Group MediCare - Base - Policy Wording

Tata AIG General Insurance Company Limited

Registered Oce: 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: TATHLGP21248V022021

Preamble

We will provide the insurance cover detailed in

the Policy to the Insured Persons up to the Sum

Insured subject to:

i. The terms, conditions and exclusions of

this Policy.

ii. Statements in the proposal/enrolment

form and information disclosed to Us

by You or on Your behalf and on behalf

of all persons to be insured which is

incorporated into the Policy and is the basis

of it.

Commencement of risk cover under the policy

is subject to receipt of premium by Us.

While the policy is in force, and if the claim is

admissible under the policy, then We shall pay

You such Reasonable and Customary Medical

Expenses incurred on treatment or pay for the

listed benet sum insured. The said treatment

must be on the advice of a qualied Medical

Practitioner.

Our liability at any time shall not exceed the

maximum sum insured applicable for the

benet as specied in Your policy schedule or

Certicate of insurance. In case of family oater,

the sum insured shall be applicable for all the

claims made by any or all the insured persons

in the family whereas in case of individual, this

shall be applicable for all the claims made by an

individual insured person.

In case of any other sum insured restrictions,

the same shall be clearly specied in Your Policy

schedule/Certicate of Insurance.

Section 1 – Denitions

The terms dened below and at other junctures

in the Policy Wording have the meanings

ascribed to them wherever they appear in this

Policy and, where appropriate, references to

the singular include references to the plural;

references to the male include the female and

references to any statutory enactment include

subsequent changes to the same:

i. Standard Denitions

1. Accident

An accident means sudden, unforeseen

and involuntary event caused by external,

visible and violent means.

2. Any one illness

Any one illness means continuous period of

illness and includes relapse within 45 days

from the date of last consultation with the

Hospital/Nursing Home where treatment

was taken.

3. Cashless facility

Cashless facility means a facility extended

by the insurer to the insured where the

payments, of the costs of treatment

undergone by the insured in accordance

with the policy terms and conditions, are

directly made to the network provider by

the insurer to the extent pre-authorization

is approved.

4. Congenital Anomaly

Congenital Anomaly means a condition

which is present since birth, and which is

abnormal with reference to form, structure

or position.

a) Internal Congenital Anomaly

Congenital anomaly which is not in

the visible and accessible parts of the

body.

b) External Congenital Anomaly

Congenital anomaly which is in the

visible and accessible parts of the

body

5. Co-Payment

Co-payment means a cost sharing

Tata AIG General Insurance Company Limited

Registered Oce: 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: TATHLGP21248V022021

Group MediCare - Base - Policy Wording

requirement under a health insurance

policy that provides that the policyholder/

insured will bear a specied percentage

of the admissible claims amount. A co-

payment does not reduce the Sum Insured.

6. Day Care Centre

A day care centre means any institution

established for day care treatment of illness

and/or injuries or a medical setup with a

hospital and which has been registered

with the local authorities, wherever

applicable, and is under supervision

of a registered and qualified medical

practitioner AND must comply with all

minimum criterion as under –

i. has qualied nursing sta under its

employment;

ii. has qualied medical practitioner/s

in charge;

iii. has fully equipped operation theatre

of its own where surgical procedures

are carried out;

iv. maintains daily records of patients

and will make these accessible to

the insurance company’s authorized

personnel.

7. Day Care Treatment

Day care treatment means medical

treatment, and/or surgical procedure

which is:

i. undertaken under General or Local

Anesthesia in a hospital/day care

centre in less than 24 hrs because of

technological advancement, and

ii. which would have otherwise required

hospitalization of more than 24

hours.

Treatment normally taken on an out-

patient basis is not included in the scope

of this denition

8. Dental Treatment

Dental treatment means a treatment

related to teeth or structures supporting

teeth including examinations, fillings

(where appropriate), crowns, extractions

and surgery.

9. Domiciliary Hospitalization

Domiciliary hospitalization means medical

treatment for an illness/disease/injury

which in the normal course would require

care and treatment at a hospital but is

actually taken while confined at home

under any of the following circumstances:

i. the condition of the patient is such

that he/she is not in a condition to

be removed to a hospital, or

ii. the patient takes treatment at home

on account of non-availability of

room in a hospital.

10. Grace Period

Grace period means the specied period of

time immediately following the premium

due date during which a payment can be

made to renew or continue a policy in force

without loss of continuity benets such

as waiting periods and coverage of pre-

existing diseases. Coverage is not available

for the period for which no premium is

received.

11. Hospital

A hospital means any institution established

for in-patient care and day care treatment

Tata AIG General Insurance Company Limited

Registered Oce: 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: TATHLGP21248V022021

Group MediCare - Base - Policy Wording

of illness and/or injuries and which has

been registered as a hospital with the local

authorities under Clinical Establishments

(Registration and Regulation) Act 2010 or

under enactments specified under the

Schedule of Section 56(1) and the said act

Or complies with all minimum criteria as

under:

i. has qualied nursing sta under its

employment round the clock;

ii. has at least 10 in-patient beds in

towns having a population of less

than 10,00,000 and at least 15 in-

patient beds in all other places;

iii. has qualied medical practitioner(s)

in charge round the clock;

iv. has a fully equipped operation

theatre of its own where surgical

procedures are carried out;

v. maintains daily records of patients

and makes these accessible to the

insurance company’s authorized

personnel;

12. Hospitalization

Hospitalization means admission in a

Hospital for a minimum period of 24

consecutive ‘In-patient Care’ hours except

for specified procedures/ treatments,

where such admission could be for a

period of less than 24 consecutive hours.

13. Illness

Illness means a sickness or a disease

or pathological condition leading to the

impairment of normal physiological

function and requires medical treatment.

(a) Acute condition

Acute condition is a disease, illness or

injury that is likely to respond quickly

to treatment which aims to return the

person to his or her state of health

immediately before suffering the

disease/ illness/ injury which leads

to full recovery

(b) Chronic condition

A chronic condition is defined as

a disease, illness, or injury that

has one or more of the following

characteristics:

i. it needs ongoing or long-

term monitoring through

consultations, examinations,

check-ups, and /or tests

ii. it needs ongoing or long-term

control or relief of symptoms

iii. it requires rehabilitation for the

patient or for the patient to be

specially trained to cope with it

iv. it continues indenitely

v. it recurs or is likely to recur

14. Injury

Injury means accidental physical bodily

harm excluding illness or disease solely

and directly caused by external, violent,

visible and evident means which is veried

and certied by a Medical Practitioner.

15. In-patient Care

Inpatient care means treatment for which

the insured person has to stay in a hospital

for more than 24 hours for a covered event.

16. Maternity expenses

Maternity expenses means;

Tata AIG General Insurance Company Limited

Registered Oce: 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: TATHLGP21248V022021

Group MediCare - Base - Policy Wording

a. medical treatment expenses traceable

to childbirth (including complicated

deliveries and caesarean sections

incurred during hospitalization);

b. expenses towards lawful medical

termination of pregnancy during the

policy period.

17. Medical Advice

Medical Advice means any consultation

or advice from a Medical Practitioner

including the issuance of any prescription

or follow-up prescription.

