Jeevan Arogya PDF

LIFE INSURANCE CORPORATION OF INDIA
CENTRAL OFFICE
Dept: Product Development “Yogakshema”

Jeevan Bima Marg
Mumbai – 400 021
Ref: CO/PD/11 31st May, 2011
To,
All HODs of Central Office
All Zonal Offices
All Divisional Offices
All Branch Offices (through DOs)
MDCs, ZTCs, STCs, NIA and
Audit & Inspection Depts. of Zonal Offices.
Re: INTRODUCTION OF LIC’S JEEVAN AROGYA (Plan No. 903)
1. INTRODUCTION:
It has been decided to introduce LIC’s JEEVAN AROGYA (Plan No. 903) with effect from
1st June, 2011 The Unique Identification Number (UIN) for LIC’s Jeevan Arogya plan is
512N266V01. This number has to be quoted in all relevant documents furnished to the
policyholders and other users (public, distribution channels).
An individual can take the health cover under this plan for himself / herself. This individual will
be addressed as Principal Insured (PI) for the purpose of insurance under this plan. The
Spouse, Children, Parents and Parents-in-law can also be covered under the same policy.
This is non-linked health plan which provides fixed benefits for hospitalization and almost all
types of surgical procedures irrespective of actual cost incurred and the benefit is in addition
to any other health insurance cover that insured lives may have, subject to certain terms and
conditions.
The benefits offered under the plan are:

i) Hospital Cash Benefit (HCB)
ii) Major Surgical Benefit (MSB)
iii) Day Care Procedure Benefit (DCPB)
iv) Other Surgical Benefit (OSB)
Two riders viz. Term Assurance Rider and Accident Benefit Rider shall also be available
under the plan for PI and Insured Spouse only.
At the time of filling up the proposal form, PI and Spouse (if insured) have to exercise an
option whether to continue the policy in case of exit of PI from the policy, as per Annexure C
enclosed with the proposal form. If option for continuation of policy is exercised, in case of
death or expiry of cover of PI, the surviving Insured Spouse will become the Principal Insured
and the Policy will continue. In such case, the premium for the Insured Spouse will change
from the coinciding or following instalment premium due date and the new premium would be
based on tabular premium rates applicable for PIs and the age for calculation of revised
premium rate will be the age at entry of the spouse.
Other details of the plan are as follows.

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2. PREMIUM:
Under this plan multiple lives can be covered under one policy.
For each insured life, the instalment premium shall be based on the age at entry, the Initial
Daily Hospital Cash Benefit chosen, gender and whether insured life is PI or other than PI.
The tabular premium rates applicable for PI (males/females) will be different from those
applicable for other lives (males/females) as given in Annexure I. Thus, the level of premium
for PI and other insured lives shall be different for same age, same gender and same level of
cover.
The instalment premium payable during the cover period in respect of each Insured will be the
sum of:
(i) Instalment premium for the Basic Plan
(ii) Instalment premium for Accident Benefit Rider (if opted for)
(iii) Instalment premium for Term Assurance Rider (if opted for)
The total instalment premium payable in respect of each policy shall be the sum of instalment
premiums payable in respect of each insured life covered under the policy.
For example, if there are 3 lives covered under a policy- PI (male), Spouse (female) and child
(for children premium does not vary with gender). PI has opted for both Term Assurance Rider
& Accident Benefit Rider, Spouse has not opted for any rider benefit and the optional riders
are not available for child.
Thus,
Instalment premium for PI is = Instalment premium for PI under the Basic Plan + Instalment
premium for Accident Benefit Rider + Instalment premium for
Term Assurance Rider ------------- (A)
Instalment premium for Spouse = Instalment premium for Spouse under the Basic Plan
------------- (B)
Instalment premium for Child = Instalment premium for Child under the Basic Plan
------------- (C)
Therefore, Total Instalment Premium to be paid for this policy shall be [(A) + (B) + (C)]
In respect of each insured life covered under a policy, the instalment premium for Basic Plan
will be guaranteed for a period of 3 (three) years from the Date of Commencement of the
policy. The instalment premiums for Basic Plan are reviewable on every third policy
anniversary (defined as Automatic Renewal Date in para 5 a) below) starting from the date of
commencement of policy. The premium rates for the basic plan applicable on renewal, i.e.
from Automatic Renewal Date, shall be guaranteed for a further period of 3 years i.e. till next
Automatic Renewal Date.
If any additional member is included in the policy after the date of commencement, the
premium charged in respect of that member will also be guaranteed till the next Automatic
Renewal Date and hence may change even before completion of 3 years from his/her joining
the policy.
On any Automatic Renewal Date in the future, the instalment premium in respect of each
insured will be based on the entry age of that Insured (i.e. age as on the date of
commencement of policy/ age at the time of inclusion into the policy, as the case may be) and
the Corporation’s premium rates then prevailing for this product.
The Instalment premium for both the optional riders is, however, guaranteed throughout the
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term for which cover is provided.
The tabular premium rates per annum for PI and Other Insured for standard lives are given in
the Annexure - I. Also the rates of Class I extra premium per annum are enclosed as
Annexure – II to this circular.
Kindly note that maximum age at entry for PI is 65 years. However, tabular premium rates and
Class I extra for PI have been given up to age 79 years to cover the possibilities mentioned in
para 4 b) of this circular.
3. ELIGIBILITY CONDITIONS AND FEATURES:

FOR BASIC PLAN
a) Minimum / There is no specific minimum and maximum premium payable. The total
Maximum Premium premium payable will be the sum of premiums in respect of each individual
Amount member covered under the policy. The premium in respect of each individual
will be payable from the date of entry into the policy till the date of exit from
the policy.
b) Minimum entry age Principal Insured, Insured Spouse,
Parents & Parents-in-law - [18] years last birthday
Insured Dependent Children - [3] months (completed)
c) Maximum entry age Principal Insured and Insured Spouse - [65] years last birthday
Insured Parents and Parents-in-law - [75] years last birthday
Insured Dependent Children – [17] years last birthday
d) Maximum cover Principal Insured, Insured Spouse, Insured Parents & Parents-in-law –
ceasing age [80] years last birthday
Insured Dependent Children – [25] years last birthday
e) Date of cover Policy anniversary on which the Insured life attains Maximum cover ceasing
expiry in respect age or as per other conditions as specified in Para 5 (g).
of each Insured
covered under the
plan
f) Premium Rate Rates will be guaranteed for first 3 years of the policy i.e. for 3 years from the
Guarantee date of commencement of policy. At the end of every 3 years, i.e. on each
Automatic Renewal Date (defined in Para 5 a)) the premium rates may
change i.e. the policy may be treated as if it is renewed every 3 years.
The rates applicable on renewal after every 3 years shall be guaranteed for a
further period of 3 years i.e. till next renewal.
(i) For Hospital Cash Benefit (HCB) (under Basic Plan)
Feature Principal Insured Spouse (if any), Insured Dependent

Insured Insured Parents & Children (if any)
(PI) Parents-in-law (if any)
a) Minimum Initial Daily ` 1,000/- ` 1,000/- ` 1,000/-
Benefit (in a ward other
than Intensive Care Unit)
b) Maximum Initial Daily ` 4,000/- Insured Spouse- Less than Less than or equal to
Benefit or equal to that of PI that of Insured Spouse
Insured Parents/ Parents-in- (PI, if there is no
law - Less than or equal to Insured Spouse).
that of Insured Spouse (PI, Further, included
if there is no Insured children shall be
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Spouse). Further, included covered for equal
parents shall be covered for benefits.
equal benefits.
c) Maximum annual benefit 30 days in year 1, 90 days per year thereafter, inclusive of stay in
period, applicable to each ICU. Maximum number of days in ICU is restricted to 15 days in
insured year 1 and to 45 days thereafter.
d) Maximum Lifetime Benefit 720 days inclusive of stay in ICU. Maximum number of days in ICU
period, applicable to each is restricted to 360 days in respect of each Insured.
insured
Initial Hospital Cash Benefit shall be in multiples of ` 1000/-.
(ii) For Major Surgical Benefit (MSB) (under Basic Plan)
Feature Principal Insured (PI) Insured Spouse (if Insured Dependent

any),Insured Parents Children (if any)
& Parents-in-law (if
any)
a) Major Surgical 100 times of Insured Spouse- 100 100 times of ADB of each
Benefit Sum Applicable Daily times of ADB of child
Assured (MSB SA) Benefit (ADB) of PI Insured Spouse
(as specified in para Insured Parents/
4). Parents-in-law - 100
times of ADB of each
parent
b) Maximum annual 100% of Major Surgical Benefit Sum Assured
benefit, applicable
to each insured
c) Maximum Lifetime 800% of Major Surgical Benefit Sum Assured
Benefit, applicable
to each insured
(iii) For Day Care Procedure Benefit (DCPB) (under Basic Plan)
Feature Principal Insured (PI) Insured Spouse (if Insured Dependent

any),Insured Parents Children (if any)
& Parents-in-law (if
any)
a) Lump sum benefit 5 times of Applicable Insured Spouse- 5 5 times of ADB of each
payable Daily Benefit (ADB) times of ADB of child
(described in Para 4) Insured Spouse
of PI for each Surgical Insured Parents/
Procedure Parents-in-law - 5
times of ADB of each
parent
b) Maximum annual 3 Surgical Procedures
benefit, applicable
to each insured
c) Maximum Lifetime 24 Surgical Procedures
Benefit, applicable
to each insured
(iv) For Other Surgical Benefit (OSB) (under Basic Plan)

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Feature Principal
Insured Spouse (if Insured Dependent
Insuredany),Insured Parents & Children (if any)
(PI) Parents-in-law (if any)
a) Daily benefit amount 2 times of
Insured Spouse- 2 times of 2 times of ADB of
ADB of PI
ADB of Insured Spouse each child
Insured Parents/Parents-in-law-
2 times of ADB of each parent
b) Maximum annual benefit, 15 days in year 1 and 45 days per year thereafter
applicable to each insured
c) Maximum Lifetime Benefit, 360 days
applicable to each insured
FOR TERM ASSURANCE RIDER OPTION:
This rider shall be available for PI and Insured Spouse only.
(a) Minimum Term Assurance Sum Assured: ` [100] in '000's
(b) Maximum Term Assurance Sum Assured: An amount equal to the Major Surgical
Benefit Sum Assured (MSB SA) at the time of inception/ inclusion into the policy
(i.e. 100 times of Initial Daily Hospital Cash Benefit) in respect of the insured,
subject to the maximum of ` 25 lakh overall limit taking all term assurance riders
under all existing policies of the Life Assured and Term Assurance Sum Assured
under other proposals into consideration.
The Term Assurance Sum Assured shall be in multiples of ` 25,000/-.
(c) Minimum / Maximum Premium Amount: There is no specific minimum and

maximum premium payable. The premium payable will depend on the Term
Assurance Sum Assured.
The tabular premium rates per annum for Term Rider benefit are given in the
Annexure –III. Also the rates of Class I extra premium per annum are given in the
Annexure – IV.
(d) Minimum Entry Age: [18] years (completed)
(e) Maximum Entry Age: [50] years (Nearest Birthday)
(f) Maximum Benefit Ceasing Age: [60] years (Nearest Birthday)
(g) Maximum Term: [35] years
FOR ACCIDENT BENEFIT RIDER OPTION:
This rider shall only be available for PI and Insured Spouse provided Term Assurance Rider has
been opted for.
(a) Minimum Accident Benefit Sum Assured: ` [25] in '000's
(b) Maximum Accident Benefit Sum Assured: An amount equal to the Term Assurance
Sum Assured at the time of inception/ inclusion into the policy in respect of the insured,
subject to maximum of ` 50 lakhs overall limit considering the Accident Benefit Sum
Assured in respect of all existing policies on the life of the insured including the policies
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taken from Life Insurance Corporation of India and other insurance companies and the
Accident Benefit Sum Assured under new proposals into consideration.
The Accident Benefit Sum Assured shall be in multiples of `5,000/-.
(c) Minimum / Maximum Premium Amount: There is no specific minimum and maximum
premium payable. The premium payable will depend on the Accident Benefit Sum
Assured. For premium rate refer Para 6 (e) below.
(d) Minimum Entry Age: [18] years completed
(e) Maximum Entry Age: [50] years (Nearest Birthday)
(f) Maximum age for cover: [60] years (Nearest Birthday)
(g) Maximum Term: [35] years
4. BENEFITS:
Death Benefit under the basic plan: No death benefits will be payable on the death of any
Insured unless Term Assurance Rider Benefit mentioned in Para 6 f) below, along with or
without Accident Benefit Rider mentioned in Para 6 e), has been opted for.
On death of the Principal Insured (PI);
a) The surviving Insured Spouse will become the Principal Insured provided the option is
exercised at the beginning of the contract and the Policy will continue. In such case, the
premium for the Insured Spouse will change from the date coinciding with or following
instalment premium due date and the new premium would be based on tabular premium
rates applicable for PIs and the age for calculation of revised premium rate will be the age
at entry of the spouse. If the option is not exercised at the beginning of the contract, the
Insured Spouse will not become PI and the policy will terminate.
b) If the Insured Spouse had predeceased the Principal Insured or had not given the option
to continue the policy as new PI on death of PI, then the other Insured will have the option
to take a new policy and the existing Policy will terminate. In respect of these other
Insured:
i. The new policy will be issued without any underwriting if the new policy is bought
within 90 days of the termination of the existing Policy.
ii. The maximum entry age condition for the basic plan will not apply for the new policy.
iii. The outstanding Waiting periods and outstanding period of any Exclusion will however
apply under the new policy.
iv. Other terms and conditions including premium rates will be as applicable for the new
policy.
In the event of death of an Insured person other than the Principal Insured, the policy will
continue after removal of the Insured and change in premium will apply from the instalment
premium due date coinciding with or next following the date of intimation of death of the
Insured.
Maturity Benefit: No benefits are payable at end of the Cover Period.
Benefit payable on hospitalization:

If PI or any of the Insured lives covered under the policy is hospitalized due to Accidental
Bodily Injury or Sickness and the stay in hospital exceeds a continuous period of 24 hours,
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then for any continuous period of 24 hours or part thereof, provided any such part stay
exceeds a continuous period of 4 hours (after having completed the 24 hours as above) in a
non-ICU ward/room of a hospital, an amount equal to the Applicable Daily Benefit (ADB),
available under the policy during that policy year, shall be payable subject to terms and
conditions mentioned in Para 5 c) & 5 i) and exclusions mentioned in Para 7.
During the first year of cover commencement in respect of each insured, the Applicable Daily
Benefit (ADB) shall be the Initial Daily Benefit amount (i.e. the level of HCB chosen by the
insured) mentioned in the policy Schedule.
The amount of Applicable Daily Benefit (ADB) for each policy year, after the first policy year,
shall consist of 2 parts:
− An arithmetic addition of an amount equal to 5% (five percent) of the Initial Daily Benefit to
the Applicable Daily Benefit of the previous Policy Year. Such increase in the Applicable
Daily Benefit shall be effected on each Policy anniversary during the Cover Period and
shall continue until it attains a maximum amount of 1.5 times the Initial Daily Benefit
Thereafter, this amount in each Policy Year in future shall remain at that maximum level
attained.
− Further arithmetic addition of an amount equal to “No Claim Benefit” (as defined below
under the heading “No Claim Benefit”) provided the policy attracts and is eligible for it.
There shall be no maximum limit for such increase which means that if this policy is
eligible for “No Claim Benefit”, the same shall be granted throughout the Cover Period
without any maximum limit.
Consider an example where Initial Daily Benefit is Rs.1000 in respect of each insured life (say,
PI and spouse) under a policy. There is no claim admitted under the policy during first 12
years from the policy commencement except in the 5th year when a claim is admitted in
respect of spouse. In this case, year-wise Applicable Daily Benefit for each insured shall be as
follows:
Year 1 2 3 4 5 6 7 8 9 10 11 12
ADB 1000 1050 1100 1200* 1250 1300 1350** 1400 1450 1550* 1600*** 1600
* In years 4 and 10 ‘No Claim Benefit’ is added.
** In year 7 ‘No Claim Benefit’ is not added as a claim occurred in the 5th year.
*** After 11th year, ADB shall not increase as it has attained the maximum level (1.5 times of
Initial Daily Benefit). However the ADB shall increase due to ‘No Claim Benefit’ as and when
the policy shall be eligible for.
For members included subsequently under the policy, the benefit in the first year shall be
equal to Initial Daily Benefit amount and thereafter the Applicable Daily Benefit shall increase
as above.
If the member insured is required to stay in an Intensive Care Unit of a hospital, two times the
Applicable Daily Benefit, for any continuous period of 24 hours or part thereof, provided any
part stay exceeds a continuous period of 4 hours (after having completed the 24 hours as
above), will be payable subject to terms and conditions mentioned in Para 5 (c) & 5 (i) and
exclusions mentioned in Para 7.
The Applicable ICU Daily Benefit amount shall be twice the Applicable Daily Benefit amount.
No benefit will be payable for the first 24 hours of hospitalisation. However, for every
Hospitalization that extends for a continuous period of 7 days or more, the Daily Hospital Cash
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Benefit would also be paid for first 24 hours (day one) of hospitalization, regardless of whether
the Insured was admitted in a general or special ward or in an intensive care unit. It may be
noted that hospitalization for 6 days and 4 hours or more will be considered as 7 days.
Major Surgical Benefit:

In the event of an Insured under this plan, due to medical necessity, undergoing one of the
surgeries defined in Major Surgical Benefit Annexure, within the cover period in a Hospital
due to Accidental Bodily Injury or Sickness, the respective benefit percentage of the Major
Surgical Benefit Sum Assured, as specified against each of the eligible surgeries mentioned in
Major Surgical Benefit Annexure, shall be paid subject to terms and conditions mentioned in
Para 5 d) & 5 i) and exclusions mentioned in Para 7.
Ambulance Benefit: In the event that a Major Surgical Benefit falling under Category 1 or
Category 2 (as mentioned in the Major Surgical Benefit Annexure) is payable and
emergency transportation costs by an ambulance have been incurred, an additional lump sum
of `1,000 will be payable in lieu of ambulance expenses.
Premium Waiver Benefit: Further, in the event that a Major Surgical Benefit falling under
Category 1 or Category 2 (as mentioned in the Major Surgical Benefit Annexure) is payable
in respect of any Insured, the total annualized premium i.e. total one year premium in respect
of that Policy from the date of instalment premium due coinciding with or next following the
date of the Surgery will be waived.
Day Care Procedure Benefit:

In the event of an Insured under this Plan undergoing any specified Day Care Procedure
mentioned in the Day Care Procedure Benefit Annexure due to medical necessity, an
amount equal to 5 (five) times the Applicable Daily Benefit shall be paid, regardless of the
actual costs incurred, subject to terms and conditions mentioned in Para 5 e) & 5 i) and
exclusions mentioned in Para 7.
Other Surgical Benefit:

In the event of an Insured under this Plan, due to medical necessity, undergoing any Surgery
not listed under Major Surgical Benefit or Day Care Procedure Benefit, and the stay in hospital
exceeds a continuous period of 24 hours, a Daily Benefit equal to 2 (two) times the Applicable
Daily Benefit shall be paid for each continuous period of 24 hours or part thereof provided any
such part stay exceeds a continuous period of 4 hours of Hospitalization, subject to terms and
conditions mentioned in Para 5 f) & 5 i) and exclusions mentioned in Para 7.
Other Surgical Benefit shall be payable from day one of hospitalization but the minimum stay
in hospital should be atleast 24 hours.
No claim benefit:
A no claim benefit will be paid in the event that during the period between Date of
Commencement of policy and next Automatic Renewal Date or between two Automatic
Renewal Dates (described in para 5 a) below) there are no claims in respect of any Insured.
The amount of the no claim benefit would be equal to 5% (five percent) of the Initial Daily
Benefit in respect of each Insured and the resulting amount shall be added to arrive at the
Applicable Daily Benefit in respect of each Insured for the Policy Year next following the most
recent Automatic Renewal Date.
5. OTHER TERMS AND CONDITIONS:

a) Automatic Renewal Date:
The instalment premium will be guaranteed in respect of each Insured for a period of 3
(three) years from the Date of Commencement of the policy, i.e. for the first 3 years of the
policy. Thereafter, at the end of every third policy anniversary, the premiums may be
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reviewed to take into account the Corporation’s experience, subject to prior approval from
IRDA. These premium due dates, at the end of every third policy anniversary, starting from
the date of commencement of policy till the date of cover expiry, on which the instalment
premiums are reviewable, will be referred as Automatic Renewal Dates in respect of all
Insured in the Policy.
The premium rates applicable on Automatic Renewal Date after every 3 years shall be
guaranteed for a further period of 3 years i.e. till next Automatic Renewal Date.
On any Automatic Renewal Date in the future, the instalment premium will be based on
the Insured’s age at entry into the policy i.e. age as on the date of commencement of
policy/ age at the time of inclusion into the policy, as the case may be and the
Corporation’s premium rates then prevailing for this product.
b) Removal of existing members:

In the event of death or divorce, an Insured may be removed from coverage upon request
by the Principal Insured in writing. This will be effective from the instalment premium due
date coinciding with or next following the date of such a request. No further premiums are
due in respect of that Insured from such instalment premium due date.
In any other circumstances, removal of an existing Insured will be permitted at the sole
discretion of the Corporation.
c) Hospital Cash Benefit:

In the event of Accidental Bodily Injury or Sickness first occurring or manifesting itself after
the date of commencement of cover in respect of that Insured and during the Cover Period
and causing an Insured’s Hospitalization to exceed a continuous period of 24 hours within
the Cover Period, then, subject to the terms and conditions, waiting period and exclusions
of the Policy, the Daily Benefit is payable by the Corporation as follows, regardless of the
actual costs incurred:
In case of Hospitalisation in the general or special ward (i.e. a non-

Intensive Care Unit ward/room) of a Hospital:
The Applicable Daily Benefit in a Policy Year, for each continuous period of 24
hours or any part thereof (after having completed the 24 hours as above)
provided any such part stay exceeds a continuous period of 4 hours of
Hospitalization necessitated solely by reason of the said Accidental Bodily
Injury or Sickness, shall be payable.
In case of Hospitalisation in the Intensive Care Unit of a Hospital:

Two times the Applicable Daily Benefit reckoned under para 4 above for each
continuous period of 24 hours or part thereof (after having completed the 24
hours as above) provided any such part stay exceeds a continuous period of 4
hours of Hospitalization in the Intensive Care Unit of a Hospital during any
period of Hospitalization necessitated solely by reason of the said Accidental
Bodily Injury or Sickness shall be payable.
Combined stay in Non-ICU and ICU ward/room:

During one period of 24 continuous hours (i.e. one day) of Hospitalisation (after
having completed the 24 hours as above), if the said Hospitalisation included
stay in an Intensive Care Unit as well as in any other in-patient (non-Intensive
Care Unit) ward of the Hospital, the Corporation shall pay benefits as if the
admission was to the Intensive Care Unit provided that the period of
Hospitalisation in the Intensive Care Unit was at least 4 continuous hours.
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No benefit will be payable for the first 24 hours of hospitalisation.
However, for every Hospitalization that extends for a continuous period of
7 days or more, the Hospital Cash Benefit would also be paid for the first
24 hours (day one) of hospitalization, regardless of whether the Insured
was admitted in a general or special ward or in an intensive care unit.
The amount of Daily Benefit due to Hospitalization as specified in the Policy

Schedule would be the Initial Daily Benefit amount. In the first Policy Year the
Initial Daily Benefit would be the Applicable Daily Benefit amount which will
be payable per day of each eligible hospitalized day.
For each Policy Year commencing at a Policy anniversary on or after the first
anniversary, the Applicable Daily Benefit of the previous Policy Year shall be
increased by arithmetic addition of an amount equal to 5% (five percent) of the
Initial Daily Benefit. This shall be further enhanced if the policy attracts and is
eligible for “No Claim Benefit” (as defined in Para 4). And the resulting amount
shall be the Applicable Daily Benefit for that Policy Year.
Thus, the Applicable Daily Benefit for each policy year, after the first policy
year, shall consist of 2 parts:
− An arithmetic addition of an amount equal to 5% (five percent) of the
Initial Daily Benefit to the Applicable Daily Benefit of the previous Policy
Year. Such increase in the Applicable Daily Benefit shall be effected on
each Policy anniversary during the Cover Period and shall continue until it
attains a maximum amount of 1.5 times the Initial Daily Benefit
Thereafter, this amount in each Policy Year in future shall remain at that
maximum level attained.
− Further arithmetic addition of an amount equal to “No Claim Benefit”
provided the policy attracts and is eligible for it. There shall be no
maximum limit for such increase which means that if this policy is eligible
for “No Claim Benefit”, the same shall be granted throughout the Cover
Period without any maximum limit.
The amount of Daily Benefit in case of admission to the Intensive Care Unit
shall be two times the Applicable Daily Benefit.
For any new member added during the term of the policy, first policy year for
that new member for the purpose of this benefit shall start from the policy
anniversary on which the cover starts.
A no claim benefit is payable in the event that during the period between two
Automatic Renewal Dates there are no claims in respect of any Insured. The
amount of the no claim benefit would be equal to 5% (five percent) of the Initial
Daily Benefit in respect of each Insured and the resulting amount shall be
added for arriving at the amount of Applicable Daily Benefit in respect of each
Insured for that Policy Year. Such increase in the Applicable Daily Benefit shall
be effective from the next following Automatic Renewal Date.
Benefit Limits and Conditions:

i. The Hospital Cash Benefit shall be payable only if Hospitalisation has occurred
within India.
ii. The total number of days for which hospital cash benefit would be payable, in
respect of each Insured, in a Policy Year would be restricted to -
a. A maximum of 30 (thirty) days of Hospitalization out of which not more than
15 (fifteen) days shall be in an Intensive Care Unit in the first Policy Year
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following the date of commencement of cover in respect of that Insured
b. A maximum of 90 (ninety) days of Hospitalization out of which not more
than 45 (forty five) days shall be in an Intensive Care Unit in the second
and subsequent Policy Years following the date of commencement of cover
in respect of that Insured.
iii. The total number of days of Hospitalization for which Hospital Cash Benefit is
payable during the Cover Period, in respect of each and every Insured covered
under the policy, shall be limited to a maximum of 720 (seven hundred and
twenty) days out of which not more than 360 (three hundred and sixty) days
shall be in an Intensive Care Unit. Upon attainment of this limit by an Insured,
the Hospital Cash Benefit in respect of that Insured shall cease immediately.
iv. The Benefit Limits specified above in respect of an Insured under this Policy,
shall solely and exclusively apply to that Insured. Any unclaimed Hospital Cash
Benefit of any one Insured is not transferable to any other Insured.
v. The Hospital Cash Benefit shall not be payable in the event of an Insured
under this Policy undergoing any specified Day Care Procedure (as mentioned
in the Day Care Procedure Benefit Annexure).
d) Major Surgical Benefit:

In the event of an Insured under this Policy undergoing any specified Surgery (as
mentioned in the Major Surgical Benefit Annexure) in a Hospital due to Accidental
Bodily Injury or Sickness first occurring or manifesting itself after the date of
commencement of cover in respect of that Insured and during the Cover Period then,
subject to the terms and conditions, waiting period and exclusions of this Policy, a
percentage (as mentioned in the Major Surgical Benefit Annexure against the specified
Surgery performed) of the Major Surgical Benefit Sum Assured shall be payable by the
Corporation, regardless of the actual costs incurred.
In the event that a Major Surgical Benefit falling under Category 1 or Category 2 (as
mentioned in the Major Surgical Benefit Annexure) is payable and emergency
transportation costs by an ambulance have been incurred, an additional lump sum of `
1,000 will be payable in lieu of ambulance expenses.
In the event that a Major Surgical Benefit falling under Category 1 or Category 2 (as
mentioned in the Major Surgical Benefit Annexure) is payable in respect of any Insured,
the total annualized premium i.e. total one year premium in respect of that Policy from the
date of instalment premium due coinciding with or next following the date of the Surgery
will be waived.
i. If more than one Surgery is performed on the Insured, through the same
incision or by making different incisions, during the same surgical session, the
Corporation shall only pay for that Surgery performed in respect of which the
largest amount shall become payable.
ii. The Major Surgical Benefit shall be paid as a lump sum as specified for the
benefit concerned and is subject to providing proof of Surgery to the
satisfaction of the Corporation.
iii. All Surgical Procedures claimed should be confirmed as essential and required,
by a qualified Physician or Surgeon, to the satisfaction of the Corporation.
iv. The Major Surgical Benefit will be payable only after the Corporation is satisfied
on the basis of medical evidence that the specified Surgery covered under the
Policy has been performed.
v. The Major Surgical Benefit shall be payable only if the Surgery has been
performed within India.
- 11 -
vi. The amount in lieu of ambulance expenses shall be payable only once in
respect of each Insured in any Policy Year and is subject to providing
satisfactory evidence to the Corporation.
vii. The total amount payable in respect of each Insured under the Major Surgical
Benefit in any Policy Year during the Cover Period shall not exceed 100% of
the Major Surgical Benefit Sum Assured in that Policy year.
viii. The total amount payable in respect of each Insured during the Cover Period
under the Major Surgical Benefit shall not exceed a maximum limit of 800% of
the Major Surgical Benefit Sum Assured. If the total amount paid in respect of
an Insured equals this lifetime maximum limit, the Major Surgical Benefit in
respect of that Insured will cease immediately.
ix. The Benefit Limits specified in the above clauses in respect of an Insured
under this Policy, shall solely and exclusively apply to that Insured. Any
unclaimed Major Surgical Benefit of any one Insured is not transferable to any
other Insured.
x. The Major Surgical benefit for any surgery cannot be claimed and shall not be
payable more than once for the same surgery during the term of the policy.
e) Day Care Procedure Benefit:

In the event of an Insured under this Policy undergoing any specified Day Care Procedure
(as mentioned in the Day Care Procedure Benefit Annexure) in a Hospital due to
Accidental Bodily Injury or Sickness first occurring or manifesting itself after the date of
commencement of cover in respect of that Insured and during the Cover Period then,
subject to the terms and conditions, waiting period and exclusions of this Policy, an
amount equal to 5 (five) times the Applicable Daily Benefit, shall be payable by the
Corporation, regardless of the actual costs incurred.

i. If more than one Day Care Procedure is performed on the Insured, through the
same incision or by making different incisions, during the same surgical
session, the Corporation shall only pay for one Day Care Surgical Procedure.
ii. The Day Care Procedure Benefit shall be paid as a lump sum and is subject to
providing proof of Surgery to the satisfaction of the Corporation.
iv. The Day Care Procedure Benefit will be payable only after the Corporation is
satisfied on the basis of medical evidence that the specified Surgical Procedure
covered under the policy has been performed.
v. The Day Care Procedure Benefit shall be payable only if the Surgical
Procedure has been performed within India.
vi. In respect of each Insured, the Day Care Procedure Benefit will be payable
only up to a maximum of 3 (three) Surgical Procedures in any Policy Year
during the Cover Period.
vii. In respect of each Insured during the Cover Period, the Day Care Procedure
Benefit will be payable only up to a maximum of 24 (twenty four) Surgical
Procedures. If the number of Surgical Procedures eligible for the Day Care
Procedure Benefit in respect of an Insured equals this lifetime maximum limit,
the Day Care Procedure Benefit in respect of that Insured will cease
immediately.
viii. The Benefit Limits specified in the above clauses in respect of an Insured
unclaimed Day Care Procedure Benefit of any one Insured is not transferable
to any other Insured.
ix. If a Day Care Procedure Benefit is performed no Hospital Cash Benefit shall be
paid.
- 12 -
f) Other Surgical Benefit:
In the event of an Insured under this Policy undergoing any Surgery not listed under Major
Surgical Benefit or Day Care Procedure Benefit, in a Hospital due to Accidental Bodily
Injury or Sickness first occurring or manifesting itself after the date of commencement of
cover in respect of that Insured and during the Cover Period then, subject to the terms and
conditions, waiting period and exclusions of this Policy, a Daily Benefit equal to 2 (two)
times the Applicable Daily Benefit, shall be payable by the Corporation, regardless of the
actual costs incurred for each continuous period of 24 hours or part thereof provided any
such part stay exceeds a continuous period of 4 hours of Hospitalization.
Other Surgical Benefit shall be payable from day one of hospitalization but the minimum
stay in hospital should be atleast 24 hours.

i. If more than one Surgical Procedure is performed on the Insured, through the
same incision or by making different incisions, during the same surgical
session, the Corporation shall only pay for one Surgical Procedure.
ii. The Other Surgical Benefit shall be paid as a Daily Benefit and is subject to
providing proof of Surgery to the satisfaction of the Corporation.
iv. The Other Surgical Benefit will be payable only after the Corporation is satisfied
on the basis of medical evidence that the specified Surgical Procedure covered
under the policy has been performed.
v. The Other Surgical Benefit shall be payable only if the Surgical Procedure has
been performed within India.
vi. The total number of days of Hospitalization for which the Other Surgical Benefit
is payable during a Policy Year in respect of each and every Insured covered
under the Policy shall not exceed 15 (fifteen) days in the first Policy Year
following the Date of Cover Commencement in respect of that Insured and 45
(forty five) days for the second and subsequent Policy Years following the Date
of Cover Commencement in respect of that Insured.
vii. The total number of days of Hospitalization for which the Other Surgical Benefit
is payable during the Cover Period, in respect of each and every Insured
covered under the Policy shall not exceed a maximum limit of 360 (three
hundred and sixty) days. Upon attainment of this lifetime maximum limit, the
Other Surgical Benefit in respect of that Insured will cease immediately.
viii. The Benefit Limits specified in the above clauses in respect of an Insured
unclaimed Other Surgical Benefit on any one Insured is not transferable to any
other Insured.
g) Commencement And Termination Of Benefit Covers:

The Hospital Cash Benefit, Major Surgical Benefit, Day Care Procedure Benefit and Other
Surgical Benefit cover in respect of each Insured shall commence on the Date of Cover
Commencement individually stated in the Policy Schedule.
The Hospital Cash Benefit, Major Surgical Benefit, Day Care Procedure Benefit and Other
Surgical Benefit cover in respect of each Insured shall terminate at the earliest of the
following:
i. The Date of Cover Expiry mentioned in the Policy Schedule;
ii. On attaining the lifetime maximum Benefit Limits as specified above;
iii. On death or Date of Cover Expiry of the Principal Insured and if the Policy
does not continue with the Insured Spouse as the Principal Insured;
- 13 -
iv. On death or Date of Cover Expiry of Insured Spouse after the Policy continues
with the Insured Spouse as the Principal Insured after the PI dies or reaches
his/her Date of Cover Expiry.
v. On death of the Insured;
vi. In respect of the Insured Spouse, on divorce or legal separation from the
Principal Insured;
vii. On termination of the Policy due to non-payment of premium or any other
reason.
h) Termination Of Policy:
A) If policy is issued on single life:
The policy shall terminate at the earliest of the following:
i) Non-payment of premiums within the revival period described in Para 8;
ii) On death;
iii) On the Date of Cover Expiry mentioned in the Policy Schedule;
iv) On exhausting all the lifetime maximum Benefit Limits as specified above.
B) If policy is issued on more than one life:
The policy shall terminate at the earliest of the following:
i) Non-payment of premiums within the revival period;
ii) On PI exhausting all the lifetime maximum Benefit Limits as specified
above.
iii) On death or Date of Cover Expiry, of the Principal Insured and if the
Policy does not continue with the Insured Spouse as the Principal
Insured.
iv) On the death or Date of Cover Expiry, of Insured Spouse after the Policy
continues with the Insured Spouse as the Principal Insured after the PI
dies or reaches his/her Date of Cover Expiry.
i) Waiting Period:
General waiting period:

There shall be no general waiting period in case Hospitalization or Surgery is due to
Accidental Bodily Injury. There shall be a general waiting period during which no benefits
shall be payable in the event of Hospitalization or Surgery, if the said Hospitalization or
Surgery occurred due to Sickness.
i. The general waiting period shall be 90 (ninety) days from the Date of Cover
Commencement in respect of each Insured.
ii. If the policy is revived after discontinuance of the Cover then the following
shall apply in respect of each Insured:
a. If the request for revival is received by the Corporation within 90 (ninety)
days from the due date of the first unpaid premium, then there shall be a
general waiting period of 45 (forty five) days from the Date of Revival in
respect of each Insured.
b. If the request for revival is received by the Corporation beyond 90 (ninety)
general waiting period of 90 (ninety) days from the Date of Revival in
respect of each Insured.
Specific waiting period:

The specific waiting period in respect of the treatments specified in the list below shall be
- 14 -
as follows:
i. The specific waiting period shall be 2 (two) years from the Date of Cover
ii. If the policy is revived after discontinuance of the Cover then the following
shall apply in respect of each Insured:
a. If the request for revival is received by the Corporation within 90 (ninety)
days from the due date of the first unpaid premium, then the specific waiting
period shall continue to be till 2 (two) years from the Date of Cover
b. If the request for revival is received by the Corporation beyond 90 (ninety)
specific waiting period of 2 (two) years from the Date of Revival in respect
of each Insured.
In respect of each Insured, no benefits are available hereunder and no payment will be
made by the Corporation for any claim under this Policy on account of Hospitalization or
Surgery directly or indirectly caused by, based on, arising out of or howsoever attributable
to any of the following during the specific waiting period:
i. Treatment for adenoid or tonsillar disorders

ii. Treatment for anal fistula or anal fissure
iii. Treatment for benign enlargement of prostate gland
iv. Treatment for benign uterine disorders like fibroids, uterine prolapse,
dysfunctional uterine bleeding etc
v. Treatment for Cataract
vi. Treatment for Gall stones
vii. Treatment for slip disc
viii. Treatment for Piles
ix. Treatment for benign thyroid disorders
x. Treatment for Hernia
xi. Treatment for hydrocele
xii. Treatment for degenerative joint conditions
xiii. Treatment for sinus disorders
xiv. Treatment for kidney or urinary tract stones
xv. Treatment for varicose veins
xvi. Treatment for Carpal tunnel syndrome
xvii. Treatment for benign breast disorders e.g. fibroadenoma, fibrocystic disease
etc
6. OPTIONS AVAILABLE UNDER THE PLAN:

(a) Plan changes: No alterations from this plan to another plan will be allowed.
(b) Insured Spouse to become Principal Insured: In case of death or expiry of cover of
Principal Insured, the surviving Insured Spouse shall become the Principal Insured
provided the option is exercised at the time of filling up the proposal form and the policy
will continue. In such case, the premium for the Insured Spouse will change from the
coinciding or following instalment premium due date and the new premium would be
based on tabular premium rates applicable for Principal Insureds and the age for
calculation of revised premium rate will be the age at entry of the spouse.
(c) Cover to new additional members: If the PI gets married/ remarried during the term of
the policy, the spouse and parents-in-law can be included in the policy within six months
from the date of marriage/ remarriage, but the Cover shall start from the policy anniversary
coinciding with or next following the date of inclusion. Enhanced premium shall be due
from such policy anniversary.
- 15 -
Any child born/legally adopted after taking the policy can be covered from the next
immediate policy anniversary date following the date on which the child completes the age
of 3 months. If the age of legally adopted child on the date of adoption is more than 3
months, the child can be covered from policy anniversary coinciding with or next following
the date of adoption. Enhanced premiums shall be due from such policy anniversary.
Inclusion of each additional member will be subject to receipt of the proof of the event and
fulfillment of underwriting conditions. The eligibility conditions as mentioned in Para 3,
waiting period as mentioned in Para 5 i) and exclusions mentioned in Para 7 will apply for
the new Insured.
Addition in any other case will not be allowed. The existing spouse, parents, parents-in-
law and children, if not covered at the time of taking policy, shall not be covered under the
policy.
If both of the parents (father and mother) are alive and are eligible for cover, then either
both of them will have to be covered or none of them will be covered. The PI will not have
any option to choose one of them. The same condition will apply for parents-in-law also.
Any addition of new lives shall be allowed by the PI only. After the death of PI, no addition
will be allowed.
(d) Quick Cash facility: If any of the insured lives undergoes any eligible surgery covered
under Category I or II of MSB in any of the listed network hospitals, the PI will have an
option to avail Quick Cash facility. Under this facility, 50% of eligible MSB amount would
be made available even during the period of hospitalization of any of the insured lives
covered (the surgery may be either planned or emergency due to accident) instead of
waiting for making a claim for the benefit after discharge. It will be only an advance
payment to the PI in the event of hospitalization for any MSB defined in the surgeries
listed under categories I & II and permissible under the policy conditions of the plan. This
will be, however, subject to approval from the TPA (Third Party Administrator), and the
advance amount will be adjusted from the final settlement of MSB claim amount.
This facility of advance payment could be availed by submitting the Bank Account details
of the PI in the prescribed format. The amount of advance shall be credited in the PI’s
bank account directly.
(e) Accident Benefit Rider: For PI and Insured Spouse, Accident Benefit Rider will be
available under the plan by payment of additional premium of ` 0.50 for every ` 1,000/- of
the Accident Benefit Sum Assured per policy year in respect of each life to be covered. In
case of accidental death, the Accident Benefit Sum Assured will be payable as lump sum
along with the Term Assurance Sum Assured.
The maximum aggregate limit of assurance under all policies of the Corporation and that
of all insurers under individual as well as group policies on the same life to which the
benefits apply shall not exceed ` 50 lakh.
The additional premium for this benefit will not be required to be paid on and after the
Policy anniversary on which the age nearer birthday of the Insured is 60 years.
(f) Term Assurance Rider: For PI and Insured Spouse, Term Assurance as optional rider
will be available under this plan. The premiums for this option are payable along with
premium under the basic plan and an amount equal to Term Assurance Sum Assured will
be payable on death during the term for which Term Assurance Rider is opted for. The
- 16 -
maximum cover for this rider will be ` 25 lakhs under all policies of the life assured with the
Corporation taken together.
7. EXCLUSIONS:
No benefits are available hereunder and no payment will be made by the Corporation for any
claim under this policy on account of hospitalization or surgery directly or indirectly caused by,
based on, arising out of or howsoever attributable to any of the following:
i. Any Pre-existing Condition unless disclosed to and accepted by the Corporation
prior to the Date of Cover Commencement or the Date of Revival (if the Policy is
revived after discontinuance of the Cover).
ii. Any treatment or Surgery not performed by a Physician/Surgeon or any treatment
including Surgery of a purely experimental nature.
iii. Any routine or prescribed medical check up or examination.
iv. Medical Expenses relating to any treatment primarily for diagnostic, X-ray or
laboratory examinations.
v. Any Sickness that has been classified as an Epidemic by the Central or State
Government.
vi. Circumcision, cosmetic or aesthetic treatments of any description change of
gender surgery, plastic surgery (unless such plastic surgery is necessary for the
treatment of Illness or accidental Bodily Injury as a direct result of the insured
event and performed within 6 months of the same).
vii. Hospitalisation expenses or Surgery for donation of an organ by donor.
viii. Treatment for correction of birth defects or congenital anomalies.
ix. Dental treatment or surgery of any kind unless necessitated by Accidental Bodily
Injury.
x. Convalescence, general debility, nervous or other breakdown, rest cure,
congenital diseases or defect or anomaly, sterilisation or infertility (diagnosis and
treatment), any sanatoriums, spa or rest cures or long term care or hospitalization
undertaken as a preventive or recuperative measure.
xi. Self afflicted injuries or conditions (attempted suicide), and/or the use or misuse of
any drugs or alcohol and complications arising from it.
xii. Any sexually transmitted diseases or any condition directly or indirectly caused to
or associated with Human Immuno Deficiency (HIV) Virus or any Syndrome or
condition of a similar kind commonly referred to as AIDS.
xiii. Removal or correction or replacement of any material/prosthesis/medical devices
that was implanted in a former surgery before Date of Cover commencement or
Date of Revival (if the Policy is revived after discontinuance of the Cover).
xiv. Any diagnosis or treatment or surgery arising from or traceable to pregnancy
(whether uterine or extra uterine), childbirth including caesarean section, medical
termination of pregnancy and/or any treatment related to pre and post natal care
of the mother or the new born.
xv. Hospitalisation for the sole purpose of physiotherapy or any ailment for which
hospitalization is not warranted due to advancement in medical technology.
xvi. War, invasion, act of foreign enemy, hostilities (whether war be declared or not),
civil war, rebellion, revolution, insurrection military or usurped power of civil
commotion or loot or pillage in connection herewith.
xvii. Naval or military operations(including duties of peace time) of the armed forces or
air force and participation in operations requiring the use of arms or which are
ordered by military authorities for combating terrorists, rebels and the like.
xviii. Any natural peril (including but not limited to avalanche, earthquake, volcanic
eruptions or any kind of natural hazard).
xix. Participation in any hazardous activity or sports including but not limited to racing,
scuba diving, aerial sports, bungee jumping and mountaineering or in any criminal
or illegal activities.
- 17 -
xx. To any loss, damage or expense due to or arising out of, directly or indirectly,
nuclear reaction, radiation or radioactive contamination regardless of how it was
caused.
xxi. Hospitalisation expenses related to non-allopathic methods of treatment or
surgery.
xxii. Participation in any criminal or illegal activities.
xxiii. Treatment arising from the Insured’s failure to act on proper medical advice
8. DISCONTINUANCE OF PREMIUMS:
If premiums have not been paid within the days of grace (as specified in Para 16) under the
Policy, the Policy will lapse and no benefits will be payable thereafter. The Principal Insured
shall have an option to revive the policy at anytime within a period of 2 (two) years from the
due date of first unpaid premium subject to conditions in Para 9 below.
9. REVIVALS/REINSTATEMENT OF DISCONTINUED POLICIES:
The Policy can be revived by the Principal Insured anytime during a period of 2 (two) years
from the due date of first unpaid premium called the “period of revival” or “revival period”.
The revival will be subject to payment of outstanding premiums with interest, underwriting and
may be on terms different from those offered earlier. Waiting periods and Exclusions as
described earlier will apply on revival. The Principal Insured may need to provide satisfactory
evidence of good health in respect of each Insured as required by the Corporation, at his own
expense. The Date of Revival will be when all requirements for revival/reinstatement are met
and approved by the Corporation at its sole discretion.
No benefit will be paid for an event that occurred during the lapse period till the Date of
Revival when the Policy was in a discontinued state.
Further, if the Automatic Renewal Date falls during the period of lapse (the revival period) and
revival is done after the Automatic Renewal Date, the premium before and after the Automatic
Renewal Date may be different.
Revival/reinstatement will not be allowed post the revival period.
10. SURRENDER:
No surrender value will be available under the policy.
11. MODES OF PREMIUM PAYMENT:

Premiums can be paid regularly either in yearly or half yearly or quarterly or monthly (through
ECS only) instalments.
12. REBATES:
Mode Rebates:
Rebates (for basic plan) are available at the following rates:
Yearly mode : 2% of Tabular Premium
Half-yearly mode : 1% of the tabular premium
HCB Rebates:
In respect of a member covered under a policy, if HCB is more than ` 1000, then the
premium arrived at in respect of that member shall be reduced by an amount (`) given
- 18 -
below:
HCB (`) For PI For each insured
member other than PI
2000 500 250
3000 1000 500
4000 1500 750
CEIS Rebate:
The rebate for eligible employees of the Corporation shall be 10% of the tabular
premium provided the proposal is submitted directly and not through any Agent/
Corporate Agent/ Broker.
13. COMMISSION PAYABLE TO AGENTS/ CORPORATE AGENTS/ BROKERS &

DEVELOPMENT OFFICER’S CREDIT:
Agents & Corporate Agents:

1st Year 2nd & 3rd year Subsequent Years
25.0% 7.5% 5.0%
Bonus Commission: 40% of 1st year's commission is payable in the first year.
Brokers
1st Year Subsequent Years
30% 5%
Development Officer’s credit: 100% of FY premium
14. LOANS:
No loan shall be granted under this plan.
15. UNDERWRITING:
Instructions will be issued separately by Underwriting and Reinsurance Department.
16. DAYS OF GRACE:

A grace period of one calendar month but not less than 30 days will be allowed for payment of
yearly or half-yearly or quarterly premiums and 15 days will be allowed if premiums are
payable monthly (ECS). If the due premiums are not paid within the days of grace the policy
will lapse. The provisions of para 8 (i.e. Discontinuance of Premiums) of this circular shall be
applicable in that case.
17. COOLING-OFF PERIOD:

If a policyholder is not satisfied with the “Terms and Conditions” of the policy, he/she may
return the policy to the Corporation within 15 days from the date of receipt of the policy. This
period will be termed as Cooling-Off Period.
In case the policy is returned during the cooling-off period, Commission shall be recovered
from the concerned Agent and the Development Officer’s credit allowed shall be withdrawn.
The refund of premium to the policyholder shall be net of mortality charges and morbidity
charges.
It may be noted that the mortality charge shall be deducted only for such lives who opted for
Term Assurance Rider cover under this plan.
- 19 -
The mortality and morbidity charges will be deductible for proportionate number of days
subject to a minimum for one month.
18. BACK DATING:

Back dating of policy will not be allowed.
19. POLICY STAMPING:

Policy Stamping will be at the rate of `.0.20 per thousand of total Major Surgical Benefit Sum
Assured (i.e. sum of Major Surgical Benefit Sum Assured in respect of all the members
insured (including PI) at inception.
Any addition of member thereafter shall be by way of endorsement for which stamping shall
be done additionally.
Further, the policy stamping for Term Rider Sum Assured will be at the rate of ` 0.20 per
thousand sum assured.
20. ASSIGNMENTS / NOMINATION:

No Assignment will be allowed under this plan.
Notice for Nomination or change of Nominations should be submitted for registration to the
office of the Corporation, where this policy is serviced. In registering a nomination, the
Corporation does not accept any responsibility or express any opinion as to its validity or legal
effect.
21. NORMAL REQUIREMENTS FOR CLAIM:

Regarding claims, the instructions shall be issued by Health Insurance Department, Central
Office, separately.
22. REINSURANCE:
A separate treaty has been arranged for this plan. Our retention limits are as below:
Hospital Cash Benefit:

` 500 Daily Hospital Cash Benefit
Major Surgical Benefit:

` 50,000 Major Surgical Benefit Sum Assured
Day Care Procedure Benefit:

` 2,500 Day Care Procedure Benefit
Other Surgical Benefit:

` 1,000 per day benefit
Risks over and above the above retention limits shall be shared equally between LIC (i.e.
50%) and reinsurers (50%).
23. PROPOSAL FORM:

The specimen Proposal form is annexed (Annexure V).
24. POLICY DOCUMENT:
- 20 -
The specimen Policy document will be sent by the Corporate Communications Department,
Central Office.
CHIEF (PRODUCT DEVELOPMENT)
Enclosures – Annexure I, II, III, IV and V
- 21 -
MAJOR SURGICAL BENEFIT ANNEXURE
Sl. No. LIST OF MAJOR SURGERIES % of Category

