

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 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 0.25% of base sum insured and maximum of Rs.2000 per day.

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.

i.              Cancer

ii.             Kidney Failure

iii.            Myocardial Infarction

iv.           Angina

v.            Coronary bypass surgery

vi.           Stroke/Cerebral hemorrhage

vii.          Organ failure requiring transplant

viii.         Heart Valve replacement

ix.           Brain tumors

This benefit can be availed by an Insured Person once during a Policy Year.

B21.  Accidental Death Benefit (Optional Cover)

If an Insured Person suffers an accident during the policy period and this is the sole and direct cause of his death within 365 days from the date of accident, then we will pay a fixed amount of 100% of the base Sum Insured.

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

Benefit under optional cover (if opted) shall be available to the insured person, only if the particular benefit/optional cover is specifically mentioned in the policy schedule.

B22.       Cumulative Bonus / No Claim Discount

You have the option to choose between Cumulative Bonus and No Claim Discount.

i.              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.

ii.             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.

iii.            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.

iv.           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.

v.            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.

vi.           Cumulative Bonus shall be provided only if No Claim Discount has not been availed for the claim free previous Policy Year.

If you Choose No Claim Discount, We will allow 1% discount on renewal premium for every claim free Policy Year, provided that the Policy is renewed with Us without break.

B23.       Wellness Services

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 Physician

We /Our empanelled Service Provider will arrange for 8 teleconsultations upon insured person’s request through telecommunication and digital communication technologies for insured person’s health related complaints or preventive health care by a qualified Medical Practitioner.

This service can only be availed subject to the 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.            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 to the nearest Hospital.

Disclaimer (applicable to section B23)

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

2.            For services that are provided through empanelled Service Providers, we are acting as a facilitator; hence we would not be liable for any incremental costs or the services. Any additional services availed, or expenses incurred on such services or benefits which are other than those covered under this policy and explicitly excluded by this Policy, shall not be covered under this Policy and all expenses incurred shall be borne by the Insured Person.

3.            We shall not be responsible for or liable for, any actions, claims, demands, losses, damages, costs, charges and expenses which Insured Person claims to have suffered, sustained or incurred, by way of and / or on account of the benefit. We shall not be liable for any deficiency or discrepancy in the services provided by empanelled service provider/network provider under this policy.

4.            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 completely be borne by the Insured Person unless covered otherwise. However, the services under this policy should not be construed to constitute medical advice and/or substitute the Insured Person’s visit/ consultation to an independent Medical Practitioner/Healthcare professional.

5.            The Medical Practitioner may suggest/recommend/prescribe over the counter medications based on the information provided, if required on a case-to-case basis. Provided that any recommendation under this Policy shall not be valid for any medico legal purposes.

6.            The Insured Person is free to choose whether or not to act on the recommendation after seeking consultation.

7.            Any advice, recommendations or suggestions made by any medical professional shall be solely based on the information and documentation provided by the Insured Person to such medical professional. We shall not be liable towards any loss or damage (immediate or consequential) arising out of or in relation to any opinion, advice, prescription, actual or alleged errors, omissions and representations made by the medical professional from whom we have availed services or taken benefit or for any consequence of any act or omission in reliance thereon.

8.            For Ambulance Booking facility–

a.            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.

b.            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.

c.             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.

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 and the same shall be notified to the policyholders in advance prior to change effective date.

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 this Benefit will not impact Cumulative Bonus if applicable.

12.          We reserve the right to change any empanelled service provider during the currency of the policy or at renewal. The same shall be intimated to the insured atleast 15 days prior to the effective date of change.

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 Assistance 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 loss or damage resulting therefrom.

Optional covers/Riders:

You can choose optional covers listed below by paying an additional premium.

Accidental Death Benefit:

If an Insured Person suffers an accident during the policy period and this is the sole and direct cause of his death within 365 days from the date of accident, then we will pay a fixed amount of 100% of the base Sum Insured.

Note: For cover applicable to you, please refer your Policy Schedule

Section 3 – Exclusions

We will neither be liable nor make any payment for any claim in respect of any Insured Person which is caused by, arising from or in any way attributable to any of the following exclusions, unless expressly stated to the contrary in this Policy.

i.              Standard Exclusions

1.            Exclusions with waiting periods

i.              Pre-existing Diseases Waiting Period (Code- Excl 01):

a.            Expenses related to the treatment of a pre-existing Disease (PED) and its direct complications shall be excluded until the expiry of 36 months of continuous coverage after the date of inception of the first policy with us.

b.            In case of enhancement of sum insured the exclusion shall apply afresh to the extent of sum insured increase.

c.             If the Insured Person is continuously covered without any break as defined under the portability norms of the extant IRDAI (Health Insurance) Regulations, then waiting period for the same would be reduced to the extent of prior coverage.

d.            Coverage under the policy after the expiry of 36 months for any pre-existing disease is subject to the same being declared at the time of application and accepted by us.

ii.             40 Specified Disease/Procedure Waiting Period (Code- Excl 02):

