Date:13-11-2020
INSURANCE REGULATORY AND DEVELOPMENT AUTHORITY OF INDIA
In order to make available a standard Vector Borne Disease specific health insurance product addressing the needs of insuring public for getting health insurance coverage to specified Vector Borne Diseases, an exposure draft on ‘Standard Vector Borne Disease Health Policy’ along with standard terms and conditions (Annexure -1), Customer Information Sheet (Annexure- 2) and Use and File Application Format (Annexure-3) is issued and attached herewith. All general and health insurers will be encouraged to offer this product.
In the exposure draft it is proposed that the product shall be offered for a fixed term of one year with a waiting period of 15 days proposing to permit insurers to offer the product under Use and File procedure. However, stakeholders are requested to examine and furnish comments with specific reference to the following :
1. Whether standard Vector Borne Disease Product should be filed as per file and use (Chapter III) or use and file procedure (Chapter IV) of Consolidated Guidelines on Product filing in Health Insurance Business Ref: IRDAI/HLT/REG/CIR/194/07/2020 dated 22nd July,2020.
2. Whether the proposed standard vector borne disease product shall be offered for a shorter term (less than one year policy duration) as these vector-borne diseases are generally seasonal.
3. Specific suggestions on the proposed waiting period of 15 days.
Stakeholders are also requested to suggest a suitable name for the product. The person whose suggested name is selected will be issued a certificate of appreciation by Chairman, IRDAI.
All the stakeholders are requested to forward their comments/suggestions on the exposure draft by 27th November, 2020 in the attached format.
The comments along with the suggested name may be mailed to pankaj.sharma@irdai.gov.in
SURESH MATHUR
Executive Director (Health)
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FORMAT FOR SUGGESTIONS ON
Exposure Draft on
Guidelines on Standard Vector Borne Disease Health Policy
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| Note | v It is suggested that ONE Page may be used for one change.
v This will enable us to group all the suggestions and take a decision on the changes suggested |
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| Sl. No. | Page No | Guidelines /Annexure | Guidelines and Sub-Clause No./ Para Number | Comments / Change suggested | Rationale |
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Ref: IRDAI/HLT/REG/CIR/…/../2020
13th November, 2020
Exposure Draft on Standard Vector Borne Disease Health Policy
To
All General and Health Insurers (except ECGC & AIC)
Exposure Draft on Standard Vector Borne Disease Health Policy
A. Preamble:
1. In order to make available Vector Borne Disease specific health insurance product addressing the needs of insuring public for getting health insurance coverage to specified Vector Borne Diseases, the Authority encourages all general and health insurers to offer Standard Vector Borne Disease Health Policy (Here after referred as standard product).
2. Towards this, the following Guidelines on Standard Product are proposed to be issued under the provisions of Regulation 11 (e) of IRDAI (Health Insurance) Regulations, 2016.
3. All general and health insurers are encouraged to offer the Standard Product by duly complying with these guidelines.
4. The Standard Product shall have coverage as specified in these Guidelines which shall be uniform across all General and Health Insurers.
5. The Standard Product shall offer the health insurance coverage as specified in these guidelines in respect of any one or combination of the specified vector borne disease (s) opted by the policyholder and as mentioned in the policy schedule. Insurers shall price for every covered disease separately and are advised to offer discount as per underwriting policy for opting various disease combinations.
6. The insurer may determine the price keeping in view the cover proposed to be offered subject to complying with the norms specified in the IRDAI (Health Insurance) Regulations, 2016 and Guidelines notified there under.
7. Only two optional covers as specified are allowed to be offered along with the Standard Product.
8. The base covers of Standard Product shall be offered on Indemnity basis and optional covers shall be offered on benefit basis as specified in these guidelines.
9. The total amount payable in respect of base and optional covers shall not exceed 100% of the Sum Insured during a policy period. The premium payable towards Optional Cover shall be specified separately so as to enable policyholders to choose and pay based on the need.
10. The Standard Product shall offer policy tenure of one year (12 Months).
11. The Standard Product shall comply with all the provisions of Insurance Regulatory and Development Authority of India (IRDAI) (Health Insurance) Regulations, 2016, all other applicable Regulations and other applicable Guidelines as amended from time to time.
12. Insurers are allowed to offer Standard Product as group product by duly complying with the norms specified hereunder.
a. Insurers are allowed to use the standard product name for the group policy after adding the word “group”, provided all terms and conditions as applicable to the Standard Product remain the same except premium rate and specification on operation of group policy.
b. The insurers shall determine the price keeping in view the cover proposed to be offered subject to complying with the norms specified in the IRDAI (Health Insurance) Regulations, 2016 and Guidelines notified there under.
c. The product shall be filed on Use and File basis by duly complying with the norms specified in Chapter IV of the Consolidated Guidelines on product filing in health insurance business” (Ref: IRDAI/HLT/REG/CIR/194/07/2020 dated 22nd July, 2020) as modified from time to time.
d. This group product shall comply with the all other applicable norms stipulated under “Guidelines on Product filing in Health Insurance business” (IRDA/HLT/REG/CIR/150/07/2016 dated 29th July 2016).
B. Construct of Standard Vector Borne Disease Health Policy:
The Standard Product shall offer the following:
Coverage:
13. The Standard Product shall offer the health insurance coverage as specified in these guidelines in respect of any one or combination of the following vector borne disease (s) opted by the policyholder and as mentioned in the policy schedule.
i. Dengue fever
ii. Malaria
iii. Filaria (Lymphatic Filariasis)
iv. Kala-azar
v. Chikungunya
vi. Japanese Encephalitis
vii. Zika Virus
Base Covers:
14. Hospitalization Cover: The Hospitalization expenses incurred by the insured person for the treatment of specified Vector Borne Diseases on Positive diagnosis and on recommendation of hospitalization by a medical practitioner. This section shall cover the following:
a) Room, Boarding, Nursing Expenses as provided by the Hospital / Nursing Home up to 2% of the sum insured (excluding Cumulative Bonus) for the sum insured above Rs 20,000 and a fixed amount of Rs 500/day for sum insured up to Rs 20,000.
b) Surgeon, Anesthetist, Medical Practitioner, Consultants, Specialist Fees (including consultation through telemedicine as per Telemedicine Practice Guideline of 25th March 2020) whether paid directly to the treating doctor / surgeon or to the hospital.
c) Anesthesia, blood, oxygen, operation theatre charges, surgical appliances, ventilator charges, medicines and drugs, costs towards diagnostics, diagnostic imaging modalities, PPE Kit, gloves, mask and such other similar expenses.
(Expenses on Hospitalization for a minimum period of 24 hours are admissible.)
d) Intensive Care Unit (ICU) / Intensive Cardiac Care Unit (ICCU) expenses up to 5% of sum insured (excluding Cumulative Bonus) for the sum insured above Rs 20,000 and a fixed sum of Rs 1000/day for the sum insured up to Rs 20,000.
e) Expenses incurred on road Ambulance subject to a maximum of Rs.2000/- per hospitalization.
15. AYUSH Treatment: The Medical expenses incurred on hospitalization under AYUSH (as defined in IRDAI (Health Insurance) Regulations, 2016) system of medicine for the treatment of specified Vector Borne Diseases on Positive diagnosis and on recommendation of hospitalization by a medical practitioner shall be covered up to the Sum Insured without any sub-limits.
16. Pre-Hospitalization medical expenses incurred for a period of 15 days prior to the date of hospitalization following an admissible claim under this policy shall be covered.
17. Post-Hospitalization medical expenses incurred for a period of 30days from the date of discharge from the hospital following an admissible claim under this policy shall be covered.
18.Cumulative Bonus (CB): Sum insured (excluding CB) shall be increased by 5% in respect of each claim free policy year, provided the policy is renewed without a break subject to maximum of 50% of the sum insured. If a claim is made in any particular year, the cumulative bonus accrued may be reduced at the same rate at which it has accrued.
Optional Covers:
19. Hospital Cash Benefit: A fixed percentage of 0.5% of the sum insured (excluding Cumulative Bonus) shall be payable for each completed twenty-four hours (24 hours) of hospitalization (Including AYUSH Hospital) due to positive diagnosis (through laboratory examination and confirmed by the medical practitioner) of covered vector borne diseases diagnosed during the Cover Period, subject to policy terms and conditions:
The benefit shall be payable maximum up to 14 days during a policy period.
20. Diagnosis Cover: The fixed percentage of 2% of the sum insured (excluding Cumulative Bonus) shall be payable on positive diagnosis (through laboratory examination and confirmed by the medical practitioner) of covered vector borne diseases, which is diagnosed during the Cover Period, subject to policy terms and conditions, provided that insured is not hospitalized for the same illness within 15 days from diagnosis.
21. No deductibles are permitted in this product.
C. Other Norms applicable:
| Sl.No | Particulars | Norms Applicable |
| 1. | Plan Variants | No plan variants are allowed. |
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2. |
Distributions Channels |
Standard Product is allowed to be distributed across all distribution channels including Micro Insurance Agents, Point of sale persons and Common Public Service Centres.
Distribution of Standard Product shall be governed by the regulations of concerned distribution channels. In addition to the number of products allowed to be marketed as per IRDAI circular ref: IRDAI/ INT/ CIR/ PSP/ 019/01/2020 dated 13thJanuary, 2020 “Standard Vector Borne Disease Health Policy” is also allowed to be marketed by Point of Sale. |
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3. |
Family Floater |
Standard Product shall be offered on family floater basis also. |
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4. |
Definition of family |
Family consists of the proposer and any one or more of the family members as mentioned below:
(i) legally wedded spouse. (ii) Parents and Parents-in-law. (iii) dependent Children (i.e. natural or legally adopted) between the day 1 of age to 25 years. If the child above 18 years of age is financially independent, he or she shall be ineligible for coverage. |
| 5. | Category of Cover | The Standard Product shall be offered both on individual or on floater sum insured basis. |
| 6. |
Minimum and Maximum Sum Insured |
The minimum sum insured under Standard Product shall be Rs 10,000/- (Ten Thousand only)
Maximum limit shall be Rs 2,00,000/-(2Lakh) (in the multiples of ten thousands) |
| 7 | Policy Period | Standard Product shall be offered with a policy tenure of one year (12 Months). |
| 8 | Modes of premium payment | Single premium
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| 9. | Entry age | Minimum entry age shall be 18 years for principal insured and maximum age at entry shall not be less than 65 years for all the insured members including principal insured.
Dependent Child / children shall be covered from Day 1 of age to 25 years subject to the definition of ‘Family’. |
| 10. | Benefit Structure | The benefit pay out should be explicitly disclosed in the format of application (Form – IRDAI-UNF-SVHP) along with other relevant documents. |
| 11. | Underwriting | The insurer shall specify the non-medical limit and relevant details explicitly in the format specified. |
| 12. | Renewal, Portability and Migration | i. Renewal – The Standard Product shall be subject to Renewal duly complying with Regulation 13 of HIR, 2016.
ii. Migration- – The Standard Product shall comply with the provisions for migrations as specified in Regulation 17 (i) of HIR, 2016and applicable guidelines issued there under from time to time. iii. Portability –The Standard Product shall comply with Portability provisions, as specified in Schedule I of HIR 2016 and applicable Guidelines issued there under from time to time.
