nN sar dt Fara ae Pere tere tamum INSURANCE REGULATORY AND icles. DEVELOPMENT AUTHORITY OF INDIA. Rof: IRDAUHLTIREGICIRI=1/01/2020 1° January, 2020, Guidelines on Standard Individual Health Insurance Product, INDEX ‘SINO] tem Page | No. 1 “Guidelines on Standard Individual Health Insurance Product 27 7%. | Annexure-T: Policy Terms and Conditions of te Siandard Product | 832 3, | Annexure-2 Format for Gustomer Information Sheet 334 Z| Annexare-3: Form for fling the Standard Individual Health insurance | 35-44 Product (Page 1 of 44) 44, 158, een ee, scree, 60002, | Sune ho 6 Prac ret Naame, Hecht 0007 (sstalatz dona ere wera goin <3) #8140. 4000 Webste = wuvtidal gownTo All General and Health Insurers, Re: GUIDELINES ON STANDARD INDIVIDUAL HEALTH INSURANCE PRODUCT A, Preamble: 41. The health insurance market is having @ number of individual health insurance products. Each product has unique features and the insuring public may find ita challenge to choose an appropriate product. Therefore, with the following objectives, the Authority has decided to mandate all general and health insurers to offer the standard individual health insurance product: ‘+ Insurance policy to take care of basic health needs of insuring public + To have a standard product with common policy wordings across the industry ‘+ To faciitate seamless portabilty among insurers 2. Towards this, the folowing Guidelines on Standard Individual Health insurance Product are issued under the provisions of Section 34 (1) (a) of Insurance Act, 1938 3. The standard product shall have the basic mandatory covers as specified in these ‘Guidelines which shall be uniform across the market. 4. No addons or optional covers are allowed to be offered along with the standard product 5, The insurer may determine the price keeping in view the covers proposed to be offered subject to complying with the noms specified in the IRDAI (Health Insurance) Regulations, 2016 (HIR, 2016)and Guidelines notified there under. 6. The Standard Product shall be offered on indemnity basis only 7. The policy tenure ofthe standard product shall be for a period of one year 8, The standard Product shall comply with all the provisions of IRDAI (Health Insurance) Regulations, 2016, all other applicable Regulations, Guidelines on ‘Standardization in Health Insurance (Ref: IRDAHLT/REGICIR/146007/2016) dated 29! uly, 2018, Guidelines on Product Fling in Health Insurance Business (Ref: IRDAVHLTIREGICIR/150/07/2016) dated 20" July, 2016, Guidelines on Standardization of Exclusions in Health Insurance Contracts (Ref IROAVHLTIREGICIR/177/09/2019) dated 27°September, 2013 and other applicable Guidelines as amended from time to time. ‘8. Every General and Stand alone health Insurer, who has been issued a Cerificate of Registration to transact General and/or Health Insurance Business, shal ‘mandatorly offer tis product beB. Construct of Standard Health Product: The Standard Health Product shall offer the folowing mandatory covers, 10. Hospitalisation Expenses: The Hospitalisation expenses shall cover the following a) Room, Boarding, Nursing Expenses as provided by the Hospital / Nursing Home up to 2% of the Sum insured subject to maximum of Rs. £000/- per day. ) Surgeon, Anaesthetist, Medical Practitioner, Consultants, Specialist Fees whether paid directly tothe treating doctor / surgeon or tothe hospital Anaesthesia, blood, oxygen, operation theatre charges, surcical appliances, ‘medicines and drugs, costs towards diagnostics, diagnostic imaging modalities, ‘and such other similar expenses (Expenses on Hospitalistion for a minimum period of 24 hours are admissible. ‘However, this time limit of 24 hours shall not apply when the treatment does not require hospitalisation as specified in the terms and conditions of policy contract, where the \eatment is taken in the Hospitaland the Insured is «discharged on the same day) 4) Intensive Care Unit (ICU) / intensive Cardiac Care Unit (IECU} expensesup to 5% of sum insured subject to maximum of R8.10,000I- per day, under Para "C" ») Dental treatment necessitated due to disease or injury. ©) Plastic surgery, necessitated due to disease or injury d) Allthe day care treatments ) Expenses incurred on road Ambulance subject to @ maximum af Rs,2000/- per hospitalisation AYUSH Treatment: Expenses incurred on hospitalisation uncer AYUSH (as defined in IRDAI (Health insurance) Regulations, 2016) systems cf medicine shall be covered without any sub-limits, 12.Pre-Hospitalisation medical expenses incurred fora period of 30 days prior to the date of hospitalisation shall be admissible. 13. Post Hospitaisation medical expenses incurred for @ period of €0 days from the date of discharge from the hospital, folowing an admissible claim shall be included 14.Cumulative Bonus (CB): Sum insured (excluding CB) shall be increased by 5% in respect of each claim free policy year, provided the policy is renewed without a break subject to maximum of 50% of the sum insured. Ifa claim is made in any Particular year, the cumulative bonus accrued may be reduced at he same rate at which it has acerued. 16.No deductibles are permitted inthis product. Gv©. Other Norms applicabl Sino [Parieuare Norms Applicable [Plan Variants [No plan vatianis are alowed Standard product may be dtibied across a distrouton channels hotuing Mim Insurance Agents, Point of sale persons and Cormon Puble Distributions: Serie Censres. : ‘Channels Distruton of tandars produc shal be governed by the regulaons of concerned dstibuton channel Slander prow aa Booed a Tay Teer a._|Famty Floater __| basis alsa Famiy consists ofthe ropoREY an sry one oF MOTe Ofte family members 28 mentioned boon (©) egaly wedded spouse (Parents and Parents (ill) dependent Children (ie natural or 2 (Dermmion oF ari legally adopted) between the age 3 months to 285 years I the child above 18 years of age f fnancialy Independent, he of she shall be inehgble for coverage in the subsequent renewal ‘Standard product shall be offered on indemnity basis, as a standalone product. shall not be 5 Category of Cover combined with Critical Iliness Covers or Benefit Based covers. ~ Standard produc hal comly wih Regulation (We) Of HIR 2016 a the time of renewal ofthe poly 4. | Grace Period for | For Yeary payment of mode, a fed period of 30 premium payment | days isto be alowed as Grace Pared and for al ther modes of payment a fixed period of 18 days be lowed a3 grace pei ‘The minimum sum insured onder sandard product 7, [Minimum and | aha be 00,000" Maximum Sum | Maximum iit shal be Re S lakh the multiples of insured sy tovsane) a a | Potey Penaa Siandard product shal be ofered wha poly Teh of one year. = .‘Alte modes (Vy, Hly, Oy, My) shallbe alowed Tor 9, |Modes of premium | the standard product. payment ECS (Auto Debit facility is also allowed in respect of the above mentioned modes. Minimum enity age shall be 18 years for principal insured and maximum age at entty shal be 85, complying to Regulation 12() of HIR 2016, along | wi eongrenewabity. There halts no ex age ee Policy is subject to lifelong renewabil Dependent Child J children shall be covered from the ‘age of 3 months to 25 years subject to the definition of Family ‘The benelt pay Gut Shou be explely dsclosed ln 11. | Benefit iructure | the format of application (Form ~ IRCAI-UNF-HISP) along with other relevant documents Z Fixed Co-pay of % shall be applicable across athe 12, | Co-payment ‘ages and it shall be explcity disclosed in the format ‘of application (Form ~ IRDAL-UNF-HISP). Limits on cataract Surgery: The expenses incurred 43. | Sub tints on treatment of Cataract shall be covered up to 25% fof Sum insured or Rs.40,000/- whichever is tower, pereye. = Following Giseasesiveaiment are covered subject to ‘awaiting period mentioned below ‘A.24 Months Waiting Period 1. Benign ENT disorders, 2. Tonsillectomy 3. Adenoidectomy 4. Mastoidectomy 5. Tympanoplasty 8. Hysterectomy 7. All intemal and extemal benign tumours, | 44, | Spectiewatting ysis, polyps of