Major
Surgical
Benefit Sum
Assured
I CARDIOVASCULAR SYSTEM
1 Major Surgery of Aorta 100% Category 1
2 CABG (two or more coronary arteries must be bypassed) 100% Category 1
via open chest surgery
3 Heart Valve Replacement using mechanical prosthesis 100% Category 1
4 Heart/Heart-Lung Transplant 100% Category 1
5 Aortic root transplantation with coronary artery 100% Category 1
reimplantation for proximal aortic aneurysm
6 Pericardiotomy / Pericardectomy 60% Category 2
7 Initial implantation of permanent pacemaker in the heart 60% Category 2
8 Mitral valve repair 60% Category 2
9 Aortic valve repair 60% Category 2
10 Tricuspid valve repair 60% Category 2
11 Pulmonary valve repair 60% Category 2
12 Coronary Angioplasty with stent implantation (two or 40% Category 3
more coronary arteries must be stented)
13 Major vein repair with or without grafting for traumatic & 40% Category 3
nontraumatic lesions
II HAEMIC AND LYMPHATIC SYSTEM
14 Bone Marrow transplant (as recipient) 100% Category 1
15 Major Excision and grafting of Lymphoedema 60% Category 2
16 Splenectomy 60% Category 2
III NERVOUS SYSTEM
17 Repair of Cerebral or Spinal Arterio- Venous 100% Category 1
Malformations or aneurysms
18 Craniotomy for malignant Cerebral tumours 100% Category 1
19 Excision of pineal gland 100% Category 1
20 Excision of the pituitary gland 100% Category 1
21 Craniotomy for non malignant space occupying lesions 60% Category 2
22 Operations on Surbaracahnoid space of brain 60% Category 2
23 Intracranial transection of Cranial nerve 60% Category 2
24 Other operations on the meninges of the Brain 60% Category 2
25 Microvascular decompression of cranial 60% Category 2
nerves/nervectomy
26 Craniotomy for Drainage of Extradural, subdural or 40% Category 3
intracerebral space
27 Decompression surgery for Entrapment Syndrome 40% Category 3
28 Unilateral or Bilateral sympathectomy 40% Category 3
29 Peripheral nerve Graft 40% Category 3
30 Free Fascia Graft for Facial Nerve Paralysis 40% Category 3
31 Excision of deep seated peripheral nerve tumour 40% Category 3
1
Major
Surgical
Benefit Sum
Assured
32 Multiple Miscrosurgical Repair of digital nerve 40% Category 3
33 Bur-hole Drainage of Extradural, subdural or intracerebral 20% Category 4
space
IV RESPIRATORY SYSTEM
34 Lung Transplantation 100% Category 1
35 Unilateral Pneumonectomy 60% Category 2
36 Diaphragmatic/Hiatus Hernia Repair 60% Category 2
37 Thoracotoplasty 60% Category 2
38 Open Lobectomy of Lung 60% Category 2
39 Excision of benign mediastinal lesions 60% Category 2
40 Partial Extirpation of Bronchus 60% Category 2
41 Partial Pharyngectomy 60% Category 2
42 Total Pharyngectomy 60% Category 2
43 Total Laryngectomy 60% Category 2
44 Excision of Diaphragmatic tumours 60% Category 2
45 Pleurectomy or Pleural decortication 40% Category 3
46 Tracheal reconstruction for various lesion 40% Category 3
V DIGESTIVE SYSTEM
47 Excision of esophagus and stomach 100% Category 1
48 Abdominal-Perineal Pull Through Resection of rectum 100% Category 1
with Colo-Anal Anastomosis
49 Total excision of oesophagus 60% Category 2
50 Total excision of stomach 60% Category 2
51 Resection and Anastomosis of any part of digestive tract 40% Category 3
52 Open Surgery for treatment of Peptic Ulcer 40% Category 3
53 Artificial opening into stomach 20% Category 4
VI ENDOCRINE SYSTEM
54 Complete excision of adrenal glands 60% Category 2
55 Complete excision of Thyroid gland 60% Category 2
56 Complete excision of Parathyroid gland 60% Category 2
57 Partial excision of adrenal glands 40% Category 3
58 Partial excision of Thyroid gland 40% Category 3
59 Partial excision of Parathyroid gland 40% Category 3
VII ENT
60 Total ear amputation with reconstruction 60% Category 2
61 Transmastoid removal cholesteatoma with extended 60% Category 2
Mastoidectomy
62 Total Nasal Reconstruction due to Traumatic lesions 60% Category 2
63 Labyrinthotmy for various lesions 40% Category 3
VIII ORAL
64 Wide excision and Major reconstruction of malignant 60% Category 2
Oro-pharyngeal tumours
2
Major
Surgical
Benefit Sum
Assured
65 Total Glossectomy 40% Category 3
66 Wide local Excision for oral leukoplakia 20% Category 4
IX EYE
67 Orbit Tumour Exenteration /Flap reconstruction 40% Category 3
68 Corneal or Retinal Repair for Traumatic eye injuries 20% Category 4
69 Penetrating injuries of the eye or repair of ruptured globe 20% Category 4
X LIVER, GALL BLADDER & PANCREAS
70 Liver Transplantation 100% Category 1
71 Partial Resection of Liver 60% Category 2
72 Partial Pancreatectomy 60% Category 2
73 Cholecystectomy /Choledochotomy for various Gall 40% Category 3
bladder lesions
XI MUSCULOSKELETAL SYSTEM (due to accident
only)
74 Replantation of upper limb 60% Category 2
75 Replantation of lower limb 60% Category 2
76 Total prosthetic replacement of hip joint using cement 40% Category 3
77 Total prosthetic replacement of hip joint not using cement 40% Category 3
78 Other total prosthetic replacement of hip joint 40% Category 3
79 Total prosthetic replacement of knee joint using cement 40% Category 3
80 Total prosthetic replacement of knee joint not using 40% Category 3
cement
81 Other total prosthetic replacement of knee joint 40% Category 3
82 Total prosthetic replacement of other joint using cement 40% Category 3
83 Total prosthetic replacement of other joint not using 40% Category 3
cement
84 Other total prosthetic replacement of other joint 40% Category 3
85 Prosthetic replacement of head of femur using cement 40% Category 3
86 Prosthetic replacement of head of femur not using cement 40% Category 3
87 Other prosthetic replacement of head of femur 40% Category 3
88 Prosthetic replacement of head of humerus using cement 40% Category 3
89 Prosthetic replacement of head of humerus not using 40% Category 3
cement
90 Other prosthetic replacement of head of humerus 40% Category 3
91 Prosthetic replacement of any other bone using cement 40% Category 3
92 Prosthetic replacement of any other bone not using cement 40% Category 3
93 Other prosthetic replacement of any other bone 40% Category 3
94 Prosthetic interposition reconstruction of joint 40% Category 3
95 Other interposition reconstruction of joint 40% Category 3
96 Excision reconstruction of joint 40% Category 3
97 Other reconstruction of joint 40% Category 3
98 Implantation of prosthesis for limb 40% Category 3
3
Major
Surgical
Benefit Sum
Assured
99 Amputation of arm 40% Category 3
100 Amputation of leg 40% Category 3
101 Fixation of fracture of spine 40% Category 3
102 Elevation, Exploration and Fixation of fractured Zygoma 40% Category 3
103 Amputation of hand 20% Category 4
104 Amputation of foot 20% Category 4
105 Therapeutic endoscopic operations on cavity of knee joint 20% Category 4
106 Replantation of finger following traumic amputation 20% Category 4
107 Surgical Drainage and Curettage for osteomyelitis 20% Category 4
XII ORO-MAXILLOFACIAL SURGERY
108 Major reconstructive oro-maxillafacial surgery due to 60% Category 2
trauma or burns and not for cosmetic purpose
109 Osteotomy including segmental resection with bone 60% Category 2
grafting for Mandibular and maxillary lesions
XIII KIDNEY/URINARY TRACT/REPRODUCTIVE
SYSTEM
110 Renal transplant (recipient) 100% Category 1
111 Hysterectomy for malignant conditions 60% Category 2
112 Radical prostatovesiculectomy 60% Category 2
113 Microvascular reattachment of penis following traumatic 60% Category 2
amputation
114 Total nephrectomy due to medical advice (not as a 40% Category 3
transplant donor)
115 Partial excision of kidney 40% Category 3
116 Open extirpation of lesion of kidney 40% Category 3
117 Excision of ureter 40% Category 3
118 Total excision of bladder 40% Category 3
119 Kidney injury repair 40% Category 3
120 Pyloplasty / Ureterocalcycostomy for pelvic ureteric 40% Category 3
junction obstruction
121 Amputation of penis 40% Category 3
122 Excision of vagina 40% Category 3
123 Unilateral or Bilateral excision of adnexa of uterus 40% Category 3
124 Partial excision of bladder 20% Category 4
125 Therapeutic ureteroscopic operations on ureter 20% Category 4
126 Urinary diversion 20% Category 4
127 Replantation of ureter 20% Category 4
128 Unilateral or Bilateral excision of testes 20% Category 4
129 Other operations on Scrotum and tunica vaginalis testis 20% Category 4
130 Reconstruction of the testis 20% Category 4
131 Open surgical excision and destruction of prostate tissue 20% Category 4
132 Extirpation of lesion of vulva 20% Category 4
4
Major
Surgical
Benefit Sum
Assured
133 Excision of vulva 20% Category 4
XIV Operations on the sinuses
134 Operations on frontal sinus 40% Category 3
135 Operations on maxillary antrum using sublabial approach 20% Category 4
XV Others
136 Radical Mastectomy 60% Category 2
137 Malignant soft tissue tumour excision and reconstruction 40% Category 3
138 Excision and Major Flap Repair of skin and Subcutaneous 40% Category 3
tissue due to Major Burns
139 Simple Mastectomy 20% Category 4
140 TIPS procedure for portal Hypertension 20% Category 4
5
DAY CARE PROCEDURE BENEFIT ANNEXURE
S.No. DAY CARE SURGERIES

Microsurgical Operations on the middle ear
1 Stapedotomy
2 Stapedectomy
3 Revision of Stapedectomy
4 Other operations on the auditory Ossicles
5 Myringoplasty (Type-I Tympanoplasty)
6 Tympanoplasty (Closure of Eardrum Perforation / reconstruction of the Auditory
Ossicles)
7 Myringotomy with grommet insertion
8 Closure of Mastoid fistula
9 Revision of a Tympanoplasty
10 Other microsurgical operations on the Middle Ear
Other Operations on the Middle and Internal Ear
11 Myringotomy
12 Benign Tumour removal from the external ear
13 Incision of the mastiod process and Middle ear
14 Simple Mastoidectomy
15 Reconstruction of the middle ear
16 Other excisions of the middle and inner ear
17 Fenestration of the inner ear
18 Revision of fenestration of the inner ear
19 Petrous Apicectomy
20 Other microsurgical operations on the inner Ear
Operations on the nose and nasal sinuses
21 Excision and destruction of diseased tissue of the nose
22 Operation on Nasal Turbinates
23 Septoplasty (medically necessitated)
24 Functional Endoscopic Sinus Surgery
25 Endoscopic placement /removal of stents
Operations on the Eyes
26 Dacrocystorhinostomy
27 Other Operations for tear gland/ duct lesions
28 Tarsorraphy
29 Excision of the diseased tissue of the eyelid
30 Operations of canthus and epicanthus when done for adhesions due to chronic
infections
31 Corrective surgery of entropion
32 Corrective surgery for blepharoptosis
33 Excision of lacrimal sac and passage
34 Removal of a deep or embedded foreign body from cornea
35 Corrective surgery of ectropion
36 Operations for Pterygium with or without grafting
37 Other operations on the cornea
38 Removal of a foreign body from the lens of the eye
1
39 Removal of a foreign body from posterior chamber of the eye
40 Removal of a foreign body from orbit and eyeball
41 Cataract Surgery ( ECCE or Phacoemulsification with or without intraocular lens
implant)
42 Operation for glaucoma
43 Repair of corneal laceration or wound with conjunctival flap
Operations on the skin and subcutaneous tissues
44 Surgery for pilonidal sinus
45 Surgical wound toilet (Wound debridement) and removal of diseased tissue of the skin
and subcutaneous tissues under anaesthesia
46 Local excision or destruction of diseased tissue of skin and subcutaneous tissues under
anaesthesia
47 Surgery for pilonidal cyst
48 Free skin transplantation, recipient site
49 Revision of skin plasty
50 Chemosurgery for skin cancer
Operations on the tongue
51 Incision, excision and destruction of diseased tissue of the tongue.
52 Partial glossectomy
53 Reconstruction of the tongue
54 Other Operations on the tongue
55 Incision and lancing of salivary glands and Salivary ducts
56 Excision of a diseased tissue of salivary glands and Salivary ducts
57 Resection of a salivary gland with or without salivary duct
58 Reconstruction of a salivary gland and salivary duct
59 Open Sialolithotomy
Other operations on the mouth and face
60 External incision and drainage in the region of the mouth, jaw and face
61 Excision of the diseased hard and soft palate
62 Excision biopsy and/or destruction of diseased structures from the oropharynx.
63 Palatoplasty
64 Other operations in the mouth
Operations on the tonsils and adenoids
65 Transoral incision and drainage of a pharyngeal abscess
66 Tonsillectomy without adenoidectomy
67 Tonsillectomy with adenoidectomy
68 Excision and destruction of a lingual tonsil
69 Drainage of tonsillar abscess/quinsy
Trauma surgery and orthopaedics
70 Incision and Drainage of the bone for septic and aseptic conditions
71 Closed reduction of fracture
72 Closed reduction of sub-luxation
73 Epiphyseolysis with osteosynthesis
74 Suture and other Operations on tendons and tendon sheath
75 Reduction of dislocation under GA
76 Arthoscopic knee aspiration
2
Operations on the breast
77 Incision and Drainage of breast abscess
78 Operations on the nipple except congenitally inverted nipples
Operations on the digestive tract
79 Incision and excision of tissue in the perianal region
80 Surgical treatment of anal fistulas
81 Surgical treatment of Haemorrhoids.
82 Division of the anal sphincter (sphincterotomy)
83 Other operations of the anus
84 Ultrasound guided aspiration of deep seated rectal abscess
85 Sclerotherapy
86 Dilation of digestive tract strictures
87 Endoscopic gastrotomy
88 Endoscopic decompression of colon
89 Endoscopic Polypectomy
Operations on the female reproductive organs
90 Incision of the ovary
91 Other operations on the Fallopian tubes
92 Dilatation of the cervical canal
93 Conisation of the uterine cervix
94 Incision of the Uterus (Hysterotomy) not done as a part of MTP
95 Therapeutic / diagnoistic dilatation and curettage ( not done as part of MTP)
96 Culdotomy
97 Hymenectomy
98 Local excision and destruction of diseased tissue of the vagina and the pouch of
Douglas
99 Incision and drainage of the Vulva
100 Operations on the Bartholin's glands(cyst)
101 Hysteroscope guided biopsy of uterus
102 Suprapubic cytostomy
Operations on the prostate and seminal vesicles
103 Drainage of Prostatic abscess
104 Transurethral excision and destruction of prostate tissue
105 Percutaneous excision and destruction of prostate tissue
106 Excision of seminal vesicle
107 Incision and excision of periprostatic tissue
Operations on the Scrotum and tunica vaginalis testis
108 Incision and Drainage of the Scrotum and tunica vaginalis testis
109 Operations on testicular hydrocele
110 Excision or Eversion of Hydrocele
Operations on the testis
111 Incision and drainage of the testis
112 Excision or destruction of testicular lesion
113 Unilateral orchidectomy
114 Other operations on the testis
Operations on the spermatic cord,Epididymis and ductus deferens
115 Surgical treatment of a varicocele and hydrocele of a spermatic cord
3
116 Excision of epididymal cyst
117 Epididymectomy
118 Other operations on the spermatic cord, epididymis and ductus deferens (other than
vasectomy)
Operations on the Penis
119 Circumcision and other Operations on the foreskin (if medically necessitated)
120 Local excision and destruction of diseased tissue of the penis
121 Other operations on the penis
Operations on the Urinary system
122 Cystoscopic removal of stones
123 Lithotripsy
Other Operations
124 Coronary angiography
125 Bronchoscopic treatment of bleeding lesion
126 Bronchoscopic treatment of fistula/stenting
127 Bronchoalveolar lavage and biopsy
128 Pericardiocentesis
129 Insertion of filter in Inferior Vena cava
130 Insertion of gel foam in artery or vein
131 Carotid angioplasty
132 Renal angioplasty
133 Tumor embolisation
134 Endoscopic drainage of pseudo pancreatic cyst
135 Varicose vain stripping or ligation
136 Excision of dupuytren's contracture
137 Carpal tunnel Decompression
138 PCNS (Percutaneous neprostomy)
139 PCNL(Percutaneous nephro lithotomy)
140 Nail bed deformity/resection and reconstruction
4
Annexure-I
LIC's Jeevan Arogya (Plan No. 903)
Tabular Premium Rate per ` 1000/- HCB
For PI For Other Major Members For Children
PPT = 80 - Age at Entry PPT = 80 - Age at Entry PPT = 25 - Age at Entry
Age ( LBD) Male Female Age ( LBD) Male Female Age ( LBD) Child
18 1866.25 1672.15 18 1532.50 1338.35 0 792.00
19 1895.80 1698.30 19 1563.65 1366.15 1 792.00
20 1922.65 1723.65 20 1592.15 1393.15 2 792.00
21 1948.90 1750.00 21 1620.05 1421.15 3 792.50
22 1976.85 1778.75 22 1649.65 1451.60 4 793.40
23 2005.75 1807.15 23 1680.25 1481.65 5 794.75
24 2036.85 1835.75 24 1713.00 1511.90 6 796.70
25 2066.10 1864.95 25 1743.90 1542.75 7 799.25
26 2094.15 1898.65 26 1773.65 1578.15 8 802.60
27 2124.70 1934.05 27 1805.90 1615.20 9 806.90
28 2159.85 1969.70 28 1842.70 1652.50 10 812.35
29 2199.75 2005.50 29 1884.30 1690.05 11 819.35
30 2242.90 2044.50 30 1929.05 1730.65 12 828.15
31 2286.40 2084.70 31 1974.25 1772.50 13 839.15
32 2331.25 2127.75 32 2020.70 1817.20 14 853.05
33 2376.75 2172.35 33 2067.85 1863.45 15 870.75
34 2424.40 2219.90 34 2117.10 1912.60 16 893.85
35 2475.85 2269.15 35 2170.15 1963.45 17 924.20
36 2530.75 2320.45 36 2226.65 2016.35
37 2591.10 2373.15 37 2288.55 2070.60
38 2656.10 2427.85 38 2355.10 2126.85
39 2725.45 2480.85 39 2425.95 2181.35
40 2799.70 2538.65 40 2501.70 2240.60
41 2878.70 2597.15 41 2582.15 2300.60
42 2962.55 2654.85 42 2667.45 2359.70
43 3051.30 2706.90 43 2757.55 2413.15
44 3139.75 2758.25 44 2847.35 2465.80
45 3229.75 2812.95 45 2938.60 2521.85
46 3324.65 2870.40 46 3034.75 2580.50
47 3428.40 2933.10 47 3139.70 2644.35
48 3538.75 2995.65 48 3251.15 2708.05
49 3651.60 3067.30 49 3365.05 2780.75
50 3768.00 3134.70 50 3482.40 2849.10
51 3881.85 3202.00 51 3597.20 2917.30
52 4001.50 3261.10 52 3717.65 2977.25
53 4127.45 3315.80 53 3844.30 3032.70
54 4254.60 3378.15 54 3972.10 3095.65
55 4383.85 3442.60 55 4101.85 3160.65
56 4509.40 3516.75 56 4227.80 3235.15
57 4647.95 3592.35 57 4366.65 3311.05
58 4769.70 3671.40 58 4488.45 3390.15
59 4897.05 3744.45 59 4615.70 3463.10
60 5027.50 3818.60 60 4745.80 3536.90
61 5159.60 3903.65 61 4877.35 3621.35
62 5285.85 3979.70 62 5002.70 3696.55
63 5398.40 4053.45 63 5114.10 3769.15
64 5538.30 4099.10 64 5252.40 3813.20
65 5686.80 4167.95 65 5398.95 3880.10
66 5852.65 4241.25 66 5562.30 3950.90
67 6001.20 4314.85 67 5707.55 4021.20
68 6155.85 4390.20 68 5858.10 4092.45
69 6331.10 4455.15 69 6028.30 4152.30
70 6473.65 4555.75 70 6164.45 4246.55
71 6621.35 4646.30 71 6303.95 4328.95
72 6741.95 4796.65 72 6414.00 4468.65
73 6964.70 4997.15 73 6622.50 4655.00
74 7270.00 5283.80 74 6908.10 4921.95
75 7764.90 5583.65 75 7374.00 5192.70
76 8431.25 5963.15
77 9437.7 6718.25
78 11404.85 8369.5
79 20221.65 15864.3
Annexure-II
Class-I Extra Premium rate per ` 1000/-HCB
For PI For Other Major members For Children
PPT = 80 - Age at Entry PPT = 80 - Age at Entry PPT = 25 - Age at Entry
Age ( LBD) Male Female Age ( LBD) Male Female Age ( LBD) Child
18 283.83 235.29 18 283.81 235.29 0 119.98
19 292.21 242.83 19 292.21 242.83 1 120.65
20 299.93 250.18 20 299.93 250.18 2 121.49
21 307.51 257.79 21 307.51 257.79 3 122.35
22 315.51 266.00 22 315.51 265.99 4 123.30
23 323.78 274.13 23 323.76 274.11 5 124.38
24 332.59 282.31 24 332.59 282.31 6 125.55
25 340.94 290.64 25 340.94 290.65 7 126.91
26 349.00 300.11 26 349.00 300.11 8 128.44
27 357.69 310.01 27 357.68 310.03 9 130.19
28 367.51 319.96 28 367.51 319.98 10 132.20
29 378.56 330.00 29 378.55 329.99 11 134.60
30 390.39 340.78 30 390.40 340.79 12 137.40
31 402.33 351.90 31 402.31 351.90 13 140.73
32 414.59 363.71 32 414.59 363.71 14 144.74
33 427.04 375.93 33 427.04 375.91 15 149.64
34 439.99 388.88 34 439.99 388.88 16 155.81
35 453.90 402.24 35 453.90 402.24 17 163.69
36 468.68 416.13 36 468.68 416.13
37 484.83 430.33 37 484.83 430.33
38 502.11 445.04 38 502.11 445.04
39 520.49 459.33 39 520.49 459.33
40 540.08 474.80 40 540.08 474.80
41 560.84 490.46 41 560.84 490.46
42 582.83 505.88 42 582.81 505.88
43 606.00 519.91 43 606.00 519.90
44 629.10 533.73 44 629.10 533.73
45 652.56 548.39 45 652.58 548.38
46 677.26 563.70 46 677.26 563.70
47 704.15 580.30 47 704.14 580.31
48 732.65 596.86 48 732.65 596.86
49 761.76 615.69 49 761.76 615.69
50 791.74 633.41 50 791.75 633.43
51 821.08 651.10 51 821.08 651.10
52 851.80 666.70 52 851.80 666.70
53 884.10 681.19 53 884.11 681.19
54 916.66 697.55 54 916.68 697.55
55 949.73 714.43 55 949.73 714.41
56 981.81 733.65 56 981.81 733.65
57 1017.11 753.21 57 1017.10 753.21
58 1048.16 773.59 58 1048.16 773.59
59 1080.55 792.39 59 1080.54 792.39
60 1113.65 811.43 60 1113.65 811.43
61 1147.09 833.09 61 1147.08 833.09
62 1178.96 852.44 62 1178.96 852.44
63 1207.34 871.10 63 1207.34 871.09
64 1242.43 882.63 64 1242.43 882.63
65 1279.55 899.83 65 1279.55 899.81
66 1320.84 917.99 66 1320.84 917.99
67 1357.58 935.99 67 1357.58 935.99
68 1395.61 954.20 68 1395.63 954.20
69 1438.51 969.51 69 1438.51 969.51
70 1472.84 993.36 70 1472.83 993.36
71 1507.93 1014.19 71 1507.94 1014.18
72 1535.55 1049.20 72 1535.54 1049.21
73 1587.61 1095.74 73 1587.63 1095.74
74 1658.71 1162.19 74 1658.71 1162.18
75 1774.49 1229.16 75 1774.49 1229.16
76 1927.98 1310.94
77 2154.94 1475.08
78 2586.29 1827.46
79 4442.74 3353.41
Annexure-III
Term Rider Premium Rates per `1000/- Sum Assured
Term = Minimum ( 60-age at entry, 35 )
Age Term Premium (Rs.)

