Bharti AXA General Insurance

Company Limited
(
1800-103-2292
:
[email protected]

SMS <SERVICE> to 5667700

:
www.bharti-axagi.co.in

SmartHealth - Insurance Policy

- Policy Wordings
1. PREAMBLE
WHEREAS the Insured designated in the Schedule to this Policy having by a
proposal and declaration together with any statement, report or other
document which shall be the basis of this contract and shall be deemed to
be incorporated herein, has applied to Bharti AXA General Insurance
Company Limited (hereinafter called "the Company") for the insurance
hereinafter set forth and paid appropriate premium for the period as
specified in the Schedule.
1.1

NOW THIS POLICY WITNESSETH:

That subject to the terms, conditions, exclusions and definitions
contained herein or endorsed or otherwise expressed hereon the
Company, undertakes, that if during the period as specified in the
Schedule to this Policy, the Insured / Insured Person shall contract
any disease, illness or sustain any injury and if such disease, illness
or injury shall upon the advice of a duly qualified Medical Practitioner
require such Insured/Insured Person, to incur hospitalisation and /
or other related expenses towards treatment of such disease,
illness or injury at any Hospital/ Nursing Home in India (hereinafter
called "Hospital") as an inpatient or domiciliary hospitalisation
expenses in any of the circumstances mentioned hereunder, then
the Company will pay to the Insured / Insured Person, his / her
nominee, or legal representatives, as the case may be, the amount
of such hospitalisation or related expenses/charges as would fall
under the different heads mentioned below and as are reasonably
and necessarily incurred by or on behalf of such Insured / Insured
Person for
1. Hospital (Room & Boarding and Operation theatre) charges;
2. Fees of Surgeon, Anaesthetist, Nurse, Specialists etc.;
3. Cost of diagnostic tests, medicines, blood, oxygen, appliances
like pacemaker, artificial limbs and organs etc.
4. Pre and post hospitalization expenses
5. Ambulance charges
in manner, for the period and to the extent of the Sum Insured
as specified in this Policy.

2. DEFINITIONS
Any word or expression to which a specific meaning has been assigned in
any part of this Policy or the Schedule shall bear the same meaning
wherever it appears. For purposes of this Policy, the terms specified below
shall have the meaning set forth:
2.1.

2.2.

"Accident" means a sudden, unforeseen and unexpected physical

event beyond the control of the Insured/Insured Person resulting in
bodily injury, caused by external, visible and violent means.
"Bodily Injury/Injury" means any accidental physical bodily harm
solely and directly caused by external, violent and visible and evident

means which is verified and certified by a Physician but does not

include any sickness or disease.
2.3.

"Critical Illnesses" means diseases/illnesses limited to the

following:
i. Cancer represented by a malignant tumour characterized by the
uncontrolled growth and spread of malignant cells with invasion
and destruction of normal tissue.
ii. First Heart Attack involving death of a portion of the heart
muscle arising from inadequate blood supply to the relevant
area.
iii. Coronary Artery Disease involving narrowing of the lumen of
at least one coronary artery by a minimum of 75% and of two
others by a minimum of 60%, as proven by coronary
arteriography, regardless of whether or not any form of
coronary artery surgery has been performed. Coronary
arteries herein refer to left main stem, left anterior descending
circumflex and right coronary artery.
iv. Coronary Artery bypass surgery involving the actual
undergoing of open-chest surgery to correct the narrowing or
blockage of one or more coronary arteries with bypass grafts.
v. Heart Valve Surgery involving the actual undergoing of openheart surgery to replace or repair heart valve abnormalities.
vi. Surgery to Aorta involving actual undergoing of major surgery
to repair or correct aneurysm, narrowing, obstruction or
dissection of the aorta through surgical opening of the chest
or abdomen. For the purpose of this definition aorta shall
mean the thoracic and abdominal aorta but not its branches.
vii. Stroke referring to a cerebrovascular incident including
infarction of brain tissue, cerebral and subarachnoid
haemorrhage, cerebral embolism, and cerebral thrombosis.
viii.Kidney Failure involving chronic irreversible failure of
both kidneys requiring either permanent renal dialysis or
kidney transplantation
ix. Aplastic Anaemia involving Chronic persistent bone marrow
failure which results in anaemia, neutropenia and
thrombocytopenia requiring treatment
x. End Stage Lung Disease causing chronic respiratory failure
xi. End Stage Liver Failure evidenced by Permanent jaundice
ascites and Hepatic Encephalopathy.
xii. Coma that persists for at least 30 days.
xiii.Major Burns representing third degree (full thickness of the
skin) burns covering at least 30% of the surface of the Insured
/ Insured person's body..
xiv. Major Organ/Bone Marrow Transplantation involving human
bone marrow using haematopoietic stem cells preceded by
total bone marrow ablation; or any one of the human organs
limited to heart, lung, liver, kidney or pancreas, that resulted

Bharti AXA General Insurance Company Limited,

1st Floor, The Ferns Icon, Survey No. 28, Next to Akme Ballet,Doddanekundi, Off Outer Ring Road, Bangalore 560037.
ST Registration No.: AADCB2008DST001 Co. Registration No.: U66030KA2007PLC043362

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from irreversible end stage failure of the relevant organ.

xv. Multiple Sclerosis
xvi. Fulminant Hepatitis involving sub-massive to massive necrosis
of the liver by the Hepatitis virus, leading precipitously to liver
failure
xvii. Motor Neurone Disease characterised by progressive degeneration
of corticospinal tracts and anterior horn cells or bulbar efferent
neurones which include spinal muscular atrophy, progressive
bulbar palsy, amyotrophic lateral sclerosis and primary lateral
sclerosis.
xviii.Primary Pulmonary Hypertension with substantial right
ventricular enlargement confirmed by investigations including
cardiac catheterization, resulting in permanent physical
impairment due to cardiac impairment resulting in not being
able to engage in any physical activity without discomfort.
Symptoms may be present even at rest
xix. Terminal Illness involving conclusive diagnosis of an illness
that is expected to result in the death of the insured person
within 12 months.
xx. Bacterial Meningitis involving bacterial infection causing in
severe inflammation of the membranes of the brain or
spinal chord resulting in significant, irreversible and
permanent neurological deficit. The neurological deficit must
persist for at least 6 weeks.
2.4.

2.5.

2.6.

"Day Care treatment" means treatment undertaken in a Hospital/

Nursing Home on the recommendation of a Medical Practitioner for
the following diseases, illness or injury which requires
hospitalisation for less than 24 hours and includes such of those
treatments which require hospitalisation for less than 24 hours due
to technologically advanced treatment protocol.
a. Dialysis
b. Chemotherapy
c. Radiotherapy
d. Eye surgery
e. Dental surgery
f. Lithotripsy (kidney stone removal)
g. Tonsillectomy
h. Dilatation & Curettage
i. Cardiac Catheterization
j. Hydrocele surgery
k. Hernia repair surgery
l. Surgeries/procedures that require less than 24 hours
hospitalisation due to medical/ technological advancement and
infrastructural facilities.
m. TURP (Prostate Surgery)
"Disease" means an alteration in the state of the body or of some of
its organs, interrupting or disturbing the performance of the
functions, and causing or threatening pain and weakness or physical
or mental disorder and certified by a Medical Practitioner.
"Domiciliary hospitalisation" means medical treatment for a period
exceeding three days for any disease, illness or injury which in the
normal course would require care and treatment at a
Hospital/Nursing Home but is actually taken whilst confined at
home in India under any of the following circumstances, namely:a. The condition of the patient is such that he/she cannot be
removed to Hospital/Nursing Home, or
b. The patient cannot be admitted to Hospital/Nursing Home for
lack of accommodation therein.
Domiciliary hospitalisation benefits shall be subject to the limits as
specified in the Schedule to this Policy, and shall, in no case, cover
expenses incurred for:
a. Pre and post Hospital treatment,
b. Treatment of any of the following diseases:
i. Asthma
ii. Bronchitis
iii. Chronic nephritis and nephritic syndrome
iv. Diarrhoea and all types of dysenteries including astroenteritis

v.
vi.
vii.
viii.
ix.
x.
xi.

