HDFC ERGO General Insurance Company Limited Convenience at

Frequently Asked Question's (FAQ's)

WHAT IS THIS PLAN ALL ABOUT

HDFC ERGO Sampoorna Suraksha is a one-stop shop for a multitude of insurance requirements. It offers policy buyers complete protection for a varied

range of services, including Health, Home, Travel and Cyber Security.

HDFC ERGO General Insurance Company Limited

This document is a summary of the benefits offered. The information mentioned above is illustrative and not exhaustive. Information must be read in conjunction with the policy wordings.

In case of any conflict between this document and the policy wordings, the terms and conditions mentioned in the policy wordings shall prevail.

Convenience at your fingertips

On the HELP section of our website, you can:

Get Policy Copy/

80D Tax Certificate

Make Changes on Policy

Track Claim Status

Update Contact Details

Ver.OCT19

my:health Mobile App

▪ Health Calculators

Features:

▪ Vaccination

▪ Blood Donations

▪ Physical Activities

▪ Reliable offers, discounts on services and consultation

▪ Complete data security

▪ Cashless OPD and reimbursement

▪ Improved interactions

Download the App now

WHAT ARE THE CHECKS TO BE DONE AFTER

RECEIVING THE POLICY?

¡ Correspondence Address (House number, Street name, Locality,

Check the correctness and completeness of below points in the

policy schedule:

¡ Insured’s Name or Proposer’s Name (Salutation, Gender, Spelling)

¡ Policy Period

¡ Coverage or Sum Insured Details

Pincode, City, Village, Landmark, etc.)

¡ Date of Birth of insured

¡ Mobile Number, Landline Number and Personal E-mail ID

WOULD I RECEIVE ANY CONFIRMATION ON THE CHANGES DONE IN MY POLICY?

You would receive an endorsed policy schedule reflecting the changes made in the policy details on your correspondence address as per policy. Same

would be captured in the policy under the section “List of endorsements”.

HOW DO I RENEW MY POLICY?

§ Visit our nearest branch or contact your agent

You can renew your policy through any of the below options:

§ Visit our website www.hdfcergo.com and go to the Instant Renewal section

§ Give us a missed call on 1800 315 7272 and get quick assistance from Renewal expert

§ Call us on 022 6234 6234 / 0120 6234 6234 and renew instantly

§ Courier the Cheque / Demand Draft in favour of “HDFC ERGO General Insurance Company Ltd” to our Customer service office

HOW TO CONTACT US?

HOW TO TRACK MY CLAIM STATUS?

You can track your claim status through any of the options below:

¡ Visit our website www.hdfcergo.com - > Help - > Track your claim section

¡ Download mobile app, link your policy and track real time status

¡ Visit Mobile App (IPO): Login into online insurance portfolio organizer (IPO) on the home page of our website www.hdfcergo.com

Kindly mention your claim number and/or policy/reference number in the correspondence

DO I GET INCOME TAX BENEFIT?

Yes, you can avail a Tax benefit under Section 80D of Income Tax Act 1961 (Subject to change in Income Tax law). Tax certificate is provided along with the

policy copy. You can mail the same on your registered Email Id through Insurance Portfolio Organiser , online .

WHAT IS THE CLAIM PROCEDURES?

1. DETAILS TO KEEP HANDY WHILE REGISTERING A CLAIM

¡ Policy Number

¡ Nature of disease/illness

¡ Brief history of diagnosis (first diagnosis date is mandatory)

2. HOW DO I FILE MY CLAIM?

¡ For Reimbursement claim intimation, customer should visit

www.hdfcergo.com > Help > Claim registration OR Send duly

signed claim form along with required documents to below address

HDFC ERGO General Insurance company Ltd, 5th floor, Tower 1,

Stellar IT Park, C-25, Sector-62, Noida, UP, India - 201301.

¡ For preauth claim write to us [email protected]

3. WHAT ARE THE BASIC DOCUMENTS REQUIRED IN CASE OF

A CLAIM?

¡ Duly filled and signed claim form (available on our website)

¡ Copy of Photo ID proof of insured and claimant

¡ Discharge card and original discharge summary

¡ Consultation note/ Relevant treatment papers

¡ All relevant medical reports along with supporting invoices and

doctors requisition advising the same

¡ Original and final hositalisation bills with detailed breakup

¡ Pharmacy bills along with prescriptions

Please note: This is not an exhaustive list. Additional docs may be

required on case to case basis.

For claim /Policy Related please calls us at 022 6234 6234 /0120 6234 6234 or Visit the Help Section on www.hdfcergo.com

HDFC ERGO General Insurance Company Limited

Policy Wordings

Sampoorna Suraksha

Insuring Clause

In consideration of payment of Premium by You and realized by Us, We

will provide insurance cover to the Insured Person(s) under this Policy

up to Sum Insured or limits mentioned on the Schedule of Coverage

in the Policy Schedule.

This Policy is subject to Your statements in respect of all the Insured

Persons in Proposal form, declaration and/or medical reports, payment

of premium and the terms and conditions of this Policy.

Denitions

Certain words used in the Coverage description have specic meanings

which are mentioned in Denitions and which impacts the Coverage. All

such words, where ever mentioned in this document are mentioned in

Bold to enable you to identify that particular word has a specic meaning

for which You need to refer Section II, Denitions.

I. Coverage

SECTION 1: MY:HEALTH SURAKSHA

Section I 1A: Hospitalization Cover

We will pay under below listed Covers On Medically Necessary

Hospitalization of an Insured Person due to Illness or Injury sustained

or contracted during the Policy Period. The payment is subject to Sum

Insured and limits including Cumulative Bonus if applicable as specied

on the Schedule of Coverage in the Policy Schedule. Subject to otherwise

terms and conditions of the Policy.

1. Medical Expenses

i. Room rent, boarding and Nursing charges

ii. Intensive Care Unit charges

iii. Consultation fees

iv. Anesthesia, blood, oxygen, operation theatre charges, surgical

appliances

v. Medicines, drugs and consumables

vi. Diagnostic procedures

vii. The Cost of prosthetic and other devices or equipment if implanted

internally during a Surgical Procedure.

Insured Person shall bear specied percentage of admissible Claim

amount under each and every Claim If Co-payment under Section

I1C-14 is opted and specied in the Schedule of Coverage in the

Policy Schedule

a) Mental Healthcare

If an Insured Person is hospitalized for any Mental Illness contracted

during the Policy period We will pay Medical Expenses under Section

I1 A in accordance with The Mental Health Care Act, 2017,subsequent

amendments and other applicable laws and Rules provided that;

i. The Hospitalization is prescribed by a Medical Practitioner for

Mental Illness

ii. The Hospitalization is done in Mental Health Establishment

2. Home Healthcare

Insured Person can avail Hospitalization at home under Home

Healthcare for Illnesses including but not limited to following Medically

Necessary Treatment, if prescribed by treating Medical Practitioner.

We will pay Medical Expenses under Section I1A-1 incurred for

treatment of such Illness where opted.

• Gastroenteritis

• Bronchopneumonia

• Respiratory tract infection

• Chemotherapy

• Pancreatitis

• Dengue

• COPD management

• Hepatitis

• Fever management

This Cover can be availed through Cashless Facility only as procedure

given under Claims Procedure - Section IV1.

Insured Person shall bear specied percentage of admissible Claim

amount under each and every Claim If Co-payment under Section I1

C-14 is opted and specied in the Schedule of Coverage in the Policy

Schedule

3. Domiciliary Hospitalization

We will pay the Medical Expenses incurred on Domiciliary

Hospitalization of the Insured Person provided that:

i. It has been prescribed by the treating Medical Practitioner

and

ii. the condition the Insured Person is such that he/she could not be

removed to a Hospital

iii. the Medical Necessary Treatment is taken at Home on account of

non-availability of room in Hospital

Expenses incurred on Domiciliary Hospitalization in respect to following

treatment are excluded under the Policy

a. Asthma, Bronchitis, Tonsillitis and Upper Respiratory Tract infection

including Laryngitis and Pharyngitis, Cough and Cold, Inuenza

b. Arthritis, Gout and Rheumatism

c. Chronic Nephritis and Nephritic Syndrome

d. Diarrhoea and all type of Dysenteries including Gastroenteritis,

e. Diabetes Mellitus and Insipidus,

f. Epilepsy,

g. Hypertension,

h. Psychiatric or Psychosomatic Disorders of all kinds,

i. Pyrexia of unknown Origin.

j. Post Hospitalization Expenses are excluded if Insured Person opts

for Domiciliary Hospitalization

Insured Person shall bear specied percentage of admissible Claim

amount under each and every ClaimIf Co-payment under Section I1C-14

is opted and specied in the Schedule of Coverage in the Policy Schedule

4. Pre-Hospitalization cover

We will pay for the Medical Expenses incurred during the 60 days

immediately before Hospitalization of an Insured Person, provided

that such Medical Expenses are incurred for the same Illness/Injury

for which subsequent Hospitalization was required and Claim under

Section I1A-1 or 1A- 6 is admissible under the Policy.

Where Insured Person has opted for Home Healthcare treatment under

Section I1 A-2, Pre-Hospitalization expenses are payable up to 60 days

prior to start of the Medical treatment.

Insured Person shall bear specied percentage of admissible Claim

amount under each and every Claim If Co-payment under Section

I1C-14 is opted and specied in the Schedule of Coverage in the

Policy Schedule

5. Post-Hospitalization cover

We will pay for the Medical Expenses incurred upto180 days from the

date Insured Person is discharged from Hospital provided that such

costs are incurred in respect of the same Illness/Injury for which the

earlier Hospitalization was required and Claim under Section I1A-1 or

1A6 is admissibleunder the Policy

Where Insured Person has opted for Home Healthcare treatment under

Section I1A-2, Post Hospitalization expenses are payable up to 180

days post completion of the medical treatment.

Insured Person shall bear specied percentage of admissible Claim

amount under each and every ClaimIf Co-payment under Section I1

C-14 is opted and specied in the Schedule of Coverage in the Policy

Schedule

6. Day Care Procedures

We will pay for the Medical Expenses under Section I1A-1 on

Hospitalization of Insured Person in Hospital or Day Care

CentreforDay Care Treatment.

Indicative list of Day Care Treatment is attached in Annexure I

Insured Person shall bear specied percentage of admissible Claim

amount under each and every ClaimIf Co-payment under Section I1

C-14 is opted and specied in the Schedule of Coverage in the Policy

Schedule

7. Road Ambulance

We will pay for expenses incurred on Road Ambulance Services if

Insured Person is required;

i. to be transferred to the nearest Hospital following an emergency

(namely a sudden, urgent, unexpected occurrence or event, bodily

alteration or occasion requiring immediate medical attention)

ii. or from one Hospital to another Hospital

iii. of from Hospital to Home (within same City) following Hospitalization

provided that Claim under Section I1 A1 and I1 A6 is admissible under

the Policy.

Insured Person shall bear specied percentage of admissible Claim

amount under each and every ClaimIf Co-payment under Section I1C-14

is opted and specied in the Schedule of Coverage in the Policy Schedule

8. Organ Donor Expenses

We will pay Medical Expenses as listed under Section I1A-1 towards

organ donor’s Hospitalization for harvesting of the donated 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

Organ (amendment) Act, 2011,Transplantation of Human Organs and

Tissues Rules, 2014and other applicable laws and rules.

ii. Hospitalization Claim under Section I1 A-1 is admissible under

the Policy

iii. The Organ Donor’s Pre-Hospitalization and Post-Hospitalization

expenses are excluded under the Policy

iv. Any other Medical Expenses or Hospitalization consequent to the

harvesting is excluded under the Policy

Insured Person shall bear specied percentage of admissible Claim

amount under each and every ClaimIf Co-payment under Section I1

C-14 is opted and specied in the Schedule of Coverage in the Policy

Schedule

9. Alternative Treatments

We will pay Medical Expensesas listed under Section I1 A-1

on Hospitalization of Insured Person for following Alternative

Treatments prescribed by Medical Practitioner

• Ayurvedic

• Unani

• Siddha

• Homeopathy

provided that;

i. The procedure performed on the Insured Person cannot be carried

out on Outpatient basis

ii. The treatment has been undertaken in a government Hospital or in

any institute recognized by government and/or accredited by Quality

Council of India/National Accreditation Board on Health or authorised

medical council of the respective country/state as applicable

iii. In the event of admissible Claim under this Cover, no Claim shall

be admissible under SectionI1 A -1 for Allopathic treatment of same

Illness or Injury

Insured Person shall bear specied percentage of admissible Claim

amount under each and every ClaimIf Co-payment under Section I1

C-14 is opted and specied in the Schedule of Coverage in the Policy

Schedule

Section I 1 B: Renewal Benets

1. Preventive Health Check-Up

After every block ofevery four consecutive, continuous and Claim free

Policy Years with Us, We will pay towards cost of Preventive Health

Check- upto specied percentage (as mentioned on the Schedule of

Coverage) of Sum Insuredfor those Insured Persons who were Insured

under the previous 4 Policy years with Us.

Other terms and Conditions applicable to this Benet

• This benet will not be carried forward if not utilized.

• Eligibility to avail Health Check-up will be in accordance to lower of

expiring Policy Sum Insured or Renewed Policy Sum Insured.

• This cover is applicable only to Insured Person covered under all four

Policy Years and who continue to remain insured in the subsequent

Policy Year/Renewal.

• Availing of Claim under this Cover will not impact the Sum Insured or

the eligibility for Cumulative Bonus

2. Cumulative Bonus

On each Renewal of the Policy with Us, We will apply 5% of Basic

Sum Insured under expiring Policy as Cumulative Bonus in the Policy

provided that;

i. There has been no claim under the Policy in expiring year under

Section I1 A

ii. Cumulative Bonus will be reduced at the same rate as accrued in the

event of admissible Claim under Section I1 A of the Policy.

iii. Cumulative Bonus can be accumulated upto 50% of Basic Sum

Insured.

iv. Cumulative Bonus applied will be applicable only to Insured

Person covered under expiring Policy and who continue to remain

insured on Renewal.

v. In case of multiyear policies, Cumulative Bonus that has accrued

for the second and third Policy Year will be credited on Renewal.

Accrued Cumulative Bonus may be utilized in case of any Claim

during Policy tenure

3. my: Health Active

A. Fitness discount @ Renewal

Insured Person can avail discount on Renewal Premium by accumulating

Healthy Weeks as per table given below.

One Healthy Week can be accumulated by;

• Recording minimum 50,000 steps in a week subject to maximum 15,000

steps per day, tracked through Your wearable device linked to Our my:

health mobile app and Your Policy number

• burning total of 900 calories upto maximum of 300 calories in one

exercise session per day, tracked Your wearable device linked to Our

my: health mobile app and Your Policy number

• Fitness discount @ Renewal is applicable for Adult Insured Persons

only. Any Person covered as Child Dependent, irrespective of the Age

is excluded.

