LIFE INSURANCE CORPORATION OF INDIA
CENTRAL OFFICE
Dept: Product Development “Yogakshema”
Jeevan Bima Marg
Mumbai – 400 021
Draft Circular (Confidential)
Ref: CO/PD/ --- --------, 2011
To,
All HODs of Central Office
All Zonal Offices
All Divisional Offices
All Branch Offices (through DOs)
MDCs, ZTCs, STCs, NIA and
Audit & Inspection Depts. of Zonal Offices.
Re: INTRODUCTION OF LIC’S JEEVAN AROGYA (Plan No. 903)
1. INTRODUCTION:
It has been decided to introduce LIC’s JEEVAN AROGYA (Plan No. 903) with effect from
-------, 2011. The Unique Identification Number (UIN) for LIC’s Jeevan Arogya plan is ----------.
This number has to be quoted in all relevant documents furnished to the policyholders and
other users (public, distribution channels).
An individual can take the health cover under this plan for himself / herself. This individual will
be addressed as Principal Insured (PI) for the purpose of insurance under this plan. The
Spouse, Children, Parents and Parents-in-law can also be covered under the same policy.
This is non-linked plan which provides fixed benefits for hospitalization and almost all types of
surgical procedures irrespective of actual cost incurred and the benefit is in addition to any
other health insurance cover that insured lives may have, subject to certain terms and
conditions.
The benefits offered under the plan are:
i) Hospital Cash Benefit (HCB)
ii) Major Surgical Benefit (MSB)
iii) Day Care Procedure Benefit (DCPB)
iv) Other Surgical Benefit (OSB)
Two riders viz. Term Assurance Rider and Accident Benefit Rider shall also be available
under the plan for PI and Insured Spouse only.
At the time of filling up the proposal form, PI and Spouse (if insured) have to exercise an
option whether to continue the policy in case of exit of PI from the policy, as per Addendum
enclosed with the proposal form. If option for continuation of policy is exercised, in case of
death or expiry of cover of PI, the surviving Insured Spouse will become the Principal Insured
and the Policy will continue. In such case, the premium for the Insured Spouse will change - 2 -
from the coinciding or following instalment premium due date and the new premium would be
based on tabular premium rates applicable for PIs and the age for calculation of revised
premium rate will be the age at entry of the spouse.
Other details of the plan are as follows.
2. PREMIUM:
Under this plan multiple lives can be covered under one policy.
For each insured life, the installment premium shall be based on the age at entry, the Initial
Daily Hospital Cash Benefit chosen, gender and whether insured life is PI or other than PI.
The tabular premium rates applicable for PI (males/females) will be different from those
applicable for other lives (males/females) as given in Annexure I. Thus, the level of premium
for PI and other insured lives shall be different for same age, same gender and same level of
cover.
The instalment premium payable during the cover period in respect of each Insured will be the
sum of:
(i) Instalment premium for the Basic Plan
(ii) Instalment premium for Accident Benefit Rider (if opted for)
(iii) Instalment premium for Term Assurance Rider (if opted for)
The total instalment premium payable in respect of each policy shall be the sum of instalment
premiums payable in respect of each insured life covered under the policy.
For example, if there are 3 lives covered under a policy- PI (male), Spouse (female) and child
(for children premium does not vary with gender). PI has opted for both Term Assurance Rider
& Accident Benefit Rider, Spouse has not opted for any rider benefit and the optional riders
are not available for child.
Thus,
Instalment premium for PI is = Instalment premium for PI under the Basic Plan + Instalment
premium for Accident Benefit Rider + Instalment premium for
Term Assurance Rider ------------- (A)
Instalment premium for Spouse = Instalment premium for Spouse under the Basic Plan
------------- (B)
Instalment premium for Child = Instalment premium for Child under the Basic Plan
------------- (C)
Therefore, Total Instalment Premium to be paid for this policy shall be [(A) + (B) + (C)]
In respect of each insured life covered under a policy, the installment premium for Basic Plan
will be guaranteed for a period of 3 (three) years from the Date of Commencement of the
policy. The installment premiums for Basic Plan are reviewable on every third policy
anniversary (defined as Automatic Renewal Date in para 5 a) below) starting from the date of
commencement of policy. The premium rates for the basic plan applicable on renewal, i.e.
from Automatic Renewal Date, shall be guaranteed for a further period of 3 years i.e. till next
Automatic Renewal Date.
If any additional member is included in the policy after the date of commencement, the
premium charged in respect of that member will also be guaranteed till the next Automatic
Renewal Date and hence may change even before completion of 3 years from his/her joining
the policy. - 3 -
On any Automatic Renewal Date in the future, the installment premium in respect of each
insured will be based on the entry age of that Insured (i.e. age as on the date of
commencement of policy/ age at the time of inclusion into the policy, as the case may be) and
the Corporation’s premium rates then prevailing for this product.
The tabular premium rates per annum for PI and Other Insured for standard lives are given in
the Annexure - I. Also the rates of Class I extra premium per annum are enclosed as
Annexure – II to this circular.
The Installment premium for both the optional riders is however guaranteed throughout the
term for which cover is provided.
3. ELIGIBILITY CONDITIONS AND FEATURES:
FOR BASIC PLAN
a) Minimum /
Maximum Premium
Amount
There is no specific minimum and maximum premium payable. The total
premium payable will be the sum of premiums in respect of each individual
member covered under the policy. The premium in respect of each individual
will be payable from the date of entry into the policy till the date of exit from
the policy.
b) Minimum entry age Principal Insured, Insured Spouse,
Parents & Parents-in-law - [18] years last birthday
Insured Dependent Children - [3] months (completed)
c) Maximum entry age Principal Insured and Insured Spouse - [65] years last birthday
Insured Parents and Parents-in-law - [75] years last birthday
Insured Dependent Children – [17] years last birthday
d) Maximum cover
ceasing age
Principal Insured, Insured Spouse, Insured Parents & Parents-in-law –
[80] years last birthday
Insured Dependent Children – [25] years last birthday
e) Date of cover
expiry in respect
of each Insured
covered under the
plan
Policy anniversary on which the Insured life attains Maximum cover ceasing
age
f) Premium Rate
Guarantee
Rates will be guaranteed for first 3 years of the policy i.e. for 3 years from the
date of commencement of policy. At the end of every 3 years, i.e. on each
Automatic Renewal Date (defined in Para 5 a)) the premium rates may
change i.e. the policy may be treated as if it is renewed every 3 years.
The rates applicable on renewal after every 3 years shall be guaranteed for a
further period of 3 years i.e. till next renewal.
(i) For Hospital Cash Benefit (HCB) (under Basic Plan)
Feature Principal
Insured
(PI)
Insured Spouse (if any),
Insured Parents &
Parents-in-law (if any)
Insured Dependent
Children (if any)
a) Minimum Initial Daily
Benefit (in a ward other
than Intensive Care Unit)
` 1,000/- ` 1,000/- ` 1,000/-
b) Maximum Initial Daily
Benefit
` 4,000/- Insured Spouse- Less than
or equal to that of PI
Insured Parents/ Parents-inlaw - Less than or equal to
that of Insured Spouse (PI,
if there is no Insured
Less than or equal to
that of Insured Spouse
(PI, if there is no
Insured Spouse).
Further, included
children shall be - 4 -
Spouse). Further, included
parents shall be covered for
equal benefits.
covered for equal
benefits.
c) Maximum annual benefit
period, applicable to each
insured
30 days in year 1, 90 days per year thereafter, inclusive of stay in
ICU. Maximum number of days in ICU is restricted to 15 days in
year 1 and to 45 days thereafter.
d) Maximum Lifetime Benefit
period, applicable to each
insured
720 days inclusive of stay in ICU. Maximum number of days in ICU
is restricted to 360 days in respect of each Insured.
Initial Hospital Cash Benefit shall be in multiples of ` 1000/-.
(ii) For Major Surgical Benefit (MSB) (under Basic Plan)
Feature Principal Insured (PI) Insured Spouse (if
any),Insured Parents
& Parents-in-law (if
any)
Insured Dependent
Children (if any)
a) Major Surgical
Benefit Sum
Assured (MSB SA)
100 times of
Applicable Daily
Benefit (ADB) of PI
(as specified in para
4).
Insured Spouse- 100
times of ADB of
Insured Spouse
Insured Parents/
Parents-in-law - 100
times of ADB of each
parent
100 times of ADB of each
child
b) Maximum annual
benefit, applicable
to each insured
100% of Major Surgical Benefit Sum Assured
c) Maximum Lifetime
Benefit, applicable
to each insured
800% of Major Surgical Benefit Sum Assured
(iii) For Day Care Procedure Benefit (DCPB) (under Basic Plan)
Feature Principal Insured (PI) Insured Spouse (if
any),Insured Parents
& Parents-in-law (if
any)
Insured Dependent
Children (if any)
a) Lump sum benefit
payable
5 times of Applicable
Daily Benefit (ADB)
(described in Para 4)
of PI
Insured Spouse- 5
times of ADB of
Insured Spouse
Insured Parents/
Parents-in-law - 5
times of ADB of each
parent
5 times of ADB of each
child
b) Maximum annual
benefit, applicable
to each insured
3 Surgical Procedures
c) Maximum Lifetime
Benefit, applicable
to each insured
24 Surgical Procedures
(iv) For Other Surgical Benefit (OSB) (under Basic Plan)
Feature Principal
Insured
(PI)
Insured Spouse (if
any),Insured Parents &
Parents-in-law (if any)
Insured Dependent
Children (if any) - 5 -
a) Daily benefit amount 2 times of
ADB of PI
Insured Spouse- 2 times of
ADB of Insured Spouse
Insured Parents/Parents-in-law-
2 times of ADB of each parent
2 times of ADB of
each child
b) Maximum annual benefit,
applicable to each insured
15 days in year 1 and 45 days per year thereafter
c) Maximum Lifetime Benefit,
applicable to each insured
360 days
FOR TERM ASSURANCE RIDER OPTION:
This rider shall be available for PI and Insured Spouse only.
(a) Minimum Term Assurance Sum Assured: ` [100] in '000's
(b) Maximum Face Amount/Basic Sum Assured/Annuity pa: An amount equal to the
Major Surgical Benefit Sum Assured (MSB SA) at the time of inception/ inclusion
into the policy (i.e. 100 times of Initial Daily Hospital Cash Benefit) in respect of the
insured, subject to the maximum of ` 25 lakh overall limit taking all term assurance
riders under all existing policies of the Life Assured and Term Assurance Sum
Assured under other proposals into consideration.
The Term Assurance Sum Assured shall be in multiples of ` 25,000/-.
(c) Minimum / Maximum Premium Amount: There is no specific minimum and
maximum premium payable. The premium payable will depend on the Term
Assurance Sum Assured
(d) Minimum Entry Age: [18] years (completed)
(e) Maximum Entry Age: [50] years (Nearest Birthday)
(f) Maximum Maturity Age: [60] years (Nearest Birthday)
(g) Maximum Term: [35] years
FOR ACCIDENT BENEFIT RIDER OPTION:
This rider shall only be available for PI and Insured Spouse provided Term Assurance Rider has
been opted for.
(a) Minimum Accident Benefit Sum Assured: ` [25] in '000's
(b) Maximum Accident Benefit Sum Assured: An amount equal to the Term Assurance
Sum Assured at the time of inception/ inclusion into the policy in respect of the insured,
subject to maximum of ` 50 lakhs overall limit considering the Accident Benefit Sum
Assured in respect of all existing policies on the life of the insured including the policies
taken from Life Insurance Corporation of India and other insurance companies and the
Accident Benefit Sum Assured under new proposals into consideration.
The Accident Benefit Sum Assured shall be in multiples of `5,000/-.
(c) Minimum / Maximum Premium Amount: There is no specific minimum and maximum
premium payable. The premium payable will depend on the Accident Benefit Sum
Assured. - 6 -
(d) Minimum Entry Age: [18] years completed
(e) Maximum Entry Age: [50] years (Nearest Birthday)
(f) Maximum age for cover: [60] years (Nearest Birthday)
(g) Maximum Term: [35] years
4. BENEFITS:
Death Benefit under the basic plan: No death benefits will be payable on the death of any
Insured unless Term Assurance Rider Benefit mentioned in Para 6 f) below, along with or
without Accident Benefit Rider mentioned in Para 6 e), has been opted for.
On death of the Principal Insured (PI);
a) The surviving Insured Spouse will become the Principal Insured provided the option is
exercised at the beginning of the contract and the Policy will continue. In such case, the
premium for the Insured Spouse will change from the date coinciding with or following
installment premium due date and the new premium would be based on tabular premium
rates applicable for PIs and the age for calculation of revised premium rate will be the age
at entry of the spouse. If the option is not exercised at the beginning of the contract, the
Insured Spouse will not become PI and the policy will terminate.
b) If the Insured Spouse had predeceased the Principal Insured, then the other Insured will
have the option to take a new policy and the existing Policy will terminate. In respect of
these other Insured:
i. The new policy will be issued without any underwriting if the new policy is bought
within 90 days of the termination of the existing Policy.
ii. The maximum entry age condition will not apply for the new policy.
iii. The outstanding Waiting periods and outstanding period of any Exclusion will however
apply under the new policy.
iv. Other terms and conditions including premium rates will be as applicable for the new
policy.