any kind, including benign Period breast lumps 8. Benign prostate hypertrophy 8. Cataract and age related eye aiments 10.Gastie/ Duodenal Ueer ‘1.Gout and Rheumatism 12 Hemia of all ypes, 13, Hydrovele 414.Non infective Arthritis 15.Ples, Fissures and Fistula in arus 16.Pilonial sinus, Sinusitis and reated disorders eeV7 Prolapse infer Vertebral Oise and Spinal] Diseases uness arising from accent 48.Calcul in urinary system, Gall Bladder and Bile duct, excluding malignancy 19.Varicose Veins and Varicose Ulcers | 20.Intemal Congenital Anomalies B.48 Months waiting period 21.Treatment for joint replacement unless arising from accident 22. Age-related Osteoartrts & Osteoporosis Tho insurer shall speciy the non-medical limit and relevant details explicitly in the format specie. The Standard product shall be subjeci to Renewal duly complying with Regulation 13 of HIR, 2016 [The Standard Product shall have free look period complying with Regulation 14 of HIR 2016 Premium Loading | The Standard Product shall comply win Regulation 18__| and Discounts 25 of HIR 2016 in respect of loadings on Renewals. The Standard Product shall comply with Portability provisions, as specified in Schedule | of HIR 2016 land applicable Guidelines issued there under from 15, | Underwriting 16, | Renewal 17. | Free Look Period 19. | Ponabiity time to time. ‘The premium under this product shall be pan india 20, | Pricing basis and no geographic location / zone based pricing is alowed roposed const Cond ns for Standard Produc! 16. The Policy Terms and Conditions of the Standard Product shall bin the format specified in Annexure 1, Insurer may suitably modify the definiions and other clauses ofthe policy contract prospectively based on the Regulations or Guidelines: that may be issued by the Authority time to time Other Norms: 17 The nomenclature of the product shall be Arogya Sanjeevani Policy, succeeded by name of insurance company, (Arogya Sanjeevani Policy, ). No other name is alowed in any of the documents, 18.The Proposal Form used for the product shall be subject to the rorms specified under the Guidelines on Product Filing in Health Insurance. 18.Insurers shall mandatofly issue Customer Information Sheet as per the format specified in Annexure-2. YY20.The Standard Product may be offered as MICRO Insurance Product subject to ‘Sum Insured limits specified in IRDAI (Micro Insurance) Regulations, 2015, and ‘other circulars / guidelines issued inthis regard by the Authority from time to time, 21.The Standard product shall be launched without prior approval of the Authority subject to compiying wit the following conditions. ‘a. The product shall be approved by the Product Managemant Committee i. Insurers shall obtain UIN for the standard product by fing the relevant Particulars in Form ~ IRDAL-UNF-HISP (as specified in Annexure ~ 3 of these Guidelines) along with a certificate from Chief Conpliance Officer that the product filed is in compliance with the norms specified under these guidelines, 6. On review of the application, the Authority may call for such further Information as may be required and may issue suitable directions which shall be retrospectively effected in respect of all contracts issued under this product. 22.General and Health Insurers shall offer this product from 01" Apri, 2020 onwards. 23.This has the approval ofthe competent authority ys (Suresh Mathur) Executive DirectorPolicy {Company Name] Arogya Sanjeev 1, PREAMBLE This Policy is a comract of insurance issued by {name of the Company} (hercinafier called the ‘Company’ othe proporer mentioned in the schedule (hereiafer called the "Insured to cover the person(s) named inthe schedule (hereinafter called the “Insured Persons). The poi is based on the ntemens and declaration provided inthe proposal Form bythe proposer and is subject recip of ‘he egusite premium 2. OPERATIVE CLAUSE. If during the policy period one or mote Insured Person (3) is required to be hosptliad for treatment ‘ofan lessor Ijory at Hospital’ Day Care Cente, following Medical Advice ofa duly qualifies Medical Practionr, the Company shall indemnify Medically necessary, expenses towards the Coverage mentioned inthe policy schedule Provided fanher dt, any amount payable under the policy shall be subject tothe tems of coverage (including any co-pay, sob limits, exclusions, conditions and defini contained herein. Maximum lability oF the Company under all such Claims during each Policy Year sall be the Sum Insured (Undividal or Floste opted and Cumulative Bonus fan) specified in the Schedule, 3. DEFINITIONS The terms defined below and at other junctures in the Policy have the meanings eseribed to them wherever they appear in his Policy and, where, the context so requires, reference: 10 the singular ince references tothe pla references to the male inches the female and references to any statutory enactment includes subsequent changes othe same “A. Accident means sudden, unforeseen and involuntary event caused by extemal, visible and olen means 132. Age means age ofthe Insured person on last hitthday aon dae of commencement ofthe Policy 43. Any One Illness means continuous period of illaes andi includes elapse witha fry five days from the dt of lst consltation wth the hospital where treatment hasbeen take. SMLAYUSH Treatment refers 9 bospitaliaion teatments given under Ayuneda, Yoga and ‘Naturopathy, Une, Sicha and Homeopathy systems 35.An AYUSH Hospital isa healthcare feity wherein medicalsurpicalpare-scical treatment procedures and interventions are cated out by AYUSH Medical Pacitiones) comprising of ny ofthe flowing 4 Cantal or State Government AYUSH Hospital or Teaching. hospital atached to AYUSH College recognized by the Cental GovernmentCentral Cou of Indian Medicine/Cenral Counc. for Homeopsthy, -AYUSH Hospital, standalone oF co-oesed with in-patient hedthsare fcity of any recognied system of mocine, registred with the loealauhories, wherever spplicale, and is under the supervision of a qualified registered AYUSH Medical Practitioner and must comply with al the following eiterion |. Having atleast in-patient beds;ii, Having qualified AYUSH Medical Prattonr i charge round the clocks |W, Having dedicatod AYUSH therapy setions a6 reqiré andlor has ‘auipped operation theatre where sugial procedurs are tobe caried |v, Maintaining daily records ofthe paints and making them accessible to the insurance company's authorized represent AG AYUSH Day Care Centre means and includes Community Health Cente (CHC), Primary Health Cente (PHC), Dispenser, Clinie, Polyclinic or any such heath centre which is regstered With the lal authorities, wherever applicable and having faites for casing out weatent Procedures and medial or sufpicalpar-surgcal interventions or bath under te supervision of registred AYUSH Medial Practitioner (3) on day cae basis witht in-patient services and must ‘comply with all the fllorngererion it Having qualified registered AYUSH Medica! Practitone) in hae fi, Having dedicated AYUSH therapy sections as quired andlor has quipped operation theave where surgial procedures ae tobe carried Ui, Maimainiag daily records ofthe pains and make them acessible (othe insurance company's authorized representative 517. Break in Polley meas the period of gap tht occu atthe end ofthe existing pole term, when ‘he pomium de for anew on piven policy i nol pad on or before the premium renewal de (o¢within 30 days thereof 4.8 Cashlss Paciity moans a falityextanded by the insure othe insured where he payments of the costs of treatment undergone ty the insured person in accordance withthe Policy terms and conditions are directly made tothe network provider bythe insurer othe exten! preauoriaton Isapproves 49. Condition Precedent means Polizy tm ot condition upon which the Company's lailiy under he Poi x eontonl upon 10.Congenital Anomaly cfers 10 condition(s which is present since bi, nd shih is abnormal with reference fe form, suture or postion 4) Internal Congenital Anomaly ‘Congenital