THE NEW INDIA ASSURANCE CO.

LTD
Regd. & Head Office: 87, M.G. Road, Fort, Mumbai – 400 001

NEW INDIA FLEXI FLOATER GROUP MEDICLAIM POLICY

(For IDBI Bank Account Holders)

1.0 Whereas 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 THE NEW INDIA ASSURANCE CO. LTD. (hereinafter called the COMPANY) for the
insurance herein after set forth in respect of Employees/Members (including their eligible Family
Members) named in the Schedule hereto (herein after called the INSURED PERSON) and has paid
premium as consideration for such insurance.

2.0 NOW THIS POLICY WITNESSES that subject to the terms, conditions, exclusions and definitions
contained herein or endorsed or otherwise expressed here on 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 Illness (herein defined) or sustain any Injury (herein defined) and
if such Injury shall require any such Insured Person, upon the advice of a duly qualified Medical
practitioner (herein defined) or a surgeon to incur Medical Expenses/Surgery at any Hospital / Day
Care Center (herein defined) in India as an Inpatient, the Company will pay to the Insured Person
the amount of such expenses as good fall under different heads mentioned below, and as are
Reasonably and Customarily, and Medically Necessarily incurred thereof by or on behalf of such
Insured Person.

2.1 Room, Boarding Expenses as provided by the hospital including Nursing charges, not exceeding
1% of Sum Insured per day.

2.2 Intensive Care Unit (ICU) / Intensive Cardiac Care Unit (ICCU) expenses, not exceeding 2% of the
sum insured per day.

2.3 Surgeon, Anesthetist, Medical Practitioner, Consultants, Specialists Fees.

2.4 Anesthesia, Blood, Oxygen, Operation Theatre Charges, Surgical Appliances, Medicines & Drugs,
Diagnostic Materials and X-ray, Dialysis, Chemotherapy, Radiotherapy, Cost of Pacemaker, Artificial
Limbs & Cost of Organs and similar expenses.

2.5 Pre-hospitalization medical charges up to 30 days period.

2.6 Post-hospitalization medical charges up to 60 days period.

NOTE: SUB-LIMIT CLAUSE

1. The amounts payable under 2.3 and 2.4 shall be at the rate applicable to the entitled room
category. In case of admission to a room/ICU/ICCU at rates exceeding the limits as mentioned
under 2.1 and 2.2, the reimbursement/payment of all other expenses incurred at the Hospital, with
the exception of cost of medicines, shall be affected in the same proportion as the admissible rate
per day bears to the actual rate per day of room rent/ICU/ICCU charges.

2. No payment shall be made under 2.3 other than as part of the hospitalization bill.
 2

3. However, the bills raised by Surgeon, Anesthetist directly and not included in the hospitalization
bill may be reimbursed in the following manner:

a. The reasonable, customary and Medically Necessary Surgeon fee and Anesthetist fee would
be reimbursed, limited to the maximum of 25% of Sum Insured. The payment shall be
reimbursed provided the insured pays such fee(s) through cheque and the Surgeon /
Anesthetist provides a numbered bill. Bills given on letter-head of the Surgeon, Anesthetist
would not be entertained.
b. Fees paid in cash will be reimbursed up to a limit of Rs. 10,000/- only, provided the
Surgeon/Anesthetist provides a numbered bill.

(N.B: Company’s Liability in respect of all claims admitted during the period of insurance shall not exceed the
Sum Insured per person mentioned in the schedule.)

2.7 LIMIT ON PAYMENT FOR CATARACT: Company’s liability for payment of any claim relating to
Cataract shall be limited to Actual or maximum of Rs. 40,000 (inclusive of all charges, excluding
service tax), for each eye, whichever is less.

2.8 AYUSH: Expenses incurred for Ayurvedic/Homeopathic/Unani Treatment are admissible up to 25%
of the sum insured provided the treatment for illness/disease and accidental injuries, is taken in a
Government hospital or in any institute recognized by Government and /or accredited by Quality
Council Of India / National Accreditation Board on Health, excluding centers for spas, massage and
health rejuvenation procedures.

2.9 Ambulances services – 1.0 % of the sum insured or actual, whichever is less, subject to maximum of
Rs. 2,500/- in case patient has to be shifted from residence to hospital for admission in Emergency
Ward or ICU or from one Hospital to another Hospital by fully equipped ambulance for better
medical facilities.

2.10 Hospitalization expenses (excluding cost of organ) incurred on the donor during the course of organ
transplant to the insured person. The Company’s liability towards expenses incurred on the donor
and the insured recipient shall not exceed the sum insured of the insured person receiving the
organ.

3.0 DEFINITIONS:

3.1 ACCIDENT: An accident is a sudden, unforeseen and involuntary event caused by external, visible
and violent means.

3.2 ANY ONE ILLNESS means continuous Period of illness and it includes relapse within 45 days from the
date of last consultation with the Hospital/Nursing Home where treatment may have been taken.

3.3 CANCELLATION: Cancellation defines the terms on which the policy contract can be terminated
either by the insurer or the insured by giving sufficient notice to other which is not lower than a
period of fifteen days.

3.4 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 approved.

3.5 CONDITION PRECEDENT: Condition Precedent shall mean a policy term or condition upon which
the Insurer's liability under the policy is conditional upon.

IRDAI/HLT/NIA/P-H/V. II/340/15-16
 3

3.6 CONGENITAL ANOMALY refers to a condition(s) which is present since birth, and which is abnormal
with reference to form, structure or position.

3.6.1 CONGENITAL INTERNAL ANOMALY means a Congenital Anomaly which is not in the visible
and accessible parts of the body.
3.6.2 CONGENITAL EXTERNAL ANOMALY means a Congenital Anomaly which is in the visible and
accessible parts of the body

3.7 CO-PAYMENT: A co-payment is a cost-sharing requirement under a health insurance policy that
provides that the insured will bear a specified percentage of the admissible claim amount. A co-
payment does not reduce the sum insured.

3.8 CONTRIBUTION: Contribution is essentially the right of an insurer to call upon other insurers, liable
to the same insured, to share the cost of an indemnity claim on a ratable proportion.

3.9 DAY CARE TREATMENT: Day care treatment refers to medical treatment, and/or Surgical Operation
which is:

- Undertaken under General or Local Anesthesia in a Hospital/Day Care Centre in less than 24
hours because of technological advancement, and
- Which would have otherwise required a hospitalization of more than 24 hours.
Treatment normally taken on an out-patient basis is not included in the scope of this definition.

3.10 DEDUCTIBLE: A deductible is a cost-sharing requirement under a health insurance policy that
provides that the Insurer will not be liable for a specified rupee amount of the covered expenses,
which will apply before any benefits are payable by the insurer. A deductible does not reduce the sum
insured.

3.11 DENTAL TREATMENT: Dental treatment is treatment carried out by a dental practitioner including
examinations, fillings (where appropriate), crowns, extractions and surgery excluding any form of
cosmetic surgery/implants.