In the event of death of an Insured person other than the Principal Insured, the policy will
continue after removal of the Insured and change in premium will apply from the installment
premium due date coinciding with or next following the date of intimation of death of the
Insured.
Maturity Benefit: No benefits are payable at end of the Cover Period.
Benefit payable on hospitalization:
If PI or any of the Insured lives covered under the policy is hospitalized due to Accidental
Bodily Injury or Sickness and the stay in hospital exceeds a continuous period of 24 hours,
then for any continuous period of 24 hours or part thereof, provided any such part stay
exceeds a continuous period of 4 hours (after having completed the 24 hours as above) in a
non-ICU ward/room of a hospital, an amount equal to the Applicable Daily Benefit (ADB),
available under the policy during that policy year, shall be payable subject to terms and
conditions mentioned in Para 5 (c) and exclusions mentioned in Para 7.
During the first year of cover commencement in respect of each insured, the Applicable Daily
Benefit shall be the Initial Daily Benefit amount (i.e. the level of HCB chosen by the insured)
mentioned in the policy Schedule. - 7 -
The amount of Applicable Daily Benefit (ADB) for each policy year, after the first policy year,
shall consist of 2 parts:
− An arithmetic addition of an amount equal to 5% (five percent) of the Initial Daily Benefit to
the Applicable Daily Benefit of the previous Policy Year. Such increase in the Applicable
Daily Benefit shall be effected on each Policy anniversary during the Cover Period and
shall continue until it attains a maximum amount of 1.5 times the Initial Daily Benefit
Thereafter, this amount in each Policy Year in future shall remain at that maximum level
attained.
− Further arithmetic addition of an amount equal to “No Claim Benefit” provided the policy
attracts and is eligible for it. There shall be no maximum limit for such increase which
means that if this policy is eligible for “No Claim Benefit”, the same shall be granted
throughout the Cover Period without any maximum limit.
Consider an example where Initial Daily Benefit is Rs.1000 in respect of each insured life (say,
PI and spouse) under a policy. There is no claim admitted under the policy during first 12
years from the policy commencement except in the 5th year when a claim is admitted in
respect of spouse. In this case, year-wise Applicable Daily Benefit for each insured shall be as
follows:
Year 1 2 3 4 5 6 7 8 9 10 11 12
ADB 1000 1050 1100 1200* 1250 1300 1350** 1400 1450 1550* 1600*** 1600
* In years 4 and 10 ‘No Claim Benefit’ is added.
** In year 7 ‘No Claim Benefit’ is not added as a claim occurred in the 5th year.
*** After 11th year, ADB shall not increase as it has attained the maximum level (1.5 times of
Initial Daily Benefit). However the ADB shall increase due to ‘No Claim Benefit’ as and when
the policy shall be eligible for.
For members included subsequently under the policy, the benefit in the first year shall be
equal to Initial Daily Benefit amount and thereafter the Applicable Daily Benefit shall increase
as above.
If the member insured is required to stay in an Intensive Care Unit of a hospital, two times the
Applicable Daily Benefit, for any continuous period of 24 hours or part thereof, provided any
part stay exceeds a continuous period of 4 hours (after having completed the 24 hours as
above), will be payable subject to terms and conditions mentioned in Para 5 (c) & 5 (i) and
exclusions mentioned in Para 7.
The Applicable ICU Daily Benefit amount shall be twice the Applicable Daily Benefit amount.
No benefit will be payable for the first 24 hours of hospitalisation. However, for every
Hospitalization that extends for a continuous period of 7 days or more, the Daily Hospital Cash
Benefit would also be paid for first 24 hours (day one) of hospitalization, regardless of whether
the Insured was admitted in a general or special ward or in an intensive care unit. It may be
noted that hospitalization for 6 days and 4 hours or more will be considered as 7 days.
Major Surgical Benefit:
In the event of an Insured under this plan, due to medical necessity, undergoing one of the
surgeries defined in Major Surgical Benefit Annexure, within the cover period in a Hospital due
to Accidental Bodily Injury or Sickness, the respective benefit percentage of the Major Surgical
Benefit Sum Assured, as specified against each of the eligible surgeries mentioned in Major
Surgical Benefit Annexure, shall be paid subject to terms and conditions mentioned in Para 5 - 8 -
(d) & 5 (i) and exclusions mentioned in Para 7.
In the event that a Major Surgical Benefit falling under Category 1 or Category 2 (as
mentioned in the Major Surgical Benefit Annexure) is payable and emergency transportation
costs by an ambulance have been incurred, an additional lump sum of `1,000 will be payable
in lieu of ambulance expenses.
Further, in the event that a Major Surgical Benefit falling under Category 1 or Category 2 (as
mentioned in the Major Surgical Benefit Annexure) is payable in respect of any Insured, the
total annualized premium i.e. total one year premium in respect of that Policy from the date of
installment premium due coinciding with or next following the date of the Surgery will be
waived.
Day Care Procedure Benefit:
In the event of an Insured under this Plan undergoing any specified Day Care Procedure
mentioned in the Day Care Procedure Benefit Annexure due to medical necessity, an amount
equal to 5 (five) times the Applicable Daily Benefit shall be paid, regardless of the actual costs
incurred, subject to terms and conditions mentioned in Para 5 e) & 5 i) and exclusions
mentioned in Para 7.
Other Surgical Benefit:
In the event of an Insured under this Plan, due to medical necessity, undergoing any Surgery
not listed under Major Surgical Benefit or Day Care Procedure Benefit, and the stay in hospital
exceeds a continuous period of 24 hours, a Daily Benefit equal to 2 (two) times the Applicable
Daily Benefit shall be paid for each continuous period of 24 hours or part thereof provided any
such part stay exceeds a continuous period of 4 hours of Hospitalization, subject to terms and
conditions mentioned in Para 5 f) & 5 i) and exclusions mentioned in Para 7.
Other Surgical Benefit shall be payable from day one of hospitalization but the minimum stay
in hospital should be atleast 24 hours.
No claim benefit:
A no claim benefit will be paid in the event that during the period between Date of
Commencement of policy and next Automatic Renewal Date or between two Automatic
Renewal Dates (described in para 5 a) below) there are no claims in respect of any Insured.
The amount of the no claim benefit would be equal to 5% (five percent) of the Initial Daily
Benefit in respect of each Insured and the resulting amount shall be added to arrive at the
Applicable Daily Benefit in respect of each Insured for the Policy Year next following the most
recent Automatic Renewal Date.
5. OTHER TERMS AND CONDITIONS:
a) Automatic Renewal Date:
The installment premium will be guaranteed in respect of each Insured for a period of 3
(three) years from the Date of Commencement of the policy, i.e. for the first 3 years of the
policy. Thereafter, at the end of every third policy anniversary, the premiums may be
reviewed to take into account the Corporation’s experience, subject to prior approval from
IRDA. These premium due dates, at the end of every third policy anniversary, starting from
the date of commencement of policy till the date of cover expiry, on which the installment
premiums are reviewable, will be referred as Automatic Renewal Dates in respect of all
Insured in the Policy.
The premium rates applicable on Automatic Renewal Date after every 3 years shall be
guaranteed for a further period of 3 years i.e. till next Automatic Renewal Date.
On any Automatic Renewal Date in the future, the installment premium will be based on - 9 -
the Insured’s age at entry into the policy i.e. age as on the date of commencement of
policy/ age at the time of inclusion into the policy, as the case may be and the
Corporation’s premium rates then prevailing for this product.
b) Removal of existing members:
In the event of death or divorce, an Insured may be removed from coverage upon request
by the Principal Insured in writing. This will be effective from the installment premium due
date coinciding with or next following the date of such a request. No further premiums are
due in respect of that Insured from such installment premium due date.
In any other circumstances, removal of an existing Insured will be permitted at the sole
discretion of the Corporation.
c) Hospital Cash Benefit:
In the event of Accidental Bodily Injury or Sickness first occurring or manifesting itself after
the date of commencement of cover in respect of that Insured and during the Cover Period
and causing an Insured’s Hospitalization to exceed a continuous period of 24 hours within
the Cover Period, then, subject to the terms and conditions, waiting period and exclusions
of the Policy, the Daily Benefit is payable by the Corporation as follows, regardless of the
actual costs incurred:
In case of Hospitalisation in the general or special ward (i.e. a nonIntensive Care Unit ward/room) of a Hospital:
The Applicable Daily Benefit in a Policy Year, for each continuous period of 24
hours or any part thereof (after having completed the 24 hours as above)
provided any such part stay exceeds a continuous period of 4 hours of
Hospitalization necessitated solely by reason of the said Accidental Bodily
Injury or Sickness, shall be payable.
In case of Hospitalisation in the Intensive Care Unit of a Hospital:
Two times the Applicable Daily Benefit reckoned under para 4 above for each
continuous period of 24 hours or part thereof (after having completed the 24
hours as above) provided any such part stay exceeds a continuous period of 4
hours of Hospitalization in the Intensive Care Unit of a Hospital during any
period of Hospitalization necessitated solely by reason of the said Accidental
Bodily Injury or Sickness shall be payable.
Combined stay in Non-ICU and ICU ward/room:
During one period of 24 continuous hours (i.e. one day) of Hospitalisation (after
having completed the 24 hours as above), if the said Hospitalisation included
stay in an Intensive Care Unit as well as in any other in-patient (non-Intensive
Care Unit) ward of the Hospital, the Corporation shall pay benefits as if the
admission was to the Intensive Care Unit provided that the period of
Hospitalisation in the Intensive Care Unit was at least 4 continuous hours.
No benefit will be payable for the first 24 hours of hospitalisation.
However, for every Hospitalization that extends for a continuous period of
7 days or more, the Hospital Cash Benefit would also be paid for the first
24 hours (day one) of hospitalization, regardless of whether the Insured
was admitted in a general or special ward or in an intensive care unit.
The amount of Daily Benefit due to Hospitalization as specified in the Policy
Schedule would be the Initial Daily Benefit amount. In the first Policy Year the
Initial Daily Benefit would be the Applicable Daily Benefit amount which will
be payable per day of each eligible hospitalized day. - 10 -
For each Policy Year commencing at a Policy anniversary on or after the first
anniversary, the Applicable Daily Benefit of the previous Policy Year shall be
increased by arithmetic addition of an amount equal to 5% (five percent) of the
Initial Daily Benefit. This shall be further enhanced if the policy attracts and is
eligible for “No Claim Benefit” (as defined in Para 4). And the resulting amount
shall be the Applicable Daily Benefit for that Policy Year.
Thus, the Applicable Daily Benefit for each policy year, after the first policy
year, shall consist of 2 parts:
− An arithmetic addition of an amount equal to 5% (five percent) of the
Initial Daily Benefit to the Applicable Daily Benefit of the previous Policy
Year. Such increase in the Applicable Daily Benefit shall be effected on
each Policy anniversary during the Cover Period and shall continue until it
attains a maximum amount of 1.5 times the Initial Daily Benefit
Thereafter, this amount in each Policy Year in future shall remain at that
maximum level attained.
− Further arithmetic addition of an amount equal to “No Claim Benefit”
provided the policy attracts and is eligible for it. There shall be no
maximum limit for such increase which means that if this policy is eligible
for “No Claim Benefit”, the same shall be granted throughout the Cover
Period without any maximum limit.
The amount of Daily Benefit in case of admission to the Intensive Care Unit
shall be two times the Applicable Daily Benefit.
For any addition of a member during the term of the policy, first policy year for
the purpose of this benefit shall start from the policy anniversary on which the
cover starts.
A no claim benefit is payable in the event that during the period between two
Automatic Renewal Dates there are no claims in respect of any Insured. The
amount of the no claim benefit would be equal to 5% (five percent) of the Initial
Daily Benefit in respect of each Insured and the resulting amount shall be
added for arriving at the amount of Applicable Daily Benefit in respect of each
Insured for that Policy Year. Such increase in the Applicable Daily Benefit shall
be effective from the next following Automatic Renewal Date.