(Not applicable for claims arising due to an accident)

a.            Expenses related to the treatment of the listed Conditions, surgeries/treatments shall be excluded until the expiry of 24 months of continuous coverage after the date of inception of the first policy with us. This exclusion shall not be applicable for claims arising due to an accident.

b.            In case of enhancement of sum insured the exclusion shall apply afresh to the extent of sum insured increase.

c.             If any of the specified disease/procedure falls under the waiting period specified for pre-Existing diseases, then the longer of the two waiting periods shall apply.

d.            The waiting period for listed conditions shall apply even if contracted after the policy or declared and accepted without a specific exclusion.

e.            If the Insured Person is continuously covered without any break as defined under the applicable norms on portability stipulated by IRDAI, then waiting period for the same would be reduced to the extent of prior coverage.

f.             List of Specific Diseases/procedures as furnished below: (40)

I.             Tumors, Cysts, polyps including breast lumps (benign)

II.            Polycystic ovarian disease

III.           Fibromyoma

IV.          Adenomyosis

V.            Endometriosis

VI.          Prolapsed Uterus

VII.         Non-infective arthritis

VIII.        Gout and Rheumatism

IX.           Osteoporosis

X.            Ligament, Tendon or Meniscal tear

XI.           Prolapsed Inter Vertebral Disc

XII.         Cholelithiasis

XIII.        Pancreatitis

XIV.        Fissure/fistula in anus, haemorrhoids, pilonidal sinus

XV.         Ulcer & erosion of stomach & duodenum

XVI.        Gastro Esophageal Reflux Disorder (GERD)

XVII.      Liver Cirrhosis

XVIII.     Perineal Abscesses

XIX.        Perianal / Anal Abscesses

XX.         Calculus diseases of Urogenital system Example: Kidney stone, Urinary bladder stone.

XXI.        Benign Hyperplasia of prostate

XXII.       Varicocele

XXIII.     Cataract

XXIV.     Retinal detachment

XXV.      Glaucoma

XXVI.     Congenital Internal Diseases

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

XXVII.    Adenoidectomy

XXVIII.  Mastoidectomy

XXIX.     Tonsillectomy

XXX.       Tympanoplasty

XXXI.     Surgery for nasal septum deviation

XXXII.    Nasal concha resection

XXXIII.   Surgery for Turbinate hypertrophy

XXXIV.  Hysterectomy

XXXV.    Joint replacement surgeries Eg: Knee replacement, Hip replacement

XXXVI.  Cholecystectomy

XXXVII. Hernioplasty or Herniorraphy

XXXVIII. Surgery/procedure for Benign prostate enlargement

XXXIX.   Surgery for Hydrocele/ Rectocele

XL.          Surgery of varicose veins and varicose ulcers

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

(not applicable for accidents or on renewals)

a.            Expenses related to the treatment of any illness within 30 days from the first policy commencement date shall be excluded except claims arising due to an accident, provided the same are covered.

b.            This exclusion shall not, however, apply if the Insured Person has Continuous Coverage for more than twelve months.

c.             The within referred waiting period is made applicable to the enhanced sum insured in the event of granting higher sum insured subsequently.

2.            Medical Exclusions (12 + 10)

i.              Investigation and evaluation (Code- Excl 04):

a.            Expenses related to any admission primarily for diagnostics and evaluation purposes only are excluded.

b.            Any diagnostic expenses which are not related or not incidental to the current diagnosis and treatment are excluded.

ii.             Rest cure, rehabilitation and respite care (Code- Excl 05):

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

i.              Custodial care either at home or in a nursing facility for personal care such as help with activities of daily living such as bathing, dressing, moving around either by skilled nurses or assistant or non-skilled persons.

ii.             Any services for people who are terminally ill to address physical, social, emotional and spiritual needs.

iii.            Obesity/ Weight Control (Code- Excl 06):

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

a.            Surgery to be conducted is upon the advice of the Doctor.

b.            The surgery/Procedure conducted should be supported by clinical protocols.

c.             The member has to be 18 years of age or older and

d.            Body Mass Index (BMI);

i.              greater than or equal to 40 or

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

1.            Obesity-related cardiomyopathy

2.            Coronary heart disease

3.            Severe Sleep Apnea

4.            Uncontrolled Type2 Diabetes

iv.           Change-of-Gender treatments: Code- Excl07:

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

v.            Cosmetic or Plastic Surgery (Code- Excl 08):

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

vi.           Treatment for, Alcoholism, drug or substance abuse or any addictive condition and consequences thereof (Code- Excl 12).

vii.          Treatments received in heath hydros, nature cure clinics, spas or similar establishments or private beds registered as a nursing home attached to such establishments or where admission is arranged wholly or partly for domestic reasons. (Code- Excl13)

viii.         Dietary supplements and substances that can be purchased without prescription, including but not limited to Vitamins, minerals and organic substances unless prescribed by a medical practitioner as part of hospitalization claim or day care procedure. (Code-Excl14)

ix.           Refractive error (Code- Excl 15):

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

x.            Unproven treatments (Code- Excl 16):

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

xi.           Sterility and Infertility (Code- Excl 17):

Expenses related to Sterility and infertility. This includes:

i.              Any type of contraception, sterilization

ii.             Assisted               Reproduction    services including              artificial                insemination      and advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI

iii.            Gestational Surrogacy

iv.           Reversal of sterilization

xii.          Maternity (Code – Excl 18):

a.            Medical treatment expenses traceable to childbirth (including complicated deliveries and caesarean sections incurred during hospitalization) except ectopic pregnancy;

b.            Expenses towards miscarriage (unless due to an accident) and lawful medical termination of pregnancy during the policy period.