anomaly whieh sol inthe visible and accessible par ofthe boy. 1) External Congenital Anomaly Congenital anomaly which the visible and accessible par ofthe boy. ‘311.Co-payment means cost sharing requirement under «health insurance policy that provides hat the pliyholder/insred wil beara specified percentage ofthe admissible clans amount. co- payment doesnot reduce the Sum Insured 5.12.Cumulative Bonus means any increase or addition inthe Sum Insured graned by the insuer ‘without an associated increase in premium. AX Day Care Centre means any institution etblshed for éay care weatment of disease! injuries or ‘medical setup within a hospital and which has been registered wih the loeal authori,wherever applicable, and is under the supervision of a registered and qualifed medical practitioner AND must comply with all minimum eitera as unde: iL hasqulifed nursing staf under its employment, i has qualified medical practioner () in charge; Ti, has fly equiped operation theatre of own where surgical procedures are canied out iv. maining daly records of patients and shall make these accessible to the Company's authorized pesonne L14Day Care Treatment mean medical treatment, anor surgical procedure whichis {undertaken under general or local anesthesia ina hospteliny care centre in less than twenty foor hours because of technological advancement, and i, which would have etherwise required a hospitalisation of more than twenty four hours Treatmeat normally taken onan outpatient basi is ot included ia the Scope of his dtintion ‘A15 Dental Treatment means a teamentcatied outby a dental practioner incluig examinations, Fillings (where appropiate) crowns, extations and surgery ‘316 Disclosure oinformat forfeited tothe Company inthe event of misrepreseraton, mis-éscripion or nonisclosur of any materi ft. 1m norm: The policy shall be void and al premium paid thereon shall be .17.Emergeney Care: Emergency care means management fran illest o injury whic results in Symptoms which occur suddely and unexpectedly, and requies immediate eae by a medical acitioner to prevent death or srious long term impsiement ofthe insured pesos health |318.Family means, the Family tat consists ofthe proposer and any ane or more ofthe faily embers as mentioned below i Tegaly wedded spoure, i, Parents and Parentei-aw, 1 dependent Children (Le natural or legally adopted) between the age 3 months to 28 yours the Child above 18 yeas of age is financially independent, eo se shall be inaligible for coverage inthe subsequent rnowals u9.Grace Period means specified paiod of time immediately following the premium duo date ‘during which a payment can be made to renew ot continue the Policy” in fore without lost of ontinuity Benefits sush as wating period and overage of pr-eiting diseases. Coverage fs not ‘ailble for the prio for whieh no premium i reseived .320-Hospltal means any instuton established for n-patont car and daycare westment of disease! Injuries and which hasbeen registered as x hospital withthe local authritesuader the Clinical Establishments (Registation and Regulation) Aet,2010 or under the enactments specified under Schedule of Seton (1 ofthe sak Aet,OR complies with ll minim evteria as under 4. hae qualified nursing staff under its employment round the clock, |i. has atleast ten inpatint bods, in hase towns having a population of ess thn tex aks and fies inpatient hed inal other paces, i, has qualified medical prctoner in charge round the clock; is. ha fly equipped operation theatre of sown where surges procedures are carried out 1 maintains daily records of patients and shall make these aoceeible tothe Companys authorized personne. ‘321.Hospitalsation means admission in hospital for 8 minimum period of twenty four 24) onsccutive “epatint care" hours exeept for specified procedures) treatments, where sich ‘mission eould be fora period of estan twenty Tour (24) consecutive hous 322 Illness means sickness ora disease 0 ps noua! physiolog ‘medial treatment ological condition leading to the impairment of I Tuneion which manifests self during te policy perid and requires|. Acute Condition means «disease, illness or injury tha i likely 40 response quickly to teeaiment which aims to return the person this oF ber state of helininmodiatly before slering the disease! nes injury which least full recovery. Ui, Chronie Condition means « disease ies, or injury tat has one or moe of the following characteristics 48) needs ongoing or lon and/or tests 1b) teed ongoing o long-term control or ele of symptoms <)itrequite rehabilitation forthe patient or forthe patent to be special ted to cope wiht 4) itcontines indefinitely (2) recurs os kay to reer term monitoring trough consultations, examinations, check-ups, 4.24 Injury means accidental physical boy harm exclading inst or disease solely and dirty ‘olen and visible and evident meats which i verified tnd eartfid by & 324 InPatient Care means treatment for which the insured person hast sty in ahosptl for more than 24 hours fora covered event {828 Insured Person means perso(s) named nthe schedule ofthe Plies. £26 Intensive Care Unit means an identified setion, ward or wing ofa hospital whichis under the ‘constant supervision of dedizated medical pacone() abd which i specally equipped for the eoainous monitoring an iretment of paints who ao in aerial condi, or require ie Support facilities and where the level of cafe and supervision i considerably more sophisticated tnd intensive than inthe ordinary and ther wards S27ICU (Intensive Care Unit) Charges means the amount charged by 2 Hostal towards ICU ‘eapenses on a per day basis which shall include the expenses for {CU ted. general medical support services provided to any ICU patient including monitoring devices, ertical care musing ‘nd inensivst charges 32%Medieal Advice mesns any consltaton ot advice from a Medical Prasitens including the Issue of any preserpiono ello up prescription. 1329.Medieal Expenses means those expenses that an insured person has necossily and actually incured for modal weatmant on secount af illness or acident on the adsce of @ medial actions long as these are no more than woul have Been payable ifthe insured person had ‘ot been insured and no more than ether hospitals or doctors in the same lslity Would have ‘harged forte same modal eaten 4.30 Medical Practitioner means a person whe hols avail registration from the Meal Council of ‘any slate of Medical Council of India or Counel for Indian Medieine or fr Homeopathy ast up by the Government of India ora State Goverment and is thereby ented to practice medicine within json; ad is ating within the scope and jrsdiction ofthe ce A31-Medically Necessary Treatment means any team, tes, madieation, or sty in hosp part of sayin hospital which {LTS roguired fr tho medical managemont of illhess or nur suffered by the insur ii -munt not exceed the level of care necessary to provide sf, aden ané appepriate modi care in scope, duration, or intensity ii, ust have ben prescribed by a medica practioner, ins mst conform tthe profesional standards widely accepted in international medical practice ot by the medi! community in indi,|S32.Migration means, the right esorded to heath insurance policyholders (includ ng all members ‘under family over and members of group Heath insurance policy), ro transfer te ere ined far pre-eising editions and time bound exclusions, with the sue insure. {234.Network Provider means hospitals aise by insurer, TPA or jointly by an inser and TPA 10 Provide medial service to an inured bya cashless facility. 