HDFC Group Health Insurance Policy Wording

HDFC ERGO General Insurance Company Limited
HDFC Group Health Insurance

Policy Wording
Operating Clause be effected in the same proportion as the

admissible rate per day bears to the actual rate
per day of Room Rent charges. This condition
We will provide Insurance coverage to the Insured is not applicable in respect of Hospitals where
Person(s) under this Policy up to Sum Insured including differential billing for Associated Medical
Cumulative Bonus as applicable and subject to waiting Expenses is not followed based on Room
periods and limits as specified on the Schedule of Coverage category.
in the Policy Schedule/Certificate of Insurance.The Policy
is based on statements, disclosures, declarations made in
the Proposal form/Enrollment form and Medical reports. ii. Mental Illness
The Coverage for Mental illness is applicable if
Certain words used in the Coverage description have done in Mental Health Establishment and is
specific meanings which are mentioned in Definitions and subject to the provisions contained in the Mental
which impacts the Coverage. All such words, are mentioned Health Care Act, 2017, as amended from time to
in Bold to enable You to identify that the particular word has time and other applicable laws and Regulations.
a specific meaning for which You need to refer Section – F,
Definitions. 2. Pre-Hospitalization Medical Expenses Cover
We will pay for the Pre-Hospitalization Medical
Expenses incurred during the 60 days immediately
SECTION A. GOLD PLAN
before Hospitalization of an Insured Person.
We will pay under below listed Covers on Medically

3. Post-Hospitalization Medical Expenses Cover
Necessary Hospitalization of an Insured Person due to
Illness or Injury sustained or contracted during the Period We will pay for the Post-Hospitalization Medical
of Insurance subject to terms and conditions as listed below. Expenses incurred upto 90 days from the date Insured
Person is discharged from Hospital.
1. In-Patient Hospitalization
i. Room Rent and boarding chargesup to 1% of
Base Sum Insured , subject to a maximum limit 4. Day Care Procedures
of INR 3000 per day We will pay for the Medical Expenses under Section A1
ii. Intensive Care Unit charges up to 2% of Base on Hospitalization of Insured Person in Hospital or
Sum Insured Day Care Centre for Day Care Treatment.
iii. Consultation fees & Nursing charges
iv. Anesthesia, blood, oxygen, operation theatre 5. Domiciliary Hospitalization
charges, surgical appliances charges We will pay the Medical Expenses incurred on
v. Medicines, drugs and consumables Domiciliary Hospitalization of the Insured Person
presecribed by treating Medical Practitioner.
vi. Diagnostic procedures
vii. The Cost of prosthetic and other Medical devices
or equipment if implanted internally during a 6. Road Ambulance Cover
Surgical Procedure. For each admissible Claim under Section A1 and A4,
We will pay for expenses incurred on Road Ambulance
PWW/Ver - 1 OCT 2020
Services if Insured Person is required;

a. Special Conditions
i. to be transferred to the nearest Hospital
i. Room Rent & Proportionate deduction: In
following an emergency (namely a sudden,
case of admission to a room at rates exceeding
urgent, unexpected occurrence or event,
the aforesaid limits, the reimbursement/payment
bodily alteration or occasion requiring
of Room Rent charges including all Associated
immediate medical attention)
Medical Expenses incurred at Hospital shall
HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146. CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor,
HDFC House, 165-166 Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai – 400 020. Trade Logo displayed above belongs to HDFC Ltd and
ERGO International AG and used by the Company under license. UIN: HDFC Group Health Insurance - HDFHLGP21116V012021.
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ii. or from one Hospital to another Hospital a. Special Conditions
iii. or from Hospital to Home (within same i. Mental Illness
City) following Hospitalization The Coverage for Mental illness is applicable if done
in Mental Health Establishment and is subject to
7. Organ Donor Expenses the provisions contained in the Mental Health Care
Act, 2017, as amended from time to time and other
We will pay Medical Expenses coveredunder applicable laws and Regulations.
Section A1 towards organ donor’s Hospitalization
for harvesting of the donated organ where an Insured
Person is the recipient subject to condition that; 2. Pre-Hospitalization Medical Expenses cover
i. The organ donor is any person whose We will pay for the Pre-HospitalizationMedical
organ has been made available Expenses incurred during the 60 days immediately
in accordance and in compliance before Hospitalization of an Insured Person.
with The Transplantation of Human
Organ (amendment) Act, 2011,
Transplantation of Human Organs and 3. Post-Hospitalization Medical Expenses cover
Tissues Rules, 2014 and other applicable We will pay for the Post- Hospitalization Medical
Laws and/or Regulations. Expenses incurred upto 180 days from the date
ii. Hospitalization Claim under Section A1 Insured Person is discharged from Hospital.
is admissible under the coverage for the
Insured Person 4. Day Care Procedures
iii. The Organ Donor’s Pre-Hospitalization We will pay for the Medical Expenses under Section
and Post-HospitalizationMedical B1 on Hospitalization of Insured Person in Hospital
Expenses are excluded under the Policy. or Day Care Centre for Day Care Treatment.
iv. Any other Medical Expenses or
Hospitalization consequent to the
harvesting is excluded under the Policy. 5. Domiciliary Hospitalization
We will pay the Medical Expenses incurred on
Domiciliary Hospitalization of the Insured Person
SECTION B. PLATINUM PLAN presecribed by treating Medical Practitioner.
We will pay under below listed Covers on Medically 6. Road Ambulance Cover
Necessary Hospitalization of an Insured Person due to For each admissible Claim under Section B1 and B4,
Illness or Injury sustained or contracted during the Period We will pay for expenses incurred on Road Ambulance
of Insurance subject to terms and conditions as listed below. Services if Insured Person is required;
1. In-Patient Hospitalization i. to be transferred to the nearest Hospital
i. Room Rent and boarding charges following an emergency (namely a sudden,
urgent, unexpected occurrence or event,
ii. Intensive Care Unit charges
bodily alteration or occasion requiring
iii. Consultation fees & Nursing charges immediate medical attention)
iv. Anesthesia, blood, oxygen, operation theatre ii. or from one Hospital to another Hospital
charges, surgical appliances charges
iii. or from Hospital to Home (within same
v. Medicines, drugs and consumables City) following Hospitalization
vi. Diagnostic procedures 7. Organ Donor Expenses
vii. The Cost of prosthetic and other Medical devices We will pay Medical Expenses covered under
or equipment if implanted internally during a Section B1 towards organ donor’s Hospitalization
Surgical Procedure.
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for harvesting of the donated organ where an Insured eligibility as mentioned on the Schedule
Person is the recipient subject to condition that; of Coverage in the Policy Schedule/
i. The organ donor is any person whose Certificate of Insurance.
organ has been made available in • In case of Annual Eligibility, the percentage
accordance and in compliance with and limit will be calculated on expiring
The Transplantation of Human Organ Coverage SumInsured and will be only
(amendment) Act, 2011, Transplantation applicable to Insured Person covered
of Human Organs and Tissues Rules, under expiring Coverage, subject to no
2014 and other applicable Laws and/or claim under Base Coverage.
Regulations. • In case of Eligibility at the end of each
ii. Hospitalization Claim under Section B1 block of continuous years (as mentioned
is admissible under the coverage for the on the Schedule of Coverage), the
Insured Person percentage and limit will be calculated
iii. The Organ Donor’s Pre-Hospitalization on Average Sum Insured during block of
and Post-HospitalizationMedical three years and will be only applicable to
Expenses are excluded under the Policy. Insured Person covered for all previous 3
years.
iv. Any other Medical Expenses or
Hospitalization consequent to the • Claim under this Cover does not impact
harvesting is excluded under the Policy. the Sum Insured or the eligibility for
Cumulative Bonus.
• The test reports received under this
SECTION C. OPTIONAL COVERS Coverage will not be utilized for re-
underwriting the expiring coverage of
Insured Person
Insuring Clause
2. Cumulative Bonus
In consideration of payment of additional Premium or
On each continuous Renewal of the Coverage with
reduction in the Premium as applicable, it is hereby
Us, We will apply 10% of Base Sum Insured under
declared and agreed that We will pay/restrict the expenses
expiring Cover as Cumulative Bonus in the Coverage
under below listed Covers subject to waiting periods and
provided that;
limits as specified on the Schedule of Coverage in the
PolicySchedule/Certificate of Insurance. i. There has been no claim under the
Coverage in expiring year.
Subject to otherwise all other terms, conditions, exclusions
and waiting periods applicable to the Policy. ii. Cumulative Bonus will be reduced at
the same rate as accrued in the event of
These Covers are optional and applicable only if opted
admissible Claim under the Coverage.
for and upto the Sum Insured or limits mentioned on the
Schedule of Coverage in the Policy Schedule/Certificate of iii. Cumulative Bonus can be accumulated
Insurance. upto the limit mentioned on the Schedule
of Coverage in the Policy Schedule/
Certificate of Insurance.
1. Preventive Health Check Up
iv. Cumulative Bonus applied will be
We will indemnify the Insured Person towards the applicable only to Insured Person(s)
cost of Preventive Health Check – Up, up to the limit covered under the expiring Coverage
mentioned on the Schedule of Coverage in the Policy and who continue to remain insured on
Schedule/Certifiate of Insurance. Renewal.
Other terms and Conditions applicable to this Coverage
• The Coverage will be applicable as per the
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3. Hospital Cash 6. Specific Illness Waiting period
If Insured Person contracts Illness or sustains Modification Option
Injury during Period of Insurance, which results in On availing this option, Waiting Periods listed under
Medically Necessary; Section D.I.ii shall stand modified as mentioned in
i. Hospitalization Schedule of Coverage on the Policy Schedule/
ii. Domiciliary Hospitalization
All other terms and Conditions of the Policy shall
iii. Hospitalization for Alternative remain unaltered.
Treatments
7. AlternativeTreatment
of an Insured Person within India, We will pay per
day Sum Insured as specified on the Schedule We will pay Medical Expenses covered under
of Coverage in the Policy Schedule/Certificate of Section A or B as opted, on Medically Necessary
Insurancesubject to maximum number of benefit days Hospitalization of Insured Person in Ayush
for each continuous and completed period of 24 hours Hospital upto the limit mentioned on the Schedule
of such Hospitalization. of Coverage in the Policy Schedule/Certificate of
Insurance for following Alternative Treatments
prescribed by Medical Practitioner:
4. Restore Benefit • Ayurvedic
Instant addition of 100% Base Sum Insured on • Unani
complete or partial utilization of Your existing Policy
Sum Insured and Cumulative Bonus (if applicable) • Siddha
during the Policy Year. The Total amount (Base • Homeopathy
Sum Insured, Cumulative Bonus and Restore Sum
Insured) will be available to all Insured Persons for
all claims under the Coverage during the current SECTION D. WHAT IS NOT COVERED
Policy Year and subject to the condition that single
claim in a Policy Year cannot exceed the sum of
BaseSumInsured and the Cumulative Bonus (if We will not make payment for any claim in respect of any
applicable). Insured Person caused by, arising from or attributable to
any of the following unless expressly stated to the contrary
Conditions for Restore benefit:
in the Policy
a. The Sum Insured will be restored only
once in a Policy Year.
I. Waiting Periods
b. If the Restored Sum Insured is not utilized
in a Policy Year, it will expire. Claims under the Policy are covered subject to
Waiting Period as specified below:
In case of a Family Floater Policy, Restore Sum
Insured will be available on floater basis for all Insured
Persons in the Policy. i) Pre-existing Diseases – Code – Excl01
a) Expenses related to the treatment of a
5. Waiting period Modification Option pre-existing disease (PED) and its direct
complications shall be excluded until
On availing this option, Waiting Periods listed under
the expiry of 48 months of continuous
Section D.I.i shall stand modified as mentioned in
coverage after the date of inception of the
Schedule of Coverage on the Policy Schedule/
first Policy with insurer.
b) In case of enhancement of Sum Insured
All other terms and Conditions of the Policy shall
the exclusion shall apply afresh to the
remain unaltered.
extent of sum of Sum Insured increase.
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c) If the Insured Person is continuously b) In case of enhancement of Sum Insured
covered without any break as defined the exclusion shall apply afresh to the
under the portability norms of the extant extent of Sum Insured increase.
IRDAI (Health Insurance) Regulations, c) If any of the specified disease/procedure
then waiting period for the same would be falls under the waiting period specified for
reduced to the extent of prior coverage. Pre-existing diseases, then the longer of
d) Coverage under the Policy after the expiry the two waiting periods shall apply.
of 48 months for any pre-existing disease d) The waiting period for listed conditions
is subject to the same being declared at shall apply even if contracted after the
the time of application and accepted by Policy or declared and accepted without
Insurer. a specific exclusion.
e) If the Insured Person is continuously
ii) Specified Disease/Procedure waiting covered without any break as defined
period - Code - Excl02 under the applicable norms on portability
a) Expenses related to the treatment of the stipulated by IRDAI, then waiting period for
listed Conditions, surgeries/treatments the same would be reduced to the extent
shall be excluded until the expiry of 24 of prior coverage.
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.
Illnesses
Internal Congenital diseases Non infective Arthritis Pilonidal sinus

calculus diseases of Urogenital
Diseases of gall bladder including Benign tumors, cysts, nodules, polyps
system e.g.Kidneystone,Urinary
cholecystitis including breast lumps
Bladder Stone
Ulcer and erosion of stomach and
Pancreatitis Polycystic ovarian diseases
duodenum
Gastro Esophageal Reflux Disorder
All forms of Cirrhosis Sinusitis, Rhinitis
(GERD)
Perineal Abscesses Perianal Abscesses Skin tumors
Fissure/fistula in anus, Haemorrhoids
Cataract Tonsillitis
including Gout and rheumatism
Osteoarthritis and osteoporosis Fibroids ( fibromyoma) Benign Hyperplasia of Prostate
Surgical Procedures
Adenoidectomy, tonsillectomy Tympanoplasty, Mastoidectomy Hernia

Surgery for prolapsed inter vertebral
Dilatation and curettage (D&C) Nasal concha resection
disc
Surgery for varicose veins and
Myomectomy for fibroids Surgery of Genito urinary system
varicose ulcers
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Surgery on prostate Cholecystectomy Surgery for Perianal Abscesses
Hydrocele/Rectocele Joint replacement surgeries Surgery for Nasal septum deviation
Fissurectomy, Haemorrhoidectomy,
Ligament, Tendon and Meniscal tear Hysterectomy
Fistulectomy, ENT surgeries
Endometriosis Prolapsed Uterus Rectal Prolapse
Varicocele Retinal detachment Glaucoma
Nasal polypectomy
iii) 30-day waiting period – Code – Excl03 help with activities of daily living such as
a) Expenses related to the treatment of any bathing, dressing, moving around either by
Illness within 30 days from the first Policy skilled nurses or assistant or non-skilled
commencement date shall be excluded except persons.
claims arising due to an Accident, provided the b. Any services for people who are terminally
same are covered. ill to address physical, social, emotional
b) This exclusion shall not, however, apply if the and spiritual needs.
Insured Person has continuous coverage for
more than twelve months. iii. Obesity/Weight control: Code – Excl06:
c) The within referred waiting period is made Expenses related to the surgical treatment
applicable to the enhanced Sum Insured in of obesity that does not fulfil all the below
the event of granting higher Sum Insured conditions:
subsequently. a. Surgery to be conducted is upon the
advice of the doctor
II. Permanent Exclusions b. The surgery/procedure conducted should
We will not make any payment for any claim in respect be supported by clinical protocols
of any Insured Person caused by, arising from or c. The member has to be 18 years of age or
attributable to any of the following unless expressly older and
stated to the contrary in this Policy: d. Body Mass Index (BMI)
i. Greater than or equal to 40 or,
i. Investigation & Evaluation: Code - Excl04 ii. Greater than or equal to 35 in
a. Expenses related to any admission conjunction with any of the following
primarily for diagnostic and evaluation severe co-morbidities following
purposes only are excluded. failure of less invasive methods of
b. Any diagnostic expenses which are not weight loss:
related or not incidental to the current iii. Obesity related cardiomyopathy
diagnosis and treatment are excluded. iv. coronary heart disease
v. severe sleep apnoea
ii. Rest Cure, rehabilitation and respite care: vi. uncontrolled type2 diabetes
Code – Excl05: Expenses related to any
admission primarily for enforced bed rest and
not for receiving treatment. This also includes: iv. Change-of-Gender treatments: Code – Excl07:
a. Custodial care either at home or in a Expenses related to any treatment, including
nursing facility for personal care such as surgical management, to change characteristics
of the body to those of the opposite sex.
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v. Cosmetic or plastic surgery: Code – Excl08: be purchased without prescription, including but
Expenses for cosmetic or plastic surgery or not limited to Vitamins, minerals and organic
any treatment to change appearance unless substances unless prescribed by a Medical
for reconstruction following an Accident, Practitioner as part of Hospitalization claim or
Burn(s) or Cancer or as part of Medically day care procedure.Code – Excl14
Necessary Treatment to remove a direct and
immediate health risk to the insured. For this to
be considered a medical necessity, it must be xii. Expenses related to the treatment for correction
certified by the attending Medical Practitioner. of eye sight due to refractive error less than 7.5
dioptres.Code – Excl15
vi. Hazardous or Adventure Sports: Code –

Excl09– Expenses related to any treatment xiii. Unproven Treatments: Code – Excl16 -
necessitated due to participation as a Expenses related to any unproven treatment,
professional in Hazardous or Adventure services and supplies for or in connection
sports, including but not limited to, para- with any treatment. Unproven treatments are
jumping, rock climbing, mountaineering, rafting, treatments, procedures or supplies that lack
motor racing, horse racing or scuba diving, hand significant medical documentation to support
gliding, sky diving, deep sea diving. their effectiveness.
vii. Breach of Law: Code – Excl10 – Expenses for xiv. Sterility and Infertility: Code – Excl17
treatment directly arising from or consequent -Expenses related to sterility and infertility. This
upon any Insured Person committing or includes:
attempting to commit a breach of law with a. Any type of contraception, sterilization
criminal intent. b. Assisted Reproduction services including
artificial insemination and advanced reproductive
viii. Excluded Providers: Code – Excl11 – technologies such as IVF, ZIFT, GIFT, ICSI
Expenses incurred towards treatment in any c. Gestational Surrogacy
hospital or by any Medical Practitioner or d. Reversal of sterilization
any other provider specifically excluded by the
Insurer and disclosed in its website/notified to
the policyholders are not admissible. However, xv. Maternity:Code – Excl18
in case of life threatening situations or a. Medical treatment expenses traceable to
following an Accident, expenses up to the stage childbirth (including complicated deliveries
of stabilization are payable but not the complete and caesarean sections incurred during
claim. hospitalization) except ectopic pregnancy;
b. Expenses towards miscarriage (unless
ix. Treatment for Alcoholism, drug or substance due to an accident) and lawful medical
abuse or any addictive condition and termination of pregnancy during the Policy
consequences thereof.Code – Excl12 period.
x. Treatments received in health hydros, nature
cure clinics, spas or similar establishments xvi. War or any act of war (whether war be declared
or private beds registered as a nursing home or not or caused during service in the armed
attached to such establishments or where forces of any country), invasion, act of foreign
admission is arranged wholly or partly for enemy, civil war, public defence, rebellion,
domestic reasons.Code – Excl13 revolution, insurrection, military or usurped acts,
Nuclear, Chemical or Biological attack or
xi. Dietary supplements and substances that can weapons, radiation of any kind.
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xvii. Any Insured Person committing or attempting xxvii. Vaccination including inoculation and
to commit intentional self-injury or attempted immunisations (Except post Animal bite
suicide or suicide while mentally sound or treatment),
unsound.
xxviii. Non-Medical expenses such as Food charges

