Softlogic Life Insurance PLC

Level 16, One Galle Face Tower,

Colombo 02, Sri Lanka.
Registration No. : PQ 31
Care Center : 1312
Tel : (+94) 112 018 800
Fax : (+94) 112 327 123
Email : info@softlogiclife.lk
Web : www.softlogiclife.lk

The Softlogic Life Insurance PLC (herein after called “the Company”) has received a proposal for assurance
from the Life Assured / Proposer for assurance of the Assured named in the policy schedule together with
the first instalment of premium, and the Life Assured/ Proposer has entered in to a contract with the
Company for an assurance based on the terms contained in this policy.

This policy grants the benefits described in the Policy Schedule, provided that;

i) The commencement and continuation of the benefits are conditional upon the payment of
premiums relating thereto as described in the Policy Schedule.

and

ii) The Proposal submitted, together with all declarations and statements made and signed by the
Policy Owner or by any Life Assured forms the basis of the contract.

It is agreed that this contract has been entered into in utmost good faith. In the event of fraud or
misrepresentation by the Policy Owner or the Life Assured “the Company” may declare the policy null
and void.

The Proposal, Declarations, statements or schedules and endorsements attached with this policy or issued
with connection to this policy from time to time shall form part of this policy.

As the Policy owner/ Life Assured you are requested to examine the provisions of this policy for your
better understanding.

Signed on behalf of the company at Colombo on the date of the attached policy schedule.

……………………………… ……………………………….
Chief Technical Officer Chief Operating Officer
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 DEFINITIONS APPLICABLE TO THIS POLICY
Accident
An event or contiguous series of events, which are violent, unforeseen, involuntary, external and
visible in nature, which causes Bodily Injury.

Age
Age at nearest birthday

Alteration
Any attached description of additional or alternative provisions to the policy. Alterations are effective
only when signed by the company and accepted by the policyholder. Amendments are subject to all
conditions, limitations and exclusions of the policy.

Basic Sum Assured

The amount as specified in the policy schedule payable upon the death of the life assured during
the policy term, subject to the applicable terms and conditions.

Bodily Injury
An Injury which must be evidenced by external signs such as contusion, bruise and wound except
in cases of drowning and internal injury.

Claimant
The Life Assured, Proposer, Nominee or any other legally interested person (for eg. the legal heir
or administrator or executor of a deceased Life Assured) who wishes to make a claim for payment
of any benefits under the policy.

Congenital Disease
Disease, abnormality or disability which exists at the time of birth, as a result of hereditary factors or
conditions picked up during pregnancy up to the time of birth, or discovered later, at any time during
the person’s life.

Date of Commencement
The date of commencement of the insurance as specified in the policy schedule.

Date of Issuance
The date on which the proposer is accepted under this policy as a Proposer / Life Assured or
Beneficiary

Date of Reinstatement / Revival

Effective date of a restoration of a policy

Date of Inclusion
The date from which coverage for a new covered person as a new born or newly adopted child or
newly married spouse (including the spouse’s children) commences.

Date of Maturity
The date specified in the Policy Schedule on which benefits become payable provided the Life
Assured is still living. This date shall be the date on which the insurance contract ends and the
policy is terminated.

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Doctor
A Person qualified by a degree in medicine and registered with the Democratic Socialist Republic
of Sri Lanka Medical Council or legally licensed by or registered with the medical authorities of
the country where he or she is engaged in his or her medical practice. The registered Medical
Practitioner/ Doctor should not be the Life Assured or a close family members of the Insured.

Endorsement
The variation(s), if any, annexed to this Policy Document, modifying or varying any terms or
conditions contained in this policy.

Expiry Date
The date on which the Covers and Benefits provided under the Policy cease.

Exclusions
The benefits and events excluded from coverage of this policy and which shall apply to all covered
persons.

Grace Period
The length of time after the date a premium is due and unpaid during which the policy remains
inforce.

Insurer
Means Softlogic Life Insurance PLC or such other name by which Softlogic Life Insurance PLC shall
be known at a future date and includes successors in business and permitted assigns

Life Assured
The person named in the policy schedule and whose life is the object of the insurance and, if no
person is specifically named, shall mean the Policy Owner.

Minimum Guaranteed Refund (MGR)

The company guarantees a refund of the premium paid or a proportion thereof

Nominee
A person whose name has been nominated by the Policy Owner and such nomination is notified
in-writing to the Company and duly registered at the time death of the Life Assured subject to the
applicable terms & conditions.

Policy Anniversary
The annual anniversary of the date of commencement of the policy.

Policy Holder/ Owner

The person who owns this Policy and can exercise all rights, privileges and options available under
this Policy.

Policy Schedule
The schedule and any endorsements thereto issued by the Company to evidence the insurance, and,
if more than one on the same subject , then the latest in time with respect to such particular subject.

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Policy Term
The period between the Date of Commencement and the Date of Maturity.

Policy Year
The year commencing on the Date of Commencement or on a Policy Anniversary thereof.

Proposer
A person applying for the insurance policy by filling in and signing an application form.

Pre-existing condition
Any medical condition or any related condition (Eg. illnesses, symptoms, treatments, pains) that have
arisen at some point prior to the commencement of this coverage, irrespective of whether any
medical treatment or advice was sought. Any such condition or related condition about which the
Proposer / Life Assured or Beneficiary or insured dependent know, knew or could reasonably have
been assumed to have known, shall be deemed to be pre-existing. Conditions arising between
signing the application form and confirmation of acceptance by the company shall equally be
deemed to be pre-existing.

Premium paying term

No further premium payments are required upon completion of the premium paying term.

Regular premium
Premium payable by the proposer in regular intervals in the amounts, in the manner, and in the
method specified in the policy schedule.

Supplementary Benefit
An add-on benefit attached to and forming part of the policy if specified in the policy schedule.

Waiting Period
The period of time starting from the Date of Commencement / Date of Issuance or Date of inclusion
of new covered person during which a specified medical condition or type of treatment is not
covered under this policy.