Diabetes mellitus and insipidus

Epilepsy
Hypertension
Influenza, cough and cold
All psychiatric or psychosomatic disorders
Pyrexia of unknown origin for less than 10 days
Tonsillitis and upper respiratory tract infection including
aryngitis and pharangitis
xii. Arthritis, gout and rheumatism
2.7.

"Family" means the Insured, his/her lawful spouse and maximum

of two dependent children up to the age of 23 years.

2.8.

"Hospital/Nursing Home" means an establishment in India for

indoor medical care and treatment of patients which:
a. Is registered with the appropriate local authorities as such
and benefits from the supervision of a Medical Practitioner
on a 24hour basis, or
b. Complies with at least the following criteria:
i.
It has at least 10 inpatient beds (at least 7 inpatient beds
in places with a population of less than 10,00,000);
ii. It has a fully equipped operating theatre where surgery is
performed;
iii. It employs qualified nursing staff on a 24 hour basis;
iv. Maintains daily records of patients.
c. By the nature of the medical treatment provided is an
establishment properly recognized as a Hospital/Nursing Home
within the locality and fulfils all the demands ordinarily or
customarily of a Hospital for medical treatment, and where all
medical treatment is administered by a Medical Practitioner, and
is not, except incidentally, a place of rest, a place for the aged,
a place for drug-addicts or place for alcoholics, a hotel, health
spa, massage centre or any similar establishment.

2.9.

"Hospitalisation expenses" mean expenses on hospitalisation

incurred in India for minimum period of 24 hours incurred in
India, which are admissible under this Policy. However, this time
limit will not apply for specific treatments defined under Day
Care treatment taken in a Hospital / Nursing Home.

2.10. "Illness" means sickness or disease first diagnosed during the

period of insurance for which immediate treatment by a Medical
Practitioner is necessary.
2.11. "In-patient" means an Insured / Insured Person who is admitted
to Hospital / Nursing Home and stays for at least 24 hours for the
sole purpose of receiving treatment.
2.12. "Insured" means the individual who has a permanent place of
residence in India and on whose name the Policy is issued.
2.13. "Insured Person" means the person named in the Schedule to the
Policy, who has a permanent place of residence in India and for
whose benefit the insurance is proposed and appropriate
premium paid.
2.14. "Medical Practitioner" means a person who holds a
degree/diploma of a recognized institution and is registered
with the Medical Council in respective states of India. The
term Medical Practitioner includes a physician, specialist and
surgeon, provided that this person is not a member of the
Insured/Insured Person's family.
2.15. "Medical charges" mean reasonable charges unavoidably
incurred by the Insured/Insured Person for the medical treatment
of disease, illness or injury the subject matter of the claim as an
In-patient in a Hospital/ Nursing Home, and includes the costs of
a bed; treatment and care by medical staff; medical procedures,
Medical Practitioner's/ Consultant's/Specialist's fees, medicines
and consumables including cost of pacemaker, cost of organs,

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artificial limbs etc. as long as these are recommended by the

attending Medical Practitioner.
2.16. "Period of insurance" means the Policy period defined hereunder.
2.17. "Policy period" means the period between the inception date and the
expiry date as specified in the Schedule to this Policy or the
cancellation of this insurance, whichever is earlier.
2.18. "Policy" means this document of Policy describing the terms and
conditions of this contract of insurance, including the company's
covering letter to the insured if any, the Schedule attached to and
forming part of this Policy, the Insured's Proposer form and any
applicable endorsement thereon. The Policy contains details of the
scope and extent of cover available to the Insured/Insured Person,
the exclusions from the scope of cover and the terms and conditions
of the issue of the Policy.
2.19. "Post-hospitalisation expenses" mean relevant follow up medical
expenses incurred during a period up to the number of days
specified in the Schedule to this Policy following hospitalisation for
treatment of disease, illness or injury sustained and considered a
part of a claim admissible under this Policy.
2.20. "Pre-existing condition" means any condition, ailment or injury or
related condition(s) for which the Insured/Insured Person had signs
or symptoms, and/or were diagnosed and/or received medical
advice/treatment within 48 months prior to Insured/Insured
Person's first policy with the company.
2.21. "Pre-hospitalisation expenses" mean relevant medical hospitalisation
for expenses incurred during a period up to the number of days
specified in the Schedule to this Policy prior to hospitalisation for
treatment of disease, illness or injury sustained and considered a part
of a claim admissible under this Policy.
2.22. "Qualified nurse" means a person who holds a certificate of a
recognized Nursing Council and is employed on recommendation of
the attending Medical Practitioner.
2.23. "Third Party Administrator (TPA)" means any organisation or
institution that is licensed by the IRDA as a TPA and is engaged by
the Company for a fee or remuneration for providing Policy and
claims facilitation services to the Insured/ Insured Person as well as
to the Company for an insurable event.
2.24. "Schedule" means Schedule attached to and forming part of this
Policy mentioning the details of the Insured/ Insured Persons, the
Sum Insured, the period and the limits to which benefits under the
Policy are subject to.
2.25. "Sum Insured" means the sum as specified in the Schedule to this
Policy against the name of Insured / each Insured Person, which
sum represents the Company's maximum liability for any or all
claims under this Policy during the Policy period for the respective
benefit(s) against which the sum is mentioned in the Schedule to
this Policy.
2.26. "Surgical operation" means manual and/or operative procedures for
correction of deformities and defects, repair of injuries, diagnosis
and cure of diseases, relief of suffering and prolongation of life.
2.27. "Terrorism/Terrorist Incident" means any actual or threatened use of
force or violence directed at or causing damage, injury, harm or
disruption, or the commission of an act dangerous to human life or
property or government, with the stated or unstated objective of
pursuing economic, ethnic, nationalistic, political, racial or religious
interests, whether such interests are declared or not. Robberies or
other criminal acts, primarily committed for personal gain and acts

arising primarily from prior personal relationships between

perpetrator(s) and victim(s) shall not be considered terrorist
activity. Terrorism shall also include any act, which is verified or
recognized by the relevant Government as an act of terrorism.
3. SCOPE OF COVER
The Company hereby agrees subject to the terms, conditions and
exclusions herein contained or otherwise expressed, to pay and/or
reimburse the following benefits in manner, for the period and to the
extent of the Sum Insured as specified in the Schedule to this Policy.
Section I
a. Hospitalisation Expenses
Hospitalisation Expense benefit provides cover for reimbursement /
payment of hospitalisation expenses which are reasonably and
necessarily incurred by the Insured / Insured Person for treatment of
disease, illness contracted or injury sustained by the Insured /
Insured Person during the Policy period as specified in the Schedule
to this Policy, in a Hospital in India as in patient which among other
things, includes, Hospital charges (Room and Boarding and Operation
Theatre charges), admission and registration charges in the Hospital,
fees of Surgeon, Anaesthetist, Nurses, Specialists, the cost of
diagnostic tests, medicines, blood, oxygen, appliances like
pacemaker, artificial limbs and organs etc.
The Insured/Insured Person should have been hospitalized as an in
patient for a minimum period of 24 hours. However in respect of Day
Care treatment undertaken in a Hospital, 24 hours hospitalization is
not necessary. The benefit under this Section is limited to the Sum
Insured specified for this Section in the Schedule to this Policy.
b. Pre-hospitalisation
This benefit covers relevant medical expenses incurred during a
period up to the number of days as specified in the Schedule to this
Policy, prior to hospitalisation/ Day care treatment for treatment of
disease, illness contracted or injury sustained for which the Insured /
Insured Person was hospitalised, giving rise to an admissible claim
under this Policy. This benefit is a part of benefit available under
Section 1a above and is limited to the available Sum Insured under
Section 1a.
c. Post Hospitalisation
This benefit covers relevant medical expenses incurred during a
period up to the number of days as specified in the Schedule to this
Policy, after discharge from Hospital for continuous and follow up
treatment of the disease, illness contracted or injury sustained for
which the Insured/Insured Person was hospitalised, giving rise to an
admissible claim under this Policy. This benefit is a part of benefit
available under Section 1a above and is limited to the available Sum
Insured under Section 1a.
d. Pre-existing diseases
This Policy covers relevant hospitalisation expenses incurred for
treatment of pre-existing disease, illness or injury, in a Hospital as an
in-patient, after specific waiting period as mentioned in the Schedule
to this Policy. This benefit is a part of benefit available under Section
1a above and is limited to the available Sum Insured under Section
1a.

