top up policy

8/12/2019 Top Up Policy

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UNITED INDIA INSURANCE COMPANY LIMITEDREGISTERED & HEAD OFFICE: 24, WHITES ROAD, CHENNAI-600014

TOP UP MEDICARE POLICY

1. WHEREAS the insured designated in the Schedule hereto has by a proposal anddeclaration dated as stated in the Schedule (which shall be the basis of thisContract and is deemed to be incorporated herein has applied to !"#$E% #"%#A#"S!RA"CE C&'A") (hereinafter called the C&'A") for the insurancehereinafter set forth in respect of person(snamed in the Schedule hereto(hereinafter called the #"S!RE% ERS&" and has paid premium asconsideration for such insurance.

1.1 "&W $H#S &*#C) W#$"ESSES that sub+ect to the terms, conditions, e-clusionsand definitions contained herein or endorsed, or otherwise e-pressed hereon

the Company undertaes that if during the period stated in the Schedule orduring the continuance of this policy by renewal, any insured person contractsany disease or suffers from any illness (hereinafter called %#SEASE or sustainsany bodily in+ury through accident (hereinafter called #"/!R) and if suchdisease or in+ury re0uires any such insured erson, upon the adice of a duly0ualified hysician2'edical Specialist2'edical practitioner (hereinafter called'E%#CA* RAC$#$#&"ER or of a duly 0ualified Surgeon (hereinafter calledS!R3E&" to incur hospitalisation e-penses for medical2surgical treatment atany "ursing Home2Hospital2%ay Care Centre in #ndia as herein defined(hereinafter called H&S#$A* as an inpatient, the Company will pa !"#$%"T"'#( Pa#! A()'*'+!#a!$#(hereinafter called $A to the Hospital 2 "ursing

Home or the #nsured erson the amount of such e-penses specified underCoered E-penses, as are reasonably and necessarily incurred in respectthereof by or on behalf of such #nsured P#+$* +%./! !$ a+'+ $ Pa)*!Ca%+ butnot e-ceeding the Sum #nsured in aggregate in any one period ofinsurance stated in the schedule hereto.

a+'+ $ Pa)*!

1 A* /a') %*(# !"'+ p$'/ +"a paa !" C$)pa* $* 'a3 '! '+ '* #+p/! $ C$#( E5p*++ +p/''( '* !"'+ p$'/ a*(3 !" C$#( E5p*++ 5/( !" T"#+"$( a*(

/3 a ')'!+ $ #')%#+)*! %*(# a* $!"# Ha!" I*+%#a*/P$'/R')%#+)*! S/") aa'a !$ !" '*+%#( p#+$* "a* 5"a%+!(3

2 T" /a') paa %*(# !"'+ P$'/ 7' !" a)$%*! 7"'/" +%/"C$#( E5p*++ '* #+p/! $ a* "$+p'!a'+a!'$* 5/(+ !""'"# $ !" $$7'* :'3 !" T"#+"$( L $p!( $# !" '*+%#( p#+$*a)' a+

app'/a a*( +!a!( '* !" +/"(%$#

''3 !" a)$%*! #/'(#/'a %*(# a*a $!"# Ha!"I*+%#a*/ P$'/'+ 87"!"# $# *$! '++%( !" C$)pa*9

R')%#+)*! S/") /$#'* !" I*+%#( p#+$*a)' a+app'/a $# +%/" C$#( E5p*++3

Ea/" /a'), ' )$# !"a* $*, (%#'* !" p#'$( $ !"'+ p$'/ +"a +pa#a! +%./! !$ !" a$ a+'+ $ Pa)*!3

4 I* *$ /a+ +"a !" C$)pa* 'a !$ pa a* +%) '* 5/++ $ !"S%) I*+%#( '* a#a! $ a /a')+ (%#'* !" p#'$( $ !"'+ P$'/3

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132 CO;ERED E


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a $he treatment is such that it necessitates hospitalisation and the procedureinoles specialised infrastructural facilities aailable in hospitals.

b %ue to technological adances hospitalisation is re0uired for less than :@hours only.

c $hey are carried out in %ay Care Centre networed by $As wherere0uirement of minimum number of beds is oerlooed but haing (i fullye0uipped &peration $heatre, (ii fully 0ualified %ay Care Staff (c fully0ualified Surgeons2ost9&peratie attending %octors.