3.            Non-Medical Exclusions (3 + 11)

i.              Hazardous or Adventure Sports (Code- Excl 09):

Expenses related to any treatment necessitated due to participation as a professional in hazardous or adventure sports, including but not limited to, para-jumping, rock climbing, mountaineering, rafting, motor racing, horse racing or scuba diving, hand gliding, sky diving, deep-sea diving.

ii.             Breach of law (Code- Excl 10):

Expenses for treatment directly arising from or consequent upon any Insured Person committing or attempting to commit a breach of law with criminal intent .

iii.            Excluded Providers: (Code-Excl 11):

Expenses incurred towards treatment in any hospital or by any Medical Practitioner or any other provider specifically excluded by the Insurer and disclosed in its website / notified to the policyholders are not admissible. However, in case of life threatening situations or following an accident, expenses up to the stage of stabilization are payable but not the complete claim.

ii.             Specific Exclusions (Exclusions other than as mentioned under Section 3 (i) above)

1.            Medical Exclusions

i.              Alcoholic pancreatitis or Alcoholic liver disease;

ii.             Congenital External Diseases, defects or anomalies;

iii.            Stem cell therapy; however hematopoietic stem cells for bone marrow transplant for haematological conditions will be covered under benefit B1 or B4 of this policy

iv.           Growth Hormone Therapy

v.            Sleep-apnoea

vi.           Admission primarily for administration of Intra-articular or intra-lesional injections or Intravenous immunoglobulin infusion or supplementary medications like Zolendronic Acid

vii.          Venereal disease, sexually transmitted disease or illness;

viii.         All preventive care, vaccination including inoculation and immunisations (except in case of post- bite treatment and other vaccines explicitly covered);

ix.           Dental treatment or surgery of any kind except specified in ‘Inpatient Treatment – Dental’

x.            Any existing disease specifically mentioned as Permanent exclusion in the Policy Schedule.

2.            Non-Medical Exclusions

i.              War or any act of war, invasion, act of foreign enemy, war like operations (whether war be declared or not or caused during service in the armed forces of any country), civil war, public defence, rebellion, revolution, insurrection, military or usurped acts, nuclear weapons/materials, chemical and biological weapons, ionising radiation.

•             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.

ii.             Any Insured Person’s participation or involvement in naval, military or air force operation.

iii.            Intentional self-injury or attempted suicide while sane or insane.

iv.           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.

v.            Treatment rendered by a Medical Practitioner which is outside his discipline.

vi.           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.

vii.          Provision or fitting of hearing aids, spectacles or contact lenses including optometric therapy unless explicitly stated and covered in the policy.

viii.         Any treatment and associated expenses for alopecia, baldness, wigs, or toupees, medical supplies including elastic stockings, diabetic test strips, and similar products.

ix.           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.

x.            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).

xi.           Any illness diagnosed or injury sustained or where there is change in health status of the member after date of proposal and before commencement of policy and the same is not communicated and accepted by us.

Section 4 – General Terms and Clauses

i.              Standard General Terms & Clauses

1.            Disclosure of Information

The policy shall be void and all premium paid thereon shall be forfeited to the Company in the event of established fraud, misrepresentation, misdescription or non-disclosure of any material fact by the policyholder.

(Explanation: “Material facts” for the purpose of this policy shall mean all relevant information sought by the company in the proposal form and other connected documents to enable it to take informed decision in the context of underwriting the risk)

2.            Condition Precedent to Admission of Liability

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

3.            Claim Settlement (provision for Penal Interest)

i.              The Company shall settle or reject a claim, as the case may be, within 15 days from the date of receipt of last necessary document.

ii.             In the case of delay in the payment of a claim, the Company shall be liable to pay interest to the policyholder from the date of receipt of last necessary document to the date of payment of claim at a rate 2% above the bank rate.

iii.            However, where the circumstances of a claim warrant an investigation in the opinion of the Company, it shall initiate and complete such investigation at the earliest, in any case not later than 30 days from the date of receipt of last necessary document. In such cases, the Company shall settle or reject the claim within 45 days from the date of receipt of last necessary document.

iv.           In case of delay beyond stipulated 45 days, the Company shall be liable to pay interest to the policyholder at a rate 2% above the bank rate from the date of receipt of last necessary document to the date of payment of claim.