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Section II
Day Care Treatment
This benefit covers relevant hospitalisation expenses incurred by the
Insured / Insured Person in case of day care treatment (where 24 hours
of hospitalisation is not required) which includes treatments such as
dialysis, chemotherapy, radiotherapy, eye surgery, lithotripsy (kidney
stone removal), D & C, tonsillectomy undertaken in a Hospital. The
benefit under this Section is limited to the available Sum Insured under
Section 1a of this Policy as mentioned in the Schedule to this Policy.
Section III
Domiciliary Hospitalisation
This benefit covers payment of expenses incurred for medical treatment
pertaining to domiciliary hospitalisation for a period exceeding three days
for disease, illness or injury, which in the normal course, would require
care and treatment at a Hospital/Nursing Home, but is actually taken
whilst the Insured / Insured Person is confined at home in India, under
any of the following circumstances namely:a. The condition of the patient is such that he/she cannot be removed
to Hospital/Nursing Home, or
b. The patient cannot be admitted to Hospital/Nursing Home for lack of
accommodation therein.
Domiciliary hospitalisation benefits shall be subject to the Sum Insured
as specified in the Schedule to this Policy, and shall, in no case cover
expenses incurred for:
a. Pre and Post Hospital treatment,
b. Treatment of any of the following diseases / illness / injury:
i. Asthma
ii. Bronchitis
iii. Chronic nephritis and nephritic syndrome
iv. Diarrhoea & all types of dysenteries including astroenteritis
v. Diabetes mellitus and insipidu
vi. Epilepsy
vii. Hypertension
viii.Influenza, cough and cold
ix. All psychiatric or psychosomatic disorders
x. Pyrexia of unknown origin for less than 10 days
xi. Tonsillitis and upper respiratory tract infection including laryngitis &
pharangitis
xii. Arthritis, gout and rheumatism.
c. Domiciliary hospitalisation benefits also cover expenses on nurses
engaged on the recommendation of the attending Medical Practitioner. The
benefit under this Section is limited to the available Sum Insured for
Section 1a of this Policy as mentioned in the Schedule to this Policy.
Section IV

to that of Hospitalisation Sum Insured available under Section Ia.

In case the Insured / Insured Person is diagnosed to be suffering
from any of the Critical Illnesses and survives for a period of 30
days, then the Sum Insured specified under Section IV will be paid
as a lump sum. After availing the benefit under Section IV, if the
Insured / Insured Person takes treatment for the Critical Illness in
a Hospital, the hospitalisation expenses incurred for the same
would be payable/reimbursed, subject to the terms and conditions
of the Policy, out of the Sum Insured available for Hospitalisation
Benefit cover under Section Ia of this Policy. However, in case of
diagnosis of multiple illnesses qualified as Critical Illness under
the Policy, the payment of compensation shall be limited to the
Sum Insured as specified above and shall be payable only once.
b. In case the type of cover opted is Hospitalisation
Reimbursement basis
If, 60 days after the inception of this Policy, the Insured /
Insured Person is at any time during the Policy period (after
the above waiting period of 30 days), being diagnosed as
contracting any of the Critical Illnesses and is required to
undertake treatment in a Hospital for the same, the
Hospitalisation expenses incurred towards such treatment
is
covered under this benefit upto the specific Sum Insured
stated against this benefit.
The Sum Insured available for this cover is separate and
additional to that of Hospitalisation Sum Insured available
under Section Ia. In case the Insured / Insured Person is
diagnosed to be suffering from any of the Critical Illnesses
and takes treatment for the same in a Hospital, the
hospitalisation expenses incurred for the same would be
payable/reimbursed, subject to the terms and conditions of the
Policy, first out of the Sum Insured available for Critical Illness
cover under Section IV. Where the hospitalisation expenses
incurred for the treatment of the Critical Illness are in excess of
the Sum insured available under Critical Illness Cover under
Section IV, the excess may be paid / reimbursed out of the
available Sum Insured under the Hospitalisation Benefit under
Section Ia. The benefits available under Sections 1b, 1c and 1d of
this Policy as mentioned above are also applicable and available
under Critical Illness Section in case the type of cover opted is
Hospitalisation Reimbursement basis. In respect of prehospitalisation and post hospitalisation the limits of benefits are
the same as per the respective Sections of the Policy and
mentioned in the Schedule to this Policy. Where the Sum Insured
under Critical Illness is exhausted the excess amounts (which are
within the limits of these respective benefits) can be paid /
reimbursed out of the available Sum Insured under Section Ia of
the Policy. In case of diagnosis of multiple critical illnesses
requiring treatment covered under this Policy, the maximum
liability of the company under this Section shall not exceed the
Sum Insured as mentioned against this particular Section in the
Schedule to this Policy.

Critical Illness
(This benefit provides for coverage of treatment for critical
illness and the coverage depends upon the type of critical illness
cover basis (benefit or hospitalisation reimbursement basis)
selected and mentioned in the Schedule to this Policy.)
a. In case the type of cover opted is benefit basis:
If, 30 days after the inception of this Policy, the Insured /
Insured Person is at any time during the Policy period
(after the above waiting period of 30 days), being diagnosed as
contracting any Critical Illness and surviving for more than 30 days
post such diagnosis, the Sum Insured specified in the Schedule to
this Policy for this benefit shall be payable to the Insured/Insured
Person as compensatory benefit.
This Section operates as a benefit cover and compensation shall be
payable if the Insured / Insured Person is surviving for more than 30
days post diagnosis of any critical illness.
The Sum Insured available for this cover is separate and additional

Critical Illnesses in respect of which benefits are payable

under this Policy are as set out below:
1. Cancer: A malignant tumour characterized by the uncontrolled
growth and spread of malignant cells with invasion and
destruction of normal tissue. This diagnosis must be supported
by histological evidence of malignancy and confirmed by an
oncologist or pathologist.
The following are excluded:
a. Tumours showing the malignant changes of carcinomain-situ and tumours which are histologically described as
pre-malignant or non-invasive, included, but not limited
to: Carcinoma-in-situ of the Breasts, Cervical Dysplasia
CIN-1, CIN-2 and CIN-3.
b. Hyperkeratosis, basal cell and squamous skin cancers,
and melanomas of less than 1.5mm Breslow thickness,
or less than Clark Level 3, unless there is evidence of
metastases;

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c.

d.

Prostate cancers histologically described as TNM

Classification T1a or T1b or Prostate cancers of another
equivalent or lessr classification, T1N0M0 Papillary
Micro-carcinoma of the Thyroid less than 1 cm in diameter,
Papillary micro-carcinoma of the Bladder, and chronic
Lymphocytic Leukaemia less than RA1 Stage 3; and
All tumours in the presence of HIV infection.

9. Aplastic Anaemia: Chronic persistent bone marrow failure which

results in anaemia, neutropenia and thrombocytopenia requiring
treatment with at least one of the following:
a. Blood product transfusion;
b. Marrow stimulating agents;
c. Immunosuppressive agents; or
d. Bone marrow transplantation
The diagnosis must be confirmed by a haematologist.

2. First Heart Attack: Death of a portion of the heart muscle

arising from inadequate blood supply to the relevant area.
This
diagnosis must be supported by three or more of the following five
criteria which are consistent with a new heart
attack:
a. History of typical chest pain;
b. New electrocardiogram (ECG) changes proving infarction;
c. Diagnostic elevation of cardiac enzyme CK-MB;
d. Diagnostic elevation of Troponin (T or I);
e. Left ventricular ejection fraction less than 50% measured 3
months or more after the event.

10. End Stage Lung Disease: End Stage Lung Disease, causing chronic
respiratory failure. This diagnosis must be supported by evidence of
all of the following:
a. FEVI test results which are consistently less than one litre;
b. Permanent supplementary oxygen therapy for hypoxemia;
c. Arterial blood gas analyses with partial oxygen pressures of
55mm Hg or less (PaO2 <- 55 mm Hg); and
d. Dyspnea at rest.
The diagnosis must be confirmed by a respiratory physician.

3. Coronary Artery Disease: The narrowing of the lumen of at least one

coronary artery by a minimum of 75% and of two others by a
minimum of 60%, as proven by coronary arteriography, regardless of
whether or not any form of coronary artery surgery has been
performed. Coronary arteries herein refer to left main stem, left
anterior descending circumflex and right coronary artery.

