Tata Aig Medicare Premier Policy Wording

Tata AIG MediCare Premier
Policy Wording
Tata AIG General Insurance Company Limited (We,

Our or Us) will provide the insurance cover, described
in this Policy and any endorsements thereto, for the
Insured Period, as defined in the Policy schedule. The
insurance cover provided under this Policy is only
with respect to such and so many of the benefits upto
the Sum Insured as mentioned in the Policy Schedule.
Commencement of risk cover under the policy is
subject to receipt of premium by us.
The statements and declarations contained in the
Proposal signed by the Policyholder (You) and/or
medical reports shall be the basis of this Policy and
are deemed to be incorporated herein. The insurance
cover is governed by and subject to, the terms,
conditions and exclusions of this Policy.
For Tata AIG General Insurance Company Limited
Authorized Signatory
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
“Insurance is the subject matter of solicitation”. For more details
on risk factors, terms and conditions, please read policy document
carefully before concluding a sale.
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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) | www.tataaig.com
IRDA of India Registration No.:108 | CIN: U85110MH2000PLC128425 | Tata AIG MediCare Premier UIN:
Preamble Hospital/Nursing Home where treatment
was taken.
While the policy is in force, if the Insured Person
contracts any disease or suffers from any illness 3. AYUSH Hospital
or sustains bodily injury through accident and if
An AYUSH Hospital is a healthcare facility
such event requires the insured Person to incur
wherein medical/surgical/para-surgical
expenses for Medically Necessary Treatment,
treatment procedures and interventions
We will indemnify You for the amount of
are carried out by AYUSH Medical
such Reasonable and Customary Charges or
Practitioner(s) comprising of any of the
compensate to the extent agreed, upto the limits
following:
mentioned, subject to terms and conditions of
the Policy. Each Benefit is subject to its Sum a. Central or State Government AYUSH
Insured, but Our liability to make payment in Hospital or
respect of any and all Benefits shall be limited
b. Teaching hospital attached to AYUSH
to the Sum Insured unless expressly stated to
college recognized by the Central
the contrary.
Government/ Central Council of
In case of family floater policy, the sum insured Indian Medicine/ Central Council for
for all or any of the benefits shall be on a per Homeopathy, or
policy per year basis unless explicitly stated to
c. AYUSH Hospital, standalone or co-
the contrary. In case of an individual policy, the located with in-patient healthcare
sum insured for all or any of the benefits shall be facility of any recognized system of
on a per insured per year basis unless explicitly medicine, registered with the local
stated to the contrary. authorities, wherever applicable,
The said Medically Necessary Treatment must be and is under the supervision of a
on the advice of a qualified Medical Practitioner. qualified registered AYUSH Medical
Practitioner and must comply with
Section 1 – General Definitions all the following criterion:
The terms defined below and at other junctures i. Having atleast 5 in-patient beds;
in the Policy Wording have the meanings ascribed
to them wherever they appear in this Policy and, ii. Having qualified AYUSH Medical
where appropriate, references to the singular Practitioner round the clock;
include references to the plural; references to iii. Having dedicated AYUSH
the male include the female and third gender, therapy sections as required
references to any statutory enactment include and/or has equipped operation
subsequent changes to the same: theatre where surgical
procedures are to be carried
i. Standard Definitions
out
1. Accident
M a i n t a i n i n g d a i l y r e c o r d s o f t h e
An accident means sudden, unforeseen patients and making them accessible
and involuntary event caused by external, to the insurance company’s authorized
visible and violent means. representative.
2. Any one illness 4. Cashless facility
Any one illness means continuous period of Cashless facility means a facility extended
illness and includes relapse within 45 days by the insurer to the insured where the
from the date of last consultation with the payments, of the costs of treatment
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undergone by the insured in accordance ii. has qualified medical practitioner/s
with the policy terms and conditions, are in charge;
directly made to the network provider by
iii. has fully equipped operation theatre
the insurer to the extent pre-authorization
of its own where surgical procedures
is approved.
are carried out;
5. Condition Precedent
iv. maintains daily records of patients
Condition Precedent means a policy term and will make these accessible to
or condition upon which the Insurer’s the insurance company’s authorized
liability under the policy is conditional personnel.
upon. 9. Day Care Treatment
6. Congenital Anomaly: Day care treatment means medical
Congenital Anomaly means a condition treatment, and/or surgical procedure
which is present since birth, and which is which is:
abnormal with reference to form, structure i. undertaken under General or Local
or position. Anesthesia in a hospital/day care
centre in less than 24 hrs because of
a) Internal Congenital Anomaly
technological advancement, and
Congenital anomaly which is not in
ii. which would have otherwise required
the visible and accessible parts of the
hospitalization of more than 24
body.
hours.
b) External Congenital Anomaly
Treatment normally taken on an out-
Congenital anomaly which is in the patient basis is not included in the scope
visible and accessible parts of the of this definition
body
10. Dental Treatment
7. Cumulative Bonus
Dental treatment means a treatment
Cumulative Bonus means any increase or related to teeth or structures supporting
addition in the Sum Insured granted by the teeth including examinations, fillings
insurer without an associated increase in (where appropriate), crowns, extractions
premium. and surgery.
8. Day Care Centre 11. Domiciliary Hospitalization
A day care centre means any institution Domiciliary hospitalization means medical
established for day care treatment of illness treatment for an illness/disease/injury
and/or injuries or a medical setup with a which in the normal course would require
hospital and which has been registered care and treatment at a hospital but is
actually taken while confined at home
with the local authorities, wherever
under any of the following circumstances:
applicable, and is under supervision
of a registered and qualified medical i. the condition of the patient is such
practitioner AND must comply with all that he/she is not in a condition to
minimum criterion as under – be removed to a hospital, or
i. has qualified nursing staff under its ii. the patient takes treatment at home
employment; on account of non-availability of
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room in a hospital. where such admission could be for a
period of less than 24 consecutive hours.
12. Grace Period
15. Illness
Grace period means the specified period of
time immediately following the premium Illness means a sickness or a disease
due date during which a payment can be or pathological condition leading to the
made to renew or continue a policy in force impairment of normal physiological
without loss of continuity benefits such function and requires medical treatment.
as waiting periods and coverage of pre-
(a) Acute condition
existing diseases. Coverage is not available
for the period for which no premium is Acute condition is a disease, illness or
received. injury that is likely to respond quickly
to treatment which aims to return the
13. Hospital
person to his or her state of health
A hospital means any institution established immediately before suffering the
for in-patient care and day care treatment disease/ illness/ injury which leads
of illness and/or injuries and which has to full recovery
been registered as a hospital with the local
(b) Chronic condition
authorities under Clinical Establishments
(Registration and Regulation) Act 2010 or A chronic condition is defined as
under enactments specified under the a disease, illness, or injury that
Schedule of Section 56(1) and the said act has one or more of the following
Or complies with all minimum criteria as characteristics:
under:
i. it needs ongoing or long-
i. has qualified nursing staff under its term monitoring through
employment round the clock; consultations, examinations,
check-ups, and /or tests
ii. has at least 10 in-patient beds in
towns having a population of less ii. it needs ongoing or long-term
than 10,00,000 and at least 15 in- control or relief of symptoms
patient beds in all other places;
iii. it requires rehabilitation for the
iii. has qualified medical practitioner(s) patient or for the patient to be
in charge round the clock; specially trained to cope with it
iv. has a fully equipped operation iv. it continues indefinitely

theatre of its own where surgical
v. it recurs or is likely to recur
procedures are carried out;
16. Injury
v. maintains daily records of patients
and makes these accessible to the Injury means accidental physical bodily
insurance company’s authorized harm excluding illness or disease solely
personnel; and directly caused by external, violent,
visible and evident means which is verified
14. Hospitalization
and certified by a Medical Practitioner.
Hospitalization means admission in a
17. Inpatient Care
Hospital for a minimum period of 24
consecutive ‘In-patient Care’ hours except Inpatient care means treatment for which
for specified procedures/ treatments, the insured person has to stay in a hospital
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for more than 24 hours for a covered event. i. is required for the medical
management of the illness or injury
18. Maternity expenses
suffered by the insured;
Maternity expenses means; ii. must not exceed the level of care
a. medical treatment expenses traceable necessary to provide safe, adequate
to childbirth (including complicated and appropriate medical care in
deliveries and caesarean sections scope, duration, or intensity;
incurred during hospitalization); iii. must have been prescribed by a
b. expenses towards lawful medical medical practitioner;
termination of pregnancy during the iv. must conform to the professional
policy period. standards widely accepted in
international medical practice or by
19. Medical Advice
the medical community in India.
Medical Advice means any consultation
23. Migration
or advice from a Medical Practitioner
including the issuance of any prescription “Migration” means, the right accorded to
or follow-up prescription. health insurance policyholders (including
all members under family cover and
20. Medical Expenses: members of group health insurance
Medical Expenses means those expenses policy), to transfer the credit gained for
that an Insured Person has necessarily and pre-existing conditions and time bound
actually incurred for medical treatment exclusions, with the same insurer.
on account of Illness or Accident on the 24. Network Provider
advice of a Medical Practitioner, as long as
these are no more than would have been Network Provider means hospitals or
payable if the Insured Person had not been health care providers enlisted by an
insurer, TPA or jointly by an Insurer and
insured and no more than other hospitals
TPA to provide medical services to an
or doctors in the same locality would have
insured by a cashless facility.
charged for the same medical treatment.
25. New Born Baby
21. Medical Practitioner
Newborn baby means baby born during
Medical Practitioner means a person who
the Policy Period and is aged upto 90 days
holds a valid registration from the Medical
Council of any State or Medical Council of 26. Notification of Claim:
India or Council for Indian Medicine or for
Notification of claim means the process
Homeopathy set up by the Government of of intimating a claim to the insurer or TPA
India or a State Government and is thereby through any of the recognized modes of
entitled to practice medicine within its communication
jurisdiction; and is acting within its scope
and jurisdiction of license. 27. OPD treatment
22. Medically Necessary Treatment OPD treatment means the one in which
the Insured visits a clinic / hospital or
Medically necessary treatment means any associated facility like a consultation room
treatment, tests, medication, or stay in for diagnosis and treatment based on
hospital or part of a stay in hospital which: the advice of a Medical Practitioner. The
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Insured is not admitted as a day care or the hospital provided that:
in-patient.
i. Such Medical Expenses are for
28. Pre-Existing Disease the same condition for which the
insured person’s hospitalization was
Pre-existing Disease means any condition,
required, and
ailment, injury or disease:
ii. The inpatient hospitalization claim for
a. That is/are diagnosed by a physician
such hospitalization is admissible by
within 48 months prior to the
effective date of the policy issued by the insurance company
the insurer or its reinstatement or 32. Qualified Nurse
b. For which medical advice or treatment Qualified nurse means a person who
was recommended by, or received holds a valid registration from the Nursing
from, a Physician within 48 months Council of India or the Nursing Council of
Prior to the effective date of the any state in India.
policy issued by the insurer or its
reinstatement 33. Reasonable and Customary Charges
29. Pre-hospitalization Medical Expenses Reasonable and Customary charges means