xviii. Any Insured Person’s participation or (other than patient’s diet provided by hospital),
involvement in naval, military or air force laundry charges, attendant charges, ambulance
operation. collar, ambulance equipment, baby food, baby
utility charges and other such items. Full list
of Non-Medical expenses is available at www.
xix. Investigative treatment for Sleep-apnoea, hdfcergo.com.
General debility or exhaustion (“run-down
condition”).
xxix. Treatment taken on Outpatient basis.
xx. Congenital external diseases, defects or

anomalies, xxx. The provision or fitting of hearing aids, spectacles
or contact lenses.
xxi. Stem cell harvesting, or growth hormone

therapy. xxxi. Any treatment and associated expenses for
alopecia, baldness including corticosteroids
and topical immunotherapy wigs, toupees,
xxii. Dental Treatment and surgery of any kind, hair pieces, any non-surgical hair replacement
unless requiring Hospitalization. methods, Optometric therapy.
xxiii. Investigative treatments for analysis and xxxii. Any treatment or part of a treatment that is not
adjustments of spinal subluxation, diagnosis of a Reasonable and Customary charge, not
and treatment by manipulation of the skeletal Medically Necessary; treatments or drugs not
structure or for muscle stimulation by any means supported by a prescription.
except treatment of fractures (excluding hairline
fractures) and dislocations of the mandible and
extremities). xxxiii. Expenses for Artificial limbs or and/or device
used for diagnosis or treatment (except when
used intra-operatively).prosthesis, corrective
xxiv. Circumcisions (unless necessitated by Illness or devices, external durable medical equipment
Injury and forming part of treatment). of any kind, wheelchairs, crutches, and oxygen
concentrator for bronchial asthma/ COPD
xxv. Any Convalescence, sanatorium treatment, conditions, cost of cochlear implant(s) unless
private duty nursing or long-term nursing care. necessitated by an Accident. Exhaustive list of
Non-Medical Expenses also available on www.
hdfcergo.com.
xxvi. Preventive care, any physical, psychiatric or xxxiv. Any Claim arising due to Non-disclosure of Pre-
psychological examinations or testing if doesn’t existing Illness or Material fact as sought to be
require Hospitalization; and other nutritional declared on the Proposal form.
and electrolyte supplements, unless certified to
be required by the attending Medical Practitioner
as a direct consequence of an otherwise covered
claim.
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SECTION E. CLAIMS PROCEDURE
1. Notification of a Claim
Cashless Hospitalization
Procedure Reimbursement Claims
Emergencies Planned
Claim Intimation
You shall intimate the Claims to us through any available mode of communication as specified in the Policy, Health Card
or our Website
Within 48 hours of
At least 72 hours admission or before
Within 24 hours of the
Claim Intimation Timelines prior to the planned discharge from the
Emergency Hospitalization
Hospitalization Hospital, whichever is
earlier
i. The health card issued by Us
ii. KYC documents
iii. The Policy Number
iv. Name of the Policyholder
v. Name and address of Insured Person
Particulars to be provided to
us for claim notification vi. Nature of the Illness/Injury and the treatment required
vii. Name and address of the attending Medical Practitioner
viii. Name of Hospital for admission/treatment
ix. Proposed /Actual Date of admission
x. MLC/FIR copy/certificate regarding abuse of Alcohol/intoxicating agent if
applicable (in case of an injury).
i. Copy of Discharge Summary / Discharge Certificate along with time of admission
and discharge
ii. First consultation letter from treating Medical Practitioner
iii. Certificate from treating Medical Practitioner, specifying the duration and aetiology
Hospital Cash iv. MLC/FIR copy/certificate regarding abuse of Alcohol/intoxicating agent if
applicable (in case of an injury).
v. NEFT details & cancelled cheque of Claimant or Nominee (in case claimant
expired),
vi. legal heir certificate in case nominee is minor.
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i. Policy Number
ii. Name of the Insured person(s)
iii. Nature of disease/Illness/Injury
Particulars to be provided
iv. Name and address of the attending Not Applicable
for pre-authorization
Medical Practitioner/Hospital
v. Date of admission & probable date of discharge
vi. Approximate Claim Expenses
Any other relevant information as required
On receipt of duly filled pre authorization form and other