Benefit Limits and Conditions:
i. The Hospital Cash Benefit shall be payable only if Hospitalisation has occurred
within India.
ii. The total number of days for which hospital cash benefit would be payable, in
respect of each Insured, in a Policy Year would be restricted to -
a. A maximum of 30 (thirty) days of Hospitalization out of which not more than
15 (fifteen) days shall be in an Intensive Care Unit in the first Policy Year
following the date of commencement of cover in respect of that Insured
b. A maximum of 90 (ninety) days of Hospitalization out of which not more
than 45 (forty five) days shall be in an Intensive Care Unit in the second
and subsequent Policy Years following the date of commencement of cover
in respect of that Insured.
iii. The total number of days of Hospitalization for which Hospital Cash Benefit is
payable during the Cover Period, in respect of each and every Insured covered
under the policy, shall be limited to a maximum of 720 (seven hundred and
twenty) days out of which not more than 360 (three hundred and sixty) days
shall be in an Intensive Care Unit. Upon attainment of this limit by an Insured, - 11 -
the Hospital Cash Benefit in respect of that Insured shall cease immediately.
iv. The Benefit Limits specified in the above clauses in respect of an Insured
under this Policy, shall solely and exclusively apply to that Insured. Any
unclaimed Hospital Cash Benefit of any one Insured is not transferable to any
other Insured.
v. The Hospital Cash Benefit shall not be payable in the event of an Insured
under this Policy undergoing any specified Day Care Procedure (as mentioned
in the Day Care Procedure Benefit Annexure).
d) Major Surgical Benefit:
In the event of an Insured under this Policy undergoing any specified Surgery (as
mentioned in the Major Surgical Benefit Annexure) in a Hospital due to Accidental Bodily
Injury or Sickness first occurring or manifesting itself after the date of commencement of
cover in respect of that Insured and during the Cover Period then, subject to the terms and
conditions, waiting period and exclusions of this Policy, a percentage (as mentioned in the
Major Surgical Benefit Annexure against the specified Surgery performed) of the Major
Surgical Benefit Sum Assured shall be payable by the Corporation, regardless of the
actual costs incurred.
In the event that a Major Surgical Benefit falling under Category 1 or Category 2 (as
mentioned in the Major Surgical Benefit Annexure) is payable and emergency
transportation costs by an ambulance have been incurred, an additional lump sum of `
1,000 will be payable in lieu of ambulance expenses.
In the event that a Major Surgical Benefit falling under Category 1 or Category 2 (as
mentioned in the Major Surgical Benefit Annexure) is payable in respect of any Insured,
the total annualized premium i.e. total one year premium in respect of that Policy from the
date of installment premium due coinciding with or next following the date of the Surgery
will be waived.
Benefit Limits and Conditions:
i. If more than one Surgery is performed on the Insured, through the same
incision or by making different incisions, during the same surgical session, the
Corporation shall only pay for that Surgery performed in respect of which the
largest amount shall become payable.
ii. The Major Surgical Benefit shall be paid as a lump sum as specified for the
benefit concerned and is subject to providing proof of Surgery to the
satisfaction of the Corporation.
iii. All Surgical Procedures claimed should be confirmed as essential and required,
by a qualified Physician or Surgeon, to the satisfaction of the Corporation.
iv. The Major Surgical Benefit will be payable only after the Corporation is satisfied
on the basis of medical evidence that the specified Surgery covered under the
Policy has been performed.
v. The Major Surgical Benefit shall be payable only if the Surgery has been
performed within India.
vi. The amount in lieu of ambulance expenses shall be payable only once in
respect of each Insured in any Policy Year and is subject to providing
satisfactory evidence to the Corporation.
vii. The total amount payable in respect of each Insured under the Major Surgical
Benefit in any Policy Year during the Cover Period shall not exceed 100% of
the Major Surgical Benefit Sum Assured in that Policy year.
viii. The total amount payable in respect of each Insured during the Cover Period
under the Major Surgical Benefit shall not exceed a maximum limit of 800% of
the Major Surgical Benefit Sum Assured. If the total amount paid in respect of - 12 -
an Insured equals this lifetime maximum limit, the Major Surgical Benefit in
respect of that Insured will cease immediately.
ix. The Benefit Limits specified in the above clauses in respect of an Insured
under this Policy, shall solely and exclusively apply to that Insured. Any
unclaimed Major Surgical Benefit of any one Insured is not transferable to any
other Insured.
x. The Major Surgical benefit for any surgery cannot be claimed and shall not be
payable more than once for the same surgery during the term of the policy.
e) Day Care Procedure Benefit:
In the event of an Insured under this Policy undergoing any specified Day Care Procedure
(as mentioned in the Day Care Procedure Benefit Annexure) in a Hospital due to
Accidental Bodily Injury or Sickness first occurring or manifesting itself after the date of
commencement of cover in respect of that Insured and during the Cover Period then,
subject to the terms and conditions, waiting period and exclusions of this Policy, an
amount equal to 5 (five) times the Applicable Daily Benefit, shall be payable by the
Corporation, regardless of the actual costs incurred.
Benefit Limits and Conditions:
i. If more than one Day Care Procedure is performed on the Insured, through the
same incision or by making different incisions, during the same surgical
session, the Corporation shall only pay for one Day Care Surgical Procedure.
ii. The Day Care Procedure Benefit shall be paid as a lump sum and is subject to
providing proof of Surgery to the satisfaction of the Corporation.
iii. All Surgical Procedures claimed should be confirmed as essential and required,
by a qualified Physician or Surgeon, to the satisfaction of the Corporation.
iv. The Day Care Procedure Benefit will be payable only after the Corporation is
satisfied on the basis of medical evidence that the specified Surgical Procedure
covered under the policy has been performed.
v. The Day Care Procedure Benefit shall be payable only if the Surgical
Procedure has been performed within India.
vi. In respect of each Insured, the Day Care Procedure Benefit will be payable
only up to a maximum of 3 (three) Surgical Procedures in any Policy Year
during the Cover Period.
vii. In respect of each Insured during the Cover Period, the Day Care Procedure
Benefit will be payable only up to a maximum of 24 (twenty four) Surgical
Procedures. If the number of Surgical Procedures eligible for the Day Care
Procedure Benefit in respect of an Insured equals this lifetime maximum limit,
the Day Care Procedure Benefit in respect of that Insured will cease
immediately.
viii. The Benefit Limits specified in the above clauses in respect of an Insured
under this Policy, shall solely and exclusively apply to that Insured. Any
unclaimed Day Care Procedure Benefit of any one Insured is not transferable
to any other Insured.
ix. If a Day Care Procedure Benefit is performed no Hospital Cash Benefit shall be
paid.
f) Other Surgical Benefit:
In the event of an Insured under this Policy undergoing any Surgery not listed under Major
Surgical Benefit or Day Care Procedure Benefit, in a Hospital due to Accidental Bodily
Injury or Sickness first occurring or manifesting itself after the date of commencement of
cover in respect of that Insured and during the Cover Period then, subject to the terms and
conditions, waiting period and exclusions of this Policy, a Daily Benefit equal to 2 (two)
times the Applicable Daily Benefit, shall be payable by the Corporation, regardless of the
actual costs incurred for each continuous period of 24 hours or part thereof provided any - 13 -
such part stay exceeds a continuous period of 4 hours of Hospitalization.
Benefit Limits and Conditions:
i. If more than one Surgical Procedure is performed on the Insured, through the
same incision or by making different incisions, during the same surgical
session, the Corporation shall only pay for one Surgical Procedure.
ii. The Other Surgical Benefit shall be paid as a Daily Benefit and is subject to
providing proof of Surgery to the satisfaction of the Corporation.
iii. All Surgical Procedures claimed should be confirmed as essential and required,
by a qualified Physician or Surgeon, to the satisfaction of the Corporation.
iv. The Other Surgical Benefit will be payable only after the Corporation is satisfied
on the basis of medical evidence that the specified Surgical Procedure covered
under the policy has been performed.
v. The Other Surgical Benefit shall be payable only if the Surgical Procedure has
been performed within India.
vi. The total number of days of Hospitalization for which the Other Surgical Benefit
is payable during a Policy Year in respect of each and every Insured covered
under the Policy shall not exceed 15 (fifteen) days in the first Policy Year
following the Date of Cover Commencement in respect of that Insured and 45
(forty five) days for the second and subsequent Policy Years following the Date
of Cover Commencement in respect of that Insured.
vii. The total number of days of Hospitalization for which the Other Surgical Benefit
is payable during the Cover Period, in respect of each and every Insured
covered under the Policy shall not exceed a maximum limit of 360 (three
hundred and sixty) days. Upon attainment of this lifetime maximum limit, the
Other Surgical Benefit in respect of that Insured will cease immediately.
viii. The Benefit Limits specified in the above clauses in respect of an Insured
under this Policy, shall solely and exclusively apply to that Insured. Any
unclaimed Other Surgical Benefit on any one Insured is not transferable to any
other Insured.
g) Commencement And Termination Of Benefit Covers:
The Hospital Cash Benefit, Major Surgical Benefit, Day Care Procedure Benefit and Other
Surgical Benefit cover in respect of each Insured shall commence on the Date of Cover
Commencement individually stated in the Policy Schedule.
The Hospital Cash Benefit, Major Surgical Benefit, Day Care Procedure Benefit and Other
Surgical Benefit cover in respect of each Insured shall terminate at the earliest of the
following:
i. The Date of Cover Expiry mentioned in the Policy Schedule;
ii. On attaining the lifetime maximum Benefit Limits as specified above;
iii. On death or Date of Cover Expiry of the Principal Insured and if the Policy
does not continue with the Insured Spouse as the Principal Insured;
iv. On death or Date of Cover Expiry of Insured Spouse after the Policy continues
with the Insured Spouse as the Principal Insured after the PI dies or reaches
his/her Date of Cover Expiry.
v. On death of the Insured;
vi. In respect of the Insured Spouse, on divorce or legal separation from the
Principal Insured;
vii. On termination of the Policy due to non-payment of premium or any other
reason.
h) Termination Of Policy:
A) If policy is issued on single life:
The policy shall terminate at the earliest of the following: - 14 -
i) Non-payment of premiums within the revival period described in Para 8;
ii) On death;
iii) On the Date of Cover Expiry mentioned in the Policy Schedule;
iv) On exhausting all the lifetime maximum Benefit Limits as specified above.
B) If policy is issued on more than one life:
The policy shall terminate at the earliest of the following:
i) Non-payment of premiums within the revival period;
ii) On PI exhausting all the lifetime maximum Benefit Limits as specified
above.
iii) On death or Date of Cover Expiry, of the Principal Insured and if the
Policy does not continue with the Insured Spouse as the Principal
Insured.
iv) On the death or Date of Cover Expiry, of Insured Spouse after the Policy
continues with the Insured Spouse as the Principal Insured after the PI
dies or reaches his/her Date of Cover Expiry.
i) Waiting Period:
General waiting period:
There shall be no general waiting period in case Hospitalization or Surgery is due to
Accidental Bodily Injury. There shall be a general waiting period during which no benefits
shall be payable in the event of Hospitalization or Surgery, if the said Hospitalization or
Surgery occurred due to Sickness.
i. The general waiting period shall be 90 (ninety) days from the Date of Cover
Commencement in respect of each Insured.
ii. If the policy is revived after discontinuance of the Cover then the following
shall apply in respect of each Insured:
a. If the request for revival is received by the Corporation within 90 (ninety)
days from the due date of the first unpaid premium, then there shall be a
general waiting period of 45 (forty five) days from the Date of Revival in
respect of each Insured.
b. If the request for revival is received by the Corporation beyond 90 (ninety)
days from the due date of the first unpaid premium, then there shall be a
general waiting period of 90 (ninety) days from the Date of Revival in
respect of each Insured.
Specific waiting period:
In addition, in respect of each Insured, no benefits are available hereunder and no
payment will be made by the Corporation for any claim under this Policy on account of
Hospitalization or Surgery directly or indirectly caused by, based on, arising out of or
howsoever attributable to any of the following during the specific waiting period:
i. Treatment for adenoid or tonsillar disorders
ii. Treatment for anal fistula or anal fissure
iii. Treatment for benign enlargement of prostate gland
iv. Treatment for benign uterine disorders like fibroids, uterine prolapse,
dysfunctional uterine bleeding etc
v. Treatment for Cataract
vi. Treatment for Gall stones
vii. Treatment for slip disc
viii. Treatment for Piles
ix. Treatment for benign thyroid disorders
x. Treatment for Hernia
xi. Treatment for hydrocele - 15 -
xii. Treatment for degenerative joint conditions
xiii. Treatment for sinus disorders
xiv. Treatment for kidney or urinary tract stones
xv. Treatment for varicose veins
xvi. Treatment for Carpal tunnel syndrome
xvii. Treatment for benign breast disorders e.g. fibroadenoma, fibrocystic disease
etc
The specific waiting period in respect of the treatments specified in the list above shall be
as follows:
i. The specific waiting period shall be 2 (two) years from the Date of Cover
Commencement in respect of each Insured.
ii. If the policy is revived after discontinuance of the Cover then the following
shall apply in respect of each Insured:
a. If the request for revival is received by the Corporation within 90 (ninety)
days from the due date of the first unpaid premium, then the specific waiting
period shall continue to be till 2 (two) years from the Date of Cover
Commencement in respect of each Insured.
b. If the request for revival is received by the Corporation beyond 90 (ninety)
days from the due date of the first unpaid premium, then there shall be a
specific waiting period of 2 (two) years from the Date of Revival in respect
of each Insured.