Healthy Weeks Discounts

No. of Healthy Weeks

Accumulated

Discount on Renewal

Premium

1-4 0.50%

5-8 1.00%

9-12 2.00%

13-16 3.00%

17-26 6.00%

27-36 7.50%

Above 36 10.00%

Steps to accumulate Healthy Weeks

Step 1 - The my: Health mobile App must be downloaded on the mobile.

Step 2 - You can start accumulating Healthy Weeks by tracking physical

activity trough the Wearable device linked to Our my: health mobile

app and Your Policy number

We encourage and recognize all types of exercise/tness activities

by making use of wearable devices to track and record the activities

Insured Person engages in.

Application of Fitness discount @ Renewal

• Annual Policy: Discount amount accrued based on Number of

accumulated Healthy Weeks during the expiring PolicyYear will be

applied on the Renewal Premium for expiring Policy Sum Insured and

for Insured Person covered under expiring Policy

• Multi Year Policy:

o Fitness discount earned on yearly basis will be accumulated till

Policy End date.

o On Renewal of the Policy, total discount amount accrued each Policy

Year will be applied on Renewal Premium of subsequent year and for

Insured Person covered under expiring Policy

• For Policiescovering more than one Insured Person,Healthy Weeks

for each Insured Person will be tracked and accrued. Such discount

will be applicable on individual Renewal Premium for both Individual

and Floater Sum Insured basis Policies.

• Premium will be discounted to the extent applicable to coverage

corresponding to expiring Policy.

• In case of Increase in Sum Insured at Renewal, discount amount will be

applied on the premium corresponding to expiring Policy Sum Insured.

• Fitness discount @ Renewal will be applied only on Renewal of Policy

with Us and only if accrued.

B. Health Incentive

This Program encourages Insured Persons to maintain good health and

avail incentives as listed below.

Under this Program, Insured Person having Pre-Existing Diseases

or Obesity (BMI above 30) as listed under table A below, will be eligible

for reduction in Medical Underwriting Loading applied on rst inception

of the Policy with Us provided that;

i. Insured Person shall undergomedical tests and/or BMIcheck-upas

listed belowminimum 3 months prior to expiry of Policy Year (For

Multiyear Policies) or before Renewal (For Annual Policies).

ii. Medical test shall be done at Your own cost through our Network

Provider on Our my: health mobile App.

iii. If the test parameters are within normal limits, We will apply 50%

discount on the Medical Underwriting loading applied for corresponding

Pre-Existing Disease or Obesity as applicable on Renewal of the

Policy with Us.

iv. If the test parameters at subsequent Renewal are not within normal

limits or Medical test reports are not submitted in accordance with

i and ii above, the discount amount applied on Medical Underwriting

loading will be zero

Table A

Pre-existing Diseases Test

Diabetes HbA1c

Hypertension Blood Pressure reading

Hyperlipidemia Total Cholesterol

Cardiovascular Diseases ECG

Hypothyroidism Thyroid function tests

Obesity BMI

Application of Health Incentive

• Annual Policy: Discount amount accrued during the expiring Policy

year will be applied on the Renewal Premium corresponding to

expiring Policy Sum Insuredand for Insured Person covered under

expiring Policy

• Multi Year Policy:

o Discount amount earned on yearly basis will be accumulated till

Policy End date.

• On Renewal of the Policy, total discount amount accrued each year will

be applied on Renewal Premium of subsequent yearand for Insured

Person covered under expiring Policy

• For Policies covering more than one Insure Person, tests shall be done

for each Insured Person basis which such reduction in loading where

ever applicable will be applied on individual Renewal Premium for both

Individual and Floater Sum Insured basis Policies.

• Medical Underwriting loading will be discounted only on Renewal

of Policy with Us and only for Insured Person covered under such

expiring Policy

• Discount on Medical Underwriting loading under this cover is

applicable only on next Renewal and cannot be utilized if Policy not

renewed with us.

C. Wellness services:

The services listed below are available to all Insured Person through

Our Network Provider on Our my: health mobile app only. Availing

of services under this Section will not impact the Sum Insured or the

eligibility for Cumulative Bonus.

i. Health Coach:

An Insured Person will have access to Health Coaching services in

areas such as:

• Disease management

• Activity and tness

• Nutrition

• Weight management.

These services will be available through Our my: health mobile app

as a chat service or as a call back facility.

ii. Wellness services

• Discounts: on OPD, Pharmaceuticals, pharmacy, diagnostic centres.

• Customer Engagement: Monthly newsletters, Diet consultation,

health tips

• Specialized programs: like stress management, Pregnancy Care,

Work life balance management.

These services will be available through Our my: health mobile app

Disclaimer applicable to my: health Mobile app and associated

services

It is agreed and understood that Our my:health mobile app and Wellness

services intention is not to provide specic medical advice but rather

to provide users with information to better understand their health and

their diagnosed disorders. The information is not a substitute for

professional medical care by a qualied doctor or other health care

professional.

The information provided is general in nature and is not specic to you.

You must never rely on any information obtained using this app for any

medical diagnosis or recommendation for medical treatment or as an

alternative to medical advice from your physician or other professional

healthcare provider. If you think you may be suffering from any medical

condition you should seek immediate medical attention.

Reliance on any information on this App is solely at your own risk. HDFC

EGRO General Insurance Company Limited do not assume any liability

towards any loss or damage arising out of or in relation to any opinion,

actual or alleged errors, omissions and representations, any decision

made or action taken or not taken in reliance upon the information.

Section I 1 C: Optional Covers

Insuring Clause

In consideration of payment of additional Premium or reduction in the

Premium as applicable, it is hereby declared and agreed that We will

pay/restrict the expenses under below listed Covers subject to all other

terms, conditions, exclusions and waiting periods applicable to the Policy.

These Covers are optional and applicable only if opted for and upto

the Sum Insured or limits mentioned on the Schedule of Coverage in

the Policy Schedule.

1. Preventive Health Check-Up - Booster

On opting this Cover, Insured Person will be entitled for Health Check-up

after each Policy Year with Us irrespective of Claims made under the

Policy in accordance with options given below.

i. We will reimburse the cost of Preventive Health Check-upup to limits

mentioned on the Schedule of Coverage.

ii. Insured Person shall have the option to undergo Health Check-Up

at our Network Service Provider in accordance to criteria given below.

Sum Insured Tests

Upto 2 Lacs Medical Examination Report, Complete Blood

Count Urine R, Fasting Blood Sugar, Serum

Creatinine, Lipid Prole, Electro Cardio Gram

3 Lac and above Chest X Ray , 2D echo/ Stress test, PSA

for Males, PAP smear for Females, Medical

Examination Report, Complete Blood Count

Urine R, Fasting Blood Sugar, Serum

Creatinine, Lipid Prole, Electro Cardio Gram

Other Terms and Conditions applicable to this Cover

• This benet will not be carried forward if not utilized within 60 days of

Policy Anniversary/Renewal date.

• On opting this Cover, Renewal Benet 1, Preventive Health Check-up

under Section I1 B stands deleted.

2. Parent and Child care Cover - Basic

We will pay to the Insured Personsubject to waiting period as mentioned

in the Schedule of Coverage on the Policy Schedule under Covers as

given below.

I. Parent Care

i. Medical Expenses under Section I1 A1 for Maternity Expenses

limited up to 2 deliveries or 1 delivery and 1 termination or 2 terminations

during the lifetime of the Insured Person

ii. OPD Treatment in Pre-natal and Post-natal period provided Claim

under Maternity Expenses is admissible under the Policy.

II. Child Care

We will pay/coverfollowing expenses towards Child Care for New Born

Babyunder this cover if Claim for Maternity Expensesis admissible

under the Policy.

i. We will pay Medical Expenseslisted under Section I1 A1 withinSum

Insured for Parent Caretowards treatment of a New Born Babyas per

limit mentioned on Schedule of Coverage.

ii. New Born Baby Cover–We will cover New Born Baby immediately

after the birth as per original terms of the Policy on receipt of completed

proposal form and Premium received within 90 days of birth of Baby and

subject to acceptance by Us.

If this Cover is opted, General exclusion III b 1. ix) under General

Exclusions, Section III a 1 iv, stands deleted.

Exclusions applicable to this Cover.

i. Pre-Hospitalization and post-Hospitalization expenses are not

payable under this cover

ii. We will not pay any expenses related to ectopic pregnancy under

this cover. Ectopic pregnancy will be covered as a part of expenses

under SectionI 1A1 only.

iii. Treatment for impotency, treatment to effect infertility, surrogate or

vicarious pregnancy, voluntary termination of pregnancy, procedures to

assist birth control, contraceptive supplies.

3. Parent and Child care Cover – Booster

We will pay to the Insured Person subject to waiting period and limits

as mentioned in the Schedule of Coverage on the Policy Schedule under

Covers as given below.

I. Parent Care

i. Maternity Expenses - Medical Expenses for a delivery (including

caesarean section) on Hospitalization or the lawful medical termination

of pregnancy during the Policy Period.

ii. OPD Treatment in Pre-natal and post-natal periodup to the limit of

this cover, provided Claim under i. Maternity Expenses is admissible

under the Policy

iii. Infertility Treatment:Medical Expenseslisted under Section I1 A1

incurred for infertility treatment, assisted reproductive treatments like IVF

undertaken on advice of a Medical Practitioner, up to 50% of Normal

Delivery Sum Insured under this Cover. This cover is applicable for both

Male and Female Insured Person

II. Child Care

We will pay following expenses towards Child Care for New Born

Baby under this cover if Claim for Maternity Expenses is admissible

under the Policy.

i) New Born baby cover:

We will pay Medical Expenses listed under Section I1 A1 towards

treatment of a New Born Baby within the limit of Sum Insured under this

Cover as mentioned in Schedule of Coverage on the Policy Schedule

ii) Vaccination Charges:

We will pay expenses incurred on vaccination for New Born Baby

as per National Immunization Schedule until New Born Baby completes

1 year of age subject to maximum of sub limit of Sum Insured under

this Cover.

If opted, this cover General exclusion Section III b 1 .ix), x), xx) under

General Exclusions, Section III and Optional Cover 2 “Parent and Child

Cover – Basic” under Section I 1C stands deleted.

III. Waiting Period modication Option

On availing this option, Waiting Period listed under Section –III a 1, iv,

will stand modied as mentioned in the Schedule of Coverage on the

Policy Schedule.

All other terms and conditions of the Parent & Child Care Cover - Booster

shall remain unaltered.

Exclusions applicable to this Cover.

i. Pre-Hospitalization and post-Hospitalization expenses are not payable

under this cover

ii. We will not pay any expenses related to ectopic pregnancy under

this cover. Ectopic pregnancy will be covered as a part of expenses

under Section I1 A1 only.

iii. Treatment for impotency, treatment to effect infertility, surrogate or

vicarious pregnancy, voluntary termination of pregnancy, procedures to

assist birth control, contraceptive supplies.

4. Air Ambulance Cover

We will pay for Air Ambulance transportation in an airplane or helicopter

for Emergency Care which requires immediate and rapid ambulance

transportation as prescribed by a Medical Practitioner, from the site

of rst occurrence of the Illness/Accident to the nearest Hospital,that

ground transportation cannot provide. Claim would be reimbursed up to

the actual expenses subject to a maximum of Sum Insured as specied

on theSchedule of Coverage in the Policy Schedule.

Exclusion:

We will not pay for return transportation to the Insured Person’s home

by air ambulance

5. Recovery Benet

We will pay Sum Insured as specied on the Schedule of Coverage

in the Policy Schedule upon Medically Necessary Hospitalization of

an Insured Person exceeding 10 consecutive and continuous days

and for which Claim is admissible under Section I1 A– Hospitalization

Cover.

This benet is not applicable ifMedical treatment is taken under Section

I1 A2 – Home Health care and 1A3 – Domiciliary Hospitalization

6. Sum Insured Rebound

We will add to the Sum Insured, an amount equivalent to the admissible

Claim amount, subject to maximum of Basic Sum Insured, on subsequent

Hospitalization of the Insured Person during Policy Year subject to;

i. Total of Basic Sum Inured under Hospitalization Cover, Cumulative/

Extended Cumulative Bonus (if applicable) earnedand Sum Insured

Rebound will be available to all Insured Persons for all claims under

Section I1A during the current Policy Year and subject to the condition

that a single claim in a Policy Year cannot exceed the sum of Basic

Sum Insured and the Cumulative/Extended Cumulative Bonus (if

opted) earned

ii. In case of treatment for Chemotherapy and Dialysis, Sum Insured

Rebound will be applicable only once in lifetime of Policy

i. This cover will be applicable annually for policies with term more

than one year.

ii. Any unutilized amount of Sum Insured Rebound cannot be carried

over to next Policy Year or Renewal Policy

iii. The Sum Insured Rebound can be utilized for Claims under Section

I1 A only.

Illustration 1

Time Claim No.

Sum Insured

available

Cumulative Bonus

available

Admissible

Claim amount

SI Rebound

Available

Total SI Rebound

till date

Payable

amount

3 months

3,00,000 30,000 2,50,000 0 0 2,50,000

5 months 50,000 30,000 1,40,000 0 0 80,000

9 months 2 0 0 2,50,000 3,00,000 3,00,000 2,50,000

11 months 4 0 0 70,000 50,000 3,00,000 50,000

Illustration 2

Time Claim No.

Sum Insured

available

Cumulative Bonus Admissible

Claim amount

SI Rebound

Total SI Rebound

till date

Payable

amount

3 months 1 3,00,000 30,000 2,50,000 0 0 2,50,000

6 months 2 50,000 30,000 1,40,000 2,50,000 2,50,000 1,40,000

9 months 3 0 0 2,50,000

=250,000-

60,000+50,000

3,00,000 2,40,000

=240,000

11 months 4 0 0 70,000 0 3,00,000 0

7. Outpatient Dental Treatment

After threeconsecutive and continuous Policy Years with Us, We will pay

50% of Medical Expenses incurred by Insured Person towards Dental

Treatment prescribed by Medical Practitioner up to the amount as

mentioned in the Schedule of Coverage on the Policy Schedule. Claim

under this Section can be availed only through our Network Provider.

The Cover is applicable only to Insured Person covered under three

consecutive and continuous Policy Years and who continue to remain

insured in the subsequent Policy Year/Renewal

The Coverage is applicable only towards cost of X-rays, extractions,

amalgam or composite llings, root canal treatments and prescribed

drugs for the same.

Claim under this Section will not affect Cumulative Bonus under

Section I1 B2, condition ii.