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 PRIVILEGES AND GENERAL CONDITIONS

1. TRAVEL, RESIDENCE & OCCUPATION

This policy is free from all restrictions as to travel, residence and occupation, unless otherwise stated
herein.
2. PAYMENT OF PREMIUMS / DAYS OFGRACE
The following conditions apply to the payment of all premium contributions in respect of the benefits
provided by this policy;
i. All premium payments are payable on or before their relevant due dates. Premiums shall be
deemed to have been duly paid only when received by the company’s Head office, any of the
Branch offices or other institutions, and their Branch offices, which are duly authorized by the
company to accept payment of premiums.
ii. The official receipt issued by the company or any other institution duly authorized by the
company to accept payment of premium, is the only valid evidence of payment of premium.
iii. A grace period of thirty (30) days from its relevant premium due date shall be allowed for
payment of each premium after the first premium. The entire policy and all coverage under this
policy shall automatically terminate after the Grace period without the need for prior
notification if any premium remains unpaid. During this grace period all of the benefits provided
by this policy shall continue.

3. INCONTESTABILITY
When the policy has been in forced for a period of two (2) years from the date of its commencement, last
revival or reinstatement, the company will not contest the policy unless there is proof that the Assured or the
Life Assured made fraudulent statements of a material nature, in order to induce the Company in to forming
a contract under this policy with the Proposer or the Life Assured.

4. PRIMARY BENEFITS

A. DEATH BENEFIT
Upon the death of the Life Assured during the policy term, if the policy is in full force and subject to
the admission of the claim by the Company, the Company shall pay the Basic Sum Assured together
with the Minimum Guaranteed Refund as stated in First Schedule Part lll and the policy will be
terminated.

B. MATURITY BENEFIT
If the policy is in full force at the Maturity Date, the Company will refund the total premiums paid on
this policy to the Life Assured/ Policy Owner.

C. PAID-UP
A policy is considered paid-up if the policy lapses after 3 years.

The paid-up value of the policy will bear the same ratio to the Basic Sum Assured as the number of
year’s premium paid bears to the full policy term.

Upon the death of the Life Assured during the policy term, if the policy is paid-up and subject to the
admission of the claim by the Company, the Company shall pay the reduced Basic Sum Assured (paid-
up value) together with the Minimum Guaranteed Refund acquired at the time of lapse with the
accumulated interest and the policy will be terminated.

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 If the policy lapses after 3 years, Minimum Guaranteed Refund acquired at the time of lapse together
with the accumulated interest will be payable by the company upon the survival of the Life Assured
on the Maturity Date of the policy. The amount payable at the time of maturity will be capped up to
the total premiums paid.

5. GUARANTEED REFUND
The company guarantees a refund of the premium paid or a proportion thereof, provided the policy is
inforce for at least three years, commencing form the third anniversary of the policy. The amounts so
refundable are as shown in the schedule part 111. If the guaranteed refund is availed of by the assured
during the currency of the policy, the contract will forthwith terminate, if not, the guaranteed refund value
will be paid on the expiry date.

6. POLICY LOANS
Loans will not be granted on this policy.
7. REVIVAL / REINSTATEMENT OF LAPSED POLICIES
A Policy which has lapsed due to non-payment of Premium may be revived / reinstated during the lifetime of the Life
Assured but within two years from the date of lapse and before the date of maturity on the following terms:-
(a) Within six months from the due date of the first unpaid Premium, on payment of the full arrears
of Premium together with interest thereon.

(b) After six months from the due date of the first unpaid premium, on payment of the full arrears
of premiums and surcharge cost thereon and on production satisfactory to and without cost to
the company of medical evidence of the insurability of the Life Assured.
Official Receipt alone issued by the Company are taken as valid evidence of payment of premium.
Reinstatement of a Policy on medical evidence may be subject to revision of the terms and conditions under
which the Policy was issued as well as imposition of new conditions and restrictions. If the Life Assured is
found to be uninsurable, reinstatement may even be declined.
8. ASSIGNMENTS/ TRANSFERS .
Any assignment of policy shall not be binding upon the company unless written notice of such assignment is
received, recorded and acknowledged by the company. Upon receipt of any written notice of assignment, the
company shall be entitle to require the production of all original documents for examination to the company’s
satisfaction before recording such assignment. In recording assignment, the company does not accept any
responsibility or express any opinion of the contents as to its validity or legal effect.
Any assignment of this policy shall automatically cancel any nomination.

9. NOMINATIONS
(a) Subject to the provisions any law, during the term of the policy, the Life Assured may, by giving
written notice satisfactory to the Company, appoint a nominee/s change any duly appointed
nominee/s or change any duly appointed nominee/s to whom the money secured by the policy
should be paid in the event of the death of the Life Assured.

(b) Subject to the provisions of any law, a change of nominee shall be effective only after receiving
a written request from the Life Assured and it is recorded and acknowledged by the company.

(c) When the nominee is changed, the change shall be deemed effective from the date of the
Registration by the company. The receipt by nominee of sum payable by the company under
this policy shall constitute a valid discharge of the company’s liabilities under the policy. Any
acknowledgement of receipt by the nominee entitled thereto shall be conclusive proof of
payment.

(d) If there is nominee living at the time of the death of the Life Assured, then the amount payable
shall be paid to the Life Assured’s estate.

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 (e) The nominee shall only be entitled to the benefits payable as a result of the death of the Life
Assured.

(f) The Company shall not be liable for any payment made under this policy to a nominee/s duly
registered with the Company.

10. PROOF OF AGE

The company reserves the right to require proof of age of the life assured before making any payment under this
policy. If age has been misstated, this fact alone shall not invalidate the policy but an equitable adjustment shall
be made to the premium and/or benefits under the policy.

11. SUICIDE
If the Life Assured commits suicide whether sane or insane within Twelve (12) calendar months from the Date
of Commencement / Date of Issuance or the Date of Revival/ Reinstatement of the policy whichever shall be
later, the policy shall become void except to the extent of the interest of third parties acquired by bona fide
assignment for valuable consideration and written notice of such interest has been received and acknowledged
by the company prior to the date of death, the liability of the company shall not exceed the aggregate
premiums already paid without interest.

