Tata AIG Medi Care 82932b277a

Tata AIG MediCare 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 contained in the Proposal signed
by the Policyholder (You) 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
UIN: TATHLIP21224V022021
“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) • Visit us at www.tataaig.com
IRDA of India Registration No.:108 • CIN: U85110MH2000PLC128425 • UIN: TATHLIP21224V022021
Preamble with the Hospital/Nursing Home where
While the policy is in force, if the Insured Person treatment was taken.
contracts any disease or suffers from any illness 3. AYUSH Hospital
or sustains bodily injury through accident and if
such event requires the insured Person to incur An AYUSH Hospital is a healthcare facility
expenses for Medically Necessary Treatment, wherein medical/surgical/para-surgical
We will indemnify You for the amount of treatment procedures and interventions
such Reasonable and Customary Charges or are carried out by AYUSH Medical
compensate to the extent agreed, upto the limits Practitioner(s) comprising of any of the
mentioned, subject to terms and conditions of following :
the Policy. Each Benefit is subject to its Sum a. Central or State Government AYUSH
Insured, but Our liability in aggregate to make Hospital or
payment in respect of any and all Benefits shall
be limited to the Sum Insured unless expressly b. Teaching hospital attached to AYUSH
stated to the contrary. college recognized by the Central
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
the contrary. In case of individual policy, the sum c. AYUSH Hospital, standalone or co-
insured for all or any of the benefits shall be on located with in-patient healthcare
per insured per year basis unless explicitly stated facility of any recognized system of
to the contrary. medicine, registered with the local
The said Medically Necessary Treatment must be authorities, wherever applicable,
on the advice of a qualified Medical Practitioner. and is under the supervision of a
qualified registered AYUSH Medical
Section 1 – Definitions Practitioner and must comply with
all the following criterion:
The terms defined below and at other junctures
in the Policy Wording have the meanings i. Having atleast 5 in-patient beds;
ascribed to them wherever they appear in this
ii. Having qualified AYUSH Medical
Policy and, where appropriate, references to
Practitioner round the clock;
the singular include references to the plural;
references to the male include the female and iii. Having dedicated AYUSH therapy
references to any statutory enactment include sections as required and/or has
subsequent changes to the same: equipped operation theatre
where surgical procedures are
i. Standard Definitions
to be carried out;
1. Accident
iv. Maintaining daily records of
An accident means sudden, unforeseen the patients and making them
and involuntary event caused by external, accessible to the insurance
visible and violent means. company’s authorized
representative.
2. Any one illness
4. Cashless facility
Any one illness means continuous period
of illness and includes relapse within 45 Cashless facility means a facility extended
days from the date of last consultation by the insurer to the insured where the
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payments, of the costs of treatment applicable, and is under supervision
undergone by the insured in accordance of a registered and qualified medical
with the policy terms and conditions, are practitioner AND must comply with all
directly made to the network provider by minimum criterion as under –
the insurer to the extent pre-authorization
i. has qualified nursing staff under its
is approved.
employment;
5. Condition Precedent
ii. has qualified medical practitioner/s
Condition Precedent means a policy terms in charge;
or condition upon which the insurer’s
iii. has fully equipped operation theatre
liability under the policy is conditional upon.
of its own where surgical procedures
6. Congenital Anomaly: are carried out;
Congenital Anomaly means a condition iv. maintains daily records of patients

which is present since birth, and which is and will make these accessible to
abnormal with reference to form, structure the insurance company’s authorized
or position. personnel.
a) Internal Congenital Anomaly 10. Day Care Treatment
Congenital anomaly which is not in the Day care treatment means medical
visible and accessible parts of the body. treatment, and/or surgical procedure
which is:
b) External Congenital Anomaly
i. undertaken under General or Local
Congenital anomaly which is in the visible Anesthesia in a hospital/day care
and accessible parts of the body. centre in less than 24 hrs because of
7. Co-Payment technological advancement, and
Co-payment means a cost sharing ii. which would have otherwise required
requirement under a health insurance hospitalization of more than 24
policy that provides that the policyholder/ hours.
insured will bear a specified percentage Treatment normally taken on an out-
of the admissible claims amount. A co- patient basis is not included in the scope
payment does not reduce the Sum Insured. of this definition.
8. Cumulative Bonus 11. Dental Treatment
Cumulative Bonus means any increase or Dental treatment means a treatment
addition in the Sum Insured granted by the related to teeth or structures supporting
insurer without an associated increase in teeth including examinations, fillings
premium. (where appropriate), crowns, extractions
and surgery.
9. Day Care Centre
12. Domiciliary Hospitalization
A day care centre means any institution
established for day care treatment of illness Domiciliary hospitalization means medical
and/or injuries or a medical setup with a treatment for an illness/disease/injury
hospital and which has been registered which in the normal course would require
with the local authorities, wherever care and treatment at a hospital but is
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actually taken while confined at home and makes these accessible to the
under any of the following circumstances: insurance company’s authorized
personnel;
i. the condition of the patient is such
that he/she is not in a condition to 15. Hospitalization
be removed to a hospital, or
Hospitalization means admission in a
ii. the patient takes treatment at home Hospital for a minimum period of 24
on account of non-availability of consecutive ‘In-patient Care’ hours except
room in a hospital. for specified procedures/ treatments,
where such admission could be for a
13. Grace Period
period of less than 24 consecutive hours.
Grace period means the specified period of
16. Illness
time immediately following the premium
due date during which a payment can be Illness means a sickness or a disease
made to renew or continue a policy in force or pathological condition leading to the
without loss of continuity benefits such impairment of normal physiological
as waiting periods and coverage of pre- function and requires medical treatment.
existing diseases. Coverage is not available
(a) Acute condition
for the period for which no premium is
received. Acute condition is a disease, illness or
injury that is likely to respond quickly to
14. Hospital
treatment which aims to return the person
A hospital means any institution established to his or her state of health immediately
for in-patient care and day care treatment before suffering the disease/ illness/ injury
of illness and/or injuries and which has which leads 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 a disease,
under enactments specified under the illness, or injury that has one or more of
Schedule of Section 56(1) and the said act the following characteristics:
Or complies with all minimum criteria as
i. it needs ongoing or long-term
under:
monitoring through consultations,
i. has qualified nursing staff under its examinations, check-ups, and /or
employment round the clock; tests;
ii. has at least 10 in-patient beds in ii. it needs ongoing or long-term control
towns having a population of less or relief of symptoms;
than 10,00,000 and at least 15 in-
iii. it requires rehabilitation for the
patient beds in all other places;
patient or for the patient to be
iii. has qualified medical practitioner(s) specially trained to cope with it;
in charge round the clock;
iv. it continues indefinitely;
iv. has a fully equipped operation
v. it recurs or is likely to recur;
theatre of its own where surgical
procedures are carried out; 17. Injury
v. maintains daily records of patients Injury means accidental physical bodily