3.12 DOMICILIARY HOSPITALISATION: Domiciliary Hospitalization means medical treatment for an

Illness/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:

- The condition of the patient is such that he/she is not in a condition to be removed to a
Hospital, or
- The patient takes treatment at home on account of non-availability of room in a Hospital.

3.13 FLOATER BENEFIT means the Sum Insured as specified for a particular Insured and the members of
his/her family as covered under the policy and is available for any or all the members of his/her
family for one or more claims during the tenure of the policy.

3.14 HOSPITAL: A hospital means any institution established for Inpatient Care and Day Care treatment
of Illness and / or Injuries and which has been registered as a Hospital with the local authorities
under the Clinical Establishment (Registration and Regulation) Act, 2010 or under the enactments
specified under the schedule of Section 56(1) of the said act OR complies with all minimum criteria
as under:

IRDAI/HLT/NIA/P-H/V. II/340/15-16
 4

- has at least 10 inpatient beds, in those towns having a population of less than 10,00,000 and at
least 15 inpatient beds in all other places;
- has qualified nursing staff under its employment round the clock;
- has qualified medical practitioner (s) in charge round the clock;
- has a fully equipped operation theatre of its own where surgical procedures are carried out
- maintains daily records of patients and will make these accessible to the Insurance
company’s authorized personnel.

The term ‘Hospital’ 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.

3.14.1 HOSPITALISATION means admission in a Hospital for a minimum period of 24 in patient Care
consecutive hours except for specified procedures/ treatments, where such admission could be for a
period of less than 24consecutive hours.

Anti-Rabies Vaccination Hysterectomy

Appendectomy Inguinal/Ventral/Umbilical/Femoral Hernia
Coronary Angiography Lithotripsy (Kidney Stone Removal)
Coronary Angioplasty Parenteral Chemotherapy
Dental surgery following an accident Piles / Fistula
Dilatation & Curettage (D & C) of Cervix Prostate
Eye surgery Radiotherapy
Fracture / dislocation excluding hairline Fracture Sinusitis
Gastrointestinal Tract system Stone in Gall Bladder, Pancreas, and Bile Duct
Haemo-Dialysis Tonsillectomy,
Hydrocele Urinary Tract System

OR any other Surgeries / Procedures agreed by TPA/Company which require less than 24 hours
hospitalization due to advancement in Medical Technology.

Note: Procedures/treatments usually done in outpatient department are not payable under the Policy
even if converted as an In-patient in the Hospital for more than 24 hours.

3.14.2 Day Care Centre: A Day Care Centre means any institution established for Day Care treatment of
Illness and or Injuries or a medical setup within 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 criteria as under:

1) has qualified nursing staff under its employment;

2) has qualified Medical Practitioner/s in charge;
3) Has a fully equipped operation theatre of its own where Surgeries are carried out;
4) Maintains daily records of patients and will make these accessible to the insurance
company’s authorized personnel.

3.15 ID CARD means the identity card issued to the insured person by the TPA to avail cashless facility in
network hospitals.

3.16 ILLNESS: Illness means a sickness or a disease or pathological condition leading to the impairment
of normal physiological function which manifests itself during the Policy Period and requires medical
treatment.

IRDAI/HLT/NIA/P-H/V. II/340/15-16
 5

3.17 INJURY: Injury means accidental physical bodily harm excluding Illness or disease solely and directly
caused by external, violent and visible and evident means which is verified and certified by a Medical
Practitioner.

3.18 INPATIENT 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.

3.19 INSURED PERSON means You and each of the others who are covered under this Policy as shown
in the Schedule.

3.20 INTENSIVE CARE UNIT (ICU): means an identified section, ward or wing of a Hospital which is under
the constant supervision of a dedicated Medical Practitioner, and which is specially equipped for the
continuous monitoring and treatment of patients who are in a critical condition, or require life
support facilities and where the level of care and supervision is considerably more sophisticated and
intensive than in the ordinary and other wards.

3.21 MATERNITY EXPENSES: Maternity expense shall include:

a. Medical Treatment Expenses traceable to childbirth (including complicated deliveries and

caesarean sections incurred during Hospitalisation),
b. Expenses towards lawful medical termination of pregnancy during the Policy Period.

3.22 MEDICAL ADVICE: Any consultation or advice from a Medical Practitioner including the issue of any
prescription or repeat prescription.

3.23 MEDICAL EXPENSES: Medical Expenses means those expenses that an Insured Person has
necessarily and actually incurred for medical treatment on account of Illness or Injury 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.

3.24 MEDICALLY NECESSARY: treatment is defined as any treatment, tests, medication, or stay in
Hospital or part of a stay in Hospital which

- is required for the medical management of the Illness or Injury suffered by the insured;
- must not exceed the level of care necessary to provide safe, adequate and appropriate medical
care in scope, duration, or intensity;
- must have been prescribed by a Medical Practitioner;
- must confirm to the professional standards widely accepted in international medical practice or
by the medical community in India.

3.25 MEDICAL PRACTITIONER is 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 the scope and jurisdiction of his license.

Note: The Medical Practitioner should not be the insured or close family members.

3.26 NETWORK HOSPITAL: All such Hospitals, Day Care Centers or other providers that the Insurance
Company / TPA have mutually agreed with, to provide services like cashless access to policyholders.
The list is available with the insurer/TPA and subject to amendment from time to time.

IRDAI/HLT/NIA/P-H/V. II/340/15-16
 6

3.27 NON-NETWORK HOSPITAL: Any Hospital, Day Care centre or other provider that is not part of the
Network.

3.28 OPD TREATMENT: OPD treatment is 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 Inpatient.

3.29 PERIOD OF INSURANCE means the period for which this Policy is taken as specified in the Schedule.

3.30 PRE-EXISTING CONDITION/DISEASE: Any condition, ailment or Injury or related condition(s) for
which you had signs or symptoms, and / or were diagnosed, and / or received medical advice /
treatment within 48 months prior to the first policy issued by the insurer.

3.31 PRE-HOSPITALISATION MEDICAL EXPENSES mean Medical Expenses incurred immediately before
the Insured Person is Hospitalized, provided that:

i. Such Medical Expenses are incurred 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.

3.32 POST-HOSPITALISATION MEDICAL EXPENSES mean Medical Expenses incurred immediately after
the Insured Person is discharged from the Hospital provided that:

i. Such Medical Expenses are incurred 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.

3.33 PORTABILITY: Portability means transfer by an individual health insurance policyholder (including
family cover) of the credit gained for pre-existing conditions and time-bound exclusions if he/she
chooses to switch from one insurer to another.

3.34 QUALIFIED NURSE: Qualified nurse is a person who holds a valid registration from the Nursing
Council of India or the Nursing Council of any state in India.

3.35 REASONABLE AND CUSTOMARY CHARGES: Reasonable charges means the charges for services or
supplies, which are the standard charges for the specific 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.

3.36 RENEWAL: Renewal defines 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 all waiting periods.

3.37 ROOM RENT: Room Rent means the amount charged by a Hospital for the occupancy of a bed per
day (twenty-four hours) basis and shall include associated medical expenses.