the charges for services or supplies, which
Pre-hospitalization Medical Expenses
are the standard charges for the specific
means medical expenses incurred during
provider and consistent with the prevailing
predefined number of days preceding
charges in the geographical area for
the hospitalization of the Insured Person,
identical or similar services, taking into
provided that:
account the nature of the illness / injury
i. Such Medical Expenses are incurred involved.
for the same condition for which the
34. Renewal
Insured Person’s Hospitalization was
required, and Renewal means the terms on which the
contract of insurance can be renewed on
ii. The In-patient Hospitalization claim
mutual consent with a provision of grace
for such Hospitalization is admissible
by the Insurance Company. period for treating the renewal continuous
for the purpose of gaining credit for pre-
30. Portability existing diseases, time-bound exclusions
“Portability” means, the right accorded to and for all waiting periods.
individual health insurance policyholders 35. Room Rent
(including all members under family
cover), to transfer the credit gained for Room Rent means the amount charged
pre-existing conditions and time bound by a Hospital towards Room and Boarding
exclusions, from one insurer to another expenses and shall include the associated
insurer. medical expenses.
31. Post-hospitalization Medical Expenses 36. Surgery or Surgical Procedure
Post-hospitalization Medical Expenses Surgery or Surgical Procedure means

means medical expenses incurred during manual and / or operative procedure
predefined number of days immediately (s) required for treatment of an illness
after the insured person is discharged from or injury, correction of deformities and
defects, diagnosis and cure of diseases,
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relief from suffering and prolongation of 6. Shared Accommodation
life, performed in a hospital or day care
Shared Accommodation means a hospital
centre by a medical practitioner.
room with two or more patient beds. This
37. Unproven/Experimental treatment definition does not apply to ICU or ICCU.
Unproven/Experimental treatment means Section 2 – Benefits

the treatment including drug experimental
Below listed benefits are payable subject to
therapy which is not based on established
Terms and Conditions of the policy.
medical practice in India, is treatment
experimental or unproven. The company’s maximum liability in aggregate
for payment of any claim under Section B1,
ii. Specific Definitions (Definitions other
B2, B3, B4 and B7 shall not exceed the opted
than as mentioned under Section 1 (i)
sum insured. However, any payment under
above)
cumulative bonus shall be over and above.
1. Age
The sequence of utilization of benefits for a claim
Means the completed age of the Insured shall be as per the following:
Person on his / her most recent birthday
i. Sum Insured,
as per the English calendar, regardless of
the actual time of birth. ii. Any accrued Cumulative Bonus, if
applicable
2. Policy
iii. Restore benefit amount, if applicable
Policy means the contract of insurance
including but not limited to Policy Schedule, B1. In-Patient Treatment
Endorsements and Policy Wordings.
We will cover for expenses for
3. Policy period hospitalization due to disease/illness/Injury
during the policy period that requires an
Policy Period means the time during
Insured Person’s admission in a hospital
which this Policy is in effect. Such period
as an inpatient.
commences from Commencement Date
and ends on the Expiry Date and specifically Medical expenses directly related to the
appears in the Policy Schedule. hospitalization would be payable.
4. Policy Schedule B2. Pre-Hospitalization expenses
Policy Schedule means the Policy Schedule We will cover for expenses for Pre-
attached to and forming part of Policy Hospitalization consultations,
investigations and medicines incurred
5. Policy year
upto 60 days before the date of admission
Policy Year means a period of twelve to the hospital.
months beginning from the date of
The benefit is payable if We have admitted
commencement of the Policy period
a claim under section B1 or B4 or B6 or B31
and ending on the last day of such
of this policy.
twelve-month period. For the purpose of
subsequent years, policy year shall mean B3. Post-Hospitalization expenses
a period of twelve months commencing
We will cover for expenses for Post-
from the end of the previous policy year
Hospitalization consultations,
and lapsing on the last day of such twelve-
investigations and medicines incurred after
month period, till the Policy Expiry date
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discharge from the hospital, upto number are available on our website (www.
of days as specified in the table below. tataaig.com)
• In case we or the empanelled service

Basic Sum insured Number of days
provider fails to provide any of
Upto Rs. 50 Lacs 90 days the services as mentioned in this
Rs.75 Lacs to Rs.3 policy or is unable to implement
200 days
Crore , in whole or in part due to force
majeure, non-availability of services,
In case the insured person has opted sum
change in law, rule or regulations
insured Rs. 75 Lacs and above, then We will
which affects the services, or if any
arrange up to 15 physiotherapy sessions regulatory or governmental agency
at home within India, wherever available, having jurisdiction over a party takes
within the city in which you reside through a position which affects the services,
our empanelled service provider subject to then the service provider services
following conditions: suspended, curtailed or limited
• This limit on physiotherapy sessions performance shall not constitute
is applicable to each insured person, breach of contract and the company
per post-hospitalization event or the empanelled service provider
shall have no liability whatsoever
• Availing the services for physiotherapy including but not limited to any
at home under this Benefit is at immediate or consequential loss
insured person’s sole discretion and resulting therefrom.
risk. We do not assume any liability
The benefit is payable if We have admitted
towards quality of service rendered,
a claim under section B1 or B4 or B6 or B31
any immediate or consequential loss
of this policy.
arising out of or in relation to these
services rendered by the empanelled B4. Day Care Procedures
service provider.
We will cover expenses for Day Care
• The said physiotherapy must be Treatment due to disease/illness/Injury
advised in writing by the treating during the policy period taken at a hospital
medical practitioner. or a Day Care Centre.
• The above services may be provided Treatment normally taken on out-patient

by the company /network providers basis is not included in the scope of this
or other empaneled hospitals / cover.
service providers. Any additional
B5. Organ Donor
expenses other than the eligible
expenses shall be borne by the We will cover for Medical and surgical
insured person which shall not be Expenses of the organ donor for harvesting
covered under this policy unless the organ where an Insured Person is the
specified otherwise recipient provided that:
• This facility may be availed through i. The organ donor is any person whose
our website or our mobile application organ has been made available
or through calling our call centre on in accordance and in compliance
the toll free number specified in the with The Transplantation of Human
policy schedule. Alternatively, details Organs (Amendment) Bill, 2011 and
of our empanelled service provider the organ donated is for the use of
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the Insured Person, and less than or Equal to Rs. 50 Lacs: This
benefit shall be applicable annually
ii. We have accepted an inpatient
for policies with tenure of more than
Hospitalization claim for the insured
1 year.
member under section B1 of this
policy. For policy with Basic Sum Insured Rs. 75
Lacs and above:
B6. Domiciliary Treatment
This benefit shall be applicable annually
We will cover for expenses related to
Domiciliary Hospitalization of the insured for multiyear policies. However, for single
person if the treatment exceeds beyond premium multiyear policies, the insured
three days. The treatment must be for shall have the right to utilize the available
management of an illness and not for restorations anytime during the policy
enteral feedings or end of life care. period, except for the first claim, for e.g. a
policy with tenure of 2 years where entire
At the time of claiming under this benefit, premium is paid upfront, the insured is
we shall require certification from the eligible for a total of 2 restorations anytime
treating doctor fulfilling the conditions as during the policy period except for the first
mentioned under the general definitions claim in each policy year.
(Section 1) of this policy.
d. The unutilized restored sum insured
B7. Restore benefit cannot be carried forward to the next
We will automatically restore the Basic Sum policy year.
Insured if the Sum Insured and accrued
e. Restore will not trigger for the first
Cumulative Bonus is insufficient to pay a
claim under each policy year.
claim during the policy year. This benefit
can be availed once during the policy year f. The maximum liability under a single
subject to the following conditions: claim under this benefit shall be the
sum Insured.
a. The restored sum insured can be used
for all claims made by the insured This benefit shall not be available for
person(s) who have not claimed section B13 and B31 of this policy.
earlier under Sections B1 to B4. In
case the insured has claimed under B8. AYUSH Benefit
these sections, then this automatic We will cover for expenses incurred
restoration benefit is available for for treatment as in-patient in an Ayush
admissions due to unrelated illness/ Hospital.
diseases. However, this benefit for
related illness/diseases would be B9. Ambulance Cover
available, in case of claimed insured
We will cover for expenses incurred on
person(s), for admissions after 45
transportation of Insured Person in a
days from the date of discharge of
registered ambulance to a Hospital for
the earlier claim.
admission in case of an Emergency or from
b. In case of Family Floater policy, one hospital to another hospital for better
Reinstatement of Sum Insured will medical facilities and treatment, subject to
be available for all Insured Persons limited as specified in the table below.
in the Policy on floater basis
c. For policy with Basic Sum Insured
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B11. Compassionate travel
Basic Sum Insured Limit
Upto Rs. 5000 per a) Domestic
Up to Rs. 50 Lacs
hospitalization
In the event the Insured Person
Upto Rs. 7500 per is Hospitalized in India for more
Rs. 75 Lacs
hospitalization than Five consecutive days in a
Upto Rs. 10000 place where no adult member of
Rs. 1 Crore
per hospitalization his immediate family is present, we
Upto Rs. 20000 will cover for expenses related to a
Rs. 2 Crore round trip economy class air ticket, or
per hospitalization
first-class railway ticket, to allow the
Upto Rs. 30000
Rs. 3 Crore Immediate Family Member be at his
per hospitalization
bedside for the duration of his stay
For this claim to be paid, the claim must be in the hospital.
admissible under section B1 or B4 of this
The benefit shall be payable if an
policy.
inpatient Hospitalization claim for the
B10. Health Checkup insured member is admissible under
section B1 of this Policy.
We will cover for expenses for a Preventive
Health Check-up upto 1% of policy sum b) Global (Applicable for sum insured
insured subject to a maximum limit as above Rs. 50 Lacs):
specified in the table below. The limit is
the maximum per policy in case of floater In the event the Insured person is
policy and per insured person in case of hospitalized outside India and claim is
individual policy admissible under section B13 (Global
cover for Planned Hospitalization) of
The benefit is payable every year this policy, We will cover expenses
irrespective of claims under the policy. related to round trip economy class
This benefit has a separate limit (over and air ticket, to allow the Immediate
above base sum insured) and does not Family Member to accompany the
affect cumulative bonus. Insured person for the purpose of
planned treatment outside India.
Basic Sum Insured
Limit
(Rs.) This benefit has a separate limit (over
Up to Rs. 50 Lacs Upto Rs. 10000 and above base sum insured) as
specified in the policy schedule and
Rs. 75 Lacs Upto Rs. 15000 does not affect cumulative bonus.
Rs. 1 Crore Upto Rs. 20000
We shall require the following
Rs. 2 Crore Upto Rs. 25000 additional documents (proof of
Rs. 3 Crore Upto Rs. 25000 travel) supporting the claim under
this benefit: Copy of Passport (in case
For the purpose of this benefit, Preventive of Global), Boarding Pass, or Railway
Health Check-up means medical test(s) ticket or any other document to show
undertaken for general assessment of proof of travel.
health status and does not include any
diagnostic or investigative medical tests B12. Consumables Benefit
for evaluation of illness or a disease.
We will pay for expenses incurred, for
specified consumables which are listed in
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‘Annexure I – List I- Optional Items’ under contact us for any claim assistance.
‘Guidelines on Standardization in Health
The payment of any claim under
Insurance, 2016’ and its amendments,
this benefit will be in Indian Rupees
which are consumed during the period
based on the rate of exchange as
of hospitalization directly related to the
on the date of invoice, published by
insured’s medical or surgical treatment of
Reserve Bank of India (RBI) and shall
illness/disease/injury. Details of Annexure
be used for conversion of foreign
I-List I-Optional items are available on our
currency into Indian Rupees for
website (www.tataaig.com)
claims payment. If these rates are not
However, the following items shall be published on the date of invoice, the
excluded from scope of this coverage: exchange rate next published by RBI
shall be considered for conversion.
• Items of personal comfort, toiletries,
cosmetics and convenience shall be Only basic sum insured along with
excluded from scope of this coverage. Cumulative Bonus can be used
for this and not the restored sum
• External durable devices like Bilevel
insured.
Positive Airway Pressure (BIPAP)
machine, Continuous Positive Airway We shall require the following
Pressure (CPAP) machine, Peritoneal additional documents supporting
Dialysis (PD) equipment and supplies, the claim under this benefit:
Nimbus/water/air bed, dialyzer and
• Proof of diagnosis in India
other medical equipments.
• Insured’s Passport and Visa
• Any item which is neither medical
consumable nor medically necessary b. Visa Services Fees (Applicable only for
nor prescribed by Doctor. Sum Insured above Rs.50 Lacs)
For this claim to be paid, the main We will cover for reasonable and
claim must be admissible under customary expenses incurred
section B1 or B4 or B31 of this policy. towards obtaining visa for medical
treatment of the insured person
B13. Global Cover for Planned Hospitalization
travelling abroad upto the sum
a. Global Cover for Planned insured subject to claim being
Hospitalization (Medical Expenses) admissible under section B13
(a – Global Cover for Planned
We will cover for Medical Expenses of
Hospitalization (Medical Expenses))
the Insured Person incurred outside
of this policy.
India, upto the sum insured, provided
that the diagnosis was made in India • We shall require valid receipts/bills of
and the insured travels abroad for visa fee services supporting the claim
treatment. under this benefit.
The Medical Expenses payable B14. Bariatric Surgery Cover