18. Medical Expenses

Medical Expenses means those expenses

that an Insured Person has necessarily and

actually incurred for medical treatment

on account of Illness or Accident on the

advice of a Medical Practitioner, as long as

these are no more than would have been

payable if the Insured Person had not been

insured and no more than other hospitals

or doctors in the same locality would have

charged for the same medical treatment.

19. Medical Practitioner

Medical Practitioner means a person who

holds a valid registration from the Medical

Council of any State or Medical Council of

India or Council for Indian Medicine or for

Homeopathy set up by the Government of

India or a State Government and is thereby

entitled to practice medicine within its

jurisdiction; and is acting within its scope

and jurisdiction of license.

20. Medically Necessary Treatment

Medically necessary treatment means any

treatment, tests, medication, or stay in

hospital or part of a stay in hospital which:

i. is required for the medical

management of the illness or injury

suered by the insured;

ii. must not exceed the level of care

necessary to provide safe, adequate

and appropriate medical care in

scope, duration, or intensity;

iii. must have been prescribed by a

medical practitioner;

iv. must conform to the professional

standards widely accepted in

international medical practice or by

the medical community in India.

21. Network Provider

Network Provider means hospitals or

health care providers enlisted by an

insurer, TPA or jointly by an Insurer and

TPA to provide medical services to an

insured by a cashless facility.

22. OPD treatment

OPD treatment means the one in which

the Insured visits a clinic / hospital or

associated facility like a consultation room

for diagnosis and treatment based on

the advice of a Medical Practitioner. The

Insured is not admitted as a day care or

in-patient.

23. Pre-Existing Disease

Pre-Existing Disease means any condition,

ailment , injury or disease

o That is/are diagnosed by a Physician

within 48 months prior to the

eective date of the Policy issued by

the Insurer or its reinstatement; or

o For which medical advice or treatment

was recommended by, or received

Tata AIG General Insurance Company Limited

Registered Oce: 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: TATHLGP21248V022021

Group MediCare - Base - Policy Wording

from, a Physician within 48 months

prior to the effective date of the

Policy issued by the Insurer; or its

reinstatement.

24. Pre-hospitalization Medical Expenses

Pre-hospitalization Medical Expenses

means medical expenses incurred during

predefined number of days preceding

the hospitalization of the Insured Person,

provided that:

i. Such Medical Expenses are incurred

for the same condition for which the

Insured Person’s Hospitalization was

required, and

ii. The In-patient Hospitalization claim

for such Hospitalization is admissible

by the Insurance Company.

25. Post-hospitalization Medical Expenses

Post-hospitalization Medical Expenses

means medical expenses incurred during

predened number of days immediately

after the insured person is discharged from

the hospital provided that:

i. Such Medical Expenses are for

the same condition for which the

insured person’s hospitalization was

required, and

ii. The inpatient hospitalization claim for

such hospitalization is admissible by

the insurance company

26. Migration

Migration” means, the right accorded to

health insurance policyholders (including

all members under family cover and

members of group health insurance

policy), to transfer the credit gained for

pre-existing conditions and time bound

exclusions, with the same insurer.

27. Qualied Nurse

Qualified nurse means a person who

holds a valid registration from the Nursing

Council of India or the Nursing Council of

any state in India.

28. Reasonable and Customary Charges

Reasonable and Customary charges means

the charges for services or supplies, which

are the standard charges for the specic

provider and consistent with the prevailing

charges in the geographical area for

identical or similar services, taking into

account the nature of the illness / injury

involved.

29. Renewal

Renewal means the terms on which the

contract of insurance can be renewed on

mutual consent with a provision of grace

period for treating the renewal continuous

for the purpose of gaining credit for pre-

existing diseases, time-bound exclusions

and for all waiting periods.

30. Room Rent

Room Rent means the amount charged

by a Hospital towards Room and Boarding

expenses and shall include the associated

medical expenses.

31. Surgery or Surgical Procedure

Surgery or Surgical Procedure means

manual and / or operative procedure

(s) required for treatment of an illness

or injury, correction of deformities and

defects, diagnosis and cure of diseases,

relief from suering and prolongation of

Tata AIG General Insurance Company Limited

Registered Oce: 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: TATHLGP21248V022021

Group MediCare - Base - Policy Wording

life, performed in a hospital or day care

centre by a medical practitioner.

32. Unproven/Experimental treatment

Unproven/Experimental treatment means

the treatment including drug experimental

therapy which is not based on established

medical practice in India, is treatment

experimental or unproven.

ii. Specic Denitions(Denitions other

than as mentioned under Section 1 (i)

above)

1. Age

Means the completed age of the Insured

Person on his / her most recent birthday

as per the English calendar, regardless of

the actual time of birth.

2. Room Category

Room Category shall mean one of the

following:

a. Single Private Room means a hospital

room with one patient bed and such

room must be the most economical

of all accommodations available in

that hospital as single occupancy.

b. Shared Accommodation means a

hospital room with two or more

patient beds.

c. Economy Ward means a hospital

room with more than three patient

beds.

This denition does not apply to ICU or

ICCU.

3. We/Us/Our means TATA AIG General

Insurance Company Limited.

4. You/Your/Yourself means the Policy

Holder and/or Insured Person(s) who is

named in the Policy Schedule.

5. Associated Medical Expenses

Associated Medical Expenses shall

include Room Rent, nursing charges,

operation theatre charges, fees of

Medical Practitioner/surgeon/ anesthetist/

Specialist conducted within the same

Hospital where the Insured Person has

been admitted.

6. Policyholder

The Policyholder shall be the Employer

who has taken the group insurance policy

as a service benet to his Employees or a

Group Manager of a homogeneous group

of persons who assemble together for a

commonality of purpose and there is a

clearly evident relationship between the

member and group manager for services

other than insurance.

Section 2: Benets (Base Covers)

The following benets are payable subject to

Terms and Conditions of the policy:

B1. In-Patient Treatment

We will cover for expenses for

hospitalization due to disease/illness/Injury

during the policy period that requires an

Insured Person’s admission in a hospital

as an inpatient.

Medical expenses directly related to

the hospitalization would be payable

provided:

i. Limit on Room Rent/Room

Category:

We will, limit Room Rent up to the

amount/percentage of Sum Insured

or room category as specified in

the Policy Schedule/ Certificate of

Insurance.

Tata AIG General Insurance Company Limited

Registered Oce: 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: TATHLGP21248V022021

Group MediCare - Base - Policy Wording

ii. Associated Medical Expenses:

a. If the Insured Person is admitted

in a room where the Room

Rent expenses incurred is

higher than limit specified in

the Policy Schedule/ Certicate

of Insurance, then the Insured

Person shall bear a rateable

proportion of the total

Associated Medical Expenses

(including surcharge or taxes

thereon), except pharmacy

charges, diagnostic costs,

costs of implants & medical

devices and consumables

expenses, in the proportion

of the dierence between the

eligible Room Rent expenses

to the Room Rent expenses

actually incurred. Proportionate

Expenses is applied in respect

of the Hospital which follow

dierential billing or for those

expenses in respect of which

differential billing is adopted

based on the Room Category.

b. If the Insured Person is admitted

in a hospital room where the

room category opted is higher

than the category specied in

the Policy Schedule/Certicate

of Insurance, then the Insured

Person shall bear 10% of

admissible claim amount

In case of unavailability of specied

room category, the Insured Person

is eligible for next immediate

available hospital room provided

that necessary documented proof for

unavailability of such hospital room

is furnished to us.

iii. Limit on Treatment / Illness/

Surgery/ Medical Condition

We will cover the Medical Expenses

incurred towards claim for a specied

treatment of an Illness/procedure

upto the amount of Sub-Limit

applicable per claim during the

Policy Year as specied in the Policy

Schedule/ Certicate of Insurance.