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| 13 | Free look period | The Standard Product shall have free look period complying with Regulation 14 of HIR 2016. |
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13. |
Pricing | The premium under this product shall be pan India basis and no geographic location / zone based pricing is allowed. |
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14. |
Premium Loading and Discounts | The Standard Product shall comply with Regulation 25 of HIR 2016 in respect of loadings on Renewals. |
D: Construct of Terms and Conditions for Standard Vector Borne Disease Health Policy:
22. The Policy Terms and Conditions of the Standard Product shall be in the format specified in Annexure – 1. Insurer may suitably modify the definitions and other clauses of the policy contract prospectively based on the Regulations or Guidelines that may be issued by the Authority from time to time.
E: Other Norms:
23. The nomenclature of the product shall be Vector Borne Disease Health Policy, succeeded by name of insurance company, (Vector Borne Disease Health Policy, <name of insurer>). No other name is allowed in any of the documents.
24. The Proposal Form used for the product shall be subject to the norms specified under the Guidelines on Product Filing in Health Insurance.
25. Insurers shall mandatorily issue Customer Information Sheet as per the format specified in Annexure-2.
26. The Standard Product may be offered as MICRO Insurance Product subject to Sum Insured limits specified in IRDAI (Micro Insurance) Regulations, 2015, and other circulars / guidelines issued in this regard by the Authority from time to time.
27. The Standard Product shall be launched without prior approval of the Authority subject to complying with the following conditions.
a. The product shall be approved by the Product Management Committee.
b. Insurers shall obtain UIN for the Standard Product by filing the relevant particulars in Form – IRDAI-UNF-SVHP (as specified in Annexure – 3 of these Guidelines) along with a certificate from Chief Compliance Officer that the product filed is in compliance with the norms specified under these guidelines.
c. On review of the application, the Authority may call for such further information as may be required and may issue suitable directions which shall be retrospectively effected in respect of all contracts issued under this product.
28. General and Health Insurers shall endeavor to offer this product preferably by ………….
29. In terms of the provisions of Regulation 4(iii) of IRDAI (Issuance of e-Insurance Policies) Regulations, 2016 providing policy document in physical form is mandatory when policies are issued in electronic form directly to the policyholders. Since features of the Standard Product shall be common across the industry and as the terms and conditions of the policy are specified by the Authority, with the objective of reducing the operating costs and to pass on this benefit of reduced operational cost to the policyholders by way of affordable premiums, insurers are allowed to issue the policy contract of Standard Product in electronic/digital format. The digital form of the policy contract may be forwarded through email or a link shall be provided in the certificate of insurance. However, where policyholder specifically seeks the physical form of the policy contract, the same shall be provided by the Insurer.
30. Every insurer offering Standard Product shall provide a certificate of insurance to the policyholder indicating the availability of health insurance coverage. The certificate shall have a reference to access detailed terms and conditions of the policy contract. Insurer shall also clearly mention policy period (policy start date to policy end date), effective policy period (from end of waiting period to end of policy period), waiting period (policy start date to waiting period end date) in the Certificate of Insurance.
31. This has the approval of Competent Authority.
(DVS Ramesh)
General Manager
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Annexure-1
Vector Borne Disease Product, [Company Name]
1. PREAMBLE
This Policy is a contract of insurance issued by [name of the Company] (hereinafter called the ‘Company’) to the proposer mentioned in the schedule (hereinafter called the ‘Insured’) to cover the person(s) named in the schedule (hereinafter called the ‘Insured Persons’). The policy is based on the statements and declaration provided in the proposal Form by the proposer and is subject to receipt of the requisite premium
2. OPERATIVE CLAUSE
If during the policy period one or more Insured Person (s) is required to be hospitalized for treatment of covered Vector Borne Disease at a Hospital (including AYUSH Hospital) following Medical Advice of a duly qualified Medical Practitioner or diagnosed (through laboratory examination and confirmed by the medical practitioner) with covered vector borne diseases, the Company shall indemnify Medically necessary expenses towards the Coverage mentioned in the policy schedule.
Provided further that, any amount payable under the policy shall be subject to the terms of coverage exclusions, conditions and definitions contained herein. Maximum liability of the Company under all such Claims during the Policy Period shall be the Sum Insured (Individual or Floater) opted and specified in the Schedule.
3. DEFINITIONS
The terms defined below and at other junctures in the Policy have the meanings ascribed to them wherever they appear in this Policy and, where, the context so requires, references to the singular include references to the plural; references to the male includes the female and references to any statutory enactment includes subsequent changes to the same.
3.1 Age means age of the Insured person on last birthday as on date of commencement of the Policy.
3.2 Any One Illness means continuous period of illness and it includes relapse within forty-five days from the date of last consultation with the hospital where treatment has been taken.
3.3 Associated Medical Expenses means hospitalization related expenses on Surgeon, Anaesthetist, Medical Practitioner, Consultants and Specialist Fees whether paid directly to the treating doctor / surgeon or to the hospital; Anaesthetics, blood, oxygen, operation theatre charges, surgical appliances and such other similar expenses with the exception of:
i. cost of pharmacy and consumables medicines
ii. cost of implants/medical devices
iii. cost of diagnostics
The scope of this definition is limited to admissible claims where a proportionate deduction is applicable.
3.4 AYUSH Treatment refers to hospitalization treatments given under Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy systems.
3.5 An AYUSH Hospital is a healthcare facility wherein medical/surgical/para-surgical treatment procedures and interventions are carried out by AYUSH Medical Practitioner(s) comprising of any of the following:
a. Central or State Government AYUSH Hospital or
b. Teaching hospital attached to AYUSH College recognized by the Central Government/Central Council of Indian Medicine/Central Council for Homeopathy; or
c. AYUSH Hospital, standalone or co-located with in-patient healthcare facility of any recognized system of medicine, registered with the local authorities, wherever applicable, and is under the supervision of a qualified registered AYUSH Medical Practitioner and must comply with all the following criterion:
i. Having at least 5 in-patient beds;
ii. Having qualified AYUSH Medical Practitioner in charge round the clock;
iii. Having dedicated AYUSH therapy sections as required and/or has equipped operation theatre where surgical procedures are to be carried out;
iv. Maintaining daily records of the patients and making them accessible to the insurance company’s authorized representative.
3.6 AYUSH Day Care Centre means and includes Community Health Centre (CHC), Primary Health Centre (PHC), Dispensary, Clinic, Polyclinic or any such health centre which is registered with the local authorities, wherever applicable and having facilities for carrying out treatment procedures and medical or surgical/para-surgical interventions or both under the supervision of registered AYUSH Medical Practitioner (s) on day care basis without in-patient services and must comply with all the following criterion:
i. Having qualified registered AYUSH Medical Practitioner(s) in charge;
ii. Having dedicated AYUSH therapy sections as required and/or has equipped operation theatre where surgical procedures are to be carried out;
iii. Maintaining daily records of the patients and making them accessible to the insurance company’s authorized representative.
3.7 Break in Policy means the period of gap that occurs at the end of the existing policy term, when the premium due for renewal on a given policy is not paid on or before the premium renewal date or within 30 days thereof
3.8 Cashless Facility means a facility extended by the insurer to the insured where the payments, of the costs of treatment undergone by the insured person in accordance with the Policy terms and conditions, are directly made to the network provider by the insurer to the extent pre-authorization is approved.
3.9 Condition Precedent means a Policy term or condition upon which the Company’s liability under the Policy is conditional upon
3.10 Cumulative Bonus (CB) means any increase or addition in the Sum Insured granted by the insurer without an associated increase in premium.
3.11 Day Care Centre means any institution established for day care treatment of disease/ injuries or a medical setup within a hospital and which has been registered with the local authorities, wherever applicable, and is under the supervision of a registered and qualified medical practitioner AND must comply with all minimum criteria as under:
i. has qualified nursing staff under its employment;
ii. has qualified medical practitioner (s) in charge;
iii. has a fully equipped operation theatre of its own where surgical procedures are carried out
iv. maintains daily records of patients and shall make these accessible to the Company’s authorized personnel.
3.12 Day Care Treatment means medical treatment, and/or surgical procedure which is:
i. undertaken under general or local anesthesia in a hospital/day care centre in less than twenty-four hours because of technological advancement, and
ii. which would have otherwise required a hospitalization of more than twenty-four hours.
iii. Treatment normally taken on an out-patient basis is not included in the scope of this definition.
3.13 Disclosure to information norm: The policy shall be void and all premiums paid thereon shall be forfeited to the Company in the event of misrepresentation, mis-description or non-disclosure of any material fact by the policyholder.
3.14 Emergency care means management for an illness or injury which results in symptoms which occur suddenly and unexpectedly, and requires immediate care by a medical practitioner to prevent death or serious long term impairment of the insured person’s health.
3.15 Family means, the Family that consists of the proposer and any one or more of the family members as mentioned below:
i. Legally wedded spouse.
ii. Parents and Parents-in-law.
iii. Dependent Children (i.e. natural or legally adopted) between the day 1 of ageto25 years. If the child above 18 years of age is financially independent, he or she shall be ineligible for coverage.
3.16 Grace period means the specified period of time immediately following the premium due date during which a payment can be made to renew or continue a policy in force without loss of continuity benefits such as waiting periods and coverage of pre-existing diseases. Coverage is not available for the period for which no premium is received.
3.17 Hospital means any institution established for in-patient care and day care treatment of disease/ injuries and which has been registered as a hospital with the local authorities under the Clinical Establishments (Registration and Regulation) Act, 2010 or under the enactments specified under Schedule of Section 56(1) of the said Act, OR complies with all minimum criteria as under:
i. has qualified nursing staff under its employment round the clock;
ii. has at least ten inpatient beds, in those towns having a population of less than ten lakhs and fifteen inpatient beds in all other places;
iii. has qualified medical practitioner (s) in charge round the clock;
iv. has a fully equipped operation theatre of its own where surgical procedures are carried out
v. maintains daily records of patients and shall make these accessible to the Company’s authorized personnel.
3.18 Hospitalization means admission in a hospital for a minimum period of twenty-four (24) hours consecutive ‘In-patient care’ provided it will not include procedures/ treatments, where such admission could be for a period of less than twenty-four (24) consecutive hours
3.19 Illness means a sickness or a disease or pathological condition leading to the impairment of normal physiological function which manifests itself during the policy period and requires medical treatment
i. Acute Condition means a disease, illness or injury that is likely to response quickly to treatment which aims to return the person to his or her state of health immediately before suffering the disease/ illness/ injury which leads to full recovery.
ii. Chronic Condition means a disease, illness, or injury that has one or more of the following characteristics
a) it needs ongoing or long-term monitoring through consultations, examinations, check-ups, and / or tests
b) it needs ongoing or long-term control or relief of symptoms
c) it requires rehabilitation for the patient or for the patient to be special trained to cope with it
d) it continues indefinitely
e) it recurs or is likely to recur
3.20 In-Patient Care means treatment for which the insured person has to stay in a hospital for more than 24 hours for a covered event.
3.21 Insured Person means person(s) named in the schedule of the Policy.
3.22 Intensive Care Unit means an identified section, ward or wing of a hospital which is under the constant supervision of a dedicated medical practitioner(s), and which is specially equipped for the continuous monitoring and treatment of patients who are in a critical condition, or require life support facilities and where the level of care and supervision is considerably more sophisticated and intensive than in the ordinary and other wards.
3.23 ICU (Intensive Care Unit) Charges means the amount charged by a Hospital towards ICU expenses on a per day basis which shall include the expenses for ICU bed, general medical support services provided to any ICU patient including monitoring devices, critical care nursing and intensivist charges.
3.24 Medical Advice means any consultation or advice from a Medical Practitioner including the issue of any prescription or follow up prescription.