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

i.              In case of multiple policies taken by an insured person during a period from one or more insurers to indemnify treatment costs, the insured person shall have the right to require a settlement of his/her claim in terms of any of his/her policies. In all such cases the insurer chosen by the insured person shall be obliged to settle the claim as long as the claim is within the limits of and according to the terms of the chosen policy.

ii.             Insured person having multiple policies shall also have the right to prefer claims under this policy for the amounts disallowed under any other policy / policies even if the sum insured is not exhausted. Then the insurer shall independently settle the claim subject to the terms and conditions of this policy.

iii.            If the amount to be claimed exceeds the sum insured under a single policy, the insured person shall have the right to choose insurer from whom he/she wants to claim the balance amount and we will assist the insured person in facilitating the same.

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

6.            Fraud

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

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

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

a)            the suggestion, as a fact of that which is not true and which the insured person does not believe to be true;

b)            the active concealment of a fact by the insured person having knowledge or belief of the fact;

c)            any other act fitted to deceive; and

d)            any such act or omission as the law specially declares to be fraudulent.

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

7.            Cancellation

i.              The policyholder may cancel this policy by giving 7 days written notice and in such an event, the Company shall refund proportionate premium for unexpired policy period. No refunds of premium shall be made in respect of Cancellation where any claim has been admitted or has been lodged or any benefit under this Policy has been availed by the Insured Person.

ii.             The Company may cancel the policy at any time on grounds of established fraud, misrepresentation or non-disclosure of material facts by the Policyholder/Insured Person by giving 15 days’ written notice. There would be no refund of premium on cancellation on grounds of established fraud, misrepresentation or non-disclosure of material facts.

8.            Migration

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

For Detailed Guidelines on Migration, kindly refer

Insurance Regulatory and Development Authority of India (Insurance Products) Regulations, 2024 F. No. IRDAI/Reg/8/202/2024 dated 20th March, 2024 and Master Circular on IRDAI (Insurance Products) Regulations 2024- Health Insurance Ref: IRDAI/HLT/CIR/PRO/84/5/ 2024 dated 29th May 2024 and subsequent amendments thereof.

9.            Portability

The insured person will have the option to port the policy to other insurers by applying to such insurer to port the entire policy along with all the members of the family, if any, at least 30 days before, but not earlier than 60 days from the policy renewal date as per IRDAI guidelines. If such person is presently covered and has been continuously covered without any lapses under any health insurance policy with an Indian General/Health insurer, the proposed insured person will get the accrued continuity benefits in waiting periods as per IRDAI guidelines on portability.

For Detailed Guidelines on Portability, kindly refer

Insurance Regulatory and Development Authority of India (Insurance Products) Regulations, 2024 F. No. IRDAI/Reg/8/202/2024 dated 20th March, 2024 and Master Circular on IRDAI (Insurance Products) Regulations 2024- Health Insurance Ref: IRDAI/HLT/CIR/PRO/84/5/ 2024 dated 29th May 2024 and their subsequent amendments thereof.

Requirement:

• Completed proposal form,
• Supporting Medical papers (wherever applicable),
• Previous policy copies, IRDAI portability form (as applicable)

.

10.          Renewal of Policy

i.              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.

ii.             Request for renewal along with requisite premium shall be received by the Company before the end of the policy period.

iii.            Single premium payment mode Policy can be renewed within the Grace Period of 30 days to maintain continuity of benefits without break in policy. Coverage is not available during the grace period after the end of the policy period. If not renewed under the Grace Period, the Policy shall terminate at the end of the Grace period.

iv.           The grace period for payment of the premium during the Policy Period, for instalment premium shall be fifteen days where premium payment mode is monthly and thirty days in all other cases (Annually/Half-Yearly/Quarterly/ Limited Premium Paying Term).

v.            Coverage during such grace period (in case of instalment premium):

a.            Within the policy period – coverage will be available from the due date of instalment premium till the date of receipt of premium by Company within the grace period.

b.            At the end of the policy period – the policy shall terminate and can be renewed within the Grace Period of 30 days to maintain continuity of benefits without break in policy. Coverage is not available during the grace period after the end of the policy period.

vi.           The insured person will get the accrued continuity benefit in respect of the “Waiting Periods”, “Specific Waiting Periods” in the event of payment of premium within the stipulated grace Period.

vii.          No loading shall apply on renewals based on individual claims experience.

11.          Withdrawal of Policy

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

ii.             Insured Person will have the option to migrate to similar health insurance product available with the Company at the time of renewal with all the accrued continuity benefits such as cumulative bonus, waiver of waiting period as per IRDAI guidelines, provided the policy has been maintained without a break.

12.          Moratorium Period

After completion of five continuous years of coverage (including portability and migration) in health insurance policy, no policy and claim shall be contestable by the insurer on grounds of non-disclosure, misrepresentation, except on grounds of established fraud. This continuous period of five years is called as moratorium period. The moratorium would be applicable for the sums insured of the first policy. Wherever the sum insured is enhanced, completion of five continuous years would be applicable from the date of enhancement of sums insured only on the enhanced limits. The policies would however be subject to all limits, sub limits, co-payments, deductibles as per the policy contract.