3.38 SUM INSURED is the maximum amount of coverage opted for each Insured Person and shown in
the Schedule.

3.39 SURGERY 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

IRDAI/HLT/NIA/P-H/V. II/340/15-16
 7

of suffering or prolongation of life, performed in a Hospital or Day Care Centre by a Medical

Practitioner.

3.40 TPA: Third Party Administrators or TPA means any person who is licensed under the IRDA (Third
Party Administrators - Health Services) Regulations, 2001 by the Authority, and is engaged, for a fee
or remuneration by an insurance company, for the purposes of providing health services.

3.41 UNPROVEN / EXPERIMENTAL TREATMENT: Treatment including drug experimental therapy, which
is not based on established medical practice in India, is treatment experimental or unproven.

4.0 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 PRE-EXISTING DISEASES/ CONDITIONS / BENEIFTS will not be available for any condition(s) as
defined in the policy, until 36 months of continuous coverage have elapsed, since inception of the
first policy with us.

4.2 30 DAYS EXCLUSION Any Illness other than those stated in clause 4.3 below, contracted by the
insured person during first 30 days from the commencement date of the policy. This exclusion will
not apply if the policy is renewed with our Company without any break. The exclusion does not also
apply to treatment for any Injury.

4.3 WAITING PERIOD FOR SPECIFIED DISEASES/ALIMENTS/CONDITIONS: From the time of inception
of the cover, the policy will not cover the following diseases / ailments / conditions for the duration
shown below. This exclusion will be deleted after the duration shown, provided the policy has been
continuously renewed with our Company without any break.

S No Name of Disease/Ailment/Surgery not covered for Duration

1 Any Skin disorder Two years
All internal & external benign tumors, cysts, polyps of any kind, including benign
2 Two years
breast lumps
3 Benign Ear, Nose, Throat disorders Two years
4 Benign Prostate Hypertrophy Two years
5 Cataract & age related eye ailments Two years
6 Diabetes mellitus Two years
7 Gastric/ Duodenal Ulcer Two years
8 Gout & Rheumatism Two years
9 Hernia of all types Two years
10 Hydrocele Two years
11 Hypertension Two years
Hysterectomy for Menorrhagia/Fibromyoma, Myomectomy and Prolapse of
12 Two years
uterus
13 Non Infective Arthritis Two years
14 Piles, Fissure and Fistula in Anus Two years
15 Pilonidal Sinus, Sinusitis and related disorders Two years
16 Prolapse Inter Vertebral Disc unless arising from accident Two years
17 Stone in Gall Bladder & Bile duct Two years

IRDAI/HLT/NIA/P-H/V. II/340/15-16
 8

18 Stones in Urinary Systems Two years

19 Unknown Congenital internal disease/defects Two years
20 Varicose Veins and Varicose Ulcers Two years
21 Age related Osteoarthritis & Osteoporosis Four years
22 Joint Replacements due to Degenerative Condition Four years

4.4 Permanent Exclusions: Any medical expenses incurred for or arising out of:

4.4.1 War invasion, Act of foreign enemy, War like operations, Nuclear weapons, ionizing radiation,
contamination by radio activity, by any nuclear fuel or nuclear waste or from the combustion of
nuclear fuel.

4.4.2 Circumcision, cosmetic or aesthetic treatment, plastic surgery unless required to treat injury or
illness.

4.4.3 Vaccination & Inoculation.

4.4.4 Cost of braces, equipment or external prosthetic devices, non-durable implants, eyeglasses, Cost
of spectacles and contact lenses, hearing aids including cochlear implants, durable medical
equipment.

4.4.5 All types of Dental treatments except arising out of an accident.

4.4.6 Convalescence, general debility, ‘Run-down’ condition or rest cure, obesity treatment and its
complications, congenital external disease/defects or anomalies, treatment relating to all
psychiatric and psychosomatic disorders, infertility, sterility, use of intoxicating drugs/alcohol, use
of tobacco leading to cancer.

4.4.7 Bodily injury or sickness due to willful or deliberate exposure to danger (except in an attempt to
save human life), intentional self-inflicted injury, , attempted suicide, arising out of non-
adherence to medical advice.

4.4.8 Treatment of any Bodily injury sustained whilst or as a result of active participation in any
hazardous sports of any kind.

4.4.9 Treatment of any bodily injury sustained whilst or as a result of participating in any criminal act.

4.4.10 Sexually transmitted diseases, any condition directly or indirectly caused due to or associated with
Human T-Cell Lymphotropic Virus Type III (HTLB-III) or lymphotropathy Associated Virus (LAV) or
the Mutants Derivative or Variation Deficiency syndrome or any syndrome or condition of a similar
kind commonly referred to as AIDS.

4.4.11 Diagnosis, X-Ray or Laboratory examination not consistent with or incidental to the diagnosis of
positive existence and treatment of any ailment, sickness or injury, for which confinement is
required at a Hospital.

4.4.12 Vitamins and tonics unless forming part of treatment for injury or disease as certified by the
attending Medical Practitioner.

4.4.13 Maternity Expenses, except abdominal operation for extra uterine pregnancy (Ectopic
Pregnancy), which is proved by submission of ultra Sonographic Report and Certification by
Gynecologist that it is life threatening.

IRDAI/HLT/NIA/P-H/V. II/340/15-16
 9

4.4.14 Naturopathy Treatment.

4.4.15 Instrument used in treatment of Sleep Apnea Syndrome (C.P.A.P.) and continuous Peritoneal
Ambulatory dialysis (C.P.A.D.) and Oxygen Concentrator for Bronchial Asthmatic condition.

4.4.16 Genetic disorders and stem cell implantation / surgery.

4.4.17 Domiciliary Hospitalization.

4.4.18 Treatment taken outside India.

4.4.19 Experimental Treatment, Unproven treatment.

4.4.20 Change of treatment from one system to another unless recommended by the consultant
/ hospital under whom the treatment is taken.

4.4.21 Any expenses relating to cost of items detailed in Annexure I.

4.4.22 Service charges or any other charges levied by hospital, except registration/admission charges.

4.4.23 Treatment for Age Related Macular Degeneration (ARMD) , treatments such as Rotational Field
Quantum Magnetic Resonance (RFQMR), External Counter Pulsation (ECP), Enhanced External
Counter Pulsation (EECP), Hyperbaric Oxygen Therapy.

5.0 CONDITIONS:

5.1 COMMUNICATION: Every notice or communication to be given or made under this policy shall be
delivered in writing at the address as shown in the Schedule.

5.2 PREMIUM PAYMENT: 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. The due payment of premium
and the observance and fulfillment of the terms, provisions, conditions and endorsements of this
policy by the Insured Person in so far as they relate to anything to be done or complied with by the
Insured Person shall be 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 authorized official of the Company.

5.3 NOTICE OF CLAIM: Preliminary notice of claim with particulars relating to Policy Number, name of
insured person in respect of whom claim is to be made, nature of illness/injury and Name and Address
of the attending Medical Practitioner/Hospital/Nursing Home should be given to the Company/TPA
within 7 days from the date of hospitalization in respect of reimbursement claims.