Exclusions specic to Outpatient Dental Treatment

i. Cosmetic surgery, dentures, dental prosthesis, dental implants,

orthodontics, orthognathic surgery, jaw alignment or treatment for the

temporomandibular (jaw) joint, or upper and lower jaw bone surgery and

surgery related to the temporomandibular (jaw) unless necessitated by

an acute traumatic injury due to an accident or cancer

8. External Medical Aids

After every twoconsecutive and continuous Policy Year with Us, We

will pay up to 50% of cost incurred towards following Medical Expenses

subject to maximum of Sum Insured as mentioned in the Schedule of

Coverage, on the Policy Schedule;

i. One pair of spectacles or one pair of contact lenses,

ii. A hearing aid

Other terms

• The Cover is applicable only to Insured Person covered under two

consecutive and continuous Policy Years and who continue to remain

insured in the subsequent Policy Year/Renewal

• Under a Family Floater Policy, Our liability shall be limited to either one

pair of spectacles or contact lenses or hearing aid per family.

• Medical Expenses incurred under this Cover shall be prescribed by

our Network Provider and is payable only once after block of every

two consecutive and continuous Policy Year with Us.

• Claim under this Section will not affect Cumulative Bonus under

Section I1 B2, condition ii

9. Major Illness Hospitalization Expenses

We will payfor Medical Expenses incurred and admissible under Section

I1 A1,up to additional Sum Insured equivalent to Basic Sum Insured,on

Medically necessary Hospitalization of Insured Person for Major

illnesseslisted below whose diagnosis rst commence/occursafter the

applicable waiting period from commencement of the rst Policy with

Us, subject to the following;

i. Waiting Period – The coverage is subject to Waiting Period as

mentioned on Schedule of Coverage on the Policy Schedule

ii. Claim for each Major Illnessis payable only once during the lifetime

of Policy with Us. However, Insured Person will continue to be covered

under this Section for other Major Illnesses.

iii. Claim under this Cover is admissible only when total of Basic Sum

Insuredis completely utilized.

iv. The additional Sum Insured under this Cover is exclusive and specic

for the treatment of the rst occurrence of the above Critical Illness

undertaken in a Hospital/Nursing Home as an in-patient and will not be

available for other illnesses/hospitalization.

Major Illness Covered

1 Cancer of specied

severity

6 Major Organ/Bone Marrow

Transplant

2 Open Chest CABG 7 Stroke resulting in permanent

symptoms

3 Myocardial Infarction

(First Heart Attack of

specic severity)

8 Surgery of Aorta

4 Kidney Failure requiring

regular dialysis

9 Primary (Idiopathic)

Pulmonary Hypertension

5 Multiple Sclerosis with

Persisting Symptoms

10. Non-Medical Expenses cover

We will pay for Non-Medical Expenses upto the limit mentioned in

Schedule of Coverage in the Policy Schedule on Medically necessary

Hospitalization of Insured Person for claims admissible under Section

I1A1, 2 and 3.

In view of this Cover, Exclusion xxi) of Section III b , shall stand covered

upto the extent mentioned above.

11. Waiting period Modication Option

On availing this option, Waiting Periods listed under Section III a 1 – i,

ii and iii will stand modied as mentioned in Schedule of Coverage on

the Policy Schedule for following Sections;

Section I1 A – Hospitalization Cover

Section I1C4 – Air Ambulance

Section I1C5 – Recovery Benet

Section I1C9 – Major Illness Hospitalization Expenses

Section I1C17 –Hospital Cash

Section I1C18 – Global Health Cover

All other terms and Conditions of the respective Section and Policy

shall remain unaltered.

12. Extended Cumulative Bonus

On availing this cover, Cumulative Bonus percentage mentioned under

Section I1 B2 – Cumulative Bonus will stand modied as mentioned in

Schedule of Coverage on the Policy Schedule subject to;

i. Once the Extended Cumulative Bonus benet is availed by the

Insured Person, it cannot be opted out at subsequent Renewal.

ii. All other terms and Conditions of Renewal Benets Section I1 B, ii

shall remain unaltered.

13. Room Rent Modication Option

On availing this option, limits specied under Section I1 A1 i and I1A ii

will stand modied as below.

i. Room Rent, boarding and Nursing – limit of 1% of the Basic Sum

Insured subject to maximum of Rs. 5,000 per day

ii. Intensive care unit – limit of 2% of the Basic Sum Insured subject

to maximum of Rs. 10,000 per day

Proportionate deduction:

In case expenses incurred on i and ii above exceed respective applicable

limits under the Policy, expenses incurred under Section I1 A1, iii and

iv , shall be paid in the same proportion as the admissible rate per day

bears to the actual rate per day of Room Rent charges

14. Co-Payment

On availing this option, Co-Payment as mentioned on the Schedule

of Coverage in the Policy Schedule will be applied on each and every

admissible claim after Deductible/Excess wherever applicable under the

Policy. Once the Co-Payment option is availed by the Insured Person,

it cannot be opted out of at subsequent Renewal.

15. Major Illness – Benet

If the eldest Insured Person covered under the Policy suffers from Major

Illness as listed below, whose diagnosis rst commence/occurs after the

applicable Waiting Period from commencement of rst Policy with Us,

We will pay Sum Insured as mentioned on the Schedule of Coverage.

The Coverage under this benet shall cease to exist upon occurrence

of any one Major Illness covered for which Claim is admitted by the

Company.

Major Illness Covered

1 Cancer of specied severity 7 Permanent Paralysis of

Limbs

2 Open Chest CABG 8 Stroke resulting in

Permanent Symptoms

3 Myocardial Infarction(First

Heart Attack of specic

severity)

9 Surgery of Aorta

4 Kidney Failure requiring

regular dialysis

10 Primary (Idiopathic)

Pulmonary Hypertension

5 Major Organ/Bone Marrow

Transplant

11 Open Heart Replacement

or Repair of Heart Valves

6 Multiple Sclerosis with

Persisting Symptoms

Survival Period

Claim under this Cover is payable only if Insured Person survives 30

days from the diagnosis, fulllment of the denition of the Major illness

covered and with conrmatory diagnosis of the conditions covered

while the Insured Person is alive (A claim would not be admitted if the

diagnosis is made post mortem)

16. E-Opinion

We will pay expenses incurred towards second Medical Opinion availed

from Medical Practitionerin respect of Major Illness covered and listed

below under the Policy through our Network Provider.

The Coverage under this benet shall cease to exist upon availing

Second Opinion for any one Major Illness as listed below.

Major Illness Covered

1 Cancer of specied

severity

7 Permanent Paralysis of Limbs

2 Open Chest CABG 8 Stroke resulting in Permanent

Symptoms

3 Myocardial Infarction(First

Heart Attack of specic

severity)

9 Surgery of Aorta

4 Kidney Failure requiring

regular dialysis

10 Primary (Idiopathic)

Pulmonary Hypertension

5 Major Organ/Bone

Marrow Transplant

11 Open Heart Replacement or

Repair of Heart Valves

6 Multiple Sclerosis with

Persisting Symptoms

Disclaimer - E- Opinion Services are being offered by Network

providers through its portal/mail/App or what so ever electronic form

to Policyholders/Insured of HDFC ERGO GENERAL INSURANCE

COMPANY LIMITED. In no event shall HDFC ERGO be liable for any

direct, indirect, punitive, incidental, special consequential damages or

any other damages whatsoever caused to the Policyholders/Insured

of HDFC ERGO while receiving the services from Network providers.

17. Hospital Cash

We will pay per day Sum Insured up to maximum Number of days

and in manner as specied in Schedule of Coverage on the Policy

Schedule,for each continuous and completed period of 24 hours of

Medically Necessary Hospitalization of an eldest Insured Personin

the Policyand for which Claim is admissible under SectionI1 A –

Hospitalization Cover.

18. Global Health Cover

On availing this Cover,We will paythe Expenses incurred outside India

under Sections and Covers given below.

Section I1A: Hospitalization Cover

A1 Medical Expenses A7 Road Ambulance

A4 Pre-Hospitalization cover A8 Organ Donor Expenses

A5 Post-Hospitalization cover A9 Alternative Treatments

A6 Day Care Procedures

Section I1C: Optional Covers

C1 Preventive Health Check-Up

- Booster

C10 Non-Medical Expenses

cover

C2 Parent and Child care Cover

- Basic

C3 Parent and Child care Cover

– Booster

C15 Major Illness – Benet

C4 Air Ambulance Cover C16 E-Opinion

C5 Recovery Benet C17 Hospital Cash

C6 Sum Insured Rebound

C7 Outpatient Dental Treatment

C8 External Medical Aids

C9 Major Illness Hospitalization

Expenses

Global Cover is applicable subject to following terms and conditions

i. Global coverage for expenses towards all the listed covers is applicable

and effective only if mentioned on the Schedule of Coverage in the

Policy Schedule.

ii. A Deductible of USD 100 will apply for expenses under all the

respective covers separately for each and every claim.

iii. Claims on Reimbursement basis will be payable in INR only.

iv. All other terms and conditions of the respective Section and Covers

under the policy shall remain unaltered.

SECTION 2: MY:HEALTH CRITICAL SURAKSHA PLUS

Section I.2.A. Base Covers

I. Critical Illnesses Cover

1. Cancer Cover

If Insured Person suffers from Critical illnessor undergoesSurgical

Procedure as listed below, whose diagnosis rst commence/occurs

after the applicable Waiting Period from commencement of rst Policy

with Us, We will pay Sum Insured or percentage of Sum Insured in

accordance with table below:

Critical illness /

Surgical Procedure

Stage

Percentage of

Sum Insured

Payable

Waiting

Period

Applicable

1 Malignant Cancer of

specied Sites

Major

100% of Sum

Insured

90 days

Specied Sites-

Female

Breast

Cervix

Uterus

Fallopian Tube

Ovary

Vagina/Vulva

Critical illness /

Surgical Procedure

Stage

Percentage of

Sum Insured

Payable

Waiting

Period

Applicable

Specied Sites- Male

Major

100% of Sum

Insured

90 days

Head and Neck

Lung

Stomach

Colorectum

Prostate

2 Cancer of specied

severity

Major 100% of Sum

Insured

90 days

3 Aplastic Anemia Major 100% of Sum

Insured

90 days

4 Major Organ

Transplant – Bone

Marrow

Major 100% of Sum

Insured

90 days

5 Early Stage Cancer Minor 25% of Sum

Insured

subject to

maximum of

Rs. 1,000,000

180 days

6 Carcinoma in situ Minor

2. Heart Cover

If Insured Person suffers fromCritical illnessor undergoesSurgical

Procedure as listed below, whose diagnosis rst commence/occurs

after the applicable Waiting Period from commencement of rst Policy

with Us, We will pay Sum Insured or percentage of Sum Insured in

accordance with table below:

Critical Ailments/

Procedures

Stage

Percentage

of Sum

Insured

Payable

Waiting

Period

Applicable

1 Open Chest CABG Major

100%

of Sum

Insured

90 days

2 Myocardial Infarction

(First Heart Attack of

specied severity)

Major

3 Open Heart Replacement

or Repair of Heart Valves

Major

4 Major Organ Transplant

– Heart

Major

5 Surgery of Aorta Major

6 Primary (Idiopathic)

Pulmonary Hypertension

Major

7 Other serious coronary

artery disease

Major

8 Dissecting Aortic

Aneurysm

Major

9 Cardiomyopathy Major

10 Eisenmenger’s

Syndrome

Major

11 Infective Endocarditis Major

12 Angioplasty Minor 25%

subject to

maximum

payout

of INR

1,000,000

180 days

13 Balloon Valvotomy or

Valvuloplasty

Minor

14 Insertion of Pacemaker Minor

3. Nervous System Cover

If Insured Personsuffers from Critical illnessor undergoes Surgical

Procedure listed belowafter the applicable Waiting Period from

commencement of rst Policy with Us, We will pay Sum Insuredin

accordance with table below:

Critical illness /

Surgical Procedure

Stage

Percentage

of Sum

Insured

Payable

Waiting

Period

Applicable

1 Multiple Sclerosis with

persisting symptoms

Major

100%

of Sum

Insured

90 days

2 Permanent Paralysis

of Limbs

Major

3 Stroke resulting in

permanent symptoms

Major

4 Benign Brain Tumour Major

5 Coma of specied

severity

Major

6 Parkinson’s Disease Major

7 Alzheimer’s Disease Major

8 Motor Neurone Disease

with permanent

symptoms

Major

9 Muscular Dystrophy Major

10 Apallic Syndrome Major

11 Bacterial Meningitis Major

12 Creutzfeldt-Jakob

Disease (CJD)

Major

13 Encephalitis Major

14 Major Head Trauma Major

15 Progressive

Supranuclear Palsy

Major

16 Brain Surgery Major

17 Loss of Speech Major

4. Other Major Organ Cover

If Insured Personsuffers from Critical illnessor undergoesSurgical

Procedure listed below after the applicable Waiting Period from

commencement of rstPolicy with Us, We will pay percentage of Sum

Insured in accordance with table below:

Critical illness /Surgical

Procedure

Stage

Percentage

of Sum

Insured

Payable

Waiting

Period

Applicable

1 Kidney failure requiring

regular dialysis

Major

100%

of Sum

Insured

90 days

2 Major Organ Transplant

– Kidney, Lung, Liver and

Pancreas

Major

3 End Stage Liver Failure Major

4 Medullary Cystic Disease Major

5 Systemic Lupus

Erythematous with Lupus

Nephritis

Major

6 End Stage Lung Failure Major

7 Fulminant Hepatitis Major

8 Chronic Adrenal

Insufciency (Addison’s

Disease)

Major

9 Progressive Scleroderma Major

10 Chronic Relapsing

Pancreatitis

Major

Critical illness /Surgical

Procedure

Stage

Percentage

of Sum

Insured

Payable

Waiting

Period

Applicable

11 Elephantiasis Major

100% days

of sum

insured

90 days

12 HIV due to blood

transfusion and

occupationally acquired

HIV

Major

13 Terminal Illness Major

14 Myelobrosis Major

15 Pheochromocytoma Major

16 Crohn’s Disease Major

17 Severe Rheumatoid

Arthritis

Major

18 Severe Ulcerative Colitis Major

19 Deafness Major

20 Blindness Major

21 Third Degree Burns Major

22 Severe Osteoporosis Minor 25%

subject to

maximum

payout

of INR

1,000,000

180 days

Covers and General Conditions applicable to Section I2AI, 1 to 4

1. Reduced Premium Benet

If Insured Person is diagnosed with any covered Minor condition

covered under this section and for which Claim is admissible under the

Policy, We will waive 50% of the applicable Annual RenewalPremium

on subsequent Renewal of Policy with Us subject to:

i. Premium will be waived for the Renewal of Insured Personfor whom

the claim has been made, to the extent applicable to Coverage, terms

and conditions corresponding to expiring yearPolicy.

ii. Premium will be waived for subsequent Renewal of 5 PolicyYearsonly.

2. Survival Period

Claim under Section I2AI, 1 to 4is payable only if Insured Person

survives 7 days from the diagnosis and fulllment of the denition of

theCriticalIllness or Surgical Procedurecovered.