shall be limited to Inpatient and
We will cover for reasonable and customary
daycare Hospitalization. Any claim
expenses for Bariatric Surgery if the insured
under this cover can be made only
fulfills all of the following conditions:
on reimbursement basis. Cashless
facility may be arranged on case i. Surgery to be conducted is upon the
to case basis. Insured person can advice of the Doctor
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ii. The member has to be 18 years of
Without any
age or older and waiting period:
- Anti-rabies
iii. Body Mass Index (BMI) greater than
vaccine
or equal to 40 or following an
iv. BMI is greater than or equal to 35 in animal bite
- Typhoid
conjunction with any of the following
vaccination
severe co-morbidities following After 2 years
failure of less invasive methods of of continuous
weight loss: Rs. 75 Lacs to Rs. coverage with Us:
3 Crore. - Human
a. Obesity-related cardiomyopathy Papilloma Virus
b. Coronary heart disease (HPV) vaccine
- Hepatitis A
c. Severe sleep apnea Vaccine
- Hepatitis B
d. Uncontrolled Type2 Diabetes Vaccine
- Tetanus,
In view of this coverage getting extended, Diphtheria,
exclusion code (Code-Excl06) of this policy Pertussis
stands deleted. - Pneumococcal
B15. In-Patient Treatment - Dental Expenses related to the doctor, nurse or
any incidental expenses are not payable.
We will cover for medical expenses
This benefit has a separate limit (over and
incurred towards hospitalization for dental
above base sum insured) and does not
treatment under anesthesia necessitated
affect cumulative bonus.
due to an accident/injury/illness.
B17. Hearing Aid
B16. Vaccination cover
We will cover for reasonable charges for a
We will cover for expenses related to the hearing aid every third year. The maximum
cost of the following vaccines only: amount payable is 50% of actual cost or Rs.
10,000/- per policy, whichever is lower.
Basic Sum Insured Vaccines covered
The items must be prescribed by a
Without any
specialized Medical Practitioner as
waiting period:
medically necessary.
- Anti-rabies
vaccine This benefit has a separate limit (over and
following an above base sum insured) and does not
animal bite
- Typhoid
vaccination B18. D a i l y C a s h f o r c h o o s i n g S h a r e d
Up to Rs. 50 Lacs
After 2 years Accommodation
of continuous
coverage with Us: We will pay a fixed amount per day as
- Human mentioned in the policy schedule if the
Papilloma Virus Insured Person is Hospitalized in Shared
(HPV) vaccine Accommodation in a Network Hospital for
- Hepatitis B each continuous and completed period
Vaccine of 24 hours. The benefit payable per day
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would be 0.25% of base sum insured and This benefit can be availed by an insured
a maximum of Rs. 2000 per day. person once during a Policy Year.
For this claim to be paid, the main claim B21. Maternity Cover
must be admissible under section B1 of
We will cover for Maternity Expenses, upto
this policy. This benefit has a separate limit
limits as specified in the table below, per
(over and above base sum insured) and
policy subject to a waiting period of 4 years
does not affect cumulative bonus.
of continuous coverage under this policy.
B19. Daily Cash for Accompanying an Insured
Child Basic Sum Insured Limit
We will pay a fixed amount per day, as A maximum of

upto Rs 50,000/-.
mentioned in the policy schedule, if the
In case of birth
Insured Person Hospitalized is a child Aged of a girl child,
12 years or less, for one accompanying Up to Rs. 50 Lacs the maximum
adult for each complete period of 24 limit under this
hours. The benefit payable per day would coverage would
be 0.25% of base sum insured and a be upto Rs
maximum of Rs.2000 per day. 60,000/- per policy
A maximum of
For this claim to be paid, the main claim
upto Rs 1,00,000/-
must be admissible under section B1 of
. In case of birth
this policy. of a girl child,
This benefit has a separate limit (over and Rs.75 Lacs to Rs.3 the maximum
Crore limit under this
coverage would
affect cumulative bonus. be upto Rs
B20. Second Opinion 1,20,000/- per
policy
We will provide You a second opinion from
We will not cover ectopic pregnancy under
Network Provider or Medical Practitioner,
this benefit (although it shall be covered
if an Insured Person is diagnosed with
under section B1).
the below mentioned Illnesses during the
Policy Period. The expert opinion would be Expenses incurred for following shall be
directly sent to the Insured Person. excluded from the scope of this coverage:
i. Cancer • Expenses incurred for pre/post natal
care
ii. Kidney Failure
• Pre/Post hospitalization benefit
iii. Myocardial Infarction
(Section B2 and B3 of this policy)
iv. Angina
In view of this coverage getting extended,
v. Coronary bypass surgery maternity exclusion code 18 stands
deleted. However, no coverage is available
vi. Stroke/Cerebral hemorrhage
for voluntary termination of pregnancy
vii. Organ failure requiring transplant during the policy period under this policy.
viii. Heart Valve replacement B22. Delivery Complications Cover
ix. Brain tumors We will cover for medical expenses

13
incurred for the medically necessary medically necessary treatment subject to
treatment of the new born baby upto limits as specified in the table below, per
limits as specified in the table below, for policy year:
complications related to delivery if claim
is admitted under the maternity benefit i. Brain Perfusion imaging
(B21) of this policy. ii. Computed Tomography (CT) guided
Biopsy
iii. C o m p u t e d T o m o g r a p h y ( C T )
Up to Rs.50 Lacs Upto Rs. 10000
Urography
Rs. 75 Lacs to Rs.
Upto Rs. 25000
3 Crore iv. Digital Subtraction Angiography (DSA)
B23. First year Vaccinations v. Liver Biopsy
We will pay for vaccination expenses for vi. Magnetic Resonance Cholangiography
up to one year after the birth of the child Scan
subject to a limit of Rs. 10,000/- provided
the child is covered with Us. In case of girl vii. Positron Emission Tomography
child, applicable limit under this coverage Computed Tomography (PET CT)
would be Rs.15,000/-. viii. Positron emission tomography
For the claim to be paid under this benefit, Magnetic Resonance Imaging (PET
the expenses related to maternity should MRI)
be admissible under section B21 of this
ix. Renogram
policy. The limit of Rs.10,000 (Rs.15,000 in
case of girl child) is a lifetime limit and not Basic Sum Insured Limit
a policy limit which will be applicable for
each child. Up to Rs. 25,000
Up to Rs.50 Lacs
per policy year
B24. Prolonged Hospitalization Benefit
Rs. 75 Lacs to Rs. Up to Rs. 50,000
We will pay a fixed amount of 1% of 3 Crore per policy year
sum insured, in the event of insured
hospitalized for a disease/illness/injury for
a continuous period exceeding 10 days.
This benefit will be triggered provided that
B26. OPD Treatment
the hospitalization claim is accepted under
section B1 of this policy. Once the insured has completed two years
of continuous coverage with Us, We will pay
This benefit shall not be applicable for
section B6 / B 31 of this policy. for expenses related to consultations and
pharmacy up to limits specified in the table
This benefit has a separate limit (over and below, per policy year annually subject to
above base sum insured) and does not policy terms and conditions.
B25. High End Diagnostics Basic Sum Insured Limit