details, We may;
• Issue the authorization letter specifying the sanctioned
Process for amount, limitation, and non-payable items, if applicable
Not Applicable
pre-authorization Or
• Reject the request for pre-authorization specifying
reasons for the rejection.
List of Claim documents Not Applicable As enlisted below
If the claim is not notified/ or submitted to Us within the specified time limits, then We
Condonation of Delay shall be provided the reasons for the delay in writing. We will condone such delay on
merits where the delay has been proved to be for reasons beyond the claimant’s control
2. List of documents for Reimbursement Claims e.g. lens sticker and invoice in cataract Surgery,
i. Completely filled claim form, duly signed (by stent invoice and sticker in Angioplasty Surgery.
claimant/proposer) and stamped (by Hospital). viii. All previous consultation papers indicating
ii. Government approved Photo ID & Age Proof history and treatment details for current Illness
and advice for current hospitalization.
iii. Copy of claim intimation letter / reference of
Claim Intimation Number in the absence of main ix. All diagnostic reports (including imaging and
claim documents laboratory) along with prescription by Medical
Practitioner and invoice / bill with receipt from
iv. Copy of the Hospital’s Registration Certificate/ diagnostic centre
Hospital Registration number in case of
Hospitalization in any non-network hospital of x. All medicine / pharmacy bills along with
HDFC ERGO GIC or certificate from Hospital prescription by Medical Practitioner
authorities providing facilities available including xi. MLC / FIR Copy – in Accidental cases only
number of beds. xii. History of alcohol consumption or any
v. Discharge Card / Day Care Summary / Transfer intoxication certified by first treating doctor in
Summary case of accidental cases.
vi. Final hospital bill with all deposit and final xiii. Copy of Death Summary and copy of Death
payment receipt and refund receipt(s), if advance Certificate (in death claims only)
amount refunded xiv. Pre and Post-Operative Imaging reports
vii. Invoice with payment receipt and implant xv. Copy of indoor case papers with nursing sheet
stickers for all implants used during surgeries
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detailing medical history of the patient, treatment specified time limits, then We shall be provided
details, and patient’s progress (to be submitted the reasons for the delay in writing. We will
wherever required by the insurer). condone such delay on merits where the delay
xvi. Invoice for Vaccination and payment receipt has been proved to be for reasons beyond the
claimant’s control
xvii. KYC documents (in all claims above Rs 1 lakh)
- (Ration Card/ Driving License/ Aadhar Card/
Passport /any other Government authorized 4. Payment of a Claim
identity proof of the Claimant carrying name, i. If there are any deficiencies in the necessary
photograph & address) and duly filled KYC form claim documents which are not met or are
with 1 signed across passport size coloured partially met, We will send a maximum of 3
photograph of the Claimant *** (three) reminders following which We will send a
xviii. Duly filled NEFT form with cancelled blank closure letter or make a part-payment if We have
cheque (with IFSC code, A/C number, and name not received the deficiency documents after 45
mentioned on cheque leaf) days from the date of the initial request for such
xix. Settlement letter(s), copy (-ies) of payment documents
receipts, and entire certified copy of paid claims ii. The Company shall settle or reject a claim, as
in case of partial claim settlement from other the case may be, within 30 days from the date of
insurer. receipt of last necessary document.
iii. In the case of delay in the payment of a claim,
*** In case of death of Insured Person, the same the Company shall be liable to pay interest to
document reuqirement would be for nominee/ the Policyholder/Insured Person from the date
legal heir of Insured Person(NOC in favour of of receipt of last necessary document to the date
1 or more than 1 undisputedly selected legal of payment of claim at a rate 2% above the Bank
heir(s) by remanining legal heir(s). Rate.
iv. However, where the circumstances of a claim
warrant an investigation in the opinion of the
3. Conditions for obtaining Cashless facility Company, it shall initiate and complete such
i. Cashless facility can be availed only at Our investigation at the earliest, in any case not
Network Provider. The complete list of Network later than 30 days from the date of receipt of
Providers and empanelled Service Providers is last necessary document. In such cases, the
available on Our website and can be obtained by Company shall settle or reject the claim within
contacting Us. 45 days from the date of receipt of last necessary
ii. We reserve the right to modify, add or restrict any document.
Network Provider for Cashless Facilities at Our v. In case of delay beyond stipulated 45 days, the
sole discretion. The same shall be duly updated Company shall be liable to pay interest to the
on Our website. You shall check the updated Policyholder/Insured Person at a rate 2%
list of Network Providers before applying for above the Bank Rate from the date of receipt of
Cashless Claim. last necessary document to the date of payment
iii. Pre-authorization is valid for 15 days from of claim.
date of issuance and if all the details of the vi. If We, for any reason decide to reject the claim,
Hospitalization/treatment, including dates, the reasons regarding the rejection shall be
Hospital and locations match with the details as communicated to You in writing within 30 days
per Cashless authorized. of the receipt of documents.
iv. We will make payment for the Cashless vii. If requested by Us, at Our cost, the Insured
authorized amount directly to the Network Person must submit to medical examination
Provider. by Our Medical Practitioner as often as We
v. If the claim is not notified to Us within the consider reasonable and necessary and We/
Our representatives must be permitted to
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inspect the medical and Hospitalization records Hospital is a healthcare facility wherein
pertaining to the Insured Person’s treatment medical/surgical/para-surgical treatment
and to investigate the circumstances pertaining procedures and interventions are carried
to the claim. out by AYUSH Medical Practitioner (s)
viii. We and Our representatives must be given comprising of any of the following:
all reasonable co-operation in investigating a. Central or State Government AYUSH
the claim in order to assess Our liability and Hospital; or
quantum in respect of the claim b. Teaching hospital attached to AYUSH
College recognized by the Central
Government /Central Council of
SECTION F. DEFINITIONS Indian Medicine/Central Council for
Homeopathy; or
The terms defined below have the meanings as described c. AYUSH Hospital, standalone or co-
to them wherever they appear in this Policy and, where located within-patient healthcare
appropriate, references to the singular include references to facility of any recognized system of
the plural; references to the male include the female and medicine, registered with the local
references to any statutory enactment include subsequent authorities, wherever applicable,
changes to the same and is under the supervision of a
qualified registered AYUSH Medical
Practitioner and must comply with all
Def. 1. Accident or Accidental means a sudden, the following criterion:
unforeseen and involuntary event caused by
i. Having at least 5 in-patient beds;
external, visible and violent means.
ii. Having qualified AYUSH Medical
Def. 2. Adventurous/Hazardous Sports means any
Practitioner in charge round the clock;
sport or activity involving physical exertion
and skill in which an Insured Person iii. Having dedicated AYUSH therapy
participates or competes for entertainment sections as required and/or
or as part of his Profession whether he / she has equipped operation theatre
is trained or not. where surgical procedures are to
be carried out;
Def. 3. Age or Aged means completed years as at
the Policy Commencement Date. iv. Maintaining daily records of the
patients and making them accessible
Def. 4. Any one illness means continuous period
to the insurance company’s authorized
of Illness and includes relapse within 45
representative.
days from the date of last consultation
with the Hospital/Nursing Home where Def. 8. AYUSH Day Care Centre means and
treatment was taken includes Community Health Centre (CHC),
Primary Health Centre (PHC), Dispensary,
Def. 5. Alternative treatment means forms of
Clinic, Polyclinic or any such health center
treatments other than treatment “Allopathy”
which is registered with the local authorities,
or “modern medicine” and includes
wherever applicable and having facilities
Ayurveda, Unani, Siddha and Homeopathy
for carrying out treatment procedures
in the Indian context.
and medical or surgical/para-surgical
Def. 6. Associated Medical Expenses means interventions or both under the supervision
consultation fees, charges on Operation of registered AYUSH Medical Practitioner(s)
theatre, surgical appliances & nursing, and on day care basis without in-patient services
expenses on Anaesthesia, blood, oxygen and must comply with all the following
incurred during Hospitalization of the criterion:
Insured Person.
i. Having qualified registered AYUSH
Def. 7. AYUSH HOSPITAL means an AYUSH Medical Practitioner (s) in charge;
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ii. Having dedicated AYUSH therapy Def. 16. Congenital Anomaly means a condition(s)
sections as required and/or has which is present since birth, and which is
equipped operation theatre where abnormal with reference to form, structure
surgical procedures are to be carried or position.
out; a) Internal Congenital Anomaly:
iii. Maintaining daily records of the Congenital Anomaly which is not in
patients and making them accessible the visible and accessible parts of the
to the insurance company’s authorized body.
representative. b) External Congenital Anomaly:
Def. 9. Bank rate means the rate fixed by the Congenital Anomaly which is in the
Reserve Bank of India (RBI) at the beginning visible and accessible parts of the
of the financial year in which claim has fallen body
due. Def. 17. Coverage Period means the Period
Def. 10. Break in Policy means the period of gap between the Coverage effective date and
that occurs at the end of the existing Policy the expiry date applicable to Insured Person
term, when the premium due for renewal specified in the Policy Schedule/Certificate
on a given Policy is not paid on or before of Insurance.
the premium renewal date or within 30 days Def. 18. Cumulative Bonus means any increase or
thereof addition in the Sum Insured granted by the
Def. 11. Biological attack or weapons the emission, Insurer without an associated increase in
discharge, dispersal, release or escape of premium.
any pathogenic (disease producing) micro- Def. 19. Day care Centre means any institution
organisms and/or biologically produced established for Day Care Treatment
toxins (including genetically modified of Illness and / or injuries or a medical
organisms and chemically synthesized set -up with a Hospital and which has
toxins) which are capable of causing any been registered with the local authorities,
Illness, incapacitating disablement or death. wherever applicable, and is under the
Def. 12. Cashless Facility means a facility extended supervision of a registered and qualified
by the insurer to the insured where the medical practitioner AND must comply with
payments, of the costs of treatment all minimum criterion as under:-
undergone by the insured in accordance i. has qualified nursing staff under its
with the Policy terms and conditions, are employment;
directly made to the Network Provider by
the insurer to the extent pre-authorization is ii. has qualified medical practitioner/s in
approved. charge;
Def. 13. Chemical attack or weapons means the iii. has fully equipped operation theatre of
emission, discharge, dispersal, release its own where surgical procedures are
or escape of any solid, liquid or gaseous carried out;
chemical compound which, when suitably iv. maintains daily records of patients
distributed, is capable of causing any Illness, and will make these accessible to
incapacitating disablement or death. the insurance company’s authorized
Def. 14. Commencement Date means the personnel
commencement date of the Policy as Def. 20. Day Care Treatment/Procedures means
specified in the Policy Schedule/Certificate those medicaltreatment, and/or surgical
of Insurance. procedure which is
Def. 15. Condition Precedent means a Policy term i) undertaken under General or Local
or condition upon which the Insurer’s liability Anaesthesia in a Hospital/Day Care
under the Policy is conditional upon Centre in less than 24 hours because
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of technological advancement, and ii. the patient takes treatment at home
ii) which would have otherwise required on account of non-availability of room
Hospitalization of more than 24 in a Hospital
hours, Def. 27. Emergency Care means management
Treatment normally taken on an Out-patient for an Illness or injury which results in
basis is not included in the scope of symptoms which occur suddenly and
this definition unexpectedly, and requires immediate care
by a Medical Practitioner to prevent death
Def. 21. Dependent Child/Children means living or serious long term impairment of the
dependent child or children of Insured insured person’s health.
Person up to age of 25 years as on date of
Injury, including legally adopted and step- Def. 28. Family Floater means a Policy described
children. as such in the Policy Schedule/Certificate
of Insurance where under You and Your
Def. 22. Dependents means only the family Dependents (Spouse, dependent children,
members listed below: dependent parents/parents in laws) named
a) Your legally married spouse as long in the Policy Schedule/Certificate of
as she continues to be married to You Insurance are insured under this Policy as
b) Your children Aged between 91 days at the Commencement Date on floater Sum
and 25 years if they are unmarried, still Insured basis.
financially dependent on You and have Def. 29. Grace Period means the specified period of
not established their own independent time immediately following the premium due
households; date during which a payment can be made
c) Your natural parents or parents that to renew or continue a Policy in force without
have legally adopted You, and Your loss of continuity benefits such as waiting
parent in laws periods and coverage of pre –existing
diseases. Coverage is not available for the
Def. 23. Dependent Parents means Your natural period for which no premium is received.
parents, parents that have legally adopted
you or Your parents in law. Def. 30. Hospital means any institution established
for In-patient Care and Day Care Treatment
Def. 24. Dental Treatment means a treatment of Illness and/or injuries and which has
related to teeth or structures supporting been registered as a Hospital with the local
teeth including examinations, fillings (where authorities under the clinical Establishments
appropriate), crowns, extractions and (Registration and Regulation) Act, 2010 or
surgery under the enactments specified under the
Def. 25. Disclosure of information norm means the Schedule of Section 56(1) of the said Act
Policy shall be void and all premiums paid OR complies with all minimum criteria as
hereon shall be forfeited to the Company, under:
in the event of misrepresentation, mis- • has at least 10 in-patient beds, in towns
description or non-disclosure of any material having a population of less than 10,00,000
fact. and 15 in-patient beds in all other places,
Def. 26. Domiciliary Hospitalization means • has qualified nursing staff under its
medical treatment for an Illness/disease/ employment round the clock,
Injury whichin the normal course would
require care and treatment at a Hospital • has qualified Medical Practitioner(s) in
but is actually takenwhile confined at home charge round the clock,
under any of the following circumstances: • has a fully equipped operation theatre
i. the condition of the patient is such of its own where surgical procedures are
that he/she is not in a condition to be carried out,
removed to a Hospital, or • maintains daily records of patients and
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will make these accessible to the insurance the Insured Person has to stay in a Hospital
company’s authorized personnel. for more than 24 hours for a covered event.
Def. 31. Hospitalization means admission in a Def. 36. Insured Person means You and the
Hospital for a minimum period of 24 persons named in the Policy Schedule/
consecutive ‘In-patient Care’ hours except Certificate of Insurance who are insured
for specified procedures/treatments, where under the Policy.
such admission could be for a period of less Def. 37. Intensive Care Unit means an identified
than 24 consecutive hours. section, ward or wing of a Hospital
Def. 32. Illness/Illnesses means a sickness or a which is under the constant supervision
disease or pathological condition leading of a dedicated Medical Practitioner(s),
to the impairment of normal physiological and which is specially equipped for the
function which manifests itself during continuous monitoring and treatment of
the Policy Period and requires medical patients who are in a critical condition, or
treatment require life support facilities and where the
(a) Acute condition - Acute condition is a level of care and supervision is considerably
disease, Illness or Injury that is likely to more sophisticated and intensive than in the
respond quickly to treatment which aims to ordinary and other wards.
return the person to his or her state of health Def. 38. ICU (Intensive Care Unit) Charges
immediately before suffering the disease/ means the amount charged by a Hospital
Illness/Injury which leads to full recovery towards ICU expenses which shall include
(b) Chronic condition - A chronic condition the expenses for ICU bed, general medical
is defined as a disease, Illness, or Injury support services provided to any ICU
that has one or more of the following patient including monitoring devices, critical
characteristics: care nursing and intensive charges
1. it needs on-going or long-term Def. 39. Material Facts means all relevant
monitoring through consultations, information sought by the Company in
examinations, check-ups, and /or tests the Proposal Form and other connected
documents to enable it to take informed
2. it needs on-going or long-term decision in the context of underwriting the
control or relief of symptoms risk.
3. it requires rehabilitation for the Def. 40. Maternity Expenses means
patient or for the patient to be specially
trained to cope with it a. Medical treatment expenses traceable
to childbirth (including complicated
4. it continues indefinitely deliveries and caesarean section
5. it recurs or is likely to recur incurred during Hospitalization).
Def. 33. Injury means Accidental physical bodily b. Expenses towards lawful medical
harm excluding Illness or disease solely termination of pregnancy during the
and directly caused by external, violent and Policy Period.
visible and evident means which is verified Def. 41. Medical Advice means any consultation or
and certified by a Medical Practitioner. advice from a Medical Practitioner including
Def. 34. Immediate Family mean an Insured the issue of any prescription or follow up
Person’s Spouse; children; children-in-law, prescription.
siblings; siblings-in-law; parents; parents- Def. 42. Medical Expenses means those expenses
in-law; grandparents; grandchildren; legal that an Insured Person has necessarily
guardian, ward, step or adopted children; and actually incurred for medical treatment
step-parents; aunts, uncles; nieces, and on account of Illness or Accident on the
nephews. advice of a Medical Practitioner, as long as
Def. 35. In-patient Care means treatment for which these are no more than would have been
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payable if the Insured Person had not been arrested or incomplete development of mind
insured and no more than other hospitals of a person, specially characterised by sub
or Medical practitioners in the same locality normality of intelligence;
would have charged for the same medical Def. 47. Mental Health Establishment means any
treatment. health establishment, including Ayurveda,
Def. 43. Medically Necessary treatment means Yoga and Naturopathy, Unani, Siddha and
any treatment, test, medication, or stay in Homoeopathy establishment, by whatever
Hospital or part of stay in Hospital which name called, either wholly or partly,
• Is required for the medical management meant for the care of persons with mental
of the Illness or Injury suffered by the Illness, established, owned, controlled or
Insured Person; maintained by the appropriate Government,
local authority, trust, whether private or
• Must not exceed the level of care public, corporation, co-operative society,
necessary to provide safe, adequate and organisation or any other entity or person,