13.          Possibility of Revision of Terms of the Policy Including the Premium Rates

The Company may revise or modify the terms of the Policy including the premium rates. The Insured Person shall be notified three months before the changes are effected.

14.          Free look period

The Free Look Period shall be applicable on new individual health insurance policies and not on 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

At TATA AIG, we strive to provide the best service to our customers. If you’re not satisfied and wish to lodge a complaint, please call our 24/7 toll-free number 1800-266-7780/1800 22 9966 (For Senior Citizens) or 022-66939500 (toll charges apply), or email us at customersupport@tataaig.com. We will investigate and respond within the regulatory turnaround time (TAT).

Escalation Level 1

If you do not receive a response or are not satisfied with the resolution, please contact us at

manager.customersupport@tataaig.com.

Escalation Level 2

If you still need assistance, reach out to the Head of Customer Services at head.customerservices@tataaig.com. We will provide our final response within the regulatory TAT.

If you’re still not satisfied after this process, you may approach the Insurance Ombudsman of concerned jurisdiction.

You can also lodge a grievance on the Bima Bharosa Grievance Redressal Portal: https://bimabharosa.irdai.gov. in

The name and address of the Insurance Ombudsman of competent jurisdiction is provided under Annexure A of this Policy.

16.          Nomination

The policyholder is required at the inception of the policy to make a nomination for the purpose of payment of claims under the policy in the event of death of the policyholder. Any change of nomination shall be communicated to the company in writing and such change shall be effective only when an endorsement on the policy is made. In the event of death of the policyholder, the Company will pay the nominee {as named in the Policy Schedule/

/Endorsement (if any)} and in case there is no subsisting nominee, to the legal heirs or legal representatives of the policyholder whose discharge shall be treated as full and final discharge of its liability under the policy.

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

17.          Premium Payment

i.              Premium to be paid for the Policy Period before Policy Commencement date as opted by You in the proposal form.

ii.             If you have opted to pay premium in full (lump sum) 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.

iii.            Long term premium discount of 5% and 10% is applicable for policy with tenure of 2 and 3 years respectively.

3. Discounts on premium:
   i. 10% long term discount on premium in case insured opts policy term of 3 years
   ii. 5% long term discount on premium in case insured opts policy term of 2 years
   iii. Family floater discount on premium:
   • 2 members -20%
   • 3 members -28%
   • > 3 members-32%
   iv. 10% discount on premium in case insured opts for shared room category
   v. 10% discount to all TATA Group employees

18.          Insured Person

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

ii.             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.

iii.            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

i.              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).

ii.             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.

iii.            The loading shall only be applied basis an outcome of Our medical underwriting.

iv.           These loadings are applied from Commencement Date of the Policy including subsequent renewal(s) with Us or on the receipt of the request of increase in Sum Insured (for the increased Sum Insured).

a.            We will inform You about the applicable risk loading through a counter offer letter.

b.            You need to revert to Us with consent and additional premium (if any), within 15 days of the issuance of such counter offer letter.

c.             In case, you neither accept the counter offer nor revert to Us within 15 days, We shall cancel Your application and refund the premium paid within next 10 days subject to deduction of the Pre-Policy Check up charges, as applicable.

v.            Please note that We will issue Policy only after getting Your consent.

20.          Entire Contract

i.              This Policy, its Schedule, endorsement(s), proposal constitutes the entire contract of insurance. No change in this policy shall be valid unless approved by Us and such approval be endorsed hereon.

ii.             This Policy and the Schedule shall be read together as one contract and any word or expression to which a specific meaning has been attached in any part of this Policy or of the Schedule shall bear such meaning wherever it may appear.

21.          Sum Insured Enhancement /Change in Sum Insured

i.              Sum Insured can be enhanced only at the time of renewal subject to underwriting guidelines of the company.

ii.             In case of increase in the Sum Insured waiting period and exclusions will apply afresh in relation to the amount by which the Sum Insured has been enhanced. However, the acceptance of Sum Insured enhancement request & quantum of increase shall be as per Our underwriting guidelines. For claims arising in respect of accident, injury or illness contracted or suffered during a preceding Policy period, liability of the Company shall be only to the extent of the Sum Insured under the Policy in force at the time when it was contracted or suffered.

22.          Change of Policyholder

i.              The change of Policyholder is permitted only at the time of renewal.

ii.             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.

23.          Notices

i.              Any notice, direction or instruction under this Policy shall be in writing and if it is to:

a.            Any Insured Person, then it shall be sent to You at Your address specified in the Schedule to this Policy and You shall act for all Insured Persons for these purposes.

b.            Us, it shall be delivered to Our address specified in the Schedule to this Policy. No insurance agents, brokers or other person or entity is authorised to receive any notice, direction or instruction on Our behalf unless We have expressly stated to the contrary in writing.

24.          Conditions applicable for In-patient Treatment (B1)

i.  If the insured person is admitted in a hospital room where the room category opted is higher than the eligible category as specified in the policy schedule, then the policy holder/insured person shall bear 10% of the admissible claim amount.