The Claim is admissible only with conrmatory diagnosis of the conditions

covered while the Insured Person is alive (A claim would not be admitted

if the diagnosis is made post mortem)

3. Number of Claims and Benets payable

Only one claim is payable under each of the stages given below during

lifetime of the Policy under this Sectionsubject to maximum 100% of

Sum Insured mentioned on the Policy Schedule irrespective of Number

of Sections opted and Number of Policies held by the Insured Person.

Minor Stage - On the admissibility of Claim under Minor Stage condition

under the Policy, coverage for all other Minor stage Conditions shall

cease to exist. The Policy shall continue to Cover Major Stage condition

for the Balance Sum Insured.

Major Stage – On the admissibility of Claim under Major Stage condition,

coverage under this Policy shall cease to exist.

In the event where an Insured Person holds multiple Policies insuring

different Covers under this Section of this product, Claim will be

admissible under one Cover only and Total Sum Insured as applicable

under such Cover across all policies of this product will be paid by the

Company. Insurance for other Covers, if applicable, shall cease to exist.

II. Multipay Critical Illnesses Cover

1. Cancer Cover

If Insured Person suffers fromCritical illnessor undergoesSurgical

Procedure as listed below, whose diagnosis rst commence/occurs

after the applicable Waiting Period from commencement of rst Policy

with Us, We will pay Sum Insured or percentage of Sum Insured in

accordance with table below:

Sr.

No.

Critical illness /

Surgical Procedure

Stage

Percentage

of Sum

Insured

Payable

Waiting

Period

Applicable

1 Cancer of Specied

Severity

Major

100%

of Sum

Insured

90 days2 Aplastic Anemia Major

3 Major Organ Transplant

– Bone Marrow

Major

2. Heart Cover

If Insured Person suffers fromCritical illnessor undergoes Surgical

Procedure as listed below, whose diagnosis rst commence/occurs

after the applicable Waiting Period from commencement of rst Policy

with Us, We will pay Sum Insured or percentage of Sum Insured in

accordance with table below:

CriticalAilments /

Surgical Procedures

Stage

Percentage

of Sum

Insured

Payable

Waiting

Period

Applicable

1 Open Chest CABG Major

100% of Sum

Insured

90 days

2 Myocardial Infarction

(First Heart Attack of

specied severity)

Major

3 Open Heart

Replacement or Repair

of Heart Valves

Major

4 Major Organ Transplant

– Heart

Major

5 Surgery of Aorta Major

6 Primary (Idiopathic)

Pulmonary

Hypertension

Major

7 Other serious coronary

artery disease

Major

8 Dissecting Aortic

Aneurysm

Major

9 Cardiomyopathy Major

10 Eisenmenger’s

Syndrome

Major

11 Infective Endocarditis Major

B* Angioplasty Minor 25% subject

to maximum

payout of

INR1,000,000

180 days

*B - Angioplasty

We will pay 25% of Sum Insured subject to maximum of INR 10,00,000

if Insured Person undergoes Angioplasty,whose diagnosis and/or

manifestation rst commence/occurs more than 180 days after the

commencement of rst Policy with Us.

On the admissibility of Claim under Angioplasty, coverage for Angioplasty

shall cease to exist. The Policy shall continue to cover other Critical

illnessor Surgical Procedureunder this cover, for Balance Sum

Insuredin accordance with table above.

3. Nervous System Cover

If Insured Personsuffers from Critical illnessor undergoes Surgical

Procedure listed below after the applicable Waiting Period from

commencement of rst Policy with Us, We will pay percentage of Sum

Insured in accordance with table below:

Critical illness /Surgical

Procedure

Stage

Percentage

of Sum

Insured

Payable

Waiting

Period

Applicable

1 Multiple Sclerosis with

persisting symptoms

Major

100%

of Sum

Insured

90 days

2 Permanent Paralysis of

Limbs

Major

3 Stroke resulting in

permanent symptoms

Major

4 Benign Brain Tumour Major

5 Coma of specied

severity

Major

6 Parkinson’s Disease Major

7 Alzheimer’s Disease Major

8 Motor Neurone Disease

with permanent

symptoms

Major

9 Muscular Dystrophy Major

10 Apallic Syndrome Major

11 Bacterial Meningitis Major

12 Creutzfeldt-Jakob

Disease (CJD)

Major

13 Encephalitis Major

14 Major Head Trauma Major

15 Progressive Supranuclear

Palsy

Major

16 Brain Surgery Major

17 Loss of Speech Major

4. Other Major Organ Cover

If Insured Personsuffers from Critical illnessor undergoes Surgical

Procedure listed below after the applicable Waiting Period from

commencement of rst Policy with Us, We will pay percentage of Sum

Insured in accordance with table below:

Critical illness /Surgical

Procedure

Stage

Percentage

of Sum

Insured

Payable

Waiting

Period

Applicable

1 Kidney failure requiring

regular dialysis

Major

100%

of Sum

Insured

90 days

2 Major Organ Transplant

– Kidney, Lung, Liver and

Pancreas

Major

3 End Stage Liver Failure Major

4 Medullary Cystic Disease Major

5 Systemic Lupus

Erythematous with Lupus

Nephritis

Major

6 End Stage Lung Failure Major

7 Fulminant Hepatitis Major

8 Chronic Adrenal

Insufciency (Addison’s

Disease)

Major

9 Progressive Scleroderma Major

10 Chronic Relapsing

Pancreatitis

Major

11 Elephantiasis Major

Critical illness /Surgical

Procedure

Stage

Percentage

of Sum

Insured

Payable

Waiting

Period

Applicable

12 HIV due to blood

transfusion and

occupationally acquired

HIV

Major

100%

of Sum

Insured

90 days

13 Terminal Illness Major

14 Myelobrosis Major

15 Pheochromocytoma Major

16 Crohn’s Disease Major

17 Severe Rheumatoid

Arthritis

Major

18 Severe Ulcerative Colitis Major

19 Deafness Major

20 Blindness Major

21 Third Degree Burns Major

Covers and General Conditions applicable to Section I2 AII, 1 to 4

1. Reduced Premium Benet

If Insured Person is diagnosed with any coveredCriticalIllness

under any Cover from Section I 2AII, 1 to 4 and for which Claim is

admissible under the Policy, We will waive 50% of the applicable

Annual RenewalPremium on subsequent Renewal of Policysubject to:

i. Premium will be waived for the renewal of Insured person for whom

the claim has been made, to the extent applicable to Coverage, terms

and conditions corresponding to expiring Policy.

ii. Premium will be waived for subsequent Renewal of 5 Policy Years,

following every admissible claim under each Cover.

2. Survival Period

Each Claim under Section I2AII, 1 to 4 is payable only if Insured Person

survives 7 days from the diagnosis and fulllment of the denition of

theCritical Illness or Surgical Procedure covered.

The Claim is admissible only with conrmatory diagnosis of the conditions

covered while the Insured Person is alive (A claim would not be admitted

if the diagnosis is made post mortem)

3. Number of Claims and Waiting Period

Coverage under this Section shall cease to exist; once a Claim has

been admitted under each of the Covers as opted by the Insured Person

and maximum 100% of the Sum Insured is paid by the Company under

such Covers subject to 12 months waiting period between Claims under

any two Covers.

In the event where an Insured Person holds multiple Policies under

this Section of this product, Total Sum Insured under this section

across all policies of this product will be paid by the Company for each

admissible claimsubject to 12 months waiting period between Claims

under any two Covers.

For Example: If an Insured Person suffers a Stroke resulting in

permanent symptoms and at any time within 12 months also suffers

from Myocardial Infraction (First Heart Attack of specied severity)

thereby triggering claims under both Nervous System Cover and Cardiac

Cover, the Company will pay maximum 100% of Sum Insured under one

Cover only. However, if the two incidences were separated by more than

12 months’ time period, theCompany will pay maximum 100% of Sum

Insured under each Cover.

Section B. my: health Active

1. Fitness discount @ Renewal

Insured Person can avail discount on Renewal Premium by

accumulating Healthy Weeks as per table given below.

One Healthy Week can be accumulated by;

• Recording minimum 50,000 steps in a week subject to maximum 15,000

steps per day, tracked through Your wearable device linked to Ourmy:

health mobile app andYourPolicy number

• burning total of 900 calories up to maximum of 300 calories in one

exercise session per day, tracked Your wearable device linked to Ourmy:

health mobile appendYourPolicy number

Healthy Weeks Discounts

No. of Healthy Weeks

Accumulated

Discount on Renewal

Premium

1-4 0.50%

5-8 1.00%

9-12 2.00%

13-16 3.00%

17-26 6.00%

27-36 7.50%

Above 36 10.00%

Steps to accumulate Healthy Weeks

Step 1 - The my: Health App must be downloaded on the mobile.

Step 2 - You can start accumulating Healthy Weeks by tracking physical

activity trough the Wearable device linkedtomy: Health App

We encourage and recognize all types of exercise/tness activities

by making use of wearable devices to track and record the activities

Insured Person engages in.

Application of Fitness discount @ Renewal

• Annual Policy: Discount amount accrued based on Number of

accumulated Healthy Weeks during the expiring Policy year will be

applied on the Renewal Premium for expiring Policy Sum Insured.

· Multi Year Policy:

o Fitness discount earned on yearly basis will be accumulated till

Policy End date.

o On Renewal of the Policy, total discount amount accrued each year

will be applied on Renewal Premium of subsequent year.

• For Policiescovering more than one Insured Person, Healthy Weeks

for each Insured Person will be tracked andaccumulated. Such

discount will be applicable on individual RenewalPremium.Premium

will be discounted to the extent applicable to coverage corresponding

to expiring Policy.

• In case of Increase in Sum Insured at Renewal, discountpercentage

will be applied on the Sum Insured applicable under expiring Policy.

• Fitness discount @ Renewal will be applied only on Renewal of

Policy with Us.

2. Health Incentive

This Program encourages Insured Person to maintain good health and

avail incentives as listed below.

Under this Program, Insured Person having Pre-Existing Diseases

orObesity (BMI above 30)as listed under table A below, will be eligible

for reduction in Medical Underwriting Loading applied at rst inception

of the Policy with Us provided that;

i. Insured Person shall undergo medical tests and/or BMI check-up

below minimum 3 months prior to expiry of Policy Year (For Multiyear

Policies) or before Renewal (For Annual Policies).

ii. Medical test shall be done at Your own cost through our Network

Providerthrough Our my: health mobile app App.

iii. If the test parameters are within normal limits, We will apply 50%

discount on the Medical Underwriting loading applied for corresponding

Obesityas applicableon Renewal of the Policy with Us.

iv. If the test parameters at subsequent renewal is not within normal

limits or Medical test reports are not submitted in accordance with i

and ii above, the discount amount applied on Medical Underwriting

loading will be zero.

Table A

Pre-existing Diseases Test

Diabetes HbA1c

Hypertension Blood Pressure reading

Hyperlipidemia Total Cholesterol

Hypothyroidism Thyroid function tests

Obesity BMI

Application of Health Incentive

• Annual Policy: Discount amount accrued during the expiring Policy

year will be applied on the Renewal Premium for expiring Policy Sum

Insured.

• Multi Year Policy:

o Discount amount earned on yearly basis will be accumulated till

Policy End date.

o On Renewal of the Policy, total discount amount accrued each year

will be applied on Renewal Premium of subsequent renewal.

• For Policiescovering more than one Insure Person,tests shall be done

for each Insured Person basis which such reduction in loading will be

applicable on individual Renewal Premium.

• Medical Underwriting loading will be discounted only on Renewal of

Policy with Us

• Discount on Medical Underwriting loading under this cover is applicable

only on next Renewal and cannot be utilized if Policyis not renewed

with Us.

3. Wellness services:

The services listed below are available to all Insured Person through

Our Network Provider on Ourmy: health mobile apponly.

i. Health Coach:

An Insured Person will have access to Health Coaching services in

areas such as:

• Disease management

• Activity and tness

• Nutrition

• Weight management.

These services will be available through Our my: health mobile app

as a chat service or as a call back facility.

ii. Wellness services

• Discounts: on OPD, Pharmaceuticals, pharmacy, diagnostic centers.

• Customer Engagement: Monthly newsletters, Diet consultation,

health tips

• Specialized programs: like stress management, Pregnancy Care,

Work life balance management

These services will be available through Our my: health mobile app

Disclaimer applicable to my: health Mobile app and associated

services

It is agreed and understood that Our my:health mobile app and Wellness

services are not providing and shall not be deemed to be providing any

Medical Advice, they shall only provide a suggestion for the Insured

Person’s consideration and it is the Insured Person’s sole and absolute

choice to follow the suggestion for any health related advice. We do

not assume any liability towards any loss or damage arising out of

or in relation to any opinion, actual or alleged errors, omissions and

representations suggested under this benet.

Section C. Renewal Benet

1. Preventive Health Check Up

Insured Person will be entitled for Preventive Health Check-up

onRenewal of the Policy with Us, at our Network Diagnostic centers

or hospitals in accordance to r list of tests, eligibility criteria and waiting

period as specied below:

Health Checkup- on each Policy Renewal

Age / Expiring

Policy Sum

Insured

1 Lac to

10Lacs

11 Lacs to

50 Lacs

Above

50 Lacs

18 to 40 Years Set 1 Set 1, Thyroid,

USG abdomen

and pelvis

Set 1, Thyroid , USG

abdomen and pelvis,

Lipid Prole, Renal

Prole

41 Yrs and

Above

Set 1,

Sr Creat

Set 1,SrCreat,

Thyroid, USG

abdomen and

pelvis

Set 1, Thyroid, USG

abdomen and pelvis,

Lipid Prole,Renal

prole, ECG

Set 1 -Comprises of, Complete Blood Count, Urine R,FBS,Sr Cholesterol

Health Checkup – Additional Tests

Age Gender Type of Test Waiting Period

Sum

Insured

Below

40 years

Female PAP Smear &

Mammography

Once in two

years

All Sum

Insured

Male PSA

Above

40 years

Female PAP Smear &

Mammography

Once in four

years

All Sum

Insured

Male PSA

Other terms and Conditions applicable to this Benet

• This benet will not be carried forward if not utilized within 60 days of

RenewalPolicy Inception date.

• Eligibility to avail Health Check-up will be in accordance to expiring

Policy Sum Insured.

• The test reports received under this benet shall not be utilized for

re-underwriting the Policy

Procedure for availing this benet

i. Insured personwill be intimated to undergo the health check-up at

our Network Provider, through Our my: health App.

ii. Test reports from our Network Provider will be made available to

You on Our my: health App

iii. You havethe option to avail this benet at our Network Provider

through Phone/Email or other modes of communication available

time to time.

Section D. Optional Covers

Insuring Clause

In consideration of payment of additional Premium by You, We will

provide insurance to the Insured Person(s)under below listed Covers,

up toSum Insuredor limits mentioned on the Schedule of Coverage

in the Policy Schedule.These Covers are optional and applicable

only if opted for.

