UNITED INDIA INSURANCE COMPANY LIMITED
REGISTERED & HEAD OFFICE: 24, WHITES ROAD, CHENNAI-600014
HEALTH INSURANCE POLICY – GROUP
1 WHEREAS the insured designated in the Schedule hereto has by a proposal and declaration
dated as stated in the Schedule which shall be the basis of this Contract and is deemed to
be incorporated herein has applied to UNITED INDIA INSURANCE COMPANY LTD. (hereinafter
called the COMPANY) for the insurance hereinafter set forth in respect of
Employees/Members (including their eligible family members) named in the Schedule
hereto (hereinafter called the INSURED PERSON) and has paid premium as consideration for
such insurance.
1.1 NOW THIS POLICY WITNESSES that subject to the terms, conditions, exclusions and
definitions contained herein or endorsed, or otherwise expressed hereon the Company
undertakes that if during the period stated in the Schedule or during the continuance of
this policy by renewal any insured person shall contract any disease or suffer from any
illness (hereinafter called DISEASE) or sustain any bodily injury through accident
(hereinafter called INJURY) and if such disease or injury shall require any such insured
Person, upon the advice of a duly qualified Physician/Medical Specialist/Medical
practitioner (hereinafter called MEDICAL PRACTITIONER) or of a duly qualified Surgeon
(hereinafter called SURGEON) to incur hospitalisation/domiciliary hospitalisation expenses
for medical/surgical treatment at any Nursing Home/Hospital in India as herein defined
(hereinafter called HOSPITAL) as an inpatient, the Company will pay through TPA to the
Hospital / Nursing Home or Insured the amount of such expenses as are reasonably and
necessarily incurred in respect thereof by or on behalf of such Insured Person but not
exceeding the Sum Insured in aggregate in any one period of insurance stated in the
schedule hereto.
1.2 In the event of any claim becoming admissible under this scheme, the company will pay
through TPA to the Hospital / Nursing Home or insured person the amount of such expenses
as would fall under different heads mentioned below and as are reasonably and necessarily
incurred thereof by or on behalf of such insured person but not exceeding the Sum Insured
in aggregate mentioned in the schedule hereto.
A. Room, Boarding and Nursing expenses as provided by the Hospital/Nursing Home
not exceeding 1% of the sum insured per day or the actual amount whichever is less. This
also includes nursing care, RMO charges, IV Fluids/Blood transfusion/injection
administration charges and similar expenses.
B. Intensive Care Unit (ICU) expenses not exceeding 2% of the sum insured per day or
actual amount whichever is less.
C. Surgeon, Anaesthetist, Medical Practitioner, Consultants, Specialists Fees.
D. Anaesthetic, Blood, Oxygen, Operation Theatre Charges, surgical appliances,
Medicines & Drugs, Dialysis, Chemotherapy, Radiotherapy, Cost of Artificial Limbs, cost of
prosthetic devices implanted during surgical procedure like pacemaker, orthopaedic
implants, infra cardiac valve replacements, vascular stents, relevant laboratory/diagnostic
tests, X-ray and other medical expenses related to the treatment.
E. Hospitalisation expenses (excluding cost of organ) incurred on donor in respect of
organ transplant to the insured.
Note : 1. The amount payable under 1.2 C & D above shall be at the rate applicable to the
entitled room category. In case the Insured person opts for a room with rent higher than the
entitled category as in 1.2 A above, the charges payable under 1.2 C & D shall be limited to the
charges applicable to the entitled category. This will not be applicable in respect of medicines &
drugs and implants.
2. No payment shall be made under 1.2 C other than as part of the hospitalisation bill.
1.2.1 Expenses in respect of the following specified illnesses will be restricted as detailed below:
Hospitalisation Benefits LIMITS per surgery RESTRICTED TO
a. Actual expenses incurred or 25% of the sum
a. Cataract, Hernia, Hysterectomy
insured whichever is less
b. Actual expenses incurred or 70% of the Sum
b. Major surgeries* Insured whichever is less
* Major surgeries include Cardiac surgeries, Brain Tumor surgeries, Pacemaker implantation for sick
sinus syndrome, Cancer surgeries, Hip, Knee, joint replacement surgery, Organ Transplant.
* The above limits specified are applicable per hospitalization/surgery.
