Tata Aig Medicare Premier: Policy Wordings

Tata AIG MediCare Premier
UIN: TATHLIP21257V022021

POLICY WORDINGS
Tata AIG General Insurance Co. Ltd.

Registered Office:
Peninsula Business Park, Tower A, 15th Floor,
G.K. Marg, Lower Parel, Mumbai – 400013
24X7 Toll Free No: 1800 266 7780 or 1800 22 9966 (Senior Citizen)
Fax: 022 6693 8170
Email: customersupport@tataaig.com Website: www.tataaig.com
IRDA of India Registration No: 108 CIN:U85110MH2000PLC128425
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Tata AIG General Insurance Company Limited - Registered Office: Peninsula Business Park, Tower A, 15th Floor, G.K. Marg, Lower Parel, Mumbai – 400013
24X7 Toll Free No: 1800 266 7780 or 1800 22 9966 (Senior Citizen) Fax: 022 6693 8170 Email: customersupport@tataaig.com Website: www.tataaig.com
IRDA of India Registration No: 108 CIN: U85110MH2000PLC128425
Tata AIG General Insurance Company Limited (We, Our or Us) will B2. Pre-Hospitalization expenses
provide the insurance cover, described in this Policy and any We will cover for expenses for Pre-Hospitalization
endorsements thereto, for the Insured Period, as defined in the consultations, investigations and medicines incurred upto 60
Policy schedule. The insurance cover provided under this Policy is days before the date of admission to the hospital.
only with respect to such and so many of the benefits upto the Sum The benefit is payable if We have admitted a claim under B1 or
B4 or B6.
Insured in excess of Aggregate Deductible as mentioned in the Policy
B3. Post-Hospitalization expenses
Schedule. Commencement of risk cover under the policy is subject
We will cover for expenses for Post-Hospitalization
to receipt of premium by us.
consultations, investigations and medicines incurred upto 90
The statements contained in the Proposal signed by the Policyholder days after discharge from the hospital.
(You) shall be the basis of this Policy and are deemed to be The benefit is payable if We have admitted a claim under B1 or
incorporated herein. The insurance cover is governed by and subject B4 or B6.
to, the terms, conditions and exclusions of this Policy. B4. Day Care Procedures
We will cover expenses for listed Day Care Treatment due to
For Tata AIG General Insurance Company Limited disease/illness/Injury during the policy period taken at a
hospital or a Day Care Centre. The list of such day care
procedures covered is available on our website
Authorized Signatory (www.tataaig.com)
Treatment normally taken on out-patient basis is not included
Registered Office: in the scope of this cover.
TATA AIG General Insurance Company Limited, B5. Organ Donor
Peninsula Business Park, Tower A, 15th Floor, G. K. Marg, We will cover for Medical and surgical Expenses of the organ
Lower Parel, Mumbai- 400013, Maharashtra, India donor for harvesting the organ where an Insured Person is the
Toll Free No. 1800 266 7780 or 1800 22 9966 (Senior Citizen) recipient provided that:
Visit us at www.tataaig.com i. The organ donor is any person whose organ has been
IRDA of India Registration No.:108 made available in accordance and in compliance with The
CIN: U85110MH2000PLC128425 Transplantation of Human Organs (Amendment) Bill, 2011
and the organ donated is for the use of the Insured
“Insurance is the subject matter of solicitation”. For details on risk Person, and
factors, terms and conditions, please read policy document carefully ii. We have accepted an inpatient Hospitalization claim for
before concluding a sale. the insured member under In Patient Hospitalization
Treatment (section B1).
B6. Domiciliary Treatment
Preamble We will cover for expenses related to Domiciliary
While the policy is in force, if the Insured Person contracts any Hospitalization of the insured person if the treatment exceeds
disease or suffers from any illness or sustains bodily injury through beyond three days. The treatment must be for management of
accident and if such event requires the insured Person to incur an illness and not for enteral feedings or end of life care.
expenses for Medically Necessary Treatment, We will indemnify You At the time of claiming under this benefit, we shall require
for the amount of such Reasonable and Customary Charges or certification from the treating doctor fulfilling the conditions as
compensate to the extent agreed, upto the limits mentioned, subject mentioned under the general definitions (Section 2-) of this
to terms and conditions of the Policy. Each Benefit is subject to its policy.
Sum Insured, but Our liability to make payment in respect of any and B7. Restore benefits
all Benefits shall be limited to the Sum Insured unless expressly We will automatically restore the Basic Sum Insured upon
stated to the contrary. exhaustion of the Sum Insured and accrued Cumulative Bonus,
In case of family floater policy, the sum insured for all or any of the during the policy period. This benefit can be availed once during
benefits shall be on a per policy per year basis unless explicitly stated the policy period subject to the following conditions:
to the contrary. In case of an individual policy, the sum insured for all a. The restored sum insured can be used for all claims made
or any of the benefits shall be on a per insured per year basis unless by the insured person(s) who have not claimed earlier
explicitly stated to the contrary. under Sections B1 to B4. In case the insured has claimed
The said Medically Necessary Treatment must be on the advice of a under these sections, then this automatic restoration
qualified Medical Practitioner. benefit is available for admissions due to unrelated
Section 1 – Benefits illness/diseases. However, this benefit for related
The following benefits are payable subject to Terms and Conditions illness/diseases would be available, in case of claimed
of the policy: insured person(s), for admissions after 45 days from the
B1. In-Patient Treatment date of discharge of the earlier claim.
We will cover for expenses for hospitalization due to b. In case of Family Floater policy, Reinstatement of Sum
disease/illness/Injury during the policy period that requires an Insured will be available for all Insured Persons in the
Insured Person’s admission in a hospital as an inpatient. Policy on floater basis
Medical expenses directly related to the hospitalization would c. This benefit shall be applicable annually for policies with
be payable. tenure of more than 1 year.
d. The unutilized restored sum insured cannot be carried
forward.
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This benefit shall not be applicable for Global Cover (section