1. Pre Diagnosis Cover

If a Claim is admissible under Section I2A I or I2A II as opted, We will pay

the expenses incurred towards diagnostic tests/ procedures incurred up

to 30 days priorto the diagnosis of such Critical Illness or Undergoing

of such Surgical Procedure.

Indicative list of Procedures covered

Sr.

No.

List of Diagnostic tests/ Procedures

1 Renal/Cardiac Angiogram.

2 Intravenous Pyelogram.

3 Ultrasonagraphy.

4 Ultrasound Guided FNAC.

5 Colour Doppler.

6 Mammography.

Sr.

No.

List of Diagnostic tests/ Procedures

7 CT Scan.

8 MRI Scan.

9 Treadmill Test ECHO.

10 Cardiogram.

11 Electrophysiology.

12 Endoscopic Procedures.

13 Special Radiological Procedures such as barium meal

investigations

14 Arthrogram, ERCP, Intravenous Urogram, Cystourethrogram,

15 Nephrostogram.

16 Special Blood Investigations such as Assay of Various Blood

Factors.

17 Virology Markers, Complete Coagulation Work up

2. Post Diagnosis Support

a. Second Medical Opinion

We will pay expenses incurred towards second Medical Opinion availed

from Medical Practitionerin respect of Critical Illness/Surgical

Procedurefor which Claim is admissible under the Policy.

b. Molecular Gene Expression Proling Test

We will pay the expenses incurred towards the expenses for Molecular

Gene Expression Proling Test for Treatment Guidance on diagnosis

of any Major stage Cancer for which Claim is admissible under Section

I2A I.1or I2A II.1, Cancer Cover as opted. The benet under this cover

can be availed only once during lifetime of the Policy.

c. Post Diagnosis Assistance

We will paySum Insuredtowardsoutpatient counseling required upon

diagnosis ofCritical Illnessesand Surgical Proceduresfor which Claim

is admissible under Section I2 A I or I2A II as opted. The Cover is subject

to maximum number of sessions as specied on Schedule of Coverage.

Applicability of Cover (Applicable to a. and c.)

Section I 2A I – if Base Coverage is opted under Section I2A I, the

Claim under this cover is admissible only once in life time of the Policy

Section I 2 A II – if Base Coverage is opted under Section I2A II, the

Claim under this cover is admissible after every admissible Claim

under the Policy

3. Loss of Job

We will pay Sum Insured if Insured Person suffers from Loss of Job

due to his/her Voluntary Resignation or Termination from the employment

within six months of diagnosis of any of the Major stage Critical Illnesses

or undergoing any of the Major stage Surgical Proceduresfor which

Claim is admissible under Section I2A I or I2A II of the Policy.

SECTION 3: MY:HEALTH MEDISURE SUPER TOP UP

INSURANCE

If during the PolicyPeriod, You suffer from any illness or accident which

requires Hospitalization as an inpatient, We will reimburse the amount

of such Medical Expenses as per the benets given below, in excess of

Aggregate Deductible and subject to a maximum of the Sum Insured

as stated in the Schedule.

1. In-patient Hospitalization Expenses:

If any Insured Person suffers an Illness or Accident during the Policy

Period requiring Inpatient Hospitalization, We will pay the Medical

Expenses incurred for

1.1 Room Rent/ Boarding & Nursing;

1.2 ICU Rent/Boarding & Nursing;

1.3 Fees of Surgeon, Anesthetist, Nurses and Specialists;

1.4 Cost of Operation Theatre, diagnostic tests, medicines, blood, oxygen

and cost of prosthetic and other devices or equipment if implanted

internally like pacemaker during a surgical procedure.

Occurrence of same illness after a lapse of 45 days will be considered

as fresh illness for the purpose of this Policy

2. Pre-Hospitalization Medical Expenses –

The Medical Expenses incurred in the 30 days immediately before You

were Hospitalized, provided that:

i. Such Medical Expenses were in fact incurred for the same condition

requiring subsequent Hospitalization, and;

ii. We have accepted the Claim under Scope of Cover 1 “In-patient

Hospitalization expenses”.

3. Post Hospitalization Medical Expenses –

The Medical Expenses incurred in the 60 days immediately after You

were discharged, provided that:

i. Such Medical Expenses were in fact incurred for the same condition

for which Your Hospitalization was required, and;

ii. We have accepted the Claim under Scope of Cover 1, “In-patient

Hospitalization expenses”.

3. Post Hospitalization Medical Expenses –

The Medical Expenses incurred in the 60 days immediately after You

were discharged, provided that:

i. Such Medical Expenses were in fact incurred for the same condition

for which Your Hospitalization was required, and;

ii. We have accepted the Claim under Scope of Cover 1, “In-patient

Hospitalization expenses”.

4. Day Care treatment –

The Medical Expenses for a day care treatment where the procedure

or surgery

- is undertaken is under General or Local Anaesthesia in a Hospital/

Day care centre for less than 24 hours because of technological

advancement, and

- which would have otherwise required hospitalization of more than

24 hours

- does not cover any treatment in an outpatient department or diagnostic

procedures.

Please refer annexure 1 at the end of this document for indicative list

of covered Day Care treatments

SECTION 4: MY:HEALTH HOSPITAL CASH BENEFIT

ADD ON

Section I. 4. A: Coverage

1. Hospital Cash Benet

We will pay Sum Insured on Medically NecessaryHospitalization

of an Insured Persondue to Illnessor Injurysustained or contracted

during the Policy Period. The payment is subject to per day benet Sum

Insuredas specied on the Schedule of Coverage in the Policy Schedule

for up to maximum of 30 days.

2. Companion Benet:

We will pay additional amount upto the limit specied on the Schedule of

Coverage in the Policy Schedule towards expenses of an accompanying

person during Hospitalizationfor up to maximum of 30 days.

Section I. 4 B: Optional Cover

Insuring Clause

In consideration of payment of additional Premium, it is hereby declared

and agreed that We will pay under below listed Cover subject to all other

terms, conditions, exclusions and waiting periods applicable to the add

on and Policy on which this add on is attached.

The Cover is optional and applicable only if opted for and up to the

Sum Insured or limits mentioned on the Schedule of Coverage in the

Policy Schedule.

1. Hospital Cash benet - Global

On availing this option, Wewill pay Sum Insured on Medically

NecessaryHospitalization of an Insured Personoutside India due

to Illnessor Injurysustained or contracted during the Policy Period.

2. Waiting period Modication Option

On availing this option, Waiting Periods listed under Section III

a 1: Waiting Periods will stand modied as mentioned in Schedule of

Coverage on the Policy Schedule.

All other terms and Conditions of the respective Section and Policy

shall remain unaltered.

Section C: Renewal Benets

A. Fitness discount @ Renewal

Insured Person can avail discount on Renewal Premium by accumulating

Healthy Weeks as per table given below.

One Healthy Week can be accumulated by;

• Recording minimum 50,000 steps in a week subject to maximum 15,000

steps per day, tracked through Your wearable device linked to Ourmy:

health mobile appandYourPolicy number

• burning total of 900 calories upto maximum of 300 calories in one

exercise session per day, tracked Your wearable device linked to Ourmy:

health mobile appandYourPolicy number

• Fitness discount @ Renewal is applicable for Adult Insured Persons

only. Any Person covered as Child Dependent, irrespective of the Age

is excluded

Healthy Weeks Discounts

No. of Healthy Weeks

Accumulated

Discount on Renewal

Premium

01-04 0.50%

05-08 1.00%

09-12 2.00%

13-16 3.00%

17-26 6.00%

27-36 7.50%

Above 36 10.00%

Steps to accumulate Healthy Weeks

Step 1 - The my: Health App must be downloaded on the mobile.

• Step 2 - You can start accumulating Healthy Weeks by tracking physical

activity trough the Wearable device linkedto Ourmy: health mobile

appandYourPolicy number

We encourage and recognize all types of exercise/tness activities

by making use of wearable devices to track and record the activities

Insured Person engages in.

Application of Fitness discount @ Renewal

• Annual Policy: Discount amount accrued based on Number of

accumulated Healthy Weeks during the expiring Policy year will be

applied on the Renewal Premium for expiring Policy Sum Insured.

• Multi Year Policy:

o Fitness discount earned on yearly basis will be accumulated till

Policy End date.

o On Renewal of the Policy, total discount amount accrued each year

will be applied on Renewal Premium of subsequent year.

• For Policiescovering more than one Insure Person,Healthy Weeks for

each Insured Person will be tracked andaccumulated. Such discount

will be applicable on individual Renewal Premium for both Individual

and Floater Sum Insured basis Policies.

• Premium will be discounted to the extent applicable to terms

corresponding to expiring Policy.

• In case of Increase in Sum Insured at Renewal, discount amount

will be applied on the Sum Insured applicable under expiring Policy.

• Fitness discount @ Renewal will be applied only on Renewal of

Policy with Us.

B. Health Incentive

This Program encourages Insured Persons to maintain good health and

avail incentives as listed below.

Under this Program, Insured Personhaving Pre-Existing Diseasesor

Obesity (BMI above 30) as listed under table A below, will be eligible for

reduction in Medical Underwriting Loading applied from rst inception

of the Policy with Us provided that;

i. Insured Person shall undergomedical tests and/or BMIcheck-upas

listed belowminimum 3 months prior to expiry of Policy Year (For

Multiyear Policies) or before Renewal (For Annual Policies).

ii. Medical test shall be done at Your own cost through our Network

Provider on my:Health mobile App.

iii. If the test parameters are within normal limits, We will apply 50%

discount on the Medical Underwriting loading applied for corresponding

Pre-Existing Diseaseor Obesity as applicableon Renewal of the

Policy with Us.

iv. If the test parameters at subsequent renewal are not within normal

limits or Medical test reports are not submitted in accordance with i

and ii above, the discount amount applied on Medical Underwriting

loading will be zero

v. The test reports received to avail the health incentive benet shall not

be utilised for re underwriting the policy

Table A

Pre-existing Diseases Test

Diabetes HbA1c

Hypertension Blood Pressure reading

Hyperlipidemia Total Cholesterol

Cardiovascular Diseases ECG

Hypothyroidism Thyroid function tests

Obesity BMI

Application of Health Incentive

• Annual Policy: Discount amount accrued during the expiring Policy

year will be applied on the Renewal Premium for expiring Policy Sum

Insured.

• Multi Year Policy:

o Discount amount earned on yearly basis will be accumulated till

Policy End date.

o On Renewal of the Policy, total discount amount accrued each year

will be applied on Renewal Premium of subsequent year.

• For Policiescovering more than one Insure Person,testsshall be done

for each Insured Person basis which such reduction in loading will be

applicable on individual RenewalPremium for both Individual and Floater

Sum Insured basis Policies.

• Discount on Medical Underwriting loading under this cover is

applicable only on next Renewal and cannot be utilized if Policy not

renewed with us.

C. Wellness services:

The services listed below are available to all Insured persons through

Our Network Provider on Our mobile application only. Availing of

services under this Section will not impact the Sum Insured or the

eligibility for Cumulative Bonus.

i. Health Coach:

An Insured Person will have access to Health Coaching services in

areas such as:

• Disease management

• Activity and tness

• Nutrition

• Weight management.

These services will be available through Our mobile application as a

chat service or as a call back facility.

ii. Online Wellness services

• Discounts: on OPD, Pharmaceuticals,pharmacy, , diagnostic centres

etc.

• Customer Engagement: Monthly newsletters, Diet consultation,

health tips

• Specialized programs: like stress management, Pregnancy Care,

Work life balance management etc.

Disclaimer applicable to my: health Mobile app and associated

services

It is agreed and understood that Our my:health mobile app and Wellness

services are not providing and shall not be deemed to be providing any

Medical Advice, they shall only provide a suggestion for the Insured

Person’s consideration and it is the Insured Person’s sole and absolute

choice to follow the suggestion for any health related advice. We do

not assume any liability towards any loss or damage arising out of

or in relation to any opinion, actual or alleged errors, omissions and

representations suggested under this benet.

SECTION 5: PERSONAL ACCIDENT INSURANCE

1. Accidental Death

If during the Period of Insurance an Insured Person sustains Bodily

Injury which directly and independently of all other causes results

in Death within twelve (12) months of the Date of Loss, then the

Company agrees to pay to the Insured Person’s Beneciary or legal

representative the Compensation stated in the Schedule.

Specic Extensions

1) Disappearance: In the event of the disappearance of the Insured

Person, following a forced landing, stranding, sinking or wrecking of a

conveyance in which such Insured Person was known to have been

travelling as an occupant, it shall be deemed after twelve (12) months,

subject to all other terms and conditions of this Policy, that such Insured

Person shall have died as the result of an Accident. If at any time,

after the payment of the Accidental death benet, it is discovered that

the Insured Person is still alive; all payments shall be reimbursed in

full to the Company.

2) Exposure: Death as a direct result of exposure to the elements shall

be deemed to be Bodily Injury.

Specic Conditions

If applicable and if payment has been made under the Permanent

Disablement Section, any amounts paid under that Section would be

deducted from payment of a claim under this Section of the Policy.

2. Permanent Disablement

If during the Period of Insurance an Insured Person sustains Bodily

Injury which directly and independently of all other causes results in

disablement within twelve (12) months of the Date of Loss, then the

Company agrees to pay to the Insured Person the Compensation

stated in the specic Table of Benets below, which is shown as the Table

of Benets in the Schedule. The Deductible or Franchise, if applicable,

shall be deducted from the Compensation payable.

Specic Extensions

Exposure: Permanent disablement as a direct result of exposure to the

elements shall be deemed to be Bodily Injury.

Specic Provisions

1) Ankylosis of the ngers (other than thumb and forenger) and of the

toes (other than the big toe) shall be limited to fty percent (50%) of the

Compensation payable for the loss of the said members.

2) Any benet payable under item 23 of Table (C) shall be at the complete

discretion of the Company taking into consideration the nature of the

Bodily Injury in conjunction with the stated Compensation percentages

for more specic injuries shown in the Table of Benets.

Specic Conditions

1) The insurance shall terminate for an Insured Person under this

Section upon payment of a benet equal to the Total Sum Insured.

2) The total amount payable in respect of more than one disablement

due to the same Accident is arrived at by adding together the various

percentages shown in the Table of Benets, but shall not exceed the

Total Sum Insured.

3) The Deductible or Franchise, if applicable, shall apply to the total

amount payable, irrespective of the number of benets an Insured

Person is entitled to.

4) If an Insured Person dies as the result of the Bodily Injury any

amount claimed and paid to an Insured Person under the Permanent

Disablement Section will be deducted from any payment under the

Accidental Death Section.

Specic Denitions for all Tables of Benets

1) Limb means the hand above the wrist joint or foot above the ankle

joint.

2) Loss of Hearing means the total and irrecoverable Loss of Hearing.

3) Loss of Mastication means the total and irrecoverable loss of ability

to chew food.