appropriate medical care in scope, duration where persons with mental Illness are
or intensity. admitted and reside at, or kept in, for care,
• Must have been prescribed by a Medical treatment, convalescence and rehabilitation,
Practitioner. either temporarily or otherwise; and includes
• Must conform to the professional any general Hospital or general nursing
standards widely accepted in international home established or maintained by the
medical practice or by the medical appropriate Government, local authority,
community in India. trust, whether private or public, corporation,
co-operative society, organisation or any
Def. 44. Medical Consultation is a procedure other entity or person; but does not include a
where a Medical Practitioner reviews an family residential place where a person with
Insured Person’s medical history, medically mental Illness resides with his relatives or
examines the Insured Person and makes friends;
recommendations as to care and treatment.
Def. 48. Mental Health Nurse means a person with
Def. 45. Medical Practitioner means a person who a diploma or degree in general nursing or
holds a valid registration from the Medical diploma or degree in psychiatric nursing
Council of any State or Medical Council of recognised by the Nursing Council of India
India or Council for Indian Medicine or for established under the Nursing Council of
Homeopathy set up by the Government India Act, 1947 and registered as such with
of India or a State Government and is the relevant nursing council in the State
thereby entitled to practice medicine within
its jurisdiction; and is acting within the Def. 49. Migration means, the right accorded to the
scope and jurisdiction of license.Medical health insurance policyholders (including all
Practitioner who is sharing the same members under family cover and members
residence with the Insured person`s and is a of group health insurance Policy), to
member of Insured Person’s family are not transfer the credit gained for pre-existing
considered as Medical Practitioner under conditions and time bound exclusions, with
the scope of this Policy. the same insurer.
Def. 46. Mental Illness means a substantial disorder Def. 50. my: Health App is proprietary App of HDFC
of thinking, mood, perception, orientation ERGO General Insurance Company. With
or memory that grossly impairs judgment, my: Health App you can:
behaviour, capacity to recognise reality or o Access YourPolicy Details
ability to meet the ordinary demands of life, • Manage YourPolicy, download
mental conditions associated with the abuse YourPolicy Schedule/Certificate of
of alcohol and drugs, but does not include Insurance and access to Your e-card will
mental retardation which is a condition of always be at Your fingertips, 24 x 7.
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o Policy Endorsement made easy Practitioner. The Insured is not admitted as
• By submitting a request to us through a day care or in-patient.
my: Health App, you can make any Def. 58. Period of Insurance means the period
modifications in YourPolicy, for e.g. between the Coverage Commencement
change in spelling of the name, contact Date and the Expiry Date specified in the
number etc. Policy Schedule/Certificate of Insurance
o Effortless Claims Management under the Policy with the Company under
which Insured Person is covered.
• Now you can submit Your claims from
the app for faster processing and track Def. 59. Pre-existing disease means any condition,
the status at Your fingertips. You can also ailment, injury or disease:
intimate a claim using the app. You can i. That is/are diagnosed by a physician
also view Network hospitals in Your area within 48 months prior to the
with directions. effective date of the Policy issued
o Stay Active – Short Walks, Big Benefits by the insurer or its reinstatement or
• The App tracks Your steps, fitness ii. For which Medical advice or treatment
session and lets you earn incentive on was recommended by, or received
renewal discount on YourPolicy. from, a physician within 48 months
prior to the effective date of the
Def. 51. Newborn Baby means baby born during the Policy or its reinstatement.
Policy Period and is Aged up to 90 days
Def. 60. Preventive Health Check-up -Preventive
Def. 52. Network Provider means Hospitals or Health Check-up means a package of
health care providers enlisted by an insurer, medical test(s) undertaken for general
TPA or jointly by an Insurer and TPA to assessment of health status, it does not
provide medical services to an insured by a include any diagnostic or investigative
Cashless facility. medical tests for evaluation of illness or a
Def. 53. Non Network means any Hospital, Day disease.
Care Centre or other provider that is not Def. 61. Policy means Your statements in the
part of the Network proposal form (which are the basis of this
Def. 54. Non-Medical Expenses – Are expenses Policy), this policy wording (including
other than those defined as Medical endorsements, if any), and the Policy
Expenses and which are listed on our Schedule/Certificate of Insurance (as the
website www.hdfcergo.com same may be amended from time to time).
Def. 55. Notification of Claim means the process Def. 62. Policy Period means the period between
of intimating a claim to the insurer or TPA the Commencement Date and the Expiry
through any of the recognized modes of Date specified in the Policy Schedule.
communication For Insured Person it means Period of
Def. 56. Nuclear attack means the use of any Insurance as specified in the Certificate of
nuclear weapon or device or waste or Insurance or Endorsement
combustion of nuclear fuel or the emission, Def. 63. Policyholder means the Group Owner/
discharge, dispersal, release or escape of Organization/association/entity/society
fissile/ fusion material emitting a level of named in the Policy Schedule who has
radioactivity capable of causing any Illness, concluded the terms on behalf of the
incapacitating disablement or death. Insured Persons and in whose name the
Def. 57. OPD Treatment - OPD treatment means Policy is issued.
the one in which the Insured visits a Def. 64. Policy Schedule means Schedule attached
clinic / Hospital or associated facility like to and forming part of this Policy mentioning
a consultation room for diagnosis and the details of the Insured Persons, the Sum
treatment based on the advice of a Medical Insured, the period and the limits to which
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benefits under the Policy are subject to India or the nursing council of any state in
(Schedule of coverage), including any India
Annexure and/or endorsements, made to or Def. 70. Renewal means the terms on which the
on it from time to time, and if more than one, contract of insurance can be renewed on
then the latest in time. mutual consent with a provision of Grace
Def. 65. Policy Year means a period of twelve Period for treating the Renewal continuous
months beginning from the date of for the purpose of gaining credit for Pre-
commencement of the Policy Period and Existing Diseases, time-bound exclusions
ending on the last day of such twelve-month and for all waiting periods
period. For the purpose of subsequent Def. 71. Room Rent means the amount charged
years, Policy year shall mean a period of by a Hospital towards Room and Boarding
twelve months commencing from the end expenses and shall include the associated
of the previous Policy Year and lapsing on Medical Expenses
the last day of such twelve-month period,
till the Policy Period, as mentioned in the Def. 72. Reasonable and Customary Charges
schedule means the charges for services or supplies,
which are the standard charges for a
Def. 66. Portability means, the right accorded to specific provider and consistent with the
individual health insurance policyholders prevailing charges in the geographical
(including all members under family cover), area for identical or similar services ,taking
to transfer the credit gained for pre-existing into account the nature of Illness/ Injury
conditions and time bound exclusions, from involved.
one insurer to another insurer.
Def. 73. Sum Insured means the sum shown in the
Def. 67. Pre-hospitalizationMedical Expenses Policy Schedule/Certificate of Insurance
means Medical Expenses incurred during which represents Our maximum liability for
pre-defined number of days preceding the each Insured Person for any and all benefits
Hospitalization of the Insured Person, claimed for during the Policy Year, and in
provided that: relation to a Family Floater represents Our
i. Such Medical Expenses are incurred maximum liability for any and all claims
for the same condition for which the made by You and all of Your Dependents
Insured Person’s Hospitalization during the Policy Year
was required, and Def. 74. Sub-limit means a cost sharing requirement
ii. The In-patient Hospitalization claim for under a health insurance Policy in which
such Hospitalization is admissible an insurer would not be liable to pay any
by the Insurance Company amount in excess of the pre-defined limit
Def. 68. Post-hospitalization Medical Expenses Def. 75. Surgery or Surgical Procedure means
means Medical Expenses incurred during manual and / or operative procedure (s)
pre-defined number of days immediately required for treatment of an Illness or
after the insured person is discharged from Injury, correction of deformities and defects,
the Hospital provided that: diagnosis and cure of diseases, relief from
i. Such Medical Expenses are for the suffering and prolongation of life, performed
same condition for which the insured in a Hospital or Day Care Centre by a
person’s Hospitalization was medical practitioner.
required, and Def. 76. Time Deductible means a cost sharing
ii. The inpatient Hospitalization claim for requirement under a health insurance
such Hospitalizationis admissible Policy that provides that the Insurer will
by the insurance Company. not be liable for a specified number of days,
which will apply before any benefits are
Def. 69. Qualified Nurse is a person who holds a payable by the insurer. A Time Deductible
valid registration from the nursing council of
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does not reduce the Sum Insured c) Levy underwriting loading from the first
Def. 77. Unproven/Experimental Treatment is year of issuance of Policy or renewal,
a treatment including drug experimental whichever is later.
therapy, which is based on established
medical practice in India, is a treatment The above options will not prejudice the rights of the
experimental or unproven. Company to invoke cancellation under clause 1
Def. 78. We/Our/Us/Insurer/Company means the i above.
HDFC ERGO General Insurance Company
Limited.
2. Disclosure of Information
Def. 79. You/Your means the Insured Person
named in the Policy Schedule/Certificate of The Policy shall be void and all premium paid thereon
Insurance who is insured under the Policy. shall be forfeited to the Company in the event of
misrepresentation, mis description or non-disclosure
of any Material Fact by the Policyholder.
SECTION G. GENERAL CONDITIONS
3. Condition Precedent to Admission of Liability
1. Non - Disclosure or Misrepresentation The terms and conditions of the Policy must be fulfilled
by the Insured Person for the Company to make any
i. If at the time of issuance of Policy or during
payment for claim(s) arising under the Policy.
continuation of the Policy, the information
provided to Us in the Proposal Form or otherwise,
by You or the Insured Person or anyone acting 4. Complete Discharge
on behalf of You or an Insured Person, is found
Any payment to the Policyholder, Insured Person or
to be incorrect, incomplete, suppressed or not
his/ her nominees or his/ her legal representative or
disclosed, wilfully or otherwise, the Policy shall
assignee or to the Hospital, as the case may be, for
be:
any benefit under the Policy shall be a valid discharge
a) cancelled ab initio from the inception date towards payment of claim by the Company to the
or the Renewal date (as the case may be), extent of that amount for the particular claim.
or the Policy may be modified by Us at
Our sole discretion, upon 30 day notice by
sending an endorsement to Your address 5. Multiple Policies
shown in the Policy Schedule/Certificate i. In case of multiple policies taken by an
of Insurance, and InsuredPerson during a period from one or
b) the claim under such Policy if any, shall be more insurers to indemnify treatment costs, the
prejudiced. InsuredPerson shall have the right to require a
settlement of his/her claim in terms of any of his/
ii. We may also exercise any of the below listed
her policies. In all such cases the Insurer chosen
options for the purpose of continuing the health
by the Insured Person shall be obliged to settle
insurance coverage in case of Non-Disclosure/
the claim as long as the claim is within the limits of
Misrepresentation of Pre-existing Diseases
and according to the terms of the chosen Policy.
subject to your prior consent;
ii. Insured Person having multiple policies shall also
a) Permanently exclude the disease/
have the right to prefer claims under this Policy for
condition and continue with the Policy
the amounts disallowed under any other Policy /
b) Incorporate additional waiting period of not policies even if the sum insured is not exhausted.
exceeding 4 years for the said undisclosed Then the Insurer shall independently settle the
disease or condition from the date the claim subject to the terms and conditions of this
non-disclosed condition was detected and Policy.
continue with the Policy.
iii. If the amount to be claimed exceeds the Sum
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Insured under a single Policy, the InsuredPerson a) the suggestion, as a fact of that which is not
shall have the right to choose Insurer from whom true and which the Insured Person does
he/she wants to claim the balance amount. not believe to be true;
iv. Where an Insured Person has policies from b) the active concealment of a fact by the
more than one Insurer to cover the same risk on Insured Person having knowledge or
indemnity basis, the Insured Person shall only belief of the fact;
be indemnified the treatment costs in accordance c) any other act fitted to deceive; and
with the terms and conditions of the chosen
Policy. d) any such act or omission as the law specially
declares to be fraudulent
6. Moratorium Period
The Company shall not repudiate the claim and / or
After completion of eight continuous years under the forfeit the Policy benefits on the ground of fraud, if
Policy, no look back to be applied. This period of eight the Insured Person / beneficiary can prove that the
years is called as Moratorium Period. The moratorium misstatement was true to the best of his knowledge
would be applicable for the Sums Insured of the first and there was no deliberate intention to suppress the
Policy and subsequently completion of 8 continuous fact or that such misstatement of or suppression of
years would be applicable from date of enhancement Material fact are within the knowledge of the Insurer.
of Sums Insured only on the enhanced limits. After
the expiry of Moratorium Period no health insurance
claim shall be contestable except for proven fraud and 8. Geography
permanent exclusions specified in the Policy contract. This Policy only covers Medical Treatment taken
The policies would however be subject to all limits, within India.
sub limits, co-payments, deductibles as per the Policy
contract.
9. Loadings
7. Fraud i. We may apply loading on the premium, based
on the declarations made in the proposal form
If any claim made by the Insured Person, is in any and the health status, habits and lifestyle, past
respect fraudulent, or if any false statement, or medical records, and the results of the Pre-Policy
declaration is made or used in support thereof, or if any medical examination of the persons proposed for
fraudulent means or devices are used by the Insured insurance.
Person or anyone acting on his/her behalf to obtain
any benefit under this Policy, all benefits under this ii. The maximum Medical Underwriting loading
Policy and the premium paid shall be forfeited. shall not exceed 100% for each condition and a
total of 150% for each Insured Person
iii. Loadings will be applied from Commencement
Any amount already paid against claims made under date of the Policy including subsequent
this Policy but which are found fraudulent later shall Renewal(s) with Us or on increased Sum
be repaid by all recipient(s)/policyholder(s), who has Insured. We will not apply any additional loading
made that particular claim, who shall be jointly and on Your Policy premium at Renewal based on
severally liable for such repayment to the Insurer. claim experience in Your Policy.
iv. We will inform You about the proposed loading
For the purpose of this clause, the expression “fraud” with time bound exclusion (if any) through a
means any of the following acts committed by the counter offer letter and will issue the Policy only
Insured Person or by his agent or the Hospital/ on Your acceptance within 15 days of the receipt
doctor/any other party acting on behalf of the Insured of such counter offer letter. In case, You neither
Person, with intent to deceive the Insurer or to induce accept the counter offer nor revert to Us within
the Insurer to issue an insurance Policy: 15 days, We shall cancel Your application and
refund the premium paid within next 7 days.
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10. Renewal of Policy: i. a refund of the premium paid less any
The Company shall be under no obligation to renew expenses incurred by the Company on medical
the Policy/Coverage on expiry of the period for which examination of the Insured Person and the
premium has been paid. The Company reserves stamp duty charges or
the right to offer revised rates, terms and conditions ii. where the risk has already commenced and the
at renewal based on claim experience and a fresh option of return of the Policy is exercised by
assessment of the risk. This Policy may be renewed the Insured Person, a deduction towards the
only by mutual consent and subject to payment in proportionate risk premium for period of cover or
advance of the total premium at the rate in force at iii. Where only a part of the insurance coverage
the time of renewal. The Company, however, shall has commenced, such proportionate premium
not be bound to give notice that the Policy is due commensurate with the insurance coverage
for Renewal or to accept any Renewal premium. during such period.
Unless renewed as herein provided, this Policy shall
automatically terminate at the expiry of the Policy
Period/ Coverage Period. 13. Migration
The Insured Person will have the option to migrate
11. Grace Period the Policy to other health insurance products/plans
offered by the Company by applying for Migration
i. A Grace Period of 30 days is available for of the Policy atleast 30 days before the Policy
Renewal of the Coverage. Any Illness, disease renewal date as per IRDAI guidelines on Migration.
or condition contracted during Grace Period If such person is presently covered and has been
will not be covered and will be treated as Pre- continuously covered without any lapses under
existing diseases. any health insurance product/plan offered by the
ii. For Renewal received after completion of Grace Company, the Insured Person will get the accrued
Period, the Coverage would be considered as continuity benefits in waiting periods as per IRDAI
fresh without any Renewal benefits guidelines on Migration.
iii. For Policies on instalment basis, Grace Period is
available as given below. For Detailed Guidelines on Migration, kindly refer the
link
https://www.irdai.gov.in/ADMINCMS/cms/
Instalment Grace Period frmGuidelines_Layout.aspx?page=PageNo3987
Premium Option applicable
Half Yearly 30 days 14. Portability
Quarterly 30 days The Insured Person will have the option to port the
Policy to other insurers by applying to such Insurer
Monthly 15 days 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
12. Free look period
as per IRDAI guidelines related to Portability. If
The Free Look Period shall be applicable on new such person is presently covered and has been
individual health insurance policies and not on continuously covered without any lapses under any
renewals or at the time of porting/migrating the Policy. health insurance Policy with an Indian General/Health
The Insured Person shall be allowed Free Look insurer, the proposed Insured Person will get the
period of fifteen days from date of receipt of the Policy accrued continuity benefits in waiting periods as per
document to review the terms and conditions of the IRDAI guidelines on Portability.
Policy, and to return the same if not acceptable.
If the Insured has not made any claim during the Free
Look Period, the Insured shall be entitled to
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For Detailed Guidelines on Portability, kindly refer 16. Cancellation
the link i. The Policyholder may cancel this Policy by
https://www.irdai.gov.in/ADMINCMS/cms/ giving 15days’ written notice and in such an
frmGuidelines_Layout.aspx?page=PageNo3987 event, the Company shall refund premium for the
unexpired Policy Period as detailed below.
15. Endorsements For Policies where instalment option is not