3.25 Medical Expenses means those expenses that an insured person has necessarily and actually incurred for medical treatment on account of illness or accident on the advice of a medical practitioner, as long as these are no more than would have been payable if the insured person had not been insured and no more than other hospitals or doctors in the same locality would have charged for the same medical treatment.
3.26 Medical Practitioner means a person who holds a valid registration from the Medical Council of any state or Medical Council of India or Council for Indian Medicine or for Homeopathy set up by the Government of India or a State Government and is thereby entitled to practice medicine within its jurisdiction; and is acting within the scope and jurisdiction of the licence.
3.27 Medically Necessary Treatment means any treatment, tests, medication, or stay in hospital or part of a stay in hospital which
i. is required for the medical management of illness or injury suffered by the insured;
ii. must not exceed the level of care necessary to provide safe, adequate and appropriate medical care in scope, duration, or intensity;
iii. must have been prescribed by a medical practitioner;
iv. must conform to the professional standards widely accepted in international medical practice or by the medical community in India.
3.28 “Migration” means, the right accorded to health insurance policyholders (including all members under family cover and members of group health insurance policy), to transfer the credit gained for pre-existing conditions and time bound exclusions, with the same insurer.
3.29 Network Provider means hospitals enlisted by insurer, TPA or jointly by an insurer and TPA to provide medical services to an insured by a cashless facility.
3.30 Nominee means the person nominated by the insured to receive the insurance benefits under this policy payable on the death of the insured.
3.31 Non- Network Provider means any hospital that is not part of the network.
3.32 Notification of Claim means the process of intimating a claim to the Insurer or TPA through any of the recognized modes of communication.
3.33 Out-Patient (OPD) Treatment means treatment in which the insured visits a clinic / hospital or associated facility like a consultation room for diagnosis and treatment based on the advice of a medical practitioner. The insured is not admitted as a day care or in-patient.
3.34 Pre-Existing Disease (PED): Preexisting disease means any condition, ailment, injury or disease:
a) That is/are diagnosed by a physician within 48 months prior to the effective date of the policy issued by the insurer or its reinstatement
b) For which medical advice or treatment was recommended by, or received from, a physician within 48 months prior to the effective date of the policy issued by the Insurer or its reinstatement.
3.35 Pre-hospitalization Medical Expenses means medical expenses incurred during the period of 15 days preceding the hospitalization of the Insured Person, provided that:
i.Such Medical Expenses are incurred for the same condition for which the Insured Person’s Hospitalization was required, and
ii. The In-patient Hospitalization claim for such hospitalization is admissible by the Insurance Company.
3.36 Post-hospitalization Medical Expenses means medical expenses incurred during the period of 30 days immediately after the insured person is discharged from the hospital provided that:
i. Such Medical Expenses are for the same condition for which the insured person’s hospitalization was required, and
ii. The inpatient hospitalization claim for such hospitalization is admissible by the Insurance Company.
3.37 “Portability” means, the right accorded to individual health insurance policyholders (including all members under family cover), to transfer the credit gained for pre-existing conditions and time bound exclusions, from one insurer to another insurer.
3.38 Post-hospitalization Medical Expenses means medical expenses incurred during the period of 30 days immediately after the insured person is discharged from the hospital provided that:
i. Such Medical Expenses are for the same condition for which the insured person’s hospitalization/home care treatment was required, and
ii. The inpatient hospitalization/home care treatment claim for such hospitalization/home care treatment is admissible by the Insurance Company.
3.39 Policy means these Policy wordings, the Policy Schedule and any applicable endorsements or extensions attaching to or forming part thereof. The Policy contains details of the extent of cover available to the Insured person, what is excluded from the cover and the terms & conditions on which the Policy is issued to the Insured person.
3.40 Policy period means period of one policy year as mentioned in the schedule for which the Policy is issued.
3.41 Policy Schedule means the Policy Schedule attached to and forming part of Policy.
3.42 Policy year means a period of twelve months beginning from the date of commencement of the policy period and ending on the last day of such twelve-month period. For the purpose of subsequent years, policy year shall mean a period of twelve months commencing from the end of the previous policy year and lapsing on the last day of such twelve-month period, till the policy period, as mentioned in the schedule.
3.43 Portability means the right accorded to an individual health insurance policyholder (including all members under family cover), to transfer the credit gained for pre-existing conditions and time bound exclusions, from one insurer to another insurer.
3.44 Qualified Nurse means a person who holds a valid registration from the Nursing Council of India or the Nursing Council of any state in India.
3.45 Renewal means the terms on which the contract of insurance can be renewed on mutual consent with a provision of grace period for treating the renewal continuous for the purpose of gaining credit for pre-existing diseases, time-bound exclusions and for all waiting periods.
3.46 Room Rent means the amount charged by a hospital towards Room and Boarding expenses and shall include the associated medical expenses.
3.47 Sum Insured means the pre-defined limit specified in the Policy Schedule. Sum Insured and Cumulative Bonus represents the maximum, total and cumulative liability for any and all claims made under the Policy, in respect of that Insured Person (on Individual basis) or all Insured Persons (on Floater basis) during the Policy Period.
3.48 Surgery or Surgical Procedure means manual and / or operative procedure (s) required for treatment of an illness or injury, correction of deformities and defects, diagnosis and cure of diseases, relief of suffering and prolongation of life, performed in a hospital or day care centre by a medical practitioner.
3.49 Third Party Administrator (TPA) means a Company registered with the Authority, and engaged by an insurer, for a fee or by whatever name called and as may be mentioned in the health services agreement, for providing health services.
3.50 Unproven/Experimental treatment means the treatment including drug experimental therapy which is not based on established medical practice in India.
3.51 Waiting Period means a period from the inception of this Policy during which specified vector borne disease is not covered.
4. Scope of Cover:
The Policy shall offer the health insurance coverage as specified in the policy in respect of any one or combination of the following vector borne disease (s) opted by the policyholder and as mentioned in the policy schedule.
i. Dengue fever
ii. Malaria
iii. Filaria (Lymphatic Filariasis)
iv. Kala-azar
v. Chikungunya
vi. Japanese Encephalitis
vii. Zika Virus
I. Base Cover:
The covers listed below are in-built Policy benefit and shall be available to all insured persons in accordance with the procedures set out in this Policy.
4.1 Hospitalization Cover: The Hospitalization expenses incurred by the insured person for the treatment of specified Vector Borne Diseases on Positive diagnosis and on recommendation of hospitalization by a medical practitioner. This section shall cover the following:
a) Room, Boarding, Nursing Expenses as provided by the Hospital / Nursing Home up to 2% of the sum insured (excluding CB) for the sum insured above Rs 20,000 and a fixed amount of Rs 500/day for the sum insured up to Rs 20,000.
b) Surgeon, Anesthetist, Medical Practitioner, Consultants, Specialist Fees (including consultation through telemedicine as per Telemedicine Practice Guideline of 25th March 2020) whether paid directly to the treating doctor / surgeon or to the hospital.
c) Anesthesia, blood, oxygen, operation theatre charges, surgical appliances, ventilator charges, medicines and drugs, costs towards diagnostics, diagnostic imaging modalities, PPE Kit, gloves, mask and such other similar expenses.
d) Intensive Care Unit (ICU) / Intensive Cardiac Care Unit (ICCU) expenses up to 5% of sum insured (excluding CB) for the sum insured above Rs 20,000 and a fixed sum of Rs 1000/day for Sum Insured up to Rs 20,000.
e) Expenses incurred on road Ambulance subject to a maximum of Rs. 2000/- per hospitalization.
4.1.1. Other expenses
i.All the day care treatments for specified vector borne disease (s)
Note:
i. Expenses of Hospitalization for a minimum period of 24 consecutive hours only shall be admissible. However, the time limit shall not apply in respect of Day Care Treatment for specified vector borne disease.
ii. In case of admission to a room at rates exceeding the aforesaid limits, the reimbursement/payment of “Associated Medical Expenses” incurred at the Hospital shall be affected in the same proportion as the admissible rate per day bears to the actual rate per day of Room Rent charges.
iii. Proportionate Deductions shall not be applied in respect of ICU or hospitals where differential billing is not followed or for those expenses where differential billing is not adopted based on the room category.
4.2 AYUSH Treatment: The Medical expenses incurred on hospitalization under AYUSH (as defined in IRDAI (Health Insurance) Regulations, 2016) system of medicine for the treatment of specified Vector Borne Diseases on Positive diagnosis and on recommendation of hospitalization by a medical practitioner shall be covered up to the Sum Insured without any sub-limits.
4..3 Pre-Hospitalization medical expenses incurred for a period of 15 days prior to the date of hospitalization following an admissible claim under this policy shall be covered.
4.4 Post-Hospitalization medical expenses incurred for a period of 30 days from the date of discharge from the hospital following an admissible claim under this policy shall be covered.
II. Optional Covers:
4.5 Hospital Cash Benefit: A fixed percentage of 0.5% of the sum insured (excluding CB) shall be payable for each completed twenty-four hours (24 hours) of hospitalization (Including AYUSH Hospital) due to positive diagnosis (through laboratory examination and confirmed by the medical practitioner) of covered vector borne diseases diagnosed during the Cover Period, subject to policy terms and conditions:
The benefit shall be payable maximum up to 14 days during a policy period.
4.6 Diagnosis Cover: The fixed percentage of 2% of the sum insured (excluding CB) shall be payable on positive diagnosis (through laboratory examination and confirmed by the medical practitioner) of covered vector borne diseases, which is diagnosed during the Cover Period, subject to policy terms and conditions, provided that insured is not hospitalized for the same illness within 15 days from diagnosis.
Note: The total amount payable in respect of Covers 4.1, 4.2,4.3,4.4,4.5,4.6 shall not exceed 100% of the Sum Insured and Cumulative bonus during a policy period.
5. Cumulative Bonus (CB)
Sum Insured (Excluding CB) will be increased by 5% in respect of each claim free policy year (where no claims are reported), provided the policy is renewed with the company without a break subject to maximum of 50% of the sum insured under the current policy year. If a claim is made in any particular year, the cumulative bonus accrued shall be reduced at the same rate at which it has accrued. However, sum insured will be maintained and will not be reduced in the policy year.
Notes:
i. In case where the policy is on individual basis, the CB shall be added and available individually to the insured person if no claim has been reported. CB shall reduce only in case of claim from the same Insured Person.
ii. In case where the policy is on floater basis, the CB shall be added and available to the family on floater basis, provided no claim has been reported from any member of the family. CB shall reduce in case of claim from any of the Insured Persons.
iii. CB shall be available only if the Policy is renewed/ premium paid within the Grace Period.
iv. If the Insured Persons in the expiring policy are covered on an individual basis as specified in the Policy Schedule and there is an accumulated CB for such Insured Person under the expiring policy, and such expiring policy has been renewed on a floater policy basis as specified in the Policy Schedule then the CB to be carried forward for credit in such renewed policy shall be the one that is applicable to the lowest among all the Insured Persons
v. In case of floater policies where Insured Persons renew their expiring policy by splitting the Sum Insured in to two or more floater policies/individual policies or in cases where the policy is split due to the child attaining the age of 25 years, the CB of the expiring policy shall be apportioned to such renewed policies in the proportion of the Sum Insured of each Renewed Policy
vi. If the Sum Insured has been reduced at the time of renewal, the accrued CB shall be protected subject to the condition that the CB shall be limited to maximum of 50% of the sum insured under the current policy year.
vii. If the Sum Insured under the Policy has been increased at the time of Renewal the CB shall be calculated on the Sum Insured of the last completed Policy Year.
viii. If a claim is made in the expiring Policy Year, and is notified to Us after the acceptance of Renewal premium any awarded CB shall be withdrawn
6. Waiting Period:
6.1 Pre-Existing Diseases (Code- Excl01)
a) Expenses related to the treatment of a pre-existing Disease (PED) and its direct complications shall be excluded until the expiry of 48 months of continuous coverage after the date of inception of the first policy with us.
b) In case of enhancement of sum insured the exclusion shall apply afresh to the extent of sum insured increase.
c) If the Insured Person is continuously covered without any break as defined under the portability norms of the extant IRDAI (Health Insurance) Regulations, then waiting period for the same would be reduced to the extent of prior coverage.
d) Coverage under the policy after the expiry of 48 months for any pre-existing disease is subject to the same being declared at the time of application and accepted by us.