18 35 2.16
19 35 2.25
20 35 2.36
21 35 2.47
22 35 2.60
23 35 2.74
24 35 2.90
25 35 3.07
26 34 3.27
27 33 3.49
28 32 3.74
29 31 4.01
30 30 4.31
31 29 4.49
32 28 4.68
33 27 4.89
34 26 5.11
35 25 5.35
36 24 5.61
37 23 5.88
38 22 6.17
39 21 6.48
40 20 6.80
41 19 7.15
42 18 7.51
43 17 7.90
44 16 8.33
45 15 8.78
46 14 9.11
47 13 9.62
48 12 10.15
49 11 10.72
50 10 11.32
Annexure-IV
Term Rider Class I Extra Premium rates per `1000/- Sum Assured
Age Term Premium (Rs.)

18 35 0.45
19 35 0.47
20 35 0.50
21 35 0.53
22 35 0.56
23 35 0.59
24 35 0.62
25 35 0.66
26 34 0.71
27 33 0.76
28 32 0.81
29 31 0.87
30 30 0.94
31 29 0.98
32 28 1.03
33 27 1.08
34 26 1.14
35 25 1.19
36 24 1.26
37 23 1.32
38 22 1.40
39 21 1.47
40 20 1.55
41 19 1.64
42 18 1.73
43 17 1.83
44 16 1.93
45 15 2.05
46 14 2.13
47 13 2.26
48 12 2.39
49 11 2.53
50 10 2.68
Inward Number___________________ Plan Name. ________________________
Proposal Number__________________ Plan No. ________________________
Date of receipt of Proposal _________ Pol. Term /PPT _____________________
Policy Number_________________ Premium Mode _____________________
Risk Date/DOC____________________ Installment Premium ________________
PROPOSAL FORM FOR HEALTH INSURANCE POLICY

Branch Office…………………………………………. Divisional Office………………………………….R/U/F/S……………………………..
Agent’s Name …………………………………………Code No.……………..Licence No………………Licence expiry date………………
Development Officer’s name.......................................................………..…Development Officer’s Code………………………………...
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
1. PROPOSER (Principal Insured) DETAILS:
Full Name (Max 40 Char)
Father’s Name
Name for printing on Nationality
Health card (Max 40 char)
Initial Daily Cash Rs.
Benefit chosen
Age Proof Date of Birth Age Sex Male/Female

Address
City/Town District
State PIN Code
Telephone STD code …………… Phone No.…………………….. Mobile
E-Mail id
Residence Proof If NRI, Country
of Residence
Qualification Annual Income Rs.
Occupation Income Proof
Name of Employer Designation
Nature of Duty Length of Service
PAN Number
Height (cms) Weight (Kgs) Medical Code M/G/S
Previous Health Policy no. Initial Daily Rs. Lapsed/In-force
with LIC Cash Benefit
availed
(Sum assured)
Term Assurance Rider sum Accident Benefit Rider sum
proposed proposed
2. PROPOSAL DEPOSIT DETAILS: Cash Cheque

Cheque No. Dated Drawn on
Transaction/BOC No. Dated Amount Rs.
3. NOMINATION DETAILS:
========================================================================================
For Office Use only (Details to be given separately for each life for Sl. Nos. 1, 2, 3, 4, 5)
1. Underwriting decision ………………………………………………………………………………....……………………………………………….. 1
2. Restrictive conditions/Restrictive clauses ……………………………………………………………………………………………………….
3. Installment premium……………………………………………………………………………………………………………………………………….
4. IDCB allowed …………………………………………………………………………………………………………………………………………………..
5. Extra charged if any………………………………………………………………………………………………………………………………………..
6. Date of decision………………………………………………………………………………………………………………………………………………
Nominee’s Full Name
Age Relationship
Appointee’s Name Appointee’s
(if Nominee is minor) Signature
Appointee’s address
4. BANK DETAILS: (Please enclose a cancelled cheque)

IFSC (11 digits) MICR Number (As given on
the cheque leaf)
Account Number (As given Account Type
on the cheque leaf) (Savings/Current)
Bank Name Bank Branch
5. NO. OF LIVES TO BE COVERED UNDER THE POLICY (INCLUDING PRINCIPAL INSURED):

6. DETAILS OF OTHER MEMBERS TO BE INSURED:
Other Member to be Insured (1)
Full Name (Max 40 char)
Name for printing on Initial Daily Rs.
Health card (Max 40 char) Cash Benefit
chosen

Nationality & country of Relationship to the Proposer
residence
Educational qualification Occupation
Nature of Duty and Length Name of the School/
of Service Class studying
Height (cms) Weight (kgs) Medical Code M/G/S
Previous Health Policy no. IDCB Rs. Lapsed/In force
with LIC availed/SA

Name for printing on Initial Daily Rs.
health card (Max 40 char) Cash Benefit
chosen

residence
Height (cms) Weight (kgs) Medical Code M/G/S
with LIC availed/SA
Full Name(max 40 char)
Name for printing on Initial Daily Cash Rs.
health card (Max 40 char)
Proposal Form for LIC Health Insurance policy 2
Benefit chosen

residence
Height (cms) Weight( Kgs) Medical Code M/G/S
with LIC availed/SA
QUESTIONS APPLICABLE FOR SPOUSE ONLY:

Term Assurance Rider sum Accident Benefit Rider sum
proposed proposed
QUESTIONS APPLICABLE FOR FEMALE LIVES ONLY:
Principal Other Other Other

Insured Insured 1 Insured 2 Insured 3
i) Are you Pregnant now? Yes No Yes No Yes No Yes No

If yes, please state the Expected Date of Delivery ……………… ……………… …………….. ………………
ii) Have you ever had an abortion or miscarriage or Yes No Yes No Yes No Yes No
caesarian Section? (If so give details in a separate sheet)
iii) Are you suffering from any Gynaecological disorders? Yes No Yes No Yes No Yes No
If Yes, please provide details in a separate sheet.
iv) Date of last delivery & Date of last menstruation
v) Husband’s Full Name
vi) Husband’s existing health insurance cover (SA amount)
vii) Husband’s Occupation and Annual Income
7. INVESTMENT PATTERN OF THE FUND: (TO BE FILLED IN RESPECT OF UNIT LINKED HEALTH POLICIES)
Fund Type Investments in Govt. / Short term investments such as Investment listed equity Details and objective of the
Govt. securities Money market investments etc., shares fund
8. QUESTIONS IN CASE OF SERVICES IN ARMED FORCES: (PI – Principal Insured; OI – Other Insured)
PI OI 1 OI 2 OI 3 OI 4 OI 5 OI 6
i) Wing to which you belong & Rank therein
ii) Place of current posting & Nature of duties
iii) Are you presently in Category 1
9. DETAILS OF PREVIOUS POLICIES: Give details of previous policies as per Annexure ‘B’ in respect of each life
to be Insured under this proposal.