4) Loss of Sight means the total and irrecoverable Loss of Sight. This

is considered to have occurred if the degree of sight remaining after

correction is 3 / 60 or less on the Snellen Scale.

5) Loss of Speech means the total and irrecoverable Loss of Speech.

Specic Denitions for Table (A)

Loss used with reference to Limb means the loss by physical severance

of such Limb.

Specic Denitions for Table (B)

Loss used with reference to Limb means the loss by physical severance

or the total and permanent loss of use of such Limb.

Specic Denitions for Table (C) and (D)

Loss used with reference to Limb and / or ngers, thumbs or toes,

means the loss by physical severance or the total and permanent loss

of use of said member.

TABLE OF BENEFITS – TABLE (A)

The Disablement

Compensation

Expressed as a

Percentage of Total

Sum Insured

1) Permanent Total Disablement 100%

2) Permanent and incurable insanity 100%

3) Permanent Total Loss of two Limbs 100%

4) Permanent Total Loss of Sight in

both eyes

100%

5) Permanent Total Loss of Sight of one

eye and one Limb

100%

6) Permanent Total Loss of Speech 100%

7) Complete removal of the lower jaw 100%

8) Permanent Total Loss of Mastication 100%

9) Permanent Total Loss of the central

nervous system or the thorax and

all abdominal organs resulting in the

complete inability to engage in any

job and the inability to carry out Daily

Activities essential to life without full

time assistance

100%

10) Permanent Total Loss of Hearing in

both ears

75%

11) Permanent Total Loss of one Limb 50%

12) Permanent Total Loss of Sight of

one eye

50%

TABLE OF BENEFITS – TABLE (B)

The Disablement

Compensation

Expressed as a

Percentage of Total

Sum Insured

1) Permanent Total Disablement 100%

2) Permanent and incurable insanity 100%

3) Permanent Total Loss of two Limbs 100%

4) Permanent Total Loss of Sight in

both eyes

100%

5) Permanent Total Loss of Sight of one

eye and one Limb

100%

6) Permanent Total Loss of Speech 100%

7) Complete removal of the lower jaw 100%

8) Permanent Total Loss of Mastication 100%

9) Permanent Total Loss of the central

nervous system or the thorax and

all abdominal organs resulting in the

complete inability to engage in any

job and the inability to carry out Daily

Activities essential to life without full

time assistance

100%

10) Permanent Total Loss of Hearing in

both ears

75%

11) Permanent Total Loss of one Limb 50%

12) Permanent Total Loss of Sight of

one eye

50%

TABLE OF BENEFITS – TABLE (C)

The Disablement

Compensation

Expressed as

a Percentage

of Total Sum

Insured

1) Permanent Total Disablement 100%

2) Permanent and incurable insanity 100%

3) Permanent Total Loss of two Limbs 100%

4) Permanent Total Loss of Sight in both eyes 100%

5) Permanent Total Loss of Sight of one eye

and one Limb

100%

6) Permanent Total Loss of Speech 100%

7) Complete removal of the lower jaw 100%

8) Permanent Total Loss of Mastication 100%

9) Permanent Total Loss of the central nervous

system or the thorax and all abdominal

organs resulting in the complete inability to

engage in any job and the inability to carry

out Daily Activities essential to life without

full time assistance

100%

10) Permanent Total Loss of Hearing in both

ears

75%

11) Permanent Total Loss of one Limb 50%

12) Permanent Total Loss of Sight of one eye 50%

13) Permanent Total Loss of Hearing in one ear 15%

14) Permanent Total Loss of the lens in one eye 25%

15) Permanent Total Loss of use of four ngers

and thumb of either hand

40%

16) Permanent Total Loss of use of four ngers

of either hand

20%

The Disablement

Compensation

Expressed as

a Percentage

of Total Sum

Insured

17) Permanent Total Loss of use of one thumb

of either hand:

a) Both joints 20%

b) One joint 10%

18) Permanent Total Loss of one nger of either

hand:

a) Three joints 5%

b) Two joints 3.5%

c) One joint 2%

19) Permanent Total Loss of use of toes:

a) All – one foot 15%

b) Big – both joints 5%

c) Big – one joint 2%

d) Other than Big – each toe 2%

20) Established non-union of fractured leg or

kneecap

10%

21) Shortening of leg by at least 5 cms. 7.50%

22) Ankylosis of the elbow, hip or knee 20%

23) Permanent disablement not otherwise

provided for under Items 2-22 inclusive up to

a maximum of

75%

TABLE OF BENEFITS – TABLE (D)

The Disablement

Compensation

Expressed as a

Percentage of Total

Sum Insured

1) Permanent Total Disablement 100%

2) Permanent and incurable insanity 100%

3) Permanent Total Loss of two Limbs 100%

4) Permanent Total Loss of Sight in

both eyes

100%

5) Permanent Total Loss of Sight of one

eye and one Limb

100%

6) Permanent Total Loss of Speech 100%

7) Complete removal of the lower jaw 100%

8) Permanent Total Loss of Mastication 100%

9) Permanent Total Loss of the central

nervous system or the thorax and

all abdominal organs resulting in the

complete inability to engage in any

job and the inability to carry out Daily

Activities essential to life without full

time assistance

100%

10) Permanent Total Loss of Hearing in

both ears

75%

11) Permanent Total Loss of one Limb 50%

12) Permanent Total Loss of Sight of

one eye

50%

13) Permanent Total Loss of Hearing in

one ear

15%

14) Permanent Total Loss of the lens in

one eye

25%

The Disablement

Compensation

Expressed as a

Percentage of Total

Sum Insured

15) Permanent Total Loss of use of four

ngers and thumb of either hand

40%

16) Permanent Total Loss of use of four

ngers of either hand

20%

17) Permanent Total Loss of use of one

thumb of either hand:

a) Both joints 20%

b) One joint 10%

18) Permanent Total Loss of one nger of

either hand:

a) Three joints 5%

b) Two joints 3.5%

c) One joint 2%

19) Permanent Total Loss of use of toes:

a) All – one foot 15%

b) Big – both joints 5%

c) Big – one joint 2%

d) Other than Big – each toe 2%

20) Established non-union of fractured leg

or kneecap

10%

21) Shortening of leg by at least 5 cms. 7.50%

22) Ankylosis of the elbow, hip or knee 20%

3. In-Hospital Medical Expenses – Accident Only

If, during the Period of Insurance, an Insured Person sustains Bodily

Injury and is hospitalized as an in-patient for twenty-four (24) continuous

hours or more, then the Company will reimburse the Insured Person

the necessary Usual and Reasonable In-Hospital Medical Expenses,

incurred within twelve (12) months from the Date of Loss up to the

Total Sum Insured stated in the Schedule, subject to the Terms and

Conditions of this Policy. The Deductible or Franchise, if applicable,

shall be deducted from the Compensation payable.

Specic Conditions

1) Usual and Reasonable In-Hospital Medical Expenses shall include

and be limited to the following services:

a) charges for semi private Hospital room and board, use of the

operating room, emergency room, and Ambulatory Medical Centre

b) fees of Physicians.

c) charges for laboratory tests, ambulance service (to or from the

Hospital), prescription medicines or drugs, therapeutics, anaesthetics

(including administration of anaesthetics), transfusions, articial Limbs

or eyes (excluding repair or replacement of these items), x-rays,

prosthetic appliances.

d) charges for a registered nurse (R.N).

2) If an Insured Person has other insurance against a loss covered by

this Section, then the Company shall not be liable for a greater proportion

of the loss than the applicable benet under this Section bears to the

total applicable benet under all such insurance.

Specic Denitions

1) Ambulatory Medical Centre means a licensed facility providing

ambulatory surgical or medical treatment, other than a Hospital, clinic

or Physician’s ofce.

2) Usual and Reasonable In-Hospital Medical Expenses means

fees and prices generally charged in the locality where performed for

medically necessary services and supplies required for treatment of

cases of comparable severity and nature, but not to include charges

that would not have been made if no insurance existed.

Specic Exclusions

The Company shall not be liable to pay any benet in respect of any

Insured Person for:

1) Any Usual and Reasonable In-Hospital Medical Expenses before

the Period of Insurance.

2) any dental work.

3) any claim caused by or arising from or due to Sickness of any and

every kind.

4. Emergency Medical Expenses – Accident Only

If, during the Period of Insurance, an Insured Person sustains Bodily

Injury, then the Company will reimburse the Insured Person the

necessary Usual and Reasonable Medical Expenses, incurred within

twelve (12) months from the Date of Loss up to the Sum Insured stated

in the Schedule, subject to the Terms and Conditions of this Policy. The

Deductible or Franchise, if applicable, shall be deducted from the

Compensation payable.

Specic Conditions

1) Medical Expenses shall include and be limited to the following

services:

a) charges for semi-private Hospital room and board, use of the

operating room, emergency room, and Ambulatory Medical Centre.

b) fees of Physicians.

c) Medical Expenses, in or out of Hospital, including: laboratory tests,

ambulance service (to or from the Hospital), prescription medicines

or drugs, therapeutics, anaesthetics (including administration of

anaesthetics), transfusions, articial Limbs or eyes (excluding repair or

replacement of these items), x-rays, prosthetic appliances.

d) charges for a registered nurse (R.N).

2) If an Insured Person has other insurance against a loss covered by

this Section, then the Company shall not be liable for a greater proportion

of the loss than the applicable benet under this Section bears to the

total applicable benet under all such insurance.

Specic Denitions

1) Ambulatory Medical Centre means a licensed facility providing

ambulatory surgical or medical treatment, other than a Hospital, clinic

or Physician’ s ofce.

2) Usual and Reasonable Medical Expenses means fees and

prices generally charged in the locality where performed for medically

necessary services and supplies required for treatment of cases of

comparable severity and nature, but not to include charges that would

not have been made if no insurance existed.

Specic Exclusions

The Company shall not be liable to pay any benet in respect of any

Insured Person for:

1) AnyMedical Expenses incurred where an Insured Journey is

undertaken against the advice of a qualied licensed medical practitioner.

2) AnyMedical Expenses incurred when the specic purpose of a

journey is to receive medical treatment or advice.

3) AnyMedical Expenses incurred within the territorial limits that are

not stated in the Schedule.

4) any medical treatment, drugs or medicines, prescribed or applied,

before the Period of Insurance.

5) any dental work.

6) any claim caused by or arising from or due to Sickness of any and

every kind.

5. Emergency Medical Expenses

If, during the Period of Insurance, an Insured Person sustains

Bodily Injury or sudden unexpected Sickness, then the Company will

reimburse the Insured Person the necessary Usual and Reasonable

Medical Expenses, incurred within twelve (12) months from the Date

of Loss up to the Sum Insured stated in the Schedule. The Deductible

or Franchise, if applicable, shall be deducted from the Compensation

payable.

Specic Conditions

1) Medical Expenses shall include and be limited to the following

services:

a) charges for semi-private Hospital room and board, use of the

operating room, emergency room, and Ambulatory Medical Centre.

b) fees of Physicians.

c) Medical Expenses, in or out of Hospital, including: laboratory tests,

ambulance service (to or from the Hospital), prescription medicines

or drugs, therapeutics, anaesthetics (including administration of

anaesthetics), transfusions, articial Limbs or eyes (excluding repair or

replacement of these items), x-rays, prosthetic appliances.

d) charges for a registered nurse (R.N).

2) If an Insured Person has other insurance against a loss covered by

this Section, then the Company shall not be liable for a greater proportion

of the loss than the applicable benet under this Section bears to the

total applicable benet under all such insurance.

Specic Denitions

1) Ambulatory Medical Centre means a licensed facility providing

ambulatory surgical or medical treatment, other than a Hospital, clinic

or Physician’ s ofce.

2) Usual and Reasonable Medical Expenses means fees and

prices generally charged in the locality where performed for medically

necessary services and supplies required for treatment of cases of

comparable severity and nature, but not to include charges that would

not have been made if no insurance existed.

Specic Exclusions

The Company shall not be liable to pay any benet in respect of any

Insured Person for:

1) AnyMedical Expenses incurred where an Insured Journey is

undertaken against the advice of a qualied licensed medical practitioner.

2) AnyMedical Expenses incurred when the specic purpose of a

journey is to receive medical treatment or advice.

3) AnyMedical Expenses incurred within the territorial limits that are

not stated in the Schedule.

4) any medical treatment, drugs or medicines, prescribed or applied,

before the Period of Insurance.

any dental work.

6. Hospital Cash – Accident Only

If during the Period of Insurance an Insured Person sustains Bodily

Injury which directly and independently of all other causes results in

the Insured Person being in a Hospital as an inpatient within one (1)

calendar month of the Date of Loss, then the Company agrees to pay

to the Insured Person the Daily Benet stated in the Schedule. The

Deductible or Franchise, if applicable, shall be deducted from the

Compensation payable.

Specic Provisions

In case of successive Hospital stays with less than sixty (60) Days

between each one for a same cause, the Deductible or Franchise will

only apply once, as the Hospital stays will be deemed as one event.

Special Conditions

Once the Company has paid the Daily Benet up to the maximum

number of Days stated in the Schedule, cover under this Section will

cease for such Insured Person.

7. Hospital Cash & Home Convalescence – Accident Only

If during the Period of Insurance an Insured Person sustains Bodily

Injury which directly and independently of all other causes results in

the Insured Person being in a Hospital as an inpatient within one (1)

calendar month of the Date of Loss, then the Company agrees to pay

to the Insured Person the Daily Benet stated in the Schedule. In

addition, if the Insured Person is instructed by a Physician to complete

his/her recovery at home, then the Company will pay the Daily Home

Allowance stated in the Schedule. The Deductible or Franchise, if

applicable, shall be deducted from the Compensation payable.

Specic Provisions

In case of successive Hospital stays with less than sixty (60) Days

between each one for a same cause, the Deductible or Franchise will

only apply once, as the Hospital stays will be deemed as one event.

Specic Conditions

1) The Daily Home Allowance will be limited to the maximum number

of Days an Insured Person was in Hospital as an in-patient or the

maximum number of Days stated in the Schedule, whichever is the

lesser.

2) Once the Company has paid the Daily Benet and Daily Home

Allowance up to the maximum number of Days stated in the Schedule,

cover under this Section will cease for such Insured Person.

8. Hospital Cash – Accident & Sickness

If during the Period of Insurance an Insured Person sustains Bodily

Injury or Sickness which directly and independently of all other causes

results in the Insured Person being in a Hospital as an in-patient within

one (1) calendar month of the Date of Loss, then the Company agrees

to pay to the Insured Person the Daily Benet stated in the Schedule.

The Deductible or Franchise, if applicable, shall be deducted from the

Compensation payable.

Specic Provisions

In case of successive Hospital stays with less than sixty (60) Days

between each one for a same cause, the Deductible or Franchise will

only apply once, as the Hospital stays will be deemed as one event.