Up to Rs.50 Lacs Upto Rs. 5,000/-
We will cover for reasonable charges
incurred for the following diagnostic tests Rs.75 Lacs Upto Rs. 7,500/-
only on OPD basis if required as part of a Rs. 1 Crore Upto Rs. 10,000/-
14
The Medical Evacuation should be
Rs. 2 Crore Upto Rs. 15,000/-
prescribed by a Medical Practitioner and
Rs. 3 Crore Upto Rs. 20,000/- should be Medically Necessary.
This benefit has a separate limit (over and This benefit shall only be payable if We
above base sum insured) and does not have accepted an inpatient Hospitalization
affect cumulative bonus. claim for the Insured member under
B27. OPD Treatment - Dental section B1 of this policy.
Once the Insured has completed two years Basic Sum Insured Limit
of continuous coverage with Us, we will pay
Up to Rs.50 Lacs Up to Rs. 500,000
for expenses related to the following dental
treatments only subject to a maximum of Up to Rs. 500,000
limit specified in the table below, per policy for Non Network;
Rs.75 Lacs to Rs. 3
year annually: Upto Sum Insured
Crore
for Network
- Root Canal Treatment (single or Provider
multiple sittings)
- Tooth extraction(s) above base sum insured) and does not
affect Cumulative Bonus.
- Filling
B29. Accidental Death Benefit
If an Insured Person suffers an accident
Up to Rs. 50 Lacs Upto Rs. 10,000/-
during the policy period and this is the
Rs. 75 Lacs Upto Rs. 12,500/- sole and direct cause of his death within
Rs.1 Crore Upto Rs. 15,000/- 365 days from the date of accident, then
We will pay a fixed amount of 100% of the
Rs.2 Crore Upto Rs. 20,000/-
base Sum Insured, maximum up to Rs 50
Rs.3 Crore. Upto Rs. 25,000/- Lakhs.
This benefit has a separate limit (over and This benefit is not applicable for dependent
above base sum insured) and does not children covered in the policy.
affect Cumulative Bonus.
B30. Cumulative Bonus
In view of this coverage getting extended,
dental exclusion (General Exclusions ii. i. 50% cumulative bonus will be applied
1. ix) is not applicable for this particular on the Sum Insured for next policy
coverage. year under the Policy after every
claim free Policy Year, provided
B28. Emergency Air Ambulance Cover
that the Policy is renewed with Us
We will pay for ambulance transportation and without a break. The maximum
of the Insured Person in an airplane or cumulative bonus shall not exceed
helicopter subject to maximum of limit 100% of the Sum Insured in any Policy
specified in the table below, for emergency Year.
life threatening health conditions which
ii. If a Cumulative Bonus has been
require immediate and rapid ambulance
applied and a claim is made, then
transportation to the hospital/medical
in the subsequent Policy Year We
centre for further medical management.
will automatically decrease the
Cumulative Bonus by 50% of the
15
Sum Insured in that following Policy a. The medical practitioner advices the
Year. There will be no impact on insured person to undergo treatment
the Inpatient Sum Insured, only the at home.
accrued Cumulative Bonus will be
b. There is a continuous active line
decreased.
of treatment with monitoring of
iii. In policies with a tenure of more than the health status by a medical
one year, the above guidelines of practitioner for each day through the
Cumulative Bonus shall be applicable duration of the home care treatment.
post completion of each policy year
c. Daily monitoring chart including
iv. In relation to a Family Floater, the records of treatment administered
Cumulative Bonus so applied will duly signed by the treating doctor is
only be available in respect of those maintained
Insured Persons who were Insured
d. Home care treatment is availed in
Persons in the claim free Policy Year
India.
and continue to be Insured Persons
in the subsequent Policy Year. e. Home treatment services may be
provided through network service
v. For purpose of computation of
provider/ empanelled service
Cumulative Bonus, the percentage
provider in select cities for select
(%) of Cumulative Bonus will be
treatment procedures only. Please
applied on the base Sum Insured
contact us or visit our website (www.
only. Restored sum insured will not
tataaig.com) for updated list of
be taken into consideration.
treatment procedures and cities
B31. Home Care Treatment Cover (Applicable where home treatment service is
only for Sum Insured Rs.75 Lacs and provided
above)
f. Insured shall be permitted to avail the
We will co ver fo r re as o nab l e and services as prescribed by the medical
customary medical expenses incurred practitioner.
for treatment taken at home, which are
g. In case the insured intends to
“Equivalent Medical charges” as defined in
avail the services of non-network
this policy, for below specified conditions/
provider, claim shall be subject to
illness upto the sum insured (excluding
reimbursement, a prior approval
accrued cumulative bonus) for the Insured
from the insurer needs to be taken
Person’s medically necessary treatment at
before availing such services from
home. Restore benefit sum insured is not
a registered home care provider.
applicable for this benefit.
Insurer shall respond to approval
Home Care Treatment means treatment request within 4 working hours
availed by the Insured Person at home of receiving the last necessary
for below listed conditions/ illness/ requirement.
procedures, which in normal course
Specified conditions/ illness covered under
would require hospitalization of more than
Home care treatment:
24 hours or would have been admissible
under Day Care Procedures but is actually a. Dialysis at home
taken at home provided that:
b. Chemotherapy at home
c. Pandemic Care at home for a

16
maximum period of 15 days and i. Teleconsultation - General
maximum upto 25% of the base sum
We /our empanelled Service Provider
insured excluding cumulative bonus
will arrange for teleconsultations
(Pandemic as defined and declared by
upon insured person’s request
World Health Organization (WHO) or
through telecommunications and
any equivalent healthcare authority)
digital communication technologies
In this benefit, the following shall be for insured person’s health related
covered if prescribed by the treating complaints or preventive health care
medical practitioner and is related to by a qualified Medical Practitioner/
treatment covered under the policy, Health Care Professional, as per
the limit specified in your Policy
a. Diagnostic tests undergone at home Schedule.
or at diagnostics center
This service can only be availed
b. Medicines prescribed in writing subject to condition below:
c. Consultation charges of the medical - Consultation will be provided
practitioner through various specified
d. Nursing charges related to medical modes of communication
staff (including but not limited to) like
audio, video, online portal, chat,
e. Medical procedures limited digital customer application or
to parenteral administration of any other digital mode.
medicines
ii. Teleconsultation - Speciality
f. Including but not limited to cost of
Pulse Oximeter, Oxygen cylinder and We /Our empanelled Service Provider
nebulizer wherever applicable will arrange for teleconsultations
upon insured person’s request
For the purpose of this cover, “Equivalent through telecommunications and
Medical charges” shall mean the charges digital communication technologies
for services or supplies, which are the for insured person’s health related
standard/equivalent charges for the complaints or preventive health
specific provider and not more than the care by a qualified & specialist
prevailing charges in the geographical area Medical Practitioner/ Health Care
for identical or similar services taken on Professional, as per the limit/
inpatient/day care basis, considering the speciality specified in your Policy
nature of the illness / injury involved. Schedule.
B32. Wellness Services This service can only be availed
subject to conditions below:
We / our Empanelled Service Provider
will provide below mentioned wellness - Consultation will be provided
services designed to assist insured persons through various specified
in maintaining and improving good health modes of communication
and fitness. These Wellness Services will be (including but not limited to) like
available for the insured person during the audio, video, online portal, chat,
policy period and as specified in the Policy digital customer application or
schedule. any other digital mode.
17
iii. Ambulance Booking facility certain specified products/ services
to promote wellness and fitness of
We / Our empanelled Service Provider
the insured person.
will provide a facility to book a road
ambulance in India, for transportation vi. Health Condition Management
of an Insured Person to a Hospital for
We / our empanelled service provider
admission or from one hospital to
will provide consultative services
another hospital for better medical
related to health conditions/ illnesses
facilities and treatment.
with the objective of maintaining
This booking service can be availed good health and improving it
at Our Network subject to the through various health condition
transportation of the Insured Person management programmes
will be offered to the nearest Hospital including but not limited to nutrition
management, weight management,
iv. Emergency - Help me feature
chronic condition management,
In case of an emergency, insured stress management, health coach (as
person will have an option to share approved by the regulator from time
his/her location with the ‘designated to time) and offered by us.
caregiver’ through our customer
Consultative services will be provided
application provided the insured
through various specified modes of
person has registered on our App.
communication (including but not
The app will trigger a message and limited to) audio, video, online portal,
call to the designated caregiver chat, digital customer application or
informing about the emergency and any other digital mode.
sharing the location of the Insured
Definition:
Person.
For the purpose of section B 32 of this
For the purpose of this benefit,
policy, a Health Care Professional is a
‘designated caregiver’ shall mean that
person who holds a valid qualification
individual who has been specified as
from regulatory body as set up by
a caregiver at the time of registration
the Government of India or a State
in the customer App.
Government or any other relevant
Please note authority and is engaged in actions
with an objective of maintaining and
- This service will be improving individual’s good health.
available subject to suitable
infrastructure, connectivity, B33. Wellness Program
device restrictions and device
We / our empanelled service provider will
functionality.
provide a wellness program designed to
- promote wellness and fitness amongst the
insured persons. This wellness program is
v. Redeemable voucher/Discount on structured to reward the insured person
services in the form of measurable wellness score
We / our empanelled service for the prescribed physical efforts/fitness
provider will provide redeemable activity undertaken by such insured person
vouchers/ discount (as approved by during the policy period. This is a voluntary
the regulator from time to time) on program available for insured with age
18
above 18 years, at the start of the policy lifestyle disease as compared to
year. It is advisable to the insured person peers in the same age and gender
to consult his/her physician before starting group.
any physical exercise/ activity.
• Yellow – moderate risk for developing
It is a pre-condition for enrolment under lifestyle disease as compared to
this wellness programme, that the insured peers in the same age and gender
person should have undergone the health group.
risk assessment as specified below and
depending on the outcome from health • Red – higher risk for developing
risk assessment, the wellness reward and lifestyle disease as compared to
its scoring should be administered. The peers in the same age and gender
earnings under the wellness program is group.
linked to your wellness category and shall The overall wellness category is valid till
be valid for one year from the date of credit the expiry of the policy year in which the
of daily score in insured person’s wellness insured undergoes the assessment and
account, provided the policy is renewed will be updated based on HRA results of
within the grace period. Daily score will be subsequent assessment undergone by
credited after the completion of a healthy the insured person in each consecutive
day. policy year, subject to renewal of the policy
For the purpose of understanding if the within the grace period. In the event of a
daily score is credited on 1st Jan 2022 it long-term policy (greater than 1 year) the
will be valid up to 31st Dec 2022. insured has to undergo HRA in each policy
year to be eligible for wellness rewards. If
i) Health risk assessment the insured does not undergo assessment
We / our empanelled service provider will in the consecutive policy year, henceforth
provide a health risk assessment (HRA) no rewards will be earned for any physical
questionnaire, which is an online tool for activity undertaken. However, earned
evaluation of status of health and quality rewards will be carried forward till its
of the insured person’s life. This tool helps validity and will be available for utilization.
insured persons to review their lifestyle
ii) Wellness Rewards
practises which may impact their health
status. Mechanism to earn Wellness Reward:
To undertake the health risk assessment, We will encourage physical exercise

you can log into your account on our and fitness and recognise the effort by
customer application. This can be rewarding the insured person on daily
undertaken once a policy year. basis for each healthy day.
On completion of the health risk A healthy day can be earned by undertaking
assessment and based on the insured below activity on a calendar day:
person’s assessment results, we / our
1. Recording 10, 000 steps / day# in
empanelled service provider will identify
the wellness category in which the insured the activity tracking apps or fitness
person falls in. tracker devices as prescribed by the
company or our empanelled service
Wellness categories for this purpose are provider: or
defined as below:
2. Burning 500 calories or more in a
• Green – low risk for developing day through activity as measured by
19
fitness tracker devices. of individual performance rewards
would be considered for computation
The company may at its discretion change
of wellness reward.
the above criteria and the same would
be mentioned in the policy schedule/ - # The company may also use
customer application. alternative measurement criteria in
lieu of steps and calories burnt and
Wellness reward will be earned depending
the same shall be mentioned on the
on the wellness category of the insured
policy schedule
person and as per the grid below:
- Data entered manually in the fitness
Wellness category tracking apps or devices will not be
Green Yellow Red considered for tracking healthy day
Rewards per - Calories burnt during basic

10 7 5
Healthy Day metabolism shall not be considered
for tracking healthy day (here basic
Note:
metabolism refers to activities
- HRA registration will be allowed done while at rest to maintain vital
anytime during the policy year and functions such as breathing and
healthy activities will be tracked keeping warm etc.)
throughout the policy year, however,
Mechanism to Utilise Wellness Reward:
for each policy year, activities
completed in first 300 days of the Wellness Reward accumulated through
policy year will be considered for fitness activities can be converted into
reward in the same year, activities monetary value as per method defined
completed on or after 301st day of below and can be utilized towards the
the policy year will be carried forward payment of services/items under below
to the next policy year and will be categories, available through our Network/
available for utilization in the next empanelled service provider:
year provided the policy has been
• OPD consultation/ treatment
inforce or renewed with us without
any break within the grace period. • Pharmaceuticals
- In case of individual policy, each • Health-check-ups/ diagnostics

insured person would be tracked
• Health Supplements
separately and shall earn wellness
reward based on one’s own individual • Coverage of cost of treatment of
performance/physical activity as per any admissible claim in respect of
the grid above non-payable items that are specified
under the terms and conditions of
- In case of family floater policy, each
the base policy
insured person, with age above 18
years, at the start of the policy year, • Or any other items as prescribed by the
would be tracked separately and company or our empanelled service
shall earn wellness reward based on provider as approved by the Regulator
one’s own individual performance/ as a redeemable item from time to time.
physical activity as per the grid above.
Note:
In order to compute the wellness
reward for such policies, average - Wellness Reward can be converted
20
into a monetary value after every Healthy Day, during the Cover Period
- Monetary value of the Wellness score earned is equivalent to the:
Wellness score earned X (Per year Policy Premium without Taxes/ 10,000).
o In case of policy with tenure more than one year, ‘per year policy Premium without
Taxes’ = (Total Policy premium without tax, for the tenure/ policy tenure).
o In case of family floater policy, reward will be calculated on average premium per
person which is equivalent to the Total Policy premium without tax/ number of
Insured persons covered in the policy on floater basis
Illustration
Age of the Insured Person (Years) 40