1.3 Pre and Post Hospitalisation expenses payable in respect of each hospitalisation shall be the
actual expenses incurred subject to a maximum of 10% of the Sum Insured.
1.4 In addition to the above, the following would apply to claims arising out of persons aged
more than 60 years
TO BE SETTLED WITH A CO-PAY ON 80:20 BASIS.
EXPENSES ON MAJOR ILLNESSES
The co-pay of 20% will be applicable on the
CHARGED AS A TOTAL PACKAGE
admissible claim amount.
(N.B: Company's Liability in respect of all claims admitted during the period of insurance shall not
exceed the Sum Insured per person as mentioned in the schedule)
2. DEFINITIONS:
2.1 HOSPITAL / NURSING HOME means any institution in India established for indoor care and
treatment of sickness and injuries and which
Either
(a) has been registered as a Hospital or Nursing Home with the local authorities and is
under the supervision of a registered and qualified Medical Practitioner.
Or
(b) Should comply with minimum criteria as under:-
i) It should have at least 15 inpatient beds.
ii) Fully equipped operation theatre of its own wherever surgical operations are
carried out.
iii) Fully qualified Nursing Staff under its employment round the clock.
iv) Fully qualified Doctor (s) should be in-charge round the clock.
v) Maintains a daily record for each of its patients.
N.B: 1. In class 'C' towns condition 2.1 b(i) in respect of number of beds be reduced to 10.
2. For Ayurvedic/Homeopathic/Unani Treatment. Hospitalization expenses are admissible only
when the treatment is taken as in patient in a Government Hospital/Medical College
Hospital.
2.1.1 The term ' Hospital / Nursing Home ' shall not include an establishment which is a place of
rest, a place for the aged, a place for drug-addicts or place for alcoholics a hotel or a
similar place.
2.2 'Surgical Operation' means manual and / or operative procedures for correction of
deformities and defects, repair of injuries, diagnosis and cure of diseases, relief of suffering
and prolongation of life.
2.3 Hospitalisation means admission in a Hospital/Nursing Home in India upon the written advice
of a Medical Practitioner for a minimum period of 24 consecutive hours. However, this time
limit is not applied to specific treatments, such as
1. Adenoidectomy 19. FESS
2. Appendectomy 20. Haemo dialysis
3. Ascitic/Pleural tapping 21. Fissurectomy/Fistulectomy
4. Auroplasty 22. Mastoidectomy
5. Coronary angiography 23. Hydrocele
6. Coronary angioplasty
24. Hysterectomy
7. Dental surgery 25. Inguinal/ventral/umbilical/
Femoral hernia
8. D&C 26. Parenteral chemotherapy
9. Endoscopies 27. Polypectomy
10. Excision of Cyst/Granuloma/lump 28. Septoplasty
11. Eye surgery 29. Piles/fistula
12. Fracture/dislocation excluding hairline fracture 30. Prostate
13. Radiotherapy 31. Sinusitis
14. Lithotripsy 32. Tonsilectomy
15. Incision and drainage of abcess 33. Liver aspiration
16. Colonoscopy 34. Sclerotherapy
17. Varicocelectomy 35. Varicose Vein Ligation
18. Wound suturing
Or any other surgeries / procedures agreed by the TPA/ Company which require less than 24
hours hospitalisation and for which prior approval from TPA is mandatory.
2.3.1 Further if the treatment/procedure/surgeries of above diseases are carried out, in Day care
centres which is fully equipped with advanced technology and specialized infrastructure
where the insured is discharged on the same day, the requirement of minimum beds will be
overlooked provided following conditions are met.
i. The operation theatre is fully equipped for the surgical operation required in
respect of sickness/ailment/injured covered under the policy.
ii. Day Care nursing staff is fully qualified.
iii. The doctor performing the surgery or procedure as well as post operative attending
doctors are also fully qualified for the specific surgery/procedure.