"ote= rocedures2treatments usually done in out patient department are notpayable under the policy een if conerted as an in9patient in the hospital formore than :@ hours or carried out in %ay Care Centres.

:.@ Reasonable and "ecessary E-penses shall mean the cost of surgical 2 medicaltreatment that is necessary, customary and reasonable for treating thecondition for which insured person was hospitalised to the e-tent relatable to

such condition.

30 ANY ONE ILLNESS: -

Any one illness will be deemed to mean continuous period of illness and itincludes relapse within 4=days from the date of discharge from the Hospital 2"ursing Home where treatment has been taen. &ccurrence of the same illnessafter a lapse of 4=days as stated aboe will be considered as fresh illness forthe purpose of this policy.

31 PRE - HOSPITALISATION:-

Releant medical e-penses incurred during period up to ?< days prior toHospitalisation on disease 2 illness 2 in+ury sustained will be considered as partof claim as mentioned under item 1.: aboe

32 POST HOSPITALISATION: -

Releant medical e-penses incurred upto a ma-imum period of < days fromthe date of discharge will be considered as part of claim as mentioned underitem 1.: aboe. Howeer, in case of relapse and readmission to hospital before< days, the period for consideration of ost9Hospitalisation e-penses will end

on the day before readmission.

?.?'E%#CA* RAC$#$#&"ER means a person who holds a degree 2 diploma of arecognised institution and is registered with 'edical Council of respectie State of#ndia. $he term 'edical ractitioner would include hysician, Specialist andSurgeon.

?.@D!A*#6#E% "!RSE means a person who holds a certificate of a recognised "ursingCouncil and who is employed on recommendation of the attending 'edicalractitioner.

?.;$A means a $hird arty Administrator who holds a alid *icense from #nsuranceRegulatory and %eelopment Authority to act as a $H#R% AR$) A%'#"#S$RA$&Rand is empanelled by the Company for the proision of health serices as specifiedin the agreement between the Company and $A.

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@.1 Any pre9e-isting condition(s as defined in the policy, until @ months ofcontinuous coerage of such insured person hae elapsed, since inception ofhis2her $& ! 'E%#CARE olicy with theCompany.re9E-isting Condition2%isease definition F Any condition, ailment or in+ury orrelated condition(s for which insured person had signs or symptoms, and2or

were diagnosed, and2or receied medical adice2treatment, within @ monthsprior to his2her $& ! 'E%#CARE policy with theCompany.

".4.= #n case of persons haing any other Health #nsurance olicy from anyCompany with a Sum #nsured aboe $hreshold *eel at the time of taingthis policy, the e-clusion period of @ months for re9e-isting%isease2Condition will be reconed from the date of inception of thepolicy for such portion of Sum #nsured, including Cumulatie 4onusearned if any, aboe the $hreshold *eel. #f e-piring policy sum insuredhas increased oer the years, the @ months of continuous coerage hasto be completed for the incremental sum insured.

@.:#n+ury 2 disease directly or indirectly caused by or arising from or attributable toinasion, Act of 6oreign enemy, War lie operations (whether war be declared ornot

4.3 a. Circumcision unless necessary for treatment of a disease not e-cludedhereunder or as may be necessitated due to an accident

b. accination or inoculation or change of life or cosmetic or aesthetictreatment of any description

c. plastic surgery other than as may be necessitated due to an accident oras a part of any illness.

4.4 Cost of spectacles, contact lenses and hearing aids.

4.5 %ental treatment or surgery of any ind unless re0uiring hospitalisation.

4.6 Conalescence, general debility run9down condition or rest cure, Congenitale-ternal disease or defects or anomalies, Sterility, 5enereal disease, intentionalself in+ury and use of into-ication drugs 2 alcohol

4.7 All e-penses arising out of any condition directly or indirectly caused to orassociated with Human $9Cell *ymphotropic 5irus $ype ### (H$*4 9 ### orlymphadinopathy Associated 5irus (*A5 or the 'utants %eriatie or 5ariation

%eficiency Syndrome or any syndrome or condition of a similar ind commonlyreferred to as A#%S.