3.34. Nom: Network Provider mea any hospital dai not pr ofthe network .336.Notiiaton of Clam means the proces fitting claim to the Insurer or TPA through ay ofthe revognized modes of eommaniation 5.36, Out-Patient (OPD) Treatment msans eaent in which the insured isis a enc / hospital or ‘sssocitd fs liks a consultation room for diagnosis and weatment based or the advice of & ‘medial pacitone. The insured snot died as «day care or n-paten, ‘Aa Pre-Exiating Divease (PED): Pre exiting disease meuns any condition, alent, injury oe ‘disse 1) That are diagnosed by a physician within 4# months rior tothe effstive date of the policy isued bythe insurer or ') For which medical advice or teatment was recommended by, oF ressived fiom, a psician within ‘mons prior othe effective date ofthe policy os easaterent «) A condition for which any symptoms an o signi presented and have esuked within tree months ofthe isuance ofthe policy ins diagnosis lines of medial condition, 3.38.Pre-hosptalsation Medical Expenses means medical expenses inured dur the period of days preceding the hospitalisation ofthe Insured Person, provided that j. Such Medical Expenses re incurred forthe same condition for which the Insured Person's Fosptlistion was requis, and ii, The Impatient Hospitalistion claim for such Hospitalsation is admissible by the Insurance Company 128. Post-hospitalisation Medical Expenses means medical expenses incurred during the period of ‘odays inmediatly fer he insured person is lschaged from the hospi proved tht i Such Medical Expenses are forthe sume condition for which the insred persons lopitalation was required, and 11 "The inpatient hospitalisation clan fo such hospitalisation i admissible by the Lnsurance Company. San Polley means tese Polly wordings, the Poliy Schedule and any appliableendosements o ‘xtesion ataching to or forming pt hero, The Policy contin details ofthe extent of cover ‘allable tothe Insured perso, what i exclu from the cover and the terms & conditions ob ‘wih he Poly i sued to The Inswed person |S41-Poliey period mcens period of one policy years mentioned inthe shedle for which the Policy is sued $4. Poliey Schedule means he Policy Schedule attache and forming art of Poy 4.43 Poliey year means apie of twelve months beglaning om the date of comazncement ofthe policy peied and ending on the last day of soch twelve-month period. For the purpose of Subsequent yeas, polly yur shall mean a pio oF syelve months commenciag fom the end of the previous policy year and lasing om the lst day of atch twelve-month peri sil he polisy period, as mentioned inthe schedule 2144 Portability means the ight accorded oan individual health insurance policyholder Cincladingll ‘members under family cover) o transfer the eet gained fr pre-existing conditions an tne ound exclusions, fom one insurer to ante aster.48.Qualiied Nurse means a person who holds a vali rgistation fom the Nursing Council of India the Nursing Coun of any sate i Indi d&Renewal: Renewal means the teams on hich the contract of insrance ci be renewed on ‘mutual consent with a provision of grate period for weaing the renewal eantinuous for the ‘orpose ‘of gnining credit for preexisting dssases,tnesbound exclusions an fr all waiting perlods. ‘S47. Room Rent means the amount charged by «hospital owns Room and Boaring expenses and Shall lade the associated medial expenses ‘348 Sub-imit means a cost sharing equrement under a health insurance paliey in which an insure ‘would no be liable o pay ay amount in excess of he pre-defined limit 349.Sum Insured means the pre-defined lit specified inthe Policy Sched, Som Insured and ‘Cumulative Bons represents the maximum, total and cumulative ability for ny and all elas made under the Policy, n respect ofthat Insured Person (on Individual bass) or all Insured Pesons (on Floater bass) uring the Policy Year {sn.Surgery or Sergical Procedure means manual and / or operative procedure (6) required for treatment ofan illness or injury, coreation of defonnites and defets, diagosis and cure of AUseases, rele of sufering and prolongation of if, performed ina hospi or ay ear centre by ‘medica practioner. 3S1-Thind Party Administrator (TPA) means e Company reystered with the Authorty, and engaged by an insurer, Tora fee or by whatever name ealled and as may be mentioned inthe health sevices agreement, or proving helt serves 42. Waiting Period means « peiod fom the inception of this Policy during which specified Aiseasesreatments are not covered. On completion of the period, dseasesreamens shall be covered provided the Poliey has buen continously renewed without ny bres, 4 COVERAGE The cover listed below are inbuilt Policy benefis and shal be available to all Insured Persons in accordance withthe procedures stout inthis Poi 4.1 Hospitalization ‘The Company shall indemnity medical expenses incured for Hospitalization ofthe Insured Person daring the Policy year up tothe Sum Insured snd Cumulative Bonus specified inte policy schedule, for, iF” Room Rent, Boarding. Nusing Expenses as provide by the Hospital / Nursing Home up to 2% of ‘the sum insured subject to maximum of RS-5000, pr day li Intensive Cate Unit (ICU) Intensive Cardiac Care Unit ICCU) expenses up 10S of sum ineed ‘subject o maximum oF RS 10,000 per day ii, Surgeon, Anesheti, Medial Practitioner, Consultan, Specialist Fees whether pid diet tothe treating doctor surgeon oo the hospital Iv. Anesthesia, blood, oxygen, operation theatre char ost towards dignosts, diagnos imaging moda {ULLOter expenses i, Expenses inured on testment of eatat subject othe sub mits Ti, Dental weatment, necessitated de to disease o injury Ti, Plastic surgery nocestated duet disesse oir iv, llth day care treatments ‘Expenses inured on road Ambulance subject 0 @ maximum of Rs. 2000 pe hsptalistion 2, srgcal appliances, medicines and drugs, igs and sch similar ater expenses,ote: {Expenses of Hospitalization for «minimum perio of 24 consecutive hous only sal be sdnisibl However, the tine limit shall not apply in espect of Day Care Treatment 2.'In case of admission to m room/CUNICCU at rates exceeding the afonseid limits, the ‘eimbursmeatpayment of al ther expense incurred athe Hospital, wih the exception of cos of ‘medicines, shal be efeted inthe same proportion sth admissible ae po day boas othe etal ate Der day of Room RenvICLINCCU charges 42, AYUSH Treatment ‘The Company shall indemnify medical expenses incured for inpatient cae teutment under /Ayurved,Yogs and Naturopathy, Una, Sila and Homeopathy systoms of medizines during each Policy Year up tothe limit of sun insured as specified in the policy schedule in any AYUSH Hospital, 43. Cataract Treatment ‘The Company shall indemnity medical expenses inured for weatment of Catru, sbjet ta limitof 25% af Sum Insured rR 40,000, whichever slower, per each eye ia oe ply jeu “The company shall indemnify prehospitliction medical expenses incured, elated to an admissible hospitalization reqiig inpatient cafe, for & Fixed period of 30 days prior fo the date of admissible hosptalietion covered ander the poli 45 Post Hospitaisation ‘The company shall indemnity post hospitalization mada expenses incurred, rele oan admissible hospitalization requiing ipatiem care, fora fixed period of 60 days Trom the date of discharge fom the hospital, following an admissible hospitalization covered under the pole. ‘46. The Following procedues wil be covered (wherever medically indicated) citer in patent or as part of day eare treatment in a hospital up to SO% of Sum Insured, specified in the policy Sehedale during the pliy period: ‘A. Uterine Aery Embolization and HIFU (High intensity Focused ulasound) Balloon Sinuplasty Deep Brain stimulation D. Onl chemotierpy . Immunotherapy: Monoclonal Antibody to be given a injection tne vite injections 4. Robotic surgeries H, Stereotactic radio surgeries |. BronehicalTRermoplasty 4. Vapoisation ofthe prostate (Green laser testmet ov hoi laser treat) 1K, IONM - (its Operative Newro Monitoring) 1. Stem cell therapy: Hematopiatic sem ess for bone marrow ttspiat fr hematologic conditions to be covered.447. The expenses that are not covered inthis poliey ae placed under List of Amneare-A. The ist of ‘expenses that ae to be susuned ino rom charges, or procedure charges or cots of rate ane placed under List-ILListl and List-1V of AnwexureA respectively, Cumulative Bonus (CB) {Cumolative Bonus wil be increased by $% in respect ofeach claim fre poly ye (where no claims se reported), provided the policy i renewed wih the company without a break suet to maximum of 5% ofthe sum insured under the curteat pli year. I' claim ie made i any patelar year, the cumulative bonus aerued shal be rediced atthe se rte at whieh hae asred. However som Insured wil be minnie and wil ot be rede in the policy yar, iv ease where the policy ison individual bass, the CB shal be added and avaible individually to the insured person if no claim hasbeen pares. CB shall reduce only in ese of claim fom the same Insite Peron, li Incase where the pole & on Noster basi, the CB shall be added and avilable tothe family on Ate basis, provided no claim hasbeen epted fom any member ofthe fami. CB shall reduce incase of claim fom any ofthe Insured Persons. 