Group Medi Care 6c57b64356

Group MediCare - Base - Policy Wording
Preamble references to the male include the female and

We will provide the insurance cover detailed in references to any statutory enactment include
the Policy to the Insured Persons up to the Sum subsequent changes to the same:
Insured subject to: i. Standard Definitions
i. The terms, conditions and exclusions of 1. Accident
this Policy. An accident means sudden, unforeseen
ii. Statements in the proposal/enrolment and involuntary event caused by external,
form and information disclosed to Us visible and violent means.
by You or on Your behalf and on behalf 2. Any one illness
of all persons to be insured which is Any one illness means continuous period of
incorporated into the Policy and is the basis illness and includes relapse within 45 days
of it. from the date of last consultation with the
Commencement of risk cover under the policy Hospital/Nursing Home where treatment
is subject to receipt of premium by Us. was taken.
While the policy is in force, and if the claim is 3. Cashless facility
admissible under the policy, then We shall pay Cashless facility means a facility extended
You such Reasonable and Customary Medical by the insurer to the insured where the
Expenses incurred on treatment or pay for the payments, of the costs of treatment
listed benefit sum insured. The said treatment undergone by the insured in accordance
must be on the advice of a qualified Medical with the policy terms and conditions, are
Practitioner. directly made to the network provider by
Our liability at any time shall not exceed the the insurer to the extent pre-authorization
maximum sum insured applicable for the is approved.
benefit as specified in Your policy schedule or 4. Congenital Anomaly
Certificate of insurance. In case of family floater, Congenital Anomaly means a condition
the sum insured shall be applicable for all the which is present since birth, and which is
claims made by any or all the insured persons abnormal with reference to form, structure
in the family whereas in case of individual, this or position.
shall be applicable for all the claims made by an a) Internal Congenital Anomaly
individual insured person.
Congenital anomaly which is not in
In case of any other sum insured restrictions, the visible and accessible parts of the
the same shall be clearly specified in Your Policy body.
schedule/Certificate of Insurance.
b) External Congenital Anomaly
Section 1 – Definitions Congenital anomaly which is in the
The terms defined below and at other junctures visible and accessible parts of the
in the Policy Wording have the meanings body
ascribed to them wherever they appear in this
5. Co-Payment
Policy and, where appropriate, references to
the singular include references to the plural; Co-payment means a cost sharing
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Tata AIG General Insurance Company Limited
Registered Office: Peninsula Business Park, Tower A, 15th Floor, G. K. Marg, Lower Parel, Mumbai- 400013,
Maharashtra, India 24x7 Toll Free No. 1800 266 7780 or 1800 22 9966 (Senior Citizen) • Visit us at www.tataaig.com
IRDA of India Registration No.:108 • CIN: U85110MH2000PLC128425 • UIN: TATHLGP21248V022021
requirement under a health insurance hours.

policy that provides that the policyholder/
Treatment normally taken on an out-
insured will bear a specified percentage
patient basis is not included in the scope
of the admissible claims amount. A co-
of this definition
payment does not reduce the Sum Insured.
8. Dental Treatment
6. Day Care Centre
Dental treatment means a treatment
A day care centre means any institution
related to teeth or structures supporting
established for day care treatment of illness
teeth including examinations, fillings
and/or injuries or a medical setup with a
(where appropriate), crowns, extractions
hospital and which has been registered
and surgery.
with the local authorities, wherever
applicable, and is under supervision 9. Domiciliary Hospitalization
of a registered and qualified medical
Domiciliary hospitalization means medical
practitioner AND must comply with all treatment for an illness/disease/injury
minimum criterion as under – which in the normal course would require
i. has qualified nursing staff under its care and treatment at a hospital but is
employment; actually taken while confined at home
under any of the following circumstances:
ii. has qualified medical practitioner/s
in charge; i. the condition of the patient is such
that he/she is not in a condition to
iii. has fully equipped operation theatre be removed to a hospital, or
of its own where surgical procedures
are carried out; ii. the patient takes treatment at home
on account of non-availability of
iv. maintains daily records of patients room in a hospital.
and will make these accessible to
the insurance company’s authorized 10. Grace Period
personnel. Grace period means the specified period of
7. Day Care Treatment time immediately following the premium
due date during which a payment can be
Day care treatment means medical made to renew or continue a policy in force
treatment, and/or surgical procedure without loss of continuity benefits such
which is: as waiting periods and coverage of pre-
existing diseases. Coverage is not available
i. undertaken under General or Local
for the period for which no premium is
Anesthesia in a hospital/day care
received.
centre in less than 24 hrs because of
technological advancement, and 11. Hospital
ii. which would have otherwise required A hospital means any institution established
hospitalization of more than 24 for in-patient care and day care treatment
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of illness and/or injuries and which has Acute condition is a disease, illness or
been registered as a hospital with the local injury that is likely to respond quickly
authorities under Clinical Establishments to treatment which aims to return the
(Registration and Regulation) Act 2010 or person to his or her state of health
under enactments specified under the immediately before suffering the
Schedule of Section 56(1) and the said act disease/ illness/ injury which leads
Or complies with all minimum criteria as to full recovery
under:
(b) Chronic condition
i. has qualified nursing staff under its
A chronic condition is defined as
employment round the clock;
a disease, illness, or injury that
ii. has at least 10 in-patient beds in has one or more of the following
towns having a population of less characteristics:
than 10,00,000 and at least 15 in- i. it needs ongoing or long-
patient beds in all other places; term monitoring through
iii. has qualified medical practitioner(s) consultations, examinations,
in charge round the clock; check-ups, and /or tests
iv. has a fully equipped operation ii. it needs ongoing or long-term

theatre of its own where surgical control or relief of symptoms
procedures are carried out; iii. it requires rehabilitation for the
v. maintains daily records of patients patient or for the patient to be
and makes these accessible to the specially trained to cope with it
insurance company’s authorized iv. it continues indefinitely
personnel;
v. it recurs or is likely to recur
12. Hospitalization
14. Injury
Hospitalization means admission in a
Injury means accidental physical bodily
Hospital for a minimum period of 24
harm excluding illness or disease solely
consecutive ‘In-patient Care’ hours except
and directly caused by external, violent,
for specified procedures/ treatments,
visible and evident means which is verified
where such admission could be for a
and certified by a Medical Practitioner.
period of less than 24 consecutive hours.
15. In-patient Care
13. Illness
Inpatient care means treatment for which
Illness means a sickness or a disease
the insured person has to stay in a hospital
or pathological condition leading to the
for more than 24 hours for a covered event.
impairment of normal physiological
function and requires medical treatment. 16. Maternity expenses
(a) Acute condition Maternity expenses means;

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a. medical treatment expenses traceable i. is required for the medical

to childbirth (including complicated management of the illness or injury
deliveries and caesarean sections suffered by the insured;
incurred during hospitalization);
ii. must not exceed the level of care
b. expenses towards lawful medical necessary to provide safe, adequate
termination of pregnancy during the and appropriate medical care in
policy period. scope, duration, or intensity;
17. Medical Advice iii. must have been prescribed by a

medical practitioner;
Medical Advice means any consultation
or advice from a Medical Practitioner iv. must conform to the professional
including the issuance of any prescription standards widely accepted in
or follow-up prescription. international medical practice or by
the medical community in India.
18. Medical Expenses
21. Network Provider
Medical Expenses means those expenses
that an Insured Person has necessarily and Network Provider means hospitals or
actually incurred for medical treatment health care providers enlisted by an
on account of Illness or Accident on the insurer, TPA or jointly by an Insurer and
advice of a Medical Practitioner, as long as TPA to provide medical services to an
these are no more than would have been insured by a cashless facility.
payable if the Insured Person had not been
22. OPD treatment
insured and no more than other hospitals
or doctors in the same locality would have OPD treatment means the one in which
charged for the same medical treatment. the Insured visits a clinic / hospital or
associated facility like a consultation room
19. Medical Practitioner
for diagnosis and treatment based on
Medical Practitioner means a person who the advice of a Medical Practitioner. The
holds a valid registration from the Medical Insured is not admitted as a day care or
Council of any State or Medical Council of in-patient.
India or Council for Indian Medicine or for
23. Pre-Existing Disease
Homeopathy set up by the Government of
India or a State Government and is thereby Pre-Existing Disease means any condition,
entitled to practice medicine within its ailment , injury or disease
jurisdiction; and is acting within its scope
o That is/are diagnosed by a Physician
and jurisdiction of license.
within 48 months prior to the
20. Medically Necessary Treatment effective date of the Policy issued by
the Insurer or its reinstatement; or
Medically necessary treatment means any
treatment, tests, medication, or stay in o For which medical advice or treatment
hospital or part of a stay in hospital which: was recommended by, or received
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from, a Physician within 48 months pre-existing conditions and time bound

prior to the effective date of the exclusions, with the same insurer.
Policy issued by the Insurer; or its
27. Qualified Nurse
reinstatement.
Qualified nurse means a person who
24. Pre-hospitalization Medical Expenses
holds a valid registration from the Nursing
Pre-hospitalization Medical Expenses Council of India or the Nursing Council of
means medical expenses incurred during any state in India.
predefined number of days preceding
28. Reasonable and Customary Charges
the hospitalization of the Insured Person,
provided that: Reasonable and Customary charges means
the charges for services or supplies, which
i. Such Medical Expenses are incurred
are the standard charges for the specific
for the same condition for which the
provider and consistent with the prevailing
Insured Person’s Hospitalization was
charges in the geographical area for
required, and
identical or similar services, taking into
ii. The In-patient Hospitalization claim account the nature of the illness / injury
for such Hospitalization is admissible involved.
by the Insurance Company.
29. Renewal
25. Post-hospitalization Medical Expenses
Renewal means the terms on which the
Post-hospitalization Medical Expenses contract of insurance can be renewed on
means medical expenses incurred during mutual consent with a provision of grace
predefined number of days immediately period for treating the renewal continuous
after the insured person is discharged from for the purpose of gaining credit for pre-
the hospital provided that: existing diseases, time-bound exclusions
and for all waiting periods.
i. Such Medical Expenses are for
the same condition for which the 30. Room Rent
insured person’s hospitalization was
Room Rent means the amount charged
required, and
by a Hospital towards Room and Boarding
ii. The inpatient hospitalization claim for expenses and shall include the associated
such hospitalization is admissible by medical expenses.
the insurance company
31. Surgery or Surgical Procedure
26. Migration
Surgery or Surgical Procedure means
Migration” means, the right accorded to manual and / or operative procedure
health insurance policyholders (including (s) required for treatment of an illness
all members under family cover and or injury, correction of deformities and
members of group health insurance defects, diagnosis and cure of diseases,
policy), to transfer the credit gained for relief from suffering and prolongation of
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life, performed in a hospital or day care Holder and/or Insured Person(s) who is
centre by a medical practitioner. named in the Policy Schedule.
32. Unproven/Experimental treatment 5. Associated Medical Expenses

Associated Medical Expenses shall
Unproven/Experimental treatment means
include Room Rent, nursing charges,
the treatment including drug experimental
operation theatre charges, fees of
therapy which is not based on established
Medical Practitioner/surgeon/ anesthetist/
medical practice in India, is treatment
Specialist conducted within the same
experimental or unproven.
Hospital where the Insured Person has
ii. Specific Definitions(Definitions other been admitted.
than as mentioned under Section 1 (i)
6. Policyholder
above)
The Policyholder shall be the Employer
1. Age
who has taken the group insurance policy
Means the completed age of the Insured as a service benefit to his Employees or a
Person on his / her most recent birthday Group Manager of a homogeneous group
as per the English calendar, regardless of of persons who assemble together for a
the actual time of birth. commonality of purpose and there is a
clearly evident relationship between the
2. Room Category member and group manager for services
Room Category shall mean one of the other than insurance.
following: Section 2: Benefits (Base Covers)
a. Single Private Room means a hospital The following benefits are payable subject to
room with one patient bed and such Terms and Conditions of the policy:
room must be the most economical B1. In-Patient Treatment
of all accommodations available in
We will cover for expenses for
that hospital as single occupancy.
hospitalization due to disease/illness/Injury
b. Shared Accommodation means a during the policy period that requires an
hospital room with two or more Insured Person’s admission in a hospital
patient beds. as an inpatient.
c. Economy Ward means a hospital Medical expenses directly related to
room with more than three patient the hospitalization would be payable
beds. provided:
i. Limit on Room Rent/Room
This definition does not apply to ICU or
Category:
ICCU.
We will, limit Room Rent up to the
3. We/Us/Our means TATA AIG General amount/percentage of Sum Insured
Insurance Company Limited. or room category as specified in
4. You/Your/Yourself means the Policy the Policy Schedule/ Certificate of
Insurance.
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ii. Associated Medical Expenses: iii. Limit on Treatment / Illness/

a. If the Insured Person is admitted Surgery/ Medical Condition
in a room where the Room We will cover the Medical Expenses
Rent expenses incurred is incurred towards claim for a specified
higher than limit specified in treatment of an Illness/procedure
the Policy Schedule/ Certificate upto the amount of Sub-Limit
of Insurance, then the Insured applicable per claim during the
Person shall bear a rateable Policy Year as specified in the Policy
proportion of the total Schedule/ Certificate of Insurance.
Associated Medical Expenses B2. Pre-Hospitalization expenses
(including surcharge or taxes
We will cover the Pre-Hospitalization
thereon), except pharmacy
expenses for consultations, investigations
charges, diagnostic costs,
and medicines incurred upto the number
costs of implants & medical
of days as specified in your policy schedule/
devices and consumables
Certificate of Insurance.
expenses, in the proportion
of the difference between the The benefit is payable if We have admitted
eligible Room Rent expenses a claim under In-patient Treatment/Day
to the Room Rent expenses Care Procedures/Domiciliary treatment.
actually incurred. Proportionate B3. Post-Hospitalization expenses
Expenses is applied in respect We will cover the Post-Hospitalization
of the Hospital which follow expenses for consultations, investigations
differential billing or for those and medicines incurred upto the number of
expenses in respect of which days, as specified in your policy schedule/
differential billing is adopted Certificate of Insurance.
based on the Room Category.
The benefit is payable if We have admitted
b. If the Insured Person is admitted a claim under In-patient Treatment/Day
in a hospital room where the Care Procedures /Domiciliary treatment.
room category opted is higher
B4. Day Care Procedures
than the category specified in
the Policy Schedule/Certificate We will cover expenses for listed Day Care
of Insurance, then the Insured treatment due to disease/illness/Injury
Person shall bear 10% of during the policy period taken at a hospital
admissible claim amount or a Day Care Centre. The list of such day
care procedures covered is available on
In case of unavailability of specified
our website (www.tataaig.com).
room category, the Insured Person
is eligible for next immediate This benefit under the policy will be
available hospital room provided limited to the amount specified in the
that necessary documented proof for Policy Schedule/ Certificate of Insurance.
unavailability of such hospital room Treatment normally taken on out-patient
is furnished to us. basis is not included in the scope of this
7 cover.
B5. Domiciliary Treatment registered ambulance to a Hospital for

We will cover for expenses related to admission in case of an Emergency or
Domiciliary Hospitalization of the insured from one hospital to another hospital for
person if the treatment exceeds beyond better medical facilities and treatment,
three days. The treatment must be for subject to amount as specified on the
management of an illness and not for policy schedule/Certificate of Insurance.
enteral feedings or end of life care. For this claim to be paid, the claim must
At the time of claiming under this benefit, be admissible under section In-patient
we shall require certification from the Treatment or Day Care Procedures of this
treating doctor fulfilling the conditions as policy.
mentioned under the general definitions B8. Maternity Cover
(Section 1-10) of this policy.
We will cover for Maternity Expenses for
This benefit under the policy will be limited the delivery of a child and/or Maternity
to the amount specified in the Policy Expenses related to a Medically Necessary
Schedule/ Certificate of Insurance. Treatment and lawful medical termination
B6. Organ Donor of pregnancy, during the Policy Year,
We will cover for Medical and surgical subject to the Sub-Limits and maternity
Expenses of the organ donor for harvesting waiting period as specified in the Policy
the organ where an Insured Person is the Schedule/ Certificate of Insurance. Medical
recipient provided that: expenses incurred for resuscitation of
newborn baby shall form part of the
i. The organ donor is any person whose
maternity sub imit.
organ has been made available
in accordance and in compliance We will not cover ectopic pregnancy under
with The Transplantation of Human this benefit (although it shall be covered
Organs Act (Amended) , 1994 and under section In-patient Treatment).
other applicable laws and rules and Expenses incurred for pre/post natal care
the organ donated is for the use of shall be excluded from the scope of this
the Insured Person, and coverage.
ii. We have accepted an inpatient B9. Pre/Post Natal Cover
Hospitalization claim for the
We will cover for Medical Expenses
insured member under In-Patient
incurred during the Policy Year on out-
Hospitalization Treatment (section
patient basis, in respect of pre- natal check-
B1).
ups, since confirmation of pregnancy,
This benefit under the policy will be limited post-natal check-ups for a period up to six
to the amount specified in the Policy weeks from date of loss, prescribed pre-
Schedule/ Certificate of Insurance. natal medicines and diagnostic tests up to
B7. Ambulance Cover the limit specified in the Policy Schedule/
We will cover for expenses incurred on Certificate of Insurance provided that:
transportation of Insured Person in a i. This Benefit is opted,
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ii. The maternity claim is admissible by parents-in-law, legal guardian, ward, step
Us under B8, and child or adopted child.
iii. Date of delivery is within policy period Section 3 – Exclusions
The sum insured applicable for pre/post
i. Standard Exclusions
natal cover on out-patient basis shall be
part of Maternity limit. 1. Exclusions with waiting period
We will not be liable to make any payment i. Pre-Existing Diseases(Code- Excl 01)
in respect of any Pre-hospitalization shall be waived off
Expenses or Post – hospitalization ii. Specified disease / procedure
Expenses paid under the Base Cover. Waiting period: (Code- Excl 02)shall
B10. Baby day one Cover be waived off
We will cover for Medical Expenses iii. 30 days waiting (Code- Excl 03) shall
incurred during the Policy Year, towards be waived off
the Treatment of the New Born Baby from 2. Medical Exclusions
the date of birth of baby up to the Sub We will neither be liable nor make any
Limit, as specified in the Policy Schedule/ payment for any claim in respect of
Certificate of Insurance, provided that You any Insured Person which is caused by,
have paid requisite premium for inclusion arising from or in any way attributable
of the newborn baby in to the policy. to any of the following exclusions, unless
New Born Baby older than 90 days can be expressly stated to the contrary in this
covered under the Policy as an Insured Policy connection with or in respect of:
Person only by way of an endorsement or 1. Investigation & Evaluation
at the next Renewal, whichever is earlier, (Code- Excl 04)
on payment of the requisite premium.
a) Expenses related to any
B11. Family Transportation Benefit admission primarily for
If We have accepted a claim under Benefit diagnostics and evaluation
B1, then We will reimburse the actual purposes only are excluded.
expenses incurred in transporting one b) Any diagnostic expenses which
Immediate Family Member from the are not related or not incidental
Insured Person’s residence to the Hospital to the current diagnosis and
where the Insured Person is admitted, treatment are excluded.
provided that such Hospital is located
at least 200 kms away from the Insured 2. Rest Cure, rehabilitation and
respite care(Code- Excl 05)
Person’s residence up to the limit as
specified in the policy schedule/Certificate Expenses related to any admission
of Insurance. primarily for enforced bed rest and
For the purpose of this benefit, Immediate not for receiving treatment. This also
Family Member means the Insured includes:
Person’s legal spouse, children, parents, i. Custodial care either at home or
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in a nursing facility for personal 4. Change-of-Gender treatments:

care such as help with activities (Code- Excl 07)
of daily living such as bathing, Expenses related to any treatment,
dressing, moving around either including surgical management, to
by skilled nurses or assistant or change characteristics of the body to
non-skilled persons. those of the opposite sex.
ii. Any services for people who 5. Cosmetic or plastic Surgery: (Code-
are terminally ill to address Excl 08)
physical, social, emotional and
Expenses for cosmetic or plastic
spiritual needs.
surgery or any treatment to change
3. Obesity/ Weight Control (Code- Excl appearance unless for reconstruction
06) following an Accident, Burn(s) or
Expenses related to the surgical Cancer or as part of medically
treatment of obesity that does not necessary treatment to remove a
fulfill all the below conditions: direct and immediate health risk to
1) Surgery to be conducted is upon the insured. For this to be considered
the advice of the Doctor a medical necessity, it must be
2) The surgery/Procedure certified by the attending Medical
conducted should be supported Practitioner.
by clinical protocols 6. Treatment for, Alcoholism, drug or
3) The member has to be 18 years substance abuse or any addictive
of age or older and condition and consequences thereof.
(Code- Excl 12)
4) Body Mass Index (BMI);
a) greater than or equal to 40 7. Treatments received in heath
or hydros, nature cure clinics, spas or
similar establishments or private
b) greater than or equal to
beds registered as a nursing home
35 in conjunction with any
attached to such establishments or
of the following severe
where admission is arranged wholly
co-morbidities following
or partly for domestic reasons.
failure of less invasive
(Code- Excl 13)
methods of weight loss:
I. Obesity-related 8. Dietary supplements and substances
cardiomyopathy that can be purchased without
prescription, including but not limited
II. Coronary heart
to Vitamins, minerals and organic
disease
substances unless prescribed by
III. Severe Sleep Apnea a medical practitioner as part of
IV. Uncontrolled Type2 hospitalization claim or day care
Diabetes procedure (Code- Excl 14)
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9. Refractive Error: (Code- Excl 15) i. Hazardous or Adventure Sports

(Code Excl09) : Expenses related
Expenses related to the treatment
to any treatment necessitated due
for correction of eye sight due to
to participation as a professional
refractive error less than 7.5 dioptres.
in hazardous or adventure
10. Unproven Treatments: (Code- Excl sports, including but not limited
16) to, para-jumping, rock climbing,
Expenses related to any unproven mountaineering, rafting, motor
treatment, services and supplies for racing, horse racing or scuba diving,
or in connection with any treatment. hand gliding, sky diving, deep-sea
Unproven treatments are treatments, diving
procedures or supplies that lack ii. Breach of law (Code Excl10): Expenses
significant medical documentation for treatment directly arising from or
to support their effectiveness. consequent upon any Insured Person
11. Sterility and Infertility: (Code- committing or attempting to commit
Excl 17) a breach of law with criminal intent.
Expenses related to sterility and iii. Expenses incurred towards treatment

infertility. This includes: in any hospital or by any Medical
Practitioner or any other provider
i. Any type of contraception,
specifically excluded by the Insurer
sterilization
and disclosed in its website /
ii. Assisted Reproduction services notified to the policyholders are not
including artificial insemination admissible. However, in case of life
and advanced reproductive threatening situations or following an
technologies such as IVF, ZIFT, accident, expenses up to the stage of
GIFT, ICSI stabilization are payable but not the
iii. Gestational Surrogacy complete claim (Code – Excl11)
iv. Reversal of sterilization ii. Specific Exclusions (Exclusions other
12. Maternity (Code - Excl 18): than as mentioned under Section 3 (i)
i. Medical treatment expenses above)
traceable to childbirth (including 1. Exclusions with waiting periods
complicated deliveries and
caesarean sections incurred i. Nine months maternity waiting
during hospitalization) except period shall be waived off
ectopic pregnancy;
2. Medical Exclusions
ii. expenses towards miscarriage
(unless due to an accident) and lawful i. Congenital External Diseases, defects
medical termination of pregnancy or anomalies.
during the policy period. ii. Stem cell therapy, however
3. Non-Medical Exclusions
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Hematopoietic stem cells for bone ii. Any Insured Person’s participation or
marrow transplant for haematological involvement in naval, military or air
conditions will be covered under force operation.
Benefit B1 and B4 of this Policy.
iii. Intentional self-injury or attempted
iii. Growth hormone therapy. suicide while sane or insane.
iv. Sleep-apnoea. iv. Items of personal comfort and

convenience like television (wherever
v. A d m i s s i o n p r i m a r i l y f o r
specifically charged for), charges for
administration of Intra-articular
access to telephone and telephone
or intra-lesional injections or
calls, internet, foodstuffs (except
Intravenous immunoglobulin infusion
patient’s diet), cosmetics, hygiene
or supplementary medications like
articles, body care products and bath
Zolendronic Acid.
additive, barber or beauty service,
vi. V e n e r e a l d i s e a s e , s e x u a l l y guest service.
transmitted disease or illness.
v. Treatment rendered by a Medical
vii. All preventive care, vaccination Practitioner which is outside his
including inoculation and discipline
immunisations (except in case of
vi. Doctor’s fees charged by the Medical
post- bite treatment and other
Practitioner sharing the same
vaccines explicitly covered).
residence as an Insured Person or
viii. Dental treatment or surgery of who is an immediate relative of an
any kind unless as a result of Insured Person’s family.
Illness/Accidental Bodily Injury to
vii. Provision or fitting of hearing aids,
natural teeth and also requiring
spectacles or contact lenses including
hospitalization.
optometric therapy unless explicitly
ix. Any non-allopathic treatment. stated and covered in the policy.
3. Non-Medical Exclusions viii. Any treatment and associated

expenses for alopecia, baldness,
i. War or any act of war, invasion, act wigs, or toupees, medical supplies
of foreign enemy, war like operations
including elastic stockings, diabetic
(whether war be declared or notor
test strips, and similar products.
caused during service in the armed
forces of any country),, civil war, ix. Any treatment or part of a treatment
public defence, rebellion, revolution, that is not of a reasonable charge,
insurrection, military or usurped acts, not medically necessary; drugs or
nuclear weapons/materials, chemical treatments which are not supported
and biological weapons, ionising by a prescription.
radiation.
x. Crutches or any other external
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appliance and/or device used for Person or anyone acting on his/her behalf
diagnosis or treatment (except when to obtain any benefit under this policy, all
used intra-operatively and explicitly benefits under this policy and the premium
stated and covered in the policy. paid shall be forfeited.
xi. Any claim incurred after date of Any amount already paid against claims
proposal/enrolment form and before made under this Policy but which are
issuance of policy/Certificate of found fraudulent later shall be repaid by all
Insurance where there is change in recipient (s)/ Policyholder(s), who has made
health status of the member and the that particular claim, who shall be jointly
same is not communicated to us. and severally liable for such repayment to
the Insurer.
Section 4 – General Terms and Clauses
For the purpose of this clause, the
i. Standard General Terms & Clauses expression “fraud” means any of the
following acts committed by the insured
1. Condition Precedent to Admission of
person or by his agent or the Hospital /
Liability
Doctor, any other party acting on behalf of
The terms and conditions of the policy the Insured Person with intent to deceive
must be fulfilled by the Insured Person the insurer or to induce the insurer to issue
for the Company to make any payment for an insurance policy:
claim(s) arising under the Policy.
a) the suggestion, as a fact of that which
2. Disclosure of Information is not true and which the insured
The policy shall be void and all premium paid person does not believe to be true;
thereon shall be forfeited to the Company b) the active concealment of a fact by the
in the event of mis-representation, mis- insured person having knowledge or
description or non-disclosure of any belief of the fact;
material fact by the Policyholder
c) any other act fitted to deceive; and
(Explanation: “Material facts” for the
d) any such act or omission as the law
purpose of this policy shall mean all
specially declares to be fraudulent
relevant information sought by the
company in the proposal form and other The Company shall not repudiate the
connected documents to enable it to claim and / or forfeit the policy benefits
take informed decision in the context of on the ground of Fraud, if the insured
underwriting the risk) person / beneficiary can prove that the
misstatement was true to the best of his
3. Fraud
knowledge and there was no deliberate
If any claim made by the Insured Person, intention to suppress the fact or that
is in any respect fraudulent, or if any false such mis-statement of or suppression of
statement, or declaration is made or used material fact are within the knowledge of
in support thereof, or if any fraudulent the insurer.
means or devices are used by the Insured
4. Multiple Policies
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i. In case of multiple policies taken by an Company is not under obligation to

insured person during a period from give any notice for renewal.
one or more insurers to indemnify ii. Renewal shall not be denied on the
treatment costs, the insured person ground that the insured had made a
shall have the right to require a claim or claims in the preceding policy
settlement of his/her claim in terms years.
of any of his/her policies. In all such
iii. Request for renewal along with
cases the insurer chosen by the
requisite premium shall be received
Insured Person shall be obliged to
by the Company before the end of
settle the claim as long as the claim
the policy period.
is within the limits of and according
to the terms of the chosen Policy. iv. At the end of the policy period, the
policy shall terminate and can be
ii. Insured person having multiple
renewed within the Grace Period
policies shall also have the right to
of 30 days to maintain continuity
prefer claims under this policy for
of benefits without Break in Policy.
the amounts disallowed under any
Coverage is not available during the
other policy / policies even if the sum
grace period.
insured is not exhausted. Then the
Insurer shall independently settle v. No loading shall apply on renewals
the claim subject to the terms and based on individual claims
conditions of this Policy. experience.
iii. If the amount to be claimed exceeds 6. Possibility of Revision of Terms of the

the sum insured under a single Policy, Policy Including the Premium Rates
the Insured person shall have the The Company, with prior approval of
right to choose insurer from whom IRDAI, may revise or modify the terms of
he/she wants to claim the balance the Policy including the premium rates.
amount. The Insured Person shall be notified three
iv. Where an insured person has policies months before the changes are effected.
from more than one insurer to cover 7. Migration
the same risk on indemnity basis,
The insured person will have the option
the insured person shall only be
to migrate the policy to other health
indemnified the hospitalization costs
insurance products/plans offered by the
in accordance with the terms and
company policy by applying for migration
conditions of the chosen Policy.
of the policy atleast 30 days before the
5. Renewal of Policy policy renewal date as per IRDAI guidelines
The Policy shall ordinarily be on Migration. If such person is presently
renewable except on grounds of fraud, covered and has been continuously
misrepresentation by the insured person. covered without any lapses under any
health insurance product/plan offered by
i. The Company shall endeavor to give
the company, the insured person will get
notice for renewal. However, the
14
the accrued continuity benefits in waiting periods as per IRDAI guidelines on Migration.
For Detailed Guidelines on Migration, kindly refer Guidelines issued by IRDAI(Insurance
Regulatory and Development Authority of India) on Migration and Portability of Health
Insurance policies – Ref: IRDAI/HLT/REG/CIR/194/07/2020) dated 22nd July 2020 and subsequent
amendments thereof.
8. Withdrawal of Policy
i. In the likelihood of this product being withdrawn in future, the Company will intimate
the Insured Person about the same 90 days prior to expiry of the Policy.
ii. Insured Person will have the option to migrate to similar health insurance product available
with the Company at the time of renewal with all the accrued continuity benefits such as
cumulative bonus, waiver of waiting period as per IRDAI guidelines provided the Policy
has been maintained without a break.
9. Cancellation
i. The Policyholder may cancel this policy by giving 15 days written notice and in such
an event, the Company shall refund premium for the unexpired policy period as
detailed below.
Notwithstanding anything contained herein or otherwise, no refunds of premium shall be made in
respect of Cancellation where, any claim has been admitted or has been lodged or any Benefit has
been availed by the Insured Person under the Policy.
ii. The Company may cancel the Policy at any time on grounds of mis-representation, non-
disclosure of material facts, fraud by the Insured Person by giving 15 days written notice.
There would be no refund of premium on cancellation on grounds of mis-representation,
non-disclosure of material facts or fraud.
Short Rate Table:
Year
Length of time Policy in force 1 2 3 4 5
Upto 1 Month 85.00% 87.50% 91.50% 96% 98%
>1 month & Upto 3 Months 70.00% 75.00% 88.50% 93% 95%
>3 months & Upto 6 Months 50.00% 62.50% 75% 78% 80%
>6 months & Upto 12 Months Nil 50.00% 66.50% 70% 72%
>12 months & Upto 15 Months Not Applicable 30% 50% 52% 54%
>15 months & Upto 18 Months Not Applicable 20% 41.50% 43% 44%
>18 months & Upto 24 months Not Applicable Nil 33% 35% 36%
>24 months & Upto 30 months Not Applicable Not Applicable 15% 20% 30%
> 30 months & Up to 36 months Not Applicable Not Applicable Nil 15% 25%
> 36 months & up to 42 Not Applicable Not Applicable Not Applicable Nil 20%
Exceeding 42 months Not Applicable Not Applicable Not Applicable Nil Nil
15
10. Free look period only when an endorsement on the Policy

is made. In the event of death of the
The Free Look Period shall be applicable
Policyholder, the Company will pay the
on new individual health insurance policies
nominee {as named in the Policy Schedule/
and not on renewals or at the time of
Policy Certificate/Endorsement (if any)} and
porting/migrating the policy.
in case there is no subsisting nominee, to
The insured person shall be allowed free the legal heirs or legal representatives of
look period of fifteen days from date of the Policyholder whose discharge shall be
receipt of the policy document to review treated as full and final discharge of its
the terms and conditions of the policy, and liability under the Policy.
to return the same if not acceptable.
12. Claim settlement (provision of Penal
If the insured has not made any claim Interest)
during the Free Look Period, the insured
i. The Company shall settle or reject a
shall be entitled to
claim, as the case may be, within 30
i. a refund of the premium paid days from the date of receipt of last
less any expenses incurred by the necessary document.
Company on medical examination
ii. ln the case of delay in the payment of
of the insured person and the stamp
a claim, the Company shall be liable
duty charges or
to pay interest to the policyholder
ii. where the risk has already from the date of receipt of last
commenced and the option of return necessary document to the date of
of the policy is exercised by the payment of claim at a rate 2% above
insured person, a deduction towards the bank rate.
the proportionate risk premium for
iii. However, where the circumstances
period of cover or
of a claim warrant an investigation
iii. Where only a part of the insurance in the opinion of the Company, it
coverage has commenced, shall initiate and complete such
such proportionate premium investigation at the earliest, in any
commensurate with the insurance case not later than 30 days from
coverage during such period the date of receipt of last necessary
document- ln such cases, the
11. Nomination:
Company shall settle or reject the
The Policyholder is required at the inception claim within 45 days from the date of
of the Policy to make a nomination for receipt of last necessary document.
the purpose of payment of claims under
iv. ln case of delay beyond stipulated
the Policy in the event of death of the
45 days, the Company shall be liable
Policyholder. Any change of nomination
to pay interest to the policyholder at
shall be communicated to the company in
a rate 2% above the bank rate from
writing and such change shall be effective
the date of receipt of last necessary
16
document to the date of payment of com/grievance-redressal-policy)

claim.
lf lnsured person is not satisfied with
(“Bank rate” shall mean the rate fixed the redressal of grievance through
above methods, the Insured Person may
by the Reserve Bank of lndia (RBl) at
also approach the office of lnsurance
the beginning of the financial year in
Ombudsman of the respective area/region
which claim has fallen due) for redressal of grievance as per lnsurance
Ombudsman Rules 2017. Grievance
13. Complete Discharge
may also be lodged at IRDAI lntegrated
Any payment to the Policyholder, Insured Grievance Management System - https://
Person or his/ her nominees or his/ her igms. irda.gov.in/
legal representative or assignee or to 15. Moratorium Period
the Hospital, as the case may be, for any
After completion of eight continuous
benefit under the policy shall be a valid
years under this policy no look back
discharge towards payment of claim by the would be applied. This period of eight
Company to the extent of that amount for years is called as moratorium period.
the particular claim. The moratorium would be applicable
for the sums insured of the first policy
14. Redressal of Grievance and subsequently completion of eight
continuous years would be applicable from
In case of any grievance the Insured Person
date of enhancement of sums insured only
may contact through
on the enhanced limits. After the expiry of
Website: www.tataaig.com Moratorium Period no health insurance
claim shall be contestable except for
Call us 24x7 toll free helpline 1800 266 7780 proven fraud and permanent exclusions
or 1800 22 9966 (Senior Citizen) Email us specified in the policy contract. The policies
at customersupport@tataaig.com would however be subject to all limits, Sub
Courier: Customer Support, Tata AIG limits, co-payments, deductibles as per the
General Insurance Company Limited, policy contract.
7th and 8th Floor, Romell Tech Park, Cama
ii. Specific terms and clauses (terms and
Industrial Estate, Western Express Highway,
clauses other than those mentioned
Goregaon(E), Mumbai, Maharashtra 400063
under Section 4 (i) above)
Visit the Servicing Branch mentioned in the
16. Condition Precedent
policy document
i. The premium for the policy will
The insured person may also approach
remain the same for the policy period
the grievance cell at any of the Company’s
as mentioned in the policy schedule.
branches with details of grievance.
ii. No change in this Policy shall be valid
lf lnsured person is not satisfied with
unless a valid endorsement is passed
the redressal of grievance through one
in the policy.
of the above methods, Insured person
may contact the grievance officer at iii. In case of master policy, the policy
manager.customersupport@tataaig.com. period would be 1 year however the
For updated details of grievance officer, period of certificate of insurance
kindly refer the link (https://www.tataaig. would be from 1 year to 5 years (in
17
case of credit linked). Details of the a. In case of Employer-Employee

policy term applicable to individual Policies:
certificate of insurance would be
clearly stated in Your certificate of • The coverage for existing
insurance. Primary Insured and
his dependents will
17. Insured Person automatically expire
from date of cessation of
i. Only those persons named as employment.
an Insured Person in the Policy
Schedule/Certificate of insurance • Pro-rata refund of
shall be covered under this Policy. premium would be made
on intimation provided
ii. Mid-term addition of Primary Insured such intimation is made
and Dependents: by a defined date and
Mid-term addition of Primary insured and no claim is made by the
dependents shall be allowed in the event Primary Insured or his
of following: dependents.
1. Intimation is given to Us by a defined b. In case of non Employer-

& agreed date and shall be subject Employee Policies, the coverage
to Guidelines on Group Insurance shall automatically expire from
Policies, dated 14th July 2005 the date the insured person
issued by Insurance Regulatory and exits the scheme.
Development Authority of India and c. In case of refund of premium
any subsequent amendments as being generated on the
published from time to time Policy due to deletion of
2. Requisite premium has been paid to Insured Persons, the same
Us. will be refunded or adjusted
accordingly against the future
3. All existing dependents must be premium installments due on
covered along with the Primary the Policy.
Insured and the addition of
Dependents shall be allowed only in 18. Entire Contract
the event of: i. This Policy, its Schedule,
• Children in the event of endorsement(s), proposal/enrolment
childbirth form constitutes the entire contract
of insurance. No change in this policy
• Spouse in the event of marriage shall be valid unless approved by
If any of the conditions (1) & Us and such approval be endorsed
(2) above are not met, coverage hereon.
will commence only from the date ii. This Policy and the Policy Schedule/
of intimation to Us or premium Certificate of insurance shall be
remittance whichever is later. read together as one contract and
iii. Mid-term deletion of Primary Insured any word or expression to which a
and Dependents: specific meaning has been attached
in any part of this Policy or of the
18
Schedule shall bear such meaning Section 5 – Claims Procedure and Claims
wherever it may appear. Payment
19. Notices
This section explains about the procedures
i. Any notice, direction or instruction involved to file a valid claim by the insured
under this Policy shall be in writing member and processes related in managing
and if it is to:
the claim by TPA or Us. All the procedures and
a. Any Insured Person, then it shall processes such as notification of claim, availing
be sent to You at Your address cashless service, supporting claim documents
specified in the Schedule to and related claim terms of payment are
this Policy and You shall act for
explained in this section.
all Insured Person(s) for these
purposes. 1. Notification of Claim
b. Us, it shall be delivered to Treatment, We or Our
Our address specified in the Consultation or TPA* must be
Schedule to this Policy. No
Procedure: informed:
insurance agents, brokers
or other person or entity is 1 If any treatment At least 48 hours
authorised to receive any for which a claim prior to the
notice, direction or instruction may be made and Insured Person’s
on Our behalf unless We have that treatment admission.
expressly stated to the contrary requires planned
in writing.
Hospitalisation:
20. Termination 2 If any treatment Within 24
i. You may terminate this Policy / for which a claim hours of the
Certificate of Insurance at any time may be made and Insured Person’s
by giving Us written notice, and the that treatment admission to
Policy/Certificate of Insurance shall r e q u i r e s Hospital.
terminate when such written notice e m e r g e n c y
is received. Hospitalisation
In case of master policy, each
Failure to furnish such intimation within
Certificate of Insurance will get
terminated on the earliest of the the time required shall not invalidate nor
following dates: reduce any claim if You can satisfy us that
it was not reasonably possible for You to
a. The date You or We cancel the
give proof of such delay within such time.
Certificate of Insurance
The Company may relax these timelines
b. The member opts out of the only in special circumstances and for
scheme the reasons beyond the control of the
c. Foreclosure/closure of loan insured.
availed (wherever applicable)\ *TPA as mentioned in the policy schedule
3. Procedure for Cashless Service

19
i. Cashless Service is only available at Network Hospitals.

ii. In order to avail cashless treatment, the following procedure must be followed by You:
2. Cashless Service
T r e a t m e n t , T r e a t m e n t , Cashless Service is We must be given
C o n s u l t a t i o n o r C o n s u l t a t i o n o r Available: notice that the Insured
Procedure: Procedure Taken at: Person wishes to
take advantage of
the cashless service
accompanied by full
particulars:
I f a n y p l a n n e d Network Hospital W e w i l l p r o v i d e At least 48 hours
t r e a t m e n t , cashless service by before the planned
consultation or making payment to t r e a t m e n t or
procedure for which the extent of Our Hospitalisation
a claim may be made: liability directly to the
Network Hospital.
I f a n y t r e a t m e n t , Network Hospital W e w i l l p r o v i d e Within 24 hours after
consultation or cashless service by t h e t r e a t m e n t o r
procedure for which making payment to Hospitalisation
a claim may be made, the extent of Our
requiring emergency liability directly to the
hospitalisation Network Hospital.
a. Prior to taking treatment and/ treatment.

or incurring Medical Expenses
d. Our designated TPA/We will
at a Network Hospital, You must
check your coverage as per
call our designated TPA/Us and
the eligibility and send an
request pre-authorization.
authorization letter to the
b. For any emergency provider. You have to provide
Hospitalization, our designated the ID card issued to You along
TPA/We must be informed with any other information
no later than 24 hours of the or documentation that is
start of Your hospitalization/ requested by the TPA/Us to
treatment. the Network Hospital.
c. For any planned e. In case of deficiency in the
hospitalization, our designated documents sent to TPA/Us for
TPA/We must be informed cashless authorization, the
atleast 48 hours prior to the same shall be communicated
start of your hospitalization/ to the hospital by TPA/Us
20
within 6 hours of receipt of the claim within 15 days or earlier of

documents. Our request or the Insured Person’s
discharge from Hospitalisation or
f. In case the ailment /treatment
completion of treatment.
is not covered under the policy
or cashless is rejected due ii. Failure to furnish such evidence
to insufficient documents within the time required shall not
submitted, a rejection letter invalidate nor reduce any claim if
would be sent to the hospital you can satisfy us that it was not
within 6 hours. reasonably possible for you to give
proof within such time.
g. Rejection of cashless in no way
indicates rejection of the claim. iii. We may accept claims where
You are required to submit documents have been provided
the claim along with required after a delayed interval only in special
documents for us to decide on circumstances and for the reasons
the admissibility of the claim. beyond the control of the Insured
Person.
h. If the cashless is approved,
the original bills and evidence iv. Such documentation will include
of treatment in respect of the the following:
same shall be left with the
a. Our claim form, duly completed
Network Hospital.
and signed for on behalf of
i. Pre-authorization does not the Insured Person. We, upon
guarantee that all costs and receipt of a notice of claim, will
expenses will be covered. We furnish Your representative
reserve the right to review each with such forms as We may
claim for Medical Expenses and require for filing proofs of loss
accordingly coverage will be or you may download the claim
determined according to the form from our Web site.
terms and conditions of this
b. Original Bills (pharmacy
Policy.
purchase bill, consultation
4. Supporting Documentation & bill, diagnostic bill) and any
Examination attachments thereto like
receipts or prescriptions in
i. You or someone claiming on
support of any amount claimed
Your behalf shall provide Us with
which will then become Our
documentation, medical records
property.
and information We or Our TPA
may request to establish the c. All medical reports, case
circumstances of the claim, its histories, investigation reports,
quantum or Our liability for the indoor case papers/ treatment
21
papers (in reimbursement k. Copy of MLC (Medico legal case)

cases, if available), discharge records, if carried out and FIR
summaries. (First information report) if
registered, in case of claims
d. A precise diagnosis of the
arising out of an accident and
treatment for which a claim is
available with the claimant.
made.
l. Regulatory requirements as
e. A detailed list of the individual
amended from time to time,
medical services and treatments
currently mandatory NEFT (to
provided and a unit price for
enable direct credit of claim
each in case not available in the
amount in bank account) and
submitted hospital bill.
KYC (recent ID/Address proof
f. Prescriptions that name the and photograph) requirements
Insured Person and in the
m. Legal heir/succession certificate,
case of drugs: the drugs
if required
prescribed, their price and a
receipt for payment. In case of n. PM report (wherever applicable
pre/post hospitalization claim and conducted)
Prescriptions must be submitted
v. Note: In case You are claiming for
with the corresponding Doctor/
the same event under an indemnity
hospital invoice.
based policy of another insurer and
g. All pre and post investigation, are required to submit the original
treatment and follow up documents related to Your treatment
(consultation) records with that particular insurer, then You
pertaining to the present may provide Us with the attested
ailment for which claim is being copies of such documents along with
made, if and where applicable. a declaration from the particular
insurer specifying the availability of
h. Treating doctor’s certificate
the original copies of the specified
regarding missing information
treatment documents with it.
in case histories e.g.
Circumstance of injury and We at our own expense, shall
Alcohol or drug influence at the have the right and opportunity to
time of accident, if available examine Insured Person(s) through
Our Authorised Medical Practitioner
i. Copy of settlement letter from
whose details will be notified to
other insurance company or
Insured Person when and as often
TPA
as We may reasonably require
j. Stickers and invoice of implants during the pendency of a claim
used during surgery hereunder.
22
5. Claims Payment and the third arbitrator to be appointed by

such two arbitrators and arbitration shall
i. We shall be under no obligation to
be conducted under and in accordance
make any payment under this Policy
with the provisions of the Arbitration and
unless We have received all premium
Conciliation Act 1996, as amended by
payments in full and on time and
Arbitration and Conciliation (Amendment)
We have been provided with the
Act, 2015 (No. 3 of 2016).
documentation and information
We or Our TPA has requested to It is clearly agreed and understood that no
establish the circumstances of the difference or dispute shall be preferable
claim, its quantum or Our liability for to arbitration as herein before provided, if
it, and unless the Insured Person has the Company has disputed or not accepted
complied with his obligations under liability under or in respect of the policy.
this Policy.
It is hereby expressly stipulated and
ii. All claims will be settled in declared that it shall be a condition
accordance with the applicable precedent to any right of action or suit
regulatory guidelines, including IRDAI upon the policy that award by such
(Protection of Policyholders Interests arbitrator/arbitrators of the amount of
Regulation), 2017. expenses shall be first obtained.
Section 6 - Dispute Resolution
1. Dispute Resolution Clause
Any and all disputes or differences

under or in relation to this Policy shall
be determined by the Indian Courts and
subject to Indian law.
2. Arbitration
If any dispute or difference shall arise as

to the quantum to be paid by the Policy,
(liability being otherwise admitted) such
difference shall independently of all other
questions, be referred to the decision
of a sole arbitrator to be appointed in
writing by the parties here to or if they
cannot agree upon a single arbitrator
within thirty days of any party invoking
arbitration, the same shall be referred to a
panel of three arbitrators, comprising two
arbitrators, one to be appointed by each
of the parties to the dispute/difference
23
List of Insurance Ombudsman
SN Centre Address & Contact
Office of the Insurance Ombudsman, Jeevan Prakash Building, 6th

floor, Tilak Marg, Relief Road, Ahmedabad – 380 001.
1 Ahmedabad
Tel.: 079 - 25501201/02/05/06
Email: bimalokpal.ahmedabad@cioins.co.in
Office of the Insurance Ombudsman, Jeevan Soudha Building,

PID No. 57-27-N-19 Ground Floor, 19/19, 24th Main Road,
2 Bengaluru JP Nagar, Ist Phase, Bengaluru – 560 078.
Tel.: 080 - 26652048 / 26652049
Email: bimalokpal.bengaluru@cioins.co.in
Office of the Insurance Ombudsman, Janak Vihar Complex,

2nd Floor, 6, Malviya Nagar, Opp. Airtel Office,
3 Bhopal Near New Market, Bhopal – 462 003.
Tel.: 0755 - 2769201 / 2769202
Email: bimalokpal.bhopal@cioins.co.in
Office of the Insurance Ombudsman, 62, Forest park,

Bhubaneswar – 751 009.
4 Bhubaneswar
Tel.: 0674 - 2596461 /2596455
Email: bimalokpal.bhubaneswar@cioins.co.in
Office of the Insurance Ombudsman, S.C.O. No. 101,

102 & 103, 2nd Floor, Batra Building, Sector 17 – D,
5 Chandigarh Chandigarh – 160 017.
Tel.: 0172 - 2706196 / 2706468
Email: bimalokpal.chandigarh@cioins.co.in
Office of the Insurance Ombudsman, Fatima Akhtar Court,

4th Floor, 453, Anna Salai, Teynampet, CHENNAI – 600 018.
6 Chennai
Tel.: 044 - 24333668 / 24335284
Email: bimalokpal.chennai@cioins.co.in
Office of the Insurance Ombudsman, 2/2 A, Universal Insurance

Building, Asaf Ali Road, New Delhi – 110 002.
7 New Delhi
Tel.: 011 - 23232481/23213504
Email: bimalokpal.delhi@cioins.co.in
Office of the Insurance Ombudsman, Jeevan Nivesh, 5th Floor,

Nr. Panbazar over bridge, S.S. Road, Guwahati – 781001(ASSAM).
8 Guwahati
Tel.: 0361 - 2632204 / 2602205
Email: bimalokpal.guwahati@cioins.co.in
24
Office of the Insurance Ombudsman, 6-2-46, 1st floor, “Moin Court”,

Lane Opp. Saleem Function Palace, A. C. Guards,
9 Hyderabad Lakdi-Ka-Pool, Hyderabad - 500 004.
Tel.: 040 - 23312122
Email: bimalokpal.hyderabad@cioins.co.in
Office of the Insurance Ombudsman, Jeevan Nidhi – II Bldg.,

Gr. Floor, Bhawani Singh Marg, Jaipur - 302 005.
10 Jaipur
Tel.: 0141 - 2740363
Email: bimalokpal.jaipur@cioins.co.in
Office of the Insurance Ombudsman, 2nd Floor, Pulinat Bldg.,

Opp. Cochin Shipyard, M. G. Road, Ernakulam - 682 015.
11 Ernakulam
Tel.: 0484 - 2358759 / 2359338
Email: bimalokpal.ernakulam@cioins.co.in
Office of the Insurance Ombudsman, Hindustan Bldg. Annexe,

7th Floor, 4, C.R. Avenue, KOLKATA - 700 072.
12 Kolkata
Tel.: 033 - 22124339 / 22124340
Email: bimalokpal.kolkata@cioins.co.in
Office of the Insurance Ombudsman, 6th Floor, Jeevan Bhawan,

Phase-II, Nawal Kishore Road, Hazratganj, Lucknow - 226 001.
13 Lucknow
Tel.: 0522 - 2231330 / 2231331
Email: bimalokpal.lucknow@cioins.co.in
Office of the Insurance Ombudsman, 3rd Floor, Jeevan Seva Annexe,

S. V. Road, Santacruz (W), Mumbai - 400 054.
14 Mumbai
Tel.: 69038821/23/24/25/26/ 27/28/28/29/30/31
Email: bimalokpal.mumbai@cioins.co.in
Office of the Insurance Ombudsman, Bhagwan Sahai Palace

4th Floor, Main Road, Naya Bans, Sector 15,
15 Noida Distt: Gautam Buddh Nagar, U.P-201301.
Tel.: 0120-2514252 / 2514253
Email: bimalokpal.noida@cioins.co.in
Office of the Insurance Ombudsman, 2nd Floor, North wing,

Lalit Bhawan, Bailey Road, Patna 800 001.
16 Patna
Tel.: 0612-2547068
Email: bimalokpal.patna@cioins.co.in
25
Office of the Insurance Ombudsman, Jeevan Darshan Bldg.,

3rd Floor, C.T.S. No.s. 195 to 198, N.C. Kelkar Road,
17 Pune Narayan Peth, Pune – 411 030.
Tel.: 020-41312555
Email: bimalokpal.pune@cioins.co.in
For updated list and details of Insurance or any rebate of the premium shown on
Ombudsman Offices, please visit website http:// the Policy, nor shall any person taking out
www.cioins.co.in/ombudsman.html or renewing or continuing a Policy accept
any rebate, except such rebate as may be
Prohibition of Rebates - Section 41 of the
allowed in accordance with the published
Insurance Act, 1938 as amended by Insurance
prospectuses or tables of the insurer.
Laws (Amendment) Act, 2015.
2. Any person making default in complying
1. No person shall allow or offer to allow,
with the provisions of this section shall be
either directly or indirectly, as an
liable for a penalty which may extend to
inducement to any person to take out
ten lakh rupees.
or renew or continue an insurance in
respect of any kind of risk relating to lives Insurance is the subject matter of the solicitation”.
or property in India, any rebate of the Please read the Policy wordings carefully before
whole or part of the commission payable concluding the sale.
26

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Group MediCare - Base - Policy Wording

Preamble references to the male include the female and

requirement under a health insurance hours.

iv. has a fully equipped operation ii. it needs ongoing or long-term

(a) Acute condition Maternity expenses means;

a. medical treatment expenses traceable i. is required for the medical

17. Medical Advice iii. must have been prescribed by a

from, a Physician within 48 months pre-existing conditions and time bound

32. Unproven/Experimental treatment 5. Associated Medical Expenses

ii. Associated Medical Expenses: iii. Limit on Treatment / Illness/

B5. Domiciliary Treatment registered ambulance to a Hospital for

in a nursing facility for personal 4. Change-of-Gender treatments:

9. Refractive Error: (Code- Excl 15) i. Hazardous or Adventure Sports

Expenses related to sterility and iii. Expenses incurred towards treatment

iv. Sleep-apnoea. iv. Items of personal comfort and

3. Non-Medical Exclusions viii. Any treatment and associated

i. In case of multiple policies taken by an Company is not under obligation to

iii. If the amount to be claimed exceeds 6. Possibility of Revision of Terms of the

Short Rate Table:

10. Free look period only when an endorsement on the Policy

document to the date of payment of com/grievance-redressal-policy)

case of credit linked). Details of the a. In case of Employer-Employee

1. Intimation is given to Us by a defined b. In case of non Employer-

3. Procedure for Cashless Service

i. Cashless Service is only available at Network Hospitals.

a. Prior to taking treatment and/ treatment.

within 6 hours of receipt of the claim within 15 days or earlier of

papers (in reimbursement k. Copy of MLC (Medico legal case)

5. Claims Payment and the third arbitrator to be appointed by

Section 6 - Dispute Resolution

1. Dispute Resolution Clause

Any and all disputes or differences

If any dispute or difference shall arise as

List of Insurance Ombudsman

SN Centre Address & Contact

Office of the Insurance Ombudsman, Jeevan Prakash Building, 6th

Office of the Insurance Ombudsman, Jeevan Soudha Building,

Office of the Insurance Ombudsman, Janak Vihar Complex,

Office of the Insurance Ombudsman, 62, Forest park,

Office of the Insurance Ombudsman, S.C.O. No. 101,

Office of the Insurance Ombudsman, Fatima Akhtar Court,

Office of the Insurance Ombudsman, 2/2 A, Universal Insurance

Office of the Insurance Ombudsman, Jeevan Nivesh, 5th Floor,

SN Centre Address & Contact

Office of the Insurance Ombudsman, 6-2-46, 1st floor, “Moin Court”,

Office of the Insurance Ombudsman, Jeevan Nidhi – II Bldg.,

Office of the Insurance Ombudsman, 2nd Floor, Pulinat Bldg.,

Office of the Insurance Ombudsman, Hindustan Bldg. Annexe,

Office of the Insurance Ombudsman, 6th Floor, Jeevan Bhawan,

Office of the Insurance Ombudsman, 3rd Floor, Jeevan Seva Annexe,

Office of the Insurance Ombudsman, Bhagwan Sahai Palace

Office of the Insurance Ombudsman, 2nd Floor, North wing,

SN Centre Address & Contact

Office of the Insurance Ombudsman, Jeevan Darshan Bldg.,

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