Sum Insured opted under the Policy (Rs.) 5 Lacs
Plan Type Individual
Policy Tenure (years) 1
Total number of members covered under
1
the policy
Net Premium paid (without Tax) 7931
Wellness Category (post Health Risk
Green
Assessment)
Healthy Day Wellness Wellness Reward Wellness Reward Wellness Reward

Reward converted to credited after valid up to 365
earned Monetary Value Healthy Day days (provided the
(per day) (per day) policy is active and
insured is covered)
1 to 300 day 10 7.931 Date of credit of 365 days from the
Wellness score Date of credit of
Wellness score
301 day 10 7.931 Date of Policy 365 days from:
onwards Anniversary - in - Date of Policy
case of Multi Anniversary - in
year policy case of Multi year
Date of renewal policy
- in case of 1 yr - Date of renewal
policy - in case of 1
yr policy, as
applicable
Maximum Total in a Policy 2894.82
Year

21
Steps to register for Wellness Program and Disclaimer (applicable to section B32 & B33)
earn & spend Wellness Rewards
1. Availing the services under this benefit is
Step 1. Register yourself on customer purely upon the Insured’s sole discretion
application and risk.
• The insured person will download 2. For services that are provided through
Tata AIG customer application on empanelled Service Providers, we are
your device and complete registration acting as a facilitator; hence would not
process by providing policy and be liable for any incremental costs or the
insured person’s details. services. Any additional services availed,
or expenses incurred on such services
Step 2. Complete health risk
or benefits which are other than those
assessment
covered under this policy and explicitly
• Submit response to the online health excluded by this policy schedule, shall
questionnaire on your device. not be covered under this policy and all
expenses incurred shall be borne by the
• On completion of the health risk insured person.
assessment, a Wellness category
will be assigned to the insured 3. We shall not be responsible for or liable
person for the policy year and will be for, any actions, claims, demands, losses,
updated based on the latest health damages, costs, charges and expenses
risk assessment in next policy year. which insured person claims to have
suffered, sustained or incurred, by way
Step 3. Comply with mechanism to earn of and / or on account of the benefit. We
Wellness Rewards shall not be liable for any deficiency or
• We will track the physical exercise discrepancy in the services provided by
and fitness activities completed by empanelled service provider/network
the insured person, through the provider under this policy.
customer app. 4. Insured person may consult any medical
• Activities completed on a calendar professional at any network provider/
day will be considered as a Healthy empanelled service provider at its sole
Day and reward will be credited to discretion. The cost of service arising
insured person’s wellness account. out of insured person choice of medical
professional at any network provider/
Step 4. Convert Healthy Day into emplaned service provider shall be
monetary value and spend completely borne by the insured person
• Insured person will have an option unless covered otherwise. However, the
to convert the accumulated rewards services under this policy should not be
into the monetary value and spend it construed to constitute medical advice
on items/ services offered under the and/or substitute the insured person’s visit/
policy consultation to an independent medical
practitioner/healthcare professional
• The unutilized rewards will be carried
forward to next Policy year till this 5. The medical practitioner may suggest/
policy is renewed with us within recommend/prescribe over the counter
grace period and is inforce subject to medications based on the information
validity period of the reward point) provided, if required on a case-to-case
basis. Provided that any recommendation
22
under this policy shall not be valid for any c. This facility may be availed through
medico legal purposes. Our digital customer application or
through calling Our call centre on the
6. The insured person is free to choose whether
tollfree number specified in the Policy
or not to act on the recommendation after
Schedule.
seeking consultation.
11. Above mentioned services are non-
7. Any advice, recommendations or
portable, annual contracts, independent of
suggestions made by any medical
policy contract and not lifelong renewable.
professional shall be solely based on
The Services provided may be added /
the information and documentation
deleted / modified at our discretion and the
provided by the insured person to such
same shall be notified to the policyholders
medical professional. We shall not be liable
in advance prior to change effective date.
towards any loss or damage (immediate or
consequential) arising out of or in relation 12. Provision of these services is subject to
to any opinion, advice, prescription, availability as per the duration specified
actual or alleged errors, omissions and by Us/the empanelled service provider.
representations made by the medical Details are available on our website (www.
professional from whom we have availed tataaig.com)
services or taken benefit or for any
13. Any service availed by the Insured
consequence of any act or omission in
Person under this Benefit will not impact
reliance thereon.
Cumulative Bonus if applicable.
8. We at our discretion may provide discounts
14. We reserve the right to change any service
on any of the above services which may
provider during the currency of the policy
vary from time to time subject to IRDAI
or at renewal. The same shall be intimated
regulations
to the insured atleast 15 days prior to
9. Any discount offered under redeemable the effective date of change. During such
voucher/discount on services by our change, all the credits earned by the
empanelled service providers are subject insured person shall be transferred to the
to modification or withdrawal. We do not new service provider.
assume any liability towards the quantum
15. In case we or the assistance service
of discount, quality of product/services and
provider fails to provide any of the services
timeline within which the product/service
as mentioned in this policy or is unable
is rendered.
to implement, in whole or in part due to
10. For Ambulance Booking facility– force majeure, non-availability of services,
change in law, rule or regulations which
a. These services are provided through
affects the services, or if any regulatory or
our empanelled service provider in
governmental agency having jurisdiction
select cities. Please contact us / refer
over a party takes a position which
to our digital customer application for
affects the services , then the assistance
more details on this service.
services’ suspended, curtailed or limited
b. We do not assume any liability performance shall not constitute breach
towards quality and turnaround of contract and the company or the
times of service rendered, any loss or assistance service provider shall have
damage arising out of or in relation no liability whatsoever including but not
to these services rendered by the limited to any loss or damage resulting
empanelled service provider. therefrom.
23
Section 3 –Exclusions period specified for pre-Existing
diseases, then the longer of the two
General Exclusions
waiting periods shall apply.
We will neither be liable nor make any payment
d. The waiting period for listed conditions
for any claim in respect of any Insured Person
shall apply even if contracted after
which is caused by, arising from or in any way
the policy or declared and accepted
attributable to any of the following exclusions,
unless expressly stated to the contrary in this without a specific exclusion.
Policy. e. If the Insured Person is continuously
i. Standard Exclusions covered without any break as defined
under the applicable norms on
1. Exclusions with waiting periods portability stipulated by IRDAI, then
i. 30 Days Waiting Period (Code-Excl03): waiting period for the same would
be reduced to the extent of prior
a. Expenses related to the treatment of coverage.
any illness within 30 days from the
first policy commencement date shall f. List of Specific Diseases/procedures
be excluded except claims arising due as furnished below:
to an accident, provided the same are
I. Tumors, Cysts, polyps including
covered.
breast lumps (benign)
b. This exclusion shall not, however,
II. Polycystic ovarian disease
apply if the Insured Person has
Continuous Coverage for more than III. Fibromyoma
twelve months.
IV. Adenomyosis
c. The within referred waiting period
is made applicable to the enhanced V. Endometriosis
sum insured in the event of granting VI. Prolapsed Uterus
higher sum insured subsequently.
VII. Non-infective arthritis
ii. Specified Disease/Procedure Waiting
Period (Code-Excl02): VIII. Gout and Rheumatism
a. Expenses related to the treatment IX. Osteoporosis

of the listed Conditions, surgeries/
X. Ligament, Tendon or Meniscal
treatments shall be excluded until the
tear
expiry of 24 months of continuous
coverage after the date of inception XI. Prolapsed Inter Vertebral Disc
of the first policy with us. This
exclusion shall not be applicable for XII. Cholelithiasis
claims arising due to an accident. XIII. Pancreatitis
b. In case of enhancement of sum XIV. F i s s u r e / f i s t u l a i n a n u s ,
insured the exclusion shall apply haemorrhoids, pilonidal sinus
afresh to the extent of sum insured
increase. XV. Ulcer & erosion of stomach &
duodenum
c. If any of the specified disease/
procedure falls under the waiting XVI. Gastro Esophageal Reflux
Disorder (GERD)
24
XVII. Liver Cirrhosis XXXIX. Surgery for Hydrocele/
Rectocele
XVIII. Perineal Abscesses
XL. Surgery of varicose veins and
XIX. Perianal / Anal Abscesses
varicose ulcers
XX. Calculus diseases of
iii. Pre-existing Diseases Waiting Period (Code-
Urogenital system Example:
Excl01)
Kidney stone, Urinary bladder
stone. a. Expenses related to the treatment
of a pre-existing Disease (PED)
XXI. Benign Hyperplasia of
and its direct complications shall
prostate
be excluded until the expiry of 24
XXII. Varicocele months of continuous coverage after
the date of inception of the first policy
XXIII. Cataract with us.
XXIV. Retinal detachment b. In case of enhancement of sum
XXV. Glaucoma insured the exclusion shall apply
afresh to the extent of sum insured
XXVI. Congenital Internal Diseases increase.
The following treatments are covered c. If the Insured Person is continuously
after a waiting period of two years covered without any break as defined
irrespective of the illness for which it under the portability norms of the
is done: extant IRDAI (Health Insurance)
XXVII. Adenoidectomy Regulations, then waiting period for
the same would be reduced to the
XXVIII. Mastoidectomy extent of prior coverage.
XXIX. Tonsillectomy d. Coverage under the policy after the
XXX. Tympanoplasty expiry of 24 months for any pre-
existing disease is subject to the
XXXI. Surgery for nasal septum same being declared at the time of
deviation application and accepted by us.
XXXII. Nasal concha resection 2. Medical Exclusions
XXXIII. S u r g e r y f o r T u r b i n a t e i. Treatment for, Alcoholism, drug or
hypertrophy substance abuse or any addictive
condition and consequences thereof
XXXIV. Hysterectomy
.(Code-Excl12)
XXXV. Joint replacement surgeries
ii. Expenses related to surgical
Eg: Knee replacement, Hip
treatment of obesity that does not
replacement
fulfil the below conditions (Code-
XXXVI. Cholecystectomy Excl06):
XXXVII. Hernioplasty or Herniorraphy a. Surgery to be conducted is upon
the advice of the Doctor
XXXVIII. S u r g e r y / p r o c e d u r e
for Benign prostate b. The surgery/Procedure
enlargement conducted should be supported
25
by clinical protocols iv. Reversal of sterilization
c. The member has to be 18 years v. Refractive error (Code -Excl15):

of age or older and Expenses related to the
treatment for correction of eye
d. Body Mass Index (BMI);
sight due to refractive error less
i. greater than or equal to 40 than 7.5 dioptres.
or
vi. Change-of-Gender treatments
ii. greater than or equal to (Code- Excl 07): Expenses
35 in conjunction with any related to any treatment,
of the following severe including surgical management,
co-morbidities following to change characteristics of the
failure of less invasive body to those of the opposite
methods of weight loss: sex
1. Obesity-related vii. Cosmetic or Plastic Surgery