12. EXCLUSION OF LIABILITY

a) No benefit shall be payable in the event of death or disability of the Life Assured arising directly or
indirectly as a result of active participation or any attempted participation of the Life Assured in any
war, invasion, act of foreign enemies, hostilities, or war like operations (whether war be declared or
not) civil war, mutiny, riots, strike, civil commotion assuming proportion of or amounting to a popular
rising, military rising, insurrection, rebellion, military or usurped power or any acts of any person
acting on behalf of or in connection with any organization directed towards the overthrow by force
of any government or to the influencing of it by terrorism or violence.
b) No benefit shall be payable where the Life Assured has failed and/ or neglected to make a full and
frank disclosure of all material facts in the proposal, declaration and/or in any other documents/
applications related to and/ or required under this Policy; and/or
c) Where the claim has been made fraudulently or dishonestly; and/or
d) In act of breach by the Life Assured of any Law; and/or

13. DISAPPEARANCE OF THE LIFE ASSURED

Where the death of the Life assured is sought to be established on the basis of a presumption generated in
circumstances where he had not been heard of for a period of one year by those who would have naturally
heard of him if he had been alive, no money shall become due under the Policy until the effluxion of a
period of seven years computed from the time when the Life Assured had ceased to be heard of and this
fact notified to the company.

14. RIGHT OF CANCELLATION

For reason given in writing within TWENTY-ONE days after the date of receipt of the policy, the Life
Assured/Proposer may opt to have the Policy cancelled by returning the same to the Company, whereupon
the Company will refund any premiums paid to date, subject to deduction of expenses incurred on
documentation and medical examinations the company may have organized for the Life Assured.

15. LAW AND INTERPRETATION

a) This policy shall be governed by the laws of Sri Lanka.

b) Where the context admits, any reference to the Life Assured includes reference to his or her
personal representatives and the singular includes the plural, and vice-versa.
c) Any reference to the masculine gender shall also apply to the feminine gender and vice-versa.
d) Supplementary benefits applicable, as stated in the policy schedule to the policy shall also be
subject to the terms and conditions specified in the schedules of such supplementary benefits.

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 e) In the event of any inconsistency between this policy and its Sinhala and Tamil texts the English
text of this policy shall prevail.
f) Where the context admins any reference to the Life Assured includes either or both Lives
Assured in a joint Life Policy or the first Life Assured as the case may be.

16. CLAIMS

No money shall become due under the Policy until the Company’s requirements have been complied
with; and any expenses incurred in this regard should be borne by the claimant. Any payment to be
made under this policy will be made at the Head Office of the company. However, the Company is at
liberty to name at its discretion an alternate place of settlement within Sri Lanka at any time before a
claim is settled.

17. POLICY ALTERATIONS

The company may, as its sole discretion, consider requests of the Life Assured for alterations to the policy on
such terms and conditions that it may deem necessary. The privileges and conditions of this policy cannot be
waived or changed except by a policy endorsement duly approved and signed by an authorized officer of the
company.

18. NOTICE OF CHANGE OF OCCUPATION .

The Policy Owner shall duly notify the Company of any change in Life Assured’s occupation or duties
performed and the Company reserved the right to revise the premium paid for or exclude any or all of the
benefits provided by this policy.
The Company reserves the right to repudiate any claim arising from any loss or disablement caused directly,
wholly or partly by a change of occupation to a more hazardous occupation of which the Company has not
been notified. This section does not apply to the Basic Sum Assured, Additional Life Benefit & Spouse Cover
Benefit.

19. GOVERNING LAW AND DISPUTE RESALUTIONS

The parties to this Policy expressly agree that the laws of the Republic of Sri Lanka shall govern the validity,
construction, interpretation and effect of this Policy. Any dispute concerning the interpretation of the terms and
conditions, limitations and/or exclusions contained herein is understood and agreed to by both the Insured and
the Insurer to be subject to Sri Lankan law. All matters arising hereunder shall be determined in accordance
with the law and practice of such court within Sri Lankan Territory.

20. COMPLAINT HANDLING .

Any complaint relating to the policy should be referred to the Officer-in-Charge of Complaints or such other
designated officer of the Company. Any such complaint shall be processed in accordance with the established
complaint handling procedure of the Company and a resolution or response shall be provided by the
Company.
However, in the event the complaint is not satisfactorily resolved, then the Insured shall have the right to refer
such complaint for Arbitration or to the Insurance Ombudsman or Insurance Board of Sri Lanka.

21. TAXATION .
The Company is entitled to make such deductions which, its opinion, are necessary and appropriate, from
any of the benefit receivable under this insurance on account of any tax or other payment which may be
imposed by any legislation, order, or regulation or otherwise upon the Company, Policy Owner, Nominee
or Claimant.

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Hospitalization Benefit
Family Health Care Benefit
Family Health Care Super Benefit

Premier Health Benefit

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7. THIRD PARTY SERVICES

The policy benefits and/or ancillary services under this policy would be provided to you either directly
by the Company or by third party engaged directly or indirectly by the Company within Sri Lanka or
outside Sri Lanka. In such instances and out of necessity in providing you with your policy benefits and/or
ancillary services, the Company shall require to share your information including but not limited to
underwriting and claim related information with such third parties. Relying on you having understood the
aforesaid, the Company is deemed to be authorized by you to share your information including but not
limited to underwriting and claim related information as well as any ongoing decision(s) made in respect
of your proposal.

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EXCLUSIONS APPLICABLE FOR HEALTH RIDERS
EXCEPT PREMIER HEALTH BENEFIT

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26. TAXATION

The Company is entitled to make such deductions which, its opinion, are necessary and appropriate,
from any of the benefit receivable under this Insurance on account of any tax or other payment which
may be imposed by any legislation, order, or regulation or otherwise upon the Company, Policy Owner,
Nominee or Claimant.

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 PREMIER HEALTH BENEFIT

is and /

Diagnosis Ticket, O R

Premier Health Benefit S A

outside as per the table of benefits.

of the respective

and registered
& registered

Sum Assured Premier Health

Company
which
This benefit can be utilized only for one such a claim for the particular policy year.

However under the Family Floater Plan, the Reinstatement Benefit is available if the reason for
hospitalization is not related to any of the proceeding causes of hospitalization from all family members
during the policy term.

Reinstatement Benefit can not be availed for any ailments for which hospitalization claims have already
been paid in the previous policy years.

original Premier Health

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 (except Pharmacy Cover)
the Sum Assured Premier Health Benefit

Sum Assured
Sum
Assured Sum Assured Premier Health

1.3 PRE - HOSPITALIZATION EXPENSES COVER

Medical expenses incurred due to illness up to 30 days immediately before the Insured Person is
hospitalized, provided that such medical expenses are incurred for management of the diagnosis for
which the Insured Person's hospitalization was required and subject to the main claim for such
hospitalization is admissible by the Insurance Company.