11. End Stage Liver Failure: End Stage Liver Failure evidenced by all of
the following:
a. Permanent jaundice;
b. Ascites; and
c. Hepatic Encephalopathy.
Liver disease secondary to alcohol or drug abuse is excluded.

4. Coronary Artery By-pass surgery: The actual undergoing of d by

angiographic evidence of significant coronary artery obstruction and
the procedure must be considered medically necessary by a
consultant cardiologist. Balloon Angioplasty and/or any other intraarterial procedure are excluded.
open-chest surgery to correct the narrowing or blockage of one or
more coronary arteries with bypass grafts. This diagnosis must be
supported by angiographic evidence of significant coronary artery
obstruction and the procedure must be considered medically
necessary by a consultant cardiologist. Balloon Angioplasty and/or
any other intra-arterial procedure are excluded.

12. Coma: A coma that persists for at least 30 days. This diagnosis
must be supported by evidence all of the following:
a. No response to external stimuli for at least 30 days;
b. Life support measures are necessary to sustain life; and
c. Brain damage resulting in permanent neurological deficit
which must be assessed at least 30 days after the onset of
coma.
Coma resulting directly from alcohol or drug abuse is
excluded.

5. Heart Valve Surgery: The actual undergoing of open-heart surgery to

replace or repair heart valve abnormalities. The diagnosis of heart
valve abnormality must be supported by cardiac catheterization or
echocardiogram and the procedure must be considered medically
necessary by a consultant cardiologist.
6. Surgery to Aorta: The actual undergoing of major surgery to repair or
correct aneurysm, narrowing, obstruction or dissection of the aorta
through surgical opening of the chest or abdomen. For the purpose
of this definition aorta shall mean the thoracic and abdominal aorta
but not its branches. Surgery performed using only minimally
invasive or intra arterial techniques are excluded.
Angioplasty and all other intra arterial, catheter based techniques,
"keyhole" or laser procedures are excluded.
7. Stroke: A cerebrovascular incident including infarction of brain tissue,
cerebral and subarachnoid haemorrhage, cerebral embolism, and
cerebral thrombosis. This diagnosis must be supported by all of the
following conditions:
a. Evidence of permanent neurological damage confirmed by a
neurologist at least 12 weeks after the event; and
b. Findings on Magnetic Resonance imaging, Computerised
Tomography, or other reliable imaging techniques consistent with
the diagnosis of a new stroke.
The following are excluded:
a. Transient Ischaemic Attacks;
b. Brain damage due to an Accident or injury, infection,
vasculitis, and Inflammatory disease;
c. Vascular disease affecting the eye or optic nerve; and
d. Ischaemic disorders of the vestibular system
8. Kidney Failure: Chronic irreversible failure of both kidneys requiring
either permanentrenal dialysis or kidney transplantation.

13. Major Burns: Third degree (full thickness of the skin) burns
covering at least 30% of the surface of the insured person's
body.
14. Major Organ/Bone Marrow Transplantation:
The receipt of a transplant of:
a. Human bone marrow using haematopoietic stem cells
preceded by total bone marrow ablation; or
b. One of the following human organs: heart, lung, liver,
kidney, pancreas that resulted from irreversible end stage
failure of the relevant organ.
Other stem cell transplants are excluded.
15. Multiple Sclerosis: The definite occurrence of multiple
sclerosis. The diagnosis must be supported by all of the
following:
a. Investigations which unequivocally confirm the diagnosis
to be Multiple Sclerosis;
b. Multiple neurological deficits which occurred over a
continuous period of at least 6 months; and
c. Well-documented history of exacerbations and remissions of
said symptoms or neurological deficits.
Other causes of neurological damage such as SLE and HIV are
excluded.
16. Fulminant Hepatitis: A sub-massive to massive necrosis of the
liver by the Hepatitis virus, leading precipitously to liver failure.
This diagnosis must be supported by all of the following:
a. Rapid decreasing of liver size;
b. Necrosis involving entire lobules, leaving only a collapsed
reticular framework;
c. Rapid deterioration of liver function tests;
d. Deepening jaundice; and
e. Hepatic encephalopathy.

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17. Motor Neurone Disease: Motor Neurone Disease characterised by

progressive degeneration of corticospinal tracts and anterior
horn cells or bulbar efferent neurones which include spinal
muscular atrophy, progressive bulbar palsy, amyotrophic lateral
sclerosis and primary lateral sclerosis. This diagnosis must be
confirmed by a neurologist as progressive and resulting in
permanent neurological deficit.
18. Primar y Pulmonar y Hyper tension: Primar y Pulmonar y
Hypertension with substantial right ventricular enlargement
confirmed by investigations including cardiac catheterization
resulting in permanent physical impairment of Class IV of the New
York Heart Association (NYHA) Classification of Cardiac Impairment.
The NYHA Classification of Cardiac Impairment (Source
"Current Medical Diagnosis & Treatment- 39th edition"):
Class IV: Unable to engage in any physical activity without
discomfort. Symptoms may be present even at rest.
19. Terminal Illness: The conclusive diagnosis of an illness that is
expected to result in the death of the insured person within 12
months. This diagnosis must be supported by a specialist
and confirmed by the Company's appointed Doctor. Terminal illness
in the presence of HIV infection is excluded.
20. Bacterial Meningitis: Bacterial infection resulting in severe
inflammation of the membranes of the brain or spinal chord
resulting in significant, irreversible and permanent neurological
deficit. The neurological deficit must persist for at least 6
weeks. This diagnosis must be confirmed by:
a. The presence of bacterial infection in cerebrospinal fluid by lumbar
puncture; and
b. A consultant neurologist.
Bacterial Meningitis in the presence of HIV infection is excluded.
Dread Disease recuperation: If the Insured/Insured Person contracts any of the
Critical Illnesses and undertakes treatment for the same in a Hospital as an inpatient for which a valid claim under the Policy is admissible, a daily allowance
for certain number of days as specified in the Schedule to this Policy towards
Recuperation Expenses incurred post discharge from the Hospital after the
treatment for the specified critical illness, is payable under this benefit for 60
days subject to medical requirement as certified by the treating Physician.
Transplantation of Organs: Where the Insured/Insured Person contracts any of the
critical illnesses requiring major Organ Transplantation surgery and undergoes
surgery and treatment in a Hospital as an in-patient for which a valid claim under
this Policy is admissible, the hospitalisation expenses incurred by/on the Donor
towards donation of the major organ for the Insured / Insured Person for this
treatment is covered under this benefit, subject to overall limit of the Sum Insured
as specified in the Schedule to this Policy.
4. ADDITIONAL BENEFITS :
Benefits under this Section are payable as Additional Benefits upto the
limits specified in the Schedule to this Policy. A valid claim should have
been admitted under the Hospitalisation Section of the Policy, for
admission of liability under this Section. These benefits are payable also
when there is a Hospitalisation claim for Critical Illness treatment under
the Critical Illness Section.
Hospital Cash Allowance: In case the Insured / Insured Person is
hospitalized for treatment of any disease / illness / injury / critical illness
for which a valid claim is admissible under the Policy and if the
hospitalisation exceeds a specified number of days mentioned in the
Schedule to this Policy, this benefit provides for payment to the
Insured/Insured Person of a daily hospital allowance up to the specified
limits as mentioned in the Schedule to this Policy.
This benefit is applicable irrespective of the number of occurrences during
the Policy period subject to overall Sum Insured.
Home Nursing: This benefit provides for payment to the
Insured/Insured Person of an allowance for medical care services of a
nurse at the residence of the Insured/Insured Person following discharge