Note: This waiting period shall not apply in the cases of re-infection of pre-existing covered vector borne disease after complete cure of the disease.
6.2 First Fifteen Days (15 days) Waiting Period
The Company shall not be liable to make any payment under the policy if the covered vector borne disease is diagnosed or hospitalization takes place during first fifteen days (15 days) from the commencement date of this Policy unless insured person is covered under this Policy continuously and without any break in the previous Policy Year.
7. EXCLUSIONS
The Company shall not be liable to make any payment under the policy in respect of:
7.1 Claim for any illness other than for vector borne diseases as listed in Section 4.
7.2 Diagnosis /Treatment outside the geographical limits of India.
7.3 Any expenses incurred on Domiciliary Hospitalization and OPD treatment
7.4 Any laboratory test not recognized/ approved by the concerned Authorities.
7.5 Investigation &Evaluation (Code- Excl04)
a) Expenses related to any admission primarily for diagnostics and evaluation purposes.
b) Any diagnostic expenses which are not related or not incidental to the current diagnosis and treatment
7.6 Rest Cure, rehabilitation and respite care (Code- Excl05)
a) Expenses related to any admission primarily for enforced bed rest and not for receiving treatment. This also includes:
i. Custodial care either at home or in a nursing facility for personal care such as help with activities of daily living such as bathing, dressing, moving around either by skilled nurses or assistant or non-skilled persons.
ii. Any services for people who are terminally ill to address physical, social, emotional and spiritual needs.
7.7 Excluded Providers: (Code-Excl11)
Expenses incurred towards treatment in any hospital or by any Medical Practitioner or any other provider specifically excluded by the Insurer and disclosed in its website / notified to the policyholders are not admissible. However, in case of life threatening situations expenses up to the stage of stabilization are payable but not the complete claim.
(Note to Insurers: Details of excluded providers shall be provided with the policy document. Insurers to use various means of communication to notify the policyholders, such as e-mail, SMS about the updated list being uploaded in the website)
7.8 Treatments received in heath hydros, nature cure clinics, spas or similar establishments or private beds registered as a nursing home attached to such establishments or where admission is arranged wholly or partly for domestic reasons. (Code- Excl13)
7.9 Dietary supplements and substances that can be purchased without prescription, including but not limited to Vitamins, minerals and organic substances unless prescribed by a medical practitioner as part of hospitalization claim or day care procedure (Code- Excl14)
7.10 Unproven Treatments:(Code- Excl16)
Expenses related to any unproven treatment, services and supplies for or in connection with any treatment. Unproven treatments are treatments, procedures or supplies that lack significant medical documentation to support their effectiveness.
8.Moratorium Period: After completion of eight continuous years under this policy no look back would be applied. This period of eight years is called as moratorium period. The moratorium would be applicable for the sums insured of the first policy and subsequently completion of eight continuous years would be applicable from date of enhancement of sums insured only on the enhanced limits. After the expiry of Moratorium Period no claim under this policy shall be contestable except for proven fraud and permanent exclusions specified in the policy contract. The policy would however be subject to applicable terms and conditions.
9. CLAIM PROCEDURE
9.1 Procedure for Cashless claims:
(i) Treatment may be taken in a network provider and is subject to pre authorization by the Company or its authorized TPA. (ii) Cashless request form available with the network provider and TPA shall be completed and sent to the Company/TPA for authorization. (iii) The Company/ TPA upon getting cashless request form and related medical information from the insured person/ network provider will issue pre-authorization letter to the hospital after verification. (iv) At the time of discharge, the insured person has to verify and sign the discharge papers, pay for non-medical and inadmissible expenses. (v) The Company / TPA reserves the right to deny pre-authorization in case the insured person is unable to provide the relevant medical details. (vi)In case of denial of cashless access, the insured person may obtain the treatment as per treating doctor’s advice and submit the claim documents to the Company / TPA for reimbursement.
9.2 Procedure for reimbursement of claims:
For reimbursement of claims the insured person may submit the necessary documents to TPA (if applicable)/Company within the prescribed time limit as specified hereunder.
| Sl
No |
Type of Claim | Prescribed Time limit |
| 1. | Reimbursement of hospitalization, day care and pre hospitalization expenses | Within thirty days (30 days) from date of discharge from hospital |
| 2. | Reimbursement of post hospitalization expenses | Within fifteen days (15 days) from completion of post hospitalization treatment |
| 3 | Reimbursement of Diagnosis Cover claim | Within Fifteen days (15 days) of Diagnosis of the covered vector borne disease |
9.3 Notification of Claim
Notice with full particulars shall be sent to the Company/TPA (if applicable) as under:
i. Within 24 hours from the date of emergency hospitalization.
ii. At least 48 hours prior to admission in Hospital in case of a planned Hospitalization.
9.4 Documents to be submitted:
The claim is to be supported with the following documents and submitted within the prescribed time limit.
| Benefits | Claims Documents Required |
| 1.Hospitalization Cover | i. Duly filled and signed Claim Form
ii. Photo Identity proof of the patient iii. Medical practitioner’s prescription advising admission iv. Original bills with itemized break-up v. Payment receipts vi. Discharge summary including complete medical history of the patient along with other details. vii. Laboratory report(s) confirming the diagnosis viii. OT notes or Surgeon’s certificate giving details of the operation performed, wherever applicable ix. NEFT Details (to enable direct credit of claim amount in bank account) and cancelled cheque x. KYC (Identity proof with Address) of the proposer, where claim liability is above Rs 1 Lakh as per AML Guidelines xi. Legal heir/succession certificate, wherever applicable xii. Any other relevant document required by Company/TPA for assessment of the claim. |
| 2. Diagnosis Coer | i. Duly filled and signed Claim Form
ii. Photo Identity proof of the patient iii. Laboratory report(s) confirming the diagnosis iv. Payment receipt (s) v. Laboratory report(s) confirming the diagnosis vi. NEFT Details (to enable direct credit of claim amount in bank account) and cancelled cheque vii. Legal heir/succession certificate, wherever applicable viii. Any other relevant document required by Company/TPA for assessment of the claim. |
[Note: Insurer may specify the documents required in original and waive off any of the above requirement as per their claim procedure]
Note:
1. The company shall only accept bills/invoices/medical treatment related documents only in the Insured Person’s name for whom the claim is submitted
2. In the event of a claim lodged under the Policy and the original documents having been submitted to any other insurer, the Company shall accept the copy of the documents and claim settlement advice, duly certified by the other insurer subject to satisfaction of the Company
3. Any delay in notification or submission may be condoned on merit where delay is proved to be for reasons beyond the control of the Insured Person
9.5 Claim Settlement (provision for Penal Interest)
i. The Company shall settle or reject a claim, as the case may be, within 30 days from the date of receipt of last necessary document.
ii. In the case of delay in the payment of a claim, the Company shall be liable to pay interest to the policyholder from the date of receipt of last necessary document to the date of payment of claim at a rate 2% above the bank rate.
iii. However, where the circumstances of a claim warrant an investigation in the opinion of the Company, it shall initiate and complete such investigation at the earliest, in any case not later than 30 days from the date of receipt of last necessary document. In such cases, the Company shall settle or reject the claim within 45 days from the date of receipt of last necessary document.
iv. In case of delay beyond stipulated 45 days, the Company shall be liable to pay interest to the policyholder at a rate 2% above the bank rate from the date of receipt of last necessary document to the date of payment of claim.
(Explanation: “Bank rate” shall mean the rate fixed by the Reserve Bank of India (RBI) at the beginning of the financial year in which claim has fallen due)
(Note to Insurers: The Clause shall be suitably modified by the insurer based on the amendment(s), if any to the relevant provisions of Protection of Policyholder’s Interests Regulations, 2017)
9.6 Services Offered by TPA (To be stated where TPA is involved)
Servicing of claims, i.e., claim admissions and assessments, under this Policy by way of pre-authorization of cashless treatment or processing of claims other than cashless claims or both, as per the underlying terms and conditions of the policy.
The services offered by a TPA shall not include
i. Claim settlement and claim rejection;
ii. Any services directly to any insured person or to any other person unless such service is in accordance with the terms and conditions of the Agreement entered into with the Company.
9.7 Payment of Claim
All claims under the policy shall be payable in Indian currency only.
10. GENERAL TERMS &CONDITIONS
10.1 Disclosure of Information
The policy shall be void and all premium paid thereon shall be forfeited to the Company in the event of misrepresentation, mis description or non-disclosure of any material fact by the policyholder.
(Explanation: “Material facts” for the purpose of this policy shall mean all relevant information sought by the company in the proposal form and other connected documents to enable it to take informed decision in the context of underwriting the risk)
10.2 Condition Precedent to Admission of Liability
The terms and conditions of the policy must be fulfilled by the insured person for the Company to make any payment for claim(s) arising under the policy.
10.3 Material Change
The Insured shall notify the Company in writing of any material change in the risk in relation to the declaration made in the proposal form or medical examination report at each Renewal and the Company may, adjust the scope of cover and / or premium, if necessary, accordingly.
10.4 Records to be maintained
The Insured Person shall keep an accurate record containing all relevant medical records and shall allow the Company or its representatives to inspect such records. The Policyholder or Insured Person shall furnish such information as the Company may require for settlement of any claim under the Policy, within reasonable time limit and within the time limit specified in the Policy
10.5 Complete Discharge
Any payment to the policyholder, insured person or his/ her nominees or his/ her legal representative or assignee or to the Hospital, as the case may be, for any benefit under the policy shall be a valid discharge towards payment of claim by the Company to the extent of that amount for the particular claim.
10.6 Notice & Communication
i. Any notice, direction, instruction or any other communication related to the Policy should be made in writing.
ii. Such communication shall be sent to the address of the Company or through any other electronic modes specified in the Policy Schedule.
iii. The Company shall communicate to the Insured at the address or through any other electronic mode mentioned in the schedule.
10.7 Territorial Limit
All medical treatment for the purpose of this insurance will have to be taken in India only.
10.8 Multiple Policies
i. In case of multiple policies taken by an insured person during a period from one or more insurers to indemnify treatment costs, the insured person shall have the right to require a settlement of his/her claim in terms of any of his/her policies. In all such cases the insurer chosen by the insured person shall be obliged to settle theclaim as long as the claim is within the limits of and according to the terms of the chosen policy.
ii. Insured person having multiple policies shall also have the right to prefer claims under this policy for the amounts disallowed under any other policy / policies even if the sum insured is not exhausted. Then the insurer shall independently settle the claim subject to the terms and conditions of this policy.
iii. If the amount to be claimed exceeds the sum insured under a single policy, the insured person shall have the right to choose insurer from whom he/she wants to claim the balance amount.
iv. Where an insured person has policies from more than one insurer to cover the same risk on indemnity basis, the insured person shall only be indemnified the treatment costs in accordance with the terms and conditions of the chosen policy.