1.4 POST - HOSPITALIZATION EXPENSES COVER

Medical expenses incurred due to illness up to 30 days immediately after the Insured Person is discharged
from the hospital, provided that such medical expenses are incurred for the same condition for which the
Insured Person’s hospitalization was required, and the claim for such hospitalization is admissible by the
Insurance Company.

1.5

an
Premier Health subject to a
maximum of Rs. 20,000/-,
up to 60 days per year.

Sum Assured

1.6 ROUTINE DENTAL COVER

Dental expenses incurred in the form of treatments, consultations, surgeries are covered under this policy.
Dental expenses covered under this benefit are;

i. Scaling and Cleaning

ii. Dental filling or restoration
iii. Examinations
iv. X- Rays
v. Extraction of Teeth
vi. Root Canal Treatment
vii. Treatment of gum disease

This cover is applicable only for the Life Assured/ Spouse for treatment taken within Sri Lanka.

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1.7 MATERNITY EXPENSES COVER

Where the Policy Owner has opted for Maternity Expenses Cover, only the medical expenses for the
delivery of a child (Normal or surgical delivery), miscarriages in a hospital in Sri Lanka will be covered.
Maternity Cover will be limited to 2 deliveries and miscarriages during the policy term irrespective
of number of policies. This cover is applicable only for Life Assured or Spouse and age of the claimant
must be less than 45 years. Once this cover is opted, removal of the benefit will not be allowed during
the term of the policy.

1.8 ROUTINE OPTICAL COVER

Expenses incurred for treatment to correct refractive errors of the eye will be covered. This cover is granted
once in every two years and cover the below;

i. Fees Charged for eye examinations. ( Maximum once per two years)
ii. The cost of spectacle frames, corrective lenses as prescribed. (Maximum one pair per two years)

This Routine Optical Cover is applicable only for the Life Assured/ Spouse for the purchases and
investigation expenses occurred within Sri Lanka.

1.9 WELLBEING COVER

Health check ups, tests and examinations undertaken on an OPD basis will be reimbursed under this cover.
This cover is payable only once in every two years. This Wellbeing Cover is applicable only for the Life
Assured / Spouse for examination/ tests performed within Sri Lanka.

1.10 PHARMACY COVER

The cost of the purchase of medicines prescribed by the qualified Doctor shall be reimbursed under
this cover. The maximum amount payable under this benefit is limited to per policy irrespective of
number of beneficiaries. This Pharmacy Cover is applicable only for purchase of medicine within
Sri Lanka and bills pertaining to same should be submitted within 30 days from the date of purchase.

1.11 DEDUCTIBLE OPTION

Where the Policy Owner has opted Deductible Option, the Deductible amount is the claim amount which
has to be borne by the Insured Person before the relevant benefits are payable under this policy. An
annual aggregate deductible is the accumulative total amount of medical expenses incurred by an
Insured Person during any one policy year in excess of which the policy will indemnify or compensate
the Insured Person for medical expenses covered by the policy. This Deductible Option is applicable for
all covers except Pharmacy Cover.

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 TABLE OF BENEFITS
Plan Plan A Plan B Plan C
(A) Limits (LKR)
Annual Limit per year 500,000 750,000 1,000,000

(B) Geographical Coverage

(i) Inbuilt Cover

(Once this cover is opted, removal of the benefit Sri Lanka Only
(ii) Optional Cover
will not be allowed during the term of the policy.)

(C) Inpatient Cover (LKR)

Reimbursement of Hospital Room and Board and ICU Ward

1 Daily Hospital Room and Board Cover
is subject to a maximum of 30% of the Basic Sum Assured

Maximum room rent per day for treatment within Sri Lanka 15,000 20,000
10,000
As-charged, subject to the sub-limit as stated.

Maximum room rent per day for treatment outside Sri Lanka
As-charged, subject to the sub-limit as stated. N.A. N.A. N.A.

Daily ICU Hospital Room and Board

Maximum room rent per day for treatment within Sri Lanka
As-charged, subject to the sub-limit as stated. 20,000 30,000 40,000

Maximum room rent per day for treatment outside Sri Lanka
N.A. N.A. N.A.
As-charged, subject to the sub-limit as stated.

2 Surgical Cover, such as

- Surgeon’s Fee As-charged, subject to usual, customary,
- Anesthetist's Fee and reasonable clause.
- Operating Theatre Fee, etc.

3 Hospital Miscellaneous Expenses Cover, such as

-
- Consultancy Fee As-charged, subject to usual, customary,
Drugs and intravenous feeding
- and reasonable clause.
Laboratory tests, pathology, radiological tests
-
Medical equipment and supplies, etc.

4 Ambulance Charges Cover

- As-charged, subject to the sub-limit as stated. 10,000 15,000 20,000
- Payable once in a policy year, subject to the claim being admissible
and payable only when a licensed ambulance service is used.

As-charged, subject to usual, customary,

5 Day Care Treatment Cover (inpatient for less than 24 hours) and reasonable clause.

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 Plan Plan A Plan B Plan C
6 Conventional Chemotherapy Cover
Received as part of an out-patient Treatment and done under the 150,000 225,000 300,000
medical supervision of a Medical Practitioner, on an as-charged
basis per year, subject to the sub-limit as stated.

7 Conventional Radiotherapy Cover

Received as part of an out-patient Treatment and done under the 150,000 225,000 300,000
medical supervision of a Medical Practitioner, on an as-charged
basis per year, subject to the sub-limit as stated.

8 Dialysis for Kidney Failure Cover

Outpatient kidney dialysis at a legally registered dialysis centre, 150,000 225,000 300,000
on an as - charged basis per year, subject to the sub-limit as stated.

9 Pre-Hospitalisation Expenses Cover

(applicable for all hospitalisations, irrespective of Private 25,000 37,500 50,000
or Public Hospital)

10 Post-Hospitalisation Expenses Cover

25,000 37,500 50,000
(applicable for all hospitalisations, irrespective of Private
or Public Hospital)

Covered in the overall Basic Sum Insured of the donee

11 Organ Donor Expenses Cover and payable only for hospitalization expenses for the donor.

12 Prosthesis and Implants

100,000 150,000 200,000
As-charged, subject to a max. sub-limit as stated.