Specic Conditions

Once the Company has paid the daily benet up to the maximum number

of Days stated in the Schedule, cover under this Section will ease for

such Insured Person.

9. Hospital Cash & Home Convalescence – Accident & Sickness

If during the Period of Insurance an Insured Person sustains Bodily

Injury or Sickness which directly and independently of all other causes

results in the Insured Person being in a Hospital as an in-patient within

one (1) calendar month of the Date of Loss, then the Company agrees

to pay to the Insured Person the Daily Benet stated in the Schedule. In

addition, if the Insured Person is instructed by a Physician to complete

his/her recovery at home, then the Company will pay the Daily Home

Allowance stated in the Schedule. The Deductible or Franchise, if

applicable, shall be deducted from the Compensation payable.

Specic Provisions

In case of successive Hospital stays with less than sixty (60) Days

between each one for a same cause, the Deductible or Franchise will

only apply once, as the Hospital stays will be deemed as one event.

Specic Conditions

1) The Daily Home Allowance will be limited to the maximum number

of Days an Insured Person was in Hospital as an in-patient or the

maximum number of Days stated in the Schedule, whichever is the

lesser.

2) Once the Company has paid the Daily Benet and Daily Home

Allowance up to the maximum number of days stated in the Schedule,

cover under this Section will cease for such Insured Person.

10. Broken Bones

If during the Period of Insurance an Insured Person sustains Bodily

Injury which directly and independently of all other causes results in a

broken bone as specied in this Section, then the Company agrees to

pay to the Insured Person the Compensation stated in the Table of

Benets up to the Total Sum Insured in the Schedule. The Deductible

or Franchise, if applicable, shall be deducted from the Compensation

payable.

TABLE OF BENEFITS

Fracture

% of Sum

Insured

1) Fractures of the Skull:

a) Compound fracture with damage to the brain

tissue

100

b) Compound fracture without damage to the

brain tissue

c) All other fractures 50

2) Fractures of hip or pelvis (excluding thigh or

coccyx):

a) Multiple fractures (at least one compound &

one complete)

100

b) All other compound fractures 50

c) Multiple fractures, at least one complete 30

d) All other fractures 20

3) Fracture of thigh or heel:

a) Multiple fractures (at least one compound &

one complete)

b) All other compound fractures 40

c) Multiple fractures, at least one completed) 30

All other fractures 20

4) Fracture of Lower Leg, Clavicle, Ankle, Elbow,

Upper or Lower Arm (including wrist, but

excluding Colles-type fracture):

a) Multiple fractures (at least one compound &

one complete)

b) All other compound fractures

c) Multiple fractures, at least one complete

d) All other fractures 40302012

5) Fractures of Lower Jaw:

a) Multiple fractures (at least one compound &

one complete)

b) All other compound fractures

c) Multiple fractures, at least one complete

d) All other fractures 3020168

6) Fractures of Shoulder Blade, Kneecap, Sternum,

Hand (excluding ngers and wrist), Foot

(excluding toes and heel):

a) All compound fractures

b) All other fractures 2010

7) Colles type fracture to the Lower Arm:

a) Compound 20

b) Other 10

8) Fractures of Spinal Column (Vertebrae but

excluding coccyx):

a) All compression fractures 20

b) All spinous, transverse process or pedicle

fractures

c) All other vertebral fractures 10

9) Fractures of Rib or Ribs, Cheekbone, Coccyx,

Upper Jaw, Nose, Toe and toes, nger or ngers:

a) Multiple fractures (at least one compound &

one complete)

b) All other compound fractures 12

c) Multiple fractures, at least one complete 8

d) All other fractures 4

Specic Conditions

1) No benet will be paid before any fracture is recognized medically

and a Physician has established the extent and nature of the fracture.

2) The total amount payable under this Section, in respect of more

than one fracture due to the same Bodily Injury, will be calculated

by adding the various benets together, but shall not exceed the Total

Sum Insured.

3) In the event that an Insured Person has received a benet under this

Section, and the same Bodily Injury results in permanent disablement,

any benets paid under this Section will be deducted from the Permanent

Disablement benet

11. Burns

If during the Period of Insurance an Insured Person sustains Bodily

Injury whilst on a Common Carrier which directly and independently

of all other causes results in second or third degree burns, then the

Company agrees to pay to the Insured Person the Compensation

stated in the Table of Benets up to the Total Sum Insured in the

Schedule. The Deductible or Franchise, if applicable, shall be deducted

from the Compensation payable.

TABLE OF BENEFITS

Description

Percentage

of Total Sum

Insured

1) Head a) Third degree burns of 8% or

more of the total head surface

area

100%

b) Second degree burns of 8%

or more of the total head surface

area

50%

c) Third degree burns of 5% or

more, but less than 8% of the total

head surface area

80%

d) Second degree burns of 5% or

more, but less than 8% of the total

head surface area

40%

e) Third degree burns of 2% or

more, but less than 5% of the total

head surface area

60%

f) Second degree burns of 2% or

more, but less than 5% of the total

head surface area

30%

2) Rest of

Body

a) Third degree burns of 20% or

more of the total body surface

area

100%

b) Second degree burns of 20%

or more of the total body surface

area

50%

c) Third degree burns of 15% or

more, but less than 20% of the

total body surface area

80%

d) Second degree burns of 15%

or more, but less than 20% of the

total body surface area

40%

e) Third degree burns of 10% or

more, but less than 15% of the

total body surface area

60%

f) Second degree burns of 10%

or more, but less than 15% of the

total body surface area

30%

g) Third degree burns of 5% or

more, but less than 10% of the

total body surface area

20%

h) Second degree burns of 5%

or more, but less than 10% of the

total body surface area

10%

Specic Conditions

1) If the Bodily Injury results in more than one of the Descriptions

above, then the Company shall be liable for the largest Description only.

2) If an Insured Person dies or is permanently disabled as the result

of the Bodily Injury, then any amount claimed and paid to an Insured

Person under this Section will be deducted from any payment made

under Accidental Death or Permanent Disablement.

12. Last Rites Costs – Accident & Sickness

If during the Period of Insurance an Insured Person sustains Bodily

Injury or Sickness which directly and independently of all other causes

results within one (1) calendar month of the Date of Loss in death, then

the Company agrees to pay to the Insured Person’s Beneciary or

legal representative the Compensation stated in the Schedule towards

the cost of the last rites of the Insured Person.

13. In Hospital Surgery Benet

If during the Period of Insurance an Insured Person is hospitalised

as the result of Bodily Injury or Sickness and is charged for a surgical

procedure, performed by a Physician, then the Company agrees to

pay an amount equal to the costs of the surgical procedure or the

amount stated in the Table of Benets as a percentage of the Total

Sum Insured stated in the Schedule, whichever is the lesser. The

Deductible or Franchise, if applicable, shall be deducted from the

Compensation payable.

Specic Conditions

1) Should there be more than one surgical procedure performed during

the same operative sessions, the Company shall be liable for the

largest procedure only.

2) Any surgical procedure not mentioned in the Table of Benets shall

be compensated at the complete discretion of the Company taking

into consideration the nature of the surgical procedure in conjunction

with the stated Compensation percentages for more specic surgical

procedures shown in the Table of Benets.

Specic Denitions

1) In-Patient means a person who is conned in a Hospital as a

resident patient and who is charged at least one (1) Day’s room and

board in the Hospital.

2) Invasive Surgery means any surgery that involves entering the

specic body cavity shown in the Table of Benets.

Specic Exclusions

The Company shall not be liable to pay any benet in respect of any

Insured Person for:

1) congenital anomalies and conditions arising there from.

2) pregnancy, childbirth, miscarriage or abortion or any female organs

disease.

3) anyHospital, surgical treatment or surgical procedure as the result of

Sickness within ninety (90) Days of the Policy Effective Date.

4) cosmetic or plastic surgery, except as the result of an Accident.

5) any infection occurring during In-Patient care.

6) anyHospital, surgical treatment or surgical procedure on adenoids or

tonsils within one hundred eighty (180) Days of the Policy Effective Date.

Table Of Benets

Description of surgical procedure

The Benet

Expressed as

a % of Sum

Insured

1) Abdomen

a) Two or more surgical procedures

performed through the same abdominal

incision will be considered as one operation.

i) Appendectomy 50

ii) Resection of bowel 70

iii) Resection of stomach 70

Description of surgical procedure

The Benet

Expressed as

a % of Sum

Insured

iv) Gastro-enterostomy 60

v) Removal of gall-bladder 70

vi) Laparotomy for diagnostic or treatment

purposes or the removal of one or more

organs, unless herein provided

vii) Laparoscopy for diagnostic or treatment

purposes

2) Abscess

a) Incision of supercial abscess, boil or

furuncle, one or more

b) Treatment of carbuncle or abscess

requiring a Hospital stay, one or more

3) Amputation Of

a) one nger or one toe 10

b) hand, forearm or foot at ankle 20

c) leg, arm or thigh 40

d) thigh at hip 70

4) Breast

a) Mastectomy of one or both, radical with

resection into axilla

b) Mastectomy one or both, partial 40

5) Chest

a) Complete thoracoplasty 100

b) Removal of lung or portion of lung 70

c) Thoracoscopy for diagnostic, or treatment

purposes

d) Bronchoscopy – diagnostic 10

e) Bronchoscopy - operative, excluding

biopsy

f) Cardiac surgery involving valvular

replacement

100

g) Cardiac surgery involving bypass surgery 75

h) Cardiac surgery involving angioplasty 50

6) Ear

a) Myringotomy 5

b) Mastoidectomy – radical – one side 50

c) Mastoidectomy – radical – both sides 60

d) Fenestration, one or both sides 100

7) Esophagus

a) Operation for stricture 40

b) Gastroscopy 10

8) Eye

a) Detached retina – multiple fusions 100

b) Cataract 50

c) Glaucoma 30

d) Removal of eyeball 30

e) Removal of pterygium 20

f) Incision of sty or chalazion

9) Fractures treatment of simple

a) For compound fractures the benet is

increased by 50%, but will not exceed the

Total Sum Insured in the Schedule.

Description of surgical procedure

The Benet

Expressed as

a % of Sum

Insured

b) For fractures requiring an open operation

including bone grafting or bone splicing,

the benet is increased by 100%, but will

not exceed the Total Sum Insured in the

Schedule.

i) Collar bone, shoulder blade, or forearm,

one bone

ii) Coccyx, tarsals, metatarsals or Talar bone 10

iii) Thigh 40

iv) Upper arm or leg 25

v) Fingers or toes, each, or rib 5

vi) Forearm – two bones, knee cap, or pelvis

not requiring traction

vii) Leg, two bones 30

viii) Jaw, lower 20

ix) Carpals, metacarpals, nose, ribs (two or

more) or Sternum

x) Pelvis, requiring traction 30

xi) Vertebrae, transverse processes, each 5

xii) Vertebrae, compression fracture, one

or more

xiii) Wrist 10

10) Genito – Urinary Tract

a) Removal of kidney 70

b) Fixation of kidney 70

c) Laparotomy for diagnostic or treatment

purposes of tumours or stones in kidney,

urethra, or bladder by Invasive Surgery

d) Laparotomy for diagnostic or treatment

purposes or the removal of tumours or

stones in kidney, urethra, or bladder

by cauterisation, endoscopic means or

lithotripsy

e) Stricture or urethra – open operation 30

f) intra-urethral by Invasive Surgery 15

g) Prostrate entire removal of open

operation – complete procedure

h) Prostrate partial removal – by endoscopic

means

i) Prostrate by other cutting operation 50

j) Orchidectomy or epididymectomy 25

k) Hydrocele or variocele 10

l) Removal of broid tumours, without

abdominal approach

11) Thyroid

a) partial or total removal of thyroid,

including all stages of operative procedure

12) Hernia

a) Invasive Surgery – single hernia 20

b) Invasive Surgery – double hernia 25

c) Radical operation, including injection

treatment for cure of single hernia

d) Radical operation, including injection

treatment for cure of double hernia

Description of surgical procedure

The Benet

Expressed as

a % of Sum

Insured

13) Joints And Dislocations

a) For dislocations requiring an open

operation the benet is increased by 100%,

but will not exceed the Total Sum Insured in

the Schedule.

i) Incision into joint for disease or disorder,

except as herein otherwise provided and

except tapping

ii) Arthroscopy of shoulder, elbow, hip or

knee joint, tapping excepted

iii) Excision , open xation, disarticulation or

arthoplasty on shoulder, hip or spine

iv) Excision , open xation, disarticulation or

arthoplasty on knee, elbow, wrist or ankle

v) Dislocation of ngers or toes, each 5

vi) Dislocation of shoulder or elbow, wrist

or ankle

vii) Dislocation of lower jaw 5

viii) Dislocation of hip or knee, knee cap

excepted

ix) Dislocation of knee cap 5

14) Nose

a) Intranasal sinus operation 15

b) extra nasal sinus operation 35

c) polyps, removal one or more 5

d) submucous resection 25

e) turbinectomy 10

15) Paracentesis tapping of:

a) Abdomen 10

b) chest or bladder, catheterization excepted

c) ear drum, hydrocele, joints or spine 5

16) Rectum And Rectoscopy

a) radical resection for malignancy, all

stages including colostomy

100

b) haemorrhoids, external only, excision –

complete procedure

c) haemorrhoids internal or internal and

external including prolapsed rectum, total for

excision or complete injection treatment

d) stula in ano 15

e) ssure in ano 5

f) rectoscopy with or without biopsy 10

g) colonoscopy with or without biopsy 15

h) other cutting operations on rectum 20

17) Skull

a) Craniotomy for urgent removal of

hematoma

100

b) Craniotomy involving vascular surgery 75

c) Craniotomy for removal of tumours 75

18) Throat

a) Tonsillectomy or tonsillectomy and

adenoidectomy for adults and children 15

years of age and older

Description of surgical procedure

The Benet

Expressed as

a % of Sum

Insured

b) Tonsillectomy or tonsillectomy and

adenoidectomy for children under 15 years

of age

c) use of laryngoscope for diagnosis 5

19) Tumours– surgical removal of:

a) Malignant tumours except those of the

mucous membrane, skin and subcutaneous

tissue

b) Malignant tumours of the mucous

membrane, skin and subcutaneous tissue

c) Pilonidal sinus or cyst, cutting operation 25

d) benign tumours of the testicle or breast 20

e) ganglion 5

f) benign tumours, one or more, except as

otherwise herein provided

g) varicose – complete procedure on all

veins whether cutting operation or injection

treatment – one leg

h) varicose – complete procedure on all

veins whether cutting operation or injection

treatment – two legs

9. Temporary Total Disablement – Accident Only

If during the Period of Insurance an Insured Person sustains

Bodily Injury which directly and independently of all other causes

results (starting during the Period of Insurance) in Temporary Total

Disablement, then the Company agrees to pay to the Insured Person

the amount stated in the Schedule. The Deductible or Franchise, if

applicable, shall be deducted from the Compensation payable.