10.9 Fraud
If any claim made by the insured person, is in any respect fraudulent, or if any false statement, or declaration is made or used in support thereof, or if any fraudulent means or devices are used by the insured person or anyone acting on his/her behalf to obtain any benefit under this policy, all benefits under this policy and the premium paid shall be forfeited.
Any amount already paid against claims made under this policy but which are found fraudulent later shall be repaid by all recipient(s)/policyholder(s), who has made that particular claim, who shall be jointly and severally liable for such repayment to the insurer.
For the purpose of this clause, the expression “fraud” means any of the following acts committed by the insured person or by his agent or the hospital/doctor/any other party acting on behalf of the insured person, with intent to deceive the insurer or to induce the insurer to issue an insurance policy:
a) the suggestion, as a fact of that which is not true and which the insured person does not believe to be true;
b) the active concealment of a fact by the insured person having knowledge or belief of the fact;
c) any other act fitted to deceive; and
d) any such act or omission as the law specially declares to be fraudulent
The Company shall not repudiate the claim and / or forfeit the policy benefits on the ground of Fraud, if the insured person / beneficiary can prove that the misstatement was true to the best of his knowledge and there was no deliberate intention to suppress the fact or that such misstatement of or suppression of material fact are within the knowledge of the insurer.
10.10 Cancellation
i. The policyholder may cancel this policy by giving 15days’ written notice and in such an event, the Company shall refund premium for the unexpired policy period as detailed below.
| Refund of Premium (basis Policy Period) | |
| Risk Period (Policy in force) | Refund % |
| Up to 30 days | 75.00% |
| 31 to 90 days | 50.00% |
| 3 to 6 months | 25.00% |
| 6 to 12 months | 0.00% |
Notwithstanding anything contained herein or otherwise, no refunds of premium shall be made in respect of Cancellation where, any claim has been admitted or has been lodged or any benefit has been availed by the insured person under the policy.
ii. The Company may cancel the policy at any time on grounds of misrepresentation non-disclosure of material facts, fraud by the insured person by giving 15 days’ written notice. There would be no refund of premium on cancellation on grounds of misrepresentation, non-disclosure of material facts or fraud.
10.11 Renewal of Policy
The policy shall ordinarily be renewable except on grounds of fraud, misrepresentation by the insured person.
i. The Company shall endeavor to give notice for renewal. However, the Company is not under obligation to give any notice for renewal.
ii. Renewal shall not be denied on the ground that the insured person had made a claim or claims in the preceding policy years.
iii. Request for renewal along with requisite premium shall be received by the Company before the end of the policy period.
iv. At the end of the policy period, the policy shall terminate and can be renewed within the Grace Period of …… days (Note : Insurer to specify grace period as per product design) to maintain continuity of benefits without break in policy. Coverage is not available during the grace period.
v. No loading shall apply on renewals based on individual claims experience.
10.12 Migration
The insured person will have the option to migrate the policy to other health insurance products/plans offered by the company by applying for migration of the policy at least 30 days before the policy renewal date as per IRDAI guidelines on Migration. If such person is presently covered and has been continuously covered without any lapses under any health insurance product/plan offered by the company, the insured person will get the accrued continuity benefits in waiting periods as per IRDAI guidelines on migration.
For Detailed Guidelines on migration, kindly refer the link ………
(Note: Insurer to provide link to the IRDAI guidelines on migration. Timelines for applying for migration may be relaxed by the insurer subject to product design)
10.13 Portability
The insured person will have the option to port the policy to other insurers by applying to such insurer to port the entire policy along with all the members of the family, if any, at least 45 days before, but not earlier than 60 days from the policy renewal date as per IRDAI guidelines related to portability. If such person is presently covered and has been continuously covered without any lapses under any health insurance policy with an Indian General/Health insurer, the proposed insured person will get the accrued continuity benefits in waiting periods as per IRDAI guidelines on portability.
For Detailed Guidelines on portability, kindly refer the link ………
(Note: Insurer to provide link to the IRDAI guidelines related to portability. Timelines for applying for portability may be relaxed by the insurer subject to product design)
10.14 Withdrawal of Policy
i. In the likelihood of this product being withdrawn in future, the Company will intimate the insured person about the same 90 days prior to expiry of the policy.
ii. Insured Person will have the option to migrate to similar health insurance product available with the Company at the time of renewal with all the accrued continuity benefits such as cumulative bonus, waiver of waiting period as per IRDAI guidelines, provided the policy has been maintained without a break.
10.15 Automatic change in Coverage under the policy
1. In the case of his/ her (Insured Person) demise. However, the cover shall continue for the remaining Insured Persons till the end of Policy Period. The other insured persons may also apply to renew the policy. In case, the other insured person is minor, the policy shall be renewed only through any one of his/her natural guardian or guardian appointed by court. All relevant particulars in respect of such person (including his/her relationship with the insured person) must be submitted to the company along with the application. Provided no claim has been made, and termination takes place on account of death of the insured person, pro-rata refund of premium of the deceased insured person for the balance period of the policy will be effective.
2. Upon exhaustion of sum insured and cumulative bonus, for the policy year. However, the policy is subject to renewal on the due date as per the applicable terms and conditions.
10.16 Territorial Jurisdiction
All disputes or differences under or in relation to the interpretation of the terms, conditions, validity, construct, limitations and/or exclusions contained in the Policy shall be determined by the Indian court and according to Indian law.
10.17 Arbitration
i. If any dispute or difference shall arise as to the quantum to be paid by the Policy, (liability being otherwise admitted) such difference shall independently of all other questions, be referred to the decision of a sole arbitrator to be appointed in writing by the parties here to or if they cannot agree upon a single arbitrator within thirty days of any party invoking arbitration, the same shall be referred to a panel of three arbitrators, comprising two arbitrators, one to be appointed by each of the parties to the dispute/difference and the third arbitrator to be appointed by such two arbitrators and arbitration shall be conducted under and in accordance with the provisions of the Arbitration and Conciliation Act 1996, as amended by Arbitration and Conciliation (Amendment) Act, 2015 (No. 3 of 2016).
ii. It is clearly agreed and understood that no difference or dispute shall be preferable to arbitration as herein before provided, if the Company has disputed or not accepted liability under or in respect of the policy.
iii. It is hereby expressly stipulated and declared that it shall be a condition precedent to any right of action or suit upon the policy that award by such arbitrator/arbitrators of the amount of expenses shall be first obtained.
10.18 Possibility of Revision of Terms of the Policy Including the Premium Rates
The Company, with prior approval ofIRDAI, may revise or modify the terms of the policy including the premium rates. The insured person shall be notified three months before the changes are affected.
10.19 Free look period
The Free Look Period shall be applicable on new individual health insurance policies and not on renewals or at the time of porting/migrating the policy.
The insured person shall be allowed free look period of fifteen days from date of receipt of the policy document to review the terms and conditions of the policy, and to return the same if not acceptable.
If the insured has not made any claim during the Free Look Period, the insured shall be entitled to
i. a refund of the premium paid less any expenses incurred by the Company on medical examination of the insured person and the stamp duty charges or
ii. where the risk has already commenced and the option of return of the policy is exercised by the insured person, a deduction towards the proportionate risk premium for period of coveror
iii. Where only a part of the insurance coverage has commenced, such proportionate premium commensurate with the insurance coverage during such period;
(Note to insurers: Insurer may increase the free look period as per the product design)
10.20 Endorsements (Changes in Policy)
i. This policy constitutes the complete contract of insurance. This Policy cannot be modified by anyone (including an insurance agent or broker) except the company. Any change made by the company shall be evidenced by a written endorsement signed and stamped.
ii. The policyholder may be changed during the Policy Period only in case of his/her demise or him/her moving out of India. The new policyholder must be the legal heir/immediate family member. Such change would be subject to acceptance by the company and payment of premium (if any).
10.21 Change of Sum Insured
Sum insured can be changed (increased/ decreased) only at the time of renewal or at any time, subject to underwriting by the Company. For any increase in SI, the waiting period shall start afresh only for the enhanced portion of the sum insured.
10.22 Terms and conditions of the Policy
The terms and conditions contained herein and in the Policy Schedule shall be deemed to form part of the Policy and shall be read together as one document.
10.23 Nomination
The policyholder is required at the inception of the policy to make a nomination for the purpose of payment of claims under the policy in the event of death of the policyholder. Any change of nomination shall be communicated to the company in writing and such change shall be effective only when an endorsement on the policy is made. In the event of death of the policyholder, the Company will pay the nominee {as named in the Policy Schedule/Policy Certificate/Endorsement (if any)} and in case there is no subsisting nominee, to the legal heirs or legal representatives of the policyholder whose discharge shall be treated as full and final discharge of its liability under the policy.
11. REDRESSAL OF GRIEVANCE
In case of any grievance the insured person may contact the company through:
Website:
Toll free:
E-mail:
Fax :
Courier:
Insured person may also approach the grievance cell at any of the company’s branches with the details of grievance
If Insured person is not satisfied with the redressalof grievance through one of the above methods, insured person may contact the grievance officerat ………….
For updated details of grievance officer, kindly refer the link……….
Insurance Ombudsman – If Insured person is not satisfied with the redressalof grievance through above methods, theinsured person may also approach the office of Insurance Ombudsman of the respective area/region for redressal of grievanceas per Insurance Ombudsman Rules 2017.The contact details of the Insurance Ombudsman offices have been provided as Annexure-B.
Grievance may also be lodged at IRDAI Integrated Grievance Management System – https://igms.irda.gov.in/
10. TABLE OF BENEFITS
| Name | Vector Borne Disease Health Policy,[Company Name] |
| Product Type | Individual/ Floater |
| Category of Cover | Benefit |
| Sum insured |
Rs 10,000/- (Ten Thousand) to2,00,000/- (Two Lakh) (in the multiples of ten thousand)
On Individual basis – SI shall apply to each individual family member
On Floater basis – SI shall apply to the entire family |
| Policy Period | Standard Product shall be offered with a policy tenure of one year (12 Months). |
| Eligibility | Policy can be availed by persons above the age of 18 years as Proposer.