2,500 3,750 5,000

13 Hospitalisation in a non-paying ward (Public Hospitals or similar) Expenses pertaining to the investigations and drugs
prescribed by the doctor in relation to the hospitalized
condition will be payable maximum up to 70% of the
Basic Annual SumInsured per year.

14 Routine Dental Cover 10,000 15,000 20,000

15 Routine Optical Cover 10,000 15,000 20,000

16 Wellbeing Cover 10,000 15,000 20,000

17 Pharmacy Cover 5,000 7,500 10,000

OPTIONAL BENEFIT (LKR)

18 Maternity Expenses 50,000 75,000 150,000

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 Plan Plan D Plan E Plan F Plan G Plan H
(A) Limits (LKR)

Annual Limit per year 2,000,000 3,000,000 4,000,000 5,000,000 10,000,000

(B) Geographical Coverage

(i) Inbuilt Cover Sri Lanka, India, Singapore, Malaysia and Thailand

(Once this cover is opted, removal

(ii) Optional Cover of the benefit will not be allowed Worldwide (exclude US and Canada)
during the term of the policy.)

(C) Inpatient Cover (LKR)

1 Daily Hospital Room and Board Cover Reimbursement of Hospital Room and Board and ICU Ward
is subject to a maximum of 30% of the Basic Sum Assured

Maximum room rent per day for treatment

within Sri Lanka As-charged, subject to 40,000 60,000 80,000 100,000 200,000
the sub-limit as stated.
Maximum room rent per day for treatment
outside Sri Lanka As-charged, subject to 60,000 90,000 120,000 150,000 300,000
the sub-limit as stated.

Daily ICU Hospital Room and Board

Maximum room rent per day for treatment

within Sri Lanka As-charged, subject to 80,000 120,000 160,000 200,000 400,000
.
the sub-limit as stated.
Maximum room rent per day for treatment
outside Sri Lanka As-charged, subject to 120,000 180,000 240,000 300,000 600,000
the sub-limit as stated.

2 Surgical Cover , such as

- Surgeon’s Fee As-charged, subject to usual, customary,
- Anesthetist's Fee and reasonable clause.
- Operating Theatre Fee, etc.

3 Hospital Miscellaneous Expenses Cover, such as

- Consultancy Fee (i) As-charged, subject to usual, customary, and reasonable clause.
- Drugs and intravenous feeding (ii) In case of overseas treatment, there is a maximun cap of 2 doctor visits
- Laboratory tests, pathology, radiological tests per patient per day.
- Medical equipment and supplies, etc.

4 Ambulance Charges Cover

- As-charged, subject to the sub-limit as stated.
- Payable once in a policy year, subject to the claim 40,000 60,000 80,000 100,000 200,000
being admissible and payable only when a licensed
ambulance service is used.

As-charged, subject to usual, customary,

5 Day Care Treatment Cover (inpatient for less than 24 hours) and reasonable clause.

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 Plan Plan D Plan E Plan F Plan G Plan H
6 Conventional Chemotherapy Cover
Received as part of an out-patient Treatment and done
under the medical supervision of a Medical Practitioner, 600,000 900,000 1,200,000 1,500,000 3,000,000
on an as-charged basis per year, subject to the sub-limit
as stated.

7 Conventional Radiotherapy Cover

Received as part of an out-patient Treatment and done
under the medical supervision of a Medical Practitioner, 600,000 900,000 1,200,000 1,500,000 3,000,000
on an as-charged basis per year, subject to the sub-limit
as stated.

8 Dialysis for Kidney Failure Cover

Outpatient kidney dialysis at a legally registered dialysis 600,000 900,000 1,200,000 1,500,000 3,000,000
centre, on an as - charged basis, subject
to the sub-limit as stated.

9 Pre-Hospitalisation Expenses Cover

(applicable for all hospitalisations, irrespective of Private 100,000 150,000 200,000 250,000 500,000
or Public Hospital)

10 Post-Hospitalisation Expenses Cover

(applicable for all hospitalisations, irrespective of Private 100,000 150,000 200,000 250,000 500,000
or Public Hospital)

Covered in the overall Basic Sum Insured of the donee

11 Organ Donor Expenses Cover
and payable only for hospitalization expenses for the donor.

12 Prosthesis and Implants

400,000 600,000 800,000 1,000,000 2,000,000
As-charged, subject to a max. sub-limit as stated.

10,000 15,000 20,000 20,000 20,000

13 Hospitalisation in a non-paying ward
(Public Hospitals or similar)
Expenses pertaining to the investigations and drugs prescribed by
the doctor in relation to the hospitalized condition will be payable
maximum up to 70% of the Basic Annual Sum Insured per year.

14 Routine Dental Cover 50,000 50,000 50,000 50,000 50,000

15 Routine Optical Cover 25,000 30,000 40,000 50,000 50,000

16 Wellbeing Cover 50,000 50,000 50,000 50,000 50,000

17 Pharmacy Cover 25,000 25,000 25,000 25,000 25,000

OPTIONAL BENEFIT (LKR)

18 Maternity Expenses 200 ,000 300,000 300,000 300,000 300,000

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 Plan Plan F Plan G Plan H Plan I Plan J Plan K Plan L Plan M
(A) Limits (LKR)
Annual Limit per year (LKR) 15,000,000 20,000,000 25,000,000 30,000,000 50,000,000
4,000,000 5,000,000 10,000,000
(B) Geographical Coverage
(i) Inbuilt Cover Sri Lanka, India, Singapore, Malaysia and Thailand

(Once this cover is opted, removal

(ii) Optional Cover of the benefit will not be allowed Worldwide (exclude US and Canada)
during the term of the policy.)

(C) Inpatient Cover (LKR)

Reimbursement of Hospital Room and Board and ICU Ward

1 Daily Hospital Room and Board Cover
is subject to a maximum of 30% of the Basic Sum Assured

Maximum room rent per day

80,000 for treatment 200,000
100,000
within Sri Lanka As-charged, subject to 300,000 400,000 500,000 600,000 700,000
the sub-limit as stated.

Maximum room120,000 150,000

rent per day for treatment 300,000
outside Sri Lanka As-charged, subject to 450,000 600,000 750,000 900,000 1,050,000
the sub-limit as stated.

Daily ICU Hospital Room and Board

Maximum room rent per day

160,000 for treatment 400,000
200,000
within Sri Lanka As-charged, subject to 600,000 800,000 1,000,000 1,200,000 1,400,000
the sub-limit as stated.

