TATA AIG General Insurance Company Limited

Tata AIG MediCare LITE - Prospectus

1. Suitability:
a. This policy covers persons in the age group 91 days onwards (Dependent children
between 91 days and 5 years can be insured only when both parents are getting insured).
The maximum entry age is 65 years.
b. There is no maximum cover ceasing age under this policy.
c. The policy will be issued for a period 1/2/3 years.
d. This policy can be issued to an individual and/or to a family on family floater basis.
e. The family includes spouse and economically dependent children and up to 2 parents and
up to 2 parent-in-laws.
Relationships covered: Self, spouse, upto 3 dependent children , upto 2 parents & upto 2
parents-in-laws. In case of family floater, where the dependent child(ren) attains 26 years
of age at renewal, the child(ren) can be covered under a separate policy with eligible
continuity benefit.

2. Sum Insured options (in ₹):

• 5 Lacs
• 7.5 Lacs
• 10 Lacs
• 15 Lacs
• 20 Lacs

3. Zone(s):
For the purpose of premium computation, the country is categorized in three Zones and premium
payable under the policy will be calculated based on the residential location/address as provided
by the proposer/insured person in the proposal form:

• Zone A: Mumbai (including Mumbai Metropolitan Region), Delhi (including National

Capital Region, Faridabad, Ghaziabad), Ahmedabad, Surat & Baroda
• Zone B: Hyderabad (including Secunderabad), Bengaluru, Kolkata, Indore, Chennai,
Chandigarh (including, Mohali, Punchkula, Zirakpur), Pune (including Pimpri Chinchwad)
and Rajkot
• Zone C: Rest of India

4. Key Benefits:
a) Range of benefits: Indemnity based health insurance cover with range of benefits.
b) Network of hospitals: We are equipped to offer you quality health care with our strong
network of hospitals (Valued Provider – Pan India) across India.

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c) Lifelong renewal: We offer you a lifelong renewal for your policy provided premium is
paid without any break. Your premiums will be basis the age, sum insured, plan, zone and
optional cover. Your renewal premium will be basis your age on renewal and there will be
no extra loadings based on your individual claim.
d) Restore Benefit: If the balance Sum Insured and accrued Cumulative Bonus is insufficient
to pay an admissible claim under In-Patient Treatment, Pre-Hospitalization Expenses,
Post-Hospitalization Expenses, Day Care Treatment, Organ Donor cover or Domiciliary
Treatment cover, We will automatically reinstate 100% of the Sum Insured once during
the policy year. In case of Any One Illness, this benefit for related Illness/ Injury would be
available to the Insured Person(s), who have claimed earlier, only for Hospitalization/
Domiciliary Hospitalization where date of admission is beyond 45 days from the date of
discharge of the immediately preceding Hospitalization/ date of end of Domiciliary
Hospitalization, for which claim has been paid. This unutilized Restored Sum Insured
cannot be carried forward to the next Policy Year.
e) Cumulative bonus/No Claim Discount: You have the option to choose between
Cumulative Bonus and No Claim Discount. If you choose Cumulative Bonus, sum insured
will increase by 50% for every claim free policy year subject to maximum of 100% of sum
insured. In 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. 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.
f) Wellness Services: Teleconsultation - General
We /Our empanelled service provider will arrange for teleconsultations upon Insured
Person’s request through telecommunications and digital communication technologies
for Insured Person’s health related complaints or preventive health care by a qualified
Medical Practitioner/ Health Care Professional.
g) 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.

5. Salient Features:
i. In-patient Treatment: Covers Medical expenses for Medically Necessary Treatment in a
Hospital, due to disease/Illness/Injury, that requires an Insured Person’s admission in a
Hospital for an Inpatient Care, during the Policy Period. Medical expenses directly related
to the hospitalization would be payable.
ii. Pre-Hospitalisation Expenses: Covers Medical Expenses incurred upto 60 days prior to
the date of admission to the hospital.
iii. Post-Hospitalisation Expenses: Covers Medical Expenses incurred upto 180 days
immediately after the Insured Person was discharged post Hospitalisation.
iv. Day Care Treatment: Covers expenses for Day Care Treatment due to
disease/illness/Injury, taken in a hospital or a Day Care Centre during the policy period..

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v. Organ Donor: Covers Medical Expenses incurred by or in respect of the organ donor, for
an organ transplant Surgery, solely towards the harvesting of the organ donated. The
insured person must be the recipient of the organ so donated by the organ donor.
vi. Domiciliary Treatment: Covers Medical Expenses related to Domiciliary Hospitalization
of the Insured Person if the treatment exceeds beyond three consecutive days and is
availed during the Policy Period. The treatment must be for management of an Illness and
not for enteral feedings or end of life care.
vii. Restore Benefit: Automatically reinstate 100% of the Sum Insured , if the balance Sum
Insured and accrued Cumulative Bonus is insufficient to pay an admissible claim under In-
Patient Treatment, Pre-Hospitalization Expenses, Post-Hospitalization Expenses, Day Care
Treatment, Organ Donor or Domiciliary Treatment cover, during the policy year.
viii. AYUSH Benefit: Covers medical Expenses incurred for In-patient/Day care treatment
taken in an AYUSH hospital/AYUSH day care centre, including pre and post hospitalization
expenses.
ix. Ambulance Cover: Covers expenses incurred on transportation of Insured Person in a
registered ambulance to a hospital for admission in case of an emergency.
x. Health Checkup: We / Our empaneled service provider will arrange for listed medical
tests every Policy Year, only on cashless basis.
xi. Compassionate Travel: In the event the Insured Person is Hospitalized in India for more
than Five consecutive days in a place where no adult member of his immediate family is
present, we will cover expenses related to a round trip economy class domestic air ticket,
or first-class railway ticket, to allow the Immediate Family Member be at his bedside for
the duration of his stay in the hospital, subject to a maximum limit during a Policy Year,
as mentioned in the ‘Benefit Table’.
xii. Bariatric Surgery Cover: Covers reasonable and customary expenses for Bariatric surgery
if the insured person fulfills all the following conditions:
i. Surgery to be conducted upon the advice of the Doctor
ii. The surgery/Procedure conducted should be supported by clinical
protocols.
iii. The member has to be 18 years of age or older and
iv. Body Mass Index (BMI) greater than or equal to 40 or
v. BMI greater than or equal to 35 in conjunction with any of the following
severe comorbidities following failure of less invasive methods of weight
loss:
a) Obesity-related cardiomyopathy,
b) Severe sleep apnea,
c) Uncontrolled Type2 Diabetes, or
d) Coronary heart disease
xiii. In-patient Treatment- Dental: Covers medical expenses incurred towards hospitalization
for dental treatment under anesthesia necessitated due to an accident/injury/illness
xiv. Vaccination Cover: Covers the cost of the following vaccines:
- Anti-rabies vaccine following an animal bite
- Typhoid vaccination
After 2 years of continuous coverage with us:
- Human Papilloma Virus (HPV) vaccine

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- Hepatitis B Vaccine
xv. Hearing Aid: Covers reasonable charges for a hearing aid for the Insured Person, every
third year, subject to a maximum limit as mentioned in the ‘Benefit Table’.
xvi. Daily cash for choosing shared accommodation: We will pay a fixed amount per day, if
the Insured Person is Hospitalized in Shared Accommodation in a Hospital in Our network
of Valued Provider – Pan India, for each continuous and completed period of 24 hours of
Hospitalization. The benefit payable per day would be subject to a maximum limit as
mentioned in the ‘Benefit Table’.
xvii. Daily cash for accompanying an insured child: We will pay a fixed amount per day, if the
Insured Person Hospitalized is a child Aged 12 years or less, for one accompanying adult
for each completed period of 24 hours of Hospitalization in Our network of Valued
Provider – Pan India. The benefit payable per day would be subject to a maximum limit as
mentioned in the ‘Benefit Table’.
xviii. Second Opinion: We will provide You a second opinion from Our Empaneled Service
Provider, if an Insured Person is diagnosed with the mentioned Illnesses during the Policy
Period.