Policy can be availed for Self and the following family members i. legally wedded spouse. ii. Parents and Parents-in-law. iii. Dependent Children (i.e. natural or legally adopted) between the day 1 of age to 25 years. If the child above 18 years of age is financially independent, he or she shall be ineligible. |
| Hospitalization Cover | The Hospitalization expenses incurred by the insured person for the treatment of specified Vector Borne Diseases on Positive diagnosis and on recommendation of hospitalization by a medical practitioner subject to policy terms and conditions. |
| AYUSH Treatment | The Medical expenses incurred on hospitalization under AYUSH (as defined in IRDAI (Health Insurance) Regulations, 2016) system of medicine for the treatment of specified Vector Borne Diseases on Positive diagnosis and on recommendation of hospitalization by a medical practitioner shall be covered up to the Sum Insured without any sub-limits.
|
| Pre Hospitalization | For 15days prior to the date of hospitalization. |
| Post Hospitalization | For 30days from the date of discharge from the hospital |
| Hospital Cash Benefit | A fixed percentage of 0.5% of the sum insured (excluding CB) shall be payable for each completed twenty-four hours (24 hours) of hospitalization (Including AYUSH Hospital) due to positive diagnosis (through laboratory examination and confirmed by the medical practitioner) of covered vector borne diseases diagnosed during the Cover Period, subject to policy terms and conditions. The benefit shall be payable maximum up to 14 days during a policy period. |
| Diagnosis Cover | The fixed percentage of 2% of the sum insured (excluding CB) shall be payable on positive diagnosis (through laboratory examination and confirmed by the medical practitioner) of covered vector borne diseases, which is diagnosed during the Cover Period, subject to policy terms and conditions, provided that insured is not hospitalized for the same illness within 15 days from diagnosis. |
| Sub-limits |
i. Hospital Cash Benefit: 0.5% of sum insured (excluding CB) for each completed twenty-four hours (24 hours) of hospitalization. The benefit shall be payable maximum up to 14 days during a policy period. ii. Diagnosis cover: 2% of sum insured (excluding CB) iii. Room Rent: 2% of the sum insured (excluding CB) for the sum insured above Rs 20,000 and a fixed amount of Rs 500/day for the sum insured up to Rs 20,000. iv. ICU: 5% of sum insured (excluding CB) for the sum insured above Rs 20,000 and a fixed sum of Rs 1000/day for Sum Insured up to Rs 20,000. v. Ambulance: Up to Rs. 2000/- per hospitalization. |
Annexure-A
List I – Items for which coverage is not available in the policy
| Sl No | Item |
| 1 | BABY FOOD |
| 2 | BABY UTILITIES CHARGES |
| 3 | BEAUTY SERVICES |
| 4 | BELTS/ BRACES |
| 5 | BUDS |
| 6 | COLD PACK/HOT PACK |
| 7 | CARRY BAGS |
| 8 | EMAIL / INTERNET CHARGES |
| 9 | FOOD CHARGES (OTHER THAN PATIENT’s DIET PROVIDED BY HOSPITAL) |
| 10 | LEGGINGS |
| 11 | LAUNDRY CHARGES |
| 12 | MINERAL WATER |
| 13 | SANITARY PAD |
| 14 | TELEPHONE CHARGES |
| 15 | GUEST SERVICES |
| 16 | CREPE BANDAGE |
| 17 | DIAPER OF ANY TYPE |
| 18 | EYELET COLLAR |
| 19 | SLINGS |
| 20 | BLOOD GROUPING AND CROSS MATCHING OF DONORS SAMPLES |
| 21 | SERVICE CHARGES WHERE NURSING CHARGE ALSO CHARGED |
| 22 | TELEVISION CHARGES |
| 23 | SURCHARGES |
| 24 | ATTENDANT CHARGES |
| 25 | EXTRA DIET OF PATIENT (OTHER THAN THAT WHICH FORMS PART OF BED CHARGE) |
| 26 | BIRTH CERTIFICATE |
| 27 | CERTIFICATE CHARGES |
| 28 | COURIER CHARGES |
| 29 | CONVEYANCE CHARGES |
| 30 | MEDICAL CERTIFICATE |
| 31 | MEDICAL RECORDS |
| 32 | PHOTOCOPIES CHARGES |
| 33 | MORTUARY CHARGES |
| 34 | WALKING AIDS CHARGES |
| 35 | SPIROMETRE |
| 36 | STEAM INHALER |
| 37 | ARMSLING |
| 38 | THERMOMETER |
| 39 | CERVICAL COLLAR |
| 40 | SPLINT |
| 41 | DIABETIC FOOT WEAR |
| 42 | KNEE BRACES (LONG/ SHORT/ HINGED) |
| 43 | KNEE IMMOBILIZER/SHOULDER IMMOBILIZER |
| 44 | LUMBO SACRAL BELT |
| 45 | NIMBUS BED OR WATER OR AIR BED CHARGES |
| 46 | AMBULANCE COLLAR |
| 47 | AMBULANCE EQUIPMENT |
| 48 | ABDOMINAL BINDER |
| 49 | PRIVATE NURSES CHARGES- SPECIAL NURSING CHARGES |
| 50 | SUGAR FREE TABLETS |
| 51 | CREAMS POWDERS LOTIONS (Toiletries are not payable, only prescribed medical pharmaceuticals payable) |
| 52 | ECG ELECTRODES |
| 53 | ANY KIT WITH NO DETAILS MENTIONED [DELIVERY KIT, ORTHOKIT, RECOVERY KIT, ETC] |
| 54 | KIDNEY TRAY |
| 55 | OUNCE GLASS |
| 56 | PELVIC TRACTION BELT |
| 57 | PAN CAN |
| 58 | TROLLY COVER |
| 59 | UROMETER, URINE JUG |
List II – Items that are to be subsumed into Room Charges
| Sl No | Item |
| 1 | BABY CHARGES (UNLESS SPECIFIED/INDICATED) |
| 2 | HAND WASH |
| 3 | CRADLE CHARGES |
| 4 | COMB |
| 5 | EAU-DE-COLOGNE / ROOM FRESHNERS |
| 6 | GOWN |
| 7 | SLIPPERS |
| 8 | TISSUE PAPER |
| 9 | TOOTH PASTE |
| 10 | TOOTH BRUSH |
| 11 | BED PAN |
| 12 | FLEXI MASK |
| 13 | HAND HOLDER |
| 14 | SPUTUM CUP |
| 15 | DISINFECTANT LOTIONS |
| 16 | LUXURY TAX |
| 17 | HVAC |
| 18 | HOUSE KEEPING CHARGES |
| 19 | AIR CONDITIONER CHARGES |
| 20 | IM IV INJECTION CHARGES |
| 21 | CLEAN SHEET |
| 22 | BLANKET/WARMER BLANKET |
| 23 | ADMISSION KIT |
| 24 | DIABETIC CHART CHARGES |
| 25 | DOCUMENTATION CHARGES / ADMINISTRATIVE EXPENSES |
| 26 | DISCHARGE PROCEDURE CHARGES |
| 27 | DAILY CHART CHARGES |
| 28 | ENTRANCE PASS / VISITORS PASS CHARGES |
| 29 | EXPENSES RELATED TO PRESCRIPTION ON DISCHARGE |
| 30 | FILE OPENING CHARGES |
| 31 | INCIDENTAL EXPENSES / MISC. CHARGES (NOT EXPLAINED) |
| 32 | PATIENT IDENTIFICATION BAND / NAME TAG |
| 33 | PULSEOXYMETER CHARGES |
List III – Items that are to be subsumed into Procedure Charges
| Sl
No. |
Item |
| 1 | HAIR REMOVAL CREAM |
| 2 | DISPOSABLES RAZORS CHARGES (for site preparations) |
| 3 | EYE PAD |
| 4 | EYE SHEILD |
| 5 | CAMERA COVER |
| 6 | DVD, CD CHARGES |
| 7 | GAUSE SOFT |
| 8 | GAUZE |
| 9 | WARD AND THEATRE BOOKING CHARGES |
| 10 | ARTHROSCOPY AND ENDOSCOPY INSTRUMENTS |
| 11 | MICROSCOPE COVER |
| 12 | SURGICAL BLADES, HARMONICSCALPEL,SHAVER |
| 13 | SURGICAL DRILL |
| 14 | EYE KIT |
| 15 | EYE DRAPE |
| 16 | X-RAY FILM |
| 17 | BOYLES APPARATUS CHARGES |
| 18 | COTTON |
| 19 | COTTON BANDAGE |
| 20 | SURGICAL TAPE |
| 21 | APRON |
| 22 | TORNIQUET |
| 23 | ORTHOBUNDLE, GYNAEC BUNDLE |
List IV – Items that are to be subsumed into costs of treatment
| Sl
No. |
Item |
| 1 | ADMISSION/REGISTRATION CHARGES |
| 2 | HOSPITALISATION FOR EVALUATION/ DIAGNOSTIC PURPOSE |
| 3 | URINE CONTAINER |
| 4 | BLOOD RESERVATION CHARGES AND ANTE NATAL BOOKING CHARGES |
| 5 | BIPAP MACHINE |
| 6 | CPAP/ CAPD EQUIPMENTS |
| 7 | INFUSION PUMP– COST |
| 8 | HYDROGEN PEROXIDE\SPIRIT\ DISINFECTANTS ETC |
| 9 | NUTRITION PLANNING CHARGES – DIETICIAN CHARGES- DIET CHARGES |
| 10 | HIV KIT |
| 11 | ANTISEPTIC MOUTHWASH |
| 12 | LOZENGES |
| 13 | MOUTH PAINT |
| 14 | VACCINATION CHARGES |
| 15 | ALCOHOL SWABES |
| 16 | SCRUB SOLUTION/STERILLIUM |
| 17 | Glucometer& Strips |
| 18 | URINE BAG |
Annexure-B
The contact details of the Insurance Ombudsman offices are as below-
| Areas of Jurisdiction | Office of the Insurance Ombudsman |
| Gujarat , UT of Dadra and Nagar Haveli, Daman and Diu | Office of the Insurance Ombudsman, JeevanPrakash Building, 6th floor, TilakMarg, Relief Road, Ahmedabad – 380 001. Tel.: 079 – 25501201/02/05/06 Email: bimalokpal.ahmedabad@ecoi.co.in |
| Karnataka | Office of the Insurance Ombudsman, JeevanSoudhaBuilding,PID No. 57-27-N-19, Ground Floor, 19/19, 24th Main Road,JP Nagar, Ist Phase, Bengaluru – 560 078. Tel.: 080 – 26652048 / 26652049 Email: bimalokpal.bengaluru@ecoi.co.in |
| Madhya Pradesh and Chhattisgarh | Office of the Insurance Ombudsman, JanakVihar Complex, 2nd Floor, 6, Malviya Nagar, Opp. Airtel Office, Near New Market, Bhopal – 462 003. Tel.: 0755 – 2769201 / 2769202 Fax: 0755 – 2769203 Email: bimalokpal.bhopal@ecoi.co.in |
| Odisha | Office of the Insurance Ombudsman, 62, Forest park, Bhubneshwar – 751 009. Tel.: 0674 – 2596461 /2596455 Fax: 0674 – 2596429 Email: bimalokpal.bhubaneswar@ecoi.co.in |
| Punjab , Haryana, Himachal Pradesh, Jammu and Kashmir, UT of Chandigarh | Office of the Insurance Ombudsman, S.C.O. No. 101, 102 & 103, 2nd Floor, Batra Building, Sector 17 – D, Chandigarh – 160 017. Tel.: 0172 – 2706196 / 2706468 Fax: 0172 – 2708274 Email: bimalokpal.chandigarh@ecoi.co.in |
| Tamil Nadu, UT–Pondicherry Town and Karaikal (which are part of UT of Pondicherry) | Office of the Insurance Ombudsman, Fatima Akhtar Court, 4th Floor, 453, Anna Salai, Teynampet, CHENNAI – 600 018. Tel.: 044 – 24333668 / 24335284 Fax: 044 – 24333664 Email: bimalokpal.chennai@ecoi.co.in |
| Delhi | Office of the Insurance Ombudsman, 2/2 A, Universal Insurance Building, Asaf Ali Road, New Delhi – 110 002. Tel.: 011 – 23232481/23213504 Email: bimalokpal.delhi@ecoi.co.in |