Maximum room rent per day

240,000 for treatment 600,000
300,000
outside Sri Lanka As-charged, subject to 900,000 1,200,000 1,500,000 1,800,000 2,100,000
the sub-limit as stated.

2 Surgical Cover, such as

- Surgeon’s Fee As-charged, subject to usual, customary,
- Anesthetist's Fee and reasonable clause.
- Operating Theatre Fee, etc.

3 Hospital Miscellaneous Expenses Cover, such as

- Consultancy Fee (i) As-charged, subject to usual, customary, and reasonable clause.
- Drugs and intravenous feeding (ii) In case of overseas treatment, there is a maximun cap of 2 doctor visits
- Laboratory tests, pathology, radiological tests per patient per day.
- Medical equipment and supplies, etc.

80,000 100,000 200,000

4 Ambulance Charges Cover
- As-charged, subject to the sub-limit as stated.
- Payable once in a policy year, subject to the claim 300,000 400,000 500,000 600,000 700,000
being admissible and payable only when a licensed
ambulance service is used.

As-charged, subject to usual, customary,

5 Day Care Treatment Cover (inpatient for less than 24 hours)
and reasonable clause.

1,200,000
1,200,000 1,500,000 3,000,000
1,200,000 1,500,000 3,000,000

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 4,500,000 6,000,000 7,500,000 9,000,000 10,500,000

1,200,000 1,500,000 3,000,000

Plan Plan I Plan J Plan K Plan L Plan M

6 Conventional Chemotherapy Cover

Received as part of an out-patient Treatment and done
under the medical supervision of a Medical Practitioner, 4,500,000 6,000,000 7,500,000 9,000,000 10,500,000
on an as-charged basis per year, subject to the sub-limit
as stated.

7 Conventional Radiotherapy Cover

Received as part of an out-patient Treatment and done
under the medical supervision of a Medical Practitioner, 4,500,000 6,000,000 7,500,00 9,000,000 10,500,000
on an as-charged basis per year, subject to the sub-limit
as stated.

8 Dialysis for Kidney Failure Cover

1,200,000 1,500,000 3,000,000
Outpatient kidney dialysis at a legally registered
4,500,000 6,000,000 7,500,000 9,000,000 10,500,000
dialysis centre, on an as - charged basis, subj ect
to the sub-limit as stated.

200,000 250,000 500,000

9 Pre-Hospitalisation Expenses Cover
(applicable for all hospitalisations, irrespective of Private 750,000 1,000,000 1,250,000 1,500,000 1,750,000
or Public Hospital)

200,000 250,000 500,000

10 Post-Hospitalisation Expenses Cover
750,000 1,000,000 1,250,000 1,500,000 1,750,000
(applicable for all hospitalisations, irrespective of Private
or Public Hospital)
Covered in the overall Basic Sum Insured of the donee
11 Organ Donor Expenses Cover and payable only for hospitalization expenses for the donor.
12 Prosthesis and Implants 250,000
800,000 1,000,000 as stated.
2,000,000 3,000,000 4,000,000 5,000,000 6,000,000 7,000,000
As-charged, subject to a max. sub-limit
20,000 20,000 20,000
20,000 20,000 20,000 20,000 20,000

13 Hospitalisation in a non-paying ward

(Public Hospitals50,000
or similar) 50,000 50,000 Expenses pertaining to the investigations and drugs prescribed by
the doctor in relation to the hospitalized condition will be payable
maximum up to 70% of the Basic Annual Sum Insured per year.

14 Routine Dental Cover 50,000 50,000 50,000 50,000 50,000

50,000 50,000 50,000

15 Routine Optical Cover 50,000 50,000 50,000 50,000 50,000

16 Wellbeing Cover 50,000 50,000 50,000 50,000 50,000

50,000 50,000 50,000

17 Pharmacy Cover 25,000 25,000 25,000 25,000 25,000

OPTIONAL BENEFIT (LKR)

150,000 200,000
18 Maternity Expenses 300,000 300,000 300,000 300,000 300,000

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2.1 TREATMENT WITHIN SRI LANKA

Premier Health Benefit shall become effective Ninety (90) days after the Date of Commencement of the Policy, or
Date of Policy or Date of Revival/ Reinstatement of policy or Date of Inclusion if the benefit is included subsequent
to the Policy Commencement Date, whichever is later.

2.2 TREATMENT OUTSIDE SRI LANKA

Premier Health Benefit become effective Hundred and Eighty (180) days after the Date of Commencement of the
Policy, or Date of Policy or Date of Revival/ Reinstatement of policy or Date of Inclusion if the benefit is included
subsequent to the Policy Commencement Date, whichever is later.

2.3 PHARMACY COVER

Cover shall become effective Hundred and Eighty (180) days after the Date of Commencement of the
Policy, or Date of Policy or Date of Revival/ Reinstatement of policy or Date of Inclusion if the benefit
is included subsequent to the Policy Commencement Date, whichever is later.

2.4 ROUTINE DENTAL COVER / WELLBEING COVER / ROUTINE OPTICAL COVER

Cover shall become effective after 2 years after the Date of Commencement of the Policy, or Date of Policy or Date
of Revival/ Reinstatement of policy or Date of Inclusion if the benefit is included subsequent to the Policy
Commencement Date, whichever is later.

2.5 MATERNITY EXPENSES COVER

Cover shall become effective after 2 years after the Date of Commencement of the Policy, or Date of Policy or Date
of Revival/ Reinstatement of policy or Date of Inclusion if the benefit is included subsequent to the Policy
Commencement Date, whichever is later. Miscarriage will be covered after Hundred and Eighty (180) days
from the above dates.

2.6 SPECIAL SURGERIES / AILMENTS

Premier Health Benefit shall become effective for the following list of Surgeries or ailments, after 1 year from the
Date of Commencement of the Policy, or Date of Policy or Date of Revival/ Reinstatement of policy or Date of
Inclusion if the benefit is included subsequent to the Policy Commencement Date, whichever is later.