B2. Pre-Hospitalization expenses

We will cover the Pre-Hospitalization

expenses for consultations, investigations

and medicines incurred upto the number

of days as specied in your policy schedule/

Certicate of Insurance.

The benet is payable if We have admitted

a claim under In-patient Treatment/Day

Care Procedures/Domiciliary treatment.

B3. Post-Hospitalization expenses

We will cover the Post-Hospitalization

expenses for consultations, investigations

and medicines incurred upto the number of

days, as specied in your policy schedule/

Certicate of Insurance.

The benet is payable if We have admitted

a claim under In-patient Treatment/Day

Care Procedures /Domiciliary treatment.

B4. Day Care Procedures

We will cover expenses for listed Day Care

treatment due to disease/illness/Injury

during the policy period taken at a hospital

or a Day Care Centre. The list of such day

care procedures covered is available on

our website (www.tataaig.com).

This benefit under the policy will be

limited to the amount specified in the

Policy Schedule/ Certicate of Insurance.

Treatment normally taken on out-patient

basis is not included in the scope of this

cover.

Tata AIG General Insurance Company Limited

Registered Oce: 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: TATHLGP21248V022021

Group MediCare - Base - Policy Wording

B5. Domiciliary Treatment

We will cover for expenses related to

Domiciliary Hospitalization of the insured

person if the treatment exceeds beyond

three days. The treatment must be for

management of an illness and not for

enteral feedings or end of life care.

At the time of claiming under this benet,

we shall require certification from the

treating doctor fullling the conditions as

mentioned under the general denitions

(Section 1-10) of this policy.

This benet under the policy will be limited

to the amount specified in the Policy

Schedule/ Certicate of Insurance.

B6. Organ Donor

We will cover for Medical and surgical

Expenses of the organ donor for harvesting

the organ where an Insured Person is the

recipient provided that:

i. The organ donor is any person whose

organ has been made available

in accordance and in compliance

with The Transplantation of Human

Organs Act (Amended) , 1994 and

other applicable laws and rules and

the organ donated is for the use of

the Insured Person, and

ii. We have accepted an inpatient

Hospitalization claim for the

insured member under In-Patient

Hospitalization Treatment (section

B1).

This benet under the policy will be limited

to the amount specified in the Policy

Schedule/ Certicate of Insurance.

B7. Ambulance Cover

We will cover for expenses incurred on

transportation of Insured Person in a

registered ambulance to a Hospital for

admission in case of an Emergency or

from one hospital to another hospital for

better medical facilities and treatment,

subject to amount as specified on the

policy schedule/Certicate of Insurance.

For this claim to be paid, the claim must

be admissible under section In-patient

Treatment or Day Care Procedures of this

policy.

B8. Maternity Cover

We will cover for Maternity Expenses for

the delivery of a child and/or Maternity

Expenses related to a Medically Necessary

Treatment and lawful medical termination

of pregnancy, during the Policy Year,

subject to the Sub-Limits and maternity

waiting period as specied in the Policy

Schedule/ Certicate of Insurance. Medical

expenses incurred for resuscitation of

newborn baby shall form part of the

maternity sub imit.

We will not cover ectopic pregnancy under

this benet (although it shall be covered

under section In-patient Treatment).

Expenses incurred for pre/post natal care

shall be excluded from the scope of this

coverage.

B9. Pre/Post Natal Cover

We will cover for Medical Expenses

incurred during the Policy Year on out-

patient basis, in respect of pre- natal check-

ups, since confirmation of pregnancy,

post-natal check-ups for a period up to six

weeks from date of loss, prescribed pre-

natal medicines and diagnostic tests up to

the limit specied in the Policy Schedule/

Certicate of Insurance provided that:

i. This Benet is opted,

Tata AIG General Insurance Company Limited

Registered Oce: 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: TATHLGP21248V022021

Group MediCare - Base - Policy Wording

ii. The maternity claim is admissible by

Us under B8, and

iii. Date of delivery is within policy period

The sum insured applicable for pre/post

natal cover on out-patient basis shall be

part of Maternity limit.

We will not be liable to make any payment

in respect of any Pre-hospitalization

Expenses or Post – hospitalization

Expenses paid under the Base Cover.

B10. Baby day one Cover

We will cover for Medical Expenses

incurred during the Policy Year, towards

the Treatment of the New Born Baby from

the date of birth of baby up to the Sub

Limit, as specied in the Policy Schedule/

Certicate of Insurance, provided that You

have paid requisite premium for inclusion

of the newborn baby in to the policy.

New Born Baby older than 90 days can be

covered under the Policy as an Insured

Person only by way of an endorsement or

at the next Renewal, whichever is earlier,

on payment of the requisite premium.

B11. Family Transportation Benet

If We have accepted a claim under Benet

B1, then We will reimburse the actual

expenses incurred in transporting one

Immediate Family Member from the

Insured Person’s residence to the Hospital

where the Insured Person is admitted,

provided that such Hospital is located

at least 200 kms away from the Insured

Person’s residence up to the limit as

specied in the policy schedule/Certicate

of Insurance.

For the purpose of this benet, Immediate

Family Member means the Insured

Person’s legal spouse, children, parents,

parents-in-law, legal guardian, ward, step

child or adopted child.

Section 3 – Exclusions

i. Standard Exclusions

1. Exclusions with waiting period

i. Pre-Existing Diseases(Code- Excl 01)

shall be waived o

ii. Specied disease / procedure

Waiting period: (Code- Excl 02)shall

be waived o

iii. 30 days waiting (Code- Excl 03) shall

be waived o

2. Medical Exclusions

We will neither be liable nor make any

payment for any claim in respect of

any Insured Person which is caused by,

arising from or in any way attributable

to any of the following exclusions, unless

expressly stated to the contrary in this

Policy connection with or in respect of:

1. Investigation & Evaluation

(Code- Excl 04)

a) Expenses related to any

admission primarily for

diagnostics and evaluation

purposes only are excluded.

b) Any diagnostic expenses which

are not related or not incidental

to the current diagnosis and

treatment are excluded.

2. Rest Cure, rehabilitation and

respite care(Code- Excl 05)

Expenses related to any admission

primarily for enforced bed rest and

not for receiving treatment. This also

includes:

i. Custodial care either at home or

Tata AIG General Insurance Company Limited

Registered Oce: 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: TATHLGP21248V022021

Group MediCare - Base - Policy Wording

in a nursing facility for personal

care such as help with activities

of daily living such as bathing,

dressing, moving around either

by skilled nurses or assistant or

non-skilled persons.

ii. Any services for people who

are terminally ill to address

physical, social, emotional and

spiritual needs.