6. Optional Covers:
You can choose below mentioned optional cover by paying an additional premium.

• Accidental Death Benefit: If an Insured Person suffers an accident during the policy period
and this is the sole and direct cause of his death within 365 days from the date of accident,
then we will pay the Sum Insured as mentioned in the ‘Benefit Table’. This benefit is not
applicable for insured children or Insured Person less than 18 years of Age as on Policy
commencement date.

7. Cost Sharing:
a) Age linked Co-Payment
If the entry Age of the Insured Person is 61 years or above at the time of first coverage under
this Policy, then such Insured Person shall bear 20% of each admissible claim.

b) Co-Payment for treatment availed out of Our Network of Valued Provider - Pan India
If the Insured Person avails treatment outside Our network of “Valued Provider-Pan India”,
then a Co-Payment of 30% will be applicable for each such claim resulting from admission of
the Insured Person in a Hospital/ Day Care Centre/ AYUSH Hospital/ AYUSH Day Care Centre.
However, no Co-Payment under this sub section shall be applicable if Hospitalization is for an
Injury arising from an Accident.

Note: ‘Valued Provider - Pan India’ is a specific network of Hospital(s), designated as such. It
consists of a defined list of Hospital(s) or health care providers enlisted by Us, and/or TPA to
provide medical services to an Insured Person by a Cashless Facility. The updated list of Valued
Provider - Pan India is available on Our website (www.tataaig.com).

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8. Discounts on premium:
a) 10% long term discount on premium in case insured opts policy term of 3 years
b) 5% long term discount on premium in case insured opts policy term of 2 years
c) Family floater discount on the base premium:
• 2 members -20%
• 3 members -28%
• 3+ members-32%
d) 10% discount to all TATA Group employees

9. Renewal Incentives:
Cumulative Bonus: We will provide Cumulative Bonus in the form of 50% of the base Sum
Insured of the expiring Policy, on each Renewal of the Policy, after every claim free Policy Year,
provided that the Policy is renewed with Us without a break. The total accrued Cumulative
Bonus shall not exceed 100% of the base Sum Insured in any Policy Year. Cumulative Bonus shall
be provided only if No Claim Discount has not been availed for the claim free previous Policy
Year. Alternately, No Claim Discount in premium can be opted, in which case policy will not be
entitled for Cumulative Bonus.

10. 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 45 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.

11. 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 toa refund of the premium paid

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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

12. Waiting Period:

i. 30 days Waiting Period (Code- Excl 03)::

a. Expenses related to the treatment of any illness within 30 days from the first policy
commencement date shall be excluded except claims arising due to an accident, provided
the same are covered.
b. This exclusion shall not, however, apply if the Insured Person has Continuous Coverage
for more than twelve months.
c. The within referred waiting period is made applicable to the enhanced sum insured in the
event of granting higher sum insured subsequently.

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

a) Expenses related to the treatment of the listed Conditions, surgeries/treatments shall be
excluded until the expiry of 24 months of continuous coverage after the date of inception
of the first policy with us. This exclusion shall not be applicable for claims arising due to
an accident.
b) In case of enhancement of sum insured the exclusion shall apply afresh to the extent of
sum insured increase.
c) If any of the specified disease/procedure falls under the waiting period specified for pre-
Existing 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 disease/conditions/treatments:
I. Tumors, Cysts, polyps including breast lumps (benign)
II. Polycystic ovarian disease, Fibromyoma, Adenomyosis, Endometriosis
III. Prolapsed Uterus
IV. Rheumatism
V. Ligament, Tendon or Meniscal tear
VI. Prolapsed Inter-Vertebral Disc
VII. Cholelithiasis
VIII. Pancreatitis
IX. Fissure/fistula in anus, haemorrhoids, pilonidal sinus
X. Ulcer & erosion of stomach & duodenum
XI. Gastro Esophageal Reflux Disorder (GERD)
XII. Liver Cirrhosis

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XIII. Perineal Abscesses

XIV. Perianal / Anal Abscesses
XV. Calculus diseases of Urogenital system Example: Kidney stone, Urinary
bladder stone.
XVI. Benign Hyperplasia of prostate
XVII. Varicocele
XVIII. Cataract, Retinal detachment, Glaucoma
XIX. Congenital Internal Diseases

List of procedure/surgeries/treatments:

XX. Adenoidectomy
XXI. Mastoidectomy
XXII. Tonsillectomy
XXIII. Tympanoplasty
XXIV. Surgery for nasal septum deviation
XXV. Nasal concha resection
XXVI. Surgery for Turbinate hypertrophy
XXVII. Hysterectomy
XXVIII. Osteoarthritis, joint replacement, osteoporosis,
XXIX. Systemic connective tissue disorders, inflammatory polyarthropathies,
Rheumatoid, Gout
XXX. Cholecystectomy
XXXI. Hernioplasty or Herniorraphy
XXXII. Surgery/procedure for Benign prostate enlargement
XXXIII. Surgery for Hydrocele/ Rectocele/Spermatocele
XXXIV. Surgery of varicose veins and varicose ulcers

iii. 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.

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13. General Exclusions:

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

Medical Exclusions:

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):

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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. Expenes towards miscarriage (unless due to an accident) and lawful medical termination
of pregnancy during the policy period.
xiii. Alcoholic pancreatitis or Alcoholic liver disease;
xiv. Congenital External Diseases, defects or anomalies;
xv. Stem cell therapy; however hematopoietic stem cells for bone marrow transplant for
haematological conditions will be covered under this policy;
xvi. Growth Hormone Therapy;
xvii. Sleep-apnoea and Sleeping disorder;
xviii. Admission primarily for administration (via any form or mode) of immunoglobulin infusion or
supplementary medications like Zolendronic Acid, etc;
xix. Venereal disease, sexually transmitted disease or illness;
xx. All preventive care, vaccination including inoculation and immunisations;

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xxi. Dental treatment or Dental Surgery of any kind unless incidental to an admissible hospitalization
claim where the cause of admission is accident/ illness; cost of dentures, dental implants and
braces;
xxii. Any existing disease specifically mentioned as Permanent exclusion in the Policy Schedule;
xxiii. Non payable items as mentioned in Annexure I – List I of optional items available on Our website
(www.tataaig.com);

Non-Medical Exclusions:

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.
iv. 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.
v. Nuclear, chemical or biological attack or weapons, contributed to, caused by, resulting from or
from any other cause or event contributing concurrently or in any other sequence to the loss,
claim or expense
vi. Any Insured Person’s participation or involvement in naval, military or air force operation,
vii. Intentional self-injury or attempted suicide while sane or insane.
viii. 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.
ix. Treatment rendered by a Medical Practitioner which is outside his discipline.
x. 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.
xi. Fitting of hearing aids, provision/fitting of spectacles or contact lenses including optometric therapy.
xii. Any treatment and associated expenses for alopecia, baldness, wigs, or toupees, medical supplies
including elastic stockings, diabetic test strips, and similar products.

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xiii. Any treatment or part of a treatment that does not form part of ‘Reasonable and Customary
Charges’ nor is Medically Necessary.
xiv. Expenses which are either not supported by a prescription of a Medical Practitioner or are not related
to Illness or disease for which claim is admissible under the Policy
xv. Any external appliance and/or device used for diagnosis or treatment except when used intra-
operatively.
xvi. 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.