Name of Surgeries / Ailments

Medical or Surgical management of DNS, diseases if Tonsils, Adenoids and Sinuses and related
i)
conditions ( except Malignancy)
ii) All types of Hernias and Benign Prostatic Hypertrophy
iii) Hydrocoele/ Varicocoele/ Spermatocoele
iv) Piles/ Fissure/ Fistula-in-Ano / Rectal Prolapse/ Pilonidal Sinus
Treatment of all gynaecological conditions ( Such as but not limited to Uterine Fibroid,
v) Dysfunctional Uterine Bleeding, Hysterectomy, Uterine Prolapse, Endometriosis, Adenomyosis
Uteri, Ovarian Cyst etc) except those arising from malignancy.
vi) Medical or Surgical management of Prolapsed Intervertebral Disc.
Skin and all internal cysts / tumors / nodules / polyps / ganglions / lipomas of any kind unless
vii)
malignant
viii) Calculus Diseases of any etiology
ix) Peripheral vascular diseases of any etiology, including treatment for Varicose
All types of CRF and acute on chronic Renal Failures but not ARF, including Renal Failure due to
x)
Diabetes
Osteoporosis / Pathological Fracture / Degenerative Joint Diseases including joint replacement
xi) surgeries. However, joint surgeries necessitated due to accidents would not be a part of this
exclusion
xii) Cataract, Retinopathy and Retinal detachment

The Company may waive off the above Waiting Period in the event of Hospitalization and/or Surgical
procedures required due to an accident. (Except Wellbeing Cover and Pharmacy Cover)

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 room and administrative

9 Removal of a tympanic drain

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33
 P

admission.

Any planned treatment under taken out-side Sri Lanka, to be intimated to the Insured and pre-authorization
is mandatory. Emergency hospitalization need to be intimated to insurer within 48hrs of hospitalization
and in case at higher than eligible room category was opted for a Co-payment of 25% would be applicable
on the eligible insurance claim amount.

However, if the Insured dies during the hospitalization, the claim can be paid to legal nominee
of the Insured.

Bonus

4.9 Diagnosis of illness should have been arrived at for the first time after expiry of 90 days from the Date of
commencement of the policy or the Date of issuance of the policy or Date of Revival / Reinstatement of
the policy or Date of inclusion of benefit whichever is later, but not later than Seventy (70th) birthday of
the Life Assured / Spouse or the Twenty Second( 22nd ) birthday of child.

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5 EXCLUSIONS

5.1 The policy exclusions as specified in privileges and general conditions will be applicable to this benefit.

5.2 PRE- EXISTING CONDITIONS

5.3 CONGENITAL CONDITIONS

5.4 OPD TREATMENT

i.

ii.

iii.

5.5 MATERNITY

i. Any fertility, sub fertility treatment or assisted conception operation or sterilization procedure,
birth control related treatment, treatment for sexual dysfunction and voluntary termination of
pregnancy.
ii. Private nurse cost.
iii. Routine visits, any diagnostic tests, treatment/ consultancy for maternity related conditions
iv. Any kind of child birth, miscarriages are not covered, if the “Maternity Expenses Cover” is not opted.

5.6 DENTAL CARE

i. Mouth guards, gum shields or any dental appliances.

ii. Implants and all costs associated with the preparation and fitting of such a device. (Including
Crowns and Bridges)
iii. Bleaching or other tooth whitening and orthodontics.
iv. Cosmetic Treatment meaning dental Treatment not necessary for the establishment or maintenance
of oral health.
v. Specialist Treatment, meaning any form of dental care or Treatment beyond the scope of the
average competent Dentist.
vi. Wisdom teeth extraction, other than those extracted at the Dentist’s surgery.
vii. Treatment, care, repair to, or in connection with tooth jewellery.
viii. Any Treatment required as a result of damage or injury caused whilst training for, or participating
in, contact sports unless recommended mouth protection is worn.
ix. Expense for prosthetic organs and equipment, including prosthetic tooth or dental inventions.

5.7 OPTICAL CARE

Any claim directly or indirectly from costs of tinted / reactive lenses, sunglasses, non-corrective contact
lenses, whether prescribed or not and laser eye surgery or any other similar technique.

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5.8 ROUTINE

s. (Applicable for in-patient only)

5.9 TREATMENT NOT RECOMMENDED BY PHYSICIAN

5.10 EPILEPSY AND PSYCHIATRIC / PSYCHOLOGICAL CONDITIONS

5.11 REST CURES AND PREVENTIVE MEASURES

5.12

5.13

5.14

5.15

5.16

5.17

5.18

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5.19

5.20

5.21

5.22

5.23

5.24

5.25

5.26

5.27

5.28

5.29 TAXATION

The Company is entitled to make such deductions which, its opinion, are necessary and appropriate,
from any of the benefit receivable under this Insurance on account of any tax or other payment which
may be imposed by any legislation, order, or regulation or otherwise upon the Company, Policy Owner,
Nominee or Claimant.

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 List of Approved Hospitals applicable under
Family Health Care Benefit/ Family Healthcare Super Benefit/ Family Healthcare Super Benefit
+ Overseas Treatment and Premier Health Benefit

Name of the Hospital (Alpha wise) Address

Asiri Hospital Holding PLC # 181, Kirula Road, Colombo 05.