from Hospital after a treatment for a disease / illness / injury / critical

illness for which a valid claim under this Policy is admissible provided
such medical care services are confirmed as being necessary by the
attending Medical Practitioner and the same relate directly to the
disease / illness / injury / critical illness for which the Insured/Insured
Person has undertaken treatment during the hospitalisation, subject to
the limit prescribed in the Schedule to this Policy.
This benefit is applicable irrespective of the number of occurrences
during the Policy period subject to the overall Sum Insured.
Ambulance Charges: This benefit provides for reimbursement to the
Insured/Insured Person of expenses incurred for his/her transportation
by ambulance to and from the Hospital for treatment of disease / illness
/ injury / critical illness in a Hospital as an in-patient for which a valid
claim under this Policy is admissible, subject to the limits as specified in
the Schedule to this Policy.
This benefit is applicable irrespective of the number of occurrences
during the Policy period subject to the overall Sum Insured.
In-patient Physiotherapy Charges: This benefit provides for
reimbursement of charges incurred towards physiotherapy in the
Hospital that is confirmed as being necessary by the attending Medical
Practitioner and the same relates directly to the disease / illness / injury
/ critical illness for which the Insured/Insured Person has undertaken
treatment in the Hospital for which a valid claim is admissible under this
Policy, subject to limits as specified in the Schedule to this Policy.
Recovery Grant: In case the Insured / Insured Person is hospitalized for a
period of 8 days or more for treatment of any disease / illness / injury /
critical illness for which a valid claim is admissible under the Policy, this
benefit provides for payment to the Insured / Insured Person of a fixed
allowance as mentioned in the Schedule to this Policy.
This benefit is applicable irrespective of the number of occurrences
during the Policy period subject to overall limit of the Sum Insured.
Accompanying Person's Expenses: This benefit provides for payment an
allowance to the Insured/Insured Person towards expenses incurred on
the accompanying person at the Hospital/Nursing Home during
hospitalisation treatment of the Insured/Insured Person for the disease
/ illness / injury / critical illness necessitating hospitalization, subject to
the limit of Sum Insured as mentioned in the Schedule to this Policy.
Parent Accommodation as Companion for Child: This benefit provides for
payment of a fixed daily allowance towards meeting the expenses for the
stay of one of the parents at the Hospital/Nursing Home when the
Insured Person who is a child below the age of 12 years is hospitalized,
subject to the limit of Sum Insured as mentioned in the Schedule to this
Policy.
Out-patient Dental Emergency Treatment (arising out of Accident only):
This benefit provides for reimbursement of medical expenses incurred
towards emergency treatment by a Dentist following an accident where
the Insured / Insured Person suffers injuries or damage to his natural
teeth and/or gums. This benefit further provides cover for medical
expenses incurred for follow up treatment for the same accidental dental
injury up to a maximum of 15 days by the same Dentist. This benefit is
subject to overall limit of indemnity as specified in the Schedule to this
Policy.
Out-patient Emergency treatment for accidents: This benefit provides for
reimbursement of medical expenses incurred towards emergency treatment
by a Medical Practitioner for the Insured / Insured Person following an
accidental injury and such Emergency Treatment administered within 24
hours following the accident.
It also provides cover for medical expenses incurred for follow-up
treatment by the same Medical Practitioner up to 30 days from the date
of accident, including expenses incurred for medication prescribed on a
written basis by the attending Medical Practitioner for that same treatment or
consultation.
Children Education Fund: This benefit provides for payment of a fixed
amount, to a maximum of two dependant children upto the age of 23
years pursuing studies, in the event of death of the Insured / Insured
Person at Hospital whilst under treatment for disease / illness / injury /
critical illness as specified in the Schedule to this Policy.
Mortal Remains: This benefit provides for reimbursement of expenses

6 of 12

incurred for transportation of the mortal remains of the Insured / Insured

Person from Hospital to his/her place of residence in the event of death of
the Insured / Insured Person at the Hospital while under treatment for
disease / illness / injury / critical illness as specified in the Schedule to
this Policy.
Renewal Discount: The Policy shall provide for a discount, equivalent to 5%
of renewal premium every year on a progressive scale, as Renewal
Discount at the time of renewal, provided that the Policy being renewed is
claim free in the expiring year. This renewal discount on a progressive scale
will be allowed upto a maximum of 25%. In case of renewal of a Policy where
there is a loss, the Insured will lose the entire Renewal Discount
accumulated.
Income Tax Benefit: Premium paid under this Policy shall be eligible for
income tax deduction benefit under Sec 80 D as per the Income Tax Act.
Cost of Health Check-up: This Policy provides for reimbursement of cost of
medical check-up once at the end of a block of every four continuous
underwriting years, provided there were no claims reported/made under
the Policy during the block. This benefit shall be limited to 1% of the average
Sum Insured per person/family as the case may be during the block of four
underwriting years.
This additional benefit is available on the policies taken and renewed with
the Company for four continuous years, without any claim.
5. EXCLUSIONS:

n
Benign Prostatic Hypertrophy
n
Myomectomy, Hysterectomy or menorrhagia or fibromyoma

unless
n
because of malignancy
n
Dilation and curettage
n
Hernia, hydrocele, congenital internal disease, fistula in anus,

sinusitis
n
Skin and all internal tumors / cysts / nodules / polyps of any

kind including breast lumps unless malignant / adenoids and

hemorrhoids
n
Dialysis required for chronic renal failure
n
Gastric and Duodenal ulcers
n
Joint Replacement Surgeries unless necessitated by accident
n
This exclusion, however, doesn't apply for subsequent renewals
with the Company without a break. Further this exclusion shall
not apply in case of the Insured / Insured Person having been
covered
n
under any similar health insurance policy of any other general
insurance company including group insurance schemes in India
for a continuous period of preceding 24 months without any
break.
n
However, if the renewal premium is paid with in 15 days from the
date of policy expiry, coverage shall be deemed to be
continuous
n
with out break for the purpose of this exclusion.

The Company shall not be liable to make any payment for any claim directly
or indirectly caused by, based on, arising out of or howsoever attributable to
any of the following:

5. Circumcision unless necessary for treatment of a disease,

illness or injury not excluded hereunder, or, as may be necessitated
due to an accident.

6. Dental treatment which are not excluded hereunder or surgery of any

kind unless requiring hospitalisation.

Pre-existing diseases / illness / injury / conditions - The benefits will

not be available for any condition(s) as defined in the policy, until 48
months of continuous coverage have elapsed, since inception of the
first policy with the Company.
However, if the renewal premium is paid with in 15 days from the date of
policy expiry, coverage shall be deemed to be continuous with out
break for the purpose of this exclusion.

2. Any benefit under Critical Illness Section within 60 days of the

inception date of this Policy. This exclusion, however, doesn't apply for
subsequent renewals with the Company without a break. Such a
waiting period will reckon from the time the Policy has been taken with
the Company and renewed with the Company without any break. In
case of policies taken from other companies and renewed with the
Company with or without break, the waiting period as mentioned above
would be counted only from the time the Policy is renewed with the
Company and no credit will be given for the earlier years.
However, if the renewal premium is paid with in 15 days from the date of
policy expiry, coverage shall be deemed to be continuous with out
break for the purpose of this exclusion.
3. Hospitalisation expenses incurred for treatment undertaken for
disease or illness and/or for critical illness within 30 days of the
inception date of this Policy. This exclusion, however, doesn't apply for
subsequent renewals with the Company without a break. Further this
exclusion shall not apply in case of the Insured / Insured Person having
been covered under any similar health insurance policy of any other
general insurance company including group insurance schemes in
India for a continuous period of preceding 12 months without any
break.
However, if the renewal premium is paid with in 15 days from the date of
policy expiry, coverage shall be deemed to be continuous with out
break for the purpose of this exclusion.
4. Hospitalisation Expenses incurred on treatment of following
diseases, illness, injury within the first two years from the
inception of this Policy, will not be payable:
n
Cataract

7. Birth control procedures, hormone replacement therapy,

treatment arising from or traceable to pregnancy, childbirth
including caesarean section and voluntary medical termination of
pregnancy during the first 12 weeks from the date of conception.
However, this exclusion will not apply to Ectopic Pregnancy proved by
diagnostic means and certified to be life threatening by the
attending Medical Practitioner.
8. Any fertility, sub-fertility or assisted conception operation
9. Routine medical, eye and ear examinations, cost of spectacles, laser
surgery, contact lenses or hearing aids, issue of medical certificates
and examinations as to suitability for employment or travel.
10. Acquired Immune Deficiency Syndrome (AIDS), AIDS related
complex syndrom (ARCS) and all diseases / illness / injury caused by
and/or related to HIV.
11. Vitamins and tonics unless forming part of treatment for
disease, illness or injury as certified by the Medical Practitioner.
12. Treatment of obesity, general debility, convalescence, rundown
condition or rest cure, congenital external / disease / illness or
defects or anomalies, sterility, venereal disease or intentional selfinjury and use of intoxicating drugs/alcohol.
13. Any treatment received in convalescent homes, convalescent
hospitals, health hydros, nature cure clinics or similar establishments.
14. Medical Treatment following use of intoxicating drugs and alcohol or
drug abuse, solvent abuse or any addiction or medical condition
resulting from or relating to such abuse or addiction.
15. Sex change or treatment, which results from, or is in any way related
to, sex change.
16. Vaccination and inoculation of any kind.