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harm excluding illness or disease solely India or Council for Indian Medicine or for
and directly caused by external, violent, Homeopathy set up by the Government of
visible and evident means which is verified India or a State Government and is thereby
and certified by a Medical Practitioner. entitled to practice medicine within its
jurisdiction; and is acting within its scope
18. Inpatient Care
and jurisdiction of license.
Inpatient care means treatment for which
23. Medically Necessary Treatment
the insured person has to stay in a hospital
for more than 24 hours for a covered event. Medically necessary treatment means any
treatment, tests, medication, or stay in
19. Intensive Care Unit:
hospital or part of a stay in hospital which:
Intensive care unit means an identified
i. is required for the medical
section, ward or wing of a hospital which
management of the illness or injury
is under the constant supervision of
suffered by the insured;
a dedicated medical practitioner(s),
and which is specially equipped for the ii. must not exceed the level of care
continuous monitoring and treatment of necessary to provide safe, adequate
patients who are in a critical condition, and appropriate medical care in
or require life support facilities and scope, duration, or intensity;
where the level of care and supervision
iii. must have been prescribed by a
is considerably more sophisticated and
medical practitioner;
intensive than in the ordinary and other
wards. iv. must conform to the professional
standards widely accepted in
20. Medical Advice
international medical practice or by
Medical Advice means any consultation the medical community in India.
or advice from a Medical Practitioner
24. Migration
including the issuance of any prescription
or follow-up prescription. “Migration” means, the right accorded to
health insurance policyholders (including
21. Medical Expenses:
all members under family cover and
Medical Expenses means those expenses members of group health insurance
that an Insured Person has necessarily and policy), to transfer the credit gained for
actually incurred for medical treatment pre-existing conditions and time bound
on account of Illness or Accident on the exclusions, with the same insurer.
advice of a Medical Practitioner, as long as
25. Network Provider
these are no more than would have been
payable if the Insured Person had not been Network Provider means hospitals or
insured and no more than other hospitals health care providers enlisted by an
or doctors in the same locality would have insurer, TPA or jointly by an Insurer and
charged for the same medical treatment. TPA to provide medical services to an
insured by a cashless facility.
22. Medical Practitioner
26. Notification of Claim
Medical Practitioner means a person who
holds a valid registration from the Medical Notification of claim means the process
Council of any State or Medical Council of of intimating a claim to the insurer or TPA
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through any of the recognized modes of cover), to transfer the credit gained for
communication. pre-existing conditions and time bound
exclusions, from one insurer to another
27. OPD treatment
insurer.
OPD treatment means the one in which
the Insured visits a clinic / hospital or 31. Post-hospitalization Medical Expenses
associated facility like a consultation room Post-hospitalization Medical Expenses
for diagnosis and treatment based on means medical expenses incurred during
the advice of a Medical Practitioner. The predefined number of days immediately
Insured is not admitted as a day care or after the insured person is discharged from
in-patient. the hospital provided that:
28. Pre-Existing Disease
i. Such Medical Expenses are for
Pre-existing Disease means any condition, the same condition for which the
ailment, injury or disease: insured person’s hospitalization was
required, and
a. That is/are diagnosed by a physician
within 48 months prior to the ii. The inpatient hospitalization claim for
effective date of the policy issued by such hospitalization is admissible by
the insurer or its reinstatement or the insurance company.
b. For which medical advice or treatment 32. Qualified Nurse
was recommended by, or received
from, a Physician within 48 months Qualified nurse means a person who
Prior to the effective date of the holds a valid registration from the Nursing
policy issued by the insurer or its Council of India or the Nursing Council of
reinstatement. any state in India.
29. Pre-hospitalization Medical Expenses 33. Reasonable and Customary Charges
Pre-hospitalization Medical Expenses Reasonable and Customary charges means

means medical expenses incurred during the charges for services or supplies, which
predefined number of days preceding are the standard charges for the specific
the hospitalization of the Insured Person, provider and consistent with the prevailing
provided that: charges in the geographical area for
identical or similar services, taking into
i. Such Medical Expenses are incurred
account the nature of the illness / injury
for the same condition for which the
Insured Person’s Hospitalization was involved.
required, and 34. Renewal
ii. The In-patient Hospitalization claim Renewal means the terms on which the
for such Hospitalization is admissible contract of insurance can be renewed on
by the Insurance Company. mutual consent with a provision of grace
30. Portability period for treating the renewal continuous
for the purpose of gaining credit for pre-
“Portability” means, the right accorded to
existing diseases, time-bound exclusions
individual health insurance policyholders
and for all waiting periods.
(including all members under family
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35. Room Rent 41. Policy Schedule
Room Rent means the amount charged Policy Schedule means the Policy Schedule
by a Hospital towards Room and Boarding attached to and forming part of Policy.
expenses and shall include the associated
42. Policy Year
medical expenses.
Policy Year means a period of twelve
36. Surgery or Surgical Procedure
months beginning from the date of
Surgery or Surgical Procedure means commencement of the Policy period
manual and / or operative procedure and ending on the last day of such
(s) required for treatment of an illness twelve-month period. For the purpose of
or injury, correction of deformities and subsequent years, policy year shall mean
defects, diagnosis and cure of diseases, a period of twelve months commencing
relief from suffering and prolongation of from the end of the previous policy year
life, performed in a hospital or day care and lapsing on the last day of such twelve-
centre by a medical practitioner. month period, till the Policy Expiry date.
37. Unproven/Experimental treatment 43. Shared Accommodation
Unproven/Experimental treatment means Shared Accommodation means a hospital

the treatment including drug experimental room with two or more patient beds. This
therapy which is not based on established definition does not apply to ICU or ICCU.
medical practice in India, is treatment Section 2 – Benefits
experimental or unproven.
The following benefits are payable subject to
ii. Specific Definitions (Definitions other Terms and Conditions of the policy:
than as mentioned under Section 1 (i) B1. In-Patient Treatment
above)
We will cover for expenses for
38. Age hospitalization due to disease/illness/Injury
during the policy period that requires an
Means the completed age of the Insured Insured Person’s admission in a hospital
Person on his / her most recent birthday as an inpatient.
as per the English calendar, regardless of
Medical expenses directly related to the
the actual time of birth.
hospitalization would be payable.
39. Policy B2. Pre-Hospitalization expenses
Policy means the contract of insurance We will cover for expenses for Pre-
including but not limited to Policy Schedule, Hospitalization consultations,
Endorsements, Policy Wordings and Riders. investigations and medicines incurred
upto 60 days before the date of admission
40. Policy Period
to the hospital.
Policy Period means the time during The benefit is payable if We have admitted
which this Policy is in effect. Such period a claim under B1 or B4 or B6.
commences from Commencement Date B3. Post-Hospitalization expenses
and ends on the Expiry Date and specifically
We will cover for expenses for Post-
appears in the Policy Schedule.
Hospitalization consultations,
investigations and medicines incurred upto
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90 days after discharge from the hospital. B7. Restore benefits
The benefit is payable if We have admitted We will automatically restore the Basic
a claim under B1 or B4 or B6. Sum Insured upon exhaustion of the Sum
B4. Day Care Procedures Insured and accrued Cumulative Bonus,
during the policy period. This benefit can
We will cover expenses for listed Day Care
be availed once during the policy period
Treatment due to disease/illness/Injury
subject to the following conditions:
during the policy period taken at a hospital
a. The restored sum insured can be used
or a Day Care Centre. The list of such day
for all claims made by the insured
care procedures covered is available on
person(s) who have not claimed
our website (www.tataaig.com).
earlier under Sections B1 to B4. In
Treatment normally taken on out-patient case the insured has claimed under
basis is not included in the scope of this these sections, then this automatic
cover. restoration benefit is available for
B5. Organ Donor admissions due to unrelated illness/
We will cover for Medical and surgical diseases. However, this benefit for
Expenses of the organ donor for harvesting related illness/diseases would be
the organ where an Insured Person is the available, in case of claimed insured
recipient provided that: person(s), for admissions after 45
days from the date of discharge of
i. The organ donor is any person whose
the earlier claim.
organ has been made available
b. In case of Family Floater policy,
in accordance and in compliance
Reinstatement of Sum Insured will
with The Transplantation of Human
be available for all Insured Persons
Organs (Amendment) Bill, 2011 and
in the Policy on floater basis.
the organ donated is for the use of
the Insured Person, and c. This benefit shall be applicable
annually for policies with tenure of
ii. We have accepted an inpatient
more than 1 year.
Hospitalization claim for the
insured member under In Patient d. The unutilized restored sum insured
Hospitalization Treatment (section cannot be carried forward.
B1). This benefit shall not be applicable for
B6. Domiciliary Treatment Global Cover (section B13).
We will cover for expenses related to B8. AYUSH Benefit

Domiciliary Hospitalization of the insured We will cover for expenses incurred for
person if the treatment exceeds beyond treatment as in-patient in AYUSH Hospital.
three days. The treatment must be for B9. Ambulance Cover
management of an illness and not for
We will cover for expenses incurred on
enteral feedings or end of life care.
transportation of Insured Person in a
At the time of claiming under this benefit, registered ambulance to a Hospital for
we shall require certification from the admission in case of an Emergency or from
treating doctor fulfilling the conditions as one hospital to another hospital for better
mentioned under the general definitions medical facilities and treatment, subject to
(Section 1) of this policy. Rs. 3000 per Hospitalization.
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For this claim to be paid, the claim must be ‘Guidelines on Standardization in Health
admissible under section B1 or B4 of this Insurance, 2016’ and its amendments,
policy. which are consumed during the period
B10. Health Checkup of hospitalization directly related to the
insured’s medical or surgical treatment of
We will cover for expenses for a Preventive
illness/disease/injury. Details of Annexure
Health Check-up upto 1% of previous
I-List I-Optional items are available on our
sum insured subject to a maximum of
website (www.tataaig.com).
Rs. 10,000/- per policy. The limit is the
maximum per policy and more than one However, the following items shall be
insured can utilize the amount. excluded from scope of this coverage:
The benefit is payable once after block • Items of personal comfort, toiletries,
of every two continuous claim free policy cosmetics and convenience shall be
years with us. This benefit has a separate excluded from scope of this coverage.
limit (over and above base sum insured) • External durable devices like Bilevel
and does not affect cumulative bonus. Positive Airway Pressure (BIPAP)
B11. Compassionate travel machine, Continuous Positive Airway
In the event the Insured Person is Pressure (CPAP) machine, Peritoneal
Hospitalized for more than Five consecutive Dialysis (PD) equipment and supplies,
days in a place where no adult member of Nimbus/water/air bed, dialyzer and
his immediate family is present, we will other medical equipments.
cover for expenses related to a round • Any item which is neither medical
trip economy class air ticket, or first-class consumable nor medically necessary
railway ticket, to allow the Immediate nor prescribed by doctor.
Family Member be at his bedside for the
For this claim to be paid, the main claim must be
duration of his stay in the hospital.
admissible under section B1 or B4 of this policy.
The expenses must be incurred within India
B13. Global Cover
and shall not exceed Rs. 20,000 during a
policy year. We will cover for Medical Expenses of the
Insured Person incurred outside India,
This benefit shall be payable if We have
upto the sum insured, provided that the
accepted an inpatient Hospitalization claim
diagnosis was made in India and the
for the insured member under In Patient
insured travels abroad for treatment.
Hospitalization Treatment (Section B1).
The Medical Expenses payable shall
This benefit has a separate limit (over and
be limited to Inpatient and daycare
above base sum insured) and does not
Hospitalization only on reimbursement
affect cumulative bonus.
basis. Cashless facility may be arranged
We shall require the following additional on case to case basis. Insured person can
documents (proof of travel) supporting the
contact us for any claim assistance.
claim under this benefit: Boarding Pass, or
Railway ticket or any other document to The payment of any claim under this
show proof of travel. benefit will be in Indian Rupees based
on the rate of exchange as on the date
B12. Consumables Benefit
of invoice, published by Reserve Bank of
We will pay for expenses incurred, for India (RBI) and shall be used for conversion
specified consumables which are listed in of foreign currency into Indian Rupees
‘Annexure – 1 List 1 as Optional Items’ under for claims payment. If these rates are
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not published on the date of invoice, the - Typhoid vaccination
exchange rate next published by RBI shall After 2 years of continuous coverage with
be considered for conversion. Us:
Only basic sum insured along with - Human Papilloma Virus (HPV) vaccine
Cumulative Bonus can be used for this and
- Hepatitis B Vaccine
not the restored sum insured.
Expenses related to the doctor, nurse or
We shall require the following additional
any incidental expenses are not payable.
documents supporting the claim under
This benefit has a separate limit (over and
this benefit:
above base sum insured) and does not
• Proof of diagnosis in India affect cumulative bonus.
• Insured’s Passport and Visa The maximum payable is actuals or Rs.
B14. Bariatric Surgery Cover 5,000/- per policy, whichever is lower.
We will cover for reasonable and customary B17. Hearing Aid
expenses for Bariatric Surgery if the insured We will cover for reasonable charges for a
fulfills all of the following conditions: hearing aid every third year. The maximum
i. Surgery to be conducted is upon the amount payable is 50% of actual cost or Rs.
advice of the Doctor. 10,000/- per policy, whichever is lower.
ii. The member has to be 18 years of The items must be prescribed by a
age or older and specialized Medical Practitioner as
iii. Body Mass Index (BMI) greater than medically necessary.
or equal to 40 or This benefit has a separate limit (over and
iv. BMI greater than or equal to 35 in above base sum insured) and does not
conjunction with any of the following affect cumulative bonus.
severe comorbidities following failure 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
of less invasive methods of weight Accommodation
loss: We will pay a fixed amount per day as
a. Obesity-related cardiomyopathy mentioned in the policy schedule if the
Insured Person is Hospitalized in Shared
b. Coronary heart disease
Accommodation in a Network Hospital for
c. Severe sleep apnea each continuous and completed period
d. Uncontrolled Type2 Diabetes of 24 hours. The benefit payable per day
B15. In-Patient Treatment - Dental would be 0.25% of base sum insured and a
maximum of Rs. 2000 per day. This benefit
We will cover for medical expenses
is applicable only for those cases where
incurred towards hospitalization for dental
shared accommodation category is not
treatment under anesthesia necessitated
opted by the policy holder in the policy.
due to an accident/injury/illness.
For this claim to be paid, the main claim
B16. Vaccination cover
must be admissible under section B1 of
We will cover for expenses related to the this policy. This benefit has a separate limit
cost of the following vaccines only: (over and above base sum insured) and
Without any waiting period: does not affect cumulative bonus.
- Anti-rabies vaccine following an B19. Daily Cash for Accompanying an Insured
animal bite Child
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We will pay a fixed amount per day, as Benefit under optional cover (if opted)
mentioned in the schedule, if the Insured shall be available to the insured person,
Person Hospitalized is a child Aged 12 only if the particular benefit/optional
years or less, for one accompanying adult cover is specifically mentioned in the policy
for each complete period of 24 hours. The schedule.
benefit payable per day would be 0.25% B22. Cumulative Bonus
of base sum insured and maximum of
i. 50% cumulative bonus will be applied
Rs.2000 per day.
on the Sum Insured for next policy
For this claim to be paid, the main claim year under the Policy after every
must be admissible under section B1 of claim free Policy Year, provided
this policy. that the Policy is renewed with Us
This benefit has a separate limit (over and and without a break. The maximum
above base sum insured) and does not cumulative bonus shall not exceed
affect cumulative bonus. 100% of the Sum Insured in any Policy
Year.
B20. Second Opinion
ii. If a Cumulative Bonus has been
We will provide You a second opinion from
applied and a claim is made, then
Network Provider or Medical Practitioner,
in the subsequent Policy Year We
if an Insured Person is diagnosed with
will automatically decrease the
the below mentioned Illnesses during the
Cumulative Bonus by 50% of the
Policy Period. The expert opinion would be
Sum Insured in that following Policy
directly sent to the Insured Person.
Year. There will be no impact on
i. Cancer the Inpatient Sum Insured, only the
ii. Kidney Failure accrued Cumulative Bonus will be
decreased.
iii. Myocardial Infarction
iii. In policies with a tenure of more than
iv. Angina
one year, the above guidelines of
v. Coronary bypass surgery Cumulative Bonus shall be applicable
vi. Stroke/Cerebral hemorrhage post completion of each policy year.
vii. Organ failure requiring transplant iv. In relation to a Family Floater, the
viii. Heart Valve replacement Cumulative Bonus so applied will
only be available in respect of those
ix. Brain tumors
Insured Persons who were Insured
This benefit can be availed by an Insured Person Persons in the claim free Policy Year
once during a Policy Year. and continue to be Insured Persons
B21. Accidental Death Benefit (Optional in the subsequent Policy Year.
Cover) v. For purpose of computation of
If an Insured Person suffers an accident Cumulative Bonus, the percentage
during the policy period and this is the (%) of Cumulative Bonus will be
sole and direct cause of his death within applied on the base Sum Insured
365 days from the date of accident, then only. Restored sum insured will not
we will pay a fixed amount of 100% of the be taken into consideration.
base Sum Insured. Section 3 – Exclusions
This benefit is not applicable for dependent We will neither be liable nor make any payment
children covered in the policy.
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for any claim in respect of any Insured Person shall not be applicable for claims
which is caused by, arising from or in any way arising due to an accident.
attributable to any of the following exclusions, b. In case of enhancement of sum
unless expressly stated to the contrary in this insured the exclusion shall
Policy. apply afresh to the extent of
i. Standard Exclusions sum insured increase.
1. Exclusions with waiting periods c. If any of the specified disease/
i. Pre-existing Diseases Waiting procedure falls under the
Period (Code- Excl 01) waiting period specified for
a. Expenses related to the pre-Existing diseases, then
treatment of a pre-existing the longer of the two waiting
Disease (PED) and its direct periods shall apply.
complications shall be excluded d. The waiting period for listed
until the expiry of 36 months of conditions shall apply even if
continuous coverage after the contracted after the policy or
date of inception of the first declared and accepted without
policy with us. a specific exclusion.
b. In case of enhancement of sum e. If the Insured Person is
insured the exclusion shall continuously covered without
apply afresh to the extent of any break as defined under the
sum insured increase. applicable norms on portability
c. If the Insured Person is stipulated by IRDAI, then waiting
continuously covered without period for the same would be
any break as defined under reduced to the extent of prior
the portability norms of the coverage.
extant IRDAI (Health Insurance)
f. List of Specific Diseases/
Regulations, then waiting period
procedures as furnished below:
for the same would be reduced
to the extent of prior coverage. I. Tumors, Cysts, polyps
including breast lumps
d. Coverage under the policy after
(benign)
the expiry of 36 months for any
pre-existing disease is subject II. Polycystic ovarian disease
to the same being declared III. Fibromyoma
at the time of application and
IV. Adenomyosis
accepted by us.
V. Endometriosis
ii. Specified Disease/Procedure
Waiting Period (Code- Excl 02): VI. Prolapsed Uterus
a. Expenses related to the VII. Non-infective arthritis
treatment of the listed VIII. Gout and Rheumatism
Conditions, surgeries/
IX. Osteoporosis
treatments shall be excluded
until the expiry of 24 months X. L i g a m e n t , T e n d o n o r
of continuous coverage after Meniscal tear (due to
the date of inception of the first injury or otherwise)
policy with us. This exclusion XI. Prolapsed Inter Vertebral
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Disc (due to injury or XXXIV. Hysterectomy
otherwise) XXXV. Joint replacement surgeries
XII. Cholelithiasis Eg: Knee replacement, Hip
XIII. Pancreatitis replacement
XIV. Fissure/fistula in anus, XXXVI. Cholecystectomy

