4.4.8 Treatment of any Bodily injury sustained whilst or as a result of active participation in hazardous sports of any kind
4.4.9 Treatment of any Bodily injury sustained whilst or as a result of participating in any criminal act.
4.4.10 Sexually transmitted diseases, any condition directly or indirectly caused due to or associated with Human T- Cell Lymphotropic Virus Type III (HTLB-III) or Lymphotropathy Associated Virus (LAV OR THE Mutants Derivative or variation Deficiency Syndrome or any syndrome or condition of a similar kind commonly referred to as AIDS.
4.4.11 Diagnostics, X-Ray OR Laboratory examination not consistent with or incidental to the diagnosis and treatment of positive existence or presence of any ailment, sickness or injury, for which confinement is required at a Hospital/ Nursing Home.
4.4.12 Vitamins and tonics unless forming part of treatment of injury or disease as certified by the attending physician.
4.4.13 Treatment arising from or traceable to pregnancy, childbirth, miscarriage, abortion or complications of any of these including caesarean section except abdominal operation for extra uterine pregnancy (Ectopic pregnancy which is proved by submission OF Ultra Sonographic Report and Certification by Gynecologist that it is a life threatening one if left untreated.
4.414 Any Naturopathy Treatment
4.4.15 Instrument used in treatment of Sleep Apnea Syndrome (C.P.A.P) and Continuous Peritoneal Ambulatory Dialysis (C.P.A.D ) and Oxygen Concentrator for Bronchial Asthmatic condition.
4.4.16 Genetical disorders and stem cell implantation/ surgery.
4.4.17 Any Domiciliary Hospitalization/ Treatment.
4.4.18 Treatment taken outside India.
4.4.19 Experimental and unproven treatment treatment (not recognized by Indian Medical Council)
4.4.20 Change of treatment from one system of medicine to another unless recommended by the Consultant / Hospital under whom the treatment is taken.
4.4.21 All non- medical expenses including convenience items for personal comfort such as telephone, television Aya, Private Nursing / Barber or beauty services, diet charges, baby food, cosmetics, tissue paper, diapers, sanitary pads, toiletry items and similar incidental expenses.
4.4.22 Service charges or any other charges levied by hospital, except registration/admission charges.
5.2 Contract: The proposal form, declaration, pre acceptance Health Check- up and the policy issued constitute complete contract of insurance.
5.3 Communication: Every notice or communication to be given or made under this policy other than that relating to the claim shall be delivered in writing at the address of the policy issuing office as shown in the schedule. The claim shall be reported to the TPA appointed for providing claim services as per the procedure mentioned in the guidelines circulated by the T.P.A to the policyholders. In case TPA services are not availed then claim shall be reported to policy issuing office only.
5.4 Premium Payment: The premium payable under this policy shall be paid in full and in advance. No receipt for premium shall be valid except on the official form of the company signed by a duly authorized official of the Company. The due payment of premium and the observance and fulfillment of the terms, provisions, conditions and endorsements of this policy by the Insured person in so far as they relate to anything to be done or complied with by the Insured person shall be a condition precedent to admission of any liability of the company to make any payment under the policy no waiver of any terms , provisions, conditions and endorsement of this policy shall be valid unless made in writing and signed by an authorized official of the Company.
5.5 Physical Examination: Any Medical practitioner authorized by the TPA/ Company shall be allowed to examine the Insured person in case of any alleged disease/ illness/ injury/ requiring Hospitalization. Non co-operation by the Insured person will result into rejection of his/her claim.
5.6 Fraud, Misrepresentation, Concealment: The policy shall be null and void and no benefits shall be payable in the event of misrepresentation, misdiscription or nondisclosure of any material fact/particular if such claim be in any manner fraudulent or supported by any fraudulent means or device whether by the Insured person or by any other person acting on his / her behalf.
5.7 Contribution: If at the time when any claim arises under this policy, there is in existence any other insurance (other than Cancer Insurance Policy in collaboration with Indian Cane Society/Cancer patient Aid Association) whether it be effected by or on behalf of any Insured Person in respect of whom the claim may have arisen covering the same loss, liability, compensation, cost of expenses. The benefits under this policy shall be in excess of the benefits available under Cancer Insurance Policy as indicated above.
5.8 Cancellation Clause: The Company may at any time cancel this Policy by sending the Insured 30 days notice by registered letter at the Insured’s last known address and in such event the Company shall refund to the Insured a Pro- rata premium for in-expired period of Insurance. The Company shall however, remain liable for any claim, which arose prior to the date of cancellation. The Insured may at any time cancel this policy and in such event the Company shall allow refund of premium at Company’s short period scale of rate only (table given here below) provided no claim has occurred up to the date of cancellation.