7 of 12

under respective medical councils.

17. Treatment by a family member and self-medication or any treatment
that is not scientifically recognized.
18. Medical treatment required following any criminal act of the Insured /
Insured Person.
19. Disease / illness / injury / critical illness directly or indirectly, caused
by or arising from or attributable to foreign invasion, act of foreign
enemies, hostilities (whether war be declared or not), civil war,
rebellion, revolution, insurrection, military or usurped power, riot,
strike, lockout, military or popular uprising or civil commotion.
20. Disease / illness / injury whilst performing duties as a serving member
of a military or a police force.
21. Prostheses, corrective devices and medical appliances, which are not,
required intra-operatively or for the disease/ illness/ injury for which
the Insured / Insured Person was hospitalised which is not excluded
hereunder.

36. Medical Treatment in respect of the Insured/Insured Person whilst

engaging in speed contest or racing of any kind (other than on foot),
bungee jumping, parasailing, ballooning, parachuting, skydiving,
paragliding, hang gliding, mountain or rock climbing necessitating
the use of guides or ropes, potholing, abseiling, deep sea diving
using hard helmet and breathing apparatus, polo, snow and ice
sports.
37. Medical Treatment in respect of the Insured/Insured Person whilst
flying or taking part in aerial activities (including cabin crew) except
as a fare-paying passenger in a regular Scheduled airline or air
charter company.
6. GENERAL CONDITIONS
6.1.

Duty of Disclosure: The Policy shall be null and void and no benefit
shall be payable in the event of untrue or incorrect statements,
misrepresentation, mis-description or non-disclosure of any
material particulars in the proposal form, personal statement,
declaration and connected documents, or any material
information having been withheld, or a claim being fraudulent or
any fraudulent` means or device being used by the
Insured/Insured Person or any one acting on his/their behalf to
obtain a benefit under this Policy.

6.2.

Floater Policy: Where the Policy is obtained on floater basis

covering the family members, the Sum Insured as specified in the
Schedule to this Policy, shall be available to the Insured and all
and any one of the Insured Persons for one or more claims during
the Policy period

6.3.

Reasonable Care: The Insured/Insured Person shall take all

reasonable steps to safeguard the interests of the Insured /
Insured Person against accidental loss or damage that may give
rise to a claim.

6.4.

Observance of terms and conditions: The due observance and

fulfilment of the terms, conditions and endorsements of this
Policy in so far as they relate to anything to be done or complied
with by the Insured / Insured Person, shall be a condition
precedent to any liability of the Company to make any payment
under this Policy.

6.5.

Material Change: The Insured / Insured Person shall immediately

notify the Company by fax or in writing of any material change in
the risk and cause at his own expense such additional precaution
to be taken as circumstances may require to ensure safety
thereby containing the circumstances that may give rise to a claim
and the Company may adjust the scope of the cover and/or the
premium, if necessary, accordingly.

6.6.

Fraudulent Claims: If any claim 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 / Insured Person or anyone acting on his behalf to obtain
any benefits under the Policy, all benefits under this Policy shall be
forfeited. The Company will have the right to reclaim all benefits
paid in respect of a claim which is fraudulent as mentioned above
under this condition as well as condition No. 6.1 of this Policy.

6.7.

No Constructive Notice: Any knowledge or information of any

circumstances or condition in connection with the Insured /
Insured Person, in possession of any official of the Company shall
not be the notice to or be held to bind or prejudicially affect the
Company notwithstanding subsequent acceptance of the
premium.
Notice of Charge: The Company shall not be bound to take notice

22. Any stay in Hospital without undertaking any treatment or where there
is no active regular treatment by the Medical Practitioner.
23. Treatment of mental disease / illness, stress, psychiatric or
psychological disorders.
24. Aesthetic treatment, cosmetic surgery and plastic surgery unless
necessitated due to accident or as a part of any disease/ illness /
injury not excluded hereunder.
25. Any loss, directly or indirectly, due to contamination due to an act of
terrorism or terrorist incident, regardless of any contributory causes (if
the Company alleges that by reason of this exclusion any loss is not
covered by this insurance, the burden of proving the contrary shall be
upon the Insured / Insured Person).
26. Ionizing radiation or contamination by radioactivity from any nuclear
fuel or from any nuclear waste from the combustion of nuclear fuel.
27. Disease, illness, injury, directly or indirectly, caused by or contributed to
by nuclear weapons/materials or radioactive contamination.
28. Experimental and unproven treatment.
29. Charges incurred primarily for diagnostic, X-ray or laboratory
examinations or other diagnostic studies not consistent with or
incidental to the diagnosis and treatment of the positive existence or
presence of any disease, illness or injury, for which confinement is
required at a Hospital/Nursing Home or at home under domiciliary
hospitalisation as defined.
30. Cost incurred for medicines which are not under the advice of the
Medical Practitioner and which are not consistent with or incidental to
the diagnosis and treatment.
31. Any treatment which is undertaken as an out-patient without any
admission as an in-patient at the Hospital except those that are
specifically mentioned as covered in the Schedule to this Policy.
32. Costs of donor screening or treatment, unless specifically covered and
specified in the Schedule to this Policy.
33. Naturopathy treatment.
34. Any treatment received outside India.
35. Treatment taken from persons not registered as Medical Practitioners
6.8.

8 of 12

List of Insurance Ombudsmen

Office of the Ombudsman

Name of the Ombudsmen

Contact Details

Areas of Jurisdiction

AHMEDABAD

Shri Amitabh

Insurance Ombudsman Office of the Insurance

Ombudsman , 2nd Floor, Ambica House, Nr. C.U.Shah College,
5, Navyug Colony, Ashram Road, Ahmedabad - 380014.
Tel: 079-27546150. Fax: 079-27546142.
E-mail: [email protected]

Gujarat, UT of Dadra & Nagar

Haveli, Daman and Diu

BHOPAL

Shri N.A.Khan

Insurance Ombudsman Office of the Insurance

Ombudsman, Janak Vihar Complex, 2nd Floor,
Malviya Nagar, Bhopal.
Tel: 0755-2769201/02. Fax: 0755-2769203.
E-mail: bimalokpalbhopal@airtelbr oadband.in

Madhya Pradesh &

Chattisgarh

BHUBANESHWAR

Shri S.K.Dhal

Insurance Ombudsman Office of the Insurance

Ombudsman , 62, Forest Park, Bhubaneshwar - 751009.
Tel: 0674-2596461 (Direct). Secretary No.: 0674-2596455.
Tele Fax: 0674-2596429. E-mail: [email protected]

Orissa

CHANDIGARH

Shri K.M.Chadha

Insurance Ombudsman Office of the Insurance Ombudsman,

S.C.O. No.101,102 & 103, 2nd Floor, Batra Building Sector 17-D,
Chandigarh - 160017. Tel: 0172-2706196.
Fax: 0172-2708274. E-mail: [email protected]

Punjab, Haryana,
Himachal Pradesh,
Jammu & Kashmir,
UT of Chandigarh

CHENNAI

Shri K.Sridhar

Insurance Ombudsman Office of the Insurance

Ombudsman, Fatima Akhtar Court, 4th Floor,
453 (Old 312) Anna Salai, Teynampet, Chennai - 600018.
Tel: 044-24333678. Fax: 044-24333664.
E-mail:[email protected]

Tamil Nadu, UT-Pondicherry

Town and Karaikal (which are
part of UT of Pondicherry)

NEW DELHI

Shri R.Beri

Insurance Ombudsman Office of the Insurance Ombudsman,

2/2 A, Universal Insurance Bldg.
Asaf Ali Road, New Delhi - 110002.
Tel: 011-23239611. Fax: 011-23230858.
E-mail: [email protected]