3. Obesity/ Weight Control (Code- Excl

06)

Expenses related to the surgical

treatment of obesity that does not

fulll all the below conditions:

1) Surgery to be conducted is upon

the advice of the Doctor

2) The surgery/Procedure

conducted should be supported

by clinical protocols

3) The member has to be 18 years

of age or older and

4) Body Mass Index (BMI);

a) greater than or equal to 40

b) greater than or equal to

35 in conjunction with any

of the following severe

co-morbidities following

failure of less invasive

methods of weight loss:

I. Obesity-related

cardiomyopathy

II. Coronary heart

disease

III. Severe Sleep Apnea

IV. Uncontrolled Type2

Diabetes

4. Change-of-Gender treatments:

(Code- Excl 07)

Expenses related to any treatment,

including surgical management, to

change characteristics of the body to

those of the opposite sex.

5. Cosmetic or plastic Surgery: (Code-

Excl 08)

Expenses for cosmetic or plastic

surgery or any treatment to change

appearance unless for reconstruction

following an Accident, Burn(s) or

Cancer or as part of medically

necessary treatment to remove a

direct and immediate health risk to

the insured. For this to be considered

a medical necessity, it must be

certified by the attending Medical

Practitioner.

6. Treatment for, Alcoholism, drug or

substance abuse or any addictive

condition and consequences thereof.

(Code- Excl 12)

7. Treatments received in heath

hydros, nature cure clinics, spas or

similar establishments or private

beds registered as a nursing home

attached to such establishments or

where admission is arranged wholly

or partly for domestic reasons.

(Code- Excl 13)

8. Dietary supplements and substances

that can be purchased without

prescription, including but not limited

to Vitamins, minerals and organic

substances unless prescribed by

a medical practitioner as part of

hospitalization claim or day care

procedure (Code- Excl 14)

Tata AIG General Insurance Company Limited

Registered Oce: 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: TATHLGP21248V022021

Group MediCare - Base - Policy Wording

9. Refractive Error: (Code- Excl 15)

Expenses related to the treatment

for correction of eye sight due to

refractive error less than 7.5 dioptres.

10. Unproven Treatments: (Code- Excl

16)

Expenses related to any unproven

treatment, services and supplies for

or in connection with any treatment.

Unproven treatments are treatments,

procedures or supplies that lack

signicant medical documentation

to support their eectiveness.

11. Sterility and Infertility: (Code-

Excl 17)

Expenses related to sterility and

infertility. This includes:

i. Any type of contraception,

sterilization

ii. Assisted Reproduction services

including articial insemination

and advanced reproductive

technologies such as IVF, ZIFT,

GIFT, ICSI

iii. Gestational Surrogacy

iv. Reversal of sterilization

12. Maternity (Code - Excl 18):

i. Medical treatment expenses

traceable to childbirth (including

complicated deliveries and

caesarean sections incurred

during hospitalization) except

ectopic pregnancy;

ii. expenses towards miscarriage

(unless due to an accident) and lawful

medical termination of pregnancy

during the policy period.

3. Non-Medical Exclusions

i. Hazardous or Adventure Sports

(Code Excl09) : Expenses related

to any treatment necessitated due

to participation as a professional

in hazardous or adventure

sports, including but not limited

to, para-jumping, rock climbing,

mountaineering, rafting, motor

racing, horse racing or scuba diving,

hand gliding, sky diving, deep-sea

diving

ii. Breach of law (Code Excl10): Expenses

for treatment directly arising from or

consequent upon any Insured Person

committing or attempting to commit

a breach of law with criminal intent.

iii. Expenses incurred towards treatment

in any hospital or by any Medical

Practitioner or any other provider

specically excluded by the Insurer

and disclosed in its website /

notied to the policyholders are not

admissible. However, in case of life

threatening situations or following an

accident, expenses up to the stage of

stabilization are payable but not the

complete claim (Code – Excl11)

ii. Specific Exclusions (Exclusions other

than as mentioned under Section 3 (i)

above)

1. Exclusions with waiting periods

i. Nine months maternity waiting

period shall be waived o

2. Medical Exclusions

i. Congenital External Diseases, defects

or anomalies.

ii. Stem cell therapy, however

Tata AIG General Insurance Company Limited

Registered Oce: 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: TATHLGP21248V022021

Group MediCare - Base - Policy Wording

Hematopoietic stem cells for bone

marrow transplant for haematological

conditions will be covered under

Benet B1 and B4 of this Policy.

iii. Growth hormone therapy.

iv. Sleep-apnoea.

v. Admission primarily for

administration of Intra-articular

or intra-lesional injections or

Intravenous immunoglobulin infusion

or supplementary medications like

Zolendronic Acid.

vi. Venereal disease, sexually

transmitted disease or illness.

vii. All preventive care, vaccination

including inoculation and

immunisations (except in case of

post- bite treatment and other

vaccines explicitly covered).

viii. Dental treatment or surgery of

any kind unless as a result of

Illness/Accidental Bodily Injury to

natural teeth and also requiring

hospitalization.

ix. Any non-allopathic treatment.

3. Non-Medical Exclusions

i. War or any act of war, invasion, act

of foreign enemy, war like operations

(whether war be declared or notor

caused during service in the armed

forces of any country),, civil war,

public defence, rebellion, revolution,

insurrection, military or usurped acts,

nuclear weapons/materials, chemical

and biological weapons, ionising

radiation.

ii. Any Insured Person’s participation or

involvement in naval, military or air

force operation.

iii. Intentional self-injury or attempted

suicide while sane or insane.

iv. Items of personal comfort and

convenience like television (wherever

specically charged for), charges for

access to telephone and telephone

calls, internet, foodstuffs (except

patient’s diet), cosmetics, hygiene

articles, body care products and bath

additive, barber or beauty service,

guest service.

v. Treatment rendered by a Medical

Practitioner which is outside his

discipline

vi. Doctor’s fees charged by the Medical

Practitioner sharing the same

residence as an Insured Person or

who is an immediate relative of an

Insured Person’s family.

vii. Provision or tting of hearing aids,

spectacles or contact lenses including

optometric therapy unless explicitly

stated and covered in the policy.

viii. Any treatment and associated

expenses for alopecia, baldness,

wigs, or toupees, medical supplies

including elastic stockings, diabetic

test strips, and similar products.

ix. Any treatment or part of a treatment

that is not of a reasonable charge,

not medically necessary; drugs or

treatments which are not supported

by a prescription.

x. Crutches or any other external

Tata AIG General Insurance Company Limited

Registered Oce: 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: TATHLGP21248V022021

Group MediCare - Base - Policy Wording

appliance and/or device used for

diagnosis or treatment (except when

used intra-operatively and explicitly

stated and covered in the policy.

xi. Any claim incurred after date of

proposal/enrolment form and before

issuance of policy/Certificate of

Insurance where there is change in

health status of the member and the

same is not communicated to us.

Section 4 – General Terms and Clauses

i. Standard General Terms & Clauses

1. Condition Precedent to Admission of

Liability

The terms and conditions of the policy

must be fullled by the Insured Person

for the Company to make any payment for

claim(s) arising under the Policy.