availed, We will refund premium in accordance
The following endorsements are permissible during the with the table below:
Policy Period:
Non-Financial Endorsements – which do not affect the Month % Refund
premium
Up to 1 month 85.0%
i. Minor rectification/correction in name of the
Proposer / Insured Person (and not the Up to 3 month 70.0%
complete name change) Up to 6 month 45.0%
ii. Rectification in gender of the Insured
Up to 12 month 0.0%
Person
iii. Rectification in relationship of the Insured
Person with the Proposer For Policies where Premium is paid by instalment,
50% of current instalment premium will be refunded
iv. Rectification of date of birth of the Insured
when the current period is less than 6 months in to the
Person (if this does not impact the
PolicyYear. For instalment after 6 months, no refund
premium)
will be payable.
v. Change in the correspondence address of
Notwithstanding anything contained herein or
the Insured Person/Proposer(if this does
otherwise, no refunds of premium shall be made in
not impact the premium)
respect of Cancellation where, any claim has been
vi. Change in Nominee Details admitted or has been lodged or any benefit has been
vii. Change in Height, weight, marital status (if availed by the Insured Person under the Policy.
this does not impact the premium) ii. The Company may cancel the Policy at any time
viii. Change in bank details on grounds of misrepresentation non-disclosure
of Material Facts, Fraud by the Insured Person
ix. Any other non-financial endorsement
by giving 15 days’ written notice. There would
be no refund of premium on cancellation on
Financial Endorsements – which result in alteration in grounds of misrepresentation, non-disclosure of
premium MaterialFacts or Fraud.
i. Change in Age/date of birth
ii. Change in Height, weight 17. Premium Payment in Instalments
iii. Addition of Insured Person (New Born If the Insured Person has opted for Payment of
Baby or newly wedded spouse) Premium on an instalment basis i.e. Half Yearly,
Quarterly or Monthly, as mentioned in the Policy
iv. Deletion of Insured Person on death or
Schedule/Certificate of Insurance, the following
Marital separation
Conditions shall apply (notwithstanding any terms
v. Any other financial endorsement contrary elsewhere in the Policy)
i. Grace Period as mentioned in the table below
The Policyholder/Insured Personshallapply in a would be given to pay the instalment premium
proposal form along with birthCertificate / marriage due for the Policy.
certificate as the case may be for addition of Insured
person.
26
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Bonus, waiver of waiting period as per IRDAI
Options Installment Grace Period
guidelines, provided the Policy has been
Premium applicable
maintained without a break.
Option
Option 1 Half Yearly 30 days
20. Nomination
Option 2 Quarterly 30 days The Policyholderis required at the inception of
the Policy to make a nomination for the purpose of
Option 3 Monthly 15 days
payment of claims under the Policy in the event of
death of the Policyholder. Any change of nomination
ii. During such Grace Period, coverage will not shall be communicated to the Company in writing
be available from the due date of instalment and such change shall be effective only when an
premium till the date of receipt of premium by endorsement on the Policy is made. In the event of
Company. death of the Policyholder, the Company will pay
the nominee {as named in the PolicySchedule/
iii. The Insured Person will get the accrued
PolicyCertificate/Endorsement (if any)} and in case
continuity benefit in respect of the “Waiting
there is no subsisting nominee, to the legal heirs or
Periods”, “Specific Waiting Periods” in the event
legal representatives of the Policyholder whose
of payment of premium within the stipulated
discharge shall be treated as full and final discharge of
Grace Period.
its liability under the Policy.
iv. No interest will be charged If the instalment
premium is not paid on due date.
21. Claim Settlement (provision for Penal Interest)
v. In case of instalment premium due not received
within the Grace Period, the Policy will get i. The Company shall settle or reject a claim, as
cancelled. the case may be, within 30 days from the date of
receipt of last necessary document.
vi. In the event of a claim, all subsequent premium
installments shall immediately become due and ii. In the case of delay in the payment of a claim,
payable. the Company shall be liable to pay interest to
the Policyholder from the date of receipt of last
vii. The Company has the right to recover and
necessary document to the date of payment of
deduct all the pending installments from the
claim at a rate 2% above the Bank Rate.
claim amount due under the Policy.
iii. However, where the circumstances of a claim
warrant an investigation in the opinion of the
18. Possibility of Revision of Terms of the Policy Company, it shall initiate and complete such
Including the Premium Rates investigation at the earliest, in any case not
The Company, with prior approval of IRDAI, may later than 30 days from the date of receipt of
revise or modify the terms of the Policy including the last necessary document. In such cases, the
premium rates. The Insured Person shall be notified Company shall settle or reject the claim within
three months before the changes are effected. 45 days from the date of receipt of last necessary
document.
iv. In case of delay beyond stipulated 45 days,
19. Withdrawal of Policy
the Company shall be liable to pay interest to
i. In the likelihood of this product being withdrawn the Policyholder at a rate 2% above the Bank
in future, the Company will intimate the Insured Rate from the date of receipt of last necessary
Person about the same 90 days prior to expiry of document to the date of payment of claim.
the Policy.
22. Disclaimer applicable to my: health Mobile app
ii. Insured Person will have the option to migrate and associated services
to similar health insurance product available with
It is agreed and understood that Our my:health mobile
the Company at the time of Renewal with all the
app intention is not to provide specific medical advice
accrued continuity benefits such as Cumulative
27
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but rather to provide users with information to better Reliance on any information on this App is solely
understand their health and their diagnosed disorders. at your own risk. HDFC EGRO General Insurance
The information is not a substitute for professional Company Limited do not assume any liability towards
medical care by a qualified doctor or other health care any loss or damage arising out of or in relation to
professional. any opinion, actual or alleged errors, omissions and
The information provided is general in nature and representations, any decision made or action taken or
is not specific to you. You must never rely on any not taken in reliance upon the information.
information obtained using this app for any medical
diagnosis or recommendation for medical treatment or 23. Communication & Notice
as an alternative to medical advice from your physician
or other professional healthcare provider. If you think Policy and any communication related to the Policy
you may be suffering from any medical condition you shall be sent to through electronic modes or to the
should seek immediate medical attention. address of the Insured as recorded in the Policy.
SECTION H. CUSTOMER SERVICE & GRIEVANCE REDRESSAL PROCEDURE
I. Contact Us
Within India Outside India
Service No. 022-62346234 / Toll Free No: 800 08250825

0120- 62346234 Global Toll Free No: +800 08250825
Email: healthclaims@hdfcergo.com (accessible from locations outside India
only)
Claim Intimation:
Landline no (Chargeable) :
0120-4507250
Email: healthclaims@hdfcergo.com
HDFC ERGO General Insurance HDFC ERGO General Insurance Co. Ltd.
Co. Ltd. Stellar IT Park, Tower-1, Stellar IT Park, Tower-1, 5th Floor, C - 25,
Claim document submission 5th Floor, C - 25, Noida, Sector 62,
at address Noida, Sector 62, 201301,Uttar Pradesh
201301, Uttar Pradesh
II. Redressal of Grievance
i. If You/ Policy Holder have a grievance that You/ Policy Holder wish Us to redress, You/ Policy Holder may contact Us
with the details of grievance as given below:
i. In case of any grievance the insured person may contact the company through:
• Website: www.hdfcergo.com
• Customer Service Number: 022 6234 6234 / 0120 6234 6234
• Contact Details for Senior Citizen: 022 6234 6234 / 0120 6234 6234
• E-mail: care@hdfcergo.com
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24
Insured person may also approach the grievance cell at any of the company’s branches with the details of grievance.
If Insured person is not satisfied with the redressal of grievance through one of the above methods, insured person may
contact the grievance officer at cgo@hdfcergo.com
For updated details of grievance officer, kindly refer the link: https://www.hdfcergo.com/customer-voice/grievances
Contact Points First Contact Point Escalation level 1 Escalation level 2
Contact us at 022 6234 6234 / NA NA