6. OPTIONS AVAILABLE UNDER THE PLAN:
(a) Plan changes: No alterations in the Plan (i.e. from one type of plan to another type) will
be allowed.
(b) Insured Spouse to become Principal Insured: In case of death or expiry of cover of
Principal Insured, the surviving Insured Spouse shall become the Principal Insured
provided the option is exercised at the time of filling up the proposal form and the policy
will continue. In such case, the premium for the Insured Spouse will change from the
coinciding or following installment premium due date and the new premium would be
based on tabular premium rates applicable for Principal Insureds and the age for
calculation of revised premium rate will be the age at entry of the spouse.
(c) Cover to new additional members: If the PI gets married/ remarried during the term of
the policy, the spouse and parents-in-law can be included in the policy within six months
from the date of marriage/ remarriage, but the Cover shall start from the policy anniversary
coinciding with or next following the date of inclusion. Enhanced premium shall be due
from such policy anniversary.
Any child born/legally adopted after taking the policy can be covered from the next
immediate policy anniversary date following the date on which the child completes the age
of 3 months. If the age of legally adopted child on the date of adoption is more than 3
months, the child can be covered from policy anniversary coinciding with or next following
the date of adoption. Enhanced premiums shall be due from such policy anniversary.
Inclusion of each additional member will be subject to receipt of the proof of the event and
fulfillment of underwriting conditions. The eligibility conditions, as mentioned in Para 3,
waiting period and exclusions will apply for the new Insured.
Addition in any other case will not be allowed. The existing spouse, parents, parents-in-law
and children, if not covered at the time of taking policy, shall not be covered under the - 16 -
policy.
If both of the parents (father and mother) are alive and are eligible for cover, then either
both of them will have to be covered or none of them will be covered. The PI will not have
any option to choose one of them. The same condition will apply for parents-in-law also.
Any addition of new lives shall be allowed by the PI only. After the death of PI, no addition
will be allowed.
(d) Quick Cash facility: If any of the insured lives undergoes any eligible surgery covered
under Category I or II of MSB in any of the listed network hospitals, the PI will have an
option to avail Quick Cash facility. Under this facility, 50% of eligible MSB amount would
be made available even during the period of hospitalization of any of the insured lives
covered (the surgery may be either planned or emergency due to accident) instead of
waiting for making a claim for the benefit after discharge. It will be only an advance
payment to the PI in the event of hospitalization for any MSB defined in the surgeries listed
under categories I & II and permissible under the policy conditions of the plan. This will be,
however, subject to approval from the TPA (Third Party Administrator), and the advance
amount will be adjusted from the final settlement of MSB claim amount.
This facility of advance payment could be availed by submitting the Bank Account details
of the PI in the prescribed format. The amount of advance shall be credited in the PI’s
bank account directly.
(e) Accident Benefit Rider: For PI and Insured Spouse, Accident Benefit Rider will be
available under the plan by payment of additional premium of ` 0.50 for every ` 1,000/- of
the Accident Benefit Sum Assured per policy year in respect of each life to be covered. In
case of accidental death, the Accident Benefit Sum Assured will be payable as lump sum
along with the Term Assurance Sum Assured, if Term Assurance Rider is opted for.
The maximum aggregate limit of assurance under all policies of the Corporation and that
of all insurers under individual as well as group policies on the same life to which the
benefits apply shall not exceed ` 50 lakh.
The additional premium for this benefit will not be required to be paid on and after the
Policy anniversary on which the age nearer birthday of the Insured is 60 years.
(f) Term Assurance Rider: For PI and Insured Spouse, Term Assurance as optional rider
will be available under this plan. The premiums for this option are payable along with
premium under the basic plan and an amount equal to Term Assurance Sum Assured will
be payable on death during the term for which Term Assurance Rider is opted for. The
maximum cover for this rider will be ` 25 lakhs under all policies of the life assured with the
Corporation taken together.
The tabular premium rates per annum for Term Rider benefit are given in the Annexure –
III. Also the rates of Class I extra premium per annum are given in the Annexure – IV.
7. EXCLUSIONS: - 17 -
No benefits are available hereunder and no payment will be made by the Corporation for any
claim under this policy on account of hospitalization or surgery directly or indirectly caused by,
based on, arising out of or howsoever attributable to any of the following:
i. Any Pre-existing Condition unless disclosed to and accepted by the Corporation
prior to the Date of Cover Commencement or the Date of Revival (if the Policy is
revived after discontinuance of the Cover).
ii. Any treatment or Surgery not performed by a Physician/Surgeon or any treatment
including Surgery of a purely experimental nature.
iii. Any routine or prescribed medical check up or examination.
iv. Medical Expenses relating to any treatment primarily for diagnostic, X-ray or
laboratory examinations.
v. Any Sickness that has been classified as an Epidemic by the Central or State
Government.
vi. Circumcision, cosmetic or aesthetic treatments of any description change of
gender surgery, plastic surgery (unless such plastic surgery is necessary for the
treatment of Illness or accidental Bodily Injury as a direct result of the insured
event and performed within 6 months of the same).
vii. Hospitalisation or Surgery for donation of an organ.
viii. Treatment for correction of birth defects or congenital anomalies.
ix. Dental treatment or surgery of any kind unless necessitated by Accidental Bodily
Injury.
x. Convalescence, general debility, nervous or other breakdown, rest cure,
congenital diseases or defect or anomaly, sterilisation or infertility (diagnosis and
treatment), any sanatoriums, spa or rest cures or long term care or hospitalization
undertaken as a preventive or recuperative measure.
xi. Self afflicted injuries or conditions (attempted suicide), and/or the use or misuse of
any drugs or alcohol.
xii. Any sexually transmitted diseases or any condition directly or indirectly caused to
or associated with Human Immuno Deficiency (HIV) Virus or any Syndrome or
condition of a similar kind commonly referred to as AIDS.
xiii. Removal or correction or replacement of any material that was implanted in a
former surgery before Date of Cover commencement or Date of Revival (if the
Policy is revived after discontinuance of the Cover).
xiv. Any diagnosis or treatment or surgery arising from or traceable to pregnancy
(whether uterine or extra uterine), childbirth including caesarean section, medical
termination of pregnancy and/or any treatment related to pre and post natal care
of the mother or the new born.
xv. Hospitalisation for the sole purpose of physiotherapy or any ailment for which
hospitalization is not warranted due to advancement in medical technology.
xvi. War, invasion, act of foreign enemy, hostilities (whether war be declared or not),
civil war, rebellion, revolution, insurrection military or usurped power of civil
commotion or loot or pillage in connection herewith.
xvii. Naval or military operations(including duties of peace time) of the armed forces or
air force and participation in operations requiring the use of arms or which are
ordered by military authorities for combating terrorists, rebels and the like.
xviii. Any natural peril (including but not limited to avalanche, earthquake, volcanic
eruptions or any kind of natural hazard).
xix. Participation in any hazardous activity or sports including but not limited to racing,
scuba diving, aerial sports, bungee jumping and mountaineering or in any criminal
or illegal activities.
xx. Radioactive contamination.
xxi. Non-allopathic methods of treatment or surgery.
xxii. Participation in any criminal or illegal activities.
xxiii. Treatment arising from the Insured’s failure to act on proper medical advice - 18 -
8. DISCONTINUANCE OF PREMIUMS:
If premiums have not been paid within the days of grace under the Policy, the Policy will lapse
and no benefits will be payable thereafter. The Principal Insured shall have an option to revive
the policy at anytime within a period of 2 (two) years from the due date of first unpaid premium
subject to conditions in clause 8 below.
9. REVIVALS/REINSTATEMENT OF DISCONTINUED POLICIES:
The Policy can be revived by the Principal Insured anytime during a period of 2 (two) years
from the due date of first unpaid premium called the “period of revival” or “revival period”.
The revival will be subject to payment of outstanding premiums with interest, underwriting and
may be on terms different from those offered earlier. Waiting periods and Exclusions as
described earlier will apply on revival. The Principal Insured may need to provide satisfactory
evidence of good health in respect of each Insured as required by the Corporation, at his own
expense. The Date of Revival will be when all requirements for revival/reinstatement are met
and approved by the Corporation at its sole discretion.
No benefit will be paid for an event that occurred during the lapse period till the Date of
Revival when the Policy was in a discontinued state.
Further, if the Automatic Renewal Date falls between the revival period and revival is done
after the Automatic Renewal Date, the premium before and after the Automatic Renewal Date
may be different.
Revival/reinstatement will not be allowed post the revival period.
10. SURRENDER:
No surrender value will be available under the policy.
11. MODES OF PREMIUM PAYMENT:
Premiums can be paid regularly either in yearly or half yearly or monthly (through ECS only)
installments.
12. REBATES:
Mode Rebates:
Rebates are available at the following rates:
Yearly mode : 2% of Tabular Premium
Half-yearly mode : 1% of the tabular premium
HCB Rebates:
In respect of a member covered under a policy, if HCB is more than ` 1000, then the
premium arrived at in respect of that member shall be reduced by an amount (`) given
below:
HCB (`) For PI For each insured
member other than PI
2000 500 250
3000 1000 500
4000 1500 750
CEIS Rebate:- 19 -
The rebate for eligible employees of the Corporation shall be 10% of the tabular
premium provided the proposal is submitted directly and not through any Agent/
Corporate Agent/ Broker.
13. COMMISSION PAYABLE TO AGENTS/ CORPORATE AGENTS/ BROKERS &
DEVELOPMENT OFFICER’S CREDIT:
Agents & Corporate Agents:
1
st Year 2nd & 3rd year Subsequent Years
25.0% 7.5% 5.0%
Bonus Commission: 40% of 1st year's commission is payable in the first year.
Brokers
1
st Year Subsequent Years
30% 5%
Development Officer’s credit: 100% of FY premium
14. LOANS:
No loan shall be granted under this plan.
15. UNDERWRITING:
Instructions will be issued separately by Underwriting and Reinsurance Department.
16. DAYS OF GRACE:
A grace period of one calendar month but not less than 30 days will be allowed for payment of
yearly or half-yearly premiums and 15 days will be allowed if premiums are payable monthly
(ECS). If the due premiums are not paid within the days of grace the policy will lapse. The
provisions of para 8 (i.e. Discontinuance of Premiums) of this circular shall be applicable in
that case.
17. COOLING-OFF PERIOD:
If a policyholder is not satisfied with the “Terms and Conditions” of the policy, he/she may
return the policy to the Corporation within 15 days from the date of receipt of the policy. This
period will be termed as Cooling-Off Period.
In case the policy is returned during the cooling-off period, Commission shall be recovered
from the concerned Agent and the Development Officer’s credit allowed shall be withdrawn.
The refund of premium to the policyholder shall be net of mortality charges and morbidity
charges. The mortality charges will be calculated as per CO Circular 1819/4 dated
23/08/2004. The morbidity charges deductible are given in Annexure V.
The mortality and morbidity charges will be deductible for proportionate number of days
subject to a minimum for one month.
18. BACK DATING:
Back dating of policy will not be allowed.
19. POLICY STAMPING: - 20 -
Policy Stamping will be at the rate of `.0.20 per thousand of total Major Surgical Benefit Sum
Assured (i.e. sum of Major Surgical Benefit Sum Assured in respect of all the members
insured (including PI) at inception.
Any addition of member thereafter shall be by way of endorsement for which stamping shall
be done additionally.
Further, the policy stamping for Term Rider Sum Assured will be at the rate of ` 0.20 per
thousand sum assured.
20. ASSIGNMENTS / NOMINATION:
No Assignment will be allowed under this plan.
Notice for Nomination or change of Nominations should be submitted for registration to the
office of the Corporation, where this policy is serviced. In registering a nomination, the
Corporation does not accept any responsibility or express any opinion as to its validity or legal
effect.
21. NORMAL REQUIREMENTS FOR CLAIM:
Regarding claims, the instructions shall be issued by Health Insurance Department, Central
Office, separately.
22. REINSURANCE:
A separate treaty has been arranged for this plan. Our retention limits are as below:
Hospital Cash Benefit:
` 500 Daily Hospital Cash Benefit
Major Surgical Benefit:
` 50,000 Major Surgical Benefit Sum Assured
Day Care Procedure Benefit:
` 2,500 Day Care Procedure Benefit
Other Surgical Benefit:
` 1,000 per day benefit
Risks over and above the above retention limits shall be shared equally between LIC (i.e.
50%) and reinsurers (50%).
23. PROPOSAL FORM:
The specimen Proposal form is annexed (Annexure VI).
24. POLICY DOCUMENT:
The specimen Policy document will be sent by the Corporate Communications Department,
Central Office.
CHIEF (PRODUCT DEVELOPMENT)
Enclosures – Annexure I, II, III, IV, V and VI
CENTRAL OFFICE
Dept: Product Development “Yogakshema”
Jeevan Bima Marg
Mumbai – 400 021
Draft Circular (Confidential)
Ref: CO/PD/ --- --------, 2011
To,
All HODs of Central Office
All Zonal Offices
All Divisional Offices
All Branch Offices (through DOs)
MDCs, ZTCs, STCs, NIA and
Audit & Inspection Depts. of Zonal Offices.
Re: INTRODUCTION OF LIC’S JEEVAN AROGYA (Plan No. 903)
1. INTRODUCTION:
It has been decided to introduce LIC’s JEEVAN AROGYA (Plan No. 903) with effect from
-------, 2011. The Unique Identification Number (UIN) for LIC’s Jeevan Arogya plan is ----------.
This number has to be quoted in all relevant documents furnished to the policyholders and
other users (public, distribution channels).
An individual can take the health cover under this plan for himself / herself. This individual will
be addressed as Principal Insured (PI) for the purpose of insurance under this plan. The
Spouse, Children, Parents and Parents-in-law can also be covered under the same policy.
This is non-linked plan which provides fixed benefits for hospitalization and almost all types of
surgical procedures irrespective of actual cost incurred and the benefit is in addition to any
other health insurance cover that insured lives may have, subject to certain terms and
conditions.
The benefits offered under the plan are:
i) Hospital Cash Benefit (HCB)
ii) Major Surgical Benefit (MSB)
iii) Day Care Procedure Benefit (DCPB)
iv) Other Surgical Benefit (OSB)
Two riders viz. Term Assurance Rider and Accident Benefit Rider shall also be available
under the plan for PI and Insured Spouse only.
At the time of filling up the proposal form, PI and Spouse (if insured) have to exercise an
option whether to continue the policy in case of exit of PI from the policy, as per Addendum
enclosed with the proposal form. If option for continuation of policy is exercised, in case of
death or expiry of cover of PI, the surviving Insured Spouse will become the Principal Insured
and the Policy will continue. In such case, the premium for the Insured Spouse will change - 2 -
from the coinciding or following instalment premium due date and the new premium would be
based on tabular premium rates applicable for PIs and the age for calculation of revised
premium rate will be the age at entry of the spouse.
Other details of the plan are as follows.
2. PREMIUM:
Under this plan multiple lives can be covered under one policy.
For each insured life, the installment premium shall be based on the age at entry, the Initial
Daily Hospital Cash Benefit chosen, gender and whether insured life is PI or other than PI.
The tabular premium rates applicable for PI (males/females) will be different from those
applicable for other lives (males/females) as given in Annexure I. Thus, the level of premium
for PI and other insured lives shall be different for same age, same gender and same level of
cover.
The instalment premium payable during the cover period in respect of each Insured will be the
sum of:
(i) Instalment premium for the Basic Plan
(ii) Instalment premium for Accident Benefit Rider (if opted for)
(iii) Instalment premium for Term Assurance Rider (if opted for)
The total instalment premium payable in respect of each policy shall be the sum of instalment
premiums payable in respect of each insured life covered under the policy.
For example, if there are 3 lives covered under a policy- PI (male), Spouse (female) and child
(for children premium does not vary with gender). PI has opted for both Term Assurance Rider
& Accident Benefit Rider, Spouse has not opted for any rider benefit and the optional riders
are not available for child.
Thus,
Instalment premium for PI is = Instalment premium for PI under the Basic Plan + Instalment
premium for Accident Benefit Rider + Instalment premium for
Term Assurance Rider ------------- (A)
Instalment premium for Spouse = Instalment premium for Spouse under the Basic Plan
------------- (B)
Instalment premium for Child = Instalment premium for Child under the Basic Plan
------------- (C)
Therefore, Total Instalment Premium to be paid for this policy shall be [(A) + (B) + (C)]
In respect of each insured life covered under a policy, the installment premium for Basic Plan
will be guaranteed for a period of 3 (three) years from the Date of Commencement of the
policy. The installment premiums for Basic Plan are reviewable on every third policy
anniversary (defined as Automatic Renewal Date in para 5 a) below) starting from the date of
commencement of policy. The premium rates for the basic plan applicable on renewal, i.e.
from Automatic Renewal Date, shall be guaranteed for a further period of 3 years i.e. till next
Automatic Renewal Date.
If any additional member is included in the policy after the date of commencement, the
premium charged in respect of that member will also be guaranteed till the next Automatic
Renewal Date and hence may change even before completion of 3 years from his/her joining
the policy. - 3 -
On any Automatic Renewal Date in the future, the installment premium in respect of each
insured will be based on the entry age of that Insured (i.e. age as on the date of
commencement of policy/ age at the time of inclusion into the policy, as the case may be) and
the Corporation’s premium rates then prevailing for this product.
The tabular premium rates per annum for PI and Other Insured for standard lives are given in
the Annexure - I. Also the rates of Class I extra premium per annum are enclosed as
Annexure – II to this circular.
The Installment premium for both the optional riders is however guaranteed throughout the
term for which cover is provided.
3. ELIGIBILITY CONDITIONS AND FEATURES:
FOR BASIC PLAN
a) Minimum /
Maximum Premium
Amount
There is no specific minimum and maximum premium payable. The total
premium payable will be the sum of premiums in respect of each individual
member covered under the policy. The premium in respect of each individual
will be payable from the date of entry into the policy till the date of exit from
the policy.
b) Minimum entry age Principal Insured, Insured Spouse,
Parents & Parents-in-law - [18] years last birthday
Insured Dependent Children - [3] months (completed)
c) Maximum entry age Principal Insured and Insured Spouse - [65] years last birthday
Insured Parents and Parents-in-law - [75] years last birthday
Insured Dependent Children – [17] years last birthday
d) Maximum cover
ceasing age
Principal Insured, Insured Spouse, Insured Parents & Parents-in-law –
[80] years last birthday
Insured Dependent Children – [25] years last birthday
e) Date of cover
expiry in respect
of each Insured
covered under the
plan
Policy anniversary on which the Insured life attains Maximum cover ceasing
age
f) Premium Rate
Guarantee
Rates will be guaranteed for first 3 years of the policy i.e. for 3 years from the
date of commencement of policy. At the end of every 3 years, i.e. on each
Automatic Renewal Date (defined in Para 5 a)) the premium rates may
change i.e. the policy may be treated as if it is renewed every 3 years.
The rates applicable on renewal after every 3 years shall be guaranteed for a
further period of 3 years i.e. till next renewal.
(i) For Hospital Cash Benefit (HCB) (under Basic Plan)
Feature Principal
Insured
(PI)
Insured Spouse (if any),
Insured Parents &
Parents-in-law (if any)
Insured Dependent
Children (if any)
a) Minimum Initial Daily
Benefit (in a ward other
than Intensive Care Unit)
` 1,000/- ` 1,000/- ` 1,000/-
b) Maximum Initial Daily
Benefit
` 4,000/- Insured Spouse- Less than
or equal to that of PI
Insured Parents/ Parents-inlaw - Less than or equal to
that of Insured Spouse (PI,
if there is no Insured
Less than or equal to
that of Insured Spouse
(PI, if there is no
Insured Spouse).
Further, included
children shall be - 4 -
Spouse). Further, included
parents shall be covered for
equal benefits.
covered for equal
benefits.
c) Maximum annual benefit
period, applicable to each
insured
30 days in year 1, 90 days per year thereafter, inclusive of stay in
ICU. Maximum number of days in ICU is restricted to 15 days in
year 1 and to 45 days thereafter.
d) Maximum Lifetime Benefit
period, applicable to each
insured
720 days inclusive of stay in ICU. Maximum number of days in ICU
is restricted to 360 days in respect of each Insured.
Initial Hospital Cash Benefit shall be in multiples of ` 1000/-.
(ii) For Major Surgical Benefit (MSB) (under Basic Plan)
Feature Principal Insured (PI) Insured Spouse (if
any),Insured Parents
& Parents-in-law (if
any)
Insured Dependent
Children (if any)
a) Major Surgical
Benefit Sum
Assured (MSB SA)
100 times of
Applicable Daily
Benefit (ADB) of PI
(as specified in para
4).
Insured Spouse- 100
times of ADB of
Insured Spouse
Insured Parents/
Parents-in-law - 100
times of ADB of each
parent
100 times of ADB of each
child
b) Maximum annual
benefit, applicable
to each insured
100% of Major Surgical Benefit Sum Assured
c) Maximum Lifetime
Benefit, applicable
to each insured
800% of Major Surgical Benefit Sum Assured
(iii) For Day Care Procedure Benefit (DCPB) (under Basic Plan)
Feature Principal Insured (PI) Insured Spouse (if
any),Insured Parents
& Parents-in-law (if
any)
Insured Dependent
Children (if any)
a) Lump sum benefit
payable
5 times of Applicable
Daily Benefit (ADB)
(described in Para 4)
of PI
Insured Spouse- 5
times of ADB of
Insured Spouse
Insured Parents/
Parents-in-law - 5
times of ADB of each
parent
5 times of ADB of each
child
b) Maximum annual
benefit, applicable
to each insured
3 Surgical Procedures
c) Maximum Lifetime
Benefit, applicable
to each insured
24 Surgical Procedures
(iv) For Other Surgical Benefit (OSB) (under Basic Plan)
Feature Principal
Insured
(PI)
Insured Spouse (if
any),Insured Parents &
Parents-in-law (if any)
Insured Dependent
Children (if any) - 5 -
a) Daily benefit amount 2 times of
ADB of PI
Insured Spouse- 2 times of
ADB of Insured Spouse
Insured Parents/Parents-in-law-
2 times of ADB of each parent
2 times of ADB of
each child
b) Maximum annual benefit,
applicable to each insured
15 days in year 1 and 45 days per year thereafter
c) Maximum Lifetime Benefit,
applicable to each insured
360 days
FOR TERM ASSURANCE RIDER OPTION:
This rider shall be available for PI and Insured Spouse only.
(a) Minimum Term Assurance Sum Assured: ` [100] in '000's
(b) Maximum Face Amount/Basic Sum Assured/Annuity pa: An amount equal to the
Major Surgical Benefit Sum Assured (MSB SA) at the time of inception/ inclusion
into the policy (i.e. 100 times of Initial Daily Hospital Cash Benefit) in respect of the
insured, subject to the maximum of ` 25 lakh overall limit taking all term assurance
riders under all existing policies of the Life Assured and Term Assurance Sum
Assured under other proposals into consideration.
The Term Assurance Sum Assured shall be in multiples of ` 25,000/-.
(c) Minimum / Maximum Premium Amount: There is no specific minimum and
maximum premium payable. The premium payable will depend on the Term
Assurance Sum Assured
(d) Minimum Entry Age: [18] years (completed)
(e) Maximum Entry Age: [50] years (Nearest Birthday)
(f) Maximum Maturity Age: [60] years (Nearest Birthday)
(g) Maximum Term: [35] years
FOR ACCIDENT BENEFIT RIDER OPTION:
This rider shall only be available for PI and Insured Spouse provided Term Assurance Rider has
been opted for.
(a) Minimum Accident Benefit Sum Assured: ` [25] in '000's
(b) Maximum Accident Benefit Sum Assured: An amount equal to the Term Assurance
Sum Assured at the time of inception/ inclusion into the policy in respect of the insured,
subject to maximum of ` 50 lakhs overall limit considering the Accident Benefit Sum
Assured in respect of all existing policies on the life of the insured including the policies
taken from Life Insurance Corporation of India and other insurance companies and the
Accident Benefit Sum Assured under new proposals into consideration.
The Accident Benefit Sum Assured shall be in multiples of `5,000/-.
(c) Minimum / Maximum Premium Amount: There is no specific minimum and maximum
premium payable. The premium payable will depend on the Accident Benefit Sum
Assured. - 6 -
(d) Minimum Entry Age: [18] years completed
(e) Maximum Entry Age: [50] years (Nearest Birthday)
(f) Maximum age for cover: [60] years (Nearest Birthday)
(g) Maximum Term: [35] years
4. BENEFITS:
Death Benefit under the basic plan: No death benefits will be payable on the death of any
Insured unless Term Assurance Rider Benefit mentioned in Para 6 f) below, along with or
without Accident Benefit Rider mentioned in Para 6 e), has been opted for.
On death of the Principal Insured (PI);
a) The surviving Insured Spouse will become the Principal Insured provided the option is
exercised at the beginning of the contract and the Policy will continue. In such case, the
premium for the Insured Spouse will change from the date coinciding with or following
installment premium due date and the new premium would be based on tabular premium
rates applicable for PIs and the age for calculation of revised premium rate will be the age
at entry of the spouse. If the option is not exercised at the beginning of the contract, the
Insured Spouse will not become PI and the policy will terminate.
b) If the Insured Spouse had predeceased the Principal Insured, then the other Insured will
have the option to take a new policy and the existing Policy will terminate. In respect of
these other Insured:
i. The new policy will be issued without any underwriting if the new policy is bought
within 90 days of the termination of the existing Policy.
ii. The maximum entry age condition will not apply for the new policy.
iii. The outstanding Waiting periods and outstanding period of any Exclusion will however
apply under the new policy.
iv. Other terms and conditions including premium rates will be as applicable for the new
policy.
In the event of death of an Insured person other than the Principal Insured, the policy will
continue after removal of the Insured and change in premium will apply from the installment
premium due date coinciding with or next following the date of intimation of death of the
Insured.
Maturity Benefit: No benefits are payable at end of the Cover Period.
Benefit payable on hospitalization:
If PI or any of the Insured lives covered under the policy is hospitalized due to Accidental
Bodily Injury or Sickness and the stay in hospital exceeds a continuous period of 24 hours,
then for any continuous period of 24 hours or part thereof, provided any such part stay
exceeds a continuous period of 4 hours (after having completed the 24 hours as above) in a
non-ICU ward/room of a hospital, an amount equal to the Applicable Daily Benefit (ADB),
available under the policy during that policy year, shall be payable subject to terms and
conditions mentioned in Para 5 (c) and exclusions mentioned in Para 7.
During the first year of cover commencement in respect of each insured, the Applicable Daily
Benefit shall be the Initial Daily Benefit amount (i.e. the level of HCB chosen by the insured)
mentioned in the policy Schedule. - 7 -
The amount of Applicable Daily Benefit (ADB) for each policy year, after the first policy year,
shall consist of 2 parts:
− An arithmetic addition of an amount equal to 5% (five percent) of the Initial Daily Benefit to
the Applicable Daily Benefit of the previous Policy Year. Such increase in the Applicable
Daily Benefit shall be effected on each Policy anniversary during the Cover Period and
shall continue until it attains a maximum amount of 1.5 times the Initial Daily Benefit
Thereafter, this amount in each Policy Year in future shall remain at that maximum level
attained.
− Further arithmetic addition of an amount equal to “No Claim Benefit” provided the policy
attracts and is eligible for it. There shall be no maximum limit for such increase which
means that if this policy is eligible for “No Claim Benefit”, the same shall be granted
throughout the Cover Period without any maximum limit.
Consider an example where Initial Daily Benefit is Rs.1000 in respect of each insured life (say,
PI and spouse) under a policy. There is no claim admitted under the policy during first 12
years from the policy commencement except in the 5th year when a claim is admitted in
respect of spouse. In this case, year-wise Applicable Daily Benefit for each insured shall be as
follows:
Year 1 2 3 4 5 6 7 8 9 10 11 12
ADB 1000 1050 1100 1200* 1250 1300 1350** 1400 1450 1550* 1600*** 1600
* In years 4 and 10 ‘No Claim Benefit’ is added.
** In year 7 ‘No Claim Benefit’ is not added as a claim occurred in the 5th year.
*** After 11th year, ADB shall not increase as it has attained the maximum level (1.5 times of
Initial Daily Benefit). However the ADB shall increase due to ‘No Claim Benefit’ as and when
the policy shall be eligible for.
For members included subsequently under the policy, the benefit in the first year shall be
equal to Initial Daily Benefit amount and thereafter the Applicable Daily Benefit shall increase
as above.
If the member insured is required to stay in an Intensive Care Unit of a hospital, two times the
Applicable Daily Benefit, for any continuous period of 24 hours or part thereof, provided any
part stay exceeds a continuous period of 4 hours (after having completed the 24 hours as
above), will be payable subject to terms and conditions mentioned in Para 5 (c) & 5 (i) and
exclusions mentioned in Para 7.
The Applicable ICU Daily Benefit amount shall be twice the Applicable Daily Benefit amount.
No benefit will be payable for the first 24 hours of hospitalisation. However, for every
Hospitalization that extends for a continuous period of 7 days or more, the Daily Hospital Cash
Benefit would also be paid for first 24 hours (day one) of hospitalization, regardless of whether
the Insured was admitted in a general or special ward or in an intensive care unit. It may be
noted that hospitalization for 6 days and 4 hours or more will be considered as 7 days.
Major Surgical Benefit:
In the event of an Insured under this plan, due to medical necessity, undergoing one of the
surgeries defined in Major Surgical Benefit Annexure, within the cover period in a Hospital due
to Accidental Bodily Injury or Sickness, the respective benefit percentage of the Major Surgical
Benefit Sum Assured, as specified against each of the eligible surgeries mentioned in Major
Surgical Benefit Annexure, shall be paid subject to terms and conditions mentioned in Para 5 - 8 -
(d) & 5 (i) and exclusions mentioned in Para 7.
In the event that a Major Surgical Benefit falling under Category 1 or Category 2 (as
mentioned in the Major Surgical Benefit Annexure) is payable and emergency transportation
costs by an ambulance have been incurred, an additional lump sum of `1,000 will be payable
in lieu of ambulance expenses.
Further, in the event that a Major Surgical Benefit falling under Category 1 or Category 2 (as
mentioned in the Major Surgical Benefit Annexure) is payable in respect of any Insured, the
total annualized premium i.e. total one year premium in respect of that Policy from the date of
installment premium due coinciding with or next following the date of the Surgery will be
waived.
Day Care Procedure Benefit:
In the event of an Insured under this Plan undergoing any specified Day Care Procedure
mentioned in the Day Care Procedure Benefit Annexure due to medical necessity, an amount
equal to 5 (five) times the Applicable Daily Benefit shall be paid, regardless of the actual costs
incurred, subject to terms and conditions mentioned in Para 5 e) & 5 i) and exclusions
mentioned in Para 7.
Other Surgical Benefit:
In the event of an Insured under this Plan, due to medical necessity, undergoing any Surgery
not listed under Major Surgical Benefit or Day Care Procedure Benefit, and the stay in hospital
exceeds a continuous period of 24 hours, a Daily Benefit equal to 2 (two) times the Applicable
Daily Benefit shall be paid for each continuous period of 24 hours or part thereof provided any
such part stay exceeds a continuous period of 4 hours of Hospitalization, subject to terms and
conditions mentioned in Para 5 f) & 5 i) and exclusions mentioned in Para 7.
Other Surgical Benefit shall be payable from day one of hospitalization but the minimum stay
in hospital should be atleast 24 hours.
No claim benefit:
A no claim benefit will be paid in the event that during the period between Date of
Commencement of policy and next Automatic Renewal Date or between two Automatic
Renewal Dates (described in para 5 a) below) there are no claims in respect of any Insured.
The amount of the no claim benefit would be equal to 5% (five percent) of the Initial Daily
Benefit in respect of each Insured and the resulting amount shall be added to arrive at the
Applicable Daily Benefit in respect of each Insured for the Policy Year next following the most
recent Automatic Renewal Date.
5. OTHER TERMS AND CONDITIONS:
a) Automatic Renewal Date:
The installment premium will be guaranteed in respect of each Insured for a period of 3
(three) years from the Date of Commencement of the policy, i.e. for the first 3 years of the
policy. Thereafter, at the end of every third policy anniversary, the premiums may be
reviewed to take into account the Corporation’s experience, subject to prior approval from
IRDA. These premium due dates, at the end of every third policy anniversary, starting from
the date of commencement of policy till the date of cover expiry, on which the installment
premiums are reviewable, will be referred as Automatic Renewal Dates in respect of all
Insured in the Policy.
The premium rates applicable on Automatic Renewal Date after every 3 years shall be
guaranteed for a further period of 3 years i.e. till next Automatic Renewal Date.
On any Automatic Renewal Date in the future, the installment premium will be based on - 9 -
the Insured’s age at entry into the policy i.e. age as on the date of commencement of
policy/ age at the time of inclusion into the policy, as the case may be and the
Corporation’s premium rates then prevailing for this product.
b) Removal of existing members:
In the event of death or divorce, an Insured may be removed from coverage upon request
by the Principal Insured in writing. This will be effective from the installment premium due
date coinciding with or next following the date of such a request. No further premiums are
due in respect of that Insured from such installment premium due date.
In any other circumstances, removal of an existing Insured will be permitted at the sole
discretion of the Corporation.
c) Hospital Cash Benefit:
In the event of Accidental Bodily Injury or Sickness first occurring or manifesting itself after
the date of commencement of cover in respect of that Insured and during the Cover Period
and causing an Insured’s Hospitalization to exceed a continuous period of 24 hours within
the Cover Period, then, subject to the terms and conditions, waiting period and exclusions
of the Policy, the Daily Benefit is payable by the Corporation as follows, regardless of the
actual costs incurred:
In case of Hospitalisation in the general or special ward (i.e. a nonIntensive Care Unit ward/room) of a Hospital:
The Applicable Daily Benefit in a Policy Year, for each continuous period of 24
hours or any part thereof (after having completed the 24 hours as above)
provided any such part stay exceeds a continuous period of 4 hours of
Hospitalization necessitated solely by reason of the said Accidental Bodily
Injury or Sickness, shall be payable.
In case of Hospitalisation in the Intensive Care Unit of a Hospital:
Two times the Applicable Daily Benefit reckoned under para 4 above for each
continuous period of 24 hours or part thereof (after having completed the 24
hours as above) provided any such part stay exceeds a continuous period of 4
hours of Hospitalization in the Intensive Care Unit of a Hospital during any
period of Hospitalization necessitated solely by reason of the said Accidental
Bodily Injury or Sickness shall be payable.
Combined stay in Non-ICU and ICU ward/room:
During one period of 24 continuous hours (i.e. one day) of Hospitalisation (after
having completed the 24 hours as above), if the said Hospitalisation included
stay in an Intensive Care Unit as well as in any other in-patient (non-Intensive
Care Unit) ward of the Hospital, the Corporation shall pay benefits as if the
admission was to the Intensive Care Unit provided that the period of
Hospitalisation in the Intensive Care Unit was at least 4 continuous hours.
No benefit will be payable for the first 24 hours of hospitalisation.
However, for every Hospitalization that extends for a continuous period of
7 days or more, the Hospital Cash Benefit would also be paid for the first
24 hours (day one) of hospitalization, regardless of whether the Insured
was admitted in a general or special ward or in an intensive care unit.
The amount of Daily Benefit due to Hospitalization as specified in the Policy
Schedule would be the Initial Daily Benefit amount. In the first Policy Year the
Initial Daily Benefit would be the Applicable Daily Benefit amount which will
be payable per day of each eligible hospitalized day. - 10 -
For each Policy Year commencing at a Policy anniversary on or after the first
anniversary, the Applicable Daily Benefit of the previous Policy Year shall be
increased by arithmetic addition of an amount equal to 5% (five percent) of the
Initial Daily Benefit. This shall be further enhanced if the policy attracts and is
eligible for “No Claim Benefit” (as defined in Para 4). And the resulting amount
shall be the Applicable Daily Benefit for that Policy Year.
Thus, the Applicable Daily Benefit for each policy year, after the first policy
year, shall consist of 2 parts:
− An arithmetic addition of an amount equal to 5% (five percent) of the
Initial Daily Benefit to the Applicable Daily Benefit of the previous Policy
Year. Such increase in the Applicable Daily Benefit shall be effected on
each Policy anniversary during the Cover Period and shall continue until it
attains a maximum amount of 1.5 times the Initial Daily Benefit
Thereafter, this amount in each Policy Year in future shall remain at that
maximum level attained.
− Further arithmetic addition of an amount equal to “No Claim Benefit”
provided the policy attracts and is eligible for it. There shall be no
maximum limit for such increase which means that if this policy is eligible
for “No Claim Benefit”, the same shall be granted throughout the Cover
Period without any maximum limit.
The amount of Daily Benefit in case of admission to the Intensive Care Unit
shall be two times the Applicable Daily Benefit.
For any addition of a member during the term of the policy, first policy year for
the purpose of this benefit shall start from the policy anniversary on which the
cover starts.
A no claim benefit is payable in the event that during the period between two
Automatic Renewal Dates there are no claims in respect of any Insured. The
amount of the no claim benefit would be equal to 5% (five percent) of the Initial
Daily Benefit in respect of each Insured and the resulting amount shall be
added for arriving at the amount of Applicable Daily Benefit in respect of each
Insured for that Policy Year. Such increase in the Applicable Daily Benefit shall
be effective from the next following Automatic Renewal Date.
Benefit Limits and Conditions:
i. The Hospital Cash Benefit shall be payable only if Hospitalisation has occurred
within India.
ii. The total number of days for which hospital cash benefit would be payable, in
respect of each Insured, in a Policy Year would be restricted to -
a. A maximum of 30 (thirty) days of Hospitalization out of which not more than
15 (fifteen) days shall be in an Intensive Care Unit in the first Policy Year
following the date of commencement of cover in respect of that Insured
b. A maximum of 90 (ninety) days of Hospitalization out of which not more
than 45 (forty five) days shall be in an Intensive Care Unit in the second
and subsequent Policy Years following the date of commencement of cover
in respect of that Insured.
iii. The total number of days of Hospitalization for which Hospital Cash Benefit is
payable during the Cover Period, in respect of each and every Insured covered
under the policy, shall be limited to a maximum of 720 (seven hundred and
twenty) days out of which not more than 360 (three hundred and sixty) days
shall be in an Intensive Care Unit. Upon attainment of this limit by an Insured, - 11 -
the Hospital Cash Benefit in respect of that Insured shall cease immediately.
iv. The Benefit Limits specified in the above clauses in respect of an Insured
under this Policy, shall solely and exclusively apply to that Insured. Any
unclaimed Hospital Cash Benefit of any one Insured is not transferable to any
other Insured.
v. The Hospital Cash Benefit shall not be payable in the event of an Insured
under this Policy undergoing any specified Day Care Procedure (as mentioned
in the Day Care Procedure Benefit Annexure).
d) Major Surgical Benefit:
In the event of an Insured under this Policy undergoing any specified Surgery (as
mentioned in the Major Surgical Benefit Annexure) in a Hospital due to Accidental Bodily
Injury or Sickness first occurring or manifesting itself after the date of commencement of
cover in respect of that Insured and during the Cover Period then, subject to the terms and
conditions, waiting period and exclusions of this Policy, a percentage (as mentioned in the
Major Surgical Benefit Annexure against the specified Surgery performed) of the Major
Surgical Benefit Sum Assured shall be payable by the Corporation, regardless of the
actual costs incurred.
In the event that a Major Surgical Benefit falling under Category 1 or Category 2 (as
mentioned in the Major Surgical Benefit Annexure) is payable and emergency
transportation costs by an ambulance have been incurred, an additional lump sum of `
1,000 will be payable in lieu of ambulance expenses.
In the event that a Major Surgical Benefit falling under Category 1 or Category 2 (as
mentioned in the Major Surgical Benefit Annexure) is payable in respect of any Insured,
the total annualized premium i.e. total one year premium in respect of that Policy from the
date of installment premium due coinciding with or next following the date of the Surgery
will be waived.
Benefit Limits and Conditions:
i. If more than one Surgery is performed on the Insured, through the same
incision or by making different incisions, during the same surgical session, the
Corporation shall only pay for that Surgery performed in respect of which the
largest amount shall become payable.
ii. The Major Surgical Benefit shall be paid as a lump sum as specified for the
benefit concerned and is subject to providing proof of Surgery to the
satisfaction of the Corporation.
iii. All Surgical Procedures claimed should be confirmed as essential and required,
by a qualified Physician or Surgeon, to the satisfaction of the Corporation.
iv. The Major Surgical Benefit will be payable only after the Corporation is satisfied
on the basis of medical evidence that the specified Surgery covered under the
Policy has been performed.
v. The Major Surgical Benefit shall be payable only if the Surgery has been
performed within India.
vi. The amount in lieu of ambulance expenses shall be payable only once in
respect of each Insured in any Policy Year and is subject to providing
satisfactory evidence to the Corporation.
vii. The total amount payable in respect of each Insured under the Major Surgical
Benefit in any Policy Year during the Cover Period shall not exceed 100% of
the Major Surgical Benefit Sum Assured in that Policy year.
viii. The total amount payable in respect of each Insured during the Cover Period
under the Major Surgical Benefit shall not exceed a maximum limit of 800% of
the Major Surgical Benefit Sum Assured. If the total amount paid in respect of - 12 -
an Insured equals this lifetime maximum limit, the Major Surgical Benefit in
respect of that Insured will cease immediately.
ix. The Benefit Limits specified in the above clauses in respect of an Insured
under this Policy, shall solely and exclusively apply to that Insured. Any
unclaimed Major Surgical Benefit of any one Insured is not transferable to any
other Insured.
x. The Major Surgical benefit for any surgery cannot be claimed and shall not be
payable more than once for the same surgery during the term of the policy.
e) Day Care Procedure Benefit:
In the event of an Insured under this Policy undergoing any specified Day Care Procedure
(as mentioned in the Day Care Procedure Benefit Annexure) in a Hospital due to
Accidental Bodily Injury or Sickness first occurring or manifesting itself after the date of
commencement of cover in respect of that Insured and during the Cover Period then,
subject to the terms and conditions, waiting period and exclusions of this Policy, an
amount equal to 5 (five) times the Applicable Daily Benefit, shall be payable by the
Corporation, regardless of the actual costs incurred.
Benefit Limits and Conditions:
i. If more than one Day Care Procedure is performed on the Insured, through the
same incision or by making different incisions, during the same surgical
session, the Corporation shall only pay for one Day Care Surgical Procedure.
ii. The Day Care Procedure Benefit shall be paid as a lump sum and is subject to
providing proof of Surgery to the satisfaction of the Corporation.
iii. All Surgical Procedures claimed should be confirmed as essential and required,
by a qualified Physician or Surgeon, to the satisfaction of the Corporation.
iv. The Day Care Procedure Benefit will be payable only after the Corporation is
satisfied on the basis of medical evidence that the specified Surgical Procedure
covered under the policy has been performed.
v. The Day Care Procedure Benefit shall be payable only if the Surgical
Procedure has been performed within India.
vi. In respect of each Insured, the Day Care Procedure Benefit will be payable
only up to a maximum of 3 (three) Surgical Procedures in any Policy Year
during the Cover Period.
vii. In respect of each Insured during the Cover Period, the Day Care Procedure
Benefit will be payable only up to a maximum of 24 (twenty four) Surgical
Procedures. If the number of Surgical Procedures eligible for the Day Care
Procedure Benefit in respect of an Insured equals this lifetime maximum limit,
the Day Care Procedure Benefit in respect of that Insured will cease
immediately.
viii. The Benefit Limits specified in the above clauses in respect of an Insured
under this Policy, shall solely and exclusively apply to that Insured. Any
unclaimed Day Care Procedure Benefit of any one Insured is not transferable
to any other Insured.
ix. If a Day Care Procedure Benefit is performed no Hospital Cash Benefit shall be
paid.
f) Other Surgical Benefit:
In the event of an Insured under this Policy undergoing any Surgery not listed under Major
Surgical Benefit or Day Care Procedure Benefit, in a Hospital due to Accidental Bodily
Injury or Sickness first occurring or manifesting itself after the date of commencement of
cover in respect of that Insured and during the Cover Period then, subject to the terms and
conditions, waiting period and exclusions of this Policy, a Daily Benefit equal to 2 (two)
times the Applicable Daily Benefit, shall be payable by the Corporation, regardless of the
actual costs incurred for each continuous period of 24 hours or part thereof provided any - 13 -
such part stay exceeds a continuous period of 4 hours of Hospitalization.
Benefit Limits and Conditions:
i. If more than one Surgical Procedure is performed on the Insured, through the
same incision or by making different incisions, during the same surgical
session, the Corporation shall only pay for one Surgical Procedure.
ii. The Other Surgical Benefit shall be paid as a Daily Benefit and is subject to
providing proof of Surgery to the satisfaction of the Corporation.
iii. All Surgical Procedures claimed should be confirmed as essential and required,
by a qualified Physician or Surgeon, to the satisfaction of the Corporation.
iv. The Other Surgical Benefit will be payable only after the Corporation is satisfied
on the basis of medical evidence that the specified Surgical Procedure covered
under the policy has been performed.
v. The Other Surgical Benefit shall be payable only if the Surgical Procedure has
been performed within India.
vi. The total number of days of Hospitalization for which the Other Surgical Benefit
is payable during a Policy Year in respect of each and every Insured covered
under the Policy shall not exceed 15 (fifteen) days in the first Policy Year
following the Date of Cover Commencement in respect of that Insured and 45
(forty five) days for the second and subsequent Policy Years following the Date
of Cover Commencement in respect of that Insured.
vii. The total number of days of Hospitalization for which the Other Surgical Benefit
is payable during the Cover Period, in respect of each and every Insured
covered under the Policy shall not exceed a maximum limit of 360 (three
hundred and sixty) days. Upon attainment of this lifetime maximum limit, the
Other Surgical Benefit in respect of that Insured will cease immediately.
viii. The Benefit Limits specified in the above clauses in respect of an Insured
under this Policy, shall solely and exclusively apply to that Insured. Any
unclaimed Other Surgical Benefit on any one Insured is not transferable to any
other Insured.
g) Commencement And Termination Of Benefit Covers:
The Hospital Cash Benefit, Major Surgical Benefit, Day Care Procedure Benefit and Other
Surgical Benefit cover in respect of each Insured shall commence on the Date of Cover
Commencement individually stated in the Policy Schedule.
The Hospital Cash Benefit, Major Surgical Benefit, Day Care Procedure Benefit and Other
Surgical Benefit cover in respect of each Insured shall terminate at the earliest of the
following:
i. The Date of Cover Expiry mentioned in the Policy Schedule;
ii. On attaining the lifetime maximum Benefit Limits as specified above;
iii. On death or Date of Cover Expiry of the Principal Insured and if the Policy
does not continue with the Insured Spouse as the Principal Insured;
iv. On death or Date of Cover Expiry of Insured Spouse after the Policy continues
with the Insured Spouse as the Principal Insured after the PI dies or reaches
his/her Date of Cover Expiry.
v. On death of the Insured;
vi. In respect of the Insured Spouse, on divorce or legal separation from the
Principal Insured;
vii. On termination of the Policy due to non-payment of premium or any other
reason.
h) Termination Of Policy:
A) If policy is issued on single life:
The policy shall terminate at the earliest of the following: - 14 -
i) Non-payment of premiums within the revival period described in Para 8;
ii) On death;
iii) On the Date of Cover Expiry mentioned in the Policy Schedule;
iv) On exhausting all the lifetime maximum Benefit Limits as specified above.
B) If policy is issued on more than one life:
The policy shall terminate at the earliest of the following:
i) Non-payment of premiums within the revival period;
ii) On PI exhausting all the lifetime maximum Benefit Limits as specified
above.
iii) On death or Date of Cover Expiry, of the Principal Insured and if the
Policy does not continue with the Insured Spouse as the Principal
Insured.
iv) On the death or Date of Cover Expiry, of Insured Spouse after the Policy
continues with the Insured Spouse as the Principal Insured after the PI
dies or reaches his/her Date of Cover Expiry.
i) Waiting Period:
General waiting period:
There shall be no general waiting period in case Hospitalization or Surgery is due to
Accidental Bodily Injury. There shall be a general waiting period during which no benefits
shall be payable in the event of Hospitalization or Surgery, if the said Hospitalization or
Surgery occurred due to Sickness.
i. The general waiting period shall be 90 (ninety) days from the Date of Cover
Commencement in respect of each Insured.
ii. If the policy is revived after discontinuance of the Cover then the following
shall apply in respect of each Insured:
a. If the request for revival is received by the Corporation within 90 (ninety)
days from the due date of the first unpaid premium, then there shall be a
general waiting period of 45 (forty five) days from the Date of Revival in
respect of each Insured.
b. If the request for revival is received by the Corporation beyond 90 (ninety)
days from the due date of the first unpaid premium, then there shall be a
general waiting period of 90 (ninety) days from the Date of Revival in
respect of each Insured.
Specific waiting period:
In addition, in respect of each Insured, no benefits are available hereunder and no
payment will be made by the Corporation for any claim under this Policy on account of
Hospitalization or Surgery directly or indirectly caused by, based on, arising out of or
howsoever attributable to any of the following during the specific waiting period:
i. Treatment for adenoid or tonsillar disorders
ii. Treatment for anal fistula or anal fissure
iii. Treatment for benign enlargement of prostate gland
iv. Treatment for benign uterine disorders like fibroids, uterine prolapse,
dysfunctional uterine bleeding etc
v. Treatment for Cataract
vi. Treatment for Gall stones
vii. Treatment for slip disc
viii. Treatment for Piles
ix. Treatment for benign thyroid disorders
x. Treatment for Hernia
xi. Treatment for hydrocele - 15 -
xii. Treatment for degenerative joint conditions
xiii. Treatment for sinus disorders
xiv. Treatment for kidney or urinary tract stones
xv. Treatment for varicose veins
xvi. Treatment for Carpal tunnel syndrome
xvii. Treatment for benign breast disorders e.g. fibroadenoma, fibrocystic disease
etc
The specific waiting period in respect of the treatments specified in the list above shall be
as follows:
i. The specific waiting period shall be 2 (two) years from the Date of Cover
Commencement in respect of each Insured.
ii. If the policy is revived after discontinuance of the Cover then the following
shall apply in respect of each Insured:
a. If the request for revival is received by the Corporation within 90 (ninety)
days from the due date of the first unpaid premium, then the specific waiting
period shall continue to be till 2 (two) years from the Date of Cover
Commencement in respect of each Insured.
b. If the request for revival is received by the Corporation beyond 90 (ninety)
days from the due date of the first unpaid premium, then there shall be a
specific waiting period of 2 (two) years from the Date of Revival in respect
of each Insured.
6. OPTIONS AVAILABLE UNDER THE PLAN:
(a) Plan changes: No alterations in the Plan (i.e. from one type of plan to another type) will
be allowed.
(b) Insured Spouse to become Principal Insured: In case of death or expiry of cover of
Principal Insured, the surviving Insured Spouse shall become the Principal Insured
provided the option is exercised at the time of filling up the proposal form and the policy
will continue. In such case, the premium for the Insured Spouse will change from the
coinciding or following installment premium due date and the new premium would be
based on tabular premium rates applicable for Principal Insureds and the age for
calculation of revised premium rate will be the age at entry of the spouse.
(c) Cover to new additional members: If the PI gets married/ remarried during the term of
the policy, the spouse and parents-in-law can be included in the policy within six months
from the date of marriage/ remarriage, but the Cover shall start from the policy anniversary
coinciding with or next following the date of inclusion. Enhanced premium shall be due
from such policy anniversary.
Any child born/legally adopted after taking the policy can be covered from the next
immediate policy anniversary date following the date on which the child completes the age
of 3 months. If the age of legally adopted child on the date of adoption is more than 3
months, the child can be covered from policy anniversary coinciding with or next following
the date of adoption. Enhanced premiums shall be due from such policy anniversary.
Inclusion of each additional member will be subject to receipt of the proof of the event and
fulfillment of underwriting conditions. The eligibility conditions, as mentioned in Para 3,
waiting period and exclusions will apply for the new Insured.
Addition in any other case will not be allowed. The existing spouse, parents, parents-in-law
and children, if not covered at the time of taking policy, shall not be covered under the - 16 -
policy.
If both of the parents (father and mother) are alive and are eligible for cover, then either
both of them will have to be covered or none of them will be covered. The PI will not have
any option to choose one of them. The same condition will apply for parents-in-law also.
Any addition of new lives shall be allowed by the PI only. After the death of PI, no addition
will be allowed.
(d) Quick Cash facility: If any of the insured lives undergoes any eligible surgery covered
under Category I or II of MSB in any of the listed network hospitals, the PI will have an
option to avail Quick Cash facility. Under this facility, 50% of eligible MSB amount would
be made available even during the period of hospitalization of any of the insured lives
covered (the surgery may be either planned or emergency due to accident) instead of
waiting for making a claim for the benefit after discharge. It will be only an advance
payment to the PI in the event of hospitalization for any MSB defined in the surgeries listed
under categories I & II and permissible under the policy conditions of the plan. This will be,
however, subject to approval from the TPA (Third Party Administrator), and the advance
amount will be adjusted from the final settlement of MSB claim amount.
This facility of advance payment could be availed by submitting the Bank Account details
of the PI in the prescribed format. The amount of advance shall be credited in the PI’s
bank account directly.
(e) Accident Benefit Rider: For PI and Insured Spouse, Accident Benefit Rider will be
available under the plan by payment of additional premium of ` 0.50 for every ` 1,000/- of
the Accident Benefit Sum Assured per policy year in respect of each life to be covered. In
case of accidental death, the Accident Benefit Sum Assured will be payable as lump sum
along with the Term Assurance Sum Assured, if Term Assurance Rider is opted for.
The maximum aggregate limit of assurance under all policies of the Corporation and that
of all insurers under individual as well as group policies on the same life to which the
benefits apply shall not exceed ` 50 lakh.
The additional premium for this benefit will not be required to be paid on and after the
Policy anniversary on which the age nearer birthday of the Insured is 60 years.
(f) Term Assurance Rider: For PI and Insured Spouse, Term Assurance as optional rider
will be available under this plan. The premiums for this option are payable along with
premium under the basic plan and an amount equal to Term Assurance Sum Assured will
be payable on death during the term for which Term Assurance Rider is opted for. The
maximum cover for this rider will be ` 25 lakhs under all policies of the life assured with the
Corporation taken together.
The tabular premium rates per annum for Term Rider benefit are given in the Annexure –
III. Also the rates of Class I extra premium per annum are given in the Annexure – IV.
7. EXCLUSIONS: - 17 -
No benefits are available hereunder and no payment will be made by the Corporation for any
claim under this policy on account of hospitalization or surgery directly or indirectly caused by,
based on, arising out of or howsoever attributable to any of the following:
i. Any Pre-existing Condition unless disclosed to and accepted by the Corporation
prior to the Date of Cover Commencement or the Date of Revival (if the Policy is
revived after discontinuance of the Cover).
ii. Any treatment or Surgery not performed by a Physician/Surgeon or any treatment
including Surgery of a purely experimental nature.
iii. Any routine or prescribed medical check up or examination.
iv. Medical Expenses relating to any treatment primarily for diagnostic, X-ray or
laboratory examinations.
v. Any Sickness that has been classified as an Epidemic by the Central or State
Government.
vi. Circumcision, cosmetic or aesthetic treatments of any description change of
gender surgery, plastic surgery (unless such plastic surgery is necessary for the
treatment of Illness or accidental Bodily Injury as a direct result of the insured
event and performed within 6 months of the same).
vii. Hospitalisation or Surgery for donation of an organ.
viii. Treatment for correction of birth defects or congenital anomalies.
ix. Dental treatment or surgery of any kind unless necessitated by Accidental Bodily
Injury.
x. Convalescence, general debility, nervous or other breakdown, rest cure,
congenital diseases or defect or anomaly, sterilisation or infertility (diagnosis and
treatment), any sanatoriums, spa or rest cures or long term care or hospitalization
undertaken as a preventive or recuperative measure.
xi. Self afflicted injuries or conditions (attempted suicide), and/or the use or misuse of
any drugs or alcohol.
xii. Any sexually transmitted diseases or any condition directly or indirectly caused to
or associated with Human Immuno Deficiency (HIV) Virus or any Syndrome or
condition of a similar kind commonly referred to as AIDS.
xiii. Removal or correction or replacement of any material that was implanted in a
former surgery before Date of Cover commencement or Date of Revival (if the
Policy is revived after discontinuance of the Cover).
xiv. Any diagnosis or treatment or surgery arising from or traceable to pregnancy
(whether uterine or extra uterine), childbirth including caesarean section, medical
termination of pregnancy and/or any treatment related to pre and post natal care
of the mother or the new born.
xv. Hospitalisation for the sole purpose of physiotherapy or any ailment for which
hospitalization is not warranted due to advancement in medical technology.
xvi. War, invasion, act of foreign enemy, hostilities (whether war be declared or not),
civil war, rebellion, revolution, insurrection military or usurped power of civil
commotion or loot or pillage in connection herewith.
xvii. Naval or military operations(including duties of peace time) of the armed forces or
air force and participation in operations requiring the use of arms or which are
ordered by military authorities for combating terrorists, rebels and the like.
xviii. Any natural peril (including but not limited to avalanche, earthquake, volcanic
eruptions or any kind of natural hazard).
xix. Participation in any hazardous activity or sports including but not limited to racing,
scuba diving, aerial sports, bungee jumping and mountaineering or in any criminal
or illegal activities.
xx. Radioactive contamination.
xxi. Non-allopathic methods of treatment or surgery.
xxii. Participation in any criminal or illegal activities.
xxiii. Treatment arising from the Insured’s failure to act on proper medical advice - 18 -
8. DISCONTINUANCE OF PREMIUMS:
If premiums have not been paid within the days of grace under the Policy, the Policy will lapse
and no benefits will be payable thereafter. The Principal Insured shall have an option to revive
the policy at anytime within a period of 2 (two) years from the due date of first unpaid premium
subject to conditions in clause 8 below.
9. REVIVALS/REINSTATEMENT OF DISCONTINUED POLICIES:
The Policy can be revived by the Principal Insured anytime during a period of 2 (two) years
from the due date of first unpaid premium called the “period of revival” or “revival period”.
The revival will be subject to payment of outstanding premiums with interest, underwriting and
may be on terms different from those offered earlier. Waiting periods and Exclusions as
described earlier will apply on revival. The Principal Insured may need to provide satisfactory
evidence of good health in respect of each Insured as required by the Corporation, at his own
expense. The Date of Revival will be when all requirements for revival/reinstatement are met
and approved by the Corporation at its sole discretion.
No benefit will be paid for an event that occurred during the lapse period till the Date of
Revival when the Policy was in a discontinued state.
Further, if the Automatic Renewal Date falls between the revival period and revival is done
after the Automatic Renewal Date, the premium before and after the Automatic Renewal Date
may be different.
Revival/reinstatement will not be allowed post the revival period.
10. SURRENDER:
No surrender value will be available under the policy.
11. MODES OF PREMIUM PAYMENT:
Premiums can be paid regularly either in yearly or half yearly or monthly (through ECS only)
installments.
12. REBATES:
Mode Rebates:
Rebates are available at the following rates:
Yearly mode : 2% of Tabular Premium
Half-yearly mode : 1% of the tabular premium
HCB Rebates:
In respect of a member covered under a policy, if HCB is more than ` 1000, then the
premium arrived at in respect of that member shall be reduced by an amount (`) given
below:
HCB (`) For PI For each insured
member other than PI
2000 500 250
3000 1000 500
4000 1500 750
CEIS Rebate:- 19 -
The rebate for eligible employees of the Corporation shall be 10% of the tabular
premium provided the proposal is submitted directly and not through any Agent/
Corporate Agent/ Broker.
13. COMMISSION PAYABLE TO AGENTS/ CORPORATE AGENTS/ BROKERS &
DEVELOPMENT OFFICER’S CREDIT:
Agents & Corporate Agents:
1
st Year 2nd & 3rd year Subsequent Years
25.0% 7.5% 5.0%
Bonus Commission: 40% of 1st year's commission is payable in the first year.
Brokers
1
st Year Subsequent Years
30% 5%
Development Officer’s credit: 100% of FY premium
14. LOANS:
No loan shall be granted under this plan.
15. UNDERWRITING:
Instructions will be issued separately by Underwriting and Reinsurance Department.
16. DAYS OF GRACE:
A grace period of one calendar month but not less than 30 days will be allowed for payment of
yearly or half-yearly premiums and 15 days will be allowed if premiums are payable monthly
(ECS). If the due premiums are not paid within the days of grace the policy will lapse. The
provisions of para 8 (i.e. Discontinuance of Premiums) of this circular shall be applicable in
that case.
17. COOLING-OFF PERIOD:
If a policyholder is not satisfied with the “Terms and Conditions” of the policy, he/she may
return the policy to the Corporation within 15 days from the date of receipt of the policy. This
period will be termed as Cooling-Off Period.
In case the policy is returned during the cooling-off period, Commission shall be recovered
from the concerned Agent and the Development Officer’s credit allowed shall be withdrawn.
The refund of premium to the policyholder shall be net of mortality charges and morbidity
charges. The mortality charges will be calculated as per CO Circular 1819/4 dated
23/08/2004. The morbidity charges deductible are given in Annexure V.
The mortality and morbidity charges will be deductible for proportionate number of days
subject to a minimum for one month.
18. BACK DATING:
Back dating of policy will not be allowed.
19. POLICY STAMPING: - 20 -
Policy Stamping will be at the rate of `.0.20 per thousand of total Major Surgical Benefit Sum
Assured (i.e. sum of Major Surgical Benefit Sum Assured in respect of all the members
insured (including PI) at inception.
Any addition of member thereafter shall be by way of endorsement for which stamping shall
be done additionally.
Further, the policy stamping for Term Rider Sum Assured will be at the rate of ` 0.20 per
thousand sum assured.
20. ASSIGNMENTS / NOMINATION:
No Assignment will be allowed under this plan.
Notice for Nomination or change of Nominations should be submitted for registration to the
office of the Corporation, where this policy is serviced. In registering a nomination, the
Corporation does not accept any responsibility or express any opinion as to its validity or legal
effect.
21. NORMAL REQUIREMENTS FOR CLAIM:
Regarding claims, the instructions shall be issued by Health Insurance Department, Central
Office, separately.
22. REINSURANCE:
A separate treaty has been arranged for this plan. Our retention limits are as below:
Hospital Cash Benefit:
` 500 Daily Hospital Cash Benefit
Major Surgical Benefit:
` 50,000 Major Surgical Benefit Sum Assured
Day Care Procedure Benefit:
` 2,500 Day Care Procedure Benefit
Other Surgical Benefit:
` 1,000 per day benefit
Risks over and above the above retention limits shall be shared equally between LIC (i.e.
50%) and reinsurers (50%).
23. PROPOSAL FORM:
The specimen Proposal form is annexed (Annexure VI).
24. POLICY DOCUMENT:
The specimen Policy document will be sent by the Corporate Communications Department,
Central Office.
CHIEF (PRODUCT DEVELOPMENT)
Enclosures – Annexure I, II, III, IV, V and VI
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