10. HEALTH DETAILS AND MEDICAL INFORMATION
(Annexure ‘A’ is to be used if the total number of members to be insured including PI exceeds 4 in this proposal)
DETAILS Principal Other Other Other

Insured Insured 1 Insured 2 Insured 3
1.Does the life to be insured consume Alcohol/cigarettes/bidis or tobacco in any Yes No Yes No Yes No Yes No
form?
2. Is the life to be insured currently taking any medication or drug? Yes No Yes No Yes No Yes No
3. During the past 5 years, has the life to be insured ever suffered from any illness, Yes No Yes No Yes No Yes No
disorder, disability or injury which has required any form of medical or specialized
examination (including X-ray, blood tests, ECG, USG, CT/MRI, gynaecological
investigations), Consultation, hospitalization or surgery?
4. Has the life to be insured been absent from work/school/college for more than 7 Yes No Yes No Yes No Yes No
continuous days in the last two years due to Health reasons?
5. Does the life to be insured have a parent, brother or sister who was or has been Yes No Yes No Yes No Yes No
diagnosed with heart disease, stroke, diabetes, cancer, neurolgical/mental
disorders or any hereditary disorder under the age of 65? If yes, please provide
name of condition, age at diagnosis and relationship with the life to be insured.
6. Has the life to be insured planned for a surgery or is currently aware of any Yes No Yes No Yes No Yes No
medical condition that might require medical Advice/surgery in near future?
7. Has the life to be insured ever suffered or is suffering from Yes No Yes No Yes No Yes No
i) Hypertension/high blood pressure Yes No Yes No Yes No Yes No
ii) Diabetes or raised blood sugar Yes No Yes No Yes No Yes No
iii) Cardiovascular disease, Palpitations, Heart attack, stroke, chest pain Yes No Yes No Yes No Yes No
iv) Genitourinary diseases e.g. Kidney disorder, Bladder disorder, Urine Yes No Yes No Yes No Yes No
abnormality, renal stones or genital organ disorder
v) Cancer of any type or a cyst or growth of any kind Yes No Yes No Yes No Yes No
vi) Mental Disorder e. g Depression, anxiety, schizophrenia or any other mental or Yes No Yes No Yes No Yes No
nervous disorder
vii) Endocrine diseases e.g.: Thyroid or any other hormonal disorder Yes No Yes No Yes No Yes No
viii) Digestive disease e.g.: Liver and gall bladder disorder, gastric ulcer, bleeding Yes No Yes No Yes No Yes No
from intestine or any other disorder of the digestive tract
ix) Respiratory diseases e.g.: Asthma, pneumonia, bronchitis, tuberculosis, Yes No Yes No Yes No Yes No
persistent cough, or any other disorder of the chest or lungs.
x) Musculoskeletal diseases e.g.: Osteoporosis, prolapsed disc, back or neck Yes No Yes No Yes No Yes No
complaint, any physical disability or other disorder of the bones, joints, arthritis,
gout etc
xi) Neurological diseases e.g.: Fits, epilepsy, recurrent headache, paralysis, any Yes No Yes No Yes No Yes No
other disease or disorder of the brain, spinal cord or nerves
xii) Congenital Disorders Yes No Yes No Yes No Yes No
xiii) Blood disorder e.g. Anemia, hemophilia, thalassemia Yes No Yes No Yes No Yes No
xiv) Eye, Ear, Nose, Throat or Skin disorders Yes No Yes No Yes No Yes No
8. Has the life to be insured ever been tested positive for HIV / AIDS, hepatitis B or C Yes No Yes No Yes No Yes No
or any sexually transmitted disease?
9. Does the life to be insured wear glasses? Yes No Yes No Yes No Yes No
If so, power of glasses R…… L…… R…… L…… R…… L…… R…… L……
10) Is the life to be insured currently covered under any health insurance policy with Yes No Yes No Yes No Yes No
LIC or any other company?
11)Has any proposal/ application for revival for life, medical, health, accident, Yes No Yes No Yes No Yes No
disability or critical illness cover been postponed, declined or accepted on special
terms? (If yes, Give details)
12) Has the life to be insured lost more than 5 Kgs. 0f weight in the last 12 months Yes No Yes No Yes No Yes No
except due to exercise or weight loss programmes< If yes, please state the
reason for the weight loss.
13) Is any proposal for life or health insurance on the life to be insured pending in Yes No Yes No Yes No Yes No
any of LIC offices?
14) Has the life to be insured ever been involved or is planning to pursue any Yes No Yes No Yes No Yes No
dangerous sport or hobby e.g., Diving, Mountaineering, Parachuting, private aviation
and racing
IMPORTANT: If answer to any of the above question is “Yes”, please provide details (precise diagnosis, past and current treatment, current status,
treatment plan for future) in a separate sheet of paper and submit copies of hospital/consultation/investigation reports available with you). For juvenile
lives aged below 5 years, please submit immunization records and for ages above 5, please provide latest school/college progress report.

DECLARATION BY THE PROPOSER AND OTHER MAJOR MEMBERS TO BE INSURED
I / We _____________________ declare that we are fully aware of the statements / contents etc. given by us in this proposal form along with
Annexure ‘B’ & ‘C’ and confirm that they are true and complete in all respects and the same shall form the basis of the contract . I / We do
hereby give our consent to treat the policy as null and void in case any of our statements are incorrect and I/We agree that the money paid by
us shall be forfeited to the Corporation. I / We further agree that any change / addition / deletion / alteration related to my/our health,
occupation, or any other adverse circumstance (including dropping, deferrment, acceptance at terms other than as proposed of any proposal/
revival of policy made to the Corporation or any other insurance company) after the submission of this proposal to the Corporation shall be
conveyed before the issuance of the First Premium Receipt. Any omission on my part to do so shall render this assurance invalid. I/We
hereby give my consent for undergoing medical examination/tests including test for HIV as required by the Corporation. I / We authorize the
Corporation to make any enquiry to anyone concerning our health.
In consultation with the agent / intermediary, I have taken a personal and independent decision in an informed manner to go for the Plan. I
understand that the ‘application money’ deposited by me is a token consideration under this proposal for insurance.
I / We do hereby accept the policy terms and conditions, exceptions / exemptions etc. as prescribed in the policy. I/We have read and
understood:
Sec 41 - Prohibition of Rebates : No person shall allow or offer to allow, either directly or indirectly as an inducement to any person to
take out or renew or continue Insurance in respect of any kind of risk relating to lives or property in India, any rebate of the whole or part
of the commission payable or any rebate of the premium shown on the policy, nor shall any person taking out or renewing or continuing
a policy, accept any rebate, except such rebate as may be allowed in accordance with the published prospectus or tables of the insurer.
Provided that acceptance by an insurance agent of commission in connection with a policy of life insurance taken out by himself on his
own life shall not be deemed to be an acceptance of a rebate of premium within the meaning of this sub-section if at the time of such
acceptance the insurance agent satisfied the prescribed conditions establishing that he is a bonafide insurance agent employed by the
insurer. Any person making default in complying with the provisions of this section shall be punishable with fine which may extend to
500 rupees.
Sec 45 – Indisputability Clause.: No policy of life insurance shall, after the expiry of two years from the date on which it was effected, be
called in question by an Insurer on the ground that a statement made in the proposal for insurance or any report of a medical officer or
referee or friend of the insurer or in any other document leading to the issue of the policy, was inaccurate or false, unless the insurer
shows such statements was on material matter or suppressed facts which it was material to disclose and that it was fraudulently made by
the policyholder and that the policyholder knew at the time of making it that the statement was false or that it suppressed facts which it
was material to disclose.
Note: “Material” shall mean and include all important, essential and relevant information in the context of underwriting the risk to be
covered by the Corporation.
Dated at …………………………………………………………….. On the……………………………… Day of …………………………20
Witness: Signature of the Proposer…………………………………………

(Signature, Name & Address)
Signatures of other Major Members to be insured i)………………………. ii)……………………………. iii)……………………………………………
.
In case form is filled up / signed in a language different from that of the Proposal Form:
Declaration by the person filling in the form: “I hereby declare that I have fully explained the above questions to the proposer in _________
language and I have truthfully recorded the answers given by the proposer.”
Name &Address of the declarant ______________________ Signature of the declarant:__________________________

Declaration by the Proposer/Other Major Member to be insured:
“I certify that the contents of the form and documents have been fully explained to me by Mr/ Ms:___________________ and I have understood
the significance of the proposed contract”.
Signature of the Proposer:_________ Signatures of other Major Members to be Insured i)……………………ii)…………………iii)………………
FOR MEDICAL CASES ONLY
I certify that the MEMBER TO BE INSURED has signed /in my presence after admitting that all answers to questions under “Section 6 “ in
this proposal form are properly recorded.
i)………………………………. ii)…………………………………………. iii)……………………………….. (Signatures of the members to be insured)
i)…………………………………ii)………………………………………… iii) …………………………………….(Signatures of the Medical Examiners)

AGENT’S CONFIDENTIAL REPORT/MORAL HAZARD REPORT
Agent’s Name & Code Club License No. Licence expiry Development Branch
Membership date Officer Code Code
Name of Life Proposed Age Occupation
Nature of duties
1. (a) Acquaintance with the proposer (No. of Years):
(b) Relationship with the proposer :
(c) Educational qualification of the Life Proposed:
2. Annual Income: Rs……………………………………………………….. Income Source……………………………………………………………………..

Proof of Income…………………………………………………………………. …………… Verified: …Yes/No ……………………PAN………………….
3. Physical Measurements and Identification Marks of the Proposer and other Members (beneficiaries) to be insured under the proposal.
Member To Name Height Weight Abdomen Chest Identification Marks

Be Insured (cms) (kgs) (cms) (exp/ins)
cms
PRINCIPAL
1.
INSURED
2.
OTHER 1.
INSURED 1 2.
OTHER 1.
INSURED 2 2.
OTHER 1.
INSURED 3 2.
OTHER 1.
INSURED 4 2.
OTHER 1.
INSURED 5 2.
OTHER 1.
INSURED 6 2.
4. Declaration by the Agent
I do hereby declare that I have personally seen the proposer / the members covered and I do hereby confirm that there is no physical
deformity / impaired sight / hearing problem / mental retardation or any other diseases and am personally satisfied about his / her financial
condition. I further inform that no proposal / revival has been deferred / declined / dropped / accepted with extra premium. I am fully aware
that the policy shall be issued based on my above declaration that if any information given above is incorrect, it would attract penalty under
Regulation 16 and other provisions of (Agents) Regulations, 1972, besides the other provisions of law applicable.
Dated at on the day of 20
Agent’s Address & Phone No. _____________________________ Signature of the Agent
I am fully aware and endorse the above contents; I recommend the proposal for acceptance.
Development Officer Assistant Branch Manager (Sales)/Chief/Sr./Branch Manager.

PROPOSAL FOR HEALTH INSURANCE POLICY
PHOTO ADDENDUM FOR PREPARATION OF HEALTH IDENTITY CARDS Plan No. -------------
Members to be
Insured
(In the same Proposer Other Insured 1 Other Insured 2 Other Insured 3
Sequence as given
in question Number 6) (affix stamp size (affix stamp size (affix stamp size (affix stamp size
Photo only) Photo only) Photo only) Photo only)
i) Name
ii) DOB
iii) Sex
(Mention male /Female)
iv) Relationship
Members to be
Insured
(In the same Other Insured 4 Other Insured 5 Other Insured 6

Sequence as given in
Question No. 10) (affix stamp size (affix stamp size (affix stamp size
Photo only) Photo only) Photo only)
i) Name
ii) DOB
iii) Sex
(Mention Male or Female)
iv) Relationship
Specimen Signature of the Proposer:
For Office Use: Policy Number…………………………………………………………..

Total Number of Lives Covered…………………………………….
Division Name and Code……………………………………………..
Branch Name & Code.…………………………………………………
Check list: 1. Age Proof(s) of all the Members to be insured 2. Photographs of all the Members to be insured
3. Signature of the proposer

PROPOSAL FOR HEALTH INSURANCE POLICY ANNEXURE ‘A’
HEALTH DETAILS AND MEDICAL INFORMATION (IN RESPECT OF OTHER MEMBERS TO BE INSURED)
(To be used if the total number of members to be insured excluding PI (in the proposal form) exceeds 3)
Name of the Member to be Insured:………………………………………………………………………………

Proposal No…………………………………….
Relationship with the Principal Insured:……………………………………………………………………..….
1. DETAILS OF OTHER MEMBERS TO BE INSURED
Name for printing on Health card Initial Daily Cash Rs.
(Max 40 char) Benefit chosen

Nationality & country of residence Relation to the proposer
Nature of Duty and Length of Service Name of the School/
(if in armed forces give details) Class studying
Previous Health Policy no. with LIC IDCB availed/SA Rs. Lapsed/In force

Name for printing on health card Initial Daily Cash Rs.
(Max 40 char) Benefit chosen


Full Name (max 40 char)
Name for printing on health card Initial Daily Rs.
(Max 40 char) Cash Benefit
chosen

QUESTIONS APPLICABLE FOR SPOUSE ONLY:
Term Assurance Rider sum proposed Accident Benefit Rider sum proposed

QUESTIONS APPLICABLE FOR FEMALE LIVES ONLY:
Other Other Other

Insured 4 Insured 5 Insured 6
i) Are you Pregnant now? Yes No Yes No Yes No

If yes, please state the Expected Date of Delivery ……………… …………….. ………………
ii) Have you ever had an abortion or miscarriage or Yes No Yes No Yes No
Caesarian Section? (If so give details in a separate sheet)
iii) Are you suffering from any Gynaecological disorders? Yes No Yes No Yes No
If Yes, please provide details in a separate sheet.
iv) Date of last delivery/ Date of last menstruation
v) Husband’s Full Name
vi) Husband’s existing health insurance cover (SA amount)
vii) Husband’s Occupation and Annual Income
2. HEALTH DETAILS AND MEDICAL INFORMATION
DETAILS Other Other Other