B13). B13. Global Cover
B8. AYUSH Benefit We will cover for Medical Expenses of the Insured Person
We will cover for expenses incurred for treatment as in-patient incurred outside India, upto the sum insured, provided that the
in an Ayush Hospital. diagnosis was made in India and the insured travels abroad for
B9. Ambulance Cover treatment.
We will cover for expenses incurred on transportation of The Medical Expenses payable shall be limited to Inpatient and
Insured Person in a registered ambulance to a Hospital for daycare Hospitalization only on reimbursement basis. Cashless
admission in case of an Emergency or from one hospital to facility may be arranged on case to case basis. Insured person
another hospital for better medical facilities and treatment, can contact us for any claim assistance.
subject to Rs. 5000 per Hospitalization. The payment of any claim under this benefit will be in Indian
For this claim to be paid, the claim must be admissible under Rupees based on the rate of exchange as on the date of invoice,
section B1 or B4 of this policy. published by Reserve Bank of India (RBI) and shall be used for
B10. Health Checkup conversion of foreign currency into Indian Rupees for claims
We will cover for expenses for a Preventive Health Check-up payment. If these rates are not published on the date of invoice,
upto 1% of sum insured subject to a maximum of Rs. 10,000/- the exchange rate next published by RBI shall be considered for
per policy. The limit is the maximum per policy and more than conversion.
one insured can utilize the amount. Only basic sum insured along with Cumulative Bonus can be
The benefit is payable every year irrespective of claims under used for this and not the restored sum insured.
the policy. This benefit has a separate limit (over and above We shall require the following additional documents
base sum insured) and does not affect cumulative bonus. supporting the claim under this benefit:
B11. Compassionate travel • Proof of diagnosis in India
In the event the Insured Person is Hospitalized for more than • Insured’s Passport and Visa
Five consecutive days in a place where no adult member of his B14. Bariatric Surgery Cover
immediate family is present, we will cover for expenses related We will cover for reasonable and customary expenses for
to a round trip economy class air ticket, or first-class railway Bariatric Surgery if the insured fulfills all of the following
ticket, to allow the Immediate Family Member be at his bedside conditions:
for the duration of his stay in the hospital. i. Surgery to be conducted is upon the advice of the Doctor
The expenses must be incurred within India and shall not ii. The member has to be 18 years of age or older and
exceed Rs. 20,000 during a policy year. iii. Body Mass Index (BMI) greater than or equal to 40 or
The benefit shall be payable if We have accepted an inpatient iv. BMI is greater than or equal to 35 in conjunction with any
Hospitalization claim for the insured member under In Patient of the following severe co-morbidities following failure of
Hospitalization Treatment (Section B1). less invasive methods of weight loss:
This benefit has a separate limit (over and above base sum a. Obesity-related cardiomyopathy
insured) and does not affect cumulative bonus. b. Coronary heart disease
We shall require the following additional documents (proof of c. Severe sleep apnea
travel) supporting the claim under this benefit: Boarding Pass,
d. Uncontrolled Type2 Diabetes
or Railway ticket or any other document to show proof of travel
In view of this coverage getting extended, exclusion code
B12. Consumables Benefit
(Code-Excl06) of this policy stands deleted.
We will pay for expenses incurred, for specified consumables
B15. In-Patient Treatment - Dental
which are listed in ‘Annexure I – List I- Optional Items’ under
We will cover for medical expenses incurred towards
‘Guidelines on Standardization in Health Insurance, 2016’ and
hospitalization for dental treatment under anesthesia
its amendments, which are consumed during the period of
necessitated due to an accident/injury/illness.
hospitalization directly related to the insured’s medical or
B16. Vaccination cover
surgical treatment of illness/disease/injury. Details of Annexure
I-List I-Optional items are available on our website We will cover for expenses related to the cost of the following
(www.tataaig.com) vaccines only:
However the following items shall be excluded from scope of Without any waiting period:
this coverage: - Anti-rabies vaccine following an animal bite
• Items of personal comfort, toiletries, cosmetics and - Typhoid vaccination
convenience shall be excluded from scope of this After 2 years of continuous coverage with Us:
coverage. - Human Papilloma Virus (HPV) vaccine
• External durable devices like Bilevel Positive Airway - Hepatitis B Vaccine
Pressure (BIPAP) machine, Continuous Positive Airway Expenses related to the doctor, nurse or any incidental
Pressure (CPAP) machine, Peritoneal Dialysis (PD) expenses are not payable. This benefit has a separate limit
equipment and supplies, Nimbus/water/air bed, dialyzer (over and above base sum insured) and does not affect
and other medical equipments. cumulative bonus.
• Any item which is neither medical consumable nor B17. Hearing Aid
medically necessary nor prescribed by Doctor. We will cover for reasonable charges for a hearing aid every
For this claim to be paid, the main claim must be admissible third year. The maximum amount payable is 50% of actual cost
under section B1 or B4 of this policy. or Rs. 10,000/- per policy, whichever is lower.
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The items must be prescribed by a specialized Medical complications related to delivery if claim is admitted under the
Practitioner as medically necessary. maternity benefit (B21).
This benefit has a separate limit (over and above base sum B23. First year Vaccinations
insured) and does not affect cumulative bonus. We will pay for vaccination expenses for up to one year after
B18. Daily Cash for choosing Shared Accommodation the birth of the child subject to a limit of Rs. 10,000/- provided
We will pay a fixed amount per day as mentioned in the policy the child is covered with Us. In case of girl child, applicable limit
schedule if the Insured Person is Hospitalized in Shared under this coverage would be Rs.15,000/-.
Accommodation in a Network Hospital for each continuous and For the claim to be paid under this benefit, the expenses related
completed period of 24 hours. The benefit payable per day to maternity should be admissible under B21. The limit of
would be 0.25% of base sum insured and a maximum of Rs. Rs.10,000 (Rs.15,000 in case of girl child) is a lifetime limit and
2000 per day. not a policy limit which will be applicable for each child.
For this claim to be paid, the main claim must be admissible B24. Prolonged Hospitalization Benefit
under section B1 of this policy. This benefit has a separate limit We will pay a fixed amount of 1% of sum insured, in the event
(over and above base sum insured) and does not affect of insured hospitalized for a disease/illness/injury for a
cumulative bonus. continuous period exceeding 10 days.
B19. Daily Cash for Accompanying an Insured Child This benefit will be triggered provided that the hospitalization
We will pay a fixed amount per day, as mentioned in the claim is accepted under benefit B1.
schedule, if the Insured Person Hospitalized is a child Aged 12 This benefit shall not be applicable in case of domiciliary
years or less, for one accompanying adult for each complete hospitalization (Section B6).
period of 24 hours. The benefit payable per day would be 0.25% This benefit has a separate limit (over and above base sum
of base sum insured and a maximum of Rs.2000 per day. insured) and does not affect cumulative bonus.
For this claim to be paid, the main claim must be admissible B25. High End Diagnostics
under section B1 of this policy. We will cover for reasonable charges incurred for the following
This benefit has a separate limit (over and above base sum diagnostic tests only on OPD basis if required as part of a
insured) and does not affect cumulative bonus. medically necessary treatment subject to a maximum Rs.
B20. Second Opinion 25,000 per policy year:
We will provide You a second opinion from Network Provider or i. Brain Perfusion imaging
Medical Practitioner, if an Insured Person is diagnosed with the ii. Computed Tomography (CT) guided Biopsy
below mentioned Illnesses during the Policy Period. The expert iii. Computed Tomography (CT) Urography
opinion would be directly sent to the Insured Person.
iv. Digital Subtraction Angiography (DSA)
i. Cancer v. Liver Biopsy
ii. Kidney Failure vi. Magnetic Resonance Cholangiography Scan
iii. Myocardial Infarction vii. Positron Emission Tomography– Computed Tomography
iv. Angina (PET/CT)
v. Coronary bypass surgery viii. Positron emission tomography – Magnetic Resonance
vi. Stroke/Cerebral hemorrhage Imaging (PET/MRI)
vii. Organ failure requiring transplant ix. Renogram
viii. Heart Valve replacement This benefit has a separate limit (over and above base sum
ix. Brain tumors insured) and does not affect cumulative bonus.
This benefit can be availed by an insured person once during a B26. OPD Treatment
Policy Year. Once the insured has completed two years of continuous
B21. Maternity Cover coverage with Us, We will pay for expenses related to
We will cover for Maternity Expenses upto a maximum of Rs. consultations and pharmacy subject to Rs. 5,000/- per policy
50,000/- per policy subject to a waiting period of 4 years of year annually subject to policy terms and conditions.
continuous coverage under this policy subject to IRDAI This benefit has a separate limit (over and above base sum
portability guidelines. In case of birth of a girl child, the insured) and does not affect cumulative bonus.
maximum limit under this coverage would be Rs. 60,000/- per B27. OPD Treatment - Dental
policy. Once the Insured has completed two years of continuous
We will not cover ectopic pregnancy under this benefit coverage with Us, we will pay for expenses related to the
(although it shall be covered under section B1). following dental treatments only subject to a maximum of
Expenses incurred for following shall be excluded from the Rs.10,000 per policy year annually:
scope of this coverage: - Root Canal Treatment (single or multiple sittings)
• Expenses incurred for pre/post natal care - Tooth extraction(s)
• Pre/Post hospitalization benefit (Benefit B2 and B3) - Filling
In view of this coverage getting extended, maternity exclusion This benefit has a separate limit (over and above base sum
code 18 stands deleted. However, no coverage is available for insured) and does not affect Cumulative Bonus.
voluntary termination of pregnancy during the policy period In view of this coverage getting extended, dental exclusion
under this policy. (exclusion – xviii) is not applicable for this particular coverage.
B22. New Born Baby Cover B28. Emergency Air Ambulance Cover
We will cover for medical expenses incurred for the medically We will pay for ambulance transportation of the Insured Person
necessary treatment of the new born baby upto Rs.10,000/- for in an airplane or helicopter subject to maximum of Rs. 500,000,
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for emergency life threatening health conditions which require An AYUSH Hospital is a healthcare facility wherein
immediate and rapid ambulance transportation to the medical/surgical/para-surgical treatment procedures and
hospital/medical centre for further medical management. interventions are carried out by AYUSH Medical Practitioner(s)
The Medical Evacuation should be prescribed by a Medical comprising of any of the following :
Practitioner and should be Medically Necessary. a. Central or State Government AYUSH Hospital or
This benefit shall only be payable if We have accepted an b. Teaching hospital attached to AYUSH college recognized
inpatient Hospitalization claim for the Insured member under by the Central Government/ Central Council of Indian
In Patient Hospitalization Treatment (Section B1). Medicine/ Central Council for Homeopathy, or
This benefit has a separate limit (over and above base sum c. AYUSH Hospital, standalone or co-located with in-patient
insured) and does not affect Cumulative Bonus. healthcare facility of any recognized system of medicine,
B29. Accidental Death Benefit registered with the local authorities, wherever applicable,
If an Insured Person suffers an accident during the policy and is under the supervision of a qualified registered
period and this is the sole and direct cause of his death within AYUSH Medical Practitioner and must comply with all the
365 days from the date of accident, then We will pay a fixed following criterion :
amount of 100% of the base Sum Insured. i. Having atleast 5 in-patient beds;
This benefit is not applicable for dependent children covered in ii. Having qualified AYUSH Medical Practitioner round
the policy. the clock;
B30. Cumulative Bonus iii. Having dedicated AYUSH therapy sections as
i. 50% cumulative bonus will be applied on the Sum Insured required and/or has equipped operation theatre
for next policy year under the Policy after every claim free where surgical procedures are to be carried out
Policy Year, provided that the Policy is renewed with Us Maintaining daily records of the patients and making them
and without a break. The maximum cumulative bonus accessible to the insurance company’s authorized
shall not exceed 100% of the Sum Insured in any Policy representative.
Year. 5. Cashless facility
ii. If a Cumulative Bonus has been applied and a claim is Cashless facility means a facility extended by the insurer to the
made, then in the subsequent Policy Year We will insured where the payments, of the costs of treatment
automatically decrease the Cumulative Bonus by 50% of undergone by the insured in accordance with the policy terms
the Sum Insured in that following Policy Year. There will and conditions, are directly made to the network provider by
be no impact on the Inpatient Sum Insured, only the the insurer to the extent pre-authorization is approved.