Delhi & Rajasthan

GUWAHATI

Shri Sarat Chandra Sarma

Insurance Ombudsman Office of the Insurance Ombudsman,

Jeevan Nivesh, 5th Floor, Nr. Panbazar Overbridge,
S.S. Road, Guwahati - 781001.
Tel: 0361-2131307. Fax: 0361-2732937.
E-mail: [email protected]

Assam, Meghalaya,
Manipur, Mizoram,
Arunachal Pradesh,
Nagaland and Tripura

HYDERABAD

Shri P.A.Chowdary

Insurance Ombudsman Office of the Insurance

Ombudsman, 6-2-46, 1st Floor, Moin Court Lane Opp. Saleem
Function Palace, A.C.Guards, Lakdi-Ka-Pool,
Hyderabad - 500004.
Tel: 040-23325325. Fax: 040-23376599.
E-mail: [email protected]

Andhra Pradesh, Karnataka

and UT of Yanam - a part
of the UT of Pondicherry

ERNAKULAM

Shri James Muricken

Insurance Ombudsman Office of the Insurance

Ombudsman, 2nd Floor, CC 27/2603, Pulinat Building,
Opp. Cochin Shipyard, M.G. Road, Ernakulam - 682015.
Tel: 0484-2358734.
Fax: 0484-2359336.
E-mail: [email protected]

Kerala, UT of
(a) Lakshadweep,
(b) Mahe - a part of
UT of Pondicherry

KOLKATA

Shri K. Rangabhashyam

Insurance Ombudsman Office of the Insurance Ombudsman

North British Bldg. 29, N.S. Road, 3rd Floor, Kolkata - 700001.
Tel: 033-22134869. Fax: 033-22134868.
E-mail: [email protected]

West Bengal, Bihar, Jharkhand

and UT of Andaman & Nicobar
Islands, Sikkim

LUCKNOW

Shri M.S.Pratap

Insurance Ombudsman Office of the Insurance Ombudsman

Jeevan Bhawan, Phase 2, 6th Floor, Nawal Kishore Rd.,
Hazratganj, Lucknow - 226001.
Tel: 0522-2201188. Fax: 0522-2231310.
E-mail: [email protected]

Uttar Pradesh and Uttaranchal

MUMBAI

Shri R.K.
Vashishtha

Insurance Ombudsman Office of the Insurance Ombudsman

Jeevan Seva Annexe, 3rd Floor, S.V.Road, Santacruz (W),
Mumbai - 400054.
PBX: 022-26106928. Fax: 022-26106052.
E-mail: [email protected]

Maharashtra, Goa

9 of 12

of any trust, charge, lien, assignment or other dealing with or relating

to this Policy; but the payment by the Company to the Insured /
Insured Person, his/her nominee or his legal representative, as the
case may be, of any compensation or benefit under the Policy shall in
all cases be an effectual discharge to the Company.
6.9.

Special Provisions: Any special provisions subject to which this Policy

has been entered into and endorsed on the Policy or in any separate
instrument shall be deemed to be part of this Policy and shall have
effect accordingly.

6.10. Overriding effect: The terms and conditions contained herein and in
the Schedule shall be deemed to form part of the Policy and shall be
read as if they are specifically incorporate herein.
6.11. Electronic Transaction: The Insured / Insured Person agrees to
adhere to and comply with all such terms and conditions as the
Company may prescribe from time to time and hereby agrees and
confirms that all transactions effected by or through facilities for
conducting remote transactions including the internet, world wide
web, Electronic data interchange, call centres, teleservice
operations (whether voice, video, data or combination thereof) or by
means of electronic, computer, automated machines network or
through other means of telecommunication established by or on
behalf of the Company for and in respect of the policy or its terms or
the Company's other products and services, shall constitute legally
binding and valid transactions when done in adherence to and in
compliance with the Company's terms and conditions for such
facilities, as may be prescribed from time to time. However, the
terms of this condition shall not override provisions of any law(s) or
statutory regulations including provisions of IRDA regulations for
protection of policy holder's interests.
6.12. Duty of the Insured on occurrence of loss: On the occurrence of loss
within the scope of cover under the Policy, the Insured / Insured
Person shall:
a.
Forthwith file/submit a claim form in accordance with
"Claim Procedure" clause.
b.
Allow the Medical Practitioner or Surveyor or any agent
of the Company to inspect the medical and hospitalisation
records and to examine the Insured / Insured Person
c.
Assist and not hinder or prevent the Company or any of
its agents in pursuance of their duties
In case the Insured / Insured Person does not comply with
the provisions of this clause or other obligations cast upon
the Insured / Insured Person under this Policy or in any of the
policy documents, all benefit under the Policy shall be
forfeited, at the option of the Company.
6.13. Right to Inspect: If required by the Company, an
agent/representative of the Company including a Physician
appointed in that behalf shall in case of any loss or any
circumstances that have given rise to a claim to the Insured /
Insured Person be permitted at all reasonable times to examine into
the circumstances of such loss. The Insured / Insured Person shall
on being required so to do by the Company produce all relevant
documents relating to or containing reference relating to the loss or
such circumstance in his/her possession including presenting
himself for examination and furnish copies of or extracts from such
of them as may be required by the Company so far as they relate to
such claims or will in any way assist the Company to ascertain the
correctness thereof or the liability of the Company under this Policy.
6.14. Position after a claim: As from the day of receipt of the claim amount
by the Insured / Insured Person, the Sum Insured for the remainder
of the period of insurance shall stand reduced by a corresponding
amount. On payment of any claim under Section IV of this Policy (in
case of benefit basis), the Insured / Insured Person shall not be
eligible for any further claim/benefit against the same disease any
further including subsequent renewals.
6.15. Subrogation: In the event of any claim payment under this Policy, the

Company shall be subrogated to all the Insured / Insured

Person's rights or recovery thereof against any person or
organization and the Insured / Insured Person shall execute and
deliver instruments and papers necessary to secure such rights.
The insured and any claimant under this Policy shall at the
expense of the Company do and concur in doing and permit to be
done all such acts and things as may be necessary and required
by the Company, before or after indemnification, in enforcing or
endorsing any rights or remedies or of obtaining relief or
indemnity, to which the Company shall be or would become
entitled or subrogated. Remedies or of obtaining relief or
indemnity, to which the Company shall be or would become
entitled or subrogated.
6.16. Contribution: If there shall be existing any other insurance of any
nature whatsoever covering the same Insured / Insured Person
whether effected by the Insured /Insured Person or not, then the
Company shall not be liable to pay or contribute more than its
rateable proportion of any loss or damage. However provison of
this condition will not be applicable for any benefit cover including
Critical illness, Hospital Cash, Dread disease Recuperation,
Hospital Cash Allowance, Recovery Grant, Accompanying Person
Expenses, Parent Accommodation as Companion for Child, Mortal
Remains, Children Education Funds.
6.17. Forfeiture of claims: If any claim is made and rejected and no court
action or suit commenced within 12 months after such rejection
or, in case of arbitration taking place as provided therein, within 12
calendar months after the Arbitrator or Arbitrators have made
their award, all benefits under this Policy shall be forfeited.
6.18. Cancellation/Termination: The Company may cancel this Policy, by
giving 15 days notice in writing by Registered Post
Acknowledgment Due to the Insured at his / their last known
address. The company shall exercise its right to cancel only in
case of non-cooperation of the Insured / Insured Person in
implementing the terms and conditions of this Policy in which
case the Company shall be liable to repay on demand a rateable
proportion of the premium for the unexpired term from the date of
the cancellation. The Insured may also give 15 days notice in
writing, to the Company, for the cancellation of this Policy, in which
case the Company shall from the date of receipt of notice cancel
the Policy and retain the premium for the period this Policy has
been in force at the Company's short period scales. Provided
however that refund on cancellation of Policy by the Insured shall
be made only if no claim has occurred up to the date of
cancellation of this Policy.