cardiomyopathy (Code – Excl08) : Expenses for
cosmetic or plastic surgery
2. Coronary heart or any treatment to change
disease appearance unless for
3. Severe Sleep Apnea reconstruction following an
Accident, Burn(s) or Cancer or
4. Uncontrolled Type2 as part of medically necessary
Diabetes treatment to remove a direct
iii. Investigation and evaluation (Code- and immediate health risk
Excl04): to the insured. For this to be
considered a medical necessity,
a. Expenses related to any it must be certified by the
admission primarily for attending Medical Practitioner.
diagnostics and evaluation
purposes only are excluded. viii. Rest cure, rehabilitation and
respite care (Code-Excl05):
b. Any diagnostic expenses which
are not related or not incidental a. Expenses related to any
to the current diagnosis and admission primarily for
treatment are excluded. enforced bed rest and not
for receiving treatment.
iv. Expenses related to Sterility and This also includes:
infertility (Code-Excl17). This includes:
i. Custodial care either
i. Any type of contraception, at home or in a
sterilization nursing facility for
ii. Assisted Reproduction services personal care such
including artificial insemination as help with activities
and advanced reproductive of daily living such
technologies such as IVF, ZIFT, as bathing, dressing,
GIFT, ICSI moving around either
by skilled nurses or
iii. Gestational Surrogacy assistant or non-
skilled persons.
26
ii. Any services for substances unless prescribed
people who are by a medical practitioner as part
terminally ill to of hospitalization claim or day
address physical, care procedure. (Code -Excl14)
social, emotional
3. Non-Medical Exclusions
and spiritual needs.
i. Hazardous or Adventure Sports
ix. Unproven treatments (Code-
(Code Excl09) : Expenses related
Excl16) : Expenses related
to any treatment necessitated due
to any unproven treatment,
to participation as a professional
services and supplies for or in
in hazardous or adventure
connection with any treatment.
sports, including but not limited
Unproven treatments are
to, para-jumping, rock climbing,
treatments, procedures or
mountaineering, rafting, motor
supplies that lack significant
racing, horse racing or scuba diving,
medical documentation to
hand gliding, sky diving, deep-sea
support their effectiveness.
diving
x. Maternity (Code - Excl18):
ii. Breach of law (Code Excl10): Expenses
a. Medical treatment for treatment directly arising from or
expenses traceable to consequent upon any Insured Person
childbirth (including committing or attempting to commit
complicated deliveries a breach of law with criminal intent.
and caesarean sections
iii. Excluded Providers (Code-
incurred during
Excl11):Expenses incurred towards
hospitalization) except
treatment in any hospital or by any
ectopic pregnancy;
Medical Practitioner or any other
b. Expenses towards provider specifically excluded by the
miscarriage (unless due Insurer and disclosed in its website /
to an accident) and lawful notified to the policyholders are not
medical termination of admissible. However, in case of life
pregnancy during the threatening situations or following an
policy period accident, expenses up to the stage of
stabilization are payable but not the
xi. Treatments received in heath
complete claim.
hydros, nature cure clinics,
spas or similar establishments ii. Specific Exclusions (Exclusions other
or private beds registered as than as mentioned under Section 3 (1,
a nursing home attached to 2 & 3) above)
such establishments or where
1. Medical Exclusions
admission is arranged wholly
or partly for domestic reasons. i. Alcoholic pancreatitis
(Code -Excl13)
ii. Congenital External Diseases, defects
xii. Dietary supplements and or anomalies;
substances that can be
iii. Stem cell therapy ; however
purchased without prescription,
hematopoietic stem cells for
including but not limited to
bone marrow transplant for
Vitamins, minerals and organic
27
haematological conditions will be convenience like television (wherever
covered under benefit B1 or B4 of specifically charged for), charges for
this policy; access to telephone and telephone
calls, internet, foodstuffs (except
iv. Growth hormone therapy;
patient’s diet), cosmetics, hygiene
v. Sleep-apnoea articles, body care products and bath
additive, barber or beauty service,
vi. A d m i s s i o n p r i m a r i l y f o r guest service
administration of Intra-articular
or intra-lesional injections or v. Treatment rendered by a Medical
Intravenous immunoglobulin infusion Practitioner which is outside his
or supplementary medications like discipline
Zolendronic Acid
vi. Doctor’s fees charged by the Medical
vii. V e n e r e a l d i s e a s e , s e x u a l l y Practitioner sharing the same
transmitted disease or illness; residence as an Insured Person or
who is an immediate relative of an
viii. All preventive care, vaccination Insured Person’s family.
including inoculation and
immunisations (except in case of vii. Provision or fitting of hearing aids,
post- bite treatment and other spectacles or contact lenses including
vaccines explicitly covered); optometric therapy unless explicitly
stated and covered in the policy,
ix. Dental treatment or surgery of any
kind except as specified in ‘Inpatient viii. Any treatment and associated
Treatment – Dental’. expenses for alopecia, baldness,
wigs, or toupees, medical supplies
x. Any existing disease specifically including elastic stockings, diabetic
mentioned as Permanent exclusion test strips, and similar products.
in the Policy Schedule
ix. Any treatment or part of a treatment
2. Non-Medical Exclusions that is not of a reasonable charge,
i. War or any act of war, invasion, act not medically necessary; drugs or
of foreign enemy, war like operations treatments which are not supported
(whether war be declared or not or by a prescription.
caused during service in the armed x. Crutches or any other external
forces of any country), civil war, appliance and/or device used for
public defence, rebellion, revolution, diagnosis or treatment (except when
insurrection, military or usurped acts, used intra-operatively and explicitly
nuclear weapons/materials, chemical stated and covered in the policy).
and biological weapons, ionising
radiation. xi. Any illness diagnosed or injury
sustained or where there is change
ii. Any Insured Person’s participation or in health status of the member
involvement in naval, military or air after date of proposal and before
force operation, commencement of policy and the
iii. Intentional self-injury or attempted same is not communicated and
suicide while sane or insane. accepted by us
iv. Items of personal comfort and
28
Section 4 – General Terms and Clauses claim within 45 days from the date of
receipt of last necessary document.
i. Standard General Terms and Clauses
iv. In case of delay beyond stipulated
1. Disclosure of Information
45 days, the Company shall be liable
The policy shall be void and all premium to pay interest to the policyholder at
paid thereon shall be forfeited to the a rate 2% above the bank rate from
Company in the event of misrepresentation, the date of receipt of last necessary
misdescription or non-disclosure of any document to the date of payment of
material fact by the policyholder. claim.
(Explanation: “Material facts” for the (Explanation: “Bank rate” shall mean the
purpose of this policy shall mean all rate fixed by the Reserve Bank of India
relevant information sought by the (RBl) at the beginning of the financial year
company in the proposal form and other in which claim has fallen due).The Clause
connected documents to enable it to shall be suitably modified by the insurer
take informed decision in the context of based on the amendment(s), if any to
underwriting the risk) the relevant provisions of Protection of
Policyholder’s Interests Regulations, 2017)
2. Condition Precedent to Admission of
Liability 4. Complete Discharge
The terms and conditions of the policy Any payment to the policyholder, insured
must be fulfilled by the insured person person or his/ her nominees or his/ her
for the Company to make any payment for legal representative or assignee or to
claim(s) arising under the policy. the Hospital, as the case may be, for any
benefit under the policy shall be a valid
3. Claim Settlement (provision for Penal discharge towards payment of claim by the
Interest) Company to the extent of that amount for
i. The Company shall settle or reject a the particular claim.
claim, as the case may be, within 30 5. Multiple Policies
days from the date of receipt of last
necessary document. i. In case of multiple policies taken
by an insured person during a
ii. In the case of delay in the payment of period from one or more insurers
a claim, the Company shall be liable to indemnify treatment costs, the
to pay interest to the policyholder insured person shall have the right to
from the date of receipt of last require a settlement of his/her claim
necessary document to the date of in terms of any of his/her policies. In
payment of claim at a rate 2% above all such cases the insurer chosen by
the bank rate. the insured person shall be obliged
iii. However, where the circumstances to settle the claim as long as the claim
of a claim warrant an investigation is within the limits of and according
in the opinion of the Company, it to the terms of the chosen policy.
shall initiate and complete such ii. Insured person having multiple
investigation at the earliest, in any policies shall also have the right to
case not later than 30 days from prefer claims under this policy for
the date of receipt of last necessary the amounts disallowed under any
document. In such cases, the other policy / policies even if the sum
Company shall settle or reject the
29
insured is not exhausted. Then the person does not believe to be true;
insurer shall independently settle
b) the active concealment of a fact by
the claim subject to the terms and
the insured person having knowledge
conditions of this policy.
or belief of the fact;
iii. If the amount to be claimed exceeds
c) any other act fitted to deceive; and
the sum insured under a single policy,
the insured person shall have the d) any such act or omission as the law
right to choose insurer from whom specially declares to be fraudulent
he/she wants to claim the balance
The Company shall not repudiate the
amount.
claim and / or forfeit the policy benefits
iv. Where an insured person has policies on the ground of Fraud, if the insured
from more than one insurer to person / beneficiary can prove that the
cover the same risk on indemnity misstatement was true to the best of his
basis, the insured person shall only knowledge and there was no deliberate
be indemnified the treatment costs intention to suppress the fact or that
in accordance with the terms and such misstatement of or suppression of
conditions of the chosen policy. material fact are within the knowledge of
the insurer.
6. Fraud
7. Cancellation
If any claim made by the insured person,
is in any respect fraudulent, or if any false i. The policyholder may cancel this policy by
statement, or declaration is made or used giving 15 days written notice and in such an
in support thereof, or if any fraudulent event, the Company shall refund premium
means or devices are used by the insured for the unexpired policy period as detailed
person or anyone acting on his/her behalf below:
to obtain any benefit under this policy, all
benefits under this policy and the premium Length of Tenure (Years)
paid shall be forfeited. time Policy
in force 1 2 3
Any amount already paid against claims
made under this policy but which are Upto 1
75.00% 87.50% 91.5%
Month
found fraudulent later shall be repaid by all
recipient(s)/policyholder(s), who has made >1 month
that particular claim, who shall be jointly & Upto 3 50.00% 75.00% 88.5%
and severally liable for such repayment to Months
the insurer. >3 months
& Upto 6 25.00% 62.50% 75%
For the purpose of this clause, the Months
expression “fraud” means any of the
following acts committed by the insured >6 months
& Upto 12 Nil 50.00% 66.5%
person or by his agent or the hospital/
Months
doctor/any other party acting on behalf of
the insured person, with intent to deceive >12
the insurer or to induce the insurer to issue months & Not
25% 50%
an insurance policy: Upto 15 Applicable
Months
a) the suggestion, as a fact of that which
is not true and which the insured
30
For Detailed Guidelines on Migration,
>15
months & Not kindly refer Guidelines issued by IRDAI
12.5% 41.5% (Insurance Regulatory and Development
Upto 18 Applicable
Months Authority of India) on Migration and
Portability of Health Insurance policies
>18
– Ref: IRDAI/HLT/REG/CIR/194/07/2020)
months & Not
Nil 33% dated 22nd July 2020 and subsequent
Upto 24 Applicable
months amendments thereof.
>24 9. Portability
months & Not Not
8% The insured person will have the option
Upto 30 Applicable Applicable
months to port the policy to other insurers by
applying to such insurer to port the
Exceeding Not Not
Nil entire policy along with all the members
30 months Applicable Applicable
of the family, if any, at least 45 days
Notwithstanding anything contained herein or before, but not earlier than 60 days
otherwise, no refunds of premium shall be made from the policy renewal date as per
in respect of Cancellation where, any claim has IRDAI guidelines related to portability.
been admitted or has been lodged or any benefit If such person is presently covered and
(including those provided under B 32. Wellness has been continuously covered without
Services/ B 33. Wellness Program of this policy) any lapses under any health insurance
has been availed by the insured person under policy with an Indian General/Health
the policy. insurer, the proposed insured person
will get the accrued continuity benefits in
ii. The Company may cancel the policy at waiting periods as per IRDAI guidelines on
any time on grounds of misrepresentation portability.
non-disclosure of material facts, fraud
by the insured person by giving 15 days’ For Detailed Guidelines on Portability,
written notice. There would be no refund kindly refer Guidelines issued IRDAI
of premium on cancellation on grounds (Insurance Regulatory and Development
of misrepresentation, non-disclosure of Authority of India) on Migration and
material facts or fraud. Portability of Health Insurance policies
– Ref: IRDAI/HLT/REG/CIR/194/07/2020)
8. Migration dated 22nd July 2020 and subsequent
The insured person will have the option to amendments thereof.
migrate the policy to other health insurance 10. Renewal of Policy
products/plans offered by the company by
applying for migration of the policy at least The policy shall ordinarily be
30 days before the policy renewal date as renewable except on grounds of fraud,
per IRDAI guidelines on Migration. lf such misrepresentation by the insured person.
person is presently covered and has been
i. The Company shall endeavor to give
continuously covered without any lapses
notice for renewal. However, the
under any health insurance product/
Company is not under obligation to
plan offered by the company, the insured
give any notice for renewal.
person will get the accrued continuity
benefits in waiting periods as per IRDAI ii. Renewal shall not be denied on the
guidelines on migration. ground that the insured person
had made a claim or claims in the
31
preceding policy years. to all limits, sub limits, co-payments,
deductibles as per the policy contract.
iii. Request for renewal along with
requisite premium shall be received 13. Possibility of Revision of Terms of the
by the Company before the end of Policy Including the Premium Rates
the policy period.
The Company, with prior approval of
iv. At the end of the policy period, the IRDAI, may revise or modify the terms of
policy shall terminate and can be the Policy including the premium rates.
renewed within the Grace Period The Insured Person shall be notified three
of 30 days to maintain continuity months before the changes are effected.
of benefits without break in policy.
14. Free look period
Coverage is not available during the
grace period. The Free Look Period shall be applicable
on new individual health insurance policies
v. No loading shall apply on renewals
and not on renewals or at the time of
based on individual claims experience
porting/migrating the policy.
11. Withdrawal of Policy
The insured person shall be allowed free
i. In the likelihood of this product being look period of fifteen days from date of
withdrawn in future, the Company receipt of the policy document to review
will intimate the insured person the terms and conditions of the policy, and
about the same 90 days prior to to return the same if not acceptable.
expiry of the policy.
If the insured has not made any claim
ii. Insured Person will have the option during the Free Look Period, the insured
to migrate to similar health insurance shall be entitled to
product available with the Company
i. a refund of the premium paid
at the time of renewal with all the
less any expenses incurred by the
accrued continuity benefits such as
Company on medical examination
cumulative bonus, waiver of waiting
of the insured person and the stamp
period as per IRDAI guidelines,
duty charges or
provided the policy has been
maintained without a break. ii. where the risk has already
commenced and the option of return
12. Moratorium Period
of the policy is exercised by the
After completion of eight continuous insured person, a deduction towards
years under the policy no look back to be the proportionate risk premium for
applied. This period of eight years is called period of cover or
as moratorium period. The moratorium
iii. Where only a part of the insurance
would be applicable for the sums insured
coverage has commenced,
of the first policy and subsequently
such proportionate premium
completion of 8 continuous years would
commensurate with the insurance
be applicable from date of enhancement of
coverage during such period
sums insured only on the enhanced limits.
After the expiry of Moratorium Period no 15. Redressal of Grievance
health insurance claim shall be contestable
In case of any grievance the insured person
except for proven fraud and permanent
may contact the company through
exclusions specified in the policy contract.
The policies would however be subject
32
Website: www.tataaig.com policyholder, the Company will pay the
nominee {as named in the Policy Schedule
Toll Free: 1800 266 7780 or 1800 22 9966
/Endorsement (if any)} and in case there is
(only for Senior Citizen policyholders)
no subsisting nominee, to the legal heirs
Email: customersupport@tataaig.com or legal representatives of the policyholder
whose discharge shall be treated as full
Courier: Customer Support, Tata AIG and final discharge of its liability under the
General Insurance Company Limited, 7th policy.
and 8th Floor, Romell Tech Park, Cama
Industrial Estate, Western Express Highway, ii. Specific terms and clauses (terms and
Goregaon(E), Mumbai, Maharashtra clauses other than those mentioned
400063 under Section 4 (i) above)
Insured person may also approach the 17. Premium Payment