25.          Premium Payment Zone

i.              The premium will be charged on the completed age of the Insured Person.

ii.             Premium rates are subject to change.

iii.            The premium for the policy will remain the same for the policy period as mentioned in the policy schedule.

iv.           For family floater, premium is calculated by adding the premium of respective individual members and applying family floater discount.

v.            Monthly instalment option would be allowed and following loadings shall be applicable:

Term of Policy    Loading%

1 year Policy       5%

2 year Policy       9%

3 year Policy       13%

If the insured person has opted for Payment of Premium on an installment basis i.e. Monthly, as mentioned in the policy Schedule, the following Conditions shall apply (notwithstanding any terms contrary elsewhere in the policy)

I.             Grace Period of 15 days would be given to pay the installment premium due for the policy, during the policy period.

II.            During such grace period, coverage shall be available from the due date of installment premium till the date of receipt of premium by Company.

III.           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.

IV.          No interest will be charged lf the installment premium is not paid on due date

V.            In case of installment premium due not received within the grace period, the policy will get cancelled.

VI.          In the event of a claim, all subsequent premium instalments shall immediately become due and payable.

VII.         The company has the right to recover and deduct all the pending installments from the claim amount due under the policy.

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:

Here ‘Address’ implies the place where the person ordinarily resides. In case proposed prospect(s) reside at multiple addresses, then address of the person residing in the highest Zone will be considered.

a.            Zone A:  Mumbai  including  MMR/  Thane,  Delhi  NCR/Faridabad/Ghaziabad, Ahmedabad, Surat and Baroda

b.            Zone B: Hyderabad, Bengaluru, Kolkata, Indore, Chennai, Chandigarh/ Mohali/ Punchkula/Zirakpur, Pune/Pimpri Chinchwad and Rajkot

c.             Zone C: Rest of India

Note:

i.              No co-payment shall apply due to change in zone and insured person can avail treatment in any of the zones

Note: Co-payment: 10% copayment shall be applicable in case you are admitted in a hospital room where the room category opted is higher than the eligible category as specified in the policy schedule

ii.             In case of mid-term address change which also involves change in premium payment zone, the premium would be modified and computed on pro-rata basis

27. 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

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.

The final decision on all claims is taken by Tata AIG General Insurance Company Limited. We may have a Specified Third Party Administrator (TPA) duly licensed by IRDAI to administer all claims under this policy.

1.            Notification of Claim (Intimation & Assistance)

	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

Timely intimation of claim in Our prescribed format is a pre-condition for admission of liability.

We may waive off this condition in extreme cases of hardship where it is proved to Our satisfaction that under the circumstances in which You were placed, it was not possible for You or any other person to give notice or file claim within the prescribed time limit.

Claim Related Information:

For any claim related query, intimation of claim and submission of claim related documents, You can contact us through:

Claims Servicing Details
Name	TAGIC Health Claims
Claims Administrator Address	TATA AIG General Insurance Company Limited, 5th and 6th Floor, Imperial Towers, H.No 7-1-6-617/A, GHMC No – 615,616, Ameerpet, Hyderabad – 500016, Telangana, Phone: 040-66864900
Email ID	healthclaimsupport@tataaig.com
Toll-Free No.:	1800 266 7780 or 1800 229 966 (For Senior Citizens)
Website	www.tataaig.com

2.            Cashless Service

Treatment, Consultation or Procedure:	Taken at:	Cashless Service is Available:	We must be given notice that the Insured Person wishes to avail cashless service accompanied by full particulars:
If any planned treatment, consultation or procedure for which a claim may be made:	Network Provider	We will provide cashless service by              making payment to the extent of Our liability directly to the Network Hospital.	At least 48 hours before the planned Hospitalization
If any treatment, consultation or procedure for which a claim may be made, requiring emergency Hospitalization	Network Provider	We will provide cashless service by              making payment to the extent of Our liability directly to the Network Hospital.	Within 24 hours of the Hospitalization and prior to discharge

3.  Procedure for Cashless Service

i.              Cashless Service is only available at Network Hospitals.

Please refer to our website(www.tataaig.com) or call us on our toll free number at <<1800-266- 7780>> for empaneled hospital list.

ii.             In order to avail of cashless treatment, the following procedure must be followed by You:

a.            Prior to taking treatment and/or incurring Medical Expenses at a Network Hospital, You must notify our designated TPA/Us and request pre-authorization.

b.            For any emergency Hospitalisation, our designated TPA/We must be informed no later than 24 hours of the start of Your hospitalization/ treatment.

c.             For any planned hospitalization, our designated TPA/We must be informed atleast 48 hours prior to the start of your hospitalization/treatment.

d.            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.

e.            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.

f.             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.

g.            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.

h.            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.

i.              If the cashless is approved, the original bills and evidence of treatment in respect of the same shall be left with the Network Hospital.

j.             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.

•             Insured person is entitled for cashless coverage only in our empanelled hospitals.