accrued Cumulative Bonus will be decreased. 6. Condition Precedent
iii. In policies with a tenure of more than one year, the above Condition Precedent means a policy term or condition upon
guidelines of Cumulative Bonus shall be applicable post which the Insurer’s liability under the policy is conditional upon.
completion of each policy year 7. Congenital Anomaly:
iv. In relation to a Family Floater, the Cumulative Bonus so Congenital Anomaly means a condition which is present since
applied will only be available in respect of those Insured birth, and which is abnormal with reference to form, structure
Persons who were Insured Persons in the claim free Policy or position.
Year and continue to be Insured Persons in the a) Internal Congenital Anomaly
subsequent Policy Year. Congenital anomaly which is not in the visible and
v. For purpose of computation of Cumulative Bonus, the accessible parts of the body.
percentage (%) of Cumulative Bonus will be applied on the
b) External Congenital Anomaly
base Sum Insured only. Restored sum insured will not be
Congenital anomaly which is in the visible and accessible
taken into consideration.
parts of the body
Section 2 – General Definitions
8. Cumulative Bonus
The terms defined below and at other junctures in the Policy Wording
Cumulative Bonus means any increase or addition in the Sum
have the meanings ascribed to them wherever they appear in this
Insured granted by the insurer without an associated increase
Policy and, where appropriate, references to the singular include
in premium.
references to the plural; references to the male include the female
9. Day Care Centre
and references to any statutory enactment include subsequent
A day care centre means any institution established for day care
changes to the same:
treatment of illness and/or injuries or a medical setup with a
1. Accident
hospital and which has been registered with the local
An accident means sudden, unforeseen and involuntary event
authorities, wherever applicable, and is under supervision of a
caused by external, visible and violent means.
registered and qualified medical practitioner AND must comply
2. Age with all minimum criterion as under –
Means the completed age of the Insured Person on his / her
i. has qualified nursing staff under its employment;
most recent birthday as per the English calendar, regardless of
ii. has qualified medical practitioner/s in charge;
the actual time of birth.
iii. has fully equipped operation theatre of its own where
3. Any one illness
surgical procedures are carried out;
Any one illness means continuous period of illness and includes
iv. maintains daily records of patients and will make these
relapse within 45 days from the date of last consultation with
accessible to the insurance company’s authorized
the Hospital/Nursing Home where treatment was taken.
personnel.
4. AYUSH Hospital
10. Day Care Treatment
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Day care treatment means medical treatment, and/or surgical person to his or her state of health immediately before
procedure which is: suffering the disease/ illness/ injury which leads to full
i. undertaken under General or Local Anesthesia in a recovery
hospital/day care centre in less than 24 hrs because of (b) Chronic condition
technological advancement, and A chronic condition is defined as a disease, illness, or
ii. which would have otherwise required hospitalization of injury that has one or more of the following
more than 24 hours. characteristics:
Treatment normally taken on an out-patient basis is not i. it needs ongoing or long-term monitoring through
included in the scope of this definition consultations, examinations, check-ups, and /or
11. Dental Treatment tests
Dental treatment means a treatment related to teeth or ii. it needs ongoing or long-term control or relief of
structures supporting teeth including examinations, fillings symptoms
(where appropriate), crowns, extractions and surgery. iii. it requires rehabilitation for the patient or for the
12. Domiciliary Hospitalization patient to be specially trained to cope with it
Domiciliary hospitalization means medical treatment for an iv. it continues indefinitely
illness/disease/injury which in the normal course would require v. it recurs or is likely to recur
care and treatment at a hospital but is actually taken while 17. Injury
confined at home under any of the following circumstances: Injury means accidental physical bodily harm excluding illness
i. the condition of the patient is such that he/she is not in a or disease solely and directly caused by external, violent, visible
condition to be removed to a hospital, or and evident means which is verified and certified by a Medical
ii. the patient takes treatment at home on account of non- Practitioner.
availability of room in a hospital. 18. Inpatient Care
13. Grace Period Inpatient care means treatment for which the insured person
Grace period means the specified period of time immediately has to stay in a hospital for more than 24 hours for a covered
following the premium due date during which a payment can event.
be made to renew or continue a policy in force without loss of 19. Maternity expenses
continuity benefits such as waiting periods and coverage of pre- Maternity expenses means;
existing diseases. Coverage is not available for the period for a. medical treatment expenses traceable to childbirth
which no premium is received. (including complicated deliveries and caesarean sections
14. Hospital incurred during hospitalization);
A hospital means any institution established for in-patient care b. expenses towards lawful medical termination of
and day care treatment of illness and/or injuries and which has pregnancy during the policy period.
been registered as a hospital with the local authorities under 20. Medical Advice
Clinical Establishments (Registration and Regulation) Act 2010 Medical Advice means any consultation or advice from a
or under enactments specified under the Schedule of Section
Medical Practitioner including the issuance of any prescription
56(1) and the said act Or complies with all minimum criteria as
or follow-up prescription.
under:
21. Medical Expenses:
i. has qualified nursing staff under its employment round
Medical Expenses means those expenses that an Insured
the clock;
Person has necessarily and actually incurred for medical
ii. has at least 10 in-patient beds in towns having a treatment on account of Illness or Accident on the advice of a
population of less than 10,00,000 and at least 15 in-patient Medical Practitioner, as long as these are no more than would
beds in all other places; have been payable if the Insured Person had not been insured
iii. has qualified medical practitioner(s) in charge round the and no more than other hospitals or doctors in the same
clock; locality would have charged for the same medical treatment.
iv. has a fully equipped operation theatre of its own where 22. Medical Practitioner
surgical procedures are carried out; Medical Practitioner means a person who holds a valid
v. maintains daily records of patients and makes these registration from the Medical Council of any State or Medical
accessible to the insurance company’s authorized Council of India or Council for Indian Medicine or for
personnel; Homeopathy set up by the Government of India or a State
15. Hospitalization Government and is thereby entitled to practice medicine within
Hospitalization means admission in a Hospital for a minimum its jurisdiction; and is acting within its scope and jurisdiction of
period of 24 consecutive ‘In-patient Care’ hours except for license.
specified procedures/ treatments, where such admission could 23. Medically Necessary Treatment
be for a period of less than 24 consecutive hours. Medically necessary treatment means any treatment, tests,
16. Illness medication, or stay in hospital or part of a stay in hospital
Illness means a sickness or a disease or pathological condition which:
leading to the impairment of normal physiological function and i. is required for the medical management of the illness or
requires medical treatment. injury suffered by the insured;
(a) Acute condition ii. must not exceed the level of care necessary to provide
Acute condition is a disease, illness or injury that is likely safe, adequate and appropriate medical care in scope,
to respond quickly to treatment which aims to return the duration, or intensity;
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iii. must have been prescribed by a medical practitioner; subsequent years, policy year shall mean a period of twelve
iv. must conform to the professional standards widely months commencing from the end of the previous policy year
accepted in international medical practice or by the and lapsing on the last day of such twelve-month period, till the
medical community in India. Policy Expiry date
24. Migration 35. Portability
“Migration” means, the right accorded to health insurance “Portability” means, the right accorded to individual health
policyholders (including all members under family cover and insurance policyholders (including all members under family
members of group health insurance policy), to transfer the cover), to transfer the credit gained for pre-existing conditions
credit gained for pre-existing conditions and time bound and time bound exclusions, from one insurer to another
exclusions, with the same insurer. insurer.
25. Network Provider 36. Post-hospitalization Medical Expenses
Network Provider means hospitals or health care providers Post-hospitalization Medical Expenses means medical
enlisted by an insurer, TPA or jointly by an Insurer and TPA to expenses incurred during predefined number of days
provide medical services to an insured by a cashless facility. immediately after the insured person is discharged from the
26. New Born Baby hospital provided that:
Newborn baby means baby born during the Policy Period and i. Such Medical Expenses are for the same condition for
is aged upto 90 days which the insured person’s hospitalization was required,
27. Notification of Claim: and
Notification of claim means the process of intimating a claim to ii. The inpatient hospitalization claim for such
the insurer or TPA through any of the recognized modes of hospitalization is admissible by the insurance company
communication 37. Qualified Nurse
28. OPD treatment Qualified nurse means a person who holds a valid registration
OPD treatment means the one in which the Insured visits a from the Nursing Council of India or the Nursing Council of any
clinic / hospital or associated facility like a consultation room for state in India.
diagnosis and treatment based on the advice of a Medical 38. Reasonable and Customary Charges
Practitioner. The Insured is not admitted as a day care or in- Reasonable and Customary charges means the charges for
patient. services or supplies, which are the standard charges for the
29. Pre-Existing Disease specific provider and consistent with the prevailing charges in
Pre-existing Disease means any condition, ailment, injury or the geographical area for identical or similar services, taking
disease: into account the nature of the illness / injury involved.
a. That is/are diagnosed by a physician within 48 months 39. Renewal
prior to the effective date of the policy issued by the Renewal means the terms on which the contract of insurance
insurer or its reinstatement or can be renewed on mutual consent with a provision of grace
b. For which medical advice or treatment was recommended period for treating the renewal continuous for the purpose of
by, or received from, a Physician within 48 months Prior gaining credit for pre-existing diseases, time-bound exclusions
to the effective date of the policy issued by the insurer or and for all waiting periods.
its reinstatement 40. Room Rent
30. Pre-hospitalization Medical Expenses Room Rent means the amount charged by a Hospital towards
Pre-hospitalization Medical Expenses means medical expenses Room and Boarding expenses and shall include the associated
incurred during predefined number of days preceding the medical expenses.
hospitalization of the Insured Person, provided that: 41. Shared Accommodation
i. Such Medical Expenses are incurred for the same Shared Accommodation means a hospital room with two or
condition for which the Insured Person’s Hospitalization more patient beds. This definition does not apply to ICU or
was required, and ICCU.
ii. The In-patient Hospitalization claim for such 42. Surgery or Surgical Procedure
Hospitalization is admissible by the Insurance Company. Surgery or Surgical Procedure means manual and / or operative
31. Policy procedure (s) required for treatment of an illness or injury,
Policy means the contract of insurance including but not limited correction of deformities and defects, diagnosis and cure of
to Policy Schedule, Endorsements and Policy Wordings. diseases, relief from suffering and prolongation of life,
performed in a hospital or day care centre by a medical
32. Policy period
practitioner.
Policy Period means the time during which this Policy is in
effect. Such period commences from Commencement Date 43. Unproven/Experimental treatment
and ends on the Expiry Date and specifically appears in the Unproven/Experimental treatment means the treatment
Policy Schedule. including drug experimental therapy which is not based on
established medical practice in India, is treatment experimental
33. Policy Schedule
or unproven.
Policy Schedule means the Policy Schedule attached to and
Section 3 – General Exclusions
forming part of Policy
We will neither be liable nor make any payment for any claim in
34. Policy year
respect of any Insured Person which is caused by, arising from or in
Policy Year means a period of twelve months beginning from
any way attributable to any of the following exclusions, unless
the date of commencement of the Policy period and ending on
expressly stated to the contrary in this Policy.
the last day of such twelve-month period. For the purpose of
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1. Exclusions with waiting periods XX. Calculus diseases of Urogenital system

