IN-PATIENT CARE WITH DAY/ CARE TREATMENT
If an Insured Person is diagnosed with an illness or suffers an injury whilst on a Trip during the Period of Insurance that solely and directly requires the Insured Person’s Hospitalization or the Insured Person to undergo any of the Day Care Treatments specified in Annexure – I at a Day Care Centre or Hospital, then We shall indemnify the Medical Expenses incurred on that Hospitalization or Day Care Treatment provided that:
- The Hospitalization is commenced and continued on the written advice of a Medical Practitioner;
- The treating Medical Practitioner certifies in writing that the treatment taken for that Illness or Injury is Medically Necessary Treatment;
- The treatment for the Illness or Injury commences during the Period of Insurance immediately and not exceeding 15 days following the diagnosis of the Illness or occurrence of the Injury.
For the purpose of this Benefit, ‘treatment’ shall be deemed to include only the following:
- In patient treatment in a local Hospital at the place the Insured Person is staying at the time of occurrence of an insured event or at the nearest suitable Hospital.
- Medical aid that is prescribed by a physician as necessary part of the treatment for broken limbs or injuries by the Insured Person (e.g. plaster casts, bandages and walking aids).
- Radiotherapy, heat therapy or phototherapy and other such treatment prescribed by a physician.
- X-Ray, and other diagnostic tests, provided these pertain to the diagnosed Illness/Injury due to which Hospitalization was deemed medically necessary.
- Cost of transportation, including necessary medical care en-route, by recognized emergency service providers/surface Ambulance for medical attention at the nearest Hospital or at the nearest available Physician.
- Lifesaving unforeseen emergency measures, or measures solely designed to relieve acute pain, provided to the Insured Person by medical practitioners.
2. IN-PATIENT CARE FOR INJURY WITH DAY CARE TREATMENT
If an Insured Person suffers an Injury whilst on a Trip during the Period of Insurance that solely and directly requires the Insured Person’s Hospitalization or the Insured Person to undergo any of the Day Care Treatments specified in Annexure – I at a Day Care Centre or Hospital, then We shall indemnify the Medical Expenses incurred on that Hospitalization or Day Care Treatment provided that:
- The Hospitalization is commenced and continued on the written advice of a Medical Practitioner;
- The treating Medical Practitioner certifies in writing that the treatment taken for that Injury is Medically Necessary Treatment;
- The treatment for the Injury commences during the Period of Insurance and within 15 days of the occurrence of the Injury;
- No claims in relation to any Illness suffered by the Insured Person will be considered under this Benefit.
b) OPTIONAL EXTENSIONS TO BENEFIT – ‘MEDICAL COVER’
The Certificate of Insurance will specify which of the following Optional Extensions are in force for the Insured Person. The Extensions mentioned under this Section are extensions to Section B.1(a.1) or B.1(a.2), as specified under the Policy Schedule/ Certificate of Insurance and cannot be read /selected on a standalone basis.
(i) OPTIONAL EXTENSION 1: PRE-EXISTING DISEASE COVER IN LIFE THREATENING MEDICAL CONDITION
We will indemnify the Medical Expenses incurred in respect of the Insured Person’s Hospitalization whilst on a Trip during the Period of Insurance for treatment of a Life Threatening Medical Condition in an Emergency which arises due to any sudden, unexpected, unforeseen development attributable to a Pre-existing Disease provided that:
- Section C.3.1(ii) of the Permanent Exclusions shall not apply only to the extent of cover under this Optional Extension;
- The Hospitalization is commenced and continued on the written advice of a Medical Practitioner;
- The treating Medical Practitioner certifies in writing that the treatment taken for that Pre-existing Disease is Medically Necessary Treatment;
- The Pre-existing Disease in respect of which treatment is being taken has been declared to Us and accepted and noted in the Certificate of Insurance.
- We or Our Assistance Service Provider are given written intimation within 48 hours of Hospitalization;
- Our maximum, total and cumulative liability for any and all claims under this Optional Extension in respect of the Insured Person is limited to the amount specified in the Certificate of Insurance.
- Medical Expenses incurred on the treatment taken for these emergency measures will be indemnified only until the Insured Person becomes medically stable or is relieved from acute pain. All further Medical Expenses to maintain the medically stable state or to prevent the onset of acute pain shall be borne by the Insured Person.
- All claims pertaining to this Benefit shall be indemnified by Us on reimbursement basis only.
(ii) OPTIONAL EXTENSION 2: EXTENDED COVER IN THE COUNTRY OF RESIDENCE
If We have admitted a Claim under Section B.1.(a.1) or B.1.(a.2) as applicable, then We shall also indemnify the Medical Expenses incurred on Hospitalization of the Insured Person in the Country of Residence for a maximum period of 30 days or as specified in the Certificate of Insurance from the expiry of the Period of Insurance, provided that:
- the Hospitalization is required for the same Illness or Injury for which the Claim under Section B.1.(a.1) or B.1.(a.2) was admitted for the Insured Person;
- Our pre-authorization under this Optional Extension has been obtained.
If We have admitted a Claim is admitted under Section B.1.(a.1) or B.1.(a.2) and Our pre-authorization under this Optional Extension has been obtained, then We shall also indemnify the costs of an air ticket for a direct route economy class travel for the Insured Person and one accompanying attendant to return to the Country of Residence from the place of occurrence of the Illness or Injury provided that:
- We shall be liable to pay an amount only up to the direct route economy class airfare available on the date of the journey;
- The costs for the attendant’s airfare shall be indemnified by Us only if the treating Medical Practitioner has certified in writing that an attendant must accompany the Insured Person.
(iii) OPTIONAL EXTENSION 3: AUTOMATIC EXTENSION
We shall automatically extend the Period of Insurance for coverage under Section B.1 (a.1) and / or B.1 (a.2) (as applicable) for the Insured Person without payment of any extra premium for up to 7 days from the date of expiry of the Period of Insurance provided that:
- We have admitted a Claim under Section B.1.(a.1) or B.1.(a.2); OR
- There is a delay or cancellation of the departure of the Common Carrier in which the Insured Person was booked and scheduled to return to the Country of Residence/City of Residence and such delay was beyond the control of the Insured Person and no alternative transportation was available to the Insured Person to return to the Country of Residence/City of Residence.
(iv) OPTIONAL EXTENSION 4: ADDITIONAL SUM INSURED IN CASE OF ACCIDENT
If We have admitted a Claim under Section B.1.(a.1) in respect of the Insured Person for an Injury arising due to an Accident occurring during the Period of Insurance, We shall automatically provide an Additional Sum Insured as specified in the Certificate of Insurance for Section B.1.(a.1) for that Insured Person provided that:
- The Additional Sum Insured shall be utilized only after the original Sum Insured under Section B.1(a.1) has been completely exhausted;
- The total amount payable under such Claim shall not exceed the sum of the Sum Insured and Additional Sum Insured;
- The Additional Sum Insured shall be applied only once for the Insured Person during the Period of Insurance.
(v) OPTIONAL EXTENSION 5: MATERNITY
We will indemnify the Maternity Expenses incurred in respect of the Insured Person whilst on a Trip during the Period of Insurance for Hospitalization of the Insured Person for the delivery of the Insured Person’s child provided that:
- Section C.3(h) of the Permanent Exclusions shall not apply only to the extent of cover under this Optional Extension;
- Claims under this Optional Extension are admissible only if the Maternity Expenses are incurred in a Hospital for delivery of the child as an in-patient.
- The delivery occurs after the completion of the waiting period specified in the Policy Schedule / Certificate of Insurance.
- We shall not be liable to make payment under this Optional Extension in respect of the Insured Person more than twice during the Insured Person’s lifetime.
- We shall cover the reasonable pre-natal and post-natal expenses necessarily incurred, to up to 10% of the amount specified in the Policy Schedule/Certificate of Insurance against Section B.1 provided that the condition necessitates treatment in a Hospital and the Insured Person is Hospitalized.
- Hospitalisation to treat maternity related complications which do not require delivery of the child shall be indemnified under this Benefit to up to 10% of the amount specified in the Policy Schedule/Certificate of Insurance against Section B.1 provided that the condition necessitates treatment in a Hospital and the Insured Person is Hospitalized.
- We shall only accept such number of claims under this benefit during the Period of Insurance as is specified against this Benefit Maternity in the Policy Schedule / Certificate of Insurance.
(viii) OPTIONAL EXTENSION 8: DRUG AND ALCOHOL ABUSE
We will indemnify the Medical Expenses incurred whilst the Insured Person is on a Trip during the Period of Insurance for treatment of symptoms arising from alcohol and drug abuse suffered by the Insured Person provided that:
- Section C.3(z) of the Permanent Exclusions shall not apply only to the extent of cover under this Optional Extension.
- The Insured Person is Hospitalized for such treatment and the Hospitalization is commenced and continued on the written advice of a Medical Practitioner;
- The treating Medical Practitioner certifies in writing that the treatment taken is Medically Necessary Treatment.
(ix) OPTIONAL EXTENSION 9: SELF INFLICTED INJURY
We will indemnify the Medical Expenses incurred whilst the Insured Person is on a Trip during the Period of Insurance for treatment of an Injury which is self-inflicted by the Insured Person provided that:
- Section C.3(e) of the Permanent Exclusions shall not apply only to the extent of cover under this Optional Extension.
- The Insured Person is Hospitalized for such treatment and the Hospitalization is commenced and continued on the written advice of a Medical Practitioner;
- The treating Medical Practitioner certifies in writing that the treatment taken is Medically Necessary Treatment.
(x) OPTIONAL EXTENSION 10: MATERNITY COMPLICATIONS
We will indemnify the Medical Expenses (surgical and non-surgical) incurred which require the Hospitalization of the Insured Person whilst the Insured Person is on a Trip during the Period of Insurance for treatment of any of the following maternity complications suffered by the Insured Person provided that:
- Section C.3(h) of the Permanent Exclusions shall not apply only to the extent of cover under this Optional Extension.
S. No Maternity Complication
1 Uterine rupture
2 Post partum haemorrage
3 Amniotic fluid embolism
4 Placenta previa
5 Placental Abruption
6 Disseminated Intravascular Coagulation(DIC)
7 Still Birth
8 Uterine Inversion
(xi) OPTIONAL EXTENSION 11: RESTRICTION / SUB-LIMIT ON MEDICAL EXPENSES
If this Optional Extension is in force, then Our maximum liability for Claims made in respect of the Insured Person’s Hospitalization under Section B.1(a.1) and B.1(a.2) shall be limited in accordance with the table below:
Medical Expense Sub-limit
Medical Expenses | Restriction / Sub Limits |
Room Rent | As specified in the Policy Schedule/Certificate of Insurance |
ICU Charges | As specified in the Policy Schedule/Certificate of Insurance |
Operation Theatre charges (including Surgeon charges) | As specified in the Policy Schedule/Certificate of Insurance |
Anaesthesia | As specified in the Policy Schedule/Certificate of Insurance |
Ambulance Services | As specified in the Policy Schedule/Certificate of Insurance |
Diagnostics & Radiology Services | As specified in the Policy Schedule/Certificate of Insurance |
Medical Practitioner’s visit fees | As specified in the Policy Schedule/Certificate of Insurance |
Miscellaneous Expenses | As specified in the Policy Schedule/Certificate of Insurance |
Per Hospitalisation Limit under section B.1.a.1 or B.1.a.2 | As specified in the Policy Schedule/Certificate of Insurance |
Hospitalisation or day care for Emergency Care only | As specified in the Policy Schedule/Certificate of Insurance |
For the purpose of application of the above limits:
(i) Surgery includes operation theatre charges, surgeon fees, implant charges and all other associated charges.
(ii) Ambulance Services include the cost of transportation of the Insured Person to the nearest Hospital and paramedic services.
(iii) Miscellaneous Expenses includes but is not limited to the cost of medicines, pharmacy or drugs supplies, nursing charges, blood storage and processing charges and any other services which are not specified above.
(xii) OPTIONAL EXTENSION 12: ADVENTURE SPORTS INJURY
If an Insured Person suffers an Injury whilst participating in Adventure Sports on a Trip during the Period of Insurance that solely and directly requires the Insured Person’s Hospitalization, then We shall indemnify the Medical Expenses incurred on that Hospitalization provided that:
- Section C.3(gg) of the Permanent Exclusions shall not apply only to the extent of cover under this Optional Extension;
- The Insured Person’s Hospitalization is commenced and continued on the written advice of a Medical Practitioner;
- The treating Medical Practitioner certifies in writing that the treatment taken is Medically Necessary Treatment.
- The sports activity has been carried out in accordance with the guidelines, codes of good practice and recommendations as laid down by a governing body or authority in respect of that sport.
(xiii) OPTIONAL EXTENSION 13: PROFESSSIONAL SPORTS INJURY
If an Insured Person suffers an Injury whilst participating in Professional Sports on a Trip during the Period of Insurance that solely and directly requires the Insured Person’s Hospitalization, then We shall indemnify the Medical Expenses incurred on that Hospitalization provided that:
- Section C.3(ff) of the Permanent Exclusions shall not apply only to the extent of cover under this Optional Extension;
- The Insured Person’s Hospitalization is commenced and continued on the written advice of a Medical Practitioner;
- The treating Medical Practitioner certifies in writing that the treatment taken is Medically Necessary Treatment.
- The Insured Person shall inform Us in writing of the participation in such professional sport / training session prior to the commencement of the Period of Insurance.
(xiv) OPTIONAL EXTENSION 14: CORPORATE FLOATER
If an Insured Person has exhausted the benefit amount specified in the Policy Schedule/Certificate of Insurance under Section B.1(a.1) or B.1(a.2) and further incurs any Medical Expenses that would otherwise have been admitted under Section B.1(a.1) or B.1(a.2), these Medical Expenses will be indemnified from the Sum Insured of Corporate Floater up to the limits as specified in the Policy Schedule/Certificate of Insurance. The amount payable under this Optional Extension for an Insured Person per claim shall be restricted to the amount as specified in Policy Schedule / Certificate of Insurance, however in no event exceeding the original benefit amount specified in the Certificate of Insurance under Section B.1(a.1) or B.1(a.2)for the Insured Person and is payable subject to the availability of the Sum Insured of Corporate Floater, provided that:
(i) The amount from corporate floater Sum Insured shall be utilized only after the original benefit amount specified in the Certificate of Insurance under Section B.1(a.1) or B.1(a.2) and the Additional Sum Insured specified in the Certificate of Insurance in case of Accident (if in force for the Insured Person) has been completely exhausted;
(ii) The total amount payable under such Claim shall not exceed the sum of the benefit amount specified in the Policy Schedule/Certificate of Insurance under Section B.1(a.1) or B.1(a.2) and Additional Sum Insured specified in the Certificate of Insurance in case of Accident (if in force for the Insured Person) and the eligible amount under corporate floater Sum Insured;
(iii) The amount from corporate floater Sum Insured shall be available only for such Insured Person for whom Claim for Hospitalization following an Accident / Illness has been accepted under the Policy;
(iv) The amount from corporate floater Sum Insured shall be applied only once during the Period of Insurance for an Insured Person.
(v) We shall only accept such number of claims under this benefit during the Period of Insurance as is specified against this benefit Corporate Floater in the Policy Schedule/Certificate of Insurance.
c) Documents to be submitted for any Claim under this Benefit No. B.1
It is a Condition Precedent to Our liability under this Benefit and any applicable Optional Extension under Benefit B.1 that the following necessary information and documentation shall be submitted to Us or the Assistance Service Provider immediately and in any event within 30 days of the event giving rise to the Claim under this Benefit:
(i) Original pathological or diagnostic reports, admission and discharge summary, day care summary, ROMIF, attending physician statement, indoor case papers and prescriptions issued by the treating Medical Practitioner or Hospital.
(ii) Original bills and receipts for:
i. Charges paid towards Hospital accommodation, nursing facilities and other medical services rendered.
ii. Fees paid to the Medical Practitioner and for special nursing charges.
iii. Charges incurred towards any and all test and / or examinations rendered in connection with the treatment.
iv. Charges incurred towards medicines or drugs purchased from a registered pharmacy other than the Hospital duly supported by the prescriptions of the Medical Practitioner attending to the Insured Person.
TRIP CANCELLATION AND INTERRUPTION
a) Trip Cancellation:
i. If the Insured Person’s outward journey as a fare paying passenger from the Country of Residence/City of Residence to a Place of Destination on a Common Carrier is unavoidably cancelled before the commencement of the Period of Insurance solely and directly due to one of the reasons below, then We shall indemnify for those travel expenses that the Insured Person already paid and cannot recover and for which no value can be derived:
(i) Earthquake, storm, flood, inundation, cyclone or tempest provided that the peril takes place prior to the commencement of the Period of Insurance at or in the vicinity of the Place of Origin of the journey, the ultimate scheduled Place of Destination or any intermediate place which is involved in or related to the proposed journey;
(ii) Terrorism provided that the peril takes place prior to the commencement of the Period of Insurance at or in the vicinity of the Place of Origin of the journey, the ultimate scheduled Place of Destination or any intermediate place which is involved in or related to the proposed journey;
(iii) The Insured Person’s Immediate Family Member dies or is Hospitalized in an Emergency due to an unforeseen Illness or Injury for at least 2 consecutive days provided that such Illness or Injury shall occur not earlier than 10 consecutive days from the scheduled commencement of the Period of Insurance;
(iv) The Insured Person is Hospitalized in an Emergency due to an unforeseen Illness or Injury (in case this Optional Benefit is applicable to the Insured Person along with Section B.1(a.1) or due to an unforeseen Injury (in case this Optional Benefit is applicable to the Insured Person along with B.1(a.2) and such Hospitalization commences within 10 days from the scheduled commencement of the Period of Insurance and continues for at least 2 consecutive days and the treating Medical Practitioner certifies in writing that the Insured Person is not fit to undertake travel.
(v) The treating Medical Practitioner certifies in writing that the Insured Person is not medically fit to undertake travel.
(vi) Government imposed lockdown due to pandemic/ epidemic resulting in cancellation by common carrier.
ii. If a Claim is admitted under this Optional Benefit and the Certificate of Insurance specifies that this is a Single Trip Policy, the Policy shall be immediately and automatically cancelled on Our admission of the Claim.
iii. If a Claim is admitted under this Optional Benefit and the Certificate of Insurance specifies that this is an Annual Multi Trip Policy, no other Claim shall be admitted under the Policy in respect of that Period of Insurance.
iv. Any amount refunded to the Insured Person by the Common Carrier in relation to the cancellation shall be deducted from the amount payable to the Insured Person under this Optional Benefit.
b) Trip Interruption:
i. If the Insured Person’s overseas stay is unavoidably curtailed after the commencement of the Period of Insurance solely and directly due to one of the reasons below, then We shall indemnify for the costs of direct route economy class airfare of the Insured Person to return to the Country of Residence/City of Residence:
(i) Earthquake, storm, flood, inundation, cyclone or tempest provided that the peril takes place within the Period of Insurance at or in the vicinity of the Place of Origin of the journey, the ultimate scheduled Place of Destination or any intermediate place which is involved in or related to the proposed journey.
(ii) Terrorism provided that the peril takes place within the Period of Insurance at or in the vicinity of the Place of Origin of the journey, the ultimate scheduled Place of Destination or any intermediate place which is involved in or related to the proposed journey;
(iii) The Insured Person’s Immediate Family Member dies or is Hospitalized in an Emergency due to an unforeseen Illness or Injury and such Hospitalization continues for at least 5 consecutive days;
ii. Any amount refunded to the Insured Person by the Common Carrier in relation to the curtailment shall be deducted from the amount payable to the Insured Person under this Optional Benefit.
c) Exclusions applicable to Optional Benefit 12 – Trip Cancellation and Interruption
Any Claim in respect of any Insured Person for, arising out of or directly or indirectly due to any of the following shall not be admissible under this Optional Benefit unless expressly stated to the contrary elsewhere in the Policy terms and conditions:
(i) strikes or labor disputes or slowdown;
(ii) Interruption or cancellation of the journey either wholly or in partly at the instance of the Common Carrier (apart from the reasons listed above) or by the travel agent;
(iv) Childbirth, pregnancy or any medical complications arising out of and related to maternity/pregnancy resulting within 2 months of the expected date of delivery.
(v) Negligence or fault of the travel agent.
(vi) Any charges that could have been avoided but were incurred because of any delay in cancelling travel or accommodation.
(vii) Facts or matters of which the Insured Person was aware or should have been aware (by the way of sources such as travel advisories issued by competent / Government authority(s) etc.) might result in the cancellation or curtailment of the trip.
d) Documents to be submitted in support of the Claim:
It is a Condition Precedent to Our liability under this Optional Benefit that the following necessary information and documentation (as applicable) shall be submitted to Us or the Assistance Service Provider immediately and in any event within 30 days of the event giving rise to the Claim under this Optional Benefit:
(i) Confirmation in writing of cancellation of the journey from the Common Carrier detailing the circumstances of cancellation;
(ii) Ticket / boarding pass issued by the Common Carrier indicating the cost of ticket and receipt for the refund of the fare of the Common Carrier towards the cancelled portion of the journey indicating cancellation charges retained by the Comm`on Carrier.
(iii) Boarding pass in original for return journey from the place of cancellation to the Country of Residence/City of Residence which indicates the cost of the tickets together with the receipts for the refunds obtained towards the unfulfilled portion of the journey.
(iv) A declaration from the Insured Person furnishing the circumstances that compelled him/her to cancel the journey;
(v) Medical evidence as may be required in case of the cancellation of the journey arising out of personal contingencies of the Insured Person or his/her Immediate Family Member;
(vi) Receipt for the refund of the fare of the Common Carrier towards the cancelled portion of the journey indicating the cancellation charges retained;
(vii) Boarding pass in original for return journey from the place of cancellation to the Country of Residence/City of Residence of the Insured Person together with the receipts for the refunds obtained towards the unfulfilled portion of the journey.
(viii) Death certificate (if applicable).
TRIP DELAY
a) If the departure of a Common Carrier in which the Insured Person is scheduled to travel on a valid ticket during the Period of Insurance is delayed from the schedule departure time for more than the number of consecutive and completed hours/minutes as specified in the Certificate of Insurance from the later of the declared time of departure or expected time of departure due solely and directly to any one of the following:
Option 1:
- Earthquake, flood, rains, storm, cyclone or tempest; or
- Terrorism
Option 2:
- Earthquake, flood, rains, storm, cyclone or tempest; or
- Terrorism
- Delay of a Scheduled Common Carrier caused by Inclement Weather.
- Delay due to a sudden Strike or any other action by employees of the Common Carrier.
- Delay caused by equipment failure of the Common Carrier.
- Delay caused by operational problem at the Common Carrier end (like crew / staff scheduling issues etc).
- Cancellation or rescheduling of flights done at the instance of the Common Carrier that causes delay
We shall pay the benefit amount specified in the Policy Schedule/Certificate of Insurance against this Optional Benefit provided that We or the Assistance Service Provider is given written notice of the delay immediately and in any event within 30 days of the commencement of the delay and immediate alternative arrangements are made by the Insured Person for progressing the journey as scheduled.
b) Exclusions applicable to Optional Benefit 13 – Trip Delay
Any Claim in respect of any Insured Person for, arising out of or directly or indirectly due to any of the following shall not be admissible under this Optional Benefit unless expressly stated to the contrary elsewhere in the Policy terms and conditions:
(i) Any contingencies other than those specifically named above;
(ii) The Common Carrier is taken out of service on the instructions of the concerned Authority or any similar authority;
(iii) A Claim has already been made under either Optional Benefit 10 or Optional Benefit 14.
(iv) Delay caused by strike or industrial action if already notified at the time the Insured Person booked his/her ticket or paid or committed to other travel and accommodation expenses.
(v) The failure to arrive for the Common Carrier’s departure in sufficient time to complete all departure formalities in accordance with the Common Carrier’s published time schedule.
(vi) Rescheduling of the flight by the flight operator minimum 10 hours prior to the original departure date & time of the booked common carrier is not covered.
c) Documents to be submitted in support of the Claim:
It is a Condition Precedent to Our liability under this Optional Benefit that the following necessary information and documentation shall be submitted to Us or the Assistance Service Provider immediately and in any event within 30 days of the event giving rise to the Claim under this Optional Benefit:
(i) Certificate from the Common Carrier confirming the delay and detailing the circumstances of delay.
MISSED CONNECTION
a) If the Insured Person misses the connecting train during the Period of Insurance solely and directly due to the delayed arrival of the Common Carrier in which the Insured Person was traveling on a valid ticket, We shall indemnify upto Rs. 5,000:
(i) We shall not be liable to make any payment under this Optional Benefit if the delay could reasonably have been foreseen by the Insured Person or if the Insured Person could reasonably have become aware of such delay in advance by the way of sources such as travel advisories issued by competent / Government authority(s) etc.;
(ii) We shall be liable under this Optional Benefit only if the time gap between the scheduled arrival of the Common Carrier and the connecting flight is more than the number of consecutive hours specified in the Certificate of Insurance;
(iii) Our liability to make payment under this Optional Benefit shall be in excess of the total amount refunded or returned to the Insured Person by the flight service provider.
b) Exclusions applicable to Optional Benefit 14 – Missed Connection
Any Claim in respect of any Insured Person for, arising out of or directly or indirectly due to any of the following shall not be admissible under this Optional Benefit unless expressly stated to the contrary elsewhere in the Policy terms and conditions:
(i) A Claim has already been made under either Optional Benefit 10 or Optional Benefit 13.
(ii) Missing of the train is the result of any deviation from the originally scheduled route at the instance of the Insured Person for any reason whatsoever;
(iii) Any advance intimation given to the Insured Person of a possible delay of the Common Carrier that might lead to missing of the connecting flight;
(iv) Any circumstances other than those directly attributable to the delay of the earlier Common Carrier.
c) Documents to be submitted in support of the Claim:
It is a Condition Precedent to Our liability under this Optional Benefit that the following necessary information and documentation shall be submitted to Us or the Assistance Service Provider immediately and in any event within 30 days of the event giving rise to the Claim under this Optional Benefit:
(i) Confirmation from the Common Carrier of the delay as to the expected time of arrival and the actual time of arrival at Place of Destination;
(ii) Copy of unused ticket for the missed flight;
(iii) Certificate from the Common Carrier of the missed flight that the fare for the part of the journey covered by the missed flight is forfeited in full or in part together with the amount of forfeiture;
(iv) Original used ticket obtained afresh towards the alternative flight for the part of the journey covered by the missed flight indicating the amount paid as fare.
LOSS OF LAPTOP /TABLET / HAND BAGGAGE / MOBILE
a) We shall indemnify the Insured Person for loss incurred due to theft of his/her laptop, tablet, hand baggage or mobile whilst on a Trip during the Period of Insurance provided that:
(i) The claim will be settled at the market value (subject to the benefit amount specified in the Certificate of Insurance against this Optional Benefit) of the laptop, tablet, hand baggage or mobile before the loss, which shall be arrived at by depreciating the value by 25% per annum.
(ii) It has been reported to the local police where the incidence has occurred within 24 hours of the Insured Person becoming aware of the theft and a written police report being obtained in that regard.
b) Exclusions applicable to Optional Benefit 29 – Loss of Laptop /Tablet / Hand Baggage / Mobile:
Any Claim in respect of any Insured Person for, arising out of or directly or indirectly due to any of the following shall not be admissible under this Optional Benefit unless expressly stated to the contrary elsewhere in the Policy terms and conditions:
(i) Any electrical or mechanical breakdown of the laptop, tablet or mobile
(ii) Any loss of software or data in the laptop, tablet or mobile and any consequential loss arising from the same.
(iii) Any loss as a result of any action taken by customs department / Government department.
(iv) Loss of mobile in case of domestic travel or loss reported within Indian Geography.
(v) Any loss reported due to the laptop, tablet, hand baggage or mobile being left unattended or forgotten by the Insured Person in a public place or public transport, hotel or apartment.
c) Documents to be submitted for any Claim under this Optional Benefit:
It is a Condition Precedent to Our liability under this Optional Benefit that the following information and documentation shall be submitted to Us or the Assistance Service Provider immediately and in any event within 30 days of the event giving rise to the Claim under this Optional Benefit:
(i) Copy of the police report (wherever applicable);
(ii) Details of the attempts made to trace the laptop, tablet, hand baggage or mobile;
(iii) Letter defining incidence of theft;
(iv) Bill copy for the laptop, tablet, hand baggage.
MUGGING COVER
a) We shall indemnify an amount upto the limit as specified in Certificate of Insurance in the event of a financial emergency arising due to the Insured Person being mugged of funds whilst on a Trip during the Period of Insurance, provided that:
(i) Such loss of travel fund is required to be reported to the Police having jurisdiction at the place of loss within 24 hours of the occurrence of the incident and a written report being obtained for the same.
(ii) In case if loss of traveller’s cheque the same needs to be immediately reported to the local branches of agents of the issuing authority.
(iii)Loss of travel funds covered under this Optional Benefit shall be reported and the Claim be made immediately whilst on the Trip.
(iv) Our liability shall be restricted to difference between the funds lost as a consequence of the event covered under this Optional Benefit and any funds which may have been recovered as an action taken by the police having jurisdiction or otherwise.
b) Exclusions applicable to Optional Benefit 35 – Mugging Cover
Any Claim in respect of any Insured Person for, arising out of or directly or indirectly due to any of the following shall not be admissible under this Optional Benefit unless expressly stated to the contrary elsewhere in the Policy terms and conditions:
(i) A shortage or loss of funds due to currency fluctuation, errors, omissions, exchange loss or depreciation in value.
(ii) Any loss not reported to the police having jurisdiction at the place of loss within 24 hours of the occurrence of the incidence and a written report being obtained for the same.
(iii) Any claim in respect of traveller’s cheque not immediately reported to the local branches or agents of the issuing authority.
(iv) Loss of funds not kept in personal custody of the Insured Person.
(v) Any claim made after the first arrival post incidence of the Insured Person back to the Republic of India.
c) Documents to be submitted for any Claim under this Optional Benefit:
It is a Condition Precedent to Our liability under this Optional Benefit that the following necessary information and documentation shall be submitted to Us or the Assistance Service Provider immediately and in any event within 30 days of the event giving rise to the Claim under this Optional Benefit:
- Police report issued by the police having jurisdiction at the place of loss.
- Evidence of report by the traveller’s cheque issuing authority or the agent of traveller’s cheque issuing authority.
- Detailed statement of the Insured Person for the occurrence of event.
- Bills/evidence of purchase of traveller’s cheques/instruments, currency exchange.
- Copy of passport signifying the latest entry and exit out of the country of visit where the incidence mentioned under this Optional Benefit has occurred.
- Copy of passport signifying the latest entry and exit out of Republic of India.
Claim Documentation
You or Insured Person (or Nominee or legal heir if the Insured Person is deceased) shall (at his/her expense) give the documentation specified below and any additional information or documentation specified in the Benefit and/or Optional Benefit and/or Optional Extension under which the Claim is being made to Us or the Assistance Service Provider immediately and in any event within 30 days of the occurrence of the Injury/Illness or treatment or loss.
(i) Duly completed and signed Claim form, in original;
(iii) Any other document as required by Us or Assistance Service Provider;
(iv) Additional documents as specified for each Benefit.
(v) Original pathological or diagnostic reports, discharge summary, Day Care summary, indoor case papers and prescriptions issued by the treating Medical Practitioner or Hospital as applicable.
(vi) Copy of e-ticket / boarding pass.
(vii) NEFT / banking details along with cancelled cheque copy for Insured Person / Nominee (where applicable) with pre-printed name; if name is not pre-printed please provide copy of bank passbook / bank statement.
Note: All invoices and bills should be in Insured Person’s name or as per the documents mentioned in the respective Benefit/Optional Benefits. Depending on the nature of the Claim, treatment undertaken or illness, there would be a possibility of seeking more information / document from the Claimant concerned without prejudice to his interest and the same shall be requested by any means of recognized communication channels. However, claims filed even beyond the timelines mentioned above will be considered if there are valid reasons for the delay.
4.4. Policyholder’s or Insured Person’s or Claimant’s duty at the time of Claim
It is agreed and understood that as a Condition Precedent to Our liability in respect of a Claim to be considered under this Policy:
(a) All reasonable steps and measures must be taken to avoid or minimize the quantum of any Claim that may be made under this Policy.
(b) The Insured Person shall follow the directions, advice or guidance provided by a Medical Practitioner and We shall not be obliged to make payment that is brought about or contributed to by the Insured Person failing to follow such directions, advice or guidance.
(c) Intimation of the Claim, notification of the Claim and submission or provision of all information and documentation shall be made promptly and in any event in accordance with the procedures and within the timeframes specified in Section C.4 of the Policy and the specific procedures and timeframes specified under the respective Benefit or Optional Benefit or Optional Extension under which the Claim is being made.
(d) The Insured Person shall, at Our request and at Our cost and expense, submit himself / herself for a medical examination by Our/Assistance Service Provider’s nominated Medical Practitioner as often as We consider reasonable and necessary.
(e) We/Assistance Service Provider’s Medical Practitioner and representatives shall be given access and co-operation to inspect the Insured Person’s medical and Hospitalization records and to investigate the facts and examine the Insured Person.
(f) We shall be provided with complete documentation and information which We have requested to establish Our liability for the Claim, its circumstances and its quantum.
(g) Report any information/document which helps the insurance system to eliminate bad practices in the market.
4.5. Claim Assessment
(a) All admissible Claims under this Policy shall be assessed by Us in the following progressive order:
i. If the provisions of the Contribution Section in Section C.13 are applicable, Our liability to make payment under that Claim shall first be apportioned accordingly.
ii. If any sub-limits on Medical Expenses are applicable in accordance with Section B.1 (b) (xi), Our liability to make payment shall be limited to such extent as applicable.
iii. The Deductible shall be applied to each Claim that is either paid or payable (and not excluded), under this Policy. Our liability to make payment shall commence only once the amount of the Claim payable or paid exceeds the Deductible.
iv. Co-payment shall be applicable on the amount payable by Us after applying Section C.4.5(a) (i), (ii) and (iii).
4.6. Payment terms
(a) We may change the Assistance Service Provider or utilize the service of any other assistance service provider by giving written notification to You.
(b)The obligation of the Company to make payments to the Insured Person in respect of claims made shall be to make payment in Indian Rupees and after the Insured Person’s return to India only. For all admissible Claims, the exchange rate as follows shall be applied:
- Reimbursement (indemnity) – Date of Invoice
- Fixed Benefit – Date of occurrence of insured event.
(c) If the Assistance Service Provider or We request that bills or vouchers in a local language or vernacular be accompanied by an appropriate translation into English then the costs of such translation must be borne by You or the Insured Person.
(d) The Sum Insured of the Insured Person shall be reduced by the amount payable or paid under the Policy Terms and Conditions or any Benefit / Optional Benefit / Optional Extension applicable under this Policy and only the balance amount shall be available as the Sum Insured for the unexpired Period of Insurance for the Insured Person.
(e) We shall have no liability to make payment of a Claim under the Policy in respect of an Insured Person, once the Sum Insured for that Insured Person is exhausted or if the benefit amount under the applicable Benefit/Optional Benefit/Optional Extension as specified in the Policy Schedule/Certificate of Insurance is exhausted.
(f) If the Insured Person suffers a relapse within 45 days of the date of discharge from the Hospital for which a Claim has been made, then such relapse shall be deemed to be part of the same Claim and all the limits for Any One Illness under this Policy shall be applied as if they were under a single Claim.
(g) For Cashless Facility Claims, the payment shall be made to the Network Provider whose discharge would be complete and final.
(h) For the reimbursement Claims, We shall pay to the Insured Person unless specified otherwise in the Certificate of Insurance. In the event of death of the Insured Person, unless specified otherwise in the Certificate of Insurance, We shall pay to the Nominee (as named in the Certificate of Insurance) and in case of no Nominee to the legal heir of the Insured Person whose discharge shall be treated as full and final discharge of its liability under the Policy.
(i) All claims will be investigated (as required) and settled or rejected in accordance with the applicable regulatory guidelines, including the IRDAI (Protection of Policyholders Interests) Regulations, 2017. We shall settle or reject any Claim under the Policy within 30 days of receipt of the last necessary document/ information as required for settlement of such Claim and sought by Us. In case there is delay in the payment of any claim that has been admitted as payable by Us under the Policy, beyond the time period as prescribed under IRDAI (Protection of Policyholders Interests) Regulations, 2017, We shall pay additional amount as interest at a rate which is 2% above the bank rate prevalent at the beginning of the financial year in which the claim has fallen due. For the purpose of this clause, ‘bank rate’ shall mean the existing bank rate as notified by Reserve Bank of India, unless the extant regulation requires payment based on some other prescribed interest rate.
(j) No loading based on individual claim experience shall be applicable on Renewal premium payable in case of Annual Trip cover.
5. Disclosure to Information Norm
If any untrue or incorrect statements are made or there has been a misrepresentation, mis-description or non-disclosure of any material particulars or any material information having been withheld, or if a Claim is fraudulently made or any fraudulent means or devices are used by You, the Insured Person or any one acting on his or their behalf, We shall have no liability to make payment of any Claims and the premium paid shall be forfeited to Us on cancellation of the Policy.
6. Observance of Terms and Conditions
The due observance and fulfilment of the terms and conditions of this Policy (including the realization of premium by their respective due dates and compliance with the specified procedure on all Claims) in so far as they relate to anything to be done or complied with by You or any Insured Person, shall be Condition Precedent to Our liability under the Policy.
7. Reasonable Care
Insured Persons shall take all reasonable steps to safeguard the interests against any Illness or Injury or any other loss that may give rise to a Claim.
8. Material Change
It is a Condition Precedent to Our liability under the Policy that You shall immediately and in any case within 7 days notify Us in writing of any material change in the risk on account of change in occupation or business of the Insured Person at its own expense, as per Annexure -III. We may adjust the scope of cover and / or the premium paid or payable, accordingly.
9. Records to be maintained
You and Insured Person shall keep an accurate record containing all relevant medical records and shall allow Us or Our representatives to inspect such records. You or Insured Person shall furnish such information as We may require under this Policy at any time during the Policy Period or until final adjustment (if any) and resolution of all Claims under this Policy.
10. No constructive Notice
Any knowledge or information of any circumstance or condition in relation to You or Insured Person which is in possession of Us other than that information expressly disclosed in the Proposal Form or otherwise in writing to Us, shall not be held to be binding or prejudicially affect Us.
11. Complete Discharge
Payment made by Us to the Insured Person or the Nominee or the legal heir or representative of the Insured Person, as the case may be, under the Policy shall in all cases be complete and construe as an effectual discharge in favor of Us.
12. Subrogation
You and Insured Person shall at his/her own expense do or concur in doing or permit to be done all such acts and things that may be necessary or reasonably required by Us for the purpose of enforcing and / or securing any civil or criminal rights and remedies or obtaining relief or indemnity from any other party to which We are or would become entitled upon Us paying for a Claim under this Policy, whether such acts or things shall be or become necessary or required before or after its payment. Neither You nor any Insured Person shall prejudice these subrogation rights in any manner and shall at his/er own expense provide Us with whatever assistance or cooperation is required to enforce such rights. This clause shall not apply to any Benefit or Optional Benefit or Optional Extension offered on a fixed benefit basis.
13. Contribution
(a) In case any Insured Person is covered under more than one indemnity insurance policies, with Us or with other insurers, You/Insured Person shall have the right to settle the Claim with any of Us, provided that the Claim amount payable is up to the sum insured of such Policy.
(b) In case the Claim amount under a single policy exceeds the Sum Insured after considering the deductible or co-payment, then the Insured Person shall have the right to choose the companies with whom the Claim is to be settled.
This clause shall not apply to any Benefit or Optional Benefit or Optional Extension offered on a fixed benefit basis.
14. Policy Disputes
Any and all disputes or differences under or in relation to the validity, construction, interpretation and effect to this Policy shall be determined by the Indian Courts and in accordance with Indian law.
15. Cancellation / Termination
We may at any time, cancel this Policy on grounds as specified in Section C.5 and We shall have no liability to make payment of any claims and the premium paid shall be forfeited, by giving 15 days’ notice in writing by Registered Post Acknowledgment Due / recorded delivery to You at Your last known address.
16. Communication
(a) Any communication meant for Us must be in writing and be delivered to Our address shown in the Policy Schedule/Certificate of Insurance. Any communication meant for You or the Insured Person shall be sent by Us to Your last known address or the address as shown in the Policy Schedule/Certificate of Insurance (as applicable).
(b) All notifications and declarations for Us must be in writing and sent to the address specified in the Policy Schedule/ Certificate of Insurance. Agents are not authorized to receive notices and declarations on Our behalf.
(c) Notice and instructions shall be deemed served 10 days after posting or immediately upon receipt in the case of hand delivery, facsimile or e-mail.
17. Alterations in the Policy
This Policy constitutes the complete contract of insurance. No change or alteration shall be valid or effective unless approved in writing by Us, which approval shall be evidenced by a written endorsement signed and stamped by Us.
18. Cause of Action
No Claims shall be payable under this Policy unless the event or occurrence giving rise to the Claim occurs in the Geographical Scope specified in the Certificate of Insurance.
19. Overriding effect of Policy Schedule / Certificate of Insurance
In case of any inconsistency in the terms and conditions in this Policy vis-a-vis the information contained in the Policy Schedule and/or Certificate of Insurance, the information contained in the Policy Schedule or Certificate of Insurance shall prevail.
20. Electronic Transactions
You and Insured Person agrees to adhere to and comply with all such terms and conditions as We may prescribe from time to time, and hereby agrees and confirms that all transactions effected by or through facilities for conducting remote transactions including the Internet, World Wide Web, electronic data interchange, call centers, tele-service operations (whether voice, video, data or combination thereof) or by means of electronic, computer, automated machines network or through other means of telecommunication, established by or on behalf of Us, for and in respect of the Policy or its terms, or Our other products and services, shall constitute legally binding and valid transactions when done in adherence to and in compliance with the Our terms and conditions for such facilities, as may be prescribed from time to time.
21. Grievances
In case of a grievance, the Insured Person/ You can contact Us with the details through:
To initiate a claims refer to the below details
Send ‘Claim’ to 8828800035 from your registered mobile number | |
Website | Click here to track your Claim status |
Helpline number | Call us at 18002707000 |
Email ID | Write to us at care.healthinsurance@adityabirlacapital.com |