Note: Procedures/treatments usually done in out patient department are not payable under
the policy even if converted as an in-patient in the hospital for more than 24 hours
2.4 DOMICILIARY HOSPITALISATION BENEFIT: means Medical treatment for a period exceeding
three days for such illness / disease / injury which in the normal course would require care
and treatment at a hospital / nursing home but actually taken whilst confined at home in
India under any of the following circumstances namely:-
i) The condition of the patient is such that he / she cannot be removed to the
hospital / nursing home or
ii) The patient cannot be removed to Hospital / Nursing home for lack of
accommodation therein
Subject however that domiciliary hospitalisation benefits shall not cover:
I) Expenses incurred for pre and post hospital treatment and
II) Expenses incurred for treatment for any of the following diseases:-
1) Asthma
2) Bronchitis
3) Chronic Nephritis and Nephritic Syndrome
4) Diarrhoea and all type of Dysenteries including Gastroenteritis
5) Diabetes Mellitus and Insipidus
6) Epilepsy
7) Hypertension
8) Influenza, Cough and Cold
9) All Psychiatric or Psychosomatic Disorders
10) Pyrexia of unknown Origin for less than 10 days
11) Tonsillitis and Upper Respiratory Tract infection including Laryngitis and pharangitis
12) Arthritis, Gout and Rheumatism
Note: When treatment such as dialysis, Chemotherapy, Radiotherapy., etc is taken in the
hospital / nursing home and the insured is discharged on the same day the treatment will
be considered to be taken under hospitalisation benefit section.
Liability of the company under this clause is restricted as stated in the Schedule attached
hereto.
3.0 ANY ONE ILLNESS:
Any one illness means continuous period of illness and it includes relapse within 45 days
from the date of discharge from the Hospital / Nursing Home from where treatment has
been taken. Occurrence of same illness after a lapse of 45 days as stated above will be
considered as fresh illness for the purpose of this policy.
3.1 PRE - HOSPITALISATION:
Relevant medical expenses incurred during period up to 30 days prior to Hospitalisation on
disease / illness / injury sustained will be considered as part of claim as mentioned under
item 1.2 above.
3.2 POST HOSPITALISATION:
Relevant medical expenses incurred during period up to 60 days after Hospitalisation on
disease / illness / injury sustained will be considered as part of claim mentioned under
item 1.2 above.
3.3 MEDICAL PRACTIONER means a person who holds a degree / diploma of a recognised institution
and is registered by Medical Council of respective State of India. The term Medical
Practitioner would include Physician, Specialist and Surgeon.
3.4 QUALIFIED NURSE means a person who holds a certificate of recognised Nursing Council and who
is employed on recommendation of the attending Medical Practitioner.
3.5 MATERNITY EXPENSES BENEFIT means treatment taken in Hospital/Nursing Home arising from or
traceable to pregnancy, childbirth including normal Caesarean Section. This is an optional
benefit available on payment of additional premium. When Maternity Expenses Benefit is
opted for in the policy, Exclusion 4.12 of the policy stands deleted. The hospitalisation
expenses in respect of the new born child can be covered within the Mother’s Maternity
expenses subject to an overall limit of Rs.50,000/-.
3.6 TPA means a Third Party Administrator who holds a valid License from Insurance Regulatory and
Development Authority to act as a THIRD PARTY ADMINISTRATOR and is engaged by the
Company for the provision of health services as specified in the agreement between the
Company and TPA .
3.7 Network Hospital means the Hospital/Nursing Home or such other medical aid provider that has
agreed with the TPA to provide cashless access services to Policy holders. The list of network
hospitals is maintained by and available with the TPA and the same is subject to amendment
from time to time.
3.8 Cashless facility ; means facility whereby the TPA agrees on the insured’s request to settle the
admissible claim directly to the network hospital.
3.9 ID card : means the identify card issued to the insured person by the TPA to avail cashless
facility in network hospitals.
3.10 Day-care procedure means the course of medical treatment/surgical procedure in
specialized day care centres which enables the insured to be discharged on the same day.
3.11 Pre-Existing condition/Disease – Any condition, ailment or injury or related condition(s) for
which insured person had signs or symptoms, and/or were diagnosed, and/or received medical
advice/treatment, within 48 months prior to his/her first policy with the company.
3.12 REASONABLE AND NECESSARY EXPENSES :
For a networked hospital, it shall mean the rate agreed between Networked Hospital and
the TPA for surgical/medical treatment.
For any other hospital, it shall mean the cost of surgical/medical treatment that is
necessary, customary and reasonable for treating the condition for which insured person
was hospitalized to the extent relatable to such condition.