grievance cell at any of the company’s
i. Premium to be paid for the Policy
branches with the details of grievance.
Period before Policy Commencement
If Insured person is not satisfied with the date as opted by You in the proposal
redressal of grievance through one of form.
the above methods, insured person may
ii. If you have opted to pay premium
contact the grievance officer at manager.
in full (lumpsum) upfront then the
customersupport@tataaig.com.
entire premium for the policy period
For updated details of grievance officer, shall be paid before the policy
kindly refer the link (https://www.tataaig. commencement date with an option
com/grievance-redressal-policy) of policy tenure 1/2/3 years.
lf Insured person is not satisfied with iii. Long term premium discount of 5%
the redressal of grievance through and 10% is applicable for policy with
above methods, the insured person may tenure of 2 and 3 years respectively.
also approach the office of Insurance
18. Insured Person
Ombudsman of the respective area/region
(details as mentioned in the Annexure A of i. Only those persons named as an
this policy) for redressal of grievance as per Insured Person in the Schedule shall
Insurance Ombudsman Rules 2017. be covered under this Policy.
Grievance may also be lodged at IRDAI ii. Any person may be added during
Integrated Grievance Management System the Policy Period after his application
has been accepted by Us, additional
(https://igms.irda.gov.in/)
premium has been paid and We have
16. Nomination issued an endorsement confirming
the addition of such person as an
The policyholder is required at the inception Insured Person.
of the policy to make a nomination for
the purpose of payment of claims under iii. We will be offering continuous
the policy in the event of death of the renewal with no exit age subject
policyholder. Any change of nomination to regular premium payment and
shall be communicated to the company in compliance with all provisions and
writing and such change shall be effective terms & conditions of this policy by
only when an endorsement on the policy the Insured Person.
is made. In the event of death of the
33
19. Loadings change in this policy shall be valid
unless approved by Us and such
i. We may apply a risk loading on the
approval be endorsed hereon.
premium payable (based upon the
declarations made in the proposal ii. This Policy and the Schedule shall be
form and the health status of the read together as one contract and
persons proposed for insurance). any word or expression to which a
specific meaning has been attached
ii. The maximum risk loading applicable
in any part of this Policy or of the
for an individual shall not exceed
Schedule shall bear such meaning
100% of premium per diagnosis /
wherever it may appear.
medical condition and an overall risk
loading of over 150% of premium per 21. Change of Policyholder
person.
i. The change of Policyholder is
iii. The loading shall only be applied permitted only at the time of renewal.
basis an outcome of Our medical
ii. If the Insured Person is no longer
underwriting.
eligible on grounds of age or
iv. These loadings are applied from dependency, the insured member
Commencement Date of the Policy will be eligible to apply for a new
including subsequent renewal(s) with policy and enjoy continuity benefits
Us or on the receipt of the request upto Sum Insured.
of increase in Sum Insured (for the
22. Notices
increased Sum Insured).
i. Any notice, direction or instruction
a. We will inform You about the
under this Policy shall be in writing
applicable risk loading through
and if it is to:
a counter offer letter.
a. Any Insured Person, then it shall
b. You need to revert to Us
be sent to You at Your address
with consent and additional
specified in the Schedule to
premium (if any), within 15 days
this Policy and You shall act for
of the issuance of such counter
all Insured Persons for these
offer letter.
purposes.
c. In case, you neither accept the
b. Us, it shall be delivered to
counter offer nor revert to Us
Our address specified in the
within 15 days, We shall cancel
Schedule to this Policy. No
Your application and refund the
insurance agents, brokers
premium paid within next 10
or other person or entity is
days subject to deduction of the
authorised to receive any
Pre-Policy Check up charges, as
notice, direction or instruction
applicable.
on Our behalf unless We have
v. Please note that We will issue Policy expressly stated to the contrary
only after getting Your consent. in writing.
20. Entire Contract 23. Premium Payment Zone
i. This Policy, its Schedule, For the purpose of premium computation,

endorsement(s), proposal constitutes the country is divided into following three
the entire contract of insurance. No Zones and premium payable under the
34
policy will be computed based on the Refund will be made to the Policy holder
residential location/address as provided or the nominee in case of demise of the
by the proposer/insured person in the Policy holder. We would require death
proposal form: certificate of the Deceased Insured Person
for processing of the refund amount.
a. Zone A: Mumbai including MMR/
Thane, Delhi NCR/Faridabad/ Section 5 – Claims Procedure and Claims
Ghaziabad, Ahmedabad, Surat and Payment
Baroda
This section explains about the procedures
b. Zone B: Hyderabad, Bengaluru, involved to file a valid claim by the insured
Kolkata, Indore, Chennai, Chandigarh/ member and processes related in managing
Mohali/ Punchkula/ Zirakpur, Pune/ the claim by TPA or Us. All the procedures and
Pimpri Chinchwad and Rajkot processes such as notification of claim, availing
cashless service, supporting claim documents
c. Zone C: Rest of India
and related claim terms of payment are
24. Premium Refund in case of demise of explained in this section.
the Insured Person
1. Notification of Claim
The coverage for the Insured Person(s)
shall automatically terminate in case of Treatment, We or
his/ her (Insured Person) demise. However, Consultation or Our TPA*
the cover shall continue for the remaining Procedure: must be
informed:
Insured Persons till the end of Policy
Period. The other insured persons may 1 If any treatment At least
also apply to renew the policy. In case, the for which a claim 48 hours
other insured person is minor, the policy may be made and prior to the
shall be renewed only through any one that treatment Insured
requires planned Person’s
of his/her natural guardian or guardian
Hospitalisation: admission.
appointed by court. All relevant particulars
in respect of such person (including his/ 2 If any treatment Within 24
her relationship with the insured person) for which a hours of
must be submitted to the company along claim may be the Insured
made and that Person’s
with the application. Provided no claim
treatment requires admission to
has been made, and termination takes
emergency Hospital.
place on account of death of the insured Hospitalisation
person, pro-rata refund of premium of the
deceased insured person for the balance *TPA as mentioned in the policy schedule, if
period of the policy will be made. any
35
2. Cashless Service
Treatment, Treatment, Cashless Service is We must be given