•             Please refer to our website (www.tataaig.com) or call us on our toll free number at 1800- 266-7780/ 1800 22 9966 (For Senior Citizens) for empaneled hospital list.

•             Rejection of cashless facility in no way indicates rejection of the claim.

Procedure for reimbursement claims:

•             Our TPA/We must be informed within 7 days of completion of such treatment, consultation or procedure using the Claim Intimation Form.

•             Please send the duly signed claim form and all the information/documents mentioned therein to our TPA/Us within 15 days of the occurrence of the Incident.

•             Please refer to claim form for complete documentation.

•             If there is any deficiency in the documents/information submitted by you, our TPA/We will send the deficiency letter within 7 working days of receipt of the claim documents.

•             On receipt of the complete set of claim documents, We will send the payment for the admissible amount, along with a settlement statement within 30 days.

•             The payment will be sent in the name of the proposer/ Nominee in case of death of Proposer

Kindly send the claim documents to:
Tata AIG General Insurance Company Limited, 5th and 6th Floor, Imperial Towers, H.No 7-1-6- 617/A, GHMC No – 615,616, Ameerpet, Hyderabad – 500016, Telangana, Phone-040- 66864900

Turn Around Time (TAT) for claims settlement:

TAT for preauthorization of cashless facility and for cashless final bill authorization shall be as prescribed by the Regulator under the
Master Circular on IRDAI (Insurance Products) Regulations 2024- Health Insurance Ref: IRDAI/HLT/CIR/PRO/84/5/ 2024 and its subsequent amendments thereof.

Assistance:

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

i.              We or Our TPA may require documentation, medical records and information to establish the circumstances of the claim, its quantum or Our liability for the claim within 15 days or earlier of Our request or the Insured Person’s discharge from Hospitalization or completion of treatment.

ii.             In case the delay is at Your end, failure to furnish such evidence within the time required shall not invalidate nor reduce any claim if You can satisfy Us that it was not reasonably possible for You to give proof within such time.

iii.            We may accept claims where documents have been provided after a delayed interval only in special circumstances and for the reasons beyond the control of the Insured Person.

iv.           Such documentation will include the following:

a.            Our claim form, duly completed and signed for on behalf of the Insured Person.We, upon receipt of a notice of claim, will furnish Your representative with such forms as We may require for filing proofs of loss or you may download the claim form from our Web site.

b.            Original Bills (pharmacy purchase bill, consultation bill, diagnostic bill) and any attachments thereto like receipts or prescriptions in support of any amount claimed which will then become Our property.

c.             All medical reports, case histories, investigation reports, indoor case papers/ treatment papers (in reimbursement cases, if available), discharge summaries.

d.            A precise diagnosis of the treatment for which a claim is made.

e.            A detailed list of the individual medical services and treatments provided and a unit price for each in case not available in the submitted hospital bill..

f.             Prescriptions that name the Insured Person and in the case of drugs: the drugs prescribed, their price and a receipt for payment. In case of pre/post hospitalization claim Prescriptions must be submitted with the corresponding Doctor/hospital invoice.

g.            All pre and post investigation, treatment and follow up (consultation) records pertaining to the present ailment for which claim is being made, if and where applicable.

h.            Treating doctor’s certificate regarding missing information in case histories e.g. Circumstance of injury and Alcohol or drug influence at the time of accident, if available.

i.              Copy of settlement letter from other insurance company or TPA.

j.             Stickers and invoice of implants used during surgery.

k.            Copy of MLC (Medico legal case) records, if carried out and FIR (First information report), if registered, in case of claims arising out of an accident and available with the claimant.

l.              Regulatory requirements as amended from time to time, currently mandatory NEFT (to enable direct credit of claim amount in bank account) and KYC (recent ID/Address proof and photograph) requirements.

m.           Legal heir/succession certificate, if required

n.            PM report (wherever applicable)

v.            Note: In case You are claiming for the same event under an indemnity-based Policy with Us and with another Insurer and are required to submit the original documents related to Your treatment with that particular Insurer, then We will require the attested copies of such documents along with a declaration from the particular Insurer specifying the availability of the original copies of the specified treatment documents with it.

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

i.              We shall be under no obligation to make any payment under this Policy unless

–              We have received all premium payments in full and in time and

–              We have been provided with the documentation and information which We or Our TPA has requested to establish the circumstances of the claim, its quantum or Our liability for it, and

–              unless You have complied with Your obligations under this Policy.

ii.             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.

iii.            This Policy only covers medical treatment taken within India (except in case of benefit B13- Global cover), and payments under this Policy shall only be made in Indian Rupees within India.

6.            Claims Procedure and management of Wellness Services (Section B23)

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

Teleconsultation – General Physician:

Insured Person can gain access to tele/video/digital consultation with a general physician, using Our digital Customer application.

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.

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.