2. Disclosure of Information

The policy shall be void and all premium paid

thereon shall be forfeited to the Company

in the event of mis-representation, mis-

description or non-disclosure of any

material fact by the Policyholder

(Explanation: “Material facts” for the

purpose of this policy shall mean all

relevant information sought by the

company in the proposal form and other

connected documents to enable it to

take informed decision in the context of

underwriting the risk)

3. Fraud

If any claim made by the Insured Person,

is in any respect fraudulent, or if any false

statement, or declaration is made or used

in support thereof, or if any fraudulent

means or devices are used by the Insured

Person or anyone acting on his/her behalf

to obtain any benet under this policy, all

benets under this policy and the premium

paid shall be forfeited.

Any amount already paid against claims

made under this Policy but which are

found fraudulent later shall be repaid by all

recipient (s)/ Policyholder(s), who has made

that particular claim, who shall be jointly

and severally liable for such repayment to

the Insurer.

For the purpose of this clause, the

expression “fraud” means any of the

following acts committed by the insured

person or by his agent or the Hospital /

Doctor, any other party acting on behalf of

the Insured Person with intent to deceive

the insurer or to induce the insurer to issue

an insurance policy:

a) the suggestion, as a fact of that which

is not true and which the insured

person does not believe to be true;

b) the active concealment of a fact by the

insured person having knowledge or

belief of the fact;

c) any other act tted to deceive; and

d) any such act or omission as the law

specially declares to be fraudulent

The Company shall not repudiate the

claim and / or forfeit the policy benets

on the ground of Fraud, if the insured

person / beneciary can prove that the

misstatement was true to the best of his

knowledge and there was no deliberate

intention to suppress the fact or that

such mis-statement of or suppression of

material fact are within the knowledge of

the insurer.

4. Multiple Policies

Tata AIG General Insurance Company Limited

Registered Oce: 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: TATHLGP21248V022021

Group MediCare - Base - Policy Wording

i. In case of multiple policies taken by an

insured person during a period from

one or more insurers to indemnify

treatment costs, the insured person

shall have the right to require a

settlement of his/her claim in terms

of any of his/her policies. In all such

cases the insurer chosen by the

Insured Person shall be obliged to

settle the claim as long as the claim

is within the limits of and according

to the terms of the chosen Policy.

ii. Insured person having multiple

policies shall also have the right to

prefer claims under this policy for

the amounts disallowed under any

other policy / policies even if the sum

insured is not exhausted. Then the

Insurer shall independently settle

the claim subject to the terms and

conditions of this Policy.

iii. If the amount to be claimed exceeds

the sum insured under a single Policy,

the Insured person shall have the

right to choose insurer from whom

he/she wants to claim the balance

amount.

iv. Where an insured person has policies

from more than one insurer to cover

the same risk on indemnity basis,

the insured person shall only be

indemnied the hospitalization costs

in accordance with the terms and

conditions of the chosen Policy.

5. Renewal of Policy

The Policy shall ordinarily be

renewable except on grounds of fraud,

misrepresentation by the insured person.

i. The Company shall endeavor to give

notice for renewal. However, the

Company is not under obligation to

give any notice for renewal.

ii. Renewal shall not be denied on the

ground that the insured had made a

claim or claims in the preceding policy

years.

iii. Request for renewal along with

requisite premium shall be received

by the Company before the end of

the policy period.

iv. At the end of the policy period, the

policy shall terminate and can be

renewed within the Grace Period

of 30 days to maintain continuity

of benets without Break in Policy.

Coverage is not available during the

grace period.

v. No loading shall apply on renewals

based on individual claims

experience.

6. Possibility of Revision of Terms of the

Policy Including the Premium Rates

The Company, with prior approval of

IRDAI, may revise or modify the terms of

the Policy including the premium rates.

The Insured Person shall be notied three

months before the changes are eected.

7. Migration

The insured person will have the option

to migrate the policy to other health

insurance products/plans oered by the

company policy by applying for migration

of the policy atleast 30 days before the

policy renewal date as per IRDAI guidelines

on Migration. If such person is presently

covered and has been continuously

covered without any lapses under any

health insurance product/plan oered by

the company, the insured person will get

Tata AIG General Insurance Company Limited

Registered Oce: 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: TATHLGP21248V022021

Group MediCare - Base - Policy Wording

the accrued continuity benets in waiting periods as per IRDAI guidelines on Migration.

For Detailed Guidelines on Migration, kindly refer Guidelines issued by IRDAI(Insurance

Regulatory and Development Authority of India) on Migration and Portability of Health

Insurance policies – Ref: IRDAI/HLT/REG/CIR/194/07/2020) dated 22nd July 2020 and subsequent

amendments thereof.

8. Withdrawal of Policy

i. In the likelihood of this product being withdrawn in future, the Company will intimate

the Insured Person about the same 90 days prior to expiry of the Policy.

ii. Insured Person will have the option to migrate to similar health insurance product available

with the Company at the time of renewal with all the accrued continuity benets such as

cumulative bonus, waiver of waiting period as per IRDAI guidelines provided the Policy

has been maintained without a break.

9. Cancellation

i. The Policyholder may cancel this policy by giving 15 days written notice and in such

an event, the Company shall refund premium for the unexpired policy period as

detailed below.

Notwithstanding anything contained herein or otherwise, no refunds of premium shall be made in

respect of Cancellation where, any claim has been admitted or has been lodged or any Benet has

been availed by the Insured Person under the Policy.

ii. The Company may cancel the Policy at any time on grounds of mis-representation, non-

disclosure of material facts, fraud by the Insured Person by giving 15 days written notice.

There would be no refund of premium on cancellation on grounds of mis-representation,

non-disclosure of material facts or fraud.

Short Rate Table:

Year

Length of time Policy in force 1 2 3 4 5

Upto 1 Month 85.00% 87.50% 91.50% 96% 98%

>1 month & Upto 3 Months 70.00% 75.00% 88.50% 93% 95%

>3 months & Upto 6 Months 50.00% 62.50% 75% 78% 80%

>6 months & Upto 12 Months Nil 50.00% 66.50% 70% 72%

>12 months & Upto 15 Months Not Applicable 30% 50% 52% 54%

>15 months & Upto 18 Months Not Applicable 20% 41.50% 43% 44%

>18 months & Upto 24 months Not Applicable Nil 33% 35% 36%

>24 months & Upto 30 months Not Applicable Not Applicable 15% 20% 30%

> 30 months & Up to 36 months Not Applicable Not Applicable Nil 15% 25%

> 36 months & up to 42 Not Applicable Not Applicable Not Applicable Nil 20%

Exceeding 42 months Not Applicable Not Applicable Not Applicable Nil Nil

Tata AIG General Insurance Company Limited

Registered Oce: 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: TATHLGP21248V022021

Group MediCare - Base - Policy Wording

10. Free look period

The Free Look Period shall be applicable

on new individual health insurance policies

and not on renewals or at the time of

porting/migrating the policy.

The insured person shall be allowed free

look period of fteen days from date of

receipt of the policy document to review

the terms and conditions of the policy, and

to return the same if not acceptable.

If the insured has not made any claim

during the Free Look Period, the insured

shall be entitled to

i. a refund of the premium paid

less any expenses incurred by the

Company on medical examination

of the insured person and the stamp

duty charges or

ii. where the risk has already

commenced and the option of return

of the policy is exercised by the

insured person, a deduction towards

the proportionate risk premium for

period of cover or

iii. Where only a part of the insurance

coverage has commenced,

such proportionate premium

commensurate with the insurance

coverage during such period

11. Nomination:

The Policyholder is required at the inception

of the Policy to make a nomination for

the purpose of payment of claims under

the Policy in the event of death of the

Policyholder. Any change of nomination

shall be communicated to the company in

writing and such change shall be eective

only when an endorsement on the Policy

is made. In the event of death of the

Policyholder, the Company will pay the

nominee {as named in the Policy Schedule/

Policy Certicate/Endorsement (if any)} and

in case there is no subsisting nominee, to

the legal heirs or legal representatives of

the Policyholder whose discharge shall be

treated as full and nal discharge of its

liability under the Policy.

12. Claim settlement (provision of Penal

Interest)

i. The Company shall settle or reject a

claim, as the case may be, within 30

days from the date of receipt of last

necessary document.

ii. ln the case of delay in the payment of

a claim, the Company shall be liable

to pay interest to the policyholder

from the date of receipt of last

necessary document to the date of

payment of claim at a rate 2% above

the bank rate.

iii. However, where the circumstances

of a claim warrant an investigation

in the opinion of the Company, it

shall initiate and complete such

investigation at the earliest, in any

case not later than 30 days from

the date of receipt of last necessary

document- ln such cases, the

Company shall settle or reject the

claim within 45 days from the date of

receipt of last necessary document.

iv. ln case of delay beyond stipulated

45 days, the Company shall be liable

to pay interest to the policyholder at

a rate 2% above the bank rate from

the date of receipt of last necessary

Tata AIG General Insurance Company Limited

Registered Oce: 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: TATHLGP21248V022021

Group MediCare - Base - Policy Wording

document to the date of payment of

claim.

(“Bank rate” shall mean the rate xed

by the Reserve Bank of lndia (RBl) at

the beginning of the nancial year in

which claim has fallen due)

13. Complete Discharge

Any payment to the Policyholder, Insured

Person or his/ her nominees or his/ her

legal representative or assignee or to

the Hospital, as the case may be, for any

benet under the policy shall be a valid

discharge towards payment of claim by the

Company to the extent of that amount for

the particular claim.

14. Redressal of Grievance

In case of any grievance the Insured Person

may contact through

Website: www.tataaig.com

Call us 24x7 toll free helpline 1800 266 7780

or 1800 22 9966 (Senior Citizen) Email us

at [email protected]

Courier: Customer Support, Tata AIG

General Insurance Company Limited,

and 8

Floor, Romell Tech Park, Cama

Industrial Estate, Western Express Highway,

Goregaon(E), Mumbai, Maharashtra 400063

Visit the Servicing Branch mentioned in the

policy document

The insured person may also approach

the grievance cell at any of the Company’s

branches with details of grievance.

lf lnsured person is not satisfied with

the redressal of grievance through one

of the above methods, Insured person

may contact the grievance officer at

[email protected].

For updated details of grievance ocer,

kindly refer the link (https://www.tataaig.

com/grievance-redressal-policy)

lf lnsured person is not satisfied with

the redressal of grievance through

above methods, the Insured Person may

also approach the office of lnsurance

Ombudsman of the respective area/region

for redressal of grievance as per lnsurance

Ombudsman Rules 2017. Grievance

may also be lodged at IRDAI lntegrated

Grievance Management System - https://

igms. irda.gov.in/

15. Moratorium Period

After completion of eight continuous

years under this policy no look back

would be applied. This period of eight

years is called as moratorium period.

The moratorium would be applicable

for the sums insured of the rst policy

and subsequently completion of eight

continuous years would be applicable from

date of enhancement of sums insured only

on the enhanced limits. After the expiry of

Moratorium Period no health insurance

claim shall be contestable except for

proven fraud and permanent exclusions

specied in the policy contract. The policies

would however be subject to all limits, Sub

limits, co-payments, deductibles as per the

policy contract.

ii. Specic terms and clauses (terms and

clauses other than those mentioned

under Section 4 (i) above)

16. Condition Precedent

i. The premium for the policy will

remain the same for the policy period

as mentioned in the policy schedule.

ii. No change in this Policy shall be valid

unless a valid endorsement is passed

in the policy.

iii. In case of master policy, the policy

period would be 1 year however the

period of certificate of insurance

would be from 1 year to 5 years (in

Tata AIG General Insurance Company Limited

Registered Oce: 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: TATHLGP21248V022021

Group MediCare - Base - Policy Wording

case of credit linked). Details of the

policy term applicable to individual

certificate of insurance would be

clearly stated in Your certicate of

insurance.

17. Insured Person

i. Only those persons named as

an Insured Person in the Policy

Schedule/Certificate of insurance

shall be covered under this Policy.

ii. Mid-term addition of Primary Insured

and Dependents:

Mid-term addition of Primary insured and

dependents shall be allowed in the event

of following:

1. Intimation is given to Us by a dened

& agreed date and shall be subject

to Guidelines on Group Insurance

Policies, dated 14th July 2005

issued by Insurance Regulatory and

Development Authority of India and

any subsequent amendments as

published from time to time

2. Requisite premium has been paid to

Us.

3. All existing dependents must be

covered along with the Primary

Insured and the addition of

Dependents shall be allowed only in

the event of:

• Children in the event of

childbirth

• Spouse in the event of marriage

If any of the conditions (1) &

(2) above are not met, coverage

will commence only from the date

of intimation to Us or premium

remittance whichever is later.

iii. Mid-term deletion of Primary Insured

and Dependents:

a. In case of Employer-Employee

Policies:

• The coverage for existing

Primary Insured and

his dependents will

automatically expire

from date of cessation of

employment.

• Pro-rata refund of

premium would be made

on intimation provided

such intimation is made

by a defined date and

no claim is made by the

Primary Insured or his

dependents.

b. In case of non Employer-

Employee Policies, the coverage

shall automatically expire from

the date the insured person

exits the scheme.

c. In case of refund of premium

being generated on the

Policy due to deletion of

Insured Persons, the same

will be refunded or adjusted

accordingly against the future

premium installments due on

the Policy.

18. Entire Contract

i. This Policy, its Schedule,

endorsement(s), proposal/enrolment

form constitutes the entire contract

of insurance. No change in this policy

shall be valid unless approved by

Us and such approval be endorsed

hereon.

ii. This Policy and the Policy Schedule/

Certificate of insurance shall be

read together as one contract and

any word or expression to which a

specic meaning has been attached

in any part of this Policy or of the

Tata AIG General Insurance Company Limited

Registered Oce: 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: TATHLGP21248V022021

Group MediCare - Base - Policy Wording

Schedule shall bear such meaning

wherever it may appear.

19. Notices

i. Any notice, direction or instruction

under this Policy shall be in writing

and if it is to:

a. Any Insured Person, then it shall

be sent to You at Your address

specified in the Schedule to

this Policy and You shall act for

all Insured Person(s) for these

purposes.

b. Us, it shall be delivered to

Our address specified in the

Schedule to this Policy. No

insurance agents, brokers

or other person or entity is

authorised to receive any

notice, direction or instruction

on Our behalf unless We have

expressly stated to the contrary

in writing.