4, CB stall be availabe only if the Policy is renewed premium paid within the Gace Psi. iv. We Insured Persons in the expiring policy ave covered onan indial basi as specified in the Policy Schedule and thre i aecumblsted CB for sch Insured Perso under the expiring policy, and such expiring policy has been Renewed on a cater policy basis as specified inthe Policy Sched then the CB tobe carted forward fo red in such Renewed Policy shall be the an thts applicable tothe lowest song al the Insured Persons vy. imate of floater policies where Insured Pereons Renew their expiring poiey ty splitng the Sum Insured in to two or moee ater policendvidl polices or in cases whee the pabey spi due ‘0 the child attaining the age of 25 yeas the CB ofthe expiring policy shall be sportioned to sh Renewed Policies in the proportion ofthe Sum Insured of each Renewed Policy i. Ihe Sum insure has bean reduced a he time of Renewal, the aplieable CA shall be reduced in ‘he sme peoportion othe Sum Inset n surant Policy wii, I'he Sum Insured under the Polley hasbeen increased at the te of Renewal the CB shal be caleulated onthe Sum Insured of he ast completes Poiy Yes, vii, Ia claim is mae in he exptng Policy Vea andi nolied to Us ater the acceptance of Renewal ‘premium any awarded CB shal be wir 6 Waiting Period The Compaty shall not be lable to make any payment unde the pliy in connetion with or in respest of following expenses til the expiry of waiting period mentioned below 6.1, Pre-Existing Diseass(Code-Exel01) 8) Exponss related io the testnent of pre-existing Dssase (PED) and its direct complications stall be excluded unt the expiry ef 48 months of continuous coverage afer the date of inception of the ist plicy with us by mete of enhancement of sum insured the excision shal apply aes tthe extent of sum insured incene. ©) Ite Insured Person is continuously covered without any break as defined under the portailiy norms ofthe extant IRDAT (Heath Insurance) Regulations thea waiting prod fr the sae ‘would be redoed 1a the extent of peor coverage, 4) Coverage under the policy ser the expiry of 48 months for any pre-existing disease i subject tothe sme being delaod at the tne of eppliation and accepted by us 62. lest Thirty Days Walting Period(Code- Exe3) 1 Expenses elated othe westment of any illness within 30 days fom the fst poly commencement ate shal be excluded except claims arising duc to an secident, provided the sane recovered4 This exclusion shall aot, however apply ithe Insured Parson has Continuous Coverage foe mare than eve months ‘The within refered waiting period is made applicable to the enhanced sum insur inthe event of granting higher sum insured Subsequent 63, Specie Waiting Perio: (Code- Exel2) 1) Expenses related 10 the weatment of the following listed conditions, sugeristeatments shall be ‘excluded unt he expiry of 24/48 months of continuous coverage, 1 nay be the case afte the dae (of inepton of the frst poiey withthe insurer. This exclusion shall not be aplieble for claims ising duet an accident 1) Ines of enhancement of sm insted the exclsion shall apply aes othe extn of sm inseed 1) Ifany ofthe specified diseateprocedure falls under the waiting period specif for pre-existing seats, the the longer of the two ating periods shal app 1) The waling period for listed condions shall apply even if contacted ater the pliey er delaed nd ecepted without peste exclusion Ifthe Insured Poison i continously covered without any brek as defined under the applicable norms on portability stipulated by IRDAL, then wating prod forthe same wouldbe reduced tthe ‘extent of peor coveraye 1.24 Months waiting period 23. Benign ENT disorders 24, Tonsillectomy 25. Adenoideciomy 26, Mesoidesiomy 27. Tympanoplaty 28 Hysterectomy 29, All infernal and external benign tumour, ess, polyps of any kind, including benign bras lumps 30, Benign prostate hypertophy 31, Catarat an age related eye ailments 532, Gasti/ Duodenal Ulcer 33, Gout an Rhevmati 34, Hei of all ype 35, Hyrocele 36, Non Infsive Artis 37 Piles, issues and Fistula in anus 38. Plonida sinus, Sinusitis and related disorders 39. Prolapse intr Vestal ise and Spinal Diseases wales rising fom acidew 40, Calcul ia urinay system, Gall Bladder and Bile dct, excluding malignancy “4, Varicose Veins and Varicose Ueers 42 fnteralCongenialAnomies 1.48 Mouths waiting period 1. “Treatmeat fr jit replacement unless rising tom acident 2. Age-slnted Osteoarthritis & Osteoporosis 7. EXCLUSIONS. The Company shall not be Hable to make any payment under the policy in espect of any expenses inured in conection wth orn respect of “14 Investigation & Evaluation(Ciae- Exel) 5) Expenses eat to any admission primal fr digostics and evaluation pups) Any diagnostic expenses which are not reat or not incidental t9 the curent diagnosis and 12 Rest Cure, rehaiitation and respite eare(Coude- Exel) 8) Expenses related 10 any admission primaily Tor enforced bed rest and not for reeiving treatment Thi als nees |. Castodial ear ether at home or ia a nursing fility for personal care such a6 help ith Actives of dally living seh as hahing, dressing, moving around ether by skilled nares ot sistant or no-till persons, Ti Any sevies for poople who are terminally il to addess physica, soci, emotion and spiil neds 1.3 Obesity’ Weight Control(Code-Exs106) Expenses related othe surgical treatment of ebesity that does not Fl all the below conditions: 1) Surgery to be conducted is upon the advice ofthe Doctor 2) Th surpery/Procedure conducted shouldbe supported by elisa! potocls 3) ‘The member has tobe 18 ear of ape o older and '9) Boy Mass Index (BM ‘greater than or equal 04D oF 1) grester than or equal to 35 in conjunction with any of the fllowing severe co- ‘morbid ellowing failure of les invasive methods af weight loss 1h Obesiyrlatedcarsiomyopaty Ti, Coronary hear disease Ti Severe Shep Apnea iv, Uncontrolled Type? Diabetes 7A Change-of-Gender treatments: (Code: Exel07) Expenses related to ay tote ncidingsgie! managsient, to change ebracteristies ofthe body to those ofthe opposite sex 75 Cosmet or plastie Surgery: (Code-Fxe108) Expentr for connetic or plastic surgery or any resiment to change sppearance unless for reconstruction following an Acedet, Burns) or Canes o spat of medically necessary ireatnent, fo remove a dicet and immediate health risk to the insured, Fr thie fo be considered» medal neces, mst be crite bythe attending Medical Pracitonet. 12 Mazardous or Adventure sports: (Cole- Ext05) Expenses related to any treatment necessitated de to participation as professional in hazardous or adventure spots, including but nt lined 1, paajemping, rock climbing, mountinering afing, rmofor racing, hose racing of seuba diving, hand ling, sky diving, deepsea diving, 1.7 Breach of aw: (Code: x10) Expenses for treatment directly arising from or consequent pen any Insured Pason commiting or !ntempting te commit a breach of law with eviminal int “18 Exch Providers: (Code-Exet11) Expenses inured toward treatment in any hospital or by any Medial Prattoner or any other Drovdor specially exeluded by the Insurer and diclsed in ity website! notified tothe Polieyholders are not admissible. However, in case of life theteniag situtions following a0 eden, expenses upto the stage of alization ae payable but not he compe claim 19 Treatment for, Alcoholism, drug or substance abuse or any addictive condition and consequences thereat (Code: Exel) ”‘uaTreatments recived in heth hydrs, nature cure clinis, spas or similar exablishments 0 ‘private eds repsered a a nisin home attached to sch estblishments or where admission is aanged wholly or pay Tor domestic reasons. (Coe- Exe3) “A1Diatry supplements and substances that canbe purchased without prescrip, ncuding but not lite to Vitins, minerals and organic substances unless prescribed by «medial Practitioner spat of hospitalization can or day care procedure (Coe- Exll4) “2 Refractive Error(Code- Exet8) Expenses related 0 the Weatment for eucstion of eye sight due to relactiveevor les than 75 slopes 2.1sUnproven Trestments(Code-Exel16) Expenses related to any unproven treaties, services and supplies fr or in comecton with any lreaimen. Unproven treatments ae eatiment,prosedres or supplies tht Ick significant media! documentation to support thee effectiveness. ‘.44Sterilty and Infertility (Cde-Exsl17) Expenses related to seit and infer. This incdes (Any type of steritzation (i Assisted Reproduction services including ata insemination and advanced reproductive technologies seh a IVE, ZIFT, GIFT, ICS (dy cestational Surtogtey (i) Reversal of sterilization ‘AsMaterity Expenses (Code - Exe 18) 1° Medical weatment expenses ticeable w chiabinh (ineloding complicated deliveries and cacsrean section inered during hospitalization} except ectopic regmuncy: ‘expenses towards miscanige (unless due fo an eceident) and lawful modi termination of pregnancy daring the policy period ‘LA6War (whether declared or et) and warlike oesutense or iavason ut of eign enemies, hostilities, evil war, eebelion, revolutions, isurections, mutiny, milary or usurped power, seizure, aptre, arrest, restraints and etanment ofall kinds ‘TN, chemical or biological stack or weapons, contibuted o, eused by, sulting from oe rom any other cuaneor event contributing concurently orn any other sequence othe Tas, ‘aim o expense. Forth purpose ofthis exclusion: 's) Nuclear tack or weapons means the use of any nvelear weapon or dvi oF waste oF combustion of niclear fel or the emision, discinge, dispersal sease of escape of Fale! fusion material emitting aleve of radioactivity capable of causing any les, incapacitating lsabement or death +) Chemical atack or weapons means the emission discharge, dispersal release or escape of any soi, liquid or gaseous chemical compound which, whea Suitably dstibted, is eapable of using any nes, incapacitating disablement or death, © Biclogial atack or weapons means the emission, dsshurys, dispersal, release or escape of any pathogenic (disease producing) micro-organisms andor biclgially produced toxins (inluding genetically modited organisms and chemically synthesized toxins) which are capable ‘of casing any Iles, incapacitating disablement or death, ‘asAny expenses incured on Domiciliary Hospitalization and OPD treatment‘av Treatment akon outsige the geographical limits of dia ‘ain respect ofthe existing diseases, disclosed by the insured and mentioned inthe poiey sehedulebased on insureds conse), pliyholder is ot enlild to gt the coverage for Specified ICD codes, 8. Moratorium Period: After completion of eight continuous yeas under this policy no lok back ‘wold be appie. This period of eight years i called a moratorium period. Themratoriom wouls be applicable forthe Sums insured ef the Tst polly and subsequently cxmpletion of eiht continuous years would be applicable fm date of enkancerent of sus fsured ony ofthe tnhanced Tints. Aer the expiry of Moratorium Period no elaim under this poly shal be ontestable except for proven ffané and permanent excisions specified Inthe icy cotract. The policies would however be subject to all its, sub its co-payments as per te policy. ). CLAIM PROCEDURE, 1.aProcedare for Cashlese eins: ( Treament may be aken in a newerk provider andi subject to pre authorization by the Company oF its authorized TPA. (i) Cashes request frm available wih the network provide and TPA shall be ‘completed and sent to the Company/TPA for authorization. (i) The Company! TPA pon geting éashles request form and elated medical information from the insured person! nework provider wil ‘swe pre-sthoriztion leer tothe hospital afer verfiaton(s) At the time of discharge, pron hao verify ad sgn the discharge paper, pay for onmedieal and inadmisible expenses (0) ‘The Company TPA reserves the right 1 dey pre-tthorizaton in cise the insured person is unable to provide the relevant medical deta (vIn case of denial of cashless access, the insured person may ‘btn the treatment asp treating doctor's advice and submit the claim documents to the Company / ‘TPA for reimbursement the inured 1.2 Procedure for reimbursement of lam: For reimbursement of cluims the insured person may submit the necessary dovuments to TPAC applicableyCompany within the eseribed time lini as specified hereunde. ST pType of Chaim reseibed Tie init No 1. | Reimbursement oF Rospialization, day eave and | Within Hy days oF Sue oF Gisharge pre hospitalization expenses fom hospital Z| Reimbursement of pst hospitalization expanses | Within filen days Fam completion | 9:1 Notifiation of Claims _ Notice wi il particular shall be sen tothe Company/TPAGiapplisable) a ud iL "Wihin2shours fom the date of emergency hospitalization required or before the Insied Porsnsdischarge fom Hospital, whiehever eae. Ti At Teast 8 hous pir to admission in Hospital incase of planned Hospitalization 22 Document tobe submited: ‘The reimboreement elim it be supported with the following documents and ssbmited within the prescribed ime tii Daly Completed ela form 9iPhoto Kentiyproo ofthe patient ii. Medical practitioners preserition advising admission is. Original bls with Remized break-up Payment receipts vi Discharge summary including complete medical history of the patent along with other etl, vis Investigation’ Diagnostic test reports et. supported by the prescription fom attending medical prestitioner WiLOT notes or Surgeon's certicae giving details ofthe operation pesfomned (foe surgical xs), [a Stickevlavoze ofthe Iplans, wherever applicable S MLR(Medico Legal Report copyif eared out and FIR (Fst information report) if registred, where ever applicable, si NEPT Dette (to enable diet cedt of clan amount in tenk accout) and cancelled heque i. KYC (entity proof with Addess) ofthe proposer, where clio laity is above Rs 1 Laks per AML Guidelines sii.Leglhersocessoncetiente, wherever applicable ‘iv. Any other eelevaa document requied by Company/TPA for assessment othe cai. INote: Insurer may speciy the documents required in orignal and waive off any of above required as per thei claim procedure] 1."The company shall only aeseptbillinwoicew/medicalweatment related docurems only in the Insured Person's name fr whom the cla i submited Inthe event of claim loged under he Policy and the oxiginal documents having been submited to anyother insurer, the Company shall acept the copy of the documents anc lei seernen ‘vice duly cried bythe other insre subject to ssaction of the Company 3 Any delay in otfeation or submission may be condoned on merit where delay & proved to be for reasons beyond the contol o he Insured Person 93 Co-payment Ech and every claim under the Policy shall be subject ro Copuyment of $% applicable to esi smoust admissible and payable st per the ers and condition ofthe Plicy, The amount payable hall beater dedostion ofthe copayment. 94 _ Claim Settlement (provision for Penal Interest) |. The Company stall sete or eect a claim, ab the case may be, within 30 days fom the date of teceipt of lst ecessry document ii Inthe ease of delay inthe payment of acti, the Company shall be abet pay interest rs the dat of receipt of last necestry document tthe ate of pynent Of claim tate 2% above the Sank rate ii, However, where the circumstances ofa claim warrant an investigation ia the opinion of the Company, it shall inte and complete such investigation atthe earlistin ay ese not tr than 30 ‘ays from the date of receipt of last necessary document In such cases, the Conpany shall Sele the claim within 4S days fom the dete of cele of last necessary document, iv. Imease of delay beyond stipulated 5 days the company shall be Tinble to pay ines at wate 2% above the bank ae ffom th date of reve of last necessary document tothe dt of paymen of aim. 9S. Services Offered by TPA(To be stated where TPA is involved) Servicing of clans, se, claim almissions and suessments, under this Policy by way of pre autorzatin of easless etme or processing of claims other than cashless claims or both, asp the Uundedying tes and conditions ofthe pobiy. The services offered by TPA shall nt incl i Chaim setement and claim sjeton 0|i. Any services dicey to any insured person oF 1 any other person unless such service sin secordaee withthe erm and conditions othe Agreement ene ina with he Campy. 56 Payment of Claim Allelans under the pi shal be payable fn indian eurency only 10, GENERAL TERMS & CONDITIONS 104, Disclosure of Information he Policy shal be vod and all rem pid thereon shal be frfited tthe Comgany inthe event of rmsrepresentation,mis-esrition or non-disclosure of any material act “The due observance and flfivent of the terns and ondiions ofthe policy, bythe inured person, shall be a condition prosedent to any Tibity ofthe Company to make ay payment for claims) arising under the poi. 103 Material Change ‘The insured shall oly the Company in writing of any material change inthe isk in ration to the ceranconatons _ m & Ghange-of Gender Weatmonts 7 @. Exponses for cosmetic or Basis SUBS 75 Expenses relaiod fo any Featrent neceastaied Gos Te Doicbaion Wh |7® | hazardous or adventure spots _| [Waring [a Pre Exsing Diseases willbe covered air a waling pavedat ary eight | 67 period (48) months of contnucus coverage ' Expenses related tothe treatment of any lines within 30 days Fora the ist | 62 poly commencement date shall be excluded except claims arising due fn sccdent, ._Specied surgereshveaimenisliseases ee covered afer spectiewaling [63 ered of 24 months [3 Specie surperiestreatmentaaisoases are covered ater spas wallng | __| "period of 48 mons '5 | Payment | Payment on indemnity babs (Gashless 7 Remmbureerent) basis S| Loss Tn case ofa Glan, is polcyreques you to share he olowing sis Sharing | 8. Expenses excoading the flong Sub hts 1 Room Charges(Hosptalzaton) 4s '2 Room Rent Up (0 2% of SI, subject to max of INR. 5.000 per ay »b. ICU charges - Upto 5% of SI subjoc to max o! INR 10.000 per ay, «Incase RoonvICUIICCU rent exceeds the rts speciied the {aim shalbe subject tothe proportanate decucton. iL Cataract Up to 28% of Sum insured or i 40,000" whichever is tower. | 43 Hi, Modern treatment method and lvancements In tshnolagy: Up t ‘50% ofthe Sum inured1 Each and every cai under tha Paley shall ba subjactto a Cepayrnontof 5% applesbe to aim amount admissible and payable as parte terms and conations ofthe Pal 7] Renewal Conditions The poly shall orinaly be revawabie excepi on grounds of aud, moral | 0.76 hazatd, misrepresentaton by the insured person, Renewal shal st be denieg fon the ground thatthe insured hae made a csim or clams n be preceding policy years. oF =| Renewar Benetts ‘Cumulative bonus 8. Inorease in the sum insured by 5% n respect ofeach cls fee year subject toamasimum of 0% ofS » Inthe event of claim the cumdatve bonus shal be reduced at the same 7 | Canceratie 70-| Claim ‘The Insured may cancel his Pobey by aiving 15 days wtten noes, and i uch an event, te Company shal atund premium on short term rates for the unexpired Poly Period as per the rats detailed in the ply terms and ‘condone, The Company may cancel the policy at any time on grounds. of misrepresentaon, non-disclosure of materal facts avd ty the Insured Person by giving 15 days’ writen notice 7030 “a. For Cashiess Sernca (insurer to provide he detais fae link rom where Hospital Network dts can | be ebsined) '. For Reimbursement of Cian "For reimbursement of caine the insured person may submit the necessary documents to TPAICompany witin the prescribed time imi as spected Rereunder St [Type of Chim ~~] Preseribed Time tai + Reimbursement of Win tity days of date of di hospitaizaton, day care | from hospital, and pre hospitalization expenses = 2 | Rembursment of post | Within Wear day fom completion oF hospitalization expenses _| post hosptalzaion rete: For details on claim procedure please refer he policy document Fi | Policy Servicing insurer o prove te deals of company ofa ‘Grievances? Comptaints "a Dalal of Gitevaneeredresal ac (nsurer to provide the Tak) IRDA integrated Grievance Management System tps sigs. gov in ©. Insurance Ombudsman ~The contact deals a the Insurance Ombudsman ofces have been provided as Annexure of Poly document. 12 | Insured Rights [Bo Liseng 3. Free Look period of 15 days Wom the date af receipt of te poigy Shall De applicable athe inoepton| newabiliy (except on oefain specie grounds) hae] 1038 ©. Right to migrate fom one product to another product of te Company Note: Insure to provide ermal and adaress ofthe Person to we Contacte) 1018 ‘Right to port the from one company to another company (Roe: Insurer provide email and sdeas ofthe Person to be contacted) 301s '& Change in Si uring the policy term or at the time of renewal (nsuer prove the contact details), Insurer to. specily the norms on TAT Yor Pre-Auth_ and Satioment of ‘imbursement. woz 73. | auras Pisase dsciose al pre-avstng dseasals or conaivons btore buying @poley. Non-lseosure may resultin lai not being pai Legal “The information must be readin conjunction wih the produetbrochare and poTey ‘document case of any confict between the CIS andthe poly document, te erms ana condtions ‘mentoned in he paley document shal preva 4Annexure-3 Form IRDAL-UNF-HISP [Allthe items should be fied in propery and careful. No tem must be let blank] No tem Particulars (to be filled in by insurer) Section I: General Information TA [Name af Heath 7 General Ineurer 12 | Regisvation No-alated by IRDAT 13 [Namie of Appointed Actuary [Please note that _histher ‘appointment should be in force ae on” the date of thie application) Ta | Brand Name [Give the name of the product which will be | ogy Sanjeevani, printed in Sales Literature and known in the market. This name ‘should not be alteresmodtied in ‘any form after launching in the market. This name shall appear | inal etums ete. which woul be ‘submited to IRDAT 15 [Date of approval by PC ‘Section I Underwriting [Underwriting ~Selecion of Risks [This seclion should dscuss Fow the afferent segrants of the population will be deat wth forthe purpose of underwriting (othe texan! they are relevant and a brief deta of procedure adopted fer assessment of various risk classes may be given) Z| SpecityNon-medical Lint [Where no pre-medical ‘examination is asked for] 22 Specify when and what classes of ‘lives would be subject" to medical ‘examination "23 | Whether any loading based | Yes 7No on’ the health status are applicable [Whether any loading based | Ves 7No fon the occupation are Spoicabe 5 | Speci, any ater} —— — ndenting crtera [2 [Whether Underwriting of the | Yes No product aligned to the Board [Approved Underwriting policy fof the Company. 3s27] Whether Tul coste_of pre | Yes/No policy medical check up are Bocne by the Insurer ZB_|if-no, specify the percentage propdsed to be bore by the rer. = Distibution Channels Section 3 | Disibtion channels: TT] Spealy the various distibution channels to be used for distributing the produc. reply shall be spect and can not fefer to the replies lke “as approved by IRDA] 37 [Commission scales to distrbution ‘channels— speciy the rates which are 10 be paid reply shall be spectic] 32 | Expected proportions of | Babin] Year | Year] Vear | Year ] Year business tobe procured by |chana [1 |? [8 4 15 teach channel shall be Indicated forthe next § years. Tnaavad gents 2 Corporate aes 3 isons Brokers PAesregators Smieo Insurance agers | 305C TPS Drea Oni Online So veet Marketing - Omer Theoret Separate ine foreasn ‘triton ohare 10, Oters- spect 361 Tear i “Section IV- Reinsurance arrangements Ei [Retention iit EZ | Name ofthe reinaurer @) %3 | Terms of renaurancelivps of | reinsurance, commissions, etc.) “4a [Any recapture provisions he be described, [45 | Reinsurance rates proved %8_| Whether a copy _of the reinsurance program and a copy ‘of the Treaty is submitted to the Authority YesiNo 8.1 | Whelher reinsurance program and ® copy of the teaty enclosed (tequred eniy these are ot fled win the ‘Ahoy previous) esi 462) Whether the reisurance proposed for the product SS ih line with the Boara ‘approved | reinsurance Program ‘fled with the Authority Yes No FES] Fro, particulars Turmieh the ‘Seetion Vi Pricing 1s Prem In case of General and Heath ium Loadings & Discounts (Please provide objective and transparent entra to offer dlscountsrebater.oadings ‘And compete nancial justifatons by AA to every em refered hereunder. Insurers 10 be also fuished separately in the =56<=60 =e 1 ares ee S35_| Expected sassaubaay between agolsum insured 534 _| Experience of similar products, f any for the. preceding Five Financial Years “0‘SNe Expos [ Prem’ [Numb [incur [Claim | Avera [Buri [Loss | Comb ue jum —ler of |ed |freque| ge |ng | ratio | ines Rs, | claims | claims [ney | cost | cost- ratio ‘Re per | Re. eam ad a al FZ YS Fa 7 Exposure: earned We year (no of fe earned dung particular fancll year) 2. Premium: premium earned during the nancial year; ‘Number of claims: claims occurred during the financial year 4: ncuted claims: Incurred amount a of tay for claims mentioned in 2" 5, Claim frequency: No, of claims! Exposure; | 6. Average cost per cain: Incured claims / No.of claims; 7. Burning cost Claims frequency" Average cost per cai; 8. Loss rato: Incurred elaime! Premium; 9. Combined rata: Loss ratio + Expense ratio 535 | Reaulte of Financial Projections/Sansitivity Analysts: [The profi margins Shou | bbe shown for various model points for bate.optimistc and passmistc scenarios | In a tabular format below. The definition of praft margin should be taken as the present value of et profits 10 the pv of premiums, Please specty assumptions made in each scenaria, Fo terms less than or equal to one year lss rato may be Used and for terms more than one year, proft margin may be Used.) 536 Risk discount rate used inthe | profit margin 5a7_[ Average Sum Insured Assumed ae 538 [Assumptions made under pessimistic scenario _ 338 [Assumptions made under optimistic scenario, Bad [Age (PM: Profit Pi (base | PT [PM feptimistc Margin/Loss Ratio] [Age Band | scenario) | (pessimistic | scenario) may be revisted based on the scenario) product design paratmeters] SaDE sass ~ sie 55650| Section Vi Enclosures to the Application’ “The following specimen documents should be enclosed: 536 S| Sales Literature Prospectus. This isthe erature which fo be used bythe various distiouion channels for sling the product inthe marcet. This sha ‘enumerate al fhe. salient features of the prosuct slong with ine excisions “Sppleabe forthe basic Benefits and shal be in complaince wih the relevant Crevlars sued bythe Authorty ata mes). 32 [Poly Decumenté Poicy Schedule 33 | Techical Note on Prcing 34 | Proposal form, wherever necessa%y 68 | Premium Table 35 | Certicats by Appointed Aawary and Griet Compliance Offear 67 «(Cis i ~| Soft ware used for product design and monitoring ~ (or information ofthe Authority) ‘The Insurer shall enclose a certificate from the Chief Compliance Offcer, Aprointed Actuary, countarsigned by the principal officer ef the insurer, as per specimen gren below (The Fanguage of this should not be atered) Centification by Chief Compliance Officer (Name of Chief Compliance Officer) the undersigned, on behsll of the Insurer named below, hereby affirm and deciare as follows: 1 2 That the details of the (Name of product) filed in above are true and correct and reflect what the policy and other documents indicate, ‘That the product complies with the various provisions of the IRDAI Health Insurance Regulations, 2016, Guidelines on Standardization of Health Insurance, Product Filing, Guidelines. on Standardization of Exclusions in Health Insurance Contracts, Guidelines on Standard Individual Health Insurance Product, issued thereon and the applicable provisons of extant IRDAI Regulations and all circulars issued by IRDA from time to time. ‘That this application and all other documents are complete and have been verified for correciness and consistency not only in respect o* each item of each document but also vis-a-vis one another.4, | confy thatthe policy wordings and Customer Information sheet filed along with this application is in. compliance with IRDAI (Hezlth Insurance) Regulations, 2018, Product Filing Guidelines, Guidelines on Standardization fof Health Insurance, Guidelines on Standardization of Exclusions in Heath Insurance Contracts, Guidelines on Standard Individual Health Insurance Product issued thereon, 5. | further certify that the Prospectus submited is in complance with the applicable provisions of Rules, IRDAI Regulations and Guidelines on Product Filing and Insurance Advertisements, Date: (Chief Compliance Officer) Name of Insurer Certification by Appointed Actuary: |, (mame of the appointed actuary), the appointed actuary, hereby solemnly declare that tha information furnished in this Application Form is tue. | also cary that, in my opinion, the premium rate, advantages, terms and conditions ofthe above product are workable and sound, the assumptions are ressonable and premium rates are fai.” | have carefully studied the requirements ofthe Produet Fling Procedure In relation tothe Gesign and rating of insurance products, ‘The rates, terms and conditions of the above mentioned product ate determined on technically sound basis and are sustainable on the basis of the information and claims ‘experience avaible inthe records ofthe insurer. ‘An adequate system has been putin place for collection of data on premiums and claims based on every rating factor that wil enable review ofthe rates and terms of the cover from time to me. Its planned to review the rate, tems and condtions of cover (— mention Petiodicy of review) based on emerging experience, itis further certted that the underwrting of the product now fled shal be within the Boars ‘approved underwriting philosophy ofthe Company. ‘The requirements ofthe Product Fling Procedure have been full complied with in espect of this produet or revision modication of te product ‘urther dactre that except the Sections mentioned in §.No, no other feturtbeneiclause 's modified in the product (applicable only for revision or modification ofthe product) Place Signature of the Appointed Actuary Date:Certification by Principal Officer or CEO | (eame of the Principal Officer or CEO), (mention designation) hereby confirm that: 1. The rates, terms and consitions of the above-mentioned product fed wit his cattieate have been determined in compliance withthe IRDA Act, 1989, nsurance Act, 1838, and the Regulations and guidaines cued there under, including the Fla and Use| Proguct Fling guidelines, 2, The prospectus, sales literature, polcy and endorsement documents, snd the rates, terms and condition ofthe product have been prepared on a technically sound basis and on {rms that ae fai Detwoen the neuer and th sent and are set out in language that clear and unambiguous, 3, These documents are ais flyin compliance wth the underwriting and ratng policy approved by the Board of Directors ofthe insurer ‘4 The statements made inthe fing Form IROAI-UNF-HISP are tue and correct, 5, The requirements ofthe Product Fling Guidelines have been fully complied with in respect ofthis produc, Date Signature of Principal Ocer or Designated Officer Place: Name and designation along with Company’s seal