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

i.              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

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.in	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	BHUBHANESHWAR	Office of the Insurance Ombudsman, 62,                      Forest                     park, Bhubaneswar         –          751          009. Tel.:     0674      –      2596461      /2596455 Email: bimalokpal.bhubaneswar@cioins.co.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.in	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, PuducherryTown 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
10	JAIPUR	Office of the Insurance Ombudsman, Jeevan Nidhi – II Bldg., Gr. Floor, Bhawani                Singh                Marg, Jaipur              –              302              005. Tel.:          0141-           2740363/2740798 Email: bimalokpal.jaipur@cioins.co.in	Rajasthan
11	KOCHI	Office of the Insurance Ombudsman, 10th Floor, Jeevan Prakash,LIC Building, Opp to Maharaja’s College Ground,M.G.Road, Kochi              –               682               011. Tel.:            0484             –             2358759 Email: bimalokpal.ernakulam@cioins.co.in	Kerala, Lakshadweep, Mahe-a part of Union Territory of Puducherry

12	KOLKATA	Office of the Insurance Ombudsman, Hindustan Bldg. Annexe, 7th Floor, 4,                         C.R.                     Avenue, KOLKATA           –            700            072. Tel.:    033    –    22124339    /    22124341 Email: bimalokpal.kolkata@cioins.co.in	West Bengal, Sikkim, Andaman & Nicobar Islands
13	LUCKNOW	Office of the Insurance Ombudsman, 6th Floor, Jeevan Bhawan, Phase-II, Nawal Kishore Road, Hazratganj, Lucknow             –             226             001. Tel.:  0522  –  4002082  /  3500613 Email: bimalokpal.lucknow@cioins.co.in	Districts of Uttar Pradesh                : Lalitpur, Jhansi, Mahoba, Hamirpur, Banda, Chitrakoot, Allahabad, Mirzapur, Sonbhabdra, Fatehpur, Pratapgarh, Jaunpur,Varanasi, Gazipur, Jalaun, Kanpur, Lucknow, Unnao, Sitapur, Lakhimpur, Bahraich, Barabanki, Raebareli, Sravasti, Gonda, Faizabad, Amethi, Kaushambi, Balrampur, Basti, Ambedkarnagar, Sultanpur, Maharajgang, Santkabirnagar, Azamgarh, Kushinagar, Gorkhpur, Deoria, Mau, Ghazipur, Chandauli, Ballia, Sidharathnagar
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)

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

Prohibition of Rebates – Section 41 of the Insurance Act, 1938 as amended by Insurance Laws (Amendment) Act, 2015.

1.            No person shall allow or offer to allow, either directly or indirectly, as an inducement to any person to take out or renew or continue an insurance in respect of any kind of 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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Additional points:

1. Tax Benefit:

The premium amount paid under this policy qualifies for deduction under Section 80D of the Income Tax Act. This benefit is not applicable for premium amount paid towards accidental death benefit.

Benefit Table with sub limits

Cover	Coverage
In-patient Treatment	Upto Sum Insured
Pre-Hospitalization	Upto 60 days
Post-Hospitalization	Upto 90 days
Day-Care procedures	Upto Sum Insured
Organ Donor	Upto Sum Insured
Domiciliary Treatment	Upto Sum Insured
Restore benefit	Upto Sum Insured
AYUSH benefit	Upto Sum Insured
Ambulance cover	Upto Rs. 3000 per Hospitalization
Health Check-up	Upto 1% previous year Sum Insured; max. Rs.10,000 per policy
Compassionate travel	Upto Rs.20,000 per policy year
Consumables Benefit	Upto Sum Insured
Global Cover	Upto Sum Insured
Bariatric Surgery Cover	Upto Sum Insured
In-patient Dental Treatment	Upto Sum Insured
Vaccination cover	Upto Rs.5000 per policy
Hearing Aid	50% of actuals; maximum Rs.10,000 per policy
Daily    cash    for    choosing    shared accommodation	0.25% of base Sum Insured; maximum Rs. 2000 per day
Daily cash for accompanying an insured child	0.25% of base Sum Insured; maximum Rs. 2000 per day
Second Opinion	Covered
Cumulative Bonus	50% increase in cumulative bonus for every claim free year. In the case a claim is made during the policy year, the cumulative bonus would reduce by 50% in the following year. Cumulative Bonus shall be provided only if No Claim Discount has not been availed for the claim free  previous  Policy  Year.  Alternately,  No  Claim

Terms and Conditions

• Minimum entry age – 91 days
• Policy Tenure Options-1/2/3 Years
• Covers upto 7 members (Self, Spouse, upto 3 dependent children and upto 2 parents/
  parents-in-laws)
• 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 (max. individual loading upto 100% of premium per medical
  condition) based on individual’s health status. Maximum overall risk loading shall not exceed
  150% of premium per individual.
• 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 as per regulation laid down by IRDAI is available for renewal post
  policy expiry.
• 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.
• Any product revision/modification/future withdrawal will be intimated to You at least 3 months in advance. In case of withdrawal, you have an option to migrate to our similar health
  insurance product.
• The policy is renewable except in case of established fraud or non-disclosure or
  misrepresentation by the Insured Person.