i. 30 Days Waiting Period (Code-Excl03): Example: Kidney stone, Urinary bladder stone.
a. Expenses related to the treatment of any illness XXI. Benign Hyperplasia of prostate
within 30 days from the first policy commencement XXII. Varicocele
date shall be excluded except claims arising due to XXIII. Cataract
an accident, provided the same are covered. XXIV. Retinal detachment
b. This exclusion shall not, however, apply if the XXV. Glaucoma
Insured Person has Continuous Coverage for more XXVI. Congenital Internal Diseases
than twelve months. The following treatments are covered after a
c. The within referred waiting period is made waiting period of two years irrespective of the
applicable to the enhanced sum insured in the event illness for which it is done:
of granting higher sum insured subsequently.
XXVII. Adenoidectomy
ii. Specified Disease/Procedure Waiting Period (Code-
XXVIII. Mastoidectomy
Excl02):
XXIX. Tonsillectomy
a. Expenses related to the treatment of the listed
XXX. Tympanoplasty
Conditions, surgeries/treatments shall be excluded
XXXI. Surgery for nasal septum deviation
until the expiry of 24 months of continuous coverage
after the date of inception of the first policy with us. XXXII. Nasal concha resection
This exclusion shall not be applicable for claims XXXIII. Surgery for Turbinate hypertrophy
arising due to an accident. XXXIV. Hysterectomy
b. In case of enhancement of sum insured the XXXV. Joint replacement surgeries Eg: Knee
exclusion shall apply afresh to the extent of sum replacement, Hip replacement
insured increase. XXXVI. Cholecystectomy
c. If any of the specified disease/procedure falls under XXXVII. Hernioplasty or Herniorraphy
the waiting period specified for pre-Existing XXXVIII. Surgery/procedure for Benign prostate
diseases, then the longer of the two waiting periods enlargement
shall apply. XXXIX. Surgery for Hydrocele/ Rectocele
d. The waiting period for listed conditions shall apply XL. Surgery of varicose veins and varicose ulcers
even if contracted after the policy or declared and iii. Pre-existing Diseases Waiting Period (Code-Excl01)
accepted without a specific exclusion. a. Expenses related to the treatment of a pre-existing
e. If the Insured Person is continuously covered Disease (PED) and its direct complications shall be
without any break as defined under the applicable excluded until the expiry of 24 months of continuous
norms on portability stipulated by IRDAI, then coverage after the date of inception of the first policy
waiting period for the same would be reduced to the with us.
extent of prior coverage. b. In case of enhancement of sum insured the
f. List of Specific Diseases/procedures as furnished exclusion shall apply afresh to the extent of sum
below: insured increase.
I. Tumors, Cysts, polyps including breast lumps c. If the Insured Person is continuously covered
(benign) without any break as defined under the portability
II. Polycystic ovarian disease norms of the extant IRDAI (Health Insurance)
III. Fibromyoma Regulations, then waiting period for the same would
IV. Adenomyosis be reduced to the extent of prior coverage.
V. Endometriosis d. Coverage under the policy after the expiry of 24
VI. Prolapsed Uterus months for any pre-existing disease is subject to the
VII. Non-infective arthritis same being declared at the time of application and
VIII. Gout and Rheumatism accepted by us.
IX. Osteoporosis 2. Medical Exclusions
X. Ligament, Tendon or Meniscal tear (due to i. Treatment for, Alcoholism, drug or substance abuse or
injury or otherwise) any addictive condition and consequences thereof .(Code-
Excl12)
XI. Prolapsed Inter Vertebral Disc (due to injury or
otherwise) ii. Alcoholic pancreatitis
XII. Cholelithiasis iii. Expenses related to surgical treatment of obesity that
does not fulfil the below conditions (Code-Excl06):
XIII. Pancreatitis
a. Surgery to be conducted is upon the advice of the
XIV. Fissure/fistula in anus, haemorrhoids, pilonidal
Doctor
sinus
b. The surgery/Procedure conducted should be
XV. Ulcer & erosion of stomach & duodenum
supported by clinical protocols
XVI. Gastro Esophageal Reflux Disorder (GERD)
c. The member has to be 18 years of age or older and
XVII. Liver Cirrhosis
d. Body Mass Index (BMI);
XVIII. Perineal Abscesses
i. greater than or equal to 40 or
XIX. Perianal / Anal Abscesses
8
ii. greater than or equal to 35 in conjunction with xvi. All preventive care, vaccination including inoculation and
any of the following severe co-morbidities immunisations (except in case of post- bite treatment and
following failure of less invasive methods of other vaccines explicitly covered);
weight loss: xvii. Unproven treatments (Code-Excl16) : Expenses related to
1. Obesity-related cardiomyopathy any unproven treatment, services and supplies for or in
2. Coronary heart disease connection with any treatment. Unproven treatments are
3. Severe Sleep Apnea treatments, procedures or supplies that lack significant
4. Uncontrolled Type2 Diabetes medical documentation to support their effectiveness.
iv. Congenital External Diseases, defects or anomalies; xviii. Dental treatment or surgery of any kind except as
v. Stem cell therapy ; however hematopoietic stem cells for specified in ‘Inpatient Treatment – Dental’.
bone marrow transplant for haematological conditions xix. Maternity (Code - Excl18):
will be covered under benefit B1 or B4 of this policy; a. Medical treatment expenses traceable to childbirth
vi. Growth hormone therapy; (including complicated deliveries and caesarean
sections incurred during hospitalization) except
vii. Sleep-apnoea
ectopic pregnancy;
viii. Admission primarily for administration of Intra-articular
or intra-lesional injections or Intravenous b. Expenses towards miscarriage (unless due to an
immunoglobulin infusion or supplementary medications accident) and lawful medical termination of
pregnancy during the policy period
like Zolendronic Acid
xx. Treatments received in heath hydros, nature cure clinics,
ix. Investigation and evaluation (Code-Excl04):
spas or similar establishments or private beds registered
a. Expenses related to any admission primarily for
as a nursing home attached to such establishments or
diagnostics and evaluation purposes only are
where admission is arranged wholly or partly for domestic
excluded.
reasons. (Code -Excl13)
b. Any diagnostic expenses which are not related or not
xxi. Dietary supplements and substances that can be
incidental to the current diagnosis and treatment
purchased without prescription, including but not limited
are excluded.
to Vitamins, minerals and organic substances unless
x. Venereal disease, sexually transmitted disease or illness;
prescribed by a medical practitioner as part of
xi. Expenses related to Sterility and infertility (Code-Excl17). hospitalization claim or day care procedure. (Code -
This includes: Excl14)
i. Any type of contraception, sterilization xxii. Any existing disease specifically mentioned as Permanent
ii. Assisted Reproduction services including artificial exclusion in the Policy Schedule
insemination and advanced reproductive
3. Non-Medical Exclusions
technologies such as IVF, ZIFT, GIFT, ICSI
i. War or any act of war, invasion, act of foreign enemy, war
iii. Gestational Surrogacy like operations (whether war be declared or not or caused
iv. Reversal of sterilization during service in the armed forces of any country), civil
xii. Refractive error (Code -Excl15): Expenses related to the war, public defence, rebellion, revolution, insurrection,
treatment for correction of eye sight due to refractive military or usurped acts, nuclear weapons/materials,
error less than 7.5 dioptres. chemical and biological weapons, ionising radiation.
xiii. Change-of-Gender treatments (Code- Excl 07): Expenses ii. Any Insured Person’s participation or involvement in
related to any treatment, including surgical management, naval, military or air force operation,
to change characteristics of the body to those of the iii. Hazardous or Adventure Sports (Code Excl09) : Expenses
opposite sex related to any treatment necessitated due to participation
xiv. Cosmetic or Plastic Surgery (Code – Excl08) : Expenses for as a professional in hazardous or adventure sports,
cosmetic or plastic surgery or any treatment to change including but not limited to, para-jumping, rock climbing,
appearance unless for reconstruction following an mountaineering, rafting, motor racing, horse racing or
Accident, Burn(s) or Cancer or as part of medically scuba diving, hand gliding, sky diving, deep-sea diving
necessary treatment to remove a direct and immediate iv. Breach of law (Code Excl10): Expenses for treatment
health risk to the insured. For this to be considered a directly arising from or consequent upon any Insured
medical necessity, it must be certified by the attending Person committing or attempting to commit a breach of
Medical Practitioner. law with criminal intent.
xv. Rest cure, rehabilitation and respite care (Code-Excl05): v. Intentional self-injury or attempted suicide while sane or
a. Expenses related to any admission primarily for insane.
enforced bed rest and not for receiving treatment. vi. Items of personal comfort and convenience like television
This also includes: (wherever specifically charged for), charges for access to
i. Custodial care either at home or in a nursing telephone and telephone calls, internet, foodstuffs
facility for personal care such as help with (except patient’s diet), cosmetics, hygiene articles, body
activities of daily living such as bathing, care products and bath additive, barber or beauty service,
dressing, moving around either by skilled guest service
nurses or assistant or non-skilled persons. vii. Treatment rendered by a Medical Practitioner which is
ii. Any services for people who are terminally ill to outside his discipline
address physical, social, emotional and
spiritual needs.
9
viii. Doctor’s fees charged by the Medical Practitioner sharing (Explanation: “Bank rate” shall mean the rate fixed by the
the same residence as an Insured Person or who is an Reserve Bank of India (RBl) at the beginning of the
immediate relative of an Insured Person’s family. financial year in which claim has fallen due).The Clause
ix. Provision or fitting of hearing aids, spectacles or contact shall be suitably modified by the insurer based on the
lenses including optometric therapy unless explicitly amendment(s), if any to the relevant provisions of
stated and covered in the policy, Protection of Policyholder’s Interests Regulations, 2017)
x. Any treatment and associated expenses for alopecia, 4. Complete Discharge
baldness, wigs, or toupees, medical supplies including Any payment to the policyholder, insured person or his/ her
elastic stockings, diabetic test strips, and similar products. nominees or his/ her legal representative or assignee or to the
xi. Any treatment or part of a treatment that is not of a Hospital, as the case may be, for any benefit under the policy
reasonable charge, not medically necessary; drugs or shall be a valid discharge towards payment of claim by the
treatments which are not supported by a prescription. Company to the extent of that amount for the particular claim.
xii. Crutches or any other external appliance and/or device 5. Multiple Policies
used for diagnosis or treatment (except when used intra- i. In case of multiple policies taken by an insured person
operatively and explicitly stated and covered in the policy). during a period from one or more insurers to indemnify
xiii. Any illness diagnosed or injury sustained or where there treatment costs, the insured person shall have the right to
is change in health status of the member after date of require a settlement of his/her claim in terms of any of
proposal and before commencement of policy and the his/her policies. In all such cases the insurer chosen by the
same is not communicated and accepted by us insured person shall be obliged to settle the claim as long
xiv. Excluded Providers (Code-Excl11):Expenses incurred as the claim is within the limits of and according to the
towards treatment in any hospital or by any Medical terms of the chosen policy.
Practitioner or any other provider specifically excluded by ii. Insured person having multiple policies shall also have the
the Insurer and disclosed in its website / notified to the right to prefer claims under this policy for the amounts
policyholders are not admissible. However, in case of life disallowed under any other policy / policies even if the
threatening situations or following an accident, expenses sum insured is not exhausted. Then the insurer shall