Consultation or Consultation or Available: notice that the
Procedure: Procedure Taken Insured Person
at: wishes to take
advantage of the
cashless service
accompanied by
full particulars:
If any planned Network Hospital We will provide At least 48 hours
treatment, cashless service by before the planned
consultation or making payment treatment or
procedure for to the extent of Hospitalisation
which a claim may Our liability directly
be made: to the Network
Hospital.
If any treatment, Network Hospital We will provide Within 24 hours
consultation or cashless service by after the treatment
procedure for making payment or Hospitalisation
which a claim may to the extent of
be made, requiring Our liability directly
emergency to the Network
hospitalisation Hospital.
3. Procedure for Cashless Service
i. Cashless Service is only available at Network Hospitals.
ii. In order to avail of cashless treatment, the following procedure must be followed by You:
a. Prior to taking treatment and/or incurring Medical Expenses at a Network Hospital,

You must call our designated TPA/Us and request pre-authorization.
b. For any emergency Hospitalisation, our designated TPA/We must be informed no

later than 24 hours of the start of Your hospitalization/ treatment.
c. For any planned hospitalization, our designated TPA/We must be informed atleast
48 hours prior to the start of your hospitalization/treatment.
d. Our designated TPA/We will check your coverage as per the eligibility and send an
authorization letter to the provider. You have to provide the ID card issued to You
along with any other information or documentation that is requested by the TPA/
Us to the Network Hospital.
e. In case of deficiency in the documents sent to TPA/Us for cashless authorization,

the same shall be communicated to the hospital by TPA/Us within 6 hours of receipt
of the documents.
f. In case the ailment /treatment is not covered under the policy or cashless is rejected
due to insufficient documents submitted, a rejection letter would be sent to the
hospital within 6 hours.
g. Rejection of cashless in no way indicates rejection of the claim. You are required
36
to submit the claim along with a. Our claim form, duly completed
required documents for us to and signed for on behalf of
decide on the admissibility of the Insured Person.We, upon
the claim. receipt of a notice of claim, will
furnish Your representative
h. If the cashless is approved,
with such forms as We may
the original bills and evidence
require for filing proofs of loss
of treatment in respect of the
or you may download the claim
same shall be left with the
form from our Web site.
Network Hospital.
b. Original Bills (pharmacy
i. Pre-authorization does not
purchase bill, consultation
guarantee that all costs and
bill, diagnostic bill) and any
expenses will be covered. We
attachments thereto like
reserve the right to review each
receipts or prescriptions in
claim for Medical Expenses and
support of any amount claimed
accordingly coverage will be
which will then become Our
determined according to the
property.
terms and conditions of this
Policy. c. All medical reports, case
histories, investigation reports,
4. Supporting Documentation &
indoor case papers/ treatment
Examination
papers (in reimbursement
i. You or someone claiming on cases, if available), discharge
Your behalf shall provide Us with summaries.
documentation, medical records
d. A precise diagnosis of the
and information We or Our TPA
treatment for which a claim is
may request to establish the
made.
circumstances of the claim, its
quantum or Our liability for the e. A detailed list of the individual
claim within 15 days or earlier of medical services and treatments
Our request or the Insured Person’s provided and a unit price for
discharge from Hospitalisation or each in case not available in the
completion of treatment. submitted hospital bill.
ii. Failure to furnish such evidence f. Prescriptions that name the

within the time required shall not Insured Person and in the case
invalidate nor reduce any claim if of drugs: the drugs prescribed,
you can satisfy us that it was not their price and a receipt for
reasonably possible for you to give payment. In case of pre/
proof within such time. post hospitalization claim
Prescriptions must be submitted
iii. We may accept claims where
with the corresponding Doctor/
documents have been provided
hospital invoice.
after a delayed interval only in special
circumstances and for the reasons g. All pre and post investigation,
beyond the control of the Insured treatment and follow up
Person. (consultation) records
pertaining to the present
iv. Such documentation will include
ailment for which claim is being
the following:
37
made, if and where applicable. Medical Practitioner whose details will
be notified to insured person when
h. Treating doctor’s certificate
and as often as We may reasonably
regarding missing information
require during the pendency of a
in case histories e.g.
claim hereunder.
Circumstance of injury and
Alcohol or drug influence at the 5. Claims Payment
time of accident, if available
i. We shall be under no obligation
i. Copy of settlement letter from to make any payment under this
other insurance company or Policy unless We have received all
TPA premium payments in full in time
and We have been provided with
j. Stickers and invoice of implants
the documentation and information
used during surgery
We or Our TPA has requested to
k. Copy of MLC (Medico legal case) establish the circumstances of the
records, if carried out and FIR claim, its quantum or Our liability for
(First information report) if it, and unless the Insured Person has
registered, in case of claims complied with his obligations under
arising out of an accident and this Policy.
available with the claimant.
ii. This Policy only covers medical
l. Regulatory requirements as treatment taken within India (except
amended from time to time, in case of benefit B13- Global cover
currently mandatory NEFT (to for Planned Hospitalization), and
enable direct credit of claim payments under this Policy shall only
amount in bank account) and be made in Indian Rupees within
KYC (recent ID/Address proof India.
and photograph) requirements
6. Claim procedure and management of
m. Legal heir/succession certificate, Wellness Services & Wellness Program
if required (Section B32 & B33)
n. PM report (wherever applicable) i. Utilise Wellness Points:
v. Note: In case You are claiming for Utilisation of Wellness points is

the same event under an indemnity only available at network service
based policy of another insurer and providers. To avail products or
are required to submit the original services, Insured Person must visit
documents related to Your treatment our Customer application and buy
with that particular insurer, then You the required product/ services. On
may provide Us with the attested successful purchase, an amount
copies of such documents along with equivalent to the monetary value of
a declaration from the particular the Earned Wellness points will be
insurer specifying the availability of deducted from Your policy.
the original copies of the specified
ii. Avail services under Benefits:
treatment documents with it.
Services are only available at
We at our own expense, shall have the right
network. To avail the same, following
and opportunity to examine insured
procedure must be followed:
persons through Our Authorised
38
• Teleconsultation: Section 6 - Dispute Resolution
Insured person can gain access 1. Dispute Resolution Clause

to tele/video/digital consultation
Any and all disputes or differences
with a general physician/
under or in relation to this Policy shall
specialist/psychiatrist, using our
be determined by the Indian Courts and
digital customer application.
subject to Indian law.
• Ambulance booking facility:
2. Arbitration
Insured person can use our
If any dispute or difference shall arise as
digital customer application
to the quantum to be paid by the Policy,
to book an ambulance. This
(liability being otherwise admitted) such
service will be offered on best
difference shall independently of all other
effort basis and does not have
questions, be referred to the decision
a legal binding on us.
of a sole arbitrator to be appointed in
• Emergency - Help me feature: writing by the parties here to or if they
cannot agree upon a single arbitrator
In case of an emergency,
within thirty days of any party invoking
insured person can use Our
arbitration, the same shall be referred to a
Customer application to alert
panel of three arbitrators, comprising two
designated caregiver, at a push
arbitrators, one to be appointed by each
of a button. An alert message
of the parties to the dispute/difference
will be sent to the designated
and the third arbitrator to be appointed by
caregiver, informing him/her
such two arbitrators and arbitration shall
about the emergency. By opting
be conducted under and in accordance
this feature, the insured person
with the provisions of the Arbitration and
authorizes us/our empanelled
Conciliation Act 1996, as amended by
service provider to share
Arbitration and Conciliation (Amendment)
their geo-location with the
Act, 2015 (No. 3 of 2016).
designated caregiver.
It is clearly agreed and understood that no
This service will be offered on
difference or dispute shall be preferable
best effort basis and does not
to arbitration as herein before provided, if
have a legal binding on us.
the Company has disputed or not accepted
iii. Supporting Documentation & liability under or in respect of the policy.
Examination
3. It is hereby expressly stipulated and
Insured Person or someone booking declared that it shall be a condition
services on Your behalf shall provide precedent to any right of action or suit
Us with identification documentation, upon the policy that award by such
medical records and information arbitrator/arbitrators of the amount of
We may request to establish the expenses shall be first obtained.
circumstances of the claim.
39
Annexure A
NAMES OF OMBUDSMAN AND ADDRESSES OF OMBUDSMAN CENTRES
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
40
SN Centre Address & Contact
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
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
41
For updated list and details of Insurance whole or part of the commission payable
Ombudsman Offices, please visit website https:// or any rebate of the premium shown on
www.cioins.co.in/ombudsman the policy, nor shall any person taking out
or renewing or continuing a policy accept
Prohibition of Rebates - Section 41 of the
any rebate, except such rebate as may be
Insurance Act, 1938 as amended by Insurance
allowed in accordance with the published
Laws (Amendment) Act, 2015.
prospectuses or tables of the insurer.
1. No person shall allow or offer to allow,
2. Any person making default in complying
either directly or indirectly, as an
with the provisions of this section shall be
inducement to any person to take out
liable for a penalty which may extend to
or renew or continue an insurance in
ten lakh rupees.
respect of any kind of risk relating to lives
or property in India, any rebate of the
42

Tata Aig Medicare Premier Policy Wording

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Tata AIG MediCare Premier

Tata AIG General Insurance Company Limited (We,

Tata AIG General Insurance Company Limited

2. Any one illness 4. Cashless facility

8. Day Care Centre 11. Domiciliary Hospitalization

iv. has a fully equipped operation iv. it continues indefinitely

29. Pre-hospitalization Medical Expenses Reasonable and Customary charges means

31. Post-hospitalization Medical Expenses 36. Surgery or Surgical Procedure

Post-hospitalization Medical Expenses Surgery or Surgical Procedure means

Unproven/Experimental treatment means Section 2 – Benefits

• In case we or the empanelled service

• The above services may be provided Treatment normally taken on out-patient

c. For policy with Basic Sum Insured

The Medical Expenses payable B14. Bariatric Surgery Cover

We will pay a fixed amount per day, as A maximum of

viii. Heart Valve replacement B22. Delivery Complications Cover

ix. Brain tumors We will cover for medical expenses

B23. First year Vaccinations v. Liver Biopsy

B25. High End Diagnostics Basic Sum Insured Limit

c. Pandemic Care at home for a

To undertake the health risk assessment, We will encourage physical exercise

Rewards per - Calories burnt during basic

- In case of individual policy, each • Health-check-ups/ diagnostics

- Monetary value of the Wellness score earned is equivalent to the:

Age of the Insured Person (Years) 40

Healthy Day Wellness Wellness Reward Wellness Reward Wellness Reward

a. Expenses related to the treatment IX. Osteoporosis

c. The member has to be 18 years v. Refractive error (Code -Excl15):

1. Obesity-related vii. Cosmetic or Plastic Surgery

iv. Items of personal comfort and

Insured person may also approach the 17. Premium Payment

20. Entire Contract 23. Premium Payment Zone

i. This Policy, its Schedule, For the purpose of premium computation,

Treatment, Treatment, Cashless Service is We must be given

3. Procedure for Cashless Service

i. Cashless Service is only available at Network Hospitals.

a. Prior to taking treatment and/or incurring Medical Expenses at a Network Hospital,

b. For any emergency Hospitalisation, our designated TPA/We must be informed no

e. In case of deficiency in the documents sent to TPA/Us for cashless authorization,

ii. Failure to furnish such evidence f. Prescriptions that name the

n. PM report (wherever applicable) i. Utilise Wellness Points:

v. Note: In case You are claiming for Utilisation of Wellness points is

Insured person can gain access 1. Dispute Resolution Clause

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,

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,

Office of the Insurance Ombudsman, Jeevan Darshan Bldg.,

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