20. Termination

i. You may terminate this Policy /

Certicate of Insurance at any time

by giving Us written notice, and the

Policy/Certicate of Insurance shall

terminate when such written notice

is received.

In case of master policy, each

Certificate of Insurance will get

terminated on the earliest of the

following dates:

a. The date You or We cancel the

Certicate of Insurance

b. The member opts out of the

scheme

c. Foreclosure/closure of loan

availed (wherever applicable)\

Section 5 – Claims Procedure and Claims

Payment

This section explains about the procedures

involved to file a valid claim by the insured

member and processes related in managing

the claim by TPA or Us. All the procedures and

processes such as notication of claim, availing

cashless service, supporting claim documents

and related claim terms of payment are

explained in this section.

1. Notication of Claim

Treatment,

Consultation or

Procedure:

We or Our

TPA* must be

informed:

1 If any treatment

for which a claim

may be made and

that treatment

requires planned

Hospitalisation:

At least 48 hours

prior to the

Insured Person’s

admission.

2 If any treatment

for which a claim

may be made and

that treatment

requires

emergency

Hospitalisation

Within 24

hours of the

Insured Person’s

admission to

Hospital.

Failure to furnish such intimation within

the time required shall not invalidate nor

reduce any claim if You can satisfy us that

it was not reasonably possible for You to

give proof of such delay within such time.

The Company may relax these timelines

only in special circumstances and for

the reasons beyond the control of the

insured.

*TPA as mentioned in the policy schedule

3. Procedure for Cashless Service

Tata AIG General Insurance Company Limited

Registered Oce: 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: TATHLGP21248V022021

Group MediCare - Base - Policy Wording

2. Cashless Service

Treatment,

Consultation or

Procedure:

Treatment,

Consultation or

Procedure Taken at:

Cashless Service is

Available:

We must be given

notice that the Insured

Person wishes to

take advantage of

the cashless service

accompanied by full

particulars:

If any planned

treatment,

consultation or

procedure for which

a claim may be made:

Network Hospital We will provide

cashless service by

making payment to

the extent of Our

liability directly to the

Network Hospital.

At least 48 hours

before the planned

treatment or

Hospitalisation

If any treatment,

consultation or

procedure for which

a claim may be made,

requiring emergency

hospitalisation

Network Hospital We will provide

cashless service by

making payment to

the extent of Our

liability directly to the

Network Hospital.

Within 24 hours after

the treatment or

Hospitalisation

i. Cashless Service is only available at Network Hospitals.

ii. In order to avail cashless treatment, the following procedure must be followed by You:

a. Prior to taking treatment and/

or incurring Medical Expenses

at a Network Hospital, You must

call our designated TPA/Us and

request pre-authorization.

b. For any emergency

Hospitalization, our designated

TPA/We must be informed

no later than 24 hours of the

start of Your hospitalization/

treatment.

c. For any planned

hospitalization, our designated

TPA/We must be informed

atleast 48 hours prior to the

start of your hospitalization/

treatment.

d. Our designated TPA/We will

check your coverage as per

the eligibility and send an

authorization letter to the

provider. You have to provide

the ID card issued to You along

with any other information

or documentation that is

requested by the TPA/Us to

the Network Hospital.

e. In case of deficiency in the

documents sent to TPA/Us for

cashless authorization, the

same shall be communicated

to the hospital by TPA/Us

Tata AIG General Insurance Company Limited

Registered Oce: 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: TATHLGP21248V022021

Group MediCare - Base - Policy Wording

within 6 hours of receipt of the

documents.

f. In case the ailment /treatment

is not covered under the policy

or cashless is rejected due

to insufficient documents

submitted, a rejection letter

would be sent to the hospital

within 6 hours.

g. Rejection of cashless in no way

indicates rejection of the claim.

You are required to submit

the claim along with required

documents for us to decide on

the admissibility of the claim.

h. If the cashless is approved,

the original bills and evidence

of treatment in respect of the

same shall be left with the

Network Hospital.

i. Pre-authorization does not

guarantee that all costs and

expenses will be covered. We

reserve the right to review each

claim for Medical Expenses and

accordingly coverage will be

determined according to the

terms and conditions of this

Policy.

4. Supporting Documentation &

Examination

i. You or someone claiming on

Your behalf shall provide Us with

documentation, medical records

and information We or Our TPA

may request to establish the

circumstances of the claim, its

quantum or Our liability for the

claim within 15 days or earlier of

Our request or the Insured Person’s

discharge from Hospitalisation or

completion of treatment.

ii. Failure to furnish such evidence

within the time required shall not

invalidate nor reduce any claim if

you can satisfy us that it was not

reasonably possible for you to give

proof within such time.

iii. We may accept claims where

documents have been provided

after a delayed interval only in special

circumstances and for the reasons

beyond the control of the Insured

Person.

iv. Such documentation will include

the following:

a. Our claim form, duly completed

and signed for on behalf of

the Insured Person. We, upon

receipt of a notice of claim, will

furnish Your representative

with such forms as We may

require for ling proofs of loss

or you may download the claim

form from our Web site.

b. Original Bills (pharmacy

purchase bill, consultation

bill, diagnostic bill) and any

attachments thereto like

receipts or prescriptions in

support of any amount claimed

which will then become Our

property.

c. All medical reports, case

histories, investigation reports,

indoor case papers/ treatment

Tata AIG General Insurance Company Limited

Registered Oce: 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: TATHLGP21248V022021

Group MediCare - Base - Policy Wording

papers (in reimbursement

cases, if available), discharge

summaries.

d. A precise diagnosis of the

treatment for which a claim is

made.

e. A detailed list of the individual

medical services and treatments

provided and a unit price for

each in case not available in the

submitted hospital bill.

f. Prescriptions that name the

Insured Person and in the

case of drugs: the drugs

prescribed, their price and a

receipt for payment. In case of

pre/post hospitalization claim

Prescriptions must be submitted

with the corresponding Doctor/

hospital invoice.

g. All pre and post investigation,

treatment and follow up

(consultation) records

pertaining to the present

ailment for which claim is being

made, if and where applicable.

h. Treating doctor’s certificate

regarding missing information

in case histories e.g.

Circumstance of injury and

Alcohol or drug inuence at the

time of accident, if available

i. Copy of settlement letter from

other insurance company or

TPA

j. Stickers and invoice of implants

used during surgery

k. Copy of MLC (Medico legal case)

records, if carried out and FIR

(First information report) if

registered, in case of claims

arising out of an accident and

available with the claimant.

l. Regulatory requirements as

amended from time to time,

currently mandatory NEFT (to

enable direct credit of claim

amount in bank account) and

KYC (recent ID/Address proof

and photograph) requirements

m. Legal heir/succession certicate,

if required

n. PM report (wherever applicable

and conducted)

v. Note: In case You are claiming for

the same event under an indemnity

based policy of another insurer and

are required to submit the original

documents related to Your treatment

with that particular insurer, then You

may provide Us with the attested

copies of such documents along with

a declaration from the particular

insurer specifying the availability of

the original copies of the specied

treatment documents with it.