PERIOD ON RISK RATE OF PREMIUM TO BE CHARGED
Up to one-month 1/4th of the annual rate
Up to three months 12 of the annual rate
Up to six months 3/4th of the annual rate
Exceeding six months Full annual rate
5.8 Disclaimer of claim: If the TPA/Company shall disclaim liability to the Insured for any claim hereunder and if the insured shall not within 12 calendar months from the date or receipt of the notice of such disclaimer notify the TPA/Company in writing that he does not accept such disclaimer and intends to recover his claim from the company then the claim shall for all purposes be deemed to have been abandoned and shall not thereafter be recoverable hereunder.
5.9 All medical /surgical treatment under this policy shall have to be taken in India.
6.0 RENEWAL OF POLICY:
(a) The Company sends renewal notice as a matter of courtesy if the insured does not receive the renewal notice it will not amount to deficiency of service.
(b) The Company shall not be responsible or liable for non-renewal of the policy due to non-receipt/ delayed receipt of renewal notice or due to any other reason whatsoever.
(c) Decision to accept or reject the coverage of any person at renewal of this insurance shall rest solely with the Company. The Company may at its discretion revise the premium rates and/or the terms and conditions of the policy every year upon renewal thereof. Renewal of this policy is not automatic. Premium due must be paid to the Company before the due date.
If the policy is to be renewed for enhanced sum insured then the restriction as applicable to a fresh policy will apply to additional sum insured as if a separate policy has been issued for the difference. In other words, the enhanced sum insured will not be available for an illness, disease, injury already contracted under the preceding policy periods.
7.0 MEDICAL EXPENSES INCURRED LESS THAN TWO POLICY PERIODS:
If a claim spreads over two policy periods the total benefit will not exceed the sum insured of that policy during which period the insured person was admitted to the hospital. Only that policy during which the insured person was admitted to hospital will be considered for the claim.
8.0 COMPANY’S LIABILTY: The Company’s liability in respect of all claims admitted during the period of Insurance shall not exceed the sum insured including Cumulative Bonus.
9.0 NOTICE OF CLAIM: Preliminary notice of claim with particulars relating to policy Number, name of Insured person in respect of whom claim is to be made, nature of illness /injury and Name and address of the attending medical practitioner/Hospital./Nursing Home should be given to the Company/TPA within 7 days form the date of hospitalization in respect of reimbursement of claims from time to time.
Final claim along with hospital receipt original Bills/ Cash memos, claim form and documents as listed in the claim form should be submitted to the policy issuing Office/TPA not later than 30 days of discharge from the hospital. The insured may also be required to give the Company/TPA such additional information and assistance as the Company/TPA may require in dealing with the claim, from time to time.
Waiver: Waiver of period of intimation may be considered in extreme cases of hardship where it is proved to the satisfaction of the Company/TPA that under the circumstance in which the insured was placed it was not possible for him or any other person to give such notice or file claim within the prescribed time limit. This waiver cannot be claimed as a matter of right.
10.0 PROCEDURE FOR AVAILING CASHLESS FACILITY:
Claims in respect of cashless facility will b through the agreed list of Network Hospital / Nursing Home /Day Care Centre and is subject to pre – admission authorization. The TPA shall, upon getting the related medical information from the insured person/network provider, verify that the person is eligible to claim under the policy and after satisfying itself will issue a pre-authorization letter / guarantee of payment letter to the Hospital/Nursing Home /Day Care Center mentioning the sum guaranteed as payable and also the ailment for which the person is seeking to be admitted as a patient. The TPA reserves the right to deny pre- authorization in case the Insured person is unable to provide the relevant medical details as required by the TPA. The insured person may obtain the treatment as per his/her treating doctors advice and later on submit the full claim papers to the TPA for reimbursement.
11.0 REPUDIATION OF CLAIMS:
TPA’s are authorized to repudiate claims if they are not admissible as per the terms and conditions herein. The TPA shall mention the reason for such repudiation in writing to the insured person. The insured person shall have right of appeal to the Company if he/she feels that the claim is wrongly repudiated. The Company’s decision in this regard will be final and binding on TPA.
12.0 PAYMENT OF CLAIM: All admissible claims shall be payable in Indian Currency only.
13.0 PERIOD OF POLICY: This Insurance policy is issued for a period of one year.