Name of Insurance Product /Policy

Shri Health Suraksha Insurance Policy

Policy number

Type of Insurance Product / Policy

Indemnity Based

Coverage-4

Sum Insured (Basis) (Along with amount)

Individual as well as Family floater Basis Sum insured - 50,000 to 10 lacs

Policy Coverage (What the policy covers?) (Policy Clause Number/s)

Hospitalization -Medical Expense incurred for Clause – 4 .1 Hospitalization of the Insured Person during the Policy year, up to the Sum Insured and Cumulative Bonus specified will be covered. in this Policy.

Other Expenses –Expenses incurred on treatment of cataract subject to the sub limits.

• Dental treatment, necessitated due to an injury.
• Plastic surgery necessitated due to injury.
• All day care treatment
• Expenses incurred for road ambulance subject to a maximum of 2000/- per hospitalization

AYUSH Treatment –The Company shall indemnify Medical Expenses incurred for Inpatient Care treatment under Ayurveda, Yoga and Naturopathy, Unani, Sidha and Homeopathy systems of medicines during the each policy year upto the limit of sum insured as specified in the policy schedule in any AYUSH hospital.

Cataract Treatment –The Company shall indemnify Medical Expenses incurred for treatment of Cataract, subject to a limit of 25% of Sum Insured or Rs.40,000/-, whichever is lower, per eye, under one policy year.

Pre-Hospitalization –The Company shall indemnify Pre-Hospitalization Medical Expenses incurred, related to an admissible Hospitalization requiring Inpatient Care, for a fixed period of 30 days prior to the date of admissible Hospitalization covered under the Policy.

Modern Treatment –Following procedure will be covered (wherever medically indicate) either as in patient or as part of the day care treatment in a hospital up to 50% of sum insured, specified the schedule, during the policy period.

• a. Uterine Artery Embolization and HIFU (High Intensity Focused Ultrasound)
• b. Balloon Sinuplasty
• c. Deep Brain Stimulation
• d. Oral Chemotherapy
• e. Immunotherapy – (Monoclonal Antibody to be given as injection)
• f. Intravitreal Injection
• g. Robotic Surgeries
• h. Stereotactic radio surgeries.
• i. Bronchial thermoplasty
• j. Vaporization of Prostate (Green laser treatment or holmium laser treatment)
• k. IONM- (Intra Operative Neuro Monitoring)
• l. Stem Cell Therapy: Hematopoietic stem cell for bone marrow transplant for hematological conditions to

Cumulative Bonus (CB) –5% increase in base sum insured Clause – 5 per claim free policy Year max. up to 50% of base Sum Insured

Optional Cover – Value Pack Add-on Cover –The Covers listed below shall be available to the Insured Person only if the additional premium has been received by Us.

• 1. Basic Plan

  • - Sickness Daily Hospital Cash benefitthe Company will pay to the Insured Person, Daily Hospital Cash amount mentioned in the schedule for each consecutive 24 hours of hospitalization subject to maximum number of days stated in the Schedule. Deductible – 1 day
  • - Accident Hospital Cash Benefit the Company will pay to the Insured Person, 2 times of Daily Hospital Cash amount mentioned in the schedule for each consecutive 24 hours of hospitalization subject to maximum number of days stated in the Schedule. Deductible – No
  • - Intensive Care Unit (ICU) Benefit The Company will pay 2.5 times of the Daily Hospital Cash amount for each consecutive 24 hours that the Insured Person is admitted in an Intensive Care Unit, subject to maximum of 15 days per Policy Year. Deductible - 1- day deductible is applicable on every hospitalization except accidental hospitalization.

• 2. Advance Plan

  • - Convalescence BenefitIf the Insured Person is Hospitalized in India during the Policy Period for Medically Necessary treatment of an Illness Or an Injury that occurred during the Policy Period and the continuation of such Hospitalization is Medically Necessary for at least 15 consecutive days, then will pay a lump sum amount equal to 5 times of the Daily Cash Benefit amount specified in the Policy Schedule.
  • - Child Birth Hospital CashDuring the period stated in the Schedule the insured person shall, upon the advice of a duly Qualified Medical Practitioner, require admission of the Insured Person as an In-patient in any Hospital in India for the purpose of Child Delivery, then the Company will pay to the insured person Daily Hospital Cash amount stated in the schedule subject to maximum number of days stated in the schedule.
  • - Compassionate BenefitIf the Insured Person is Hospitalized during the Policy Period for Medically Necessary treatment of an Injury due to an Accident that occurred during the Policy Period and the Insured Person dies during the course of such Hospitalization, We will pay the Nominee a lump sum amount equal to 10 times of the Daily Hospital Cash Benefit amount specified in the Policy Schedule. This benefit is payable in addition to basic plan only if there is an admissible claim under same.