| Assam , Meghalaya, Manipur, Mizoram, Arunachal Pradesh, Nagaland and Tripura | Office of the Insurance Ombudsman, JeevanNivesh, 5th Floor, Nr. Panbazar over bridge, S.S. Road, Guwahati – 781001(ASSAM). Tel.: 0361 – 2632204 / 2602205 Email: bimalokpal.guwahati@ecoi.co.in |
| Andhra Pradesh, Telangana and UT of Yanam – a part of the UT of Pondicherry | Office of the Insurance Ombudsman, 6-2-46, 1st floor, “Moin Court”, Lane Opp. Saleem Function Palace, A. C. Guards, Lakdi-Ka-Pool, Hyderabad – 500 004. Tel.: 040 – 67504123 / 23312122 Fax: 040 – 23376599 Email: bimalokpal.hyderabad@ecoi.co.in |
| Rajasthan | Office of the Insurance Ombudsman, JeevanNidhi – II Bldg., Gr. Floor, Bhawani Singh Marg, Jaipur – 302 005. Tel.: 0141 – 2740363 Email: Bimalokpal.jaipur@ecoi.co.in |
| Kerala , UT of (a) Lakshadweep, (b) Mahe – a part of UT of Pondicherry | Office of the Insurance Ombudsman, 2nd Floor, Pulinat Bldg., Opp. Cochin Shipyard, M. G. Road, Ernakulam-682015. Tel.: 0484 – 2358759/2359338 Fax: 0484-2359336 Email: bimalokpal.ernakulam@ecoi.co.in |
| West Bengal, UT of Andaman and Nicobar Islands, Sikkim | Office of the Insurance Ombudsman, Hindustan Bldg. Annexe, 4th Floor, 4, C.R. Avenue, KOLKATA – 700 072. Tel.: 033 – 22124339 / 22124340 Fax : 033 – 22124341 Email: bimalokpal.kolkata@ecoi.co.in |
| Districts of Uttar Pradesh : Laitpur, Jhansi, Mahoba, Hamirpur, Banda, Chitrakoot, Allahabad, Mirzapur, Sonbhabdra, Fatehpur, Pratapgarh, Jaunpur,Varanasi, Gazipur, Jalaun, Kanpur, Lucknow, Unnao, Sitapur, Lakhimpur, Bahraich, Barabanki,Raebareli, Sravasti, Gonda, Faizabad, Amethi, Kaushambi, Balrampur, Basti, Ambedkarnagar, Sultanpur, Maharajgang, Santkabirnagar, Azamgarh, Kushinagar, Gorkhpur, Deoria, Mau, Ghazipur, Chandauli, Ballia, Sidharathnagar. |
Office of the Insurance Ombudsman, 6th Floor, JeevanBhawan, Phase-II, Nawal Kishore Road, Hazratganj, Lucknow – 226 001. Tel.: 0522 – 2231330 / 2231331 Fax: 0522 – 2231310 Email: bimalokpal.lucknow@ecoi.co.in |
| Goa, Mumbai Metropolitan Region excluding Navi Mumbai & Thane |
Office of the Insurance Ombudsman, 3rd Floor, JeevanSevaAnnexe, S. V. Road, Santacruz (W), Mumbai – 400 054. Tel.: 022 – 26106552 / 26106960 Fax: 022 – 26106052 Email: bimalokpal.mumbai@ecoi.co.in |
| State of Uttaranchal and the following Districts of Uttar Pradesh: Agra, Aligarh, Bagpat, Bareilly, Bijnor, Budaun, Bulandshehar, Etah, Kanooj, Mainpuri, Mathura, Meerut, Moradabad, Muzaffarnagar, Oraiyya, Pilibhit, Etawah, Farrukhabad, Firozbad, Gautambodhanagar, Ghaziabad, Hardoi, Shahjahanpur, Hapur, Shamli, Rampur, Kashganj, Sambhal, Amroha, Hathras, Kanshiramnagar, Saharanpur. |
Office of the Insurance Ombudsman, BhagwanSahai Palace 4th Floor, Main Road, Naya Bans, Sector 15, Distt: GautamBuddh Nagar, U.P-201301. Tel.: 0120-2514250 / 2514252 / 2514253 Email: bimalokpal.noida@ecoi.co.in |
| Bihar, Jharkhand. |
Office of the Insurance Ombudsman, 1st Floor,Kalpana Arcade Building,, Bazar Samiti Road, Bahadurpur, Patna 800 006. Tel.: 0612-2680952 Email: bimalokpal.patna@ecoi.co.in |
| Maharashtra, Area of Navi Mumbai and Thane excluding Mumbai Metropolitan Region |
Office of the Insurance Ombudsman, JeevanDarshan Bldg., 3rd Floor, C.T.S. No.s. 195 to 198, N.C. Kelkar Road, Narayan Peth, Pune – 411 030. Tel.: 020-41312555 Email: bimalokpal.pune@ecoi.co.in |
[Note : Insurers to mention the correct address, e mail Id, phone number etc. of insurance ombudsmen while issuing policy contracts
Annexure-2
Customer Information Sheet (Description is illustrative and not exhaustive)
| No. | TITLE | DESCRIPTION |
Refer to policy clause number |
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| 1. | Product Name | Vector Borne Disease Health Policy,<name of the Insurer>. | ||||||||||
| 2. | What am I covered for | a. Hospitalization Cover : The Hospitalization expenses incurred by the insured person for the treatment of specified Vector Borne Diseases on Positive diagnosis and on recommendation of hospitalization by a medical practitioner subject to policy terms and conditions. | 4.1, | |||||||||
| b. Ambulance Charges: Expenses on road Ambulance subject to a maximum of Rs.2000/- per hospitalization. | 4.1 | |||||||||||
| c. AYUSH Treatment : The Medical expenses incurred on hospitalization under AYUSH (as defined in IRDAI (Health Insurance) Regulations, 2016) system of medicine for the treatment of specified Vector Borne Diseases on Positive diagnosis and on recommendation of hospitalization by a medical practitioner shall be covered up to the Sum Insured without any sub-limits. | 4.2 | |||||||||||
| d. Pre-hospitalization expenses- For 15 days prior to the date of hospitalization. | 4.3 | |||||||||||
| e. Post-hospitalization expenses- For 30 days prior to the date of hospitalization. | 4.4 | |||||||||||
| f. Hospital Cash Benefit: A fixed percentage of 0.5% of the sum insured (excluding CB) shall be payable for each completed twenty-four hours (24 hours) of hospitalization (Including AYUSH Hospital) due to positive diagnosis (through laboratory examination and confirmed by the medical practitioner) of covered vector borne diseases diagnosed during the Cover Period, subject to policy terms and conditions. The benefit shall be payable maximum up to 14 days during a policy period. | 4.5 | |||||||||||
| g. Diagnosis Cover : The fixed percentage of 2% of the sum insured (excluding CB) shall be payable on positive diagnosis (through laboratory examination and confirmed by the medical practitioner) of covered vector borne diseases, which is diagnosed during the Cover Period, subject to policy terms and conditions, provided that insured is not hospitalized for the same illness within 15 days from diagnosis. | 4.6 | |||||||||||
| 3. | What are the Major exclusions in the policy
|
Following is a partial list of the policy exclusions. Please refer to the policy document for the complete list of exclusions: |
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| a. Claim for any illness other than for covered vector borne diseases | 7.1 | |||||||||||
| b. Diagnosis /Treatment outside the geographical limits of India | 7.2 | |||||||||||
| c. Any expenses incurred on Domiciliary Hospitalization and OPD treatment | 7.3 | |||||||||||
| d. Admission primarily for investigation & evaluation | 7.5 | |||||||||||
| e. Admission primarily for rest Cure, rehabilitation and respite care | 7.6 | |||||||||||
| 4. | Waiting period | Pre-Existing Vector Borne Diseases will be covered after a waiting period of forty eight (48) months of continuous coverage. This waiting period shall not apply in the cases of re-infection after complete cure of a covered vector borne disease. | 6.1 | |||||||||
| Expenses related to the treatment of covered vector borne diseases within 15 days from the policy commencement date shall be excluded | 6.2 | |||||||||||
| 5. | Payment basis | The Base Cover is on indemnity basis and Optional Covers are on Benefit Basis. | ||||||||||
| 6. | Cancellation | i. The policyholder may cancel this policy by giving 15 days’ written notice and in such an event, the Company shall refund premium for the unexpired policy period as specified in the policy contract.
ii. The Company may cancel the policy at any time on grounds of misrepresentation, non-disclosure of material facts fraud by the Insured Person by giving 15 days’ written notice. |
10.
10 |
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| 7. | Claims | a. For Cashless Service:
(Insurer to provide the details /web link from where Hospital Network details can be obtained) |
9.1,
9.2 |
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b. For Reimbursement of Claim: For reimbursement of claims the insured person may submit the necessary documents to TPA/Company within the prescribed time limit as specified hereunder.
For details on claim procedure please refer the policy document. |
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| 8 | Policy Servicing | Insurer to provide the details of company officials. | ||||||||||
| Grievances/Complaints | a. Details of Grievance redressal officer (Insurer to provide the link)
b. IRDAI Integrated Grievance Management System – https://igms.irda.gov.in/ c. Insurance Ombudsman – The contact details of the Insurance Ombudsman offices have been provided as Annexure-B of Policy document. |
11 | ||||||||||
| 9 | Insured’s Rights | Insurer to specify the norms on TAT for Pre-Auth and Settlement of reimbursement. | ||||||||||
| 10 | Insured’s Obligations | Please disclose all pre-existing disease/s or condition/s before buying a policy. Non-disclosure may result in claim not being paid. | ||||||||||
| Legal Disclaimer Note: The information must be read in conjunction with the product brochure and policy document. In case of any conflict between the CIS and the policy document, the terms and conditions mentioned in the policy document shall prevail. | ||||||||||||
Annexure-3
Form IRDAI-UNF-SVHP
[All the items should be filled in properly and carefully. No item must be left blank.]
Sr.No |
Item |
Particulars (to be filled in by insurer) |
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Section I: General Information |
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1.1 |
Name of Health / General Insurer |
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1.2 |
Registration No. allotted by IRDAI |
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1.3 |
Name of Appointed Actuary [Please note that his/her appointment should be in force as on the date of this application] |
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1.4 |
Brand Name [Give the name of the product which will be printed in Sales Literature and known in the market. This name should not be altered/modified in any form after launching in the market. This name shall appear in all returns etc. which would be submitted to IRDAI |
Vector Borne Disease Health Policy, <Name of the insurer> |
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1.5 |
Date of approval by PMC |
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Section II: Underwriting |
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2. |
Underwriting –Selection of Risks [This section should discuss how the different segments of the population will be dealt with for the purpose of underwriting (to the extent they are relevant and a brief detail of procedure adopted for assessment of various risk classes may be given.) |
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2.1 |
Specify Non-medical Limit [Where no pre-medical examination is asked for] |
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2.2 |
Specify when and what classes of lives would be subject to medical examination |
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2.3 |
Whether any loading based on the health status are applicable |
Yes / No |
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2.4 |
Whether any loading based on the occupation are applicable |
Yes / No |
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2.5 |
Specify, any other underwriting criteria |
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2.6 |
Whether Underwriting of the product aligned to the Board Approved Underwriting policy of the Company |
Yes / No |
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2.7 |
Whether full costs of pre policy medical check up are borne by the Insurer |
Yes / No |
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2.8 |
If no, specify the percentage proposed to be borne by the Insurer. |
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Section III – Distribution Channels |
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3 |
Distribution channels: |
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3.1 |
Specify the various distribution channels to be used for distributing the product- [reply shall be specific and reply should not be can not refer to the replies like “as approved by IRDAI] |
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3.1 |
Commission scales to distribution channels—specify the rates which are to be paid-[reply shall be specific] |
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3.2 |
Expected proportions of business to be procured by each channel shall be indicated |
DistributionChannel |
FY 20-21 |
FY 21-22 |
FY 22-23 |
FY 24-25 |
FY 25-26 |
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1.IndividualAgents |
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2. Corporate Agents |
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3. Insurance Brokers |
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4.Web Aggregators |
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5.Micro Insurance Agents |
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6.CSC |
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7.PoS |
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8.Direct – Only Online |
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9.Direct Marketing – Others |
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(Incorporate separate line for each distribution channel)10. Others-specify |
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11. Total |
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Section IV – Reinsurance arrangements |
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4.1 |
Retention limit |
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4.2 |
Name of the reinsurer (s) |
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4.3 |
Terms of reinsurance(type of reinsurance, commissions, etc.). |
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4.4 |
Any recapture provisions shall be described. |
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4.5 |
Reinsurance rates provided |
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4.6 |
Whether a copy of the reinsurance program and a copy of the Treaty is submitted to the Authority. |
Yes/No |
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4.6.1 |
Whether reinsurance program and a copy of the treaty enclosed (required only if these are not filed with the Authority previously) |
Yes/No |
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4.6.2 |
Whether the reinsurance proposed for the product is in line with the Board approved reinsurance program filed with the Authority |
Yes / No |
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4.6.3 |
If no, furnish the particulars |
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Section V: Pricing |
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5 |
Premium Loadings & Discounts(Please provide objective and transparent criteria to offer discounts/rebate/Loadings And complete financial justifications by AA to every item referred hereunder.In case of General and Health Insurers to be also furnished separately in the Technical Note) |
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5.1 |
Sum insured rebates/discounts offered, if any |
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5.2 |
Rebates/charges for different modes offered: |
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5.3 |
Premium rebates/discounts |
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5.4 |
Staff rebates |
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5.5 |
Any other discounts offered |
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5.6 |
Maximum cap on all Discounts for all variables taken together |
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5.7 |
Any loadings proposed |
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5.8 |
Maximum Cap on all Loading for all variables taken together |
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5.9 |
Subrogation (Not applicable to Health Insurance) |
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5.10 |
Pricing Assumptions and Methodology: The pricing assumptions and the methodology may vary depending on the nature of product. Give details of the following |
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5.11 |
Give the actuarial formulae, if any, used; if not, state how premiums are arrived at briefly explaining the methodology and details: |
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5.12 |
Source of data (internal/industry/ reinsurance) |
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5.13 |
Rate of morbidity [The tables whereever relevant shall be the prescribed one.] |
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5.14 |
Rates of policy terminations. [The rates used must be in accordance with insurer’s experience. If such experience is not available, this can be from the industry/reinsurer’s experience .] |
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5.15 |
Rate of interest, if any. [The rate or rates must be consistent with the investment policy of the insurer.] |
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5.16 |
Commission scales [Give rates of commission. These are explicit items.] |
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5.17 |
Expenses – Split into First Year, and Claim related:- [Expense assumptions must be company specific. If such experience is not available, the Appointed Actuary might consider industry experience or make reasonable assumptions.] |
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5.17.1 |
First Year expenses by: sum assured related, premium related, per policy related |
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5.17.2 |
Other expenses where relevant (including overhead expenses) by : sum assured related, premium related, per policy related |
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5.17.3 |
Claim expenses |
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5.17.4 |
Future inflationary increases, if any |
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5.18 |
Allowance for transfers to shareholder, if any: [Please see section 49 of the Insurance Act, 1938] |
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5.19 |
Taxation. [Please see the relevant sections of the Income Tax Act, 1961 applicable for payment of taxes by the Insurer] |
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5.20 |
Any other parameter relevant to pricing of product –specify |
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5.21 |
Reserving assumptions (please specify all the relevant details) |
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5.22 |
Base rate (risk premium)-furnish the rate table, if any |
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5.23 |
Gross premium- furnish the rate table, if any |
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5.24 |
Annualised Premium |
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5.24.1 Minimum |
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5.24.2 Maximum |
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5.25 |
Expected loss ratio (for the product) – |
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5.26 |
Age-wise loss ratio- |
S.No |
Age |
Loss ratio |
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5.27 |
Sum insured-wise- loss ratio |
S.No |
SA |
Loss ratio |
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5.28 |
Age and sum insured wise loss ratio – |
Table given below (SI band and age bands shall be increased.The format given below is indicative.) |
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S.NO |
SI/Age bands |
50000 |
100000 |
150000 |
200000 |
250000 |
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1 |
>=0<=2 |
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2 |
>=3<=15 |
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3 |
>=16<=25 |
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4 |
>=26<=30 |
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5 |
>=31<=35 |
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6 |
>=36<=40 |
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7 |
>=41<=45 |
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8 |
>=46<=50 |
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9 |
>=51<=55 |
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10 |
>=56<=60 |
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11 |
>=61<=65 |
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12 |
>=66 |
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5.29 |
Expected combined ratio |
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5.30 |
Age-wise combined ratio- |
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5.31 |
Sum insured-wise- combined ratio |
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5.32 |
Age and sum insured wise combined ratio – to be furnished for each option or plan separately |
Table given below (SI band and age bands shall be increased.The format given below is indicative.) |
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S.NO |
SI/Age bands |
50000 |
100000 |
150000 |
200000 |
250000 |
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1 |
>=0<=2 |
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2 |
>=3<=15 |
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3 |
>=16<=25 |
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4 |
>=26<=30 |
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5 |
>=31<=35 |
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6 |
>=36<=40 |
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7 |
>=41<=45 |
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8 |
>=46<=50 |
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9 |
>=51<=55 |
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10 |
>=56<=60 |
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11 |
>=61<=65 |
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12 |
>=66 |
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5.33 |
Expected cross-subsidy between age/sum insured |
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5.34 |
Experience of similar products, if any for the preceding Five Financial Years |
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S.No |
Exposure |
Premium –Rs. |
Number of claims |
Incurred claims-Rs. |
Claim frequency |
Average cost per claim |
Burning cost-Rs. |
Loss ratio |
Combined ratio |
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FY |
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FY-1 |
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FY-2 |
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FY-3 |
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FY-4 |
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1. Exposure: earned life year (no of life earned during a particular financial year);2. Premium: premium earned during the financial year;3.Number of claims: claims occurred during the financial year;4. Incurred claims: Incurred amount as of today for claims mentioned in “3”;5. Claim frequency: No. of claims/ Exposure;6. Average cost per claim: Incurred claims / No. of claims;7. Burning cost: Claims frequency* Average cost per claim;8. Loss ratio: Incurred claims/ Premium;9. Combined ratio: Loss ratio + Expense ratio; |
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5.35 |
Results of Financial Projections/Sensitivity Analysis: [The profit margins should be shown for various model points for base,optimistic and pessimistic scenarios in a tabular format below. The definition of profit margin should be taken as the present value of net profits to the p.v of premiums. Please specify assumptions made in each scenario. For terms less than one year loss ratio may be used.] |
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5.36 |
Risk discount rate used in the profit margin |
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5.37 |
Average Sum Insured Assumed |
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5.38 |
Assumptions made under pessimistic scenario |
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5.39 |
Assumptions made under optimistic scenario |
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5.40 |
Age [PM: Profit Margin/Loss Ratio] [Age Band may be revisted based on the product design paratmeters] |
PM (base scenario) |
PM (pessimistic scenario) |
PM (optimistic scenario) |
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>=0<=2 |
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>=3<=15 |
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>=16<=25 |
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>=26<=30 |
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>=31<=35 |
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>=36<=40 |
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>=41<=45 |
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>=46<=50 |
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>=51<=55 |
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>=56<=60 |
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>=61<=65 |
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>=66 |
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|||||||||||||||||||||||||||||||||
Section VI: Enclosures to the Application:The following specimen documents should be enclosed: |
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6.1 |
Technical Note on Pricing |
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6.2 |
Proposal form, wherever necessary |
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6.3 |
Premium Table |
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6.4 |
Certificates by Appointed Actuary and Chief Compliance Officer |
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Software used for product design and monitoring — (for information of the Authority)
The Insurer shall enclose a certificate from the Chief Compliance Officer, Appointed Actuary, countersigned by the principal officer of the insurer, as per specimen given below:(The language of this should not be altered)
Certification by Chief Compliance Officer:
I——- (Name of Chief Compliance Officer) the undersigned, on behalf of the Insurer named below, hereby affirm and declare as follows:
1. That the details of the (Name of product) filled in above are true and correct and reflect what the policy and other documents indicate.
2. That the product complies with the various provisions of the IRDAI Health Insurance Regulations, 2016, Guidelines on Standardization of Health Insurance, Product Filing , Guidelines on Standard vector borne disease Health Policy, issued thereon and the applicable provisions of extant IRDAI Regulations and all circulars issued by IRDAI from time to time.
3. That this application and all other documents are complete and have been verified for correctness and consistency not only in respect of each item of each document but also vis-a-vis one another.
4. I certify that the policy wordings and Customer Information sheet is in compliance with IRDAI (Health Insurance) Regulations, 2016, Product Filing Guidelines, Guidelines on Standardization of Health Insurance, Guidelines on Standard vector borne disease Health Policy issued thereon.
5. I further certify that the Prospectus is in compliance with the applicable provisions of Rules, IRDAI Regulations and Guidelines on Product Filing and Insurance Advertisements.
Date:
(Chief Compliance Officer)
Name of Insurer
Certification by Appointed Actuary:
” I, (name of the appointed actuary), the appointed actuary, hereby solemnly declare that the information furnished in this Application Form is true. I also certify that, in my opinion, the premium rates, advantages, terms and conditions of the above product are workable and sound, the assumptions are reasonable and premium rates are fair.”
I have carefully studied the requirements of the Product Filing Procedure in relation to the design and rating of insurance products.
The rates, terms and conditions of the above mentioned product are determined on technically sound basis and are sustainable on the basis of the information and claims experience available in the records of the insurer.
An adequate system has been put in place for collection of data on premiums and claims based on every rating factor that will enable review of the rates and terms of the cover from time to time. It is planned to review the rates, terms and conditions of cover (— mention periodicity of review) based on emerging experience.
It is further certified that the underwriting of the product now filed shall be within the Board approved underwriting philosophy of the Company.
The requirements of the Product Filing Procedure have been fully complied with in respect of this product or revision or modification of the product.
I further declare that except the Sections mentioned in S.No., no other feature/benefit/clause is modified in the product (applicable only for revision or modification of the product)
Place
Signature of the Appointed Actuary
Date:
Certification by Principal Officer or CEO
I (name of the Principal Officer or CEO), (mention designation) hereby confirm that:
1. The rates, terms and conditions of the above-mentioned product filed with this certificate have been determined in compliance with the IRDA Act, 1999, Insurance Act, 1938, and the Regulations and guidelines issued there under, including the File and Use / Product Filing guidelines.
2. The prospectus, sales literature, policy and endorsement documents, and the rates, terms and conditions of the product have been prepared on a technically sound basis and on terms that are fair between the insurer and the client and are set out in language that is clear and unambiguous.
3. These documents are also fully in compliance with the underwriting and rating policy approved by the Board of Directors of the insurer.
4. The statements made in the filing Form -IRDAI-UNF-SVHP are true and correct.
5. The requirements of the Product Filing Guidelines have been fully complied with in respect of this product.
Date:
Signature of Principal Officer or Designated Officer
Place: Name and designation along with Company’s seal