Period on Risk

Rate of Premium to be retained

Up to 1 month

25% of annual rate

Up to 3 months

50% of annual rate

Up to 6 months

75% of annual rate

Exceeding six months

100%

6.19. Cause of action/Currency of payment: No claim shall be payable

under this policy unless the cause of action arises in India. All
claims shall be payable in India in Indian Rupees only.
6.20. Policy Disputes: The parties to this Policy expressly agree that the
laws of the Republic of India shall govern the validity, construction,
interpretation and effect of this Policy. Any dispute concerning the
interpretation of the terms and conditions, limitations and/or
exclusions contained herein is understood and agreed to by both
the Insured and the Company to be subject to Indian law. All
matters arising hereunder shall be determined in accordance with
the law and practice of such Court with in Indian Territory.
6.21. Arbitration: If any dispute or difference shall arise as to the

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quantum to be paid under this policy ( liability being otherwise

admitted) such difference shall independently of all other
questions be referred to the decision of a sole Arbitrator to be
appointed in writing by the parties to the dispute/difference, or
if they can not agree upon a single Arbitrator within 30 days of
any party invoking arbitration, the same shall be referred to a
panel of 3 Arbitrators, comprising of 2 Arbitrators and 1 to be
appointed by each of the parties to the dispute/difference and
the third Arbitrator to be appointed by such 2 Arbitrators.
panel of 3 Arbitrators, comprising of 2 Arbitrators and 1 to be
appointed by each of the parties to the dispute/difference and
the third Arbitrator to be appointed by such 2 Arbitrators.
Arbitration shall be conducted under and in accordance with the
provisions of the Arbitration and Conciliations Act 1996.
It is hereby agreed and understood that no dispute or difference
shall be referable to arbitration, as herein before provided, if
the Company has disputed or not accepted liability under or in
respect of this policy.
It is expressly stipulated and declared that it shall be a
condition precedent to any right of action or suit upon this policy
that the award by such Arbitrator/Arbitrators of the amount of
the loss shall be first obtained.
6.22. Renewal Notice: The Company shall give notice for renewal of
the Policy and accept renewal premium in all cases except in
case of non-cooperation of the Insured/Insured Person in
implementing the terms and conditions of this Policy. Every
renewal premium (which shall be paid and accepted in respect
of this policy) shall be so paid and accepted upon the distinct
understanding that no alteration has taken place in the facts
contained in the proposal or declaration herein before
mentioned and that nothing is known to the insured that may
result to enhance the risk of the Company under the guarantee
hereby given. No renewal receipt shall be valid unless it is on
the printed form of the Company and signed by an authorized
official of the Company.
However, in case the premium for renewal is paid with in 15
days from the policy expiring date, such renewal policy shall be
effective only from the time and date of receipt of premium. It is
further clarified that the company shall not be liable to pay
claims arising out of any disease or injury contacted during the
period between policy expiring date and receipt of renewal
premium by the company.
6.23. Notices: Any notice, direction or instruction given under this
policy shall be in writing and delivered by hand, post or facsimile
to
a. In case of the insured, at the address given in the
Schedule to the policy.
b. In case of the Company, to the policy issuing
office/nearest office of the Company.
6.24.

Customer Service: If at any time the Insured / Insured

Person requires any clarification or assistance, the insured/
Insured Person may contact the policy issuing office or any
other office of the Company or the TPA.

6.25.

Grievances: In case the Insured / Insured Person is aggrieved

in any way, the Insured / Insured Person may contact the
Company at the specified address, during normal business
hours. In case the Insured/Insured Person
has not got his/her grievances redressed by the Company
within 14 days, then he/she may approach the Insurance
Ombudsman for the redressal of the same, A list containing
the addressees of Offices of Ombudsman are attached to this
Policy. Policy holder may also obtain copy of IRDA circular
number 1385_GI-2002_ENG dated 26-04-2002, notification
on Insurance Regulatory and Development Authority

(Protesction of policy holders interests) Regulations, 2002 from

any of our offices.
6.26

Claim Notification Multi Model Intimation : It is the endeavour of

BhartiAxa to give multiple options to the insured/covered
person/patients care taker to intimate the claim to the Third
party administrator (TPA)/Company. The intimation can be given
in following ways
n
Toll Free call centre of the TPA (24x7)
n
Toll Free call centre of the Insurance Company(24x7)
n
Login to the website of the Insurance Company and
intimate the claim
n
Send an email to the TPA/Company
n
Send a fax to TPA/Company
n
Post/courier to TPA/Company
n
Direct Contact
In all the above the intimations are directed to a central team
for prompt, standardized action.
Information Details
When the insured/covered person/patients care taker
intimate the claim as mentioned above the following
information should be kept handy for prompt services.
n
Policy number
n
Name of the Insured/Covered person
n
Contact details
n
Nature of the disease, illness or injury
n
Name and address of the attending medical
ractitioner/hospital
Claim Form
Upon the notification of the claim the TPA/Company will
dispatch the claim form to the Insured/Covered person.
Claim forms will also be available with the network hospitals
and Company offices.

6.27

Claim Procedure
CASHLESS HOSPITALISATION:
n
Company will work with one or more TPAs for providing
cashless facility to the Insured/Covered person.
n
List of network hospitals will be provided to the
Insured/Covered person along with the policy and it will be
regularly updated and informed to them. Insured/Covered
person can view the updated hospital list from the website of
the TPA/Company too.
n
Insured/covered person on admission (emergency) or willing
to admit (planned admission) in the network hospitals a preauthorization request form has to be filled in by the treating
doctor/hospital and the same has to be faxed to the TPA by
the insured/hospital. The TPA after verifying the same will
decide on the issuance of authorization. The action of preauthorization will be done within 6 hours for emergency
admission and 48 hours for planned admission.
n
The preauthorization request form will be available in the
benefit guide issued along with the policy, available in the
hospitals, can be downloaded from the website of the
TPA/Company, can request for the same to the TPA/Company
via email or fax or can be collected in person from the
branches of the TPA/Company.
n
Denial of the cashless does not mean the claim has been
rejected. The insured/covered person can send the requisite
claim documents to the TPA/Company seeking
reimbursement.
n
The insured/covered person need not pay any amount to the
hospital if he has received the authorization letter except
n
If the bill amount is in excess of the sum insured
n
Non medical expenses
n
Unrelated treatments
n
Excess, if any

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n
The hospital will receive the payment from TPA/Company within

6.28

21 days from the date of receipt of complete claim documents.

REIMBURSEMENT CLAIMS

In cases where investigation is deemed necessary, the same

will be conducted in all promptitude. Every attempt will be
made to keep the process transparent.

n
Insured/covered person unwilling to utilize the cashless facility

in the network hospital can send the claim documents along

with the pre/post hospitalization documents for the period
specified in the policy to the TPA/Company for the
reimbursement with in 15 days of end of the post hospitalization
period or the medical fitness certificate issued by the attending
physician, which ever is earlier.
n
Insured/covered person admitted in a non network hospital can
send the claim documents along with the pre/post
hospitalization documents for the period specified in the policy
to the TPA/Company for the reimbursement with in 15 days of
end of the post hospitalization period or the medical fitness
certificate issued by the attending physician, which ever is
earlier.
n
Insured/covered person should intimate the claim to the
TPA/Company within reasonable period of hospitalization.
n
After receiving the complete documents the TPA/Company will
reimburse the claim amount within 14 days to the insured.

Documents
It is the policy of the Company to seek documents in a single
shot. If any further documentation is required then it will be
sought promptly.

6.29

Repudiations
The power to repudiate claims is vested in the corporate
office to ensure transparency and standardization across the
country. This is also with a view to keep the guidelines of
regulator in mind. In the unfortunate event of repudiation, the
retail customers will be informed of the existence of forums
for grievance redressal.

Checklist of documents for settling Claims:

Insurance is the subject matter of the solicitation.

Sl.
No.

CHECKLIST

1.

Claim form duly signed along with attending physician

statement

2.

Pre auth form-if cashless claim

3.

Discharge summary

4.

Hospital final bill

5.

Attending Surgeons/Physicians Prescription

advising hospitalization

6.

Surgery/consultation bills and receipts

7.

Operation theatre and pharmacy bills

8.

Medicines bill with doctors prescription

Pre hospitalization bills with receipts

10.

Post hospitalization bills with receipts

11.

Hospital payment receipt in case of reimbursements

12.

Diagnostic reports with doctors prescription

13.

Others if any

PW/SHI/ORI/09-09

9.

Tick the
boxes

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