We at our own expense, shall

have the right and opportunity to

examine Insured Person(s) through

Our Authorised Medical Practitioner

whose details will be notified to

Insured Person when and as often

as We may reasonably require

during the pendency of a claim

hereunder.

Tata AIG General Insurance Company Limited

Registered Oce: 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: TATHLGP21248V022021

Group MediCare - Base - Policy Wording

5. Claims Payment

i. We shall be under no obligation to

make any payment under this Policy

unless We have received all premium

payments in full and on time and

We have been provided with the

documentation and information

We or Our TPA has requested to

establish the circumstances of the

claim, its quantum or Our liability for

it, and unless the Insured Person has

complied with his obligations under

this Policy.

ii. All claims will be settled in

accordance with the applicable

regulatory guidelines, including IRDAI

(Protection of Policyholders Interests

Regulation), 2017.

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 dierence shall arise as

to the quantum to be paid by the Policy,

(liability being otherwise admitted) such

dierence 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

arbitration, the same shall be referred to a

panel of three arbitrators, comprising two

arbitrators, one to be appointed by each

of the parties to the dispute/dierence

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, as amended by

Arbitration and Conciliation (Amendment)

Act, 2015 (No. 3 of 2016).

It is clearly agreed and understood that no

dierence or dispute shall be preferable

to arbitration as herein before provided, if

the Company has disputed or not accepted

liability under or in respect of the policy.

It is hereby expressly stipulated and

declared that it shall be a condition

precedent to any right of action or suit

upon the policy that award by such

arbitrator/arbitrators of the amount of

expenses shall be rst obtained.

Tata AIG General Insurance Company Limited

Registered Oce: 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: TATHLGP21248V022021

Group MediCare - Base - Policy Wording

List of Insurance Ombudsman

SN Centre Address & Contact

1 Ahmedabad

Oce of the Insurance Ombudsman, Jeevan Prakash Building, 6th

oor, Tilak Marg, Relief Road, Ahmedabad – 380 001.

Tel.: 079 - 25501201/02/05/06

Email: [email protected]

2 Bengaluru

Oce 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: [email protected]

3 Bhopal

Oce of the Insurance Ombudsman, Janak Vihar Complex,

2nd Floor, 6, Malviya Nagar, Opp. Airtel Oce,

Near New Market, Bhopal – 462 003.

Tel.: 0755 - 2769201 / 2769202

Email: [email protected]

4 Bhubaneswar

Oce of the Insurance Ombudsman, 62, Forest park,

Bhubaneswar – 751 009.

Tel.: 0674 - 2596461 /2596455

Email: [email protected]

5 Chandigarh

Oce of the Insurance Ombudsman, S.C.O. No. 101,

102 & 103, 2nd Floor, Batra Building, Sector 17 – D,

Chandigarh – 160 017.

Tel.: 0172 - 2706196 / 2706468

Email: [email protected]

6 Chennai

Oce of the Insurance Ombudsman, Fatima Akhtar Court,

4th Floor, 453, Anna Salai, Teynampet, CHENNAI – 600 018.

Tel.: 044 - 24333668 / 24335284

Email: [email protected]

7 New Delhi

Oce of the Insurance Ombudsman, 2/2 A, Universal Insurance

Building, Asaf Ali Road, New Delhi – 110 002.

Tel.: 011 - 23232481/23213504

Email: [email protected]

8 Guwahati

Oce of the Insurance Ombudsman, Jeevan Nivesh, 5th Floor,

Nr. Panbazar over bridge, S.S. Road, Guwahati – 781001(ASSAM).

Tel.: 0361 - 2632204 / 2602205

Email: [email protected]

Tata AIG General Insurance Company Limited

Registered Oce: 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: TATHLGP21248V022021

Group MediCare - Base - Policy Wording

SN Centre Address & Contact

9 Hyderabad

Oce of the Insurance Ombudsman, 6-2-46, 1st oor, “Moin Court”,

Lane Opp. Saleem Function Palace, A. C. Guards,

Lakdi-Ka-Pool, Hyderabad - 500 004.

Tel.: 040 - 23312122

Email: [email protected]

10 Jaipur

Oce of the Insurance Ombudsman, Jeevan Nidhi – II Bldg.,

Gr. Floor, Bhawani Singh Marg, Jaipur - 302 005.

Tel.: 0141 - 2740363

Email: [email protected]

11 Ernakulam

Oce of the Insurance Ombudsman, 2nd Floor, Pulinat Bldg.,

Opp. Cochin Shipyard, M. G. Road, Ernakulam - 682 015.

Tel.: 0484 - 2358759 / 2359338

Email: [email protected]

12 Kolkata

Oce of the Insurance Ombudsman, Hindustan Bldg. Annexe,

7th Floor, 4, C.R. Avenue, KOLKATA - 700 072.

Tel.: 033 - 22124339 / 22124340

Email: [email protected]

13 Lucknow

Oce of the Insurance Ombudsman, 6th Floor, Jeevan Bhawan,

Phase-II, Nawal Kishore Road, Hazratganj, Lucknow - 226 001.

Tel.: 0522 - 2231330 / 2231331

Email: [email protected]

14 Mumbai

Oce of the Insurance Ombudsman, 3rd Floor, Jeevan Seva Annexe,

S. V. Road, Santacruz (W), Mumbai - 400 054.

Tel.: 69038821/23/24/25/26/ 27/28/28/29/30/31

Email: [email protected]

15 Noida

Oce of the Insurance Ombudsman, Bhagwan Sahai Palace

4th Floor, Main Road, Naya Bans, Sector 15,

Distt: Gautam Buddh Nagar, U.P-201301.

Tel.: 0120-2514252 / 2514253

Email: [email protected]

16 Patna

Oce of the Insurance Ombudsman, 2nd Floor, North wing,

Lalit Bhawan, Bailey Road, Patna 800 001.

Tel.: 0612-2547068

Email: [email protected]

Tata AIG General Insurance Company Limited

Registered Oce: 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: TATHLGP21248V022021

Group MediCare - Base - Policy Wording

SN Centre Address & Contact

17 Pune

Oce of the Insurance Ombudsman, Jeevan Darshan Bldg.,

3rd Floor, C.T.S. No.s. 195 to 198, N.C. Kelkar Road,

Narayan Peth, Pune – 411 030.

Tel.: 020-41312555

Email: [email protected]

For updated list and details of Insurance

Ombudsman Oces, please visit website http://

www.cioins.co.in/ombudsman.html

Prohibition of Rebates - Section 41 of the

Insurance Act, 1938 as amended by Insurance

Laws (Amendment) Act, 2015.

1. No person shall allow or oer to allow,

either directly or indirectly, as an

inducement to any person to take out

or renew or continue an insurance in

respect of any kind of risk relating to lives

or property in India, any rebate of the

whole or part of the commission payable

or any rebate of the premium shown on

the Policy, nor shall any person taking out

or renewing or continuing a Policy accept

any rebate, except such rebate as may be

allowed in accordance with the published

prospectuses or tables of the insurer.

2. Any person making default in complying

with the provisions of this section shall be

liable for a penalty which may extend to

ten lakh rupees.

Insurance is the subject matter of the solicitation”.

Please read the Policy wordings carefully before

concluding the sale.