up to the stage of stabilization are payable but not the independently settle the claim subject to the terms and
complete claim . conditions of this policy.
Section 4 – General Conditions iii. If the amount to be claimed exceeds the sum insured
Standard General Terms and Clauses: under a single policy, the insured person shall have the
1. Disclosure of Information right to choose insurer from whom he/she wants to claim
The policy shall be void and all premium paid thereon shall be the balance amount.
forfeited to the Company in the event of misrepresentation, iv. Where an insured person has policies from more than one
misdescription or non-disclosure of any material fact by the insurer to cover the same risk on indemnity basis, the
policyholder. insured person shall only be indemnified the treatment
costs in accordance with the terms and conditions of the
(Explanation: “Material facts” for the purpose of this policy shall
mean all relevant information sought by the company in the chosen policy.
proposal form and other connected documents to enable it to 6. Fraud
take informed decision in the context of underwriting the risk) If any claim made by the insured person, is in any respect
2. Condition Precedent to Admission of Liability fraudulent, or if any false statement, or declaration is made or
The terms and conditions of the policy must be fulfilled by the used in support thereof, or if any fraudulent means or devices
insured person for the Company to make any payment for are used by the insured person or anyone acting on his/her
behalf to obtain any benefit under this policy, all benefits under
claim(s) arising under the policy.
this policy and the premium paid shall be forfeited.
3. Claim Settlement (provision for Penal Interest)
Any amount already paid against claims made under this policy
i. The Company shall settle or reject a claim, as the case may
but which are found fraudulent later shall be repaid by all
be, within 30 days from the date of receipt of last
recipient(s)/policyholder(s), who has made that particular claim,
necessary document.
who shall be jointly and severally liable for such repayment to
ii. In the case of delay in the payment of a claim, the
the insurer.
Company shall be liable to pay interest to the policyholder
For the purpose of this clause, the expression “fraud” means
from the date of receipt of last necessary document to the
any of the following acts committed by the insured person or
date of payment of claim at a rate 2% above the bank rate.
by his agent or the hospital/doctor/any other party acting on
iii. However, where the circumstances of a claim warrant an
behalf of the insured person, with intent to deceive the insurer
investigation in the opinion of the Company, it shall
or to induce the insurer to issue an insurance policy:
initiate and complete such investigation at the earliest, in
a) the suggestion, as a fact of that which is not true and
any case not later than 30 days from the date of receipt of
which the insured person does not believe to be true;
last necessary document. In such cases, the Company
shall settle or reject the claim within 45 days from the date b) the active concealment of a fact by the insured person
of receipt of last necessary document. having knowledge or belief of the fact;
iv. In case of delay beyond stipulated 45 days, the Company c) any other act fitted to deceive; and
shall be liable to pay interest to the policyholder at a rate d) any such act or omission as the law specially declares to
2% above the bank rate from the date of receipt of last be fraudulent
necessary document to the date of payment of claim. The Company shall not repudiate the claim and / or forfeit the
policy benefits on the ground of Fraud, if the insured person /
10
beneficiary can prove that the misstatement was true to the For Detailed Guidelines on Portability, kindly refer Guidelines
best of his knowledge and there was no deliberate intention to issued IRDAI (Insurance Regulatory and Development Authority
suppress the fact or that such misstatement of or suppression of India) on Migration and Portability of Health Insurance
of material fact are within the knowledge of the insurer. policies – Ref: IRDAI/HLT/REG/CIR/194/07/2020) dated 22nd July
7. Cancellation 2020 and subsequent amendments thereof.
i. The policyholder may cancel this policy by giving 15 days 10. Renewal of Policy
written notice and in such an event, the Company shall The policy shall ordinarily be renewable except on grounds of
refund premium for the unexpired policy period as fraud, misrepresentation by the insured person.
detailed below: i. The Company shall endeavor to give notice for renewal.
Length of time Policy in Tenure (Years) However, the Company is not under obligation to give any
force 1 2 3 notice for renewal.
Upto 1 Month 75.00% 87.50% 91.5% ii. Renewal shall not be denied on the ground that the
insured person had made a claim or claims in the
>1 month & Upto 3 Months 50.00% 75.00% 88.5%
preceding policy years.
>3 months & Upto 6 Months 25.00% 62.50% 75%
iii. Request for renewal along with requisite premium shall
>6 months & Upto 12 Months Nil 50.00% 66.5%
be received by the Company before the end of the policy
>12 months & Upto 15 NA 25% 50% period.
Months
iv. At the end of the policy period, the policy shall terminate
>15 months & Upto 18 NA 12.5% 41.5% and can be renewed within the Grace Period of 30 days to
Months maintain continuity of benefits without break in policy.
>18 months & Upto 24 NA Nil 33% Coverage is not available during the grace period.
months v. No loading shall apply on renewals based on individual
>24 months & Upto 30 NA NA 8% claims experience
months 11. Withdrawal of Policy
Exceeding 30 months NA NA Nil i. In the likelihood of this product being withdrawn in future,
Notwithstanding anything contained herein or otherwise, the Company will intimate the insured person about the
no refunds of premium shall be made in respect of same 90 days prior to expiry of the policy.
Cancellation where, any claim has been admitted or has ii. Insured Person will have the option to migrate to similar
been lodged or any benefit has been availed by the health insurance product available with the Company at
insured person under the policy. the time of renewal with all the accrued continuity
ii. The Company may cancel the policy at any time on benefits such as cumulative bonus, waiver of waiting
grounds of misrepresentation non-disclosure of material period as per IRDAI guidelines, provided the policy has
facts, fraud by the insured person by giving 15 days’ been maintained without a break.
written notice. There would be no refund of premium on 12. Moratorium Period
cancellation on grounds of misrepresentation, non- After completion of eight continuous years under the policy no
disclosure of material facts or fraud. look back to be applied. This period of eight years is called as
8. Migration moratorium period. The moratorium would be applicable for
The insured person will have the option to migrate the policy to the sums insured of the first policy and subsequently
other health insurance products/plans offered by the company completion of 8 continuous years would be applicable from
by applying for migration of the policy at least 30 days before date of enhancement of sums insured only on the enhanced
the policy renewal date as per IRDAI guidelines on Migration. lf limits. After the expiry of Moratorium Period no health
such person is presently covered and has been continuously insurance claim shall be contestable except for proven fraud
covered without any lapses under any health insurance and permanent exclusions specified in the policy contract. The
product/plan offered by the company, the insured person will policies would however be subject to all limits, sub limits, co-
get the accrued continuity benefits in waiting periods as per payments, deductibles as per the policy contract.
IRDAI guidelines on migration. 13. Possibility of Revision of Terms of the Policy Including the
For Detailed Guidelines on Migration, kindly refer Guidelines Premium Rates
issued by IRDAI (Insurance Regulatory and Development The Company, with prior approval of IRDAI, may revise or
Authority of India) on Migration and Portability of Health modify the terms of the Policy including the premium rates. The
Insurance policies – Ref: IRDAI/HLT/REG/CIR/194/07/2020) Insured Person shall be notified three months before the
dated 22nd July 2020 and subsequent amendments thereof. changes are effected.
9. Portability 14. Free look period
The insured person will have the option to port the policy to The Free Look Period shall be applicable on new individual
other insurers by applying to such insurer to port the entire health insurance policies and not on renewals or at the time of
policy along with all the members of the family, if any, at least porting/migrating the policy.
45 days before, but not earlier than 60 days from the policy The insured person shall be allowed free look period of fifteen
renewal date as per IRDAI guidelines related to portability. If days from date of receipt of the policy document to review the
such person is presently covered and has been continuously terms and conditions of the policy, and to return the same if not
covered without any lapses under any health insurance policy acceptable.
with an Indian General/Health insurer, the proposed insured If the insured has not made any claim during the Free Look
person will get the accrued continuity benefits in waiting Period, the insured shall be entitled to
periods as per IRDAI guidelines on portability.
11
i. a refund of the premium paid less any expenses incurred 18. Insured Person
by the Company on medical examination of the insured i. Only those persons named as an Insured Person in the
person and the stamp duty charges or Schedule shall be covered under this Policy.
ii. where the risk has already commenced and the option of ii. Any person may be added during the Policy Period after
return of the policy is exercised by the insured person, a his application has been accepted by Us, additional
deduction towards the proportionate risk premium for premium has been paid and We have issued an
period of cover or endorsement confirming the addition of such person as
iii. Where only a part of the insurance coverage has an Insured Person.
commenced, such proportionate premium iii. We will be offering continuous renewal with no exit age
commensurate with the insurance coverage during such subject to regular premium payment and compliance with
period all provisions and terms & conditions of this policy by the
15. Redressal of Grievance Insured Person.
In case of any grievance the insured person may contact the 19. Loadings
company through i. We may apply a risk loading on the premium payable
Website: www.tataaig.com (based upon the declarations made in the proposal form
Toll Free: 1800 266 7780 or 1800 22 9966 (only for Senior Citizen and the health status of the persons proposed for
policyholders) insurance).
Email: customersupport@tataaig.com ii. The maximum risk loading applicable for an individual
Fax: 022 66938170 shall not exceed 100% of premium per diagnosis / medical
Courier: Customer Support, Tata AIG General Insurance condition and an overall risk loading of over 150% of
Company Limited premium per person.
A-501 Building No. 4 IT Infinity Park, Dindoshi, Malad (E), iii. The loading shall only be applied basis an outcome of Our
Mumbai – 400097 medical underwriting.
Insured person may also approach the grievance cell at any of iv. These loadings are applied from Commencement Date of
the company’s branches with the details of grievance. the Policy including subsequent renewal(s) with Us or on
If Insured person is not satisfied with the redressal of the receipt of the request of increase in Sum Insured (for
grievance through one of the above methods, the increased Sum Insured).
insured person may contact the grievance officer at a. We will inform You about the applicable risk loading
manager.customersupport@tataaig.com. through a counter offer letter.
For updated details of grievance officer, kindly refer the link b. You need to revert to Us with consent and additional
(https://www.tataaig.com/grievance-redressal-policy) premium (if any), within 15 days of the issuance of
lf Insured person is not satisfied with the redressal of grievance such counter offer letter.
through above methods, the insured person may also c. In case, you neither accept the counter offer nor
approach the office of Insurance Ombudsman of the respective revert to Us within 15 days, We shall cancel Your
area/region (details as mentioned in the Annexure A of this application and refund the premium paid within
policy) for redressal of grievance as per Insurance Ombudsman next 10 days subject to deduction of the Pre-Policy
Rules 2017. Check up charges, as applicable.
Grievance may also be lodged at IRDAI Integrated Grievance v. Please note that We will issue Policy only after getting Your
Management System (https://igms.irda.gov.in/) consent.
16. Nomination 20. Entire Contract
The policyholder is required at the inception of the policy to i. This Policy, its Schedule, endorsement(s), proposal
make a nomination for the purpose of payment of claims under constitutes the entire contract of insurance. No change in
the policy in the event of death of the policyholder. Any change this policy shall be valid unless approved by Us and such
of nomination shall be communicated to the company in approval be endorsed hereon.
writing and such change shall be effective only when an ii. This Policy and the Schedule shall be read together as one
endorsement on the policy is made. In the event of death of the contract and any word or expression to which a specific
policyholder, the Company will pay the nominee {as named in meaning has been attached in any part of this Policy or of
the Policy Schedule/Policy Certificate/Endorsement (if any)} and the Schedule shall bear such meaning wherever it may
in case there is no subsisting nominee, to the legal heirs or legal appear.
representatives of the policyholder whose discharge shall be 21. Change of Policyholder
treated as full and final discharge of its liability under the policy. i. The change of Policyholder is permitted only at the time
Other General Terms and Clauses: of renewal.
17. Premium Payment ii. If the Insured Person is no longer eligible on grounds of
i. Premium to be paid for the Policy Period before Policy age or dependency, the insured member will be eligible to
Commencement date as opted by You in the proposal apply for a new policy and enjoy continuity benefits upto
form. Sum Insured.
ii. If you have opted to pay premium in full (lumpsum) 22. Notices
upfront then the entire premium for the policy period i. Any notice, direction or instruction under this Policy shall
shall be paid before the policy commencement date with be in writing and if it is to:
an option of policy tenure 1/2/3 years. a. Any Insured Person, then it shall be sent to You at
iii. Long term premium discount of 5% and 10% is applicable Your address specified in the Schedule to this Policy
for policy with tenure of 2 and 3 years respectively.
12
and You shall act for all Insured Persons for these 3. Procedure for Cashless Service
purposes. i. Cashless Service is only available at Network Hospitals.
b. Us, it shall be delivered to Our address specified in ii. In order to avail of cashless treatment, the following
the Schedule to this Policy. No insurance agents, procedure must be followed by You:
brokers or other person or entity is authorised to a. Prior to taking treatment and/or incurring Medical
receive any notice, direction or instruction on Our Expenses at a Network Hospital, You must call our
behalf unless We have expressly stated to the designated TPA/Us and request pre-authorization.
contrary in writing. b. For any emergency Hospitalisation, our designated
Section 5 – Claims Procedure and Claims Payment TPA/We must be informed no later than 24 hours of
This section explains about the procedures involved to file a valid the start of Your hospitalization/ treatment.
claim by the insured member and processes related in managing the c. For any planned hospitalization, our designated
claim by TPA or Us. All the procedures and processes such as TPA/We must be informed atleast 48 hours prior to
notification of claim, availing cashless service, supporting claim the start of your hospitalization/treatment.
documents and related claim terms of payment are explained in this d. Our designated TPA/We will check your coverage as
section. per the eligibility and send an authorization letter to
1. Notification of Claim the provider. You have to provide the ID card issued
Treatment, Consultation We or Our TPA* must to You along with any other information or
or Procedure: be informed: documentation that is requested by the TPA/Us to
1 If any treatment for which a At least 48 hours prior the Network Hospital.
claim may be made and to the Insured Person’s e. In case of deficiency in the documents sent to
that treatment requires admission. TPA/Us for cashless authorization, the same shall be
planned Hospitalisation: communicated to the hospital by TPA/Us within 6
2 If any treatment for which a Within 24 hours of the hours of receipt of the documents.
claim may be made and Insured Person’s f. In case the ailment /treatment is not covered under
that treatment requires admission to Hospital. the policy or cashless is rejected due to insufficient
emergency Hospitalisation documents submitted, a rejection letter would be
*TPA as mentioned in the policy schedule sent to the hospital within 6 hours.
2. Cashless Service g. Rejection of cashless in no way indicates rejection of
Treatment, Treatment, Cashless We must be the claim. You are required to submit the claim along
Consultation Consultation Service is given notice with required documents for us to decide on the
or Procedure: or Available: that the admissibility of the claim.
Procedure Insured h. If the cashless is approved, the original bills and
Taken at: Person wishes evidence of treatment in respect of the same shall
to take be left with the Network Hospital.
advantage of i. Pre-authorization does not guarantee that all costs
the cashless and expenses will be covered. We reserve the right
service to review each claim for Medical Expenses and
accompanied accordingly coverage will be determined according
by full to the terms and conditions of this Policy.
particulars: 4. Supporting Documentation & Examination
If any planned Network We will provide At least 48 i. You or someone claiming on Your behalf shall provide Us
treatment, Hospital cashless hours before with documentation, medical records and information We
consultation service by the planned or Our TPA may request to establish the circumstances of
or procedure making treatment or the claim, its quantum or Our liability for the claim within
for which a payment to the Hospitalisation 15 days or earlier of Our request or the Insured Person’s
claim may be extent of Our discharge from Hospitalisation or completion of
made: liability directly treatment.
to the Network ii. Failure to furnish such evidence within the time required
Hospital. shall not invalidate nor reduce any claim if you can satisfy
If any Network We will provide Within 24 us that it was not reasonably possible for you to give proof
treatment, Hospital cashless hours after within such time.
consultation service by the treatment iii. We may accept claims where documents have been
or procedure making or provided after a delayed interval only in special
for which a payment to the Hospitalisation circumstances and for the reasons beyond the control of
claim may be extent of Our the Insured Person.
made, liability directly iv. Such documentation will include the following:
requiring to the Network a. Our claim form, duly completed and signed for on
emergency Hospital. behalf of the Insured Person.We, upon receipt of a
hospitalisation notice of claim, will furnish Your representative with
such forms as We may require for filing proofs of
loss or you may download the claim form from our
Web site.
13
b. Original Bills (pharmacy purchase bill, consultation Person has complied with his obligations under this
bill, diagnostic bill) and any attachments thereto like Policy.
receipts or prescriptions in support of any amount ii. This Policy only covers medical treatment taken within
claimed which will then become Our property. India (except in case of benefit B13- Global cover), and
c. All medical reports, case histories, investigation payments under this Policy shall only be made in Indian
reports, indoor case papers/ treatment papers (in Rupees within India.
reimbursement cases, if available), discharge Section 6 - Dispute Resolution
summaries. 1. Dispute Resolution Clause
d. A precise diagnosis of the treatment for which a Any and all disputes or differences under or in relation to this
claim is made. Policy shall be determined by the Indian Courts and subject to
e. A detailed list of the individual medical services and Indian law.
treatments provided and a unit price for each in case 2. Arbitration
not available in the submitted hospital bill. If any dispute or difference shall arise as to the quantum to be
f. Prescriptions that name the Insured Person and in paid by the Policy, (liability being otherwise admitted) such
the case of drugs: the drugs prescribed, their price difference shall independently of all other questions, be
and a receipt for payment. In case of pre/post referred to the decision of a sole arbitrator to be appointed in
hospitalization claim Prescriptions must be writing by the parties here to or if they cannot agree upon a
submitted with the corresponding Doctor/hospital single arbitrator within thirty days of any party invoking
invoice. arbitration, the same shall be referred to a panel of three
g. All pre and post investigation, treatment and follow arbitrators, comprising two arbitrators, one to be appointed by
up (consultation) records pertaining to the present each of the parties to the dispute/difference and the third
ailment for which claim is being made, if and where arbitrator to be appointed by such two arbitrators and
applicable. arbitration shall be conducted under and in accordance with
h. Treating doctor’s certificate regarding missing the provisions of the Arbitration and Conciliation Act 1996, as
information in case histories e.g. Circumstance of amended by Arbitration and Conciliation (Amendment) Act,
injury and Alcohol or drug influence at the time of 2015 (No. 3 of 2016).
accident, if available It is clearly agreed and understood that no difference or dispute
i. Copy of settlement letter from other insurance shall be preferable to arbitration as herein before provided, if
company or TPA the Company has disputed or not accepted liability under or in
j. Stickers and invoice of implants used during surgery respect of the policy.
k. Copy of MLC (Medico legal case) records, if carried 3. It is hereby expressly stipulated and declared that it shall
out and FIR (First information report) if registered, in be a condition precedent to any right of action or suit upon
case of claims arising out of an accident and the policy that award by such arbitrator/arbitrators of the
available with the claimant. amount of expenses shall be first obtained.
l. Regulatory requirements as amended from time to
time, currently mandatory NEFT (to enable direct Annexure A
credit of claim amount in bank account) and KYC
NAMES OF OMBUDSMAN AND ADDRESSES OF OMBUDSMAN
(recent ID/Address proof and photograph)
CENTRES
requirements
m. Legal heir/succession certificate , if required Office of the Address & Contact Jurisdiction of
Ombudsman details Office Union
n. PM report (wherever applicable)
Territory,
v. Note: In case You are claiming for the same event under
District
an indemnity based policy of another insurer and are
required to submit the original documents related to Your AHMEDABAD Office of the Insurance Gujarat,Dadra
treatment with that particular insurer, then You may Ombudsman & Nagar Haveli,
provide Us with the attested copies of such documents ,Jeevan Prakash Daman and
along with a declaration from the particular insurer Building, 6th floor, Tilak Diu.
specifying the availability of the original copies of the Marg, Relief Road,
specified treatment documents with it. Ahmedabad – 380
We at our own expense, shall have the right and opportunity to 001.Tel.: 079 -
examine insured persons through Our Authorised Medical 25501201/02/05/06
Practitioner whose details will be notified to insured person Email:
when and as often as We may reasonably require during the bimalokpal.ahmedabad
pendency of a claim hereunder. @ecoi.co.in
5. Claims Payment
BENGALURU Office of the Insurance Karnataka
i. We shall be under no obligation to make any payment Ombudsman,
under this Policy unless We have received all premium Jeevan Soudha
payments in full in time and We have been provided with Building,PID No. 57-27-
the documentation and information We or Our TPA has N-19 Ground Floor,
requested to establish the circumstances of the claim, its 19/19, 24th Main
quantum or Our liability for it, and unless the Insured Road,JP Nagar, Ist
Phase, Bengaluru – 560
14
078. Tel.: 080 - 0361 - 2132204 / Nagaland and