Final claim along with hospital receipted original Bills/Cash memos, claim form and documents as
listed in the claim form below should be submitted to the Policy issuing Office/TPA not later than
30 days of discharge from the hospital. The insured may also be required to give the Company/TPA
such additional information and assistance as the Company/TPA may require in dealing with the
claim.

a. Bill, Receipt and Discharge certificate / card from the Hospital.

b. Cash Memos from the Hospitals(s) / Chemists(s), supported by proper prescriptions.

IRDAI/HLT/NIA/P-H/V. II/340/15-16
 10

c. Receipt and Pathological test reports from Pathologist supported by the note from the
attending Medical Practitioner / Surgeon recommending such Pathological tests / pathological.
d. Surgeon's certificate stating nature of operation performed and Surgeons’ bill and
receipt.
e. Attending Doctor's/ Consultant's/ Specialist's / Anesthetist’s bill and receipt, and certificate
regarding diagnosis.
f. Certificate from attending Medical Practitioner / Surgeon that the patient is fully cured.
Waiver: Waiver of period of intimation may be considered in extreme cases of hardships where it
is proved to the satisfaction of the Company/TPA 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. This waiver cannot be claimed as a matter of right.

5.4 PHYSICAL EXAMINATION: Any medical practitioner authorized by the Company shall be allowed to
examine the Insured Person in case of any alleged injury or Disease requiring Hospitalization when
and as often as the same may reasonably be required on behalf of the Company.

5.5 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.

5.6 CONTRIBUTION: If two or more policies are taken by Insured Person during a period from one or
more insurers to indemnify treatment costs, Company shall not apply the contribution clause, but
the Insured Person shall have the right to require a settlement of his/her claim in terms of any of
his/her policies.

1. In all such cases Company shall be obliged to settle the claim without insisting on the
contribution clause as long as the claim is within the limits of and according to the terms of the
policy.
2. If the amount to be claimed exceeds the Sum Insured under a single policy after considering the
deductibles or co-pay, the Insured Person shall have the right to choose insurers by whom the
claim to be settled. In such cases, the insurer may settle the claim with contribution clause.
3. Except in benefit policies, in cases where Insured Person have policies from more than one
insurer to cover the same risk on indemnity basis, Insured Person shall only be indemnified the
Hospitalisation costs in accordance with the terms and conditions of the policy.

Note: Insured Person must disclose such other insurance at the time of making a claim under this
Policy.

5.7 CANCELLATION CLAUSE: The policy may be renewed by mutual consent. The company shall not
however be bound to give notice that it is due for renewal and the Company may at any time cancel
this Policy by sending the insured 30 days’ notice by registered letter at the Insured’s last known
address and in such event the Company shall refund to the Insured a pro-rata premium for
unexpired Period of Insurance. The Company shall, however, remain liable for any claim which arose
prior to the date of cancellation.

IRDAI/HLT/NIA/P-H/V. II/340/15-16
 11

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 OF RISK RATE OF PREMIUM TO BE CHARGED

Up to one month 1/4th of the annual rate
Up to three months ½ of the annual rate
Up to six months 3/4th of the annual rate
Exceeding six months Full annual rate

5.8 DISCLAIMER OF CLAIM: If the Company shall disclaim liability to the Insured for any claim hereunder
and if the Insured shall not within 12 calendar months from the date of receipt of the notice of such
disclaimer notify the Company in writing that he does not accept such disclaimer and intends to
recover his claim from the Company then the claim shall for all purposes be deemed to have been
abandoned and shall not thereafter be recoverable hereunder.

5.9 All medical/surgical treatment under this policy shall have to be taken in India and admissible claims
thereof shall be payable in Indian currency.

6.1 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 claims 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 into account.

Incurred Claim ratio under the Group Policy Discount (%)

Not Exceeding 60% 5%
Not Exceeding 50% 15%
Not Exceeding 40% 25%
Not Exceeding 30% 35%
Not Exceeding 25% 40%

6.2 HIGH CLAIM 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 3 completed years excluding
the year immediately preceding the date of renewal Where the Group Mediclaim Policy has not
been in force for the 3 completed years, such shorter periods of completed years excluding the year
immediately preceding the date of renewal will be taken into account.

Incurred Claim Ratio under the Group Policy Loading (%)

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

IRDAI/HLT/NIA/P-H/V. II/340/15-16
 12

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 Claim Ratio for the entire Group
insured.

(2) Incurred claim would mean claims paid plus claims outstanding at the end of the period minus
O/S at the beginning of the period in respect of the entire group insured under the policy during
the relevant period.

7.1 MATERNITY EXPENSES BENEFIT EXTENSION (OPTIONAL COVER): This is an optional cover which
can be obtained on payment of 10% of the total basic premium for all the Insured Persons under
the Policy Total basic premium means the total premium computed before applying Group Discount
and / or High Claim Ratio Loading, Low Claim Discount and special discount in lieu of agency
commission.

7.2 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.

7.3 The maximum benefit allowable under this clause will be up to 10% of the Sum Insured subject to a
maximum of Rs 30,000/-.

7.4 Special conditions applicable to Maternity Expenses Benefit Extension:

1. These Benefits are admissible only if the expenses are incurred in Hospital as inpatients in India.
2. A waiting period of 9 months is applicable for payment of any claim relating to normal delivery
or caesarian 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 surgeries 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 post-natal expenses are not covered unless admitted in Hospital and treatment is
taken there

Note: When Group Policy is extended to include Maternity Expenses Benefit, the exclusion
4.13 of the policy stands deleted.

8.0 CASHLESS SERVICE THROUGH TPAS: Claims in respect of Cashless access services will be through the
agreed list of network of hospital and is subject to pre-admission authorization. The TPA shall, upon
getting the related medical information from the insured person
/network provider, verify that the person is eligible to claim under the policy and after satisfying
itself will issue a pre-authorization letter / guarantee of payment letter to the hospital mentioning
the sum guaranteed as payable also the ailment for which the person is seeking to be admitted as a
patient. The TPA reserves the right to deny pre-authorization in case the insured person is unable to
provide the relevant medical details as required by the TPA. The TPA will make it clear to the insured
person that denial of Cashless Access is in no way construed to be denial of treatment. The insured
person may obtain the treatment as per his /her treating Medical Practitioners medical advice and
later on submit the full claim papers to the TPA for reimbursement.

IRDAI/HLT/NIA/P-H/V. II/340/15-16
 13

9.0 FRAUD, MISREPRESENTATION, CONCEALMENT: The policy shall be null and void and no benefits shall
be payable in the event of misrepresentation, misdescription or nondisclosure of any material
fact/particulars if such claim be in any manner fraudulent or supported by any fraudulent means or
device whether by the Insured Person or by any other person acting on his/her behalf.

10.0 RENEWAL CLAUSE: The Company sends renewal notice as a matter of courtesy. If the insured does
not receive the renewal notice it will not amount to any deficiency of service.

The Company shall not be responsible or liable for non-renewal of the policy due to non- receipt
/delayed receipt of renewal notice or due to any other reason whatsoever.