Clause 8 Part E – Coverage

Exclusions (what the policy does not cover)

We shall not be liable to make any payment under this Policy directly or indirectly caused by, based on, arising out of or howsoever attributable to any of the following waiting periods. All the waiting periods shall be applicable individually for each Insured Person Exclusions (what the policy does not cover) and claims shall be assessed accordingly.

General Exclusion [Applicable for Basic Plan and Advance Plan]

The Company shall not be liable for Hospital Cash Amount under this policy if the hospitalization is directly or indirectly for

• 1. Investigation & Evaluation (Code – Excl 04)

  • Expenses related to any admission primarily for diagnostics and evaluation purposes only are excluded;
  • Any diagnostic expenses which are not related or not incidental to the current diagnosis and treatment are excluded.

  2. Rest Cure, rehabilitation and respite care- (Code- Excl 05)

  a. Expenses related to any admission primarily for enforced bed rest and not for receiving treatment. This also includes:

  • i. Custodial care either at home or in a nursing facility for personal care such as help with activities of daily living such as bathing, dressing, moving around either by skilled nurses or assistant or non-skilled persons.
  • ii. Any services for people who are terminally ill to address physical, social, emotional and spiritual needs

  3. Obesity/ Weight Control (Code- Excl 06)

  Expenses related to the surgical treatment of obesity that does not fulfil all the below conditions:

  • 1. Surgery to be conducted is upon the advice of the Docto
  • 2. The surgery/Procedure conducted should be supported by clinical protocols
  • 3. The member has to be 18 years of age or older and
  • 4. Body Mass Index (BMI);
  • a. greater than or equal to 40 or

  • b. greater than or equal to 35 in conjunction with any

    • Obesity-related cardiomyopathy
    • Coronary heart disease
    • Severe Sleep Apnea
    • Uncontrolled Type2 Diabetes

  • 4. Change-of-Gender treatments: (Code- Excl 07)

    Expenses related to any treatment, including surgical management, to change characteristics of the body to those of the opposite sex.

  • 5. Cosmetic or plastic Surgery: (Code- Excl 08)

    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.

  • 6. Hazardous or Adventure sports: (Code- Excl 09)

    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.

  • 7. Breach of law: (Code- Excl 10)

    Expenses for treatment directly arising from or consequent upon any Insured Person committing or attempting to commit a breach of law with criminal intent.

  • 8. Excluded Providers (Code – Excl 11)

    Expenses incurred towards treatment in any hospital or by an Medical Practitioner or any other provider specifically excluded by the Insurer and disclosed in its website/notified to the policyholders are not admissible. However, in case of life-threatening situations or following an accident, expenses up to the stage of stabilization are payable but not the complete claim.

  • 9. Treatment for, Alcoholism, drug or substance abuse or any addictive condition and consequences thereof. (Code- Excl 12)

  • 10. Treatments received in health hydros, nature cure clinics, spas or similar establishments or private beds registered as a nursing home attached to such establishments or where admission is arranged wholly or partly for domestic reasons. (Code – Excl 13)

  • 11. Dietary supplements and substances that can be purchased without prescription, including but not limited to Vitamins, minerals and organic substances unless prescribed by a medical practitioner as part of hospitalization claim or day care procedure (Code-Excl 14)

  • 12. Refractive Error (Code – Excl 15)

    Expenses related to the treatment for correction of eye sight due to refractive error less than 7.5 dioptres

  • 13. Unproven Treatments (Code – Excl 16)

    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.

  • 14. Sterility and Infertility: (Code- Excl 17)

    Expenses related to sterility and infertility. This includes:

    • i. Any type of contraception, sterilization
    • ii. Assisted Reproduction services including artificial insemination and advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI
    • iii. Gestational Surrogacy
    • iv. Reversal of sterilization

  • 15. Maternity: (Code -Excl 18)

    i. Medical treatment expenses traceable to childbirth (including complicated deliveries and caesarean sections incurred during hospitalization) except ectopic pregnancy;

  • 16. Intentional self-injury

  • 17. Circumcision, Preputioplasty, Frenuloplasty, Preputial Dilatation and Removal of SMEGMA

  • 18. Congenital External Condition / Defects / Anomalies

  • 19. Venereal Disease and Sexually Transmitted Diseases (other than HIV)

  • 20. Injury/disease directly or indirectly caused by or arising from or attributable to war, terrorism, invasion, act of foreign enemy, warlike operations (whether war be declared or not)

  • 21. Injury or disease directly or indirectly caused by or contributed to by nuclear weapons/materials.

  • 22. Enhanced External Counter Pulsation Therapy and related therapies, Chelation therapy, Hyperbaric Oxygen Therapy, Rotational Field Quantum Magnetic Resonance Therapy, VAX-D, Low level laser therapy, Photodynamic therapy and such other therapies similar to those mentioned herein under this exclusion.

  • 23. Stem cell Therapy, Chondrocyte Implantation, Procedures using Platelet Rich plasma and Intra articular injection therapy.

  • 24. Oral Chemotherapy, Immuno therapy and Biologicals, except when administered as an inpatient, when clinically indicated and hospitalization warranted.

• 25. Inoculation or Vaccination (except for post–bite treatment and for medical treatment for therapeutic reasons

• 26. Dental treatment or surgery unless necessitated due to accidental injuries and requiring hospitalization. (Dental implants are not payable).

• 27. Medical and / or surgical treatment of Sleep apnea.

• 28. Cochlear implants and procedure related hospitalization expenses

• 29. In respect of the existing diseases, disclosed by the insured and mentioned in the policy schedule (based on insured's consent), policy holder is not entitle to get the coverage for specified ICD codes

Clause 5 Part B General Exclusions

Waiting period

• Time period during which specified diseases / treatments are not covered
• It is counted from the beginning of the policy coverage.

• 1. Pre-existing Diseases (Code - Excl 01)

  • i. Expenses related to the treatment of a pre-existing Disease (PED) and its direct complications shall be excluded until the expiry of 48 months of continuous coverage after the date of inception of the first policy with insurer.
  • ii. In case of enhancement of sum insured the exclusion shall apply afresh to the extent of sum insured increase.
  • iii. If the Insured Person is continuously covered without any break as defined under the portability norms of the extant IRDAI (Health Insurance) Regulations, then waiting period for the same would be reduced to the extent of prior coverage
  • iv. Coverage under the policy after the expiry of 48 months for any pre-existing disease is subject to the same being declared at the time of application and accepted by Insurer.

• 2.Specified disease/procedure waiting period - Two Years Exclusions (Code - Excl 02)

  • a. Expenses related to the treatment of the below listed Conditions, surgeries/treatments shall be excluded until the expiry of 24 months of continuous coverage after the date of inception of the first policy with us. This exclusion shall not be applicable for claims arising due to an accident.

  • b. In case of enhancement of sum insured the exclusion shall apply afresh to the extent of sum insured increase.
  • c. If any of the specified disease/procedure falls under the waiting period specified for pre-Existing diseases, then the longer of the two waiting periods shall apply.
  • d. The waiting period for listed conditions shall apply even if contracted after the policy or declared and accepted without a specific exclusion.
  • e. If the Insured Person is continuously covered without any break as defined under the applicable norms on portability stipulated by IRDAI, then waiting period for the same would be reduced to the extent of prior coverage.

  • f. List of specific disease/procedures -

    • i. Cataract,
    • ii. Hysterectomy for Menorrhagia or Fibromyoma or prolapse of Uterus unless necessitated by malignancy myomectomy for fibroids,
    • iii. Knee Replacement Surgery (other than caused by an Accident), Non-infectious Arthritis, Gout, Rheumatism, Osteoarthritis and Osteoporosis, Joint Replacement Surgery (other than caused by Accident), Prolapse of Inter-vertebral discs(other than caused by Accident), all Vertebrae Disorders, including but not limited to Spondylitis, Spondylolisthesis,
    • iv. Varicose Veins and Varicose Ulcers,
    • v. Stones in the urinary uro-genital and biliary systems including calculus diseases,
    • vi. Benign Prostate Hypertrophy, all types of Hydrocele, Congenital Internal Anomaly,
    • vii. Fissure, Fistula in anus, Piles, all types of Hernia, Pilonidal sinus, Haemorrhoids and any abscess related to the anal region,
    • viii. Chronic Suppurative Otitis Media (CSOM), Deviated Nasal Septum, Sinusitis and related disorders, Surgery on tonsils/Adenoids, Tympanoplasty and any other benign ear, nose and throat disorder or surgery.
    • ix. Gastric and Duodenal ulcer, any type of Cysts/ Nodules/ Polyps/ internal tumours/ skin tumours, and any type of Breast lumps(unless malignant), Polycystic Ovarian Diseases,
    • x. Any surgery of the genito-urinary system unless necessitated by malignancy.

• 3. First 30 Days Waiting Period (Code - Excl 03)

  • 1. Expenses related to the treatment of any illness within 30 days from the first policy commencement date shall be excluded except claims arising due to an accident, provided the same are covered.
  • 2. This exclusion shall not, however, apply if the Insured Person has Continuous Coverage for more than twelve months.
  • 3. The within referred waiting period shall be applicable to the enhanced sum insured in the event of granting higher sum insured subsequently

Clause 4 Policy Tenure Clause 5 Part B General Exclusion 5.14

Financial limits of coverage

• i. Sub-limit (lt is a pre- defined limit and the insurance company will not pay any amount in excess of this limit)
• ii. Co-payment (It is a Specified amount /percentage of the Admissible claim amount to be paid by policyholder /insured).
• iii. Deductible (It is a specified amount: - Up to which an insurance company will not pay any claim, and - which will be deducted from total claim amount (if claim amount is more than the specified amount)
• iv. Any other limit (as applicable)

• i. No sub limits
• ii. No co-payment
• iii. Deductible- 1- day deductible is applicable on every hospitalization, except Hospitalization due to an accident

Claims/ Claims Procedure

Claims Procedure

You or someone claiming on Your behalf must inform Us in writing immediately within 48 hours of hospitalization in case of emergency hospitalization and 48 hours prior to hospitalization in case of planned hospitalization.

• Claim Settlement

  Our Medical Practitioners will scrutinize the claims and flag the claim as settled/ rejected/ pending within the period of 30 days of the receipt of the last necessary documents.

Policy Servicing

Any notice, direction or instruction given under this Policy shall be in writing and delivered by hand, post, or facsimile/email to E-8, EPIP, RIICO Industrial Area, Sitapura, Jaipur (Rajasthan) – 302022

Phone: +91-141-3928400, 3951111,

Fax: +91-141-2770692, 2770693

Website:: www.shriramgi.com

E-mail:customer.feedback@shriramgi.in

Grievances/Complaints

Things to remember

You have a period of 15 days from the date of receipt of the first policy document to review the terms and conditions of this Policy. If You have any objections to any of the terms and conditions, You have the option of cancelling the Policy stating the reasons for cancellation. If you have not made any claim during the Free look period, you shall be entitled to refund of premium subject to, A. a deduction of the expenses incurred by Us on Your medical examination, stamp duty charges, if the risk has not commenced, B. a deduction of the stamp duty charges, medical examination charges & proportionate risk premium for period on cover, If the risk has commenced C. a deduction of such proportionate risk premium commensurating with the risk covered during such period, where only a part of risk has commenced Free Look Period will not be applicable for renewal Policies.

• a. Renewal of policy would be offered to the insured unless on grounds of moral hazard, misrepresentation, and fraud by the insured and would be subject to no claim being made on the policy during the previous year and payment of the renewal premium made prior to expiry of the policy and not later than 30 days post the expiry of the policy.
• b. If a claim was paid during this policy period for any one of the covered critical illness, then this policy will not be renewed subsequently for any other critical illness.
• c. If the policy is renewed for enhanced sum insured, then coverage for additional sum insured shall be as if a new policy has been issued for the additional sum insured. In other words, all policy conditions shall apply to the enhanced sum insured as if the same is covered under a fresh policy.
• d. If the insured was covered under a benefit policy from any other insurer in India covering the same health condition /s and under the same terms as are being covered under this policy for the previous 12 continuous months, then the 90 days waiting period clause shall not apply for such renewals, provided the renewal is continuous.
• e. In cases where Insured approaches for renewal after lapse of 30 days of policy expiry, the proposal will be treated as fresh proposal and it will be underwritten as if the proposal is received for the first time.
• f. The company may from time to time revise the premium rates/terms and conditions based on Company’s experience and to factor increasing costs, subject to prior approval from the regulator.

The insured person will have the option to port the policy to other insurers by applying to such insurer to port the entire policy along with all the members of the family, if any, at least 45 days before, but not earlier than 60 days from the policy renewal date as per IRDAI guidelines related to portability. If such person is presently covered and has been continuously covered without any lapses under any health insurance policy with an Indian General/Health insurer, the proposed insured person will get the accrued continuity benefits in waiting periods as per IRDAI guidelines on portability. For Detailed Guidelines on portability, kindly refer the link

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 and subsequently completion of 8 continuous years would be applicable from date of enhancement of sums 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 policies would however be subject to all limits, sub limits, co-payments, deductibles as per the policy contract.

Clause 8.4 for Free Look Period

Clause 8.9 for Renewal

Clause 8.6 for Portability

Clause 8.7 for Migration

Clause 8.32 for Migration

Your Obligations

• The Insured Person must disclose all Pre-Existing Disease/s before taking the Policy.
• Non-disclosure may result in claim not being paid.
• The Insured Person must disclose any material information during the Policy Period