This is a legal contract between the Policyholder and Aditya Birla Health Insurance subject to the receipt of full premium, Disclosure to information norm including the information provided by the Policyholder in the Proposal Form and the terms, conditions and exclusions of this Policy.
If any claim arising as a result of an Injury or Illness that occurs during the Policy Period becomes payable, then the insurer shall pay the Benefits specified in accordance with the terms, conditions and exclusions of the Policy.
| Criteria | Requirement |
|---|---|
| Minimum Entry Age | 1 day |
| Maximum Entry Age | No Limit |
| Minimum Group Size | 7 Employees/members |
The following relationships can be covered as dependants:
Important Note: Partner shall be taken as declared at the time of Start Date and no change in the same would be accepted during a Policy Period. However, an Insured Person may request for change at the time of Renewal of the cover.
The customer must declare that they are not suffering from or been diagnosed with, advised taken treatment or observation is suggested or undergone any investigation or consulted a doctor or undergone or advised surgery for any one or more from the following conditions:
The Benefits listed below shall be available to all Insured Persons as specified in the Policy Schedule or Certificate of Insurance. The insurer will indemnify the Reasonable and Customary Charges incurred towards Necessary Medical Treatment taken by the Insured Person during the Policy Period for an Illness, Injury or the conditions described in the Benefits below if it is contracted or sustained by an Insured Person during the Policy Period.
Benefits under this Section are subject to the terms, conditions and exclusions of this Policy and the availability of the Sum Insured and subject always to any sub-limits for the Benefit as specified in the Policy Schedule or Certificate of Insurance.
All claims must be made in accordance with the procedure set out in the claims section.
The insurer will provide a Hospital Cash Benefit specified in the Policy Schedule or Certificate of Insurance for each continuous and completed period of 24 hours of Hospitalisation of the Insured Person during the Policy Period for treatment of an Illness or Injury provided that:
The insurer will cover the Reasonable and Customary Charges incurred for medically required consultations, visit(s) to a doctor, diagnostic tests and pharmacy expenses which are incurred on an out-patient basis up to the limits as specified in the Policy Schedule or Certificate of Insurance. Alternative Treatments shall also be covered under this Benefit.
The insurer shall not be liable to make any payment for any claim under any Benefit in respect of any Insured Person directly or indirectly caused by, based on, arising out of, relating to or howsoever attributable to any of the following:
Expenses related to any admission primarily for enforced bed rest and not for receiving treatment. This also includes:
Expenses related to the surgical treatment of obesity that does not fulfil all the below conditions:
Expenses related to any treatment, including surgical management, to change characteristics of the body to those of the opposite sex.
Expenses for cosmetic or plastic surgery or any treatment to change appearance unless for reconstruction following an Accident, Burn(s) or Cancer or as part of medically necessary treatment to remove a direct and immediate health risk to the insured. For this to be considered a medical necessity, it must be certified by the attending Medical Practitioner.
Expenses related to any treatment necessitated due to participation as a professional in hazardous or adventure sports, including but not limited to, para-jumping, rock climbing, mountaineering, rafting, motor racing, horse racing or scuba diving, hand gliding, sky diving, deep-sea diving.
Expenses for treatment directly arising from or consequent upon any Insured Person committing or attempting to commit a breach of law with criminal intent.
Expenses incurred towards treatment in any hospital or by any Medical Practitioner or any other provider specifically excluded by the Insurer as per Annexure VII and as disclosed in website (www.adityabirlahealth.com/healthinsurance) / notified to the policyholders are not admissible. However, in case of life threatening situations or following an accident, expenses up to the stage of stabilization are payable but not the complete claim.
Treatment for Alcoholism, drug or substance abuse or any addictive condition and consequences thereof.
Treatments received in heath hydros, nature cure clinics, spas or similar establishments or private beds registered as a nursing home attached to such establishments or where admission is arranged wholly or partly for domestic reasons.
Dietary supplements and substances that can be purchased without prescription, including but not limited to Vitamins, minerals and organic substances unless prescribed by a medical practitioner as part of hospitalization claim or day care procedure.
Expenses related to the treatment for correction of eye sight due to refractive error less than 7.5 dioptres.
Expenses related to any unproven treatment, services and supplies for or in connection with any treatment. Unproven treatments are treatments, procedures or supplies that lack significant medical documentation to support their effectiveness.
Expenses related to sterility and infertility. This includes:
Treatment directly or indirectly arising from or consequent upon war or any act of war, invasion, act of foreign enemy, war like operations (whether war be declared or not or caused during service in the armed forces of any country), civil war, public defense, rebellion, uprising, revolution, insurrection, military or usurped acts, nuclear weapons/materials, chemical and biological weapons, ionizing radiation, contamination by radioactive material or radiation of any kind, nuclear fuel, nuclear waste.
Convalescence (except as per the coverage as coverage defined in Section III.B.22 - Recovery Benefit), cure, rest cure, sanatorium treatment, rehabilitation measures, private duty nursing.
Admission for nutritional and electrolyte supplements unless certified to be required by the attending Medical Practitioner as a direct consequence of an otherwise covered claim.
In respect of the existing diseases, disclosed by the insured and mentioned in the Policy Schedule (based on insured's consent), policyholder is not entitled to get the coverage for specified ICD codes.
The policy shall be void and all premium paid thereon shall be forfeited to the Company in the event of misrepresentation, mis description or non-disclosure of any material fact by the policyholder.
The terms and conditions of the policy must be fulfilled by the insured person for the Company to make any payment for claim(s) arising under the policy.
Any payment to the policyholder, insured person or his/her nominees or his/her legal representative or assignee or to the Hospital, as the case may be, for any benefit under the policy shall be a valid discharge towards payment of claim by the Company to the extent of that amount for the particular claim.
If any claim made by the insured person, is in any respect fraudulent, or if any false statement, or declaration is made or used in support thereof, or if any fraudulent means or devices are used by the insured person or anyone acting on his/her behalf to obtain any benefit under this policy, all benefits under this policy and the premium paid shall be forfeited.
Any amount already paid against claims made under this policy but which are found fraudulent later shall be repaid by all recipient(s)/policyholder(s), who has made that particular claim, who shall be jointly and severally liable for such repayment to the insurer.
For the purpose of this clause, the expression "fraud" means any of the following acts committed by the insured person or by his agent or the hospital/doctor/any other party acting on behalf of the insured person, with intent to deceive the insurer or to induce the insurer to issue an insurance policy:
The Company shall not repudiate the claim and/or forfeit the policy benefits on the ground of Fraud, if the insured person/beneficiary can prove that the misstatement was true to the best of his knowledge and there was no deliberate intention to suppress the fact or that such misstatement of or suppression of material fact are within the knowledge of the insurer.
The policyholder may cancel this policy by giving 15 days written notice and in such an event, the Company shall refund premium for the unexpired policy period as detailed below.
Notwithstanding anything contained herein or otherwise, no refunds of premium shall be made in respect of Cancellation where, any claim has been admitted or has been lodged or any benefit has been availed by the insured person under the policy.
| Period for which risk is retained | Refund |
|---|---|
| Less than 1 Month | 75% |
| 1 Month - less than 3 Month | 50% |
| 3 Months - less than 6 months | 25% |
| Beyond 6 Months | Nil |
The Company may cancel the policy at any time on grounds of misrepresentation non-disclosure of material facts, fraud by the insured person by giving 15 days' written notice. There would be no refund of premium on cancellation on grounds of misrepresentation, non-disclosure of material facts or fraud.
The cancellation of Policy however is not applicable for Section III.A.8 "Sub-Limit for Specified Illness/conditions" and Section III.A.4 "Chronic Management Program".
The insured person will have the option to migrate the policy to other health insurance products/plans offered by the company by applying for migration of the policy atleast 30 days before the policy renewal date as per IRDAI guidelines on Migration. If such person is presently covered and has been continuously covered without any lapses under any health insurance product plan offered by the company, the insured person will get the accrued continuity benefits in waiting periods as per IRDAI guidelines on migration.
For Detailed Guidelines on migration, kindly refer the link: https://www.adityabirlacapital.com/healthinsurance/#!/homepage
After completion of eight continuous years under the Policy, no look back to be applied. This period of eight years is called as 'Moratorium Period'. The moratorium would be applicable for the Sums Insured of the first Policy with the insurer and subsequently completion of eight continuous years would be applicable from date of enhancement of Sum Insured only on the enhanced limits. After the expiry of Moratorium Period, no health insurance claim shall be contestable except for proven fraud and permanent exclusions specified in the Policy contract. The Policy would however be subject to all limits, sub limits, co-payments, deductible as per the Policy contract.
If the insured person has opted for Payment of Premium on an instalment basis i.e. Half Yearly, Quarterly or Monthly, as mentioned in the policy Schedule/Certificate of Insurance, the following Conditions shall apply:
The Company, with prior approval of IRDAI, may revise or modify the terms of the policy including the premium rates. The insured person shall be notified three months before the changes are effected.
In case of a grievance, the Insured Person/Policyholder can contact the insurer with the details through:
Contact Information:
Insured person may also approach the grievance cell at any of the company's branches with the details of grievance.
If Insured person is not satisfied with the redressal of grievance through one of the above methods, insured person may contact the grievance officer at the link: https://www.adityabirlacapital.com/healthinsurance/#!/homepage
For Senior Citizens: Please contact the respective branch office of the Company or call or may write an e-mail at [email protected].
If Insured person is not satisfied with the redressal of grievance through above methods, the insured person may also approach the office of Insurance Ombudsman of the respective area/region for redressal of grievance as per Insurance Ombudsman Rules 2017. The contact details of the Ombudsman offices are provided on the website and in this Policy at Annexure VI.
Grievance may also be lodged at IRDAI Integrated Grievance Management System: https://igms.irda.gov.in/
The policyholder is required at the inception of the policy to make a nomination for the purpose of payment of claims under the policy in the event of death of the policyholder. Any change of nomination shall be communicated to the company in writing and such change shall be effective only when an endorsement on the policy is made. In the event of death of the policyholder, the Company will pay the nominee (as named in the Policy Schedule/Policy Certificate/Endorsement if any) and in case there is no subsisting nominee, to the legal heirs or legal representatives of the policyholder whose discharge shall be treated as full and final discharge of its liability under the policy.
Explanation: "Bank rate" shall mean the rate fixed by the Reserve Bank of India (RBI) at the beginning of the financial year in which claim has fallen due.
Material information to be disclosed includes every matter that the Policyholder/Insured Person is aware of, or could reasonably be expected to know, that relates to questions in the Proposal Form and which is relevant to the insurer in order to accept the risk of insurance. The Policyholder/Insured Person must exercise the same duty to disclose those matters before the Renewal, extension, variation, endorsement of the contract. The Policy terms and conditions will not be altered.
This Policy constitutes the complete contract of insurance. No change or alteration will be effective or valid unless approved in writing which will be evidenced by a written endorsement, signed and stamped by the insurer.
Any knowledge or information of any circumstance or condition in relation to the Policyholder/Insured Person which is in the insurer's possession and not specifically informed by the Policyholder/Insured Person shall not be held to bind or prejudicially affect the insurer notwithstanding subsequent acceptance of any premium.
The Policy may be Renewed by mutual consent and in such event the Renewal premium should be paid to the insurer on or before the date of expiry of the Policy and in no case later than the Grace Period of 30 days from the expiry of the Policy. The insurer will not be liable to pay for any claim arising out of an Illness/Injury/Accident that occurred during the Grace Period. The provisions of Section 64VB of the Insurance Act 1938 shall be applicable. All policies Renewed within the Grace Period shall be eligible for continuity of cover.
The Policy may be renewed by mutual consent and in such event the Renewal premium should be paid to the insurer on or before the date of expiry of the Policy and in no case later than the Grace Period of 30 days from the expiry of the Policy.
Renewals will not be denied except on grounds of misrepresentation, moral hazard, fraud, non-disclosure of material facts or non-co-operation by the Insured Person.
Upon the Insured Person ceasing to be an Employee/member of the Policyholder or the insurer discontinuing/withdrawing this product, such Insured Person shall have the option to migrate to an approved retail health insurance policy available with the insurer.
Any communication or notice or instruction under this Policy shall be in writing and will be sent to:
The premium for each Policy will be determined based on the available data of each group and applicable discounts and loadings. Payment of premiums will be available in single mode or instalment options of monthly/quarterly/half yearly as agreed with the Policyholder.
Any special provisions subject to which this Policy has been entered into and endorsed in the Policy or in any separate instrument shall be deemed to be part of this Policy and shall have effect accordingly.
The Policyholder agrees to comply with all the terms and conditions of electronic transactions as the insurer shall prescribe from time to time, and confirms that all transactions effected facilities for conducting remote transactions such as the internet, World Wide Web, electronic data interchange, call centres, tele-service operations (whether voice, video, data or combination thereof) or by means of electronic, computer, automated machines network or through other means of telecommunication, in respect of this Policy and claim related details, shall constitute legally binding when done in compliance with the insurer's terms for such facilities.
Sales through such electronic transactions shall ensure that all conditions of Section 41 of the Insurance Act, 1938 prescribed for the proposal form and all necessary disclosures on terms and conditions and exclusions are made known to the Policyholder. A voice recording in case of tele-sales or other evidence for sales through the World Wide Web shall be maintained and such consent will be subsequently validated/confirmed by the Policyholder.
Any dispute concerning the interpretation of the terms, conditions, limitations and/or exclusions contained herein shall be governed by Indian law and shall be subject to the jurisdiction of the Indian Courts.
The policyholder shall keep an accurate record containing all relevant medical records and shall allow the insurer or their representative(s) to inspect such records. The policyholder or the Insured Person as the case may be, shall furnish such information as may be required by the insurer under this Policy at any time during the Policy Period and up to three years after the Policy expiration, or until final adjustment (if any) and resolution of all claims under this Policy.
An Insured Person may assign the Benefits or any specific Benefit(s) under the Policy by giving written notice of the assignment and the terms and conditions of the assignment to the insurer. The insurer will record the assignment in accordance with Section 38 of the Insurance Act 1938.
The fulfillment of the terms and conditions of this Policy (including payment of premium in full and on time) insofar as they relate to anything to be done or complied with by the policyholder or any Insured Person, including complying with the following in relation to claims, shall be Conditions Precedent to admission of the insurer's liability under this Policy:
The insurer/TPA must be contacted to pre-authorise Cashless Facility for planned treatment at least 72 hours prior to the proposed treatment. Each request for pre-authorisation must be accompanied with all the following details:
Required Information:
Processing:
The insurer or the associated TPA must be contacted to pre-authorise Cashless Facility within 24 hours of the Insured Person's Hospitalization if the Insured Person has been Hospitalized in an Emergency. Each request for pre-authorisation must be accompanied with all the following details:
Required Information:
Processing:
For all claims for which Cashless Facilities have not been pre-authorised or for which treatment has not been taken at a Network Provider, the insurer shall be given written notice of the claim along with the following details within 48 hours of admission to the Hospital or before discharge from the Hospital, whichever is earlier:
Required Information:
Delay Notification: If the claim is not notified to the insurer within the earlier of 48 hours of the Insured Person's admission to the Hospital or before the Insured Person's discharge from the Hospital, then the insurer shall be provided the reasons for the delay in writing. The insurer will condone such delay on merits where the delay has been proved to be for reasons beyond the claimant's control.
The insurer or the associated TPA shall be provided the following necessary information and documentation in respect of all claims at the Insured Person's expense within 30 days of the Insured Person's discharge from the Hospital:
For those claims for which the use of Cashless Facility has been authorised, the insurer will be provided these documents by the Network Provider immediately following the Insured Person's discharge from the Hospital:
Required Documents:
Where these details are not provided in full or are insufficient for the insurer to consider the request, they will request additional information or documentation in respect of that request.
At the insurer's discretion, they may investigate claims to determine the validity of a claim. This investigation will be conducted within 15 days of the date of assigning the claim for investigation and not later than 6 months from the date of receipt of claim intimation. All costs of investigation will be borne by the insurer and all investigations will be carried out by those individuals/entities that are authorised by the insurer in writing
If there are any deficiencies in the necessary claim documents which are not met or are partially met, the insurer will send a maximum of 3 (three) reminders following which they will send a rejection letter or make a part-payment if they have not received the deficiency documents after 45 days from the date of the initial request for such documents
The insurer may decide to deduct the amount of claim for which deficiency is intimated to the Insured Person and settle the claim if they observe that such a claim is otherwise valid under the Policy. However documents/details received beyond such period shall be considered if there are valid reasons for any delay
Payment for reimbursement claims will be made to the Insured Person. In the unfortunate event of the Insured Person's death, the insurer will pay the nominee named in the Policy Schedule or Certificate of Insurance, or to the Insured Person's legal heirs or legal representatives holding a valid succession certificate
For Assistance: For details on the claims process or assistance during the process, the claimant may contact the insurer at their call centre on the toll free number specified in the Policy Schedule or Certificate of Insurance or through their website. In addition, the insurer will keep the claimant informed of the claim status and explain requirement of documents. Such means of communication shall include but not be limited to mediums such as letters, email, SMS messages, and information on the website.
Aditya Birla Health Insurance Co. Limited