We shall be entitled to decline renewal if:

a) Any fraud, moral hazard/misrepresentation or suppression by You or any one acting on Your
behalf is found either in obtaining insurance or subsequently in relation thereto, or non-
cooperation of the Insured Person, or
b) We have discontinued issue of the Policy, in which event You shall however have the option for
renewal under any similar Policy being issued by Us; provided however, benefits payable shall
be subject to the terms contained in such other Policy, or
c) You fail to remit Premium for renewal before expiry of the Period of Insurance. We may accept
renewal of the Policy if it is effected within thirty days (grace period) of the expiry of the Period
of Insurance. On such acceptance of renewal, we, however shall not be liable for any claim
arising out of Illness contracted or Injury sustained or Hospitalization commencing in the interim
period after expiry of the earlier Policy and prior to date of commencement of subsequent
Policy.

11.0 MEDICAL EXPENSES INCURRED UNDER TWO POLICY PERIODS: If the claim event falls within two
policy periods, the claims shall be paid taking into consideration the available Sum Insured of the
expiring Policy only. Sum Insured of the Renewed Policy will not be available for the Hospitalisation
(including Pre & Post Hospitalisation Expenses), which has commenced in the expiring Policy. Claim
shall be settled on per event basis.

12.0 REPUDIATION OF CLAIM: A claim, which is not covered under the Policy conditions, can be rejected.
All the documents submitted to TPA shall be electronically collected by Us for settlement and denial
of the claims by the appropriate authority.

With Our prior approval Communication of repudiation shall be sent to You, explicitly mentioning the
grounds for repudiation, through Our TPA.

13.0 PROTECTION OF POLICY HOLDERS’ INTEREST: This policy is subject to IRDA (Protection of
Policyholders’ Interest) Regulation, 2002

14.0 GRIEVANCE REDRESSAL: In the event of Insured has any grievance relating to the insurance, Insured
Person may contact any of the Grievance Cells at Regional Offices of the Company or Office of the
Insurance Ombudsman under the jurisdiction of which the Policy Issuing Office falls. The contact
details of the office of the Insurance Ombudsman are provided in the Annexure II.

15.0 PAYMENT OF CLAIM: The insurer shall settle the claim, including rejection, within thirty days of the
receipt of the last necessary document.

IRDAI/HLT/NIA/P-H/V. II/340/15-16
 14

On receipt of the duly completed documents either from the insured or Hospital the claim shall be
processed as per the conditions of the policy. Upon acceptance of claim by the insured for
settlement, the insurer or their representative (TPA) shall transfer the funds within seven working
days. In case of any extra ordinary delay, such claims shall be paid by the insurer or their
representative (TPA) with a penal interest at a rate which is 2% above the bank rate at the beginning
of the financial year in which the claim is reviewed

All admissible claims shall be payable in Indian Currency only.

16.0 ARBITRATION: If we admit liability for any claim but any difference or dispute arises as to the amount
payable for any claim the same shall be decided by reference to Arbitration.

The Arbitrator shall be appointed in accordance with the provisions of the Arbitration and
Conciliation Act, 1996.

No reference to Arbitration shall be made unless we have Admitted our liability for a claim in writing.

If a claim is declined and within 12 calendar months from such disclaimer any suit or proceeding is
not filed, then the claim shall for all purposes be deemed to have been abandoned and shall not
thereafter be recoverable hereunder.

17.0 PORTABILITY CLAUSE: This policy is subject to portability guidelines issued by IRDA.

18.0 PERIOD OF POLICY: This insurance policy is issued for a period of one year.

19.0 SPECIAL CONDITIONS: The Policy is subject to deviations from the standard wordings as mentioned
in the schedule of the policy.

The conditions are as under:

19.1 CATARACT: It is hereby declared and agreed at the request of the Insured that Clause 2.7 stands
modified. The limits shall be actual expenses incurred, up to maximum Rs. 40,000/-

19.2 AMBULANCE SERVICES: It is hereby declared and agreed at the request of the Insured that Clause
2.9 stands modified. The limits shall be 1% of SI not Exceeding Rs. 1,000 for Any One Illness.

19.3 PRE EXISTING DISEASE/CONDITION: It is hereby declared and agreed at the request of the Insured
that Exclusion 4.1 for “Pre-Existing Disease / Condition” stands modified. The waiting period of 48
months shall be read as 24 months.

19.4 30 DAYS WAITING PERIOD: It is hereby declared and agreed at the request of the Insured that
Exclusion 4.2 for “30 Days Exclusion” from inception.

19.5 2 YEARS WAITING PERIOD: It is hereby declared and agreed at the request of the Insured that
Exclusion 4.3 for “Waiting Period for Specific Diseases / Ailments / Condition” stands modified. The
waiting period of two years shall be read as one year in this policy

19.6 MATERNITY EXPENSES: It is hereby declared and agreed at the request of the Insured that
Exclusion 4.4.13 stands deleted and clause 7.1, 7.2 & 7.3 stands modified. The clause shall be read
as under:
“This maternity and child care shall be covered in the Policy. The maximum benefit allowable under
this clause will be up to a limit of 5% of the Sum Insured.”

Note: This Clause shall be read in conjunction with Clause 7.4

IRDAI/HLT/NIA/P-H/V. II/340/15-16
 15

19.7 HEALTH CHECKUP: It is hereby declared and agreed at the request of the Insured that cost of
Health checkup shall be payable under the policy. The Clause shall be read as under:
The Insured shall be entitled for reimbursement of the cost of medical checkup once at the end of
every three underwriting years provided there are no claims reported during the block. The cost so
reimbursable shall not exceed the amount equal to 1 % of the amount of average Sum Insured or
Rs 5000/- subject to previous three claim free underwriting years of the policy issued by New India
Assurance co ltd.
Note: The health checkup provision is applicable only in respect of continuous coverage without
break.

19.8 HOSPITAL CASH: It is hereby declared and agreed at the request of the Insured that Hospital Cash
shall be payable under the policy. The Clause shall be read as under:

“A Cash allowance of RS.100/- per day subject to a maximum of RS.1000/- will be given to the
parents/guardians of children up to the age of 12 who are Hospitalised and there is a valid claim
under the policy. Hospital cash shall reduce the Sum Insured.”

19.9 FUNERAL EXPENSES: It is hereby declared and agreed at the request of the Insured that Funeral
Expenses shall be payable under the policy. The Clause shall be read as under:

“In case the Insured or his family members have died following hospitalization due to an Illness /
Accident and their eyes have been donated to a recognized institution, Funeral expenses of RS.
1,000/- will be paid under the policy on production of the original certificate from the said
institution. This is subject to there being a valid claim under the Mediclaim policy. This amount will
be reimbursed over and above the Sum Insured opted.

19.10 ENHANCEMENT OF SUM INSURED: It is hereby declared and agreed that Insured may seek
enhancement of Sum Insured in writing before payment of premium for renewal, which
may be granted at Our discretion up to age of 65 years. Sum Insured can be enhanced to
the next Sum Insured band only.