14. Claim Procedure:

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.

a. Notification of claim & Assistance:

Every claim needs to be notified to Us.
Please contact our designated TPA/Us atleast 48 hours prior to an event which might give rise to
a claim. For any emergency situations, kindly contact our TPA within 24 hours of the event.

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

b. Claim Related Information:

For any claim related query, intimation of claim and submission of claim related documents, the
Policyholder/Insured Person can contact us through:

• Name of Claims Administrator: << >>

• Website : << >>
• Email : << >>
:<< >> (for Senior Citizens)

• Toll Free : << >>

: << >> (for Senior Citizens)

• Fax : << >>

• Submit claim : << >>

Any change in TPA by Us shall be communicated to You 30 days before such effect of change.

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c. Procedure for reimbursement claims:

• Please send the duly signed claim form and all the information/documents mentioned therein
to our TPA/Us within 15 days of the occurrence of the Incident.
• Please refer to claim form for complete documentation.
• If there is any deficiency in the documents/information submitted by the
Policyholder/Insured Person, our TPA/We will send the deficiency letter within 7 working days
of receipt of the claim documents.
• On receipt of the complete set of claim documents, We will send the payment for the
admissible amount, along with a settlement statement within 30 days.
• The payment will be sent in the name of the proposer/ Nominee in case of death of Proposer

d. Procedure for Cashless Service at Our network of Valued Provider – Pan India
i. Insured person is entitled for cashless coverage only in our network of Valued Provider – Pan
India .
ii. In order to avail cashless treatment, the following procedure must be followed:
• Prior to taking treatment and/or incurring Medical Expenses at a Network Hospital, the
Policyholder/Insured Person must notify our designated TPA/Us and request pre-
authorization.
• Our designated TPA/We will check your coverage as per the eligibility and send an
authorization letter to the provider.
• In case of deficiency in the documents sent to TPA/Us for cashless authorization, the same
shall be communicated to the hospital by TPA/Us..
Note:

• Please refer to our website (www.tataaig.com) or call us on our toll free number at 1800-266-
7780 or << >> (for Senior Ctizens) for updated list of Valued Provider – Pan India.
• Rejection of cashless facility in no way indicates rejection of the claim.

e. Claim settlement (provision for Penal Interest):

i. The Company shall settle or reject a claim, as the case may be, within 30 days from the date
of receipt of last necessary document.
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.

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f. Claim Procedure and management of Health Checkup & Wellness Services:

Service may be availed through Our website or Our mobile application or through calling Our call
centre on the toll free number specified in the Policy Schedule. Alternatively, details of Our
empanelled service provider are available on Our website (www.tataaig.com).

g. 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.

15. Renewal of Policy:

The policy shall ordinarily be renewable except on grounds of established fraud, non-disclosure
or misrepresentation by the insured person.

i. Renewal shall not be denied on the ground that the insured person had made a claim
or claims in the preceding policy years.
ii. Request for renewal along with requisite premium shall be received by the Company
before the end of the policy period.
iii. Single premium payment mode Policy can be renewed within the Grace Period of 30
days to maintain continuity of benefits without break in policy. Coverage is not
available during the grace period after the end of the policy period. If not renewed
under the Grace Period, the Policy shall terminate at the end of the Grace period.
iv. The grace period for payment of the premium during the Policy Period, for
instalment premium shall be fifteen days where premium payment mode is
monthlyand thirty days in all other cases (Half-Yearly/ Quarterly).
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.

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16. 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.

17. 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.

18. Withdrawal of the policy:

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

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

19. 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.

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20. 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.

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

22. Pre-policy medical check-up:

Pre-policy medical examination gird:

Age/Sum Insured All Sum Insured Options

Upto 17 Years Tele MER/ Video MER (only if positive medical declaration)
Individual: Tele MER/ Video MER
18 Years – 45
Family Floater: Tele MER / Video MER (only if positive medical
Years
declaration)
46 Years and
Tele MER/ Video MER/PPC (Applicable for all plans)
above
- In case of adverse medical declaration, we may call for additional medical tests. We may conduct
medical tests at diagnostic centre based on medical disclosure wherever applicable.
- 100% of TeleMER cost would be borne by the Company, in case of proposal acceptance.
- At least 50% of pre-policy medical checkup cost would be borne by Tata AIG in case where proposal is
accepted.
- Pre-Policy Check-up(PPC) at our network, if required. The medical reports are valid for a period of 90
days from the date of Pre-Policy Checkup.
The Company may conduct Tele MER / Video MER / Pre – Policy Check – up based on age / Sum Insured
medical declaration or any other underwriting criteria.

23. Premium Rates:

a) The premium will be charged on the completed age of the Insured Person and as per
applicable zone.
b) For family floater, premium is calculated by adding the premium of respective individual
members and applying family floater discount.

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Monthly/Quarterly/Half-Yearly instalment options would be allowed and following loadings shall be

applicable as per the selected installment option and Policy Tenure:

Policy Tenure
Installments
1 Year 2 Year 3 Year
Monthly 5.00% 9.00% 13.00%
Quarterly 4.00% 8.00% 11.50%
Half-Yearly 3.00% 7.00% 10.50%

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

I. Grace Period of 15 days would be given to pay the installment premium due for the
policy where premium payment mode is monthly and thirty days in all other cases
(Half-Yearly/Quarterly). During such grace period, coverage shall be available from
the due date of installment premium till the date of receipt of premium by Company.
II. The insured person will get the accrued continuity benefit in respect of the "Waiting
Periods", "Specific Waiting Periods" in the event of payment of premium within the
stipulated grace Period.
III. No interest will be charged lf the installment premium is not paid on due date
IV. In case installment premium due is not received within the grace period, the policy
will get cancelled.
V. In the event of a claim, all subsequent premium instalments shall immediately
become due and payable.
VI. The company has the right to recover and deduct all the pending installments from
the claim amount due under the policy.

(Annual Per Person Rates in ₹ )

Zone A
Age (in years)/ Sum Insured 5 Lakhs 7.5 Lakhs 10 Lakhs 15 Lakhs 20 Lakhs
91 Days -17 5,162 5,496 5,604 6,282 6,496
18-35 7,937 8,359 8,521 9,511 10,158
36-40 9,642 10,044 10,440 11,549 12,210
41-45 10,397 10,832 11,255 12,456 13,171
46-50 14,556 15,058 15,585 17,572 17,939
51-55 19,222 20,173 20,715 22,989 23,517
56-60 23,465 24,589 24,701 27,199 28,589
61-65 29,541 30,988 31,059 34,563 35,935
66-70^ 45,939 48,847 48,970 55,088 57,075

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71+^ 57,384 60,484 61,848 69,472 71,197

(Exclusive of taxes)

(Annual Per Person Rates in ₹ )

Zone B
Age (in years)/ Sum Insured 5 Lakhs 7.5 Lakhs 10 Lakhs 15 Lakhs 20 Lakhs
91 Days -17 4,812 5,236 5,276 6,007 6,219
18-35 6,851 7,330 7,990 8,998 9,417
36-40 8,267 8,816 9,761 11,081 11,413
41-45 8,912 9,507 10,520 11,949 12,308
46-50 13,342 14,186 14,683 16,530 17,029
51-55 17,017 18,057 18,367 20,496 21,379
56-60 20,767 21,943 22,068 24,959 25,659
61-65 25,918 27,940 28,101 31,021 32,676
66-70^ 40,227 43,964 44,171 49,756 51,669
71+^ 50,822 53,256 55,524 61,152 64,902
(Exclusive of taxes)

(Annual Per Person Rates in ₹ )