4. EXCLUSIONS:
The company shall not be liable to make any payment under this policy in respect of any expenses
whatsoever incurred by any Insured Person in connection with or in respect of:
4.1 Any Pre-existing condition(s) as defined in the policy, until 48 months of continuous coverage of
such insured person have elapsed since inception of his/her first policy with the Company.
4.2 Any disease other than those stated in clause 4.3 below, contracted by the Insured person
during the first 30 days from the commencement date of the policy. This exclusion shall
not however, apply in case of the Insured person having been covered under an Insurance
scheme with our Company for a continuous period of preceding 12 months without any
break.
4.3 During the first two years of the operation of the policy, the expenses on treatment of diseases
such as Cataract, Benign Prostatic Hyperthrophy, Hysterectomy for Menorrhagia, or
Fibromyoma, Hernia, Hydrocele, Congenital internal disease, Fistula in anus, piles, Sinusitis
and related disorders, Gall Bladder Stone removal, Gout & Rheumatism, Calculus Diseases
are not payable.
4.4 During the first four years of the operation of the policy, the expenses related to treatment of
Joint Replacement due to Degenerative Condition and age-related Osteoarthritis &
Osteoporosis are not payable.
If these diseases mentioned in Exclusion no.4.3 and 4.4 (other than Congenital Internal
Diseases) are pre-existing at the time of proposal they will not be covered even during
subsequent period of renewal subject to the pre-existing disease exclusion clause. If the
Insured is aware of the existence of congenital internal disease before inception of the
policy, the same will be treated as pre-existing.
4.5 Injury / disease directly or indirectly caused by or arising from or attributable to War, invasion,
Act of Foreign enemy, War like operations (whether war be declared or not).
4.6 a. Circumcision unless necessary for treatment of a disease not excluded hereunder or as may
be necessitated due to an accident.
b. Vaccination or inoculation.
c. Change of life or cosmetic or aesthetic treatment of any description such as correction of
eyesight., etc,
d. Plastic surgery other than as may be necessitated due to an accident or as part of any
illness.
4.7 Cost of spectacles and contact lenses, hearing aids.
4.8 Dental treatment or surgery of any kind unless necessitated by accident and requiring
hospitalisation.
4.9 Convalescence, general debility; run-down condition or rest cure, Obesity treatment and its
complications including morbid obesity, Congenital external disease/defects or anomalies,
treatment relating to all psychiatric and psychosomatic disorders, infertility, Sterility,
Venereal disease, intentional self injury and use of intoxication drugs / alcohol.
4.10 All expenses arising out of any condition directly or indirectly caused to or associated with
Human T-Cell Lymphotropic Virus Type III (HTLB - III) or lymphadinopathy 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.
4.11 Charges incurred at Hospital or Nursing Home primarily for diagnosis x-ray or Laboratory
examinations or other diagnostic studies not consistent with or incidental to the diagnosis and
treatment of positive existence of presence of any ailment, sickness or injury, for which
confinement is required at a Hospital / Nursing Home.
4.12 Expenses on vitamins and tonics unless forming part of treatment for injury or diseases as
certified by the attending physician
4.13 Injury or Disease directly or indirectly caused by or contributed to by nuclear weapon /
materials.
4.14 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 Gynaecologist that it is life threatening one if left
untreated.
4.15Naturopathy Treatment, acupressure, acupuncture, magnetic therapies, experimental and
unproven treatments/ therapies.
4.16 External and or durable Medical / Non-medical equipment of any kind
used for diagnosis and or treatment including CPAP, CAPD, Infusion pump etc. Ambulatory
devices i.e., walker, crutches, Belts, Collars, Caps, Splints, Slings, Braces, Stockings, elastocrepe
bandages, external orthopaedic pads, sub cutaneous insulin pump, Diabetic foot wear,
Glucometer / Thermometer, alpha / water bed and similar related items etc., and also any
medical equipment, which is subsequently used at home etc.
4.17Genetic disorders and Stem Cell implantation/surgery.
4.18Change of treatment from one system of medicine to another unless recommended by the
consultant/hospital under whom the treatment is taken.
4.19Treatment for Age related Macular Degeneration (ARMD), treatment such as Rotational Field
Quantum magnetic Resonance (RFQMR), Enhanced External Counter Pulsation (EECP), etc.
4.20All non-medical expenses including convenience items for personal comfort such as charges for
telephone, television, ayah, private nursing/barber or beauty services, died charges, baby food,
cosmetics, tissue paper, diapers, sanitary pads, toiletry items and similar incidental expenses.
4.21 Any kind of Service charges, Surcharges, Admission Fees/Registration Charges, Luxury Tax
and similar charges levied by the hospital
5. CONDITIONS:
5.1 Contract : the proposal form, declaration pre-acceptance health check-up and the policy
issued shall constitute the complete contract of insurance.
5.2 Every notice or communication regarding hospitalization or claim to be given or made under
this Policy shall be delivered in writing at the address of the TPA office as shown in the
Schedule. Other matters relating to the policy may be communicated to the policy issuing
office.
5.3 The premium payable under this Policy shall be paid in advance. No receipt for Premium shall
be valid except on the official form of the company signed by a duly authorised official of
the company. The due payment of premium and the observance and fulfilment 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 any liability of the Company to make any payment under this Policy.
No waiver of any terms, provisions, conditions and endorsements of this policy shall be
valid unless made in writing and signed by an authorised official of the Company.
5.4 Notice of Communication : Upon the happening of any event which may give rise to a claim
under this Policy notice with full particulars shall be sent to the TPA named in the schedule
immediately and in case of emergency hospitalization within 24 hours from the time of
Hospitalisation/Domiciliary Hospitalisation
5.5 All supporting documents relating to the claim must be filed with TPA within 15 days from the
date of discharge from the hospital. In case of post-hospitalisation, treatment (limited to
60 days), all claim documents should be submitted within 7 days after completion of such
treatment.
Note: Waiver of this Condition may be considered in extreme cases of hardship where it is proved
to the satisfaction of the Company that under the circumstances 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.
5.5 The Insured Person shall obtain and furnish the TPA with all original bills, receipts and other
documents upon which a claim is based and shall also give the TPA/ Company such
additional information and assistance as the TPA/Company may require in dealing with the
claim.
5.6 Any medical practitioner authorised by the TPA / Company shall be allowed to examine the
Insured Person in case of any alleged injury or disease leading to Hospitalisation if so
required.
5.7 The Company shall not be liable to make any payment under this policy in respect of any
claim 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 behalf.
5.8 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 Cancer Society),
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, costs or expenses, the
Company shall not be liable to pay or contribute more than its rateable proportion of any
loss, liability, compensation costs or expenses. The benefits under this Policy shall be in
excess of the benefits available under Cancer Insurance Policy.
5.9 The Policy may be renewed by mutual consent and in such event the renewal premium shall
be paid to the Company on or before the date of expiry of the Policy or of the subsequent
renewal thereof.The Company shall not be bound to give notice that such renewal premium
is due, provided however that if the insured shall apply for renewal and remit the requisite
premium before the expiry of this policy, renewal shall not normally be refused, unless the
Company has reasonable justification to do so.
Cancellation Clause :
The Company may at any time cancel this Policy by sending the Insured 15 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 unexpired 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 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
Upto one month 1/4 th of the annual rate
Upto three months 1/2 of the annual rate
Upto six months 3/4th of the annual rate
Exceeding six months Full annual rate.
5.10 If any dispute or difference shall arise as to the quantum to be paid under 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 or if
they cannot agree upon a single arbitrator within 30 days of any party invoking arbitration,
the same shall be referred to a panel of three arbitrators, comprising of two arbitrators,
one to be appointed by each of the parties to the dispute/difference and the third
arbitrator to be appointed by such two arbitrators and arbitration shall be conducted under
and in accordance with the provisions of the Arbitration and Conciliation Act, 1996.
It is clearly agreed and understood that no difference or dispute shall be referable to
arbitration as herein before provided, if the Company has disputed or not accepted liability
under or in respect of this Policy.
It is hereby expressly stipulated and declared that it shall be a condition precedent to any
right of action or suit upon this policy that award by such arbitrator/arbitrators of the
amount of the loss or damage shall be first obtained.
5.11 If the TPA, as per terms and conditions of the policy or the 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
TPA/Company then the claim shall for all purposes be deemed to have been abandoned and
shall not thereafter be recoverable hereunder.
5.12 All medical/surgical treatments under this policy shall have to be taken in India and
admissible claims thereof shall be payable in Indian currency. Payment of claim shall be
made through TPA to the Hospital/Nursing Home or the Insured Person as the case may be.