In respect of any increase in Sum Insured, exclusion 4.1 and 4.3 would apply to the
additional Sum Insured from the date of such increase.

19.11 GEOGRAPHICAL EXTENSION: It is hereby declared and agreed at the request of the Insured
that Reimbursement in Indian rupees of emergency Hospitalisation expenses for treatment
at Nepal or Bhutan while the Insured is away at these places either on holiday or business
purposes shall be payable under the policy. Cashless facility shall not be offered under this
extension.

19.12 Ambulances services – 1.0 % of the sum insured or actual, whichever is less, subject to
maximum of Rs. 1,000/- in case patient has to be shifted from residence to hospital for
admission in Emergency Ward or ICU or from one Hospital to another Hospital by fully
equipped ambulance for better medical facilities.

IRDAI/HLT/NIA/P-H/V. II/340/15-16
 16

ANNEXURE I: LIST OF EXPENSES EXCLUDED ("NON-MEDICAL")

SNO LIST OF EXPENSES EXCLUDED ("NON-MEDICAL") SUGGESTIONS

TOILETRIES/COSMETICS/ PERSONAL COMFORT OR CONVENIENCE ITEMS
1 HAIR REMOVAL CREAM Not Payable
2 BABY CHARGES (UNLESS SPECIFIED/INDICATED) Not Payable
3 BABY FOOD Not Payable
4 BABY UTILITES CHARGES Not Payable
5 BABY SET Not Payable

IRDAI/HLT/NIA/P-H/V. II/340/15-16
 17

6 BABY BOTTLES Not Payable

7 BRUSH Not Payable
8 COSY TOWEL Not Payable
9 HAND WASH Not Payable
10 MOISTURISER PASTE BRUSH Not Payable
11 POWDER Not Payable
12 RAZOR Payable
13 SHOE COVER Not Payable
14 BEAUTY SERVICES Not Payable
Essential and may be paid specifically
15 BELTS/ BRACES for cases who have undergone surgery
of thoracic or
lumbar spine.
16 BUDS Not Payable
17 BARBER CHARGES Not Payable
18 CAPS Not Payable
19 COLD PACK/HOT PACK Not Payable
20 CARRY BAGS Not Payable
21 CRADLE CHARGES Not Payable
22 COMB Not Payable
23 DISPOSABLES RAZORS CHARGES ( for site preparations) Payable
24 EAU-DE-COLOGNE / ROOM FRESHNERS Not Payable
25 EYE PAD Not Payable
26 EYE SHEILD Not Payable
27 EMAIL / INTERNET CHARGES Not Payable
FOOD CHARGES (OTHER THAN PATIENT'S DIET PROVIDED
28 Not Payable
BY HOSPITAL)
29 FOOT COVER Not Payable
30 GOWN Not Payable
Essential in bariatric and varicose vein
31 LEGGINGS surgery and should be considered for
these conditions
where surgery itself is payable.
32 LAUNDRY CHARGES Not Payable
33 MINERAL WATER Not Payable
34 OIL CHARGES Not Payable
35 SANITARY PAD Not Payable
36 SLIPPERS Not Payable
37 TELEPHONE CHARGES Not Payable
38 TISSUE PAPER Not Payable
39 TOOTH PASTE Not Payable
40 TOOTH BRUSH Not Payable
41 GUEST SERVICES Not Payable
42 BED PAN Not Payable
43 BED UNDER PAD CHARGES Not Payable
44 CAMERA COVER Not Payable
45 CLINIPLAST Not Payable
Not Payable/ Payable by the
46 CREPE BANDAGE
patient
47 CURAPORE Not Payable
48 DIAPER OF ANY TYPE Not Payable
Not Payable ( However if CD is
49 DVD, CD CHARGES
specifically sought by In

IRDAI/HLT/NIA/P-H/V. II/340/15-16
 18

surer/TPA then payable)

50 EYELET COLLAR Not Payable
51 FACE MASK Not Payable
52 FLEXI MASK Not Payable
53 GAUSE SOFT Not Payable
54 GAUZE Not Payable
55 HAND HOLDER Not Payable
56 HANSAPLAST/ADHESIVE BANDAGES Not Payable
57 INFANT FOOD Not Payable
Reasonable costs for one sling in
58 SLINGS case of upper arm fractures
should be considered
ITEMS SPECIFICALLY EXCLUDED IN THE POLICIES
59 WEIGHT CONTROL PROGRAMS/ SUPPLIES/ SERVICES Not Payable
COST OF SPECTACLES/ CONTACT LENSES/ HEARING AIDS
60 Not Payable
ETC.,
DENTAL TREATMENT EXPENSES THAT DO NOT REQUIRE
61 Not Payable
HOSPITALISATION
62 HORMONE REPLACEMENT THERAPY Not Payable
63 HOME VISIT CHARGES Not Payable
INFERTILITY/ SUBFERTILITY/ ASSISTED CONCEPTION
64 Not Payable
PROCEDURE
OBESITY (INCLUDING MORBID OBESITY) TREATMENT IF
65 Not Payable
EXCLUDED IN POLICY
66 PSYCHIATRIC & PSYCHOSOMATIC DISORDERS Not Payable
67 CORRECTIVE SURGERY FOR REFRACTIVE ERROR Not Payable
68 TREATMENT OF SEXUALLY TRANSMITTED DISEASES Not Payable
69 DONOR SCREENING CHARGES Not Payable
70 ADMISSION/REGISTRATION CHARGES Not Payable
HOSPITALISATION FOR EVALUATION/ DIAGNOSTIC
71 Not Payable
PURPOSE
EXPENSES FOR INVESTIGATION/ TREATMENT IRRELEVANT
72 Not Payable
TO THE DISEASE FOR WHICH ADMITTED OR DIAGNOSED
ANY EXPENSES WHEN THE PATIENT IS DIAGNOSED WITH
73 RETRO VIRUS + OR SUFFERING FROM /HIV/ AIDS ETC IS Not Payable
DETECTED/ DIRECTLY OR INDIRECTLY
74 STEM CELL IMPLANTATION/ SURGERY and storage Not Payable
ITEMS WHICH FORM PART OF HOSPITAL SERVICES WHERE SEPARATE CONSUMABLES ARE NOT
PAYABLE BUT THE SERVICE IS
WARD AND THEATRE BOOKING CHARGES Payable under OT Charges, not
75
separately
Rental charged by the Hospital payable.
76 ARTHROSCOPY & ENDOSCOPY INSTRUMENTS Purchase of Instruments
Not Payable.