0120 6234 6234
Contact details for Senior 022 6234 6234 / NA NA

Citizen 0120 6234 6234
Write to us at care@hdfcergo.com grievance@hdfcergo.com cgo@hdfcergo.com
Visit us Grievance cell of any of The Grievance Cell, The Chief Grievance
our Branch office HDFC ERGO General Officer, HDFC ERGO
Insurance Company Ltd., General Insurance
D-301, 3rd Floor, Company Ltd., D-301, 3rd
Eastern Business District Floor, Eastern Business
(Magnet Mall), LBS District (Magnet Mall),
Marg, Bhandup (West) LBS Marg, Bhandup (West)
Mumbai-400078 Mumbai-400078
ii. If Insured person is not satisfied with the redressal of grievance through above methods, the insured person may
also approach the office of Insurance Ombudsman of the respective area/region for redressal of grievance as per
Insurance Ombudsman Rules 2017.
iii. Grievance may also be lodged at IRDAI Integrated Grievance Management System - https://igms.irda.gov.in/
29
25
List of Ombudsman
NAMES OF OMBUDSMAN AND ADDRESSES OF OMBUDSMAN CENTRES
Jurisdiction of Office
Office Details
Union Territory, District
AHMEDABAD - Shri Kuldip Singh Gujarat,
Office of the Insurance Ombudsman, Dadra & Nagar Haveli,
Jeevan Prakash Building, 6th floor, Daman and Diu.
Tilak Marg, Relief Road, Ahmedabad – 380 001.
Tel.: 079 - 25501201/02/05/06 Email: bimalokpal.ahmedabad@ecoi.co.in
BENGALURU - Smt. Neerja Shah Karnataka.
Office of the Insurance Ombudsman,
Jeevan Soudha Building,PID No. 57-27-N-19
Ground Floor, 19/19, 24th Main Road,
JP Nagar, Ist Phase, Bengaluru – 560 078.
Tel.: 080 - 26652048 / 26652049 Email: bimalokpal.bengaluru@ecoi.co.in
BHOPAL - Shri Guru Saran Shrivastava Madhya Pradesh
Office of the Insurance Ombudsman, Chattisgarh.
Janak Vihar Complex, 2nd Floor,
6, Malviya Nagar, Opp. Airtel Office,
Near New Market, Bhopal – 462 003.
Tel.: 0755 - 2769201 / 2769202 Fax: 0755 - 2769203
Email: bimalokpal.bhopal@ecoi.co.in
BHUBANESHWAR - Shri Suresh Chandra Panda Orissa.
62, Forest park, Bhubneshwar – 751 009.
Tel.: 0674 - 2596461 /2596455 Fax: 0674 - 2596429
Email: bimalokpal.bhubaneswar@ecoi.co.in
CHANDIGARH - Dr. Dinesh Kumar Verma Punjab,
Office of the Insurance Ombudsman, Haryana,
S.C.O. No. 101, 102 & 103, 2nd Floor, Himachal Pradesh,
Batra Building, Sector 17 – D, Chandigarh – 160 017. Jammu & Kashmir,
Tel.: 0172 - 2706196 / 2706468 Fax: 0172 - 2708274 Chandigarh.
Email: bimalokpal.chandigarh@ecoi.co.in
CHENNAI - Shri M. Vasantha Krishna Tamil Nadu,
Office of the Insurance Ombudsman, Pondicherry Town and
Fatima Akhtar Court, 4th Floor, 453, Karaikal (which are part of Pondicherry).
Anna Salai, Teynampet, CHENNAI – 600 018.
Tel.: 044 - 24333668 / 24335284 Fax: 044 - 24333664
Email: bimalokpal.chennai@ecoi.co.in
DELHI - Shri Sudhir Krishna Delhi.
2/2 A, Universal Insurance Building,
Asaf Ali Road, New Delhi – 110 002.
Tel.: 011 - 23232481/23213504 Email: bimalokpal.delhi@ecoi.co.in
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GUWAHATI - Shri Kiriti .B. Saha Assam,
Office of the Insurance Ombudsman, Meghalaya,
Jeevan Nivesh, 5th Floor, Nr. Panbazar over bridge, S.S. Road, Manipur,
Guwahati – 781001(ASSAM). Mizoram,
Tel.: 0361 - 2632204 / 2602205 Email: bimalokpal.guwahati@ecoi.co.in Arunachal Pradesh,
Nagaland and Tripura.
HYDERABAD - Shri I. Suresh Babu Andhra Pradesh,
Office of the Insurance Ombudsman, Telangana,
6-2-46, 1st floor, “Moin Court”, Yanam and
Lane Opp. Saleem Function Palace, part of Territory of Pondicherry.
A. C. Guards, Lakdi-Ka-Pool, Hyderabad - 500 004.
Tel.: 040 - 67504123 / 23312122 Fax: 040 - 23376599
Email: bimalokpal.hyderabad@ecoi.co.in
JAIPUR - Smt. Sandhya Baliga Rajasthan.
Jeevan Nidhi – II Bldg., Gr. Floor,
Bhawani Singh Marg,
Jaipur - 302 005.
Tel.: 0141 - 2740363
Email: Bimalokpal.jaipur@ecoi.co.in
ERNAKULAM - Ms. Poonam Bodra Kerala, Lakshadweep,
Office of the Insurance Ombudsman, Mahe-a part of Pondicherry.
2nd Floor, Pulinat Bldg.,
Opp. Cochin Shipyard, M. G. Road, Ernakulam - 682 015.
Tel.: 0484 - 2358759 / 2359338 Fax: 0484 - 2359336
Email: bimalokpal.ernakulam@ecoi.co.in
KOLKATA - Shri P. K. Rath West Bengal, Sikkim, Andaman &
Office of the Insurance Ombudsman, Nicobar Islands.
Hindustan Bldg. Annexe, 4th Floor,
4, C.R. Avenue, KOLKATA - 700 072.
Tel.: 033 - 22124339 / 22124340 Fax : 033 - 22124341
Email: bimalokpal.kolkata@ecoi.co.in
LUCKNOW -Shri Justice Anil Kumar Srivastava Districts of Uttar Pradesh :
Office of the Insurance Ombudsman, Laitpur, Jhansi, Mahoba, Hamirpur, Ban-
6th Floor, Jeevan Bhawan, Phase-II, da, Chitrakoot, Allahabad, Mirzapur, Son-
Nawal Kishore Road, Hazratganj, Lucknow - 226 001. bhabdra, Fatehpur, Pratapgarh, Jaun-
Tel.: 0522 - 2231330 / 2231331 Fax: 0522 - 2231310 pur,Varanasi, Gazipur, Jalaun, Kanpur,
Email: bimalokpal.lucknow@ecoi.co.in Lucknow, Unnao, Sitapur, Lakhimpur,
Bahraich, Barabanki, Raebareli, Sravas-
ti, Gonda, Faizabad, Amethi, Kaushambi,
Balrampur, Basti, Ambedkarnagar,
Sultanpur, Maharajgang, Santkabirnagar,
Azamgarh, Kushinagar, Gorkhpur, Deo-
ria, Mau, Ghazipur, Chandauli, Ballia,
Sidharathnagar.
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MUMBAI - Shri Milind A. Kharat Goa, Mumbai Metropolitan Region
Office of the Insurance Ombudsman, excluding Navi Mumbai & Thane.
3rd Floor, Jeevan Seva Annexe,
S. V. Road, Santacruz (W), Mumbai - 400 054.
Tel.: 022 - 26106552 / 26106960 Fax: 022 - 26106052
Email: bimalokpal.mumbai@ecoi.co.in
NOIDA - Shri Chandra Shekhar Prasad State of Uttaranchal and the following
Office of the Insurance Ombudsman, Districts of Uttar Pradesh:
Bhagwan Sahai Palace 4th Floor, Main Road, Agra, Aligarh, Bagpat, Bareilly, Bijnor,
Naya Bans, Sector 15, Distt: Gautam Buddh Nagar, U.P-201301. Budaun, Bulandshehar, Etah, Kanooj,
Tel.: 0120-2514250 / 2514252 / 2514253 Mainpuri, Mathura, Meerut, Morad-
Email: bimalokpal.noida@ecoi.co.in abad, Muzaffarnagar, Oraiyya, Pilibhit,
Etawah, Farrukhabad, Firozbad,
Gautambodhanagar, Ghaziabad, Hardoi,
Shahjahanpur, Hapur, Shamli, Rampur,
Kashganj, Sambhal, Amroha, Hathras,
Kanshiramnagar, Saharanpur.
PATNA - Shri N. K. Singh Bihar,
Office of the Insurance Ombudsman, Jharkhand.
1st Floor,Kalpana Arcade Building, Bazar Samiti Road,
Bahadurpur, Patna 800 006.
Tel.: 0612-2680952 Email: bimalokpal.patna@ecoi.co.in
PUNE - Shri Vinay Sah Maharashtra,
Office of the Insurance Ombudsman, Area of Navi Mumbai and Thane
Jeevan Darshan Bldg., 3rd Floor, C.T.S. No.s. 195 to 198, excluding Mumbai Metropolitan Region.
N.C. Kelkar Road, Narayan Peth, Pune – 411 030.
Tel.: 020-41312555 Email: bimalokpal.pune@ecoi.co.in
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28

HDFC Group Health Insurance Policy Wording

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HDFC Group Health Insurance Policy Wording

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HDFC ERGO General Insurance Company Limited

HDFC Group Health Insurance

Operating Clause be effected in the same proportion as the

We will pay under below listed Covers on Medically

Services if Insured Person is required;

Internal Congenital diseases Non infective Arthritis Pilonidal sinus

Adenoidectomy, tonsillectomy Tympanoplasty, Mastoidectomy Hernia

vi. Hazardous or Adventure Sports: Code –

xxviii. Non-Medical expenses such as Food charges

xx. Congenital external diseases, defects or

xxi. Stem cell harvesting, or growth hormone

Any other relevant information as required

On receipt of duly filled pre authorization form and other

List of Claim documents Not Applicable As enlisted below

15. Endorsements For Policies where instalment option is not

SECTION H. CUSTOMER SERVICE & GRIEVANCE REDRESSAL PROCEDURE

Within India Outside India

Service No. 022-62346234 / Toll Free No: 800 08250825

II. Redressal of Grievance

Contact Points First Contact Point Escalation level 1 Escalation level 2

Contact us at 022 6234 6234 / NA NA

Contact details for Senior 022 6234 6234 / NA NA

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