5.13 Low Claim Ratio Discount (Bonus)
Low Claim Ratio Discount at the following scale will be allowed on the total premium at
renewal only depending upon the incurred claim ratio for the entire group insured under
the Group Mediclaim Insurance Policy for the preceding 3 completed years excluding the
year immediately preceding the date of renewal where the Group Mediclaim Insurance
Policy has not been in force for 3 completed years, such shorter period of completed years
excluding the year immediately preceding the date of renewal will be taken in to account
Incurred Claim ratio under the group Discount %
policy
Not exceeding 60% 5
Not exceeding 50% 15
Not exceeding 40% 25
Not exceeding 30% 35
Not exceeding 25% 40
5.14 High Claims Ratio Loading (MALUS)
The total premium payable at renewal of the Group Policy will be loaded at the
following scale depending upon the incurred claims ratio for the entire group insured
under the Group Mediclaim Insurance Policy for the preceding year (immediately
preceding the date of renewal).
Incurred claims ratio under Loading
this group policy
Between 70% and 100% 25 %
Between 101% and 125 % 55 %
Between 126 % and 150 % 90 %
Between 151 % and 175 % 120 %
Between 176 and 200 150%
Over 200 % Cover to be reviewed
Note:
1. Low Claim Ratio Discount (Bonus) or High Claim Ratio loading (Malus) will be applicable
to the Premium at renewal of the Policy depending on the incurred claims Ratio for the
entire Group Insured.
2. Incurred claim would mean claims paid plus claims outstanding in respect of the entire
group insured under the policy during the relevant period.
The insured shall throughout the period of insurance keep and maintain a proper record of
register containing the names of all the insured persons and other relevant details as are
normally kept in any institution/ Organisation. The insured shall declare to the company
any additions in the number of insured persons as and when arising during the period of
insurance and shall pay the additional premium as agreed.
It is hereby agreed and understood that, that this insurance being a Group Policy availed by the
Insured covering Members, the benefit thereof would not be available to Members who cease to be
part of the group for any reason whatsoever.
Such members may obtain further individual insurance directly from the Company and any claims
shall be governed by the terms thereof.
5.15 MATERNITY EXPENSES BENEFIT EXTENSION: (Wherever applicable)
This is an optional cover, which can be obtained on payment of 10% of total basic premium
for all the Insured Persons under the Policy.
Option for Maternity Benefits has to be exercised at the inception of the Policy period and
no refund is allowable in case of Insured's cancellation of this option during currency of the
policy.
5.16 The hospitalisation expenses in respect of the new born child can be covered within the
Mother’s Maternity expenses. The maximum benefit allowable under this clause will be up
to Rs. 50,000/- or the sum insured opted by the group whichever is lower.
Special conditions applicable to Maternity expenses Benefit Extension:
1. These Benefits are admissible only if the expenses are incurred in Hospital / Nursing
Home as in-patients in India
2. A waiting period of 9 months is applicable for payment of any claim relating to
normal delivery or caesarean section or abdominal operation for extra uterine
pregnancy. The waiting period may be relaxed only in case of delivery, miscarriage
or abortion induced by accident or other medical emergency.
3. Claim in respect of delivery for only first two children and / or operations
associated therewith will be considered in respect of any one Insured Person covered
under the policy or any renewal thereof. Those Insured Persons who are already
having two or more living children will not be eligible for this benefit.
4. Expenses incurred in connection with voluntary medical termination of pregnancy
during the first 12 weeks from the date of conception are not covered.
5. Pre-natal and postnatal expenses are not covered unless admitted in Hospital /
Nursing Home and treatment is taken there.
Note: When group policy is extended to include Maternity Expenses Benefit, the exclusion
No.4.14 of the policy stands deleted.
6 REASONABLE AND NECESSARY EXPENSES
1. For a networked hospital, it shall mean the rate pre-agreed between Networked Hospital
and the TPA for surgical / medical treatment that is necessary, customary and
reasonable for treating the condition for which the insured person was hospitalised
2. For any other hospital, it shall mean the cost of surgical / medical treatment that is
necessary, customary and reasonable for treating the condition for which insured
person was hospitalised to the extent relatable to such condition.
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