MICROSCOPE COVER Payable under OT Charges, not

77
separately
SURGICAL BLADES, HARMONIC SCALPEL, SHAVER Payable under OT Charges, not
78
separately

SURGICAL DRILL Payable under OT Charges, not

79
separately

EYE KIT Payable under OT Charges, not

80
separately
81 EYE DRAPE Payable under OT Charges, not

IRDAI/HLT/NIA/P-H/V. II/340/15-16
 19

separately
Payable under Radiology Charges,
82 X-RAY FILM
not as consumable
Payable under Investigation
83 SPUTUM CUP
Charges, not as consumable
Part of OT Charges, not
84 BOYLES APPARATUS CHARGES
separately
BLOOD GROUPING AND CROSS MATCHING OF DONORS
85 Part of Cost of Blood, not payable
SAMPLES
Not Payable - Part of Dressing
86 ANTISEPTIC OR DISINFECTANT LOTIONS
Charges
BAND AIDS, BANDAGES, STERLILE INJECTIONS, NEEDLES, Not Payable - Part of Dressing
87
SYRINGES charges
Not Payable -Part of Dressing
88 COTTON
Charges
Not Payable- Part of Dressing
89 COTTON BANDAGE
Charges
Not Payable – Part of Dressing
90 MICROPORE/ SURGICAL TAPE
Charges
91 BLADE Not Payable
92 APRON Not Payable
93 TORNIQUET Not Payable
Not Payable, Part of Dressing
94 ORTHOBUNDLE, GYNAEC BUNDLE
Charges
95 URINE CONTAINER Not Payable
ELEMENTS OF ROOM CHARGE
Actual tax levied by government
96 LUXURY TAX is payable. Part of room
charge for sub limits
Part of room charge, Not Payable
97 HVAC
separately
Part of room charge, Not Payable
98 HOUSE KEEPING CHARGES
separately
SERVICE CHARGES WHERE NURSING CHARGE ALSO Part of room charge, Not Payable
99
CHARGED separately
Part of room charge, Not Payable
100 TELEVISION & AIR CONDITIONER CHARGES
separately
Part of room charge, Not Payable
101 SURCHARGES
separately
Part of room charge, Not Payable
102 ATTENDANT CHARGES
separately
Part of nursing charge, Not
103 IM IV INJECTION CHARGES
Payable separately
Part of Laundry / Housekeeping,
104 CLEAN SHEET
Not Payable separately
EXTRA DIET OF PATIENT (OTHER THAN THAT WHICH Patient Diet provided by Hospital
105
FORMS PART OF BED CHARGE) is payable
Part of room charge, Not Payable
106 BLANKET/WARMER BLANKET
separately
ADMINISTRATIVE OR NON - MEDICAL CHARGES
107 ADMISSION KIT Not Payable
108 BIRTH CERTIFICATE Not Payable
BLOOD RESERVATION CHARGES AND ANTE NATAL
109 Not Payable
BOOKING CHARGES

IRDAI/HLT/NIA/P-H/V. II/340/15-16
 20

110 CERTIFICATE CHARGES Not Payable

111 COURIER CHARGES Not Payable
112 CONVENYANCE CHARGES Not Payable
113 DIABETIC CHART CHARGES Not Payable
114 DOCUMENTATION CHARGES / ADMINISTRATIVE EXPENSES Not Payable
115 DISCHARGE PROCEDURE CHARGES Not Payable
116 DAILY CHART CHARGES Not Payable
117 ENTRANCE PASS / VISITORS PASS CHARGES Not Payable
Payable under Post-
118 EXPENSES RELATED TO PRESCRIPTION ON DISCHARGE
Hospitalisation where admissible
119 FILE OPENING CHARGES Not Payable
120 INCIDENTAL EXPENSES / MISC. CHARGES (NOT EXPLAINED) Not Payable
121 MEDICAL CERTIFICATE Not Payable
122 MAINTENANCE CHARGES Not Payable
123 MEDICAL RECORDS Not Payable
124 PREPARATION CHARGES Not Payable
125 PHOTOCOPIES CHARGES Not Payable
126 PATIENT IDENTIFICATION BAND / NAME TAG Not Payable
127 WASHING CHARGES Not Payable
128 MEDICINE BOX Not Payable
Payable up to 24 hrs, shifting
129 MORTUARY CHARGES
charges not payable
130 MEDICO LEGAL CASE CHARGES (MLC CHARGES) Not Payable
EXTERNAL DURABLE DEVICES
131 WALKING AIDS CHARGES Not Payable
132 BIPAP MACHINE Not Payable
133 COMMODE Not Payable
134 CPAP/ CAPD EQUIPMENTS Device not payable
135 INFUSION PUMP – COST Device not payable
136 OXYGEN CYLINDER (FOR USAGE OUTSIDE THE HOSPITAL) Not Payable
137 PULSEOXYMETER CHARGES Device not payable
138 SPACER Not Payable
139 SPIROMETRE Device not payable
140 SP02 PROBE Not Payable
141 NEBULIZER KIT Not Payable
142 STEAM INHALER Not Payable
143 ARMSLING Not Payable
144 THERMOMETER Not Payable
145 CERVICAL COLLAR Not Payable
146 SPLINT Not Payable
147 DIABETIC FOOT WEAR Not Payable
148 KNEE BRACES ( LONG/ SHORT/ HINGED) Not Payable
149 KNEE IMMOBILIZER/SHOULDER IMMOBILIZER Not Payable
Payable for surgery of lumbar
150 LUMBOSACRAL BELT
spine.
Payable for any ICU patient
requiring more than 3 days in
ICU, all patients with paraplegia
151 NIMBUS BED OR WATER OR AIR BED CHARGES
/quadriplegia for any reason and
at reasonable cost of
approximately Rs 200/day
152 AMBULANCE COLLAR Not Payable
153 AMBULANCE EQUIPMENT Not Payable

IRDAI/HLT/NIA/P-H/V. II/340/15-16
 21

154 MICROSHEILD Not Payable

Essential and should be paid in
post-surgery patients of major
abdominal surgery including TAH,
155 ABDOMINAL BINDER LSCS, incisional hernia repair,
exploratory laparotomy for
intestinal obstruction, liver
transplant etc.
ITEMS PAYABLE IF SUPPORTED BY A PRESCRIPTION
BETADINE / HYDROGEN PEROXIDE / SPIRIT /
156 Not Payable
DISINFECTANTS ETC
PRIVATE NURSES CHARGES - SPECIAL NURSING CHARGES
157 Not Payable
Post hospitalization nursing charges
NUTRITION PLANNING CHARGES - DIETICIAN CHARGESDIET Patient Diet provided by hospital
158
CHARGES is payable
Payable -Sugar free variants of
159 SUGAR FREE Tablets admissible medicines are not
excluded
Payable when prescribed
(Toiletries are not payable, only
160 CREAMS POWDERS LOTIONS
prescribed medical
pharmaceuticals payable)
161 DIGESTION GELS Payable when prescribed
One set every second day is
162 ECG ELECTRODES
Payable.
Gloves payable / unsterilized
163 GLOVES STERILIZED
gloves not payable
164 HIV KIT payable Pre-operative screening
165 LISTERINE/ ANTISEPTIC MOUTHWASH Payable when prescribed
166 LOZENGES Payable when prescribed
167 MOUTH PAINT Payable when prescribed
If used during Hospitalisation is
168 NEBULISATION KIT
Payable reasonably
169 NOVARAPID Payable when prescribed
170 VOLINI GEL/ ANALGESIC GEL Payable when prescribed
171 ZYTEE GEL Payable when prescribed
Routine Vaccination not Payable /
172 VACCINATION CHARGES
Post Bite Vaccination Payable
PART OF HOSPITAL'S OWN COSTS AND NOT PAYABLE
Not Payable - Part of Hospital's
173 AHD
internal Cost
Not Payable - Part of Hospital's
174 ALCOHOL SWABES
internal Cost
Not Payable - Part of Hospital's
175 SCRUB SOLUTION/STERILLIUM
internal Cost
OTHERS
176 VACCINE CHARGES FOR BABY Not Payable
177 AESTHETIC TREATMENT / SURGERY Not Payable
178 TPA CHARGES Not Payable
179 VISCO BELT CHARGES Not Payable
ANY KIT WITH NO DETAILS MENTIONED [DELIVERY KIT,
180 Not Payable
ORTHOKIT, RECOVERY KIT, ETC]
181 EXAMINATION GLOVES Not payable