Asiri Surgical Hospital PLC # 21, Kirimandala Mawatha, Colombo 05.
Asiri Hospital Matara (Pvt) Ltd # 191, Anagarika Dharmapala Mw., Matara.
Asiri Diagnostic Services (Pvt) Ltd # 21/1, Keppitipola Mawatha, Kandy.
Asia Hospitals Private Limited # 110, High Level Road, Maharagama.
Ave Mariya Hospital # 1,Ave Mariya Road,Negombo.
Aloka Medical Centre # 64, Good Shed Rd., Ratnapura.
Arogya Hospital (Pvt) Ltd Colombo Road,Gampaha.
Balasooriya Hospitals Ltd # 118A Kurunegala Rd., Puttalam.
Bandaranayake Hospitals (Pvt) Ltd # 128-A, Maimbula Rd., Wathupitiwala.
Central Hospital # 70,Kaluwella,Galle.
Central Hospital Colombo Road,Vehera,Kurunegala.
Cinnamon Gardens Hospital # 67,Gregory’s Road,Colombo 07.
Co-operative Hospital Old Tangalle Road,Matara.
Co-operative Hospital Colombo Road,Kadurugashandiya, Kurunegala.
Co-operative Hospital (People) # 378,George R De Silva Mw,Colombo 13.
Co-operative Hospital Society Ltd # 43,Queens Marry’s,Galle.
Co-operative Hospital Wakwella Road,Galle.
Co-operative Hospital Keena Road,Nuwara Eliya.
Central Hospital Cocowatte Road,Badulla.
Central Hospital (Pvt) Ltd # 114, Norris Canal Road, Colombo 10.
Dehiwala Medical Centre Anagarika Dharmapala Mw,Dehiwala.
Delmon Hospital # 258,Galle Road,Colombo 06.
Dissanayake Hospital (Pvt) Ltd # 298,Colombo Road,Negombo.
Durdans Hospital # 3,Alfred Place,Colombo 03.
Electro Medical Center # Circular Road, Giriulla.
Galle Co-operative Hospitals Ltd # 65, H.W. Amarasuriya Mw., Galle.
Gampaha Co-operative Hospital # 43,Marybisso Mw,Gampaha.
Gomez Hospital (Pvt) Ltd # 63,Colombo Road,Awissawella.
Golden Key Eye & ENT Hospital # 1175, Cotta Rd., Colombo 08.
Gunarathne Hospital Main Street,Kuliyapitiya.
Hemachandra Hospital Trincomalee.
Holy Cross Health Centre New Road,Koiyathotam,Jaffna.
Hemas Hospital # 389, Negombo Rd., Wattala.
I.S.S. Hospital # 322/1, Mahakumbura Wela Rd., Akurana.
Ideal Hospital Park Road,Nuwara Eliya.
Jaffna (Pvt) Hospital Nawale Road,Jaffna.
Joseph Frazer Memorial Hospital Joseph Frazer Road,Colombo 05.
Kadawatha Clinic # 338/2,Kandy Road,Kadawatha
Kandy Pvt. Hospitals Ltd # 255/8,Katugastota Road,Kandy
Kelaniweli (Pvt) Ltd # 78/01,Colombo Road,Awissawella
K-med (Pvt) LTD Mallika Building, Colombo Rd., Wanduragala, Kurunegala.
Kegalle (Pvt) Hospital Main Street,Kegalle.
Lanka Hospitals (Apollo) Colombo 05.
Lakeside Medical Centre # 40,Sangaraja Mawatha,Kandy.

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Name of the Hospital (Alpha wise) Address

Leesons Hospital (Pvt) Ltd # 33,Tewatte Road,Ragama.

Life Care Private Hospital # 199, Colombo Road, Wennappuwa.
Macathi Private Hospital Ltd # 22,Wijerama Road,Colombo 07.
Matara Medi House (Pvt) Ltd # 15, Dharmapala Mw., Uyanwatta, Matara.
Miracle Health (Pvt) Ltd # 233, Dambulla Rd., Kurunegala.
MK Hospitals (Pvt) Ltd # 147/1, Kandy Rd., Gampola.
Medicare Hospital (Pvt) Ltd # 55,Ananda Rajakaruna Mawatha, Colombo 10.
Mohotti Hospital (Pvt) Ltd # 10,Spencer Road,Matara.
Mobile Medicare # 665 A, Peradeniya Rd., Kandy.
Nawinna Hospital Circular Road,Kurunegala.
Navinna Medicare Hospital # 416, High Level Rd., Navinna, Maharagama.
Nawaloka Hospitals PLC # 23,Sri Sugathodaya Mw,Colombo 02.
New Medicare (Pvt) Hospital Averiwatta Junction, Katunayake.
New Kandy Citihealth Hospital # 34, Market Rd., Dambulla.
New Philip Hospitals # 225, Galle Rd., Kalutara South.
New Lanka Hospital (Pvt) Ltd # 9,Bambalapitiya Drive,Colombo 04.
Nursing Home & Divulpitiya Healthcare Divulpitiya.
Oasis Hospital #18/A, E D Dabare Mw.,Colombo 05.
Osro Hospitals Kandy Road, Mawanella.
Panadura Hospitals (Pvt) Ltd #615,Galle Road,Panadura.
Park Hospital # 186, Park Road, Colombo 05.
Path Lab (Pvt) Ltd Gajaba Mawatha,Gampaha.
Private Hospital (Mohotti) Uyanwatta,Gampaha.
Royal Hospital Kada Dolaha,High Courts,Anuradhapura.
Ratnam (Pvt) Hospital # 227,Union Place,Colombo 02.
Royal Hospital (Pvt) Ltd # 62,W A De Silva Mawatha,Colombo 06.
Ruhunu Hospital (Pvt) Ltd Karapitiya,Galle.
Roseth Hospital (Pvt) Ltd # 07, Kularatne Road, Ambalangoda.
Sachithra Hospital (Pvt) Ltd # 76, Horana Rd., Panadura.
Suwa Medura Hospital Godage Mawatha,Anuradhapura.
Shanthi Clinic Vauniya.
Sethma Hospitals (Pvt) Ltd # 36, Queen Mary's Rd., Gampaha.
Suwa Sevana (Pvt) Hospital Wewala,Horana.
Seth Sevana (Pvt) Ltd Colombo Road,Kurunegala.
Seth Suwa Sewaya # 9,Hakmana Road,Matara.
Singhe Hospital 362, Colombo Road, Ratnapura.
Southern Hospital Wakwella Road,Galle.
Suwa Medura Hospitals # 35, Jayathilaka Mw., Panadura.
Suwana Hospital (Pvt) Ltd # 16, Kurunegala Rd., Chilaw.
Suwabawana Hospital # 12/1, Illawathura, Gampola
Suwasiri Hospital # 142, Kandy Rd., Kadawatha.
Suwa Sevana Hospitals (Pvt) Ltd # 53,Peradeniya Road,Kandy.
St. Joseph Hospital (Pvt) Ltd # 229/10, St. Joseph’s Street, Negombo.
The Dissanayake (Pvt) Hospital # 401/1, Colombo Rd., Negombo.
Viweka Hospital (Pvt) Ltd # 10A, Kalagedihena Rd., Vegangoda.
Ward Place Private Hospital # 2,Sulchasthan Garden,Colombo 07.
Winser Hospital # 129, S. De S. Jayasinghe Mw., Kohuwala.
Wattala Private Hospital Ltd # 279,Negombo Road,Wattala.
Wayamba Diagnostics Medical Laboratory (Pvt) Ltd # 120, Colombo Rd, Kurunegala.
West Line Hospital # 33, Colombo Rd., Marawila.
Western Infirmary (Pvt) Ltd # 218, Cotta Rd., Colombo 08.
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