Insured 4 Insured 5 Insured 6
1.Does the life to be insured consume any form of Alcohol/cigarettes/bidis or tobacco in any Yes No Yes No Yes No
other form?
2. Is the life to be insured currently taking any medication or drug? Yes No Yes No Yes No
3. During the past 5 years, has the life to be insured ever suffered from any illness, disorder, Yes No Yes No Yes No
disability or injury which has required any form of medical or specialized examination
(including X-ray, blood tests, ECG, USG, CT/MRI, gynaecological investigations), Consultation,
hospitalization or surgery?
4. Has the life to be insured been absent from work/school/college for more than 7 continuous Yes No Yes No Yes No
days in the last two years due to Health reasons?
5. Does the life to be insured have a parent, brother or sister who was or has been diagnosed Yes No Yes No Yes No
with heart disease, stroke, diabetes, cancer, neurolgical/mental disorders or any hereditary
disorder under the age of 65? If yes, please provide name of condition, age at diagnosis and
relationship with the life to be insured.
6. Has the life to be insured planned for a surgery or is currently aware of any medical condition Yes No Yes No Yes No
that might require medical Advice/surgery in near future?
7. Has the life to be insured ever suffered or is suffering from Yes No Yes No Yes No
ii) Hypertension/high blood pressure Yes No Yes No Yes No
ii) Diabetes or raised blood sugar Yes No Yes No Yes No
iii) Cardiovascular disease, Palpitations, Heart attack, stroke, chest pain Yes No Yes No Yes No
v) Genitourinary diseases e.g. Kidney disorder, Bladder disorder, Urine abnormality, renal Yes No Yes No Yes No
stones or genital organ disorder
v) Cancer of any type or a cyst or growth of any kind Yes No Yes No Yes No
vi) Mental Disorder e. g Depression, anxiety, schizophrenia or any other mental or nervous Yes No Yes No Yes No
disorder
vii) Endocrine diseases e.g.: Thyroid or any other hormonal disorder Yes No Yes No Yes No
viii) Digestive disease e.g.: Liver and gall bladder disorder, gastric ulcer, bleeding from Yes No Yes No Yes No
intestine or any other disorder of the digestive tract
ix) Respiratory diseases e.g.: Asthma, pneumonia, bronchitis, tuberculosis, persistent cough, Yes No Yes No Yes No
or any other disorder of the chest or lungs.
x) Musculoskeletal diseases e.g.: Osteoporosis, prolapsed disc, back or neck complaint, any Yes No Yes No Yes No
physical disability or other disorder of the bones, joints, arthritis, gout etc
xi) Neurological diseases e.g.: Fits, epilepsy, recurrent headache, paralysis, any other disease Yes No Yes No Yes No
or disorder of the brain, spinal cord or nerves
xii) Congenital Disorders Yes No Yes No Yes No
xiii) Blood disorder e.g. Anemia, hemophilia, thalassemia Yes No Yes No Yes No

xiv) Eye, Ear, Nose, Throat or Skin disorders Yes No Yes No Yes No
8. Has the life to be insured ever been tested positive for HIV / AIDS, hepatitis B or C or any Yes No Yes No Yes No
sexually transmitted disease?
9. Does the life to be insured wear glasses? Yes No Yes No Yes No
If so, power of glasses R…… L…… R…… L…… R…… L……
10) Is the life to be insured currently covered under any health insurance policy with LIC or any Yes No Yes No Yes No
other company?
11)Has any proposal/ application for revival for life, medical, health, accident, disability or Yes No Yes No Yes No
critical illness cover been postponed, declined or accepted on special terms? (If yes, Give
details)
12) Has the life to be insured lost more than 5 Kgs. 0f weight in the last 12 months except due to Yes No Yes No Yes No
exercise or weight loss programmes< If yes, please state the reason for the weight loss.
13) Is any proposal for life or health insurance on the life to be insured pending in any of LIC Yes No Yes No Yes No
offices?
14) Has the life to be insured ever been involved or is planning to pursue any dangerous sport Yes No Yes No Yes No
or hobby e.g., Diving, Mountaineering, Parachuting, private aviation and racing
IMPORTANT: If answer to any of the above question is “Yes”, please provide details (precise diagnosis, past and current treatment, current status,
treatment plan for future) in a separate sheet of paper and submit copies of hospital/consultation/investigation reports available with you). For juvenile
lives aged below 5 years, please submit immunization records and for ages above 5, please provide latest school/college progress report.
3. DETAILS OF PREVIOUS POLICIES: Give details of previous policies as per Annexure ‘B’ in respect of each life
to be Insured under this proposal.
DECLARATION BY THE PROPOSER AND OTHER MAJOR MEMBERS TO BE INSURED
I / We _____________________ declare that we are fully aware of the statements / contents etc. given by us in this proposal form along with
Annexure ‘B’ & ‘C’ and confirm that they are true and complete in all respects and the same shall form the basis of the contract . I / We do
hereby give our consent to treat the policy as null and void in case any of our statements are incorrect and I/We agree that the money paid by
us shall be forfeited to the Corporation. I / We further agree that any change / addition / deletion / alteration related to my/our health,
occupation, or any other adverse circumstance (including dropping, deferrment, acceptance at terms other than as proposed of any proposal/
revival of policy made to the Corporation or any other insurance company) after the submission of this proposal to the Corporation shall be
conveyed before the issuance of the First Premium Receipt. Any omission on my part to do so shall render this assurance invalid. I/We
hereby give my consent for undergoing medical examination/tests including test for HIV as required by the Corporation. I / We authorize the
Corporation to make any enquiry to anyone concerning our health.
In consultation with the agent / intermediary, I have taken a personal and independent decision in an informed manner to go for the Plan. I
understand that the ‘application money’ deposited by me is a token consideration under this proposal for insurance.
I / We do hereby accept the policy terms and conditions, exceptions / exemptions etc. as prescribed in the policy. I/We have read and
understood:
Sec 41 - Prohibition of Rebates : No person shall allow or offer to allow, either directly or indirectly as an inducement to any person to
take out or renew or continue Insurance in respect of any kind of risk relating to lives or property in India, any rebate of the whole or
part of the commission payable or any rebate of the premium shown on the policy, nor shall any person taking out or renewing or
continuing a policy, accept any rebate, except such rebate as may be allowed in accordance with the published prospectus or tables of
the insurer. Provided that acceptance by an insurance agent of commission in connection with a policy of life insurance taken out by
himself on his own life shall not be deemed to be an acceptance of a rebate of premium within the meaning of this sub-section if at the
time of such acceptance the insurance agent satisfied the prescribed conditions establishing that he is a bonafide insurance agent
employed by the insurer. Any person making default in complying with the provisions of this section shall be punishable with fine
which may extend to 500 rupees.
Sec 45 – Indisputability Clause.: No policy of life insurance shall, after the expiry of two years from the date on which it was effected, be
called in question by an Insurer on the ground that a statement made in the proposal for insurance or any report of a medical officer or
referee or friend of the insurer or in any other document leading to the issue of the policy, was inaccurate or false, unless the insurer
shows such statements was on material matter or suppressed facts which it was material to disclose and that it was fraudulently made
by the policyholder and that the policyholder knew at the time of making it that the statement was false or that it suppressed facts which
it was material to disclose.
Note: “Material” shall mean and include all important, essential and relevant information in the context of underwriting the risk to be
covered by the Corporation.

Dated at …………………………………………………………….. On the……………………………… Day of …………………………20
Witness: Signature of the Proposer…………………………………………
Signatures of other Major Members to be insured 4)……………………………….5)…………,………………………. 6)………………………………..
In case form is filled up / signed in a language different from that of the Proposal Form:
Declaration by the person filling in the form: “I hereby declare that I have fully explained the above questions to the proposer in _________
language and I have truthfully recorded the answers given by the proposer.”
Name &Address of the declarant ______________________ Signature of the declarant:__________________________

Declaration by the Proposer/Other Major Member to be insured:
“I certify that the contents of the form and documents have been fully explained to me by Mr/ Ms:___________________ and I have understood
the significance of the proposed contract”.
Signature of the Proposer:_________ Signatures of other Major Member to be Insured 4)…………….….5)………………….., 6)……………………
FOR MEDICAL CASES ONLY
I certify that the MEMBER TO BE INSURED has signed /in my presence after admitting that all answers to questions under “Section 6 “ in
this proposal form are properly recorded.
4)……………………………….5) ………………………………………… 6)……………………………….. (Signatures of the members to be insured)
4)…………………………………5)………………………………………… 6) …………………………………….(Signatures of the Medical Examiners)

ANNEXURE ‘B’
(To be attached with proposal form for a health insurance plan)
Name of the Member to be insured __________________________________
Proposal Number ______________________________
A. DETAILS OF EXISTING HEALTH INSURANCE POLICIES INCLUDING (A) POLICIES SURRENDERED/LAPSED (DURING
LAST 3 YEARS) (B) IN FORCE HEALTH INSURANCE POLICIES ( C) POLICIES ACCEPTED WITH MODIFIED TERMS OR
WITH EXTRA PREMIUM
(If No. of policies are more, please attach a separate sheet)
Policy Insurance cos. Table & Sum Term Amount of Year of a. Whether accepted as a. Whether in full force
No. from where the Term Assured assurance Accident issue proposed at ordinary for full sum assured.
previous Rider Sum Benefit rates.
policy/ies have Assured taken YES/NO
been purchased YES/NO b. If not in force, give
with address (if b. If not, mention terms due date of last
purchased from of acceptance (mention premium paid or date
LIC, give name of extra premium charged) of surrender
BO/DO)
B. DETAILS OF EXISTING LIFE INSURANCE POLICIES INCLUDING (A) POLICIES SURRENDERED/LAPSED (DURING LAST 3
YEARS) (B) IN FORCE POLICIES ( C) POLICIES ACCEPTED WITH MODIFIED TERMS OR WITH EXTRA PREMIUM
(If No. of policies are more, please attach a separate sheet)
Policy No. Insurance cos. from Table & Sum Term Amount a. Whether accepted a. Whether in full
where the previous Term Assured assurance of Year of as proposed at force for full sum
policy/ies have Rider Sum Accident issue ordinary rates. assured.
been purchased Assured Benefit
with address (if taken YES/NO YES/NO
purchased from LIC, b. If not, mention b. If not in force, give
give name of terms of acceptance due date of last
BO/DO) (mention extra premium paid or
premium charged) date of surrender
Note: The above information is required in respect of each of the member to be insured under this proposal.
Signature of Principal Insured Signature of the other Member to be Insured, proposed for
insurance by the PI
ANNEXURE ‘C’
LIC’s JEEVAN AROGYA
ADDENDUM TO PROPOSAL FORM
(To be filled in if spouse of Principal Insured is also to be covered in the policy)
Answer (a) or (b) as may be appropriate:
In case of benefit ceasing / unfortunate death of Principal Insured, the policy will:
(a) Terminate
(b) Continue with Insured Spouse acting as new Principal Insured
Note: The level of premium for Principal Insured and the other insured members are different for
same age and same level of cover. If the policy is continued after exit of Principal Insured, the
premium for the Insured Spouse will change from the coinciding or following instalment premium
due date and the new premium would be calculated based on tabular premium rates applicable for
Principal Insureds and the age for calculation of revised premium rate will be the age of spouse at
the time of purchasing/ entering into this policy. The option exercised now shall form the basis of
continuing the policy with the Insured Spouse as Principal Insured and no consent shall be taken
before revision of premium and making Insured Spouse as Principal Insured, if applicable.
Dated at ……….. On the………… Day of …………………20
Signature of Proposer (Principal Insured)………………………………………
Signature of Insured Spouse……………………………..

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LIFE INSURANCE CORPORATION OF INDIA

Dept: Product Development “Yogakshema”

Ref: CO/PD/11 31st May, 2011

Re: INTRODUCTION OF LIC’S JEEVAN AROGYA (Plan No. 903)

The benefits offered under the plan are:

Other details of the plan are as follows.

3. ELIGIBILITY CONDITIONS AND FEATURES:

(i) For Hospital Cash Benefit (HCB) (under Basic Plan)

Feature Principal Insured Spouse (if any), Insured Dependent

(ii) For Major Surgical Benefit (MSB) (under Basic Plan)

Feature Principal Insured (PI) Insured Spouse (if Insured Dependent

Feature Principal Insured (PI) Insured Spouse (if Insured Dependent

(iv) For Other Surgical Benefit (OSB) (under Basic Plan)

FOR TERM ASSURANCE RIDER OPTION:

This rider shall be available for PI and Insured Spouse only.

(a) Minimum Term Assurance Sum Assured: ` [100] in '000's

The Term Assurance Sum Assured shall be in multiples of ` 25,000/-.

(c) Minimum / Maximum Premium Amount: There is no specific minimum and

(d) Minimum Entry Age: [18] years (completed)

(e) Maximum Entry Age: [50] years (Nearest Birthday)

(f) Maximum Benefit Ceasing Age: [60] years (Nearest Birthday)

(g) Maximum Term: [35] years

FOR ACCIDENT BENEFIT RIDER OPTION:

(a) Minimum Accident Benefit Sum Assured: ` [25] in '000's

The Accident Benefit Sum Assured shall be in multiples of `5,000/-.

(d) Minimum Entry Age: [18] years completed

(e) Maximum Entry Age: [50] years (Nearest Birthday)

(f) Maximum age for cover: [60] years (Nearest Birthday)

(g) Maximum Term: [35] years

On death of the Principal Insured (PI);

Maturity Benefit: No benefits are payable at end of the Cover Period.

Benefit payable on hospitalization:

* In years 4 and 10 ‘No Claim Benefit’ is added.

Major Surgical Benefit:

Day Care Procedure Benefit:

Other Surgical Benefit:

5. OTHER TERMS AND CONDITIONS:

b) Removal of existing members:

c) Hospital Cash Benefit:

In case of Hospitalisation in the general or special ward (i.e. a non-

In case of Hospitalisation in the Intensive Care Unit of a Hospital:

Combined stay in Non-ICU and ICU ward/room:

The amount of Daily Benefit due to Hospitalization as specified in the Policy

Benefit Limits and Conditions:

d) Major Surgical Benefit:

Benefit Limits and Conditions:

e) Day Care Procedure Benefit:

Benefit Limits and Conditions:

Benefit Limits and Conditions:

g) Commencement And Termination Of Benefit Covers:

General waiting period:

Specific waiting period:

i. Treatment for adenoid or tonsillar disorders

6. OPTIONS AVAILABLE UNDER THE PLAN:

9. REVIVALS/REINSTATEMENT OF DISCONTINUED POLICIES:

Revival/reinstatement will not be allowed post the revival period.

11. MODES OF PREMIUM PAYMENT:

13. COMMISSION PAYABLE TO AGENTS/ CORPORATE AGENTS/ BROKERS &

Agents & Corporate Agents:

Development Officer’s credit: 100% of FY premium

16. DAYS OF GRACE:

17. COOLING-OFF PERIOD:

Policy Number_ Premium Mode _____

Risk Date/DOC____ Installment Premium

Name &Address of the declarant Signature of the declarant:____