Specic Conditions

1) If Bodily Injury is sustained to or suffered in relation to the spine and

its muscular girdle, ligamentous system, cartilage, nervous system and

blood supply to the spine which is not detectable by means of radiological

scanning, imaging, or neurological fallout testing, then the Company

shall only be liable in respect of this Section for a maximum period of

ve (5) weeks, in excess of the Deductible or Franchise if applicable.

2) In the event of a dispute arising as to when Temporary Total

Disablement ceased, the date shall be nally determined by a Physician

commissioned by the Company who certies:

a) the date upon which the Insured Person recovered; or

b) the date upon which the Insured Person recovered as far as he/

she ever will; or

c) the date from which the Insured Person is declared to have suffered

Permanent Total Disablement;

3) The benet shall not in any event exceed the Total Sum Insured or

the Maximum Number of Weeks as stated in the Schedule.

4) If an Insured Person has other insurance against a loss covered by

this Section, then the Company shall not be liable for a greater proportion

of the loss than the applicable benet under this Section bears to the

total applicable benet under all such insurance.

Specic Denitions

Temporary Total Disablement means disablement which temporarily

and entirely prevents an Insured Person from engaging in or giving

attention to the Insured Person’s usual occupation.

Specic Exclusions

The Company shall not be liable to pay any benet in respect of any

Insured Person for any claim caused by or arising from or due to

Sickness of any and every kind.

10. Temporary Total Disablement– Accident And Sickness

If during the Period of Insurance an Insured Person sustains Bodily

Injury or Sickness (starting during the Period of Insurance) which

directly and independently of all other causes results in Temporary Total

Disablement, then the Company agrees to pay to the Insured Person

the amount stated in the Schedule. The Deductible or Franchise, if

applicable, shall be deducted from the Compensation payable.

Specic Conditions

1) If Bodily Injury or Sickness is sustained to or suffered in relation

to the spine and its muscular girdle, ligamentous system, cartilage,

nervous system and blood supply to the spine which is not detectable

by means of radiological scanning, imaging, or neurological fallout

testing, then the Company shall only be liable in respect of this Section

for a maximum period of ve (5) weeks, in excess of the Deductible or

Franchise if applicable.

2) In the event of a dispute arising as to when Temporary Total

Disablement ceased, the date shall be nally determined by a Physician

commissioned by the Company who certies:

a) the date upon which the Insured Person recovered; or

b) the date upon which the Insured Person recovered as far as he/

she ever will; or

c) the date from which the Insured Person is declared to have suffered

Permanent Total Disablement.

3) The benet shall not in any event exceed the Total Sum Insured or

the Maximum Number of Weeks as stated in the Schedule.

4) If an Insured Person has other insurance against a loss covered by

this Section, then the Company shall not be liable for a greater proportion

of the loss than the applicable benet under this Section bears to the

total applicable benet under all such insurance.

Specic Denitions

Temporary Total Disablement means disablement which temporarily

and entirely prevents an Insured Person from engaging in or giving

attention to the Insured Person’s usual occupation.

11. Hostage Release Fees

If during the Period of Insurance an Insured Person is Kidnapped,

then the Company agrees to pay the fees incurred for a professional

negotiation organisation appointed by the Company to secure the

release of the Insured Person up to the Total Sum Insured stated

in the Schedule:

1. The Insured Person agrees to reimburse the Company for any

payments made by the Company which are ultimately determined not

to be insured because of the application of the Specic Exclusions.

2. If an Insured Person has other insurance against a loss covered by

this Section, then the Company shall not be liable for a greater proportion

of the loss than the applicable benet under this Section bears to the

total applicable benet under all such insurance.

Specic Denitions

1. Informant means any person providing information solely in return for

monetary payment paid or promised by the Policyholder.

2. Insured Person: Specic to this Section and in addition to the Insured

Person(s) stated in the Schedule, an Insured Person shall also include:

a) Immediate Family Member of an Insured Person.

b) a person legally resident in the household of an Insured Person.

c) accompanying travel companion of the Insured Person.

3) Kidnap or Kidnapped means the wrongful abduction and holding

under duress or by fraudulent means of any Insured Persons by any

person or group making a Ransom demand or series of Ransom

demands for the release of such Insured Persons.

4) Ransom means the amount demanded by any person or group who

have Kidnapped the Insured Person, or the amount paid to a person

or group for the release of the Insured Person.

Specic Exclusions

The Company will not be liable for:

1) Any Ransomamount.

2) any amount paid to an Informant or Informants.

3) any fraudulent, dishonest, or criminal acts of the Insured Person.

4) AnInsured Person being Kidnappedby an Immediate Family

Member.

5) AnyKidnapoccurring in South America, Mexico or the Philippines.

12. Assault

If during the Period of Insurance an Insured Person sustains

Bodily Injury that results in death or permanent disablement, as a

result of or arising from Assault, then the Company agrees to pay

to the Insured Person or the Insured Person’s Beneciary or legal

representatives the increased percentage of the Accidental death or

permanent disablement Total Sum Insured stated under this Section

in the Schedule.

Specic Conditions

All Specic Extensions, Specic Provisions, Specic Conditions, Specic

Denitions, Specic Claims Provisions and Specic Exclusions shall also

apply to this Section for each benet to which it attaches.

Specic Denitions

Assault means any wilful or unlawful use of force inicted upon an

Insured Person that is a criminal offence in the jurisdiction in which

it occurs and which results in Bodily Injury to an Insured Person.

Specic Exclusions

The Company shall not be liable to pay any benet in respect of any

Insured Person for an act of Assault by an Immediate Family Member.

13. Mobility Extension

If during the Period of Insurance an Insured Person sustains Bodily

Injury which directly and independently of all other causes results in

Permanent Total Disablement of such a nature that such Insured

Person needs and can operate:

1) a self-powered, climbing wheelchair; and/or

2) his/her motor vehicle with the controls suitably adjusted; and/or

3) a lift, necessary ramps, railings and holds to usual place of residence,

then the Company agrees to pay for 95% of the costs of such equipment

and the installation thereof up to the Total Sum Insured stated in the

Schedule.

14. Ambulance Costs

If during the Period of Insurance, an Insured Person sustains Bodily

Injury which is life threatening, then the Company agrees to pay the

actual ground ambulance costs incurred by the Insured Person up to

the Total Sum Insured stated in the Schedule, for transportation to the

nearest Hospital where adequate care can be provided.

15. Concussion Extension

If during the Period of Insurance, an Insured Person sustains Bodily

Injury and is hospitalized as the result of concussion, then the Company

agrees to pay to the Insured Person the following percentages of the

Total Sum Insured stated in the Schedule: Length of Hospital stay

Length of Hospital stay

Compensation Expressed as a

Percentage of Total

Sum Insured

Percentage of sum insured

payable for 0 to 4 Days

Percentage of sum insured

payable after 5 Days

25%

Percentage of sum insured

payable after 8 Days

Additional 25%

Percentage of sum insured

payable after 11 Days

Additional 25%

Percentage of sum insured

payable after 13 Days

Additional 25%

16. Animal Attack Extension

If during the Period of Insurance, an Insured Person sustains Bodily

Injury as the result of an attack by an Animal and is hospitalised for

seventy-two (72) continuous hours, then the Company agrees to pay

to the Insured Person the Total Sum Insured stated in the Schedule.

Specic Denition

Animal means any four (4) limbed animal that is not an insect or reptile.

17. Chauffeur Plan Benet

If during the Period of Insurance an Insured Person is partially

incapacitated and unable to attend to a substantial part of his / her

business commitments as a result of Bodily Injury, then the Company

agrees to pay the daily amount up to the Total Sum Insured stated in the

Schedule for the hire of a taxi or chauffeur driven car or other necessarily

incurred extra costs to maintain the Insured Person’s mobility to meet

his / her business commitments. The Deductible or Franchise, if

applicable, shall be deducted from the Compensation payable.

Specic Exclusions

The Company shall not be liable to pay any benet in respect of any

Insured Person if the Insured Person does not follow proper medical

advice from a Physician after sustaining the Bodily Injury.

18. Spouse Or Dependent Child Consolation Benet

If during the Period of Insurance an Insured Person’s Spouse

or Dependent Child sustains Bodily Injury which directly and

independently of all other causes results in Death within twelve (12)

months of the Date of Loss, then the Company agrees to pay to

the Insured Person the Compensation stated in the Schedule. The

Spouse or Dependent Child must be insured under this Policy for this

benet to be paid.

Specic Extensions

1) Disappearance: In the event of the disappearance of the Insured

Person’s Spouse or Dependent Child, following a forced landing,

stranding, sinking or wrecking of a conveyance in which such Insured

Person’s Spouse or Dependent Child was known to have been

travelling as an occupant, it shall be deemed after twelve (12) months,

subject to all other terms and conditions of this Policy, that such Insured

Person’s Spouse or Dependent Child shall have died as the result

of an Accident. If at any time, after the payment of a benet under

this Section, it is discovered that the Insured Person’s Spouse or

Dependent Child is still alive, then all payments shall be reimbursed

in full to the Company.

2) Exposure: Death as a direct result of exposure to the elements shall

be deemed to be Bodily Injury.

19. Insured Person’s Counselling Benet

If during the Period of Insurance an Insured Person’s Spouse

or Dependent Child sustains Bodily Injury which directly and

independently of all other causes results in Death within twelve (12)

months of the Date of Loss, then the Company agrees to pay the

actual costs for professional counselling for the Insured Person up to

the Compensation stated in the Schedule.

Specic Extensions

1) Disappearance: In the event of the disappearance of the Insured

Person’s Spouse or Dependent Child, following a forced landing,

stranding, sinking or wrecking of a conveyance in which such Insured

Person’s Spouse or Dependent Child was known to have been

travelling as an occupant, it shall be deemed after twelve (12) months,

subject to all other terms and conditions of this Policy, that such Insured

Person’s Spouse or Dependent Child shall have died as the result

of an Accident. If at any time, after the payment of a benet under

this Section, it is discovered that the Insured Person’s Spouse or

Dependent Child is still alive, then all payments shall be reimbursed

in full to the Company.

2) Exposure: Death as a direct result of exposure to the elements shall

be deemed to be Bodily Injury.

Specic Conditions

Solely with respect to the insurance provided in this Section, Item 16 of

Section 5, General Exclusions, is deleted in its entirety.

20. Family Counselling Benet

If during the Period of Insurance an Insured Person sustains Bodily

Injury which directly and independently of all other causes results

in Death within twelve (12) months of the Date of Loss, then the

Company agrees to pay the actual costs for professional counselling

for the Insured Person’s Spouse and Dependent Child up to the

Compensation stated in the Schedule.

Specic Extensions

1) Disappearance: In the event of the disappearance of the Insured

Person, following a forced landing, stranding, sinking or wrecking of a

conveyance in which such Insured Person was known to have been

travelling as an occupant, it shall be deemed after twelve (12) months,

subject to all other terms and conditions of this Policy, that such Insured

Person shall have died as the result of an Accident. If at any time,

after the payment of a benet under this Section, it is discovered that

the Insured Person is still alive, then all payments shall be reimbursed

in full to the Company.

2) Exposure: Death as a direct result of exposure to the elements shall

be deemed to be Bodily Injury.

Specic Conditions

1) The total Sum Insured is the total amount payable for the Spouse

and Dependent Child combined, not per person.

2) Solely with respect to the insurance provided in this Section, Item 16

of Section 5, General Exclusions, is deleted in its entirety.

21. Common Accident

If during the Period of Insurance an Insured Person and his or her

Spouse sustain Bodily Injury in the same Accident which, directly

and independently of all other causes, results in the death of both the

Insured Person and the Spouse within twelve (12) months after the

Date of Loss, then the Total Sum Insured payable for each of the

Insured Person and Spouse shall be either the Accidental Death

Total Sum Insured applicable to the Insured Person or the Accidental

Death Total Sum Insured applicable to the Spouse, whichever is greater.

This benet shall in no event exceed the Common Accident maximum

amount shown in the Schedule.

This benet applies only if:

1) the Insured Person has elected insurance under the Policy for a

Spouse; and

2) such insurance is in effect on the date of the Accident.

Specic Extensions

1) Disappearance: In the event of the disappearance of the Insured

Person, following a forced landing, stranding, sinking or wrecking of a

conveyance in which such Insured Person was known to have been

travelling as an occupant, it shall be deemed after twelve (12) months,

subject to all other terms and conditions of this Policy, that such Insured

Persons shall have died as the result of an Accident. If at any time,

after the payment of a benet under this Section, it is discovered that

an Insured Person is still alive, all payments shall be reimbursed in

full to the Company.

2) Exposure: Death as a direct result of exposure to the elements shall

be deemed to be Bodily Injury.

22. Evacuation Benet

If during the Period of Insurance an Insured Person is Evacuating

from the building that is the Primary Insured Person’s place of

employment and sustains Bodily Injury in the Evacuation which directly

and independently of all other causes results in death or disablement

within twelve (12) months of the Evacuation, then the Company agrees

to pay the Compensation stated in the Schedule.

Specic Denitions

Evacuating / Evacuation means an emergency exit due to a re, a

re alarm, a bomb scare (whether there is a bomb or not), or an armed

attack on the building or the people in the building.

23. Medical Insurance Premium Indemnity

If during the Period of Insurance an Insured Person sustains Bodily

Injury which directly and independently of all other causes results in

death within twelve (12) months of the Date of Loss,then the Company

agrees to pay the actual costs of the medical insurance premiums for

the Insured Person’s surviving Spouse and Dependent Child up to

the amount stated in the Schedule per year up to the number of years

stated in the Schedule.

Specic Extensions

1) Disappearance: In the event of the disappearance of an Insured

Person, following a forced landing, stranding, sinking or wrecking of a

conveyance in which such Insured Person was known to have been

travelling as an occupant, it shall be deemed after twelve (12) months,

subject to all other terms and conditions of this Policy, that such Insured

Person shall have died as the result of an Accident. If at any time,

after the payment of a benet under this Section, it is discovered that

an Insured Person is still alive, all payments shall be reimbursed in

full to the Company.

2) Exposure: Death as a direct result of exposure to the elements shall

be deemed to be Bodily Injury.

Specic Conditions

The total Sum Insured is the total amount payable for the Spouse and

Dependent Child combined, not per person.

24. Dependent Child Education Benet

If during the Period of Insurance an Insured Person sustains Bodily

Injury which directly and independently of all other causes results in

Death within twelve (12) months of the Date of Loss, then the Company

agrees to pay the education fees for the Insured Person’s surviving

Dependent Child up to the amount stated in the Schedule per year up

to the number of years stated in the Schedule.

Specic Conditions

1) To receive benets under this Section, the Dependent Child must

be in full time education at an accredited tertiary educational institution.

2) The Total Sum Insured is the total amount payable for all Dependent

Children combined, not per person.