26652048 / 26652049 2132205 Fax: 0361 - Tripura
Email: 2732937
bimalokpal.bengaluru@ Email: bimalokpal.
ecoi.co.in guwahati@ecoi.co.in
BHOPAL Office of the Insurance Madhya HYDERABAD Office of the Insurance Andhra
Ombudsman, Janak Pradesh, Ombudsman, 6-2-46, Pradesh,
1st floor, “Moin Court”, Telangana,
Vihar Complex, 2nd Chattisgarh
Lane Opp. Saleem Yanam and
Floor, 6, Malviya Nagar,
Function Palace, A. C. part of
Opp. Airtel Office,Near
Guards, Lakdi-Ka-Pool, Territory of
New Market, Bhopal –
Hyderabad - 500 004. Pondicherry.
462 003. Tel.: 0755 -
Tel.: 040 - 65504123 /
2769201 / 2769202 Fax:
23312122 Fax: 040 -
0755 - 2769203 Email: 23376599
bimalokpal.bhopal@eco Email: bimalokpal.
i.co.in hyderabad@ecoi.co.in
BHUBANESHWAR Office of the Insurance Orissa JAIPUR Office of the Insurance Rajasthan
Ombudsman,62, Forest Ombudsman, Jeevan
park, Bhubneshwar – Nidhi – II Bldg., Gr.
751 009. Tel.: 0674 - Floor, Bhawani Singh
2596461 /2596455 Fax: Marg, Jaipur - 302 005.
0674 - 2596429 Email: Tel.: 0141 - 2740363
bimalokpal.bhubanesw Email: Bimalokpal.
ar@ecoi.co.in jaipur@ecoi.co.in
CHANDIGARH Office of the Insurance Punjab, ERNAKULAM Office of the Insurance Kerala,
Ombudsman, 2nd Floor, Lakshadweep,
Ombudsman, S.C.O. No. Haryana,
Pulinat Bldg., Opp. Mahe-a part of
101, 102 & 103, 2nd Himachal
Cochin Shipyard, M. G. Pondicherry
Floor, Batra Building, Pradesh,
Road, Ernakulam - 682
Sector 17 – D, Jammu &
015. Tel.: 0484 -
Chandigarh – 160 017. Kashmir,
2358759 / 2359338 Fax:
Tel.: 0172 - 2706196 / Chandigarh
0484 - 2359336
2706468 Fax: 0172 - Email:
2708274 Email: bimalokpal.ernakulam@
bimalokpal.chandigarh ecoi.co.in
@ecoi.co.in
KOLKATA Office of the Insurance West Bengal,
CHENNAI Office of the Insurance Tamil Nadu, Ombudsman, Sikkim,
Ombudsman, Fatima Pondicherry Hindustan Bldg. Andaman &
Akhtar Court, 4th Floor, Town and Annexe, 4th Floor, 4, Nicobar Islands
453,Anna Salai, Karaikal (which C.R. Avenue, KOLKATA -
Teynampet, CHENNAI – are part of 700 072. Tel.: 033 -
600 018. Tel.: 044 - Pondicherry). 22124339 / 22124340
24333668 / 24335284 Fax : 033 - 22124341
Fax: 044 - 24333664 Email:
Email: bimalokpal.
bimalokpal.kolkata@eco
chennai@ecoi.co.in
i.co.in
DELHI Office of the Insurance Delhi
Ombudsman, 2/2 A, LUCKNOW Office of the Insurance Districts of
Universal Insurance Ombudsman, 6th Floor, Uttar Pradesh :
Building, Asaf Ali Road, Jeevan Bhawan, Phase- Laitpur, Jhansi,
New Delhi – 110 002. II, Nawal Kishore Road, Mahoba,
Tel.: 011 - 23239633 / Hazratganj, Lucknow - Hamirpur,
23237532 Fax: 011 - 226 001. Tel.: 0522 - Banda,
23230858 2231330 / 2231331 Fax: Chitrakoot,
Email: bimalokpal. 0522 - 2231310 Email: Allahabad,
delhi@ecoi.co.in bimalokpal.lucknow@ec Mirzapur,
oi.co.in Sonbhabdra,
GUWAHATI Office of the Insurance Assam,
Fatehpur,
Ombudsman, Jeevan Meghalaya,
Pratapgarh,
Nivesh, 5th Floor, Nr. Manipur,
Panbazar over bridge, Jaunpur,Varana
Mizoram,
S.S. Road, Guwahati – si, Gazipur,
Arunachal
781001(ASSAM). Tel.: Jalaun, Kanpur,
Pradesh,
Lucknow,
15
Unnao, Sitapur, Kashganj,