Zone C
Age (in years)/ Sum Insured 5 Lakhs 7.5 Lakhs 10 Lakhs 15 Lakhs 20 Lakhs
91 Days -17 4,050 4,310 4,377 4,951 5,098
18-35 6,273 6,506 6,742 7,632 7,786
36-40 7,575 7,991 8,097 9,244 9,594
41-45 8,160 8,611 8,719 9,961 10,340
46-50 11,306 11,849 12,071 13,456 14,196
51-55 15,284 15,577 15,767 17,888 18,486
56-60 18,241 19,160 19,479 21,303 22,140
61-65 22,905 24,183 24,238 27,154 28,358
66-70^ 35,391 37,360 37,552 41,610 44,115
71+^ 44,959 46,577 47,759 54,191 55,598
(Exclusive of taxes)

Accidental Dealth Benefit (Optional Cover) (Annual Per Person Rates in ₹ )

All Zones
Age (in Years)\Sum Insured 5 Lakh 7.5 Lakh 10 Lakh 15 Lakh 20 Lakh
All Ages 279 418 558 836 1,115
(Exclusive of taxes)
^ Premium rates for age above 65 is for renewal.

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24. Loadings:
i. We may apply a risk loading on the premium payable (based upon the declarations made in the
proposal and the health status of the persons proposed for insurance).
ii. The loading shall be applied basis outcome of Our underwriting.
iii. These loadings are applied from Commencement Date of the Policy including subsequent renewal(s)
with Us or on the receipt of the request of increase in Sum Insured (for the increased Sum Insured).
a. We will inform You about the applicable risk loading through a counter offer letter.
b. You need to revert to Us with consent and additional premium (if any), within 15 days of the
issuance of such counter offer letter.
c. In case, you neither accept the counter offer nor revert to Us within 15 days, We shall cancel
Your application and refund the premium paid within next 10 days subject to deduction of
the Pre-Policy Check up charges, as applicable.
iv. Please note that We will issue Policy only after getting Your consent.

25. Cancellation:
You may terminate this Policy at any time by giving Us written notice, and the Policy shall
terminate when such written notice is received. The cancellation shall be from the date of receipt
of such notice. If and only if no claim has been made under the Policy, then We will refund
premium in accordance with the table below:

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. provided no refunds
of premium shall be made in respect of Cancellation where, any claim has been admitted or has
been lodged or any benefit under this Policy has been availed by the Insured Person under the
Policy.

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.

26. Redressal of Grievance:

The Company is committed to extend the best possible services to its customers. However, if you
are not satisfied with our services and wish to lodge a complaint, please feel free to call our 24X7
Toll free number <<1800-266-7780 or 022-66939500>> (tolled) or you may email to the customer
service desk at [email protected]. After investigating the matter internally and
subsequent closure, we will send our response within the stipulated TAT as prescribed by the

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regulator. In case the resolution is likely to take longer time, we will inform you of the same
through an interim reply.
Escalation Level 1
For lack of a response or if the resolution still does not meet your expectations, you can write
to [email protected]. After investigating the matter internally and
subsequent closure, we will send our response within the stipulated TAT as prescribed by the
regulator from the date of receipt at this email id.
Escalation Level 2
For lack of a response or if the resolution still does not meet your expectations, you can write to
the Head - Customer Services at [email protected] After examining the
matter, we will send you our final response within the stipulated TAT as prescribed by the
regulator from the date of receipt of your complaint on this email id. Within the stipulated TAT as
prescribed by the regulator, from the date of of lodging a complaint with us, if you do not get a
satisfactory response from us and you wish to pursue other avenues for redressal of grievances,
you may approach Insurance Ombudsman appointed by IRDA under the Insurance Ombudsman
Scheme.

Grievance may also be lodged on the Bima Bharosa Grievance Redressal Portal of IRDAI
(https://bimabharosa.irdai.gov.in/)
Benefit Table
Benefit Name Coverage Limit
In-Patient Treatment Upto Sum Insured
Pre-Hospitalization expenses Upto 60 Days
Post-Hospitalization expenses Upto 180 Days
Day Care Treatment Upto Sum Insured
Organ Donor Upto Sum Insured
Domiciliary Treatment Upto Sum Insured
Restore Benefit Available
AYUSH Benefit Upto Sum Insured
Ambulance Cover Upto ₹3,000 per hospitalization
Health Checkup Once every policy year for listed tests, only on Cashless basis
Compassionate Travel Upto ₹20,000 per policy year, over and above base Sum Insured
Bariatric Surgery Cover Upto Sum Insured
In-Patient Treatment - Dental Upto Sum Insured
Upto ₹5,000 per policy year as per the list, over and above base Sum
Vaccination Cover
Insured
50% of actuals; maximum ₹10,000 per policy, every third year of
Hearing Aid continuous coverage under this Policy, over and above base Sum
Insured
0.25% of base Sum Insured; maximum ₹2000 per day, over and above
Daily Cash for choosing Shared base Sum Insured
Accommodation Benefit applicable only if hospitalization is in Our network of Valued
Provider – Pan India

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0.25% of base Sum Insured; maximum ₹2000 per day, over and above
Daily Cash for Accompanying base Sum Insured
an Insured Child Benefit applicable only if hospitalization is in Our network of Valued
Provider – Pan India
Second Opinion Covered for listed illnesses
50% of the base Sum Insured of the expiring Policy, on each Renewal
of the Policy after every claim free Policy Year, maximum upto 100%
of the base Sum Insured in any Policy Year. Cumulative bonus shall be
Cumulative Bonus provided only if No Claim Discount has not been availed for the claim
free previous Policy Year. Alternately, No Claim Discount in premium
can be opted, in which case policy will not be entitled for Cumulative
Bonus.
Accidental Death Benefit
100% of base Sum Insured
(Optional Cover)
Wellness Services Teleconsultation – General: Available
Room Category Single Private Room*
Cost Sharing
20% co-payment for each admissible claim applicable if the entry Age
Age Linked Co-Payment of the Insured Person is 61 years or above at the time of first
coverage under this Policy
Co-payment for treatment 30% co-payment for each such admissible claim applicable where the
availed out of Our Network of Insured Person avails treatment outside Our network of “Valued
Valued Provider – Pan India Provider-Pan India”.
*Note: Proportionate deduction of Associated Medical Expenses applicable in case insured person is
admitted in a room category that is higher than the Single Private Room

27. Section 41 of Insurance Act1938 (Prohibition of Rebates):

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 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 prospectus or tables of the insurer.
2. Any person making default in complying with the provision of this section shall be liable for
penalty which may extend to ten lakh rupees.

IRDAI REGULATION: This policy is subject to Insurance Regulatory and Development Authority of India
(Protection of Policyholders’ Interests, Operations and Allied Matters of Insurers) Regulations, 2024

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Disclaimer:

This is only a summary of the product features. The actual benefits available are as described in the policy,
and will be subject to the policy terms, conditions and exclusions. Please seek the advice of your insurance
advisor if you require any further information or clarification.

“Insurance is the subject matter of the solicitation”. For more details on benefits, exclusions, limitations,
terms & conditions, please refer sales brochure/ policy wordings carefully, before concluding a sale.”

Commencement of risk cover under the policy is subject to receipt of premium by Tata AIG General
Insurance Company Limited.

Tata AIG General Insurance Company Limited

Registered Office: Peninsula Business Park, Tower A, 15th Floor, G. K. Marg, Off Senapati Bapat Road,
Lower Parel, Mumbai- 400013.
24X7 Toll Free No: 1800 266 7780 or 1800 22 9966 (For Senior Citizens)
Email:[email protected] Website: www.tataaig.com IRDA of India Registration No: 108 CIN:
U85110MH2000PLC128425

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