IRDAI/HLT/NIA/P-H/V. II/340/15-16
 22

182 KIDNEY TRAY Not Payable

183 MASK Not Payable
184 OUNCE GLASS Not Payable
185 OUTSTATION CONSULTANT'S/ SURGEON'S FEES Not payable
186 OXYGEN MASK Not Payable
187 PAPER GLOVES Not Payable
Payable in case of PIVD requiring
188 PELVIC TRACTION BELT
traction
189 REFERAL DOCTOR'S FEES Not Payable
Not payable pre Hospitalisation
or post Hospitalisation / Reports
190 ACCU CHECK (Glucometery/ Strips)
and Charts required / Device not
payable
191 PAN CAN Not Payable
192 SOFNET Not Payable
193 TROLLY COVER Not Payable
194 UROMETER, URINE JUG Not Payable
195 AMBULANCE Payable
Payable - maximum of 3 in 48 hrs
196 TEGADERM / VASOFIX SAFETY
and then 1 in 24 hrs
Payable where Medically
197 URINE BAG Necessary - maximum 1 per 24
hrs
198 SOFTOVAC Not Payable
199 STOCKINGS Payable for case like CABG etc.

IRDAI/HLT/NIA/P-H/V. II/340/15-16
 23

ANNEXURE II: CONTACT DETAILS OF INSURANCE OMBUDSMEN

Office of the
Contact Details Areas of Jurisdiction
Ombudsman
Insurance Ombudsman,
Office of the Insurance Ombudsman,
2nd Floor, Ambica House,
Nr. C.U. Shah College, Gujarat , UT of Dadra &
AHMEDABAD Ashram Road, Nagar Haveli, Daman and
AHMEDABAD-380 014 Diu
Tel.:- 079-27546840
Fax : 079-27546142
Email: [email protected]
Insurance Ombudsman,
Office of the Insurance Ombudsman,
Janak Vihar Complex,
2nd Floor, 6, Malviya Nagar, Opp.
Madhya Pradesh &
BHOPAL Airtel, Near New Market,
Chhattisgarh
BHOPAL(M.P.)-462 023.
Tel.:- 0755-2569201
Fax : 0755-2769203
Email: [email protected]
Insurance Ombudsman,
Office of the Insurance Ombudsman, 62,
Forest Park,
BHUBANESHWAR BHUBANESHWAR-751 009. Orissa
Tel.:- 0674-2596455
Fax : 0674-2596429
Email: [email protected]
Insurance Ombudsman,
Office of the Insurance Ombudsman,
S.C.O. No.101-103,
Punjab , Haryana,
2nd Floor, Batra Building,
Himachal Pradesh,
CHANDIGARH Sector 17-D, CHANDIGARH-
Jammu & Kashmir , UT
160 017.
of Chandigarh
Tel.:- 0172-2706468
Fax : 0172-2708274
Email: [email protected]
Insurance Ombudsman,
Office of the Insurance Ombudsman,
Fathima Akhtar Court,
4th Floor, 453 (old 312), Tamil Nadu, UT–
Anna Salai, Teynampet, Pondicherry Town and
CHENNAI
CHENNAI-600 018. Karaikal (which are part
Tel.:- 044-24333668 / 5284 of UT of Pondicherry)
Fax : 044-24333664
Email:
[email protected]

IRDAI/HLT/NIA/P-H/V. II/340/15-16
 24

Shri Surendra Pal Singh

Insurance Ombudsman,
Office of the Insurance Ombudsman,
2/2 A, Universal Insurance Bldg.,
NEW DELHI Asaf Ali Road, Delhi & Rajasthan
NEW DELHI-110 002.
Tel.:- 011-23239633
Fax : 011-23230858
Email: [email protected]
Shri D.C. Choudhury,
Insurance Ombudsman,
Office of the Insurance Ombudsman,
Assam , Meghalaya,
“Jeevan Nivesh”, 5th Floor,
Manipur, Mizoram,
GUWAHATI Near Panbazar Overbridge, S.S. Road,
Arunachal Pradesh,
GUWAHATI-781 001 (ASSAM).
Nagaland and Tripura
Tel.:- 0361-2132204/5
Fax : 0361-2732937
Email: [email protected]
Insurance Ombudsman,
Office of the Insurance Ombudsman,
6-2-46, 1st Floor, Moin Court, Andhra Pradesh,
A.C. Guards, Lakdi-Ka-Pool, Karnataka and UT of
HYDERABAD
HYDERABAD-500 004. Yanam – a part of the
Tel : 040-65504123 UT of Pondicherry
Fax: 040-23376599
Email: [email protected]
Insurance Ombudsman,
Office of the Insurance Ombudsman,
2nd Floor, CC 27/2603, Pulinat Bldg., Kerala , UT of (a)
Opp. Cochin Shipyard, M.G. Road, Lakshadweep , (b)
KOCHI
ERNAKULAM-682 015. Mahe – a part of UT of
Tel : 0484-2358759 Pondicherry
Fax : 0484-2359336
Email: [email protected]
Ms. Manika Datta
Insurance Ombudsman,
Office of the Insurance Ombudsman,
West Bengal , Bihar ,
4th Floor, Hindusthan Bldg. Annexe, 4,
Jharkhand and UT of
KOLKATA C.R.Avenue,
Andeman & Nicobar
Kolkatta – 700 072.
Islands , Sikkim
Tel: 033 22124346/(40)
Fax: 033 22124341
Email: [email protected]

IRDAI/HLT/NIA/P-H/V. II/340/15-16
 Insurance Ombudsman,
Office of the Insurance Ombudsman,
Jeevan Bhawan, Phase-2,
6th Floor, Nawal Kishore Road,
Uttar Pradesh and
LUCKNOW Hazaratganj,
Uttaranchal
LUCKNOW-226 001.
Tel : 0522 -2231331
Fax : 0522-2231310
Email: [email protected]
Insurance Ombudsman,
Office of the Insurance Ombudsman,
S.V. Road, Santacruz(W),
MUMBAI MUMBAI-400 054. Maharashtra , Goa
Tel : 022-26106928
Fax : 022-26106052
Email: [email protected]