Lakhimpur, Sambhal,
Bahraich, Amroha,
Barabanki, Hathras,
Raebareli, Kanshiramnaga
Sravasti, r, Saharanpur
Gonda,
PATNA Office of the Insurance Bihar,
Faizabad,
Ombudsman, 1st Jharkhand
Amethi,
Floor,Kalpana Arcade
Kaushambi,
Building,, Bazar Samiti
Balrampur,
Road, Bahadurpur,
Basti,
Patna 800 006. Tel.:
Ambedkarnaga
0612-2680952 Email:
r, Sultanpur,
bimalokpal.patna@ecoi.
Maharajgang,
co.in
Santkabirnagar,
Azamgarh, PUNE Office of the Insurance Maharashtra,
Kushinagar, Ombudsman, Jeevan Area of Navi
Gorkhpur, Darshan Bldg., 3rd Mumbai and
Deoria, Mau, Floor, C.T.S. No.s. 195 to Thane
Ghazipur, 198, N.C. Kelkar Road, excluding
Chandauli, Narayan Peth, Pune – Mumbai
Ballia, 411 030. Tel.: 020- Metropolitan
Sidharathnagar 41312555 Email: Region
bimalokpal.pune@ecoi.c
MUMBAI Office of the Insurance Goa, Mumbai
o.in
Ombudsman, 3rd Floor, Metropolitan
Jeevan Seva Annexe, S. Region
V. Road, Santacruz (W), excluding Navi For updated list and details of Insurance Ombudsman Offices, please
Mumbai - 400 054. Tel.: Mumbai & visit website http://ecoi.co.in/ombudsman.html
022 - 26106552 / Thane Prohibition of Rebates - Section 41 of the Insurance Act, 1938 as
26106960Fax: 022 - amended by Insurance Laws (Amendment) Act, 2015.
26106052 Email:
bimalokpal.mumbai@ec 1. No person shall allow or offer to allow, either directly or
oi.co.in indirectly, as an inducement to any person to take out or renew
or continue an insurance in respect of any kind of risk relating
NOIDA Office of the Insurance State of to lives or property in India, any rebate of the whole or part of
Ombudsman, Bhagwan Uttaranchal the commission payable or any rebate of the premium shown
Sahai Palace 4th Floor, and the on the policy, nor shall any person taking out or renewing or
Main Road, Naya Bans, following continuing a policy accept any rebate, except such rebate as may
Sector 15, Distt: Gautam Districts of be allowed in accordance with the published prospectuses or
Buddh Nagar, U.P- Uttar Pradesh: tables of the insurer.
201301. Tel.: 0120- Agra, Aligarh,
2514250 / 2514252 / Bagpat, 2. Any person making default in complying with the provisions of
2514253 Email: Bareilly, Bijnor, this section shall be liable for a penalty which may extend to ten
bimalokpal.noida@ecoi. Budaun, lakh rupees.
co.in Bulandshehar, Tata AIG General Insurance Company Limited
Etah, Kanooj, Registered Office: Peninsula Business Park, Tower A, 15th Floor,
Mainpuri, G.K. Marg, Lower Parel, Mumbai 400013, Maharashtra, India
Mathura, 24X7 Toll Free No: 1800 266 7780 or 1800 22 9966 (For Senior
Meerut, Citizens) Fax: 022 6693 8170
Moradabad, Email:customersupport@tataaig.com Website: www.tataaig.com
Muzaffarnagar, IRDA of India Registration No: 108 CIN: U85110MH2000PLC128425
Oraiyya,
Pilibhit, Etawah,
Farrukhabad,
Firozbad,
Gautambodhan
agar,
Ghaziabad,
Hardoi,
Shahjahanpur,
Hapur, Shamli,
Rampur,
16

Tata Aig Medicare Premier: Policy Wordings

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Tata Aig Medicare Premier: Policy Wordings

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Tata AIG MediCare Premier

Tata AIG MediCare Premier

Tata AIG General Insurance Co. Ltd.

This benefit shall not be applicable for Global Cover (section

1. Exclusions with waiting periods XX. Calculus diseases of Urogenital system

078. Tel.: 080 - 0361 - 2132204 / Nagaland and

Unnao, Sitapur, Kashganj,

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