C General Exclusions
No indemnity is available or payable for claims directly or indirectly caused by, arising out of or connected to the following:
1) Any Pre-Existing Condition or related condition for which care, treatment or advice was recommended by or received from a Doctor or which was first manifested prior to the commencement date of the Insured's first Family Health Insurance Policy with the Insurer. However, this exclusion shall cease to apply to such pre-existing condition if the Insured has maintained a Family Health Insurance Policy with the Insurer for a consecutive 3-year period and no claim, care, treatment or advice has been recommended by or received from a Doctor in relation to such Pre -Existing Condition during that 3-year period.
2) Any Illness diagnosed or diagnosable within 30 days of the effective date of the Policy Period if this is the first Family Health Insurance Policy taken by the Proposer with the Insurer. If the Insured renews Family Health Insurance Policy with the Insurer and increases the Limit of Indemnity then this exclusion shall apply in relation to the amount by which the Limit of Indemnity has been increased.
3) Cataracts, Benign Prostatic Hypertrophy, Hysterectomy for Menorrhagia or Fibromyoma, Hernia, Hydrocele, Fistula in anus, Piles, Sinusitis and related disorders. This exclusion shall cease to apply if the Insured has maintained a Family Health Insurance Policy with the Insurer for 1 full year But if the Insured renews Family Health Insurance Policy with the Insurer (Insurer's own renewal) and increases the Limit of Indemnity then this exclusion shall apply in relation to the amount by which the Limit of Indemnity has been increased for a further 1-year period.
4) Circumcision unless necessary for the treatment of an Illness not otherwise excluded in this Section, or required as a result of Accidental Bodily Injury.
5) Vaccination, inoculation, cosmetic treatments (including any complications arising out of or howsoever attributable to any cosmetic treatments or the replacement of an existing breast implant), aesthetic treatments, experimental, investigational or unproven procedures or treatments, devices and pharmacological regimens of any description.
6) Vitamins and Ionics unless forming a necessary pan of the treatment for Illness as certified by the attending. Doctor.
7) Any denial treatment or surgery of a corrective, cosmetic or aesthetic nature unless it requires Hospitalization; is carried out under general anaesthesia and is necessitated by Illness or Accidental Bodily Injury.
8) Personal comfort and convenience items or services such as television, telephone, barber or beauty service, guest service and similar incidental services and supplies.
9) The treatment of obesity (including morbid obesity) and any other weigh! Control programs, services, or supplies.
10) Durable medical equipments (except those mentioned under the section External Aids and Appliances)
11) Diagnostic, X-ray or laboratory examination not incidental to or inconsistent with the diagnosis and treatment of the Illness or Injury for which the Insured was Hospitalized.
12)The Insured's participation in any hazardous activities, including but not limited to scuba diving, motor-racing, parachuting, hang-gliding, rock or mountain climbing, as a member of the armed forces, the paramilitary, the security forces, the fire or ambulance services, lifeboat service, police force and the like whether part lime or full time, voluntary or paid.
13) Charges incurred in connection with the provision or fitting of hearing aids, eyeglasses or contact lenses.
14) Any travel or transportation costs or expenses.
15) The use, misuse, or abuse of alcohol, substances or drugs (whether prescribed or not).
16) Outpatient prescribed or non-prescribed medical supplies including elastic stockings, bandages, gauze, syringes, diabetic test strips, and similar products; non-prescription drugs and treatments.
17) War, invasion, acts of foreign enemies, hostilities whether war be declared or not, civil war, revolution, insurrection, mutiny, martial law.
18) Ionising radiation or contamination by radioactivity from any nuclear waste or from combustion of nuclear fuel or otherwise; or the radioactive, toxic, explosive or other hazardous properties of any explosive nuclear assembly or nuclear component thereof, or asbestosis or any related condition resulting from the existence, production, handling, processing, manufacture, sale, distribution, deposit or use of asbestos, or asbestos products.
19) lnvitro fertilisation (IVF), gamete intrafallopian transfer (GIFT) procedures, and zygote intrafallopian transfer (ZIFT) procedures, and any related prescription medication treatment; embryo transport; donor ovum and semen and related costs, including collection and preparation; voluntary medical termination of pregnancy; pregnancy, childbirth and their consequences, including changes in chronic conditions as a resuft of pregnancy; any treatment related to infertility or sterilization.
20) HIV AIDS and all related medical conditions.
21) Costs incurred on all methods of treatment except Allopathic.
22) Any condition after the point at which it is certified by the attending Doctor to be of such a nature that further medical treatment may serve to stabilize or maintain it but is unlikely to result in a material improvement within a reasonable timeframe. .
23) Pregnancy, childbirth and their consequences, including changes in chronic conditions as a result of pregnancy.
24) All Congenital Internal and/or external illness/disease
D General Conditions
1) Observance of Terms & Conditions
It is a condition precedent to the Insurer's liability that the Insured and each of them shall comply in all respects with the terms and conditions of this Policy insofar as they require anything to be done or complied with by the Insured or any of them.
2) Due Care
The Insured and each of them shall take or procure to be taken all reasonable care and precautions to prevent a claim arising under this Policy and, in the event of a claim arising, to minimise its financial consequences.
3) Change of Occupation
a) The Proposer shall immediately and in any event within 14 days give the Insurer written notice of any change in the occupation or address of any Insured as stated in the Schedule.
b) If a change is not notified and the new occupation or address of an Insured would have resulted in the Insurer charging higher premium, then in the event of a claim the amount payable by the Insurer shall be reduced by 20% of the amount that would otherwise have been payable.
4) Procedure for Making a Claim
If the Insured suffers Accidental Bodily Injury or is diagnosed with an Illness which gives rise to or may give rise to a claim, or requires a Day Care Procedure, then it is a condition precedent to the Insurer's liability that the Proposer and/or the Insured shall immediately:
a) Give the Administrator notice of a claim;
b) Expeditiously give or arrange for the Administrator to be provided with any and all information and documentation in respect of the claim and^ or the Insurer's liability for it that may be requested by the Insurer or the Administrator;
c) Obtain the Administrator's pre-authorization for any medical treatment, which pre-authorization shall, if the Administrator is satisfied as to the validity of the claim, specify:
i) The treatment authorized;
ii) The place at which it has been authorized, and
iii) Any other conditions applicable to either.
5) Authority to Obtain Records
a) The Insured and each of them hereby agree to and authorize the disclosure to the Insurer or the Administrator (or any other person nominated by the Insurer) of any and all medical records and information held by any institution or person from which the Insured and each of them has obtained any medical or other treatment to the extent reasonably required by either the Insurer or the Administrator in connection with any claim made under this Policy or the Insurer's liability for it.
b) The Insurer and the Administrator agree that they will preserve the confidentiality of any documentation and information that comes into the possession of either pursuant to 5) a) above, and will only use it in connection with any claim made under this Policy or the Insurer's liability for it.
6) Procedure for Paying a Claim
a) Within 30 days of the completion of any treatment claimed for at a Non -Network Hospital, the Proposer and/or the Insured shall provide the Administrator with fully particularised details of the quantum of any claim to be reimbursed and any and all other information and documentation in respect of the claim and/or the Insurer's liability for it sought by the Administrator.
b) The Insurer shall be under no obligation to pay or arrange to make payment for any claim until and unless it is satisfied as to the validity and quantum of the Insured's claim, and may forlhese purposes require the Insured to be examined by a medical advisor nominated by the Insurer or the Administrator as often as and to the extent that either considers to be reasonably necessary.
i) Any treatment has been obtained or costs or expenses have been incurred beyond those pre-authorised by the Administrator, or
ii) Any conditions attached to such pre-authorisation have been breached, then the Insurer's liability to make payment shall be limited to the amount that would have been payable had the terms of the pre-authorisation been adhered to by the Insured.
d) The Insurer shall only make payment (unless already paid direct to the service provider) to the Proposer. If the Proposer is incapacitated or is deceased, the Insurer shall make payment to his heir, executor or validly appointed legal representative. Any payment made in good faith by the Insurer as aforesaid to someone other than the Proposer shall operate as a complete and final discharge of the Insurer's liability to make payment under this Policy for such claim.
e) The Insured and each of them hereby acknowledge and agree that the payment of any claim by or on behalf of the Insurer shall not constitute on the part of the Insurer any guarantee or assurance as to the quality or effectiveness of any medical treatment obtained by the Insured, it being agreed and recognised by the Insured and each of them that the Insurer is not in any way responsible or liable for the availability or quality of any service (medical or otherwise) rendered by any institution (including a Network Hospital) whether pre-authorized or not
7) No Claim Discount
As long as the Proposer renews his Family Health Plan with the Insurer without a break and as long as no claim has been made on the expiring Family Health Plan, the Insurer will provide a discount of 5%, under each subsequent Family Health Plan, on the premium rate applicable at the time of renewal for the sum insured and coverage of the expiring policy, but:
a) This discount will become applicable from the first consecutive renewal
b) In the event of a claim, the discount will be withdrawn for the next renewal
c) Nothing in this clause or otherwise obliges the Insurer to renew or grant any Family Health Plan or to give notice of renewal.
a) The Insurer may cancel this Policy by giving the Proposer 30 days written notice and the Proposer may cancel this Policy by giving the Insurer 7 days written notice, in either case without affecting the status of any claim made prior to the effective date of the cancellation.
b) As long as no claim has been made by any of the Insured, the Insurer will refund to the Proposer pro-rata premium for the unexpired Policy Period:
Period on Risk Premium Retained by Insurer
Up to 1 month 25%
Up to 3 months 50%
Upto 6 months 75%
6 months and over 100%
a) Upon the Cancellation or non-renewal of this Policy, all ID Cards shall immediately be returned to the Administrator at the Proposer's expense and the Proposer and each Insured agrees to hold and keep harmless the Insurer and the Administrator against any and all costs, expenses, liabilities and claims (whether justified or not) arising in respect of the actual or alleged use or misuse of such ID Cards prior to their return.
a) Any and all notices and declarations for the attention of the Insurer or Administrator shall be in writing and shall be delivered to the Insurer's or Administrator's address as respectively specified in the Schedule.
b) Any and all notices and declarations for the attention of any or all of the Insured shall be in writing and shall be sent to the Proposer's address as specified in the Schedule.
a) Any dispute or difference between the Insurer and any Insured or the Proposer will be resolved in accordance with Arbitration & Conciliation Act 1996 or any modification or amendment of it. The arbitration proceedings shall be conducted in the English language.
b) It is agreed a condition precedent to any right of action or suit on this Policy that a final arbitration award shall be first obtained:
c) If this arbitration clause is held to be invalid in whole or in part, then all disputes shall be referred to the exclusive jurisdiction of the Indian Courts.
If the Insured or any of them shall:
a) Make or advance any claim knowing the same to be false or fraudulent in amount or otherwise, and/or
b) permit another to use his ID Card or use another's ID Card, then this Policy shall be void in relation to that Insured, all claims or payments due shall be forfeited and all payments made shall be repaid by that Insured in full by the Insured and/or the Proposer who shall be jointly and severally liable for the same.
a) shall do or concur in doing or permit to be done everything necessary for the purpose of enforcing any civil or criminal rights and remedies or obtaining relief or indemnity from other parties to which the Insurer shall be or would become entitled or subrogated upon the Insurer paying for any claim under this Policy, whether before or after indemnification;
b) Shall not do or cause to be done anything that may cause any prejudice to the Insurer's right of Subrogation;
c) Agrees that any recoveries made shall first be applied in making good any sums paid out by or on behalf of the Insurer for the claim and the costs of recovery.
5) Governing Law
The construction, interpretation and meaning of the provisions of this Policy shall be determined in accordance with Indian law. The section headings of this Policy are descriptive only and do not form part of this Policy for the purpose of its construction or interpretation.
6) Entire Contract
The Policy constitutes the complete contract of insurance. Only the Insurer may alter the terms and conditions of this Policy. Any alteration that may be made by the Insurer shall be evidenced by a duly signed and sealed endorsement on the Policy.
If at the time of any claim there is or, but for the existence of this Policy, would be any other policy of indemnity or insurance in favour of or effected by or on behalf of any Insured applicable to any claim, the Insurer will only be liable to pay its ratable proportion.
8) Territorial Limits
This Policy covers Illness or Accidental Bodily Injury sustained by the Insured during the Policy Period anywhere in the world (subject to trade, travel and other restrictions that may be imposed by the Government of India at any time), but the Insurer's liability to make any payment shall be to make payment within India and in Indian Rupees only for medical services or procedures rendered in or undertaken within India.
9) Limitation of Liability
The liability of the insurer in no case shall exceed the Limit of Indemnity stated in the Schedule in respect of all claims made by / on account of the Insurer and the declared Dependents as appearing in the policy schedule, during the Policy Period.