haemorrhoids, pilonidal XXXVII. H e r n i o p l a s t y or
sinus Herniorraphy
XV. Ulcer & erosion of stomach XXXVIII. S u r g e r y / p r o c e d u r e
& duodenum for Benign prostate
enlargement
XVI. Gastro Esophageal Reflux
Disorder (GERD) XXXIX. Surgery for Hydrocele/
Rectocele
XVII. Liver Cirrhosis
XL. Surgery of varicose veins
XVIII. Perineal Abscesses
and varicose ulcers
XIX. Perianal / Anal Abscesses
iii. 30 Days Waiting Period(Code- Excl 03):
XX. C a l c u l u s d i s e a s e s o f
a. Expenses related to the
Urogenital system
treatment of any illness within
Example: Kidney stone, 30 days from the first policy
Urinary bladder stone. commencement date shall be
XXI. Benign Hyperplasia of excluded except claims arising
prostate due to an accident, provided the
XXII. Varicocele same are covered.
XXIII. Cataract b. This exclusion shall not, however,

apply if the Insured Person has
XXIV. Retinal detachment
Continuous Coverage for more
XXV. Glaucoma than twelve months.
XXVI. C o n g e n i t a l I n t e r n a l c. The within referred waiting
Diseases period is made applicable to the
The following treatments enhanced sum insured in the
are covered after a waiting event of granting higher sum
period of two years insured subsequently.
irrespective of the illness 2. Medical Exclusions
for which it is done: i. Investigation and evaluation
XXVII. Adenoidectomy (Code- Excl 04):
XXVIII. Mastoidectomy a. Expenses related to any
XXIX. Tonsillectomy admission primarily for
diagnostics and evaluation
XXX. Tympanoplasty
purposes only are excluded.
XXXI. Surgery for nasal septum b. Any diagnostic expenses which
deviation are not related or not incidental
XXXII. Nasal concha resection to the current diagnosis and
XXXIII. Surgery for Turbinate treatment are excluded.
hypertrophy
13
ii. Rest cure, rehabilitation and cardiomyopathy
respite care (Code- Excl 05): 2. Coronary heart
a. Expenses related to any disease
admission primarily for 3. Severe Sleep Apnea
enforced bed rest and not for
4. Uncontrolled Type2
receiving treatment. This also
Diabetes
includes:
iv. Change-of-Gender treatments:
i. Custodial care either Code- Excl07:
at home or in a nursing
Expenses related to any treatment,
facility for personal care
including surgical management, to
such as help with activities
change characteristics of the body to
of daily living such as
those of the opposite sex.
bathing, dressing, moving
around either by skilled v. Cosmetic or Plastic Surgery (Code-
nurses or assistant or non- Excl 08):
skilled persons. Expenses for cosmetic or plastic
ii. Any services for people surgery or any treatment to change
who are terminally ill to appearance unless for reconstruction
address physical, social, following an Accident, Burn(s) or
Cancer or as part of medically
emotional and spiritual
necessary treatment to remove a
needs.
direct and immediate health risk to
iii. Obesity/ Weight Control(Code- Excl the insured. For this to be considered
06) a medical necessity, it must be
Expenses related to surgical certified by the attending Medical
treatment of obesity that does not Practitioner.
fulfil the below conditions: vi. Treatment for, Alcoholism, drug or
a. Surgery to be conducted is upon substance abuse or any addictive
the advice of the Doctor. condition and consequences thereof.
(Code- Excl 12)
b. The surgery/Procedure
conducted should be supported vii. Treatments received in heath
by clinical protocols. hydros, nature cure clinics, spas or
similar establishments or private
c. The member has to be 18 years
beds registered as a nursing home
of age or older and
attached to such establishments or
d. Body Mass Index (BMI); where admission is arranged wholly
i. greater than or equal to 40 or partly for domestic reasons.
or (Code- Excl13)
ii. greater than or equal to viii. Dietary supplements and substances
35 in conjunction with any that can be purchased without
of the following severe prescription, including but not limited
co-morbidities following to Vitamins, minerals and organic
failure of less invasive substances unless prescribed by
methods of weight loss: a medical practitioner as part of
hospitalization claim or day care
1. Obesity-related
14
procedure. (Code-Excl14) adventure sports, including but
ix. Refractive error (Code- Excl 15): not limited to, para-jumping, rock
Expenses related to the treatment climbing, mountaineering, rafting,
for correction of eye sight due to motor racing, horse racing or scuba
refractive error less than 7.5 dioptres. diving, hand gliding, sky diving, deep-
sea diving.
x. Unproven treatments (Code- Excl 16):
ii. Breach of law (Code- Excl 10):
Expenses related to any unproven
treatment, services and supplies for Expenses for treatment directly
or in connection with any treatment. arising from or consequent upon
Unproven treatments are treatments, any Insured Person committing or
procedures or supplies that lack attempting to commit a breach of law
significant medical documentation with criminal intent .
to support their effectiveness. iii. Excluded Providers: (Code-Excl 11)
xi. Sterility and Infertility (Code- Excl 17): Expenses incurred towards treatment
Expenses related to Sterility and in any hospital or by any Medical
infertility. This includes: Practitioner or any other provider
specifically excluded by the Insurer
i. Any type of contraception,
and disclosed in its website /
sterilization
notified to the policyholders are not
ii. Assisted Reproduction services admissible. However, in case of life
including artificial insemination threatening situations or following an
and advanced reproductive accident, expenses up to the stage of
technologies such as IVF, ZIFT, stabilization are payable but not the
GIFT, ICSI complete claim.
iii. Gestational Surrogacy ii. Specific Exclusions (Exclusions
iv. Reversal of sterilization other than as mentioned under
Section 3 (i) above)
xii. Maternity (Code - Excl 18):
1. Medical Exclusions
a. Medical treatment expenses
traceable to childbirth (including i. Alcoholic pancreatitis;
complicated deliveries and ii. Congenital External
caesarean sections incurred Diseases, defects or
during hospitalization) except anomalies;
ectopic pregnancy; iii. Stem cell therapy;
b. Expenses towards miscarriage however hematopoietic
(unless due to an accident) and stem cells for bone
lawful medical termination of marrow transplant for
pregnancy during the policy haematological conditions
period. will be covered under
3. Non-Medical Exclusions benefit B1 or B4 of this
policy.
i. Hazardous or Adventure Sports
(Code- Excl 09): iv. Growth Hormone Therapy;
Expenses related to any treatment v. Sleep-apnoea;

necessitated due to participation vi. Admission primarily for
as a professional in hazardous or administration of Intra-
15
articular or intra-lesional iii. Intentional self-injury or
injections or Intravenous attempted suicide while
immunoglobulin infusion sane or insane.
or supplementary iv. Items of personal comfort
medications like and convenience like
Zolendronic Acid. television (wherever
vii. Venereal disease, sexually specifically charged for),
transmitted disease or charges for access to
illness; telephone and telephone
viii. A l l p r e v e n t i v e c a r e , calls, internet, foodstuffs
vaccination including (except patient’s diet),
inoculation and cosmetics, hygiene
immunisations (except articles, body care
in ca s e o f p o s t- b i te products and bath
treatment and other additive, barber or beauty
vaccines explicitly service, guest service.
covered); v. Treatment rendered by a
ix. D e n t a l t r e a t m e n t o r Medical Practitioner which
surgery of any kind except is outside his discipline.
specified in ‘Inpatient vi. Doctor’s fees charged by
Treatment – Dental’; the Medical Practitioner
x. A n y e x i s t i n g d i s e a s e sharing the same
specifically mentioned as residence as an Insured
Permanent exclusion in Person or who is an
the Policy Schedule. immediate relative of an
2. Non-Medical Exclusions Insured Person’s family.
i. War or any act of war, vii. Provision or fitting of

invasion, act of foreign hearing aids, spectacles
enemy, war like operations or contact lenses including
(whether war be declared optometric therapy unless
or not or caused during explicitly stated and
service in the armed forces covered in the policy.
of any country), civil war, viii. A n y t r e a t m e n t a n d
public defence, rebellion, associated expenses
revolution, insurrection, for alopecia, baldness,
military or usurped wigs, or toupees, medical
acts, nuclear weapons/ supplies including elastic
materials, chemical and stockings, diabetic
biological weapons, test strips, and similar
ionising radiation. products.
ii. Any Insured Person’s ix. Any treatment or part of
participation or a treatment that is not
involvement in naval, of a reasonable charge,
military or air force not medically necessary;
operation. drugs or treatments which
16
are not supported by a necessary document.
prescription. ii. In the case of delay in the payment of
x. Crutches or any other a claim, the Company shall be liable
external appliance and/or to pay interest to the policyholder
device used for diagnosis from the date of receipt of last
or treatment (except when necessary document to the date of
used intra-operatively payment of claim at a rate 2% above
and explicitly stated and the bank rate.
covered in the policy). iii. However, where the circumstances
xi. Any illness diagnosed or of a claim warrant an investigation
injury sustained or where in the opinion of the Company, it
there is change in health shall initiate and complete such
status of the member investigation at the earliest, in any
after date of proposal and case not later than 30 days from
before commencement the date of receipt of last necessary
of policy and the same is document. In such cases, the
not communicated and Company shall settle or reject the
accepted by us. claim within 45 days from the date of
Section 4 – General Terms and Clauses receipt of last necessary document.
i. Standard General Terms & Clauses iv. In case of delay beyond stipulated 45
days, the Company shall be liable to pay
1. Disclosure of Information
interest to the policyholder at a rate 2%
The policy shall be void and all premium above the bank rate from the date of
paid thereon shall be forfeited to the receipt of last necessary document to
Company in the event of misrepresentation, the date of payment of claim.
misdescription or non-disclosure of any
(Explanation: “Bank rate” shall mean
material fact by the policyholder.
the rate fixed by the Reserve Bank
(Explanation: “Material facts” for the of India (RBl) at the beginning of
purpose of this policy shall mean all the financial year in which claim
relevant information sought by the has fallen due) . The Clause shall
company in the proposal form and other be suitably modified by the insurer
connected documents to enable it to based on the amendment(s), if
take informed decision in the context of any to the relevant provisions of
underwriting the risk) Protection of Policyholder’s Interests
2. Condition Precedent to Admission of Regulations, 2017)
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
3. Claim Settlement (provision for Penal benefit under the policy shall be a valid
Interest) discharge towards payment of claim by the
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
days from the date of receipt of last 5. Multiple Policies
17
i. In case of multiple policies taken by an made under this policy but which are
insured person during a period from found fraudulent later shall be repaid by all
one or more insurers to indemnify recipient(s)/policyholder(s), who has made
treatment costs, the insured person that particular claim, who shall be jointly
shall have the right to require a and severally liable for such repayment
settlement of his/her claim in terms to the insurer.
of any of his/her policies. In all such
For the purpose of this clause, the
cases the insurer chosen by the
insured person shall be obliged to expression “fraud” means any of the
settle the claim as long as the claim following acts committed by the insured
is within the limits of and according person or by his agent or the hospital/
to the terms of the chosen policy. doctor/any other party acting on behalf of
the insured person, with intent to deceive
ii. Insured person having multiple
policies shall also have the right to the insurer or to induce the insurer to issue
prefer claims under this policy for an insurance policy:
the amounts disallowed under any a) the suggestion, as a fact of that which
other policy / policies even if the sum is not true and which the insured
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
the claim subject to the terms and
insured person having knowledge or
conditions of this policy.
belief of the fact;
iii. If the amount to be claimed exceeds
the sum insured under a single policy, c) any other act fitted to deceive; and
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
6. Fraud the insurer.
If any claim made by the insured person, 7. Cancellation
is in any respect fraudulent, or if any false i. The policyholder may cancel this
statement, or declaration is made or used
policy by giving 15 days written
in support thereof, or if any fraudulent
notice and in such an event, the
means or devices are used by the insured
Company shall refund premium
person or anyone acting on his/her behalf
for the unexpired policy period as
to obtain any benefit under this policy, all
detailed below.
benefits under this policy and the premium
paid shall be forfeited.
Any amount already paid against claims
18
Length of time Tenure person will get the accrued continuity
Policy in force 1 Year 2 3 benefits in waiting periods as per IRDAI
Years Years guidelines on migration.
Upto 1 Month 75.00% 87.50% 91.5% For Detailed Guidelines on Migration, kindly
>1 month & 50.00% 75.00% 88.5% refer Guidelines issued by IRDAI(Insurance
Upto 3 Months Regulatory and Development Authority
>3 months & 25.00% 62.50% 75% of India) on Migration and Portability of
Upto 6 Months Health Insurance policies – Ref: IRDAI/HLT/
>6 months & Nil 50.00% 66.5% REG/CIR/194/07/2020) dated 22nd July 2020
Upto 12 Months and subsequent amendments thereof.
>12 months & NA 25% 50%
9. Portability
Upto 15 Months
>15 months & NA 12.5% 41.5% The insured person will have the option
Upto 18 Months to port the policy to other insurers by
>18 months & NA Nil 33% applying to such insurer to port the
Upto 24 months entire policy along with all the members
>24 months & NA NA 8% of the family, if any, at least 45 days
Upto 30 months before, but not earlier than 60 days
Exceeding NA NA Nil from the policy renewal date as per
30 months IRDAI guidelines related to portability.
Notwithstanding anything contained If such person is presently covered and
herein or otherwise, no refunds of has been continuously covered without
premium shall be made in respect any lapses under any health insurance
of Cancellation where, any claim has policy with an Indian General/Health
been admitted or has been lodged insurer, the proposed insured person
or any benefit has been availed by will get the accrued continuity benefits in
the insured person under the policy. waiting periods as per IRDAI guidelines on
portability.
ii.
The Company may cancel the For Detailed Guidelines on Portability, kindly
policy at any time on grounds of refer Guidelines issued IRDAI(Insurance
misrepresentation non-disclosure of Regulatory and Development Authority
material facts, fraud by the insured of India) on Migration and Portability of
person by giving 15 days’ written Health Insurance policies – Ref: IRDAI/HLT/
notice. There would be no refund of REG/CIR/194/07/2020) dated 22nd July 2020
premium on cancellation on grounds and subsequent amendments thereof.
of misrepresentation, non-disclosure
10. Renewal of Policy
of material facts or fraud.
8. Migration The policy shall ordinarily be
renewable except on grounds of fraud,
The insured person will have the option to
misrepresentation by the insured person.
migrate the policy to other health insurance
products/plans offered by the company by i. The Company shall endeavor to give
applying for migration of the policy at least notice for renewal. However, the
30 days before the policy renewal date as Company is not under obligation to
per IRDAI guidelines on Migration. lf such give any notice for renewal.
person is presently covered and has been ii. Renewal shall not be denied on the
continuously covered without any lapses ground that the insured person
under any health insurance product/ had made a claim or claims in the
plan offered by the company, the insured preceding policy years.
19
iii. Request for renewal along with Policy Including the Premium Rates
requisite premium shall be received The Company, with prior approval of
by the Company before the end of IRDAI, may revise or modify the terms of
the policy period. the Policy including the premium rates.
iv. At the end of the policy period, the The Insured Person shall be notified three
policy shall terminate and can be months before the changes are effected.
renewed within the Grace Period
14. Free look period
of 30 days to maintain continuity
of benefits without break in policy. The Free Look Period shall be applicable
Coverage is not available during the on new individual health insurance policies
grace period. and not on renewals or at the time of
porting/migrating the policy.
v. No loading shall apply on renewals
based on individual claims experience. The insured person shall be allowed free
11. Withdrawal of Policy look period of fifteen days from date of
receipt of the policy document to review
i. In the likelihood of this product being
the terms and conditions of the policy, and
withdrawn in future, the Company
to return the same if not acceptable.
will intimate the insured person
about the same 90 days prior to If the insured has not made any claim
expiry of the policy. during the Free Look Period, the insured
shall be entitled to
ii. Insured Person will have the option
to migrate to similar health insurance i. a refund of the premium paid
product available with the Company less any expenses incurred by the
at the time of renewal with all the Company on medical examination
accrued continuity benefits such as of the insured person and the stamp
cumulative bonus, waiver of waiting duty charges or
period as per IRDAI guidelines, ii. where the risk has already
provided the policy has been commenced and the option of return
maintained without a break. of the policy is exercised by the
12. Moratorium Period insured person, a deduction towards
After completion of eight continuous the proportionate risk premium for
years under the policy no look back to be period of cover or
applied. This period of eight years is called iii. Where only a part of the insurance
as moratorium period. The moratorium coverage has commenced,
would be applicable for the sums insured such proportionate premium
of the first policy and subsequently commensurate with the insurance
completion of 8 continuous years would coverage during such period.
be applicable from date of enhancement of
15. Redressal of Grievance
sums insured only on the enhanced limits.
After the expiry of Moratorium Period no In case of any grievance the insured person
health insurance claim shall be contestable may contact the company through
except for proven fraud and permanent Website: www.tataaig.com
exclusions specified in the policy contract.
Toll Free: 1800 266 7780 or 1800 22 9966
The policies would however be subject
(only for Senior Citizen policyholders)
to all limits, sub limits, co-payments,
deductibles as per the policy contract. Email: customersupport@tataaig.com
13. Possibility of Revision of Terms of the Fax: 022 66938170
20
Courier: Customer Support, Tata AIG (terms and clauses other than
General Insurance Company Limited those mentioned under Section 4
A-501 Building No. 4 IT Infinity Park, (i) above)
Dindoshi, Malad (E), Mumbai – 400097 17. Premium Payment
Insured person may also approach the i. Premium to be paid for the Policy
grievance cell at any of the company’s Period before Policy Commencement
branches with the details of grievance. date as opted by You in the proposal
If Insured person is not satisfied with the form.
redressal of grievance through one of ii. If you have opted to pay premium
the above methods, insured person may in full (lump sum) upfront then
contact the grievance officer at manager. the entire premium for the policy
customersupport@tataaig.com. period shall be paid before the policy
commencement date with an option
For updated details of grievance officer,
of policy tenure 1/2/3 years.
kindly refer the link (https://www.tataaig.
com/grievance-redressal-policy) iii. Long term premium discount of 5%
and 10% is applicable for policy with
lf Insured person is not satisfied with
tenure of 2 and 3 years respectively.
the redressal of grievance through
above methods, the insured person may 18. Insured Person
also approach the office of Insurance i. Only those persons named as an
Ombudsman of the respective area/region Insured Person in the Schedule shall
(details as mentioned in the Annexure A of be covered under this Policy.
this policy) for redressal of grievance as per ii. Any person may be added during
Insurance Ombudsman Rules 2017. the Policy Period after his application
Grievance may also be lodged at IRDAI has been accepted by Us, additional
Integrated Grievance Management System premium has been paid and We have
(https://igms.irda.gov.in/) issued an endorsement confirming
16. Nomination the addition of such person as an
Insured Person.
The policyholder is required at the inception
of the policy to make a nomination for iii. We will be offering continuous
the purpose of payment of claims under renewal with no exit age subject
the policy in the event of death of the to regular premium payment and
policyholder. Any change of nomination compliance with all provisions and
shall be communicated to the company in terms & conditions of this policy by
writing and such change shall be effective the Insured Person.
only when an endorsement on the policy 19. Loadings
is made. In the event of death of the
i. We may apply a risk loading on the
policyholder, the Company will pay the
premium payable (based upon the
nominee {as named in the Policy Schedule/
declarations made in the proposal
Policy Certificate/Endorsement (if any)} and
form and the health status of the
in case there is no subsisting nominee, to
persons proposed for insurance).
the legal heirs or legal representatives of
the policyholder whose discharge shall be ii. The maximum risk loading applicable
treated as full and final discharge of its for an individual shall not exceed
liability under the policy. 100% of premium per diagnosis /
medical condition and an overall risk
ii. Specific terms and clauses
21
loading of over 150% of premium per i. Sum Insured can be enhanced
person. only at the time of renewal subject
iii. The loading shall only be applied to underwriting guidelines of the
basis an outcome of Our medical company.
underwriting. ii. In case of increase in the Sum Insured
iv. These loadings are applied from waiting period and exclusions will
Commencement Date of the Policy apply afresh in relation to the amount
including subsequent renewal(s) with by which the Sum Insured has been
Us or on the receipt of the request enhanced. However, the acceptance
of increase in Sum Insured (for the of Sum Insured enhancement request
increased Sum Insured). & quantum of increase shall be as
per Our underwriting guidelines.
a. We will inform You about the
For claims arising in respect of
applicable risk loading through
accident, injury or illness contracted
a counter offer letter.
or suffered during a preceding Policy
b. You need to revert to Us period, liability of the Company shall
with consent and additional be only to the extent of the Sum
premium (if any), within 15 days Insured under the Policy in force at
of the issuance of such counter the time when it was contracted or
offer letter. suffered.
c. In case, you neither accept the 22. Change of Policyholder
counter offer nor revert to Us
i. The change of Policyholder is
within 15 days, We shall cancel
permitted only at the time of renewal.
Your application and refund the
premium paid within next 10 ii. If the Insured Person is no longer
days subject to deduction of the eligible on grounds of age or
Pre-Policy Check up charges, as dependency, the insured member
applicable. will be eligible to apply for a new
policy and enjoy continuity benefits
v. Please note that We will issue Policy
upto Sum Insured.
only after getting Your consent.
23. Notices
20. Entire Contract
i. Any notice, direction or instruction
i. This Policy, its Schedule, under this Policy shall be in writing
endorsement(s), proposal constitutes and if it is to:
the entire contract of insurance. No a. Any Insured Person, then it shall
change in this policy shall be valid be sent to You at Your address
unless approved by Us and such specified in the Schedule to
approval be endorsed hereon. this Policy and You shall act for
ii. This Policy and the Schedule shall be all Insured Persons for these
read together as one contract and purposes.
any word or expression to which a b. Us, it shall be delivered to
specific meaning has been attached Our address specified in the
in any part of this Policy or of the Schedule to this Policy. No
Schedule shall bear such meaning insurance agents, brokers
wherever it may appear. or other person or entity is
21. Sum Insured Enhancement authorised to receive any
notice, direction or instruction
22
on Our behalf unless We have cashless service, supporting claim documents
expressly stated to the contrary and related claim terms of payment are
in writing.
explained in this section.
24. Conditions applicable for In-patient
Treatment (B1) 1. Notification of Claim
i. If the insured person is admitted
T r e a t m e n t , We or Our
in a hospital room where the room Consultation or TPA* must be
category opted is higher than the Procedure: informed:
eligible category as specified in the 1 If any treatment At least 48 hours
policy schedule, then the policy for which a claim prior to the
holder/insured person shall bear 10% may be made and Insured Person’s
of the admissible claim amount. that treatment admission.
requires planned
Section 5 – Claims Procedure and Claims
Hospitalisation:
Payment
2 If any treatment Within 24
This section explains about the procedures for which a claim hours of the
involved to file a valid claim by the insured may be made and Insured Person’s
member and processes related in managing that treatment admission to
the claim by TPA or Us. All the procedures and requires emergency Hospital.
processes such as notification of claim, availing Hospitalisation
*TPA as mentioned in the policy schedule
2. Cashless Service
Treatment, Consultation Treatment, Consultation Cashless Service is We must be given notice
or Procedure: or Procedure Taken at: Available: that the Insured Person
wishes to take advantage
of the cashless service
accompanied by full
particulars:
I f a n y p l a n n e d Network Hospital We will provide cashless At least 48 hours before
treatment, consultation s e r v i c e b y m a k i n g the planned treatment or
or procedure for which payment to the extent Hospitalisation
a claim may be made: of Our liability directly
to the Network Hospital.
I f a n y t r e a t m e n t , Network Hospital We will provide cashless Within 24 hours after
consultation or service by making t h e t r e a t m e n t o r
procedure for which payment to the extent Hospitalisation
a claim may be made, of Our liability directly
requiring emergency to the Network Hospital.
hospitalisation
23
3. Procedure for Cashless Service would be sent to the hospital
i. Cashless Service is only available at within 6 hours.
Network Hospitals. g. Rejection of cashless in no way
ii. In order to avail of cashless treatment, indicates rejection of the claim.
You are required to submit
the following procedure must be
the claim along with required
followed by You:
documents for us to decide on
a. Prior to taking treatment and/ the admissibility of the claim.
or incurring Medical Expenses
h. If the cashless is approved,
at a Network Hospital, You must
the original bills and evidence
call our designated TPA/Us and
of treatment in respect of the
request pre-authorization.
same shall be left with the
b. For any emergency Network Hospital.
Hospitalisation, our designated
i. Pre-authorization does not
TPA/We must be informed
guarantee that all costs and
no later than 24 hours of the
expenses will be covered. We
start of Your hospitalization/
reserve the right to review each
treatment.
claim for Medical Expenses and
c. For any planned hospitalization, accordingly coverage will be
our designated TPA/We must determined according to the
be informed atleast 48 hours terms and conditions of this
prior to the start of your Policy.
hospitalization/treatment. 4. Supporting Documentation &
d. Our designated TPA/We will Examination
check your coverage as per i. You or someone claiming on
the eligibility and send an Your behalf shall provide Us with
authorization letter to the documentation, medical records
provider. You have to provide and information We or Our TPA
the ID card issued to You along may request to establish the
with any other information circumstances of the claim, its
or documentation that is quantum or Our liability for the
requested by the TPA/Us to claim within 15 days or earlier of
the Network Hospital. Our request or the Insured Person’s
e. In case of deficiency in the discharge from Hospitalisation or
documents sent to TPA/Us for completion of treatment.
cashless authorization, the ii. Failure to furnish such evidence
same shall be communicated within the time required shall not
to the hospital by TPA/Us invalidate nor reduce any claim if
within 6 hours of receipt of the you can satisfy us that it was not
documents. reasonably possible for you to give
f. In case the ailment /treatment proof within such time.
is not covered under the policy iii. We may accept claims where
or cashless is rejected due documents have been provided
to insufficient documents after a delayed interval only in special
submitted, a rejection letter circumstances and for the reasons
24
beyond the control of the Insured g. All pre and post investigation,
Person. treatment and follow up
iv. Such documentation will include (consultation) records
the following: pertaining to the present
ailment for which claim is being
a. Our claim form, duly completed
made, if and where applicable.
and signed for on behalf of
the Insured Person.We, upon h. Treating doctor’s certificate
receipt of a notice of claim, will regarding missing information
furnish Your representative in case histories e.g.
with such forms as We may Circumstance of injury and
require for filing proofs of loss Alcohol or drug influence at the
or you may download the claim time of accident, if available.
form from our Web site. i. Copy of settlement letter from
b. Original Bills (pharmacy other insurance company or
purchase bill, consultation TPA.
bill, diagnostic bill) and any j. Stickers and invoice of implants
attachments thereto like used during surgery.
receipts or prescriptions in k. Copy of MLC (Medico legal case)
support of any amount claimed records, if carried out and FIR
which will then become Our (First information report), if
property. registered, in case of claims
c. All medical reports, case arising out of an accident and
histories, investigation reports, available with the claimant.
indoor case papers/ treatment l. Regulatory requirements as
papers (in reimbursement amended from time to time,
cases, if available), discharge currently mandatory NEFT (to
summaries. enable direct credit of claim
d. A precise diagnosis of the amount in bank account) and
treatment for which a claim is KYC (recent ID/Address proof
made. and photograph) requirements.
e. A detailed list of the individual m. Legal heir/succession certificate,
medical services and treatments if required
provided and a unit price for n. PM report (wherever applicable)
each in case not available in the
v. Note: In case You are claiming for
submitted hospital bill..
the same event under an indemnity
f. Prescriptions that name the based policy of another insurer and
Insured Person and in the are required to submit the original
case of drugs: the drugs documents related to Your treatment
prescribed, their price and a with that particular insurer, then You
receipt for payment. In case of may provide Us with the attested
pre/post hospitalization claim copies of such documents along with
Prescriptions must be submitted a declaration from the particular
with the corresponding Doctor/ insurer specifying the availability of
hospital invoice. the original copies of the specified
25
treatment documents with it. arbitration, the same shall be referred to
vi. We at our own expense, shall a panel of three arbitrators, comprising
have the right and opportunity to two arbitrators, one to be appointed
examine insured persons through by each of the parties to the dispute/
Our Authorised Medical Practitioner difference and the third arbitrator to be
whose details will be notified to appointed by such two arbitrators and
insured person when and as often arbitration shall be conducted under and
as We may reasonably require during in accordance with the provisions of the
the pendency of a claim hereunder. Arbitration and Conciliation Act 1996, as
amended by Arbitration and Conciliation
5. Claims Payment
(Amendment) Act, 2015 (No. 3 of 2016). It
i. We shall be under no obligation is clearly agreed and understood that no
to make any payment under this difference or dispute shall be preferable
Policy unless We have received all to arbitration as herein before provided, if
premium payments in full in time the Company has disputed or not accepted
and We have been provided with liability under or in respect of the policy. It
the documentation and information is hereby expressly stipulated and declared
We or Our TPA has requested to that it shall be a condition precedent to
establish the circumstances of the any right of action or suit upon the policy
claim, its quantum or Our liability for that award by such arbitrator/arbitrators
it, and unless the Insured Person has of the amount of expenses shall be first
complied with his obligations under obtained.
this Policy.
ii. This Policy only covers medical
treatment taken within India (except
in case of benefit B13- Global cover),
and payments under this Policy shall
only be made in Indian Rupees within
India.
Section 6 - Dispute Resolution

1. Dispute Resolution Clause
Any and all disputes or differences
under or in relation to this Policy shall
be determined by the Indian Courts and
subject to Indian law.
2. Arbitration
If any dispute or difference shall arise as
to the quantum to be paid by the Policy,
(liability being otherwise admitted) such
difference shall independently of all other
questions, be referred to the decision
of a sole arbitrator to be appointed in
writing by the parties here to or if they
cannot agree upon a single arbitrator
within thirty days of any party invoking
26
Annexure A
NAMES OF OMBUDSMAN AND ADDRESSES OF OMBUDSMAN CENTRES
Office Details Jurisdiction of Office Date Of Taking
Union Territory,District Charge
AHMEDABAD - Shri Kuldip Singh Gujarat, 03/10/2019
Office of the Insurance Ombudsman, Dadra & Nagar Haveli,
Jeevan Prakash Building, 6th floor, Daman and Diu.
Tilak Marg, Relief Road,
Ahmedabad – 380 001.
Tel.: 079 - 25501201/02/05/06
Email: bimalokpal.ahmedabad@cioins.co.in
BENGALURU - Smt. Neerja Shah Karnataka. 23/04/2018
Office of the Insurance Ombudsman,
Jeevan Soudha Building,PID No. 57-27-N-19
Ground Floor, 19/19, 24th Main Road,
JP Nagar, Ist Phase,
Bengaluru – 560 078.
Tel.: 080 - 26652048 / 26652049
Email: bimalokpal.bengaluru@cioins.co.in
BHOPAL - Shri Guru Saran Shrivastava Madhya Pradesh 24/05/2018
Office of the Insurance Ombudsman, Chattisgarh.
Janak Vihar Complex, 2nd Floor,
6, Malviya Nagar, Opp. Airtel Office,
Near New Market,
Bhopal – 462 003.
Tel.: 0755 - 2769201 / 2769202
Fax: 0755 - 2769203
Email: bimalokpal.bhopal@cioins.co.in
BHUBANESHWAR - Shri Suresh Chandra Panda Orissa. 11/09/2019
62, Forest park,
Bhubneshwar – 751 009.
Tel.: 0674 - 2596461 /2596455
Fax: 0674 - 2596429
Email: bimalokpal.bhubaneswar@cioins.co.in
CHANDIGARH - Dr. Dinesh Kumar Verma Punjab, 16/04/2018
Office of the Insurance Ombudsman, Haryana(excluding Gurugram,
S.C.O. No. 101, 102 & 103, 2nd Floor, Faridabad, Sonepat and
Batra Building, Sector 17 – D, Bahadurgarh)
Chandigarh – 160 017. Himachal Pradesh, Union Territories
Tel.: 0172 - 2706196 / 2706468 of Jammu & Kashmir,
Fax: 0172 - 2708274 Ladakh & Chandigarh.
Email: bimalokpal.chandigarh@cioins.co.in
CHENNAI - Shri M. Vasantha Krishna Tamil Nadu, 03/05/2018
Office of the Insurance Ombudsman, Tamil Nadu
Fatima Akhtar Court, 4th Floor, 453, PuducherryTown and
Anna Salai, Teynampet, CHENNAI – 600 018. Karaikal (which are part of
Tel.: 044 - 24333668 / 24335284 | Fax: 044 - 24333664 Puducherry).
Email: bimalokpal.chennai@cioins.co.in
27
DELHI - Shri Sudhir Krishna Delhi & 12/09/2019
Office of the Insurance Ombudsman, Following Districts of Haryana -
2/2 A, Universal Insurance Building, Gurugram, Faridabad, Sonepat &
Asaf Ali Road, Bahadurgarh.
New Delhi – 110 002.
Tel.: 011 - 23232481/23213504
Email: bimalokpal.delhi@cioins.co.in
GUWAHATI - Shri Kiriti .B. Saha Assam, Meghalaya, 02/05/2018
Office of the Insurance Ombudsman, Manipur, Mizoram,
Jeevan Nivesh, 5th Floor, Arunachal Pradesh,
Nr. Panbazar over bridge, S.S. Road, Nagaland and Tripura.
Guwahati – 781001(ASSAM).
Tel.: 0361 - 2632204 / 2602205
Email: bimalokpal.guwahati@cioins.co.in
HYDERABAD - Shri I. Suresh Babu Andhra Pradesh, Telangana, 11/06/2018
Office of the Insurance Ombudsman, Yanam and part of Union Territory of
6-2-46, 1st floor, “Moin Court”, Puducherry.
Lane Opp. Saleem Function Palace,
A. C. Guards, Lakdi-Ka-Pool, Hyderabad - 500 004.
Tel.: 040 - 23312122
Fax: 040 - 23376599
Email: bimalokpal.hyderabad@cioins.co.in
JAIPUR - Smt. Sandhya Baliga Rajasthan. 13/04/2018
Jeevan Nidhi – II Bldg., Gr. Floor,
Bhawani Singh Marg,
Jaipur - 302 005.
Tel.: 0141 - 2740363
Email: bimalokpal.jaipur@cioins.co.in
ERNAKULAM - Ms. Poonam Bodra Kerala, Lakshadweep, 07/11/2018
Office of the Insurance Ombudsman, Mahe-a part of Union Territory of
2nd Floor, Pulinat Bldg., Puducherry.
Opp. Cochin Shipyard, M. G. Road,
Ernakulam - 682 015.
Tel.: 0484 - 2358759 / 2359338
Fax: 0484 - 2359336
Email: bimalokpal.ernakulam@cioins.co.in
KOLKATA - Shri P. K. Rath West Bengal, Sikkim, 30/09/2019
Office of the Insurance Ombudsman, Andaman & Nicobar Islands.
Hindustan Bldg. Annexe, 4th Floor,
4, C.R. Avenue,
KOLKATA - 700 072.
Tel.: 033 - 22124339 / 22124340
Fax : 033 - 22124341
Email: bimalokpal.kolkata@cioins.co.in
28
LUCKNOW -Shri Justice Anil Kumar Srivastava Districts of Uttar Pradesh : 11/09/2019
Office of the Insurance Ombudsman, Lalitpur, Jhansi, Mahoba, Hamirpur,
6th Floor, Jeevan Bhawan, Phase-II, Banda, Chitrakoot, Allahabad,
Nawal Kishore Road, Hazratganj, Mirzapur, Sonbhabdra, Fatehpur,
Lucknow - 226 001. Pratapgarh, Jaunpur,Varanasi,
Tel.: 0522 - 2231330 / 2231331 Gazipur, Jalaun, Kanpur, Lucknow,
Fax: 0522 - 2231310 Unnao, Sitapur, Lakhimpur, Bahraich,
Email: bimalokpal.lucknow@cioins.co.in Barabanki, Raebareli, Sravasti,
Gonda, Faizabad, Amethi, Kaushambi,
Balrampur, Basti, Ambedkarnagar,
Sultanpur, Maharajgang,
Santkabirnagar, Azamgarh,
Kushinagar, Gorkhpur, Deoria,
Mau, Ghazipur, Chandauli, Ballia,
Sidharathnagar.
MUMBAI - Shri Milind A. Kharat Goa, 04/05/2018
Office of the Insurance Ombudsman, Mumbai Metropolitan Region
3rd Floor, Jeevan Seva Annexe, excluding Navi Mumbai & Thane
S. V. Road, Santacruz (W),
Mumbai - 400 054.
Tel.: 022 - 26106552 / 26106960
Fax: 022 - 26106052
Email: bimalokpal.mumbai@cioins.co.in
NOIDA - Shri Chandra Shekhar Prasad State of Uttaranchal and the 17/09/2019
Office of the Insurance Ombudsman, following Districts of Uttar Pradesh:
Bhagwan Sahai Palace Agra, Aligarh, Bagpat, Bareilly,
4th Floor, Main Road, Bijnor, Budaun, Bulandshehar, Etah,
Naya Bans, Sector 15, Kanooj, Mainpuri, Mathura, Meerut,
Distt: Gautam Buddh Nagar, Moradabad, Muzaffarnagar, Oraiyya,
U.P-201301. Pilibhit, Etawah, Farrukhabad,
Tel.: 0120-2514252 / 2514253 Firozbad, Gautambodhanagar,
Email: bimalokpal.noida@cioins.co.in Ghaziabad, Hardoi, Shahjahanpur,
Hapur, Shamli, Rampur, Kashganj,
Sambhal, Amroha, Hathras,
Kanshiramnagar, Saharanpur.
PATNA - Shri N. K. Singh Bihar, 09/10/2019

Office of the Insurance Ombudsman, Jharkhand.
1st Floor,Kalpana Arcade Building,,
Bazar Samiti Road,
Bahadurpur,
Patna 800 006.
Tel.: 0612-2680952
Email: bimalokpal.patna@cioins.co.in
29
For updated list and details of Insurance or property in India, any rebate of the
Ombudsman Offices, please visit website http:// whole or part of the commission payable
www.cioins.co.in/ombudsman.html or any rebate of the premium shown on
the policy, nor shall any person taking out
Prohibition of Rebates - Section 41 of the
or renewing or continuing a policy accept
Insurance Act, 1938 as amended by Insurance
any rebate, except such rebate as may be
Laws (Amendment) Act, 2015.
allowed in accordance with the published
1. No person shall allow or offer to allow, prospectuses or tables of the insurer.
either directly or indirectly, as an
2. Any person making default in complying
inducement to any person to take out
with the provisions of this section shall be
or renew or continue an insurance in
liable for a penalty which may extend to
respect of any kind of risk relating to lives
ten lakh rupees.
30

Tata AIG Medi Care 82932b277a

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Tata AIG MediCare Policy Wording

Tata AIG General Insurance Company Limited (We,

TATA AIG General Insurance Company Limited

Congenital Anomaly means a condition iv. maintains daily records of patients

a) Internal Congenital Anomaly 10. Day Care Treatment

v. maintains daily records of patients Injury means accidental physical bodily

29. Pre-hospitalization Medical Expenses 33. Reasonable and Customary Charges

Pre-hospitalization Medical Expenses Reasonable and Customary charges means

37. Unproven/Experimental treatment 43. Shared Accommodation

Unproven/Experimental treatment means Shared Accommodation means a hospital

We will cover for expenses related to B8. AYUSH Benefit

XIV. Fissure/fistula in anus, XXXVI. Cholecystectomy

XXIII. Cataract b. This exclusion shall not, however,

Expenses related to any treatment v. Sleep-apnoea;

i. War or any act of war, vii. Provision or fitting of

*TPA as mentioned in the policy schedule

Section 6 - Dispute Resolution

PATNA - Shri N. K. Singh Bihar, 09/10/2019

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