4.8 Charges incurred at Hospital or "ursing Home primarily for diagnosis, -9ray or*aboratory e-aminations or other diagnostic studies not consistent with orincidental to the diagnosis and treatment of positie e-istence or presence of anyailment, sicness or in+ury, for which confinement is re0uired at a Hospital 2"ursing Home

4.9 E-penses on itamins and tonics unless forming part of treatment for in+ury ordiseases as certified by the attending physician

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@.1?E-ternal and or durable 'edical 2 "on9medical e0uipment of any ind used fordiagnosis and2or treatment and2or monitoring and2or maintenance and2orsupport including CA, CA%, #nfusion pump, &-ygen concentrator etc.,Ambulatory deices i.e., waler, crutches, 4elts, Collars, Caps, Splints, Slings,4races, Stocings, etc., of any ind, %iabetic foot wear,

3lucometer2$hermometer and similar related items and also any medicale0uipment, which are subse0uently used at home.

@.1@ Any ind of Serice charges, Surcharges, Admission 6ees2Registration Chargesleied by the hospital.

@.1; All non9'edical e-penses of any ind whatsoeer.

=3 CONDITIONS:

$he roposal form, rospectus, re9acceptance Health chec9up and the olicy issued

shall constitute complete Contract of #nsurance.

;.1 Eery notice or communication regarding hospitalisation or claim under thispolicy shall be deliered in writing at the address of the $A office as shown inthe Schedule. &ther matters with regard to the policy may be communicated tothe olicy #ssuing &ffice and the $A.

;.: $he premium payable under this olicy shall be paid in adance. "o receipt forremium shall be alid e-cept on the official form of the company signed by aduly authorised official of the company. $he due payment of premium and theobserance and fulfilment of the terms, proisions, conditions and endorsements

of this olicy by the #nsured erson in so far as they relate to anything to be doneor complied with by the #nsured erson shall be a condition precedent to anyliability of the Company to mae any payment under this olicy. "o waier ofany terms, proisions, conditions and endorsements of this policy shall be alidunless made in writing and signed by an authorised official of the Company.

;.? !pon the happening of any eent which may gie rise to a claim under this olicynotice with full particulars shall be sent to the $A named in the scheduleimmediately and in case of emergency Hospitalisation, within :@ hours from thetime of Hospitalisation.

In the case of a covered hospitalisation, the costs of which were not initiallyestimated to exceed the Threshold Level but were subsequently found likely toexceed the Threshold Level, the intimation to the named TPA should besubmitted along with a copy of intimation made to the Primary ealth PolicyTPA!"eimbursement Provider immediately on knowing that the Threshold Levelis likely to be exceeded#

;.@ $he #nsured erson shall obtain and furnish to the $A with all original bills,receipts, prescriptions, reports and other documents upon which a claim is basedand shall also gie the $A 2 Company such additional information and assistanceas the $A 2 Company may re0uire in dealing with the claim.

$hen original bills, receipts, prescriptions, reports and other documents aregiven to Primary insurer or to the "eimbursement Provider, verified photocopiesattested by such other %rganisation have to be submitted#

;.; $he #nsured2#nsured erson shall be bound to disclose particulars of all otherolicies of #nsurance2Reimbursement Schemes under which he2she is coered forE-penses as are coered under this olicy.

5.6 All supporting documents relating to the claim must be filed with $A within 1;days from the date of discharge from the hospital. #n case of post9

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hospitalisation, treatment (limited to < days, all claim documents should besubmitted within &' daysafter completion of such treatment.

"ote= Waier of this Condition may be considered in e-treme cases of hardshipwhere it is proed to the satisfaction of the Company that under the

circumstances in which the insured was placed it was not possible for him orany other person to gie such notice or file claim within the prescribed time9limit.

5.7 Any medical practitioner authorised by the $A 2 Company shall be allowed toe-amine the #nsured erson in case of any alleged in+ury or disease leading toHospitalisation as may be reasonably required, at the cost of the insurer#

;. $he Company shall not be liable to mae any payment under this policy inrespect of any claim if such claim is found to be fraudulent or supported by anyfraudulent means or deice whether by the #nsured erson or by any otherperson acting on his behalf.

;.G Renewal Clause =

$he olicy may be renewed by mutual consent and in such eent the renewalpremium shall be paid to the Company on or before the date of e-piry of theolicy or of the subse0uent renewal thereof and in any case not later than 1;days from the date of e-piry of the current policy. #f, howeer, during thegrace period of 1; days, any insured person incurs any hospitalisation e-penses,he shall not be entitled for any claim. $he Company shall not be bound to gienotice that such renewal premium is due, proided howeer that if the insuredapplies for renewal and remits the re0uisite premium before the e-piry of thispolicy, renewal shall not normally be refused, unless the Company has

reasonable +ustification to do so.

A policy that is sought to be renewed after the grace period of 1; days will beunderwritten as a 6resh olicy.

Cancellation Clause =$he Company may at any time cancel the olicy on grounds ofmisrepresentation, fraud, non9disclosure of material fact or non9cooperation bythe insured by sending seen days notice in writing by Registered A2% to theinsured at his last nown address in which case the Company shall return to theinsured a proportion of the premium corresponding to the une-pired period of

insurance if no claim has been paid2admitted under the policy. $he insuredmay at any time cancel this policy and in such eent the Company shall allowrefund of premium at Companys short period rate table gien below proidedno claim has occurred upto the date of cancellation.ER#&% &" R#SB RA$E &6 RE'#!' $& 4E CHAR3E%.!pto one month 12@ th of the annual rate!pto three months 12: of the annual rate!pto si- months ?2@thof the annual rateE-ceeding si- months 6ull annual rate.

;.1< #f any dispute or difference shall arise as to the 0uantum to be paid under the

policy (liability being otherwise admitted such difference shall independently ofall other 0uestions be referred to the decision of a sole arbitrator to beappointed in writing by the parties or if they cannot agree upon a singlearbitrator within ?< days of any party inoing arbitration, the same shall bereferred to a panel of three arbitrators, comprising of two arbitrators, one to beappointed by each of the parties to the dispute2difference and the thirdarbitrator to be appointed by such two arbitrators and arbitration shall beconducted under and in accordance with the proisions of the Arbitration andConciliation Act, 1GG.

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#t is clearly agreed and understood that no difference or dispute shall bereferable to arbitration as herein before proided, if the Company has disputedor not accepted liability under or in respect of this olicy.#t is hereby e-pressly stipulated and declared that it shall be a conditionprecedent to any right of action or suit upon this policy that award by such

arbitrator2arbitrators of the amount of the loss or damage shall be firstobtained.

;.11 #f the Company, as per terms and conditions of the policy, disclaims liability tothe #nsured for any claim hereunder and if the #nsured does not within 1:calendar months from the date or receipt of the notice of such disclaimer notifythe Company in writing that he does not accept such disclaimer and intends torecoer his claim from the Company then the claim shall for all purposes bedeemed to hae been abandoned and shall not thereafter be recoerablehereunder.

63 PAYMENT OF CLAIM

All claims under this policy shall be payable in #ndian currency. Allmedical2surgical treatments for the purpose of this insurance will hae to betaen in #ndia only. ayment of claim shall be made through $A to theHospital2"ursing Home or the #nsured erson as the case may be.

I #R%A RE3!*A$#&"S = $his policy is sub+ect to Regulations of #R%A (rotection ofolicyholders #nterestRegulations, :


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TOP UP MEDICARE POLICY9SCHEDULE > INDI;IDUAL POLICY

1. olicy "o. Agency Code= %e.&fficer code=

:. Annual remium = Rs.

?. "ame of the #nsured =

@. %ate of 4irth

;. Address of the #nsured =

. %etails of the #nsured ersons =

"ame of#nsuredperson

Age2Se-

Relationship with theroposer

&ccupation

%ate ofcommencement offirstpolicy

E-cludeddiseases

Sum#nsuredopted

$hreshold*eel

I. eriod of #nsurance = 6rom $o

. %etails of other Health #nsurance olicies F (current and preious

Name of

Insurer

Healtholicyno.

eriod of#nsurance

Sum #nsured

#nsuredperson91

#nsuredperson9:

erson9? erson9@ erson9; $A

"otice or communication to be gien in respect of a claim or for any other reason to $AG "ame and Address of $A

"ame2s of the contact person2s=

$elephone "umber2s=

Call centre $elephone number=

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TOP UP MEDICARE POLICY

SCHEDULE > FAMILY POLICY

1. olicy "o. Agency Code= %e.&fficer code=

:. Annual remium = Rs.

?. "ame of the roposer =

@. %ate of 4irth

;. Address of the roposer =

. %etails of the #nsured ersons =

"ame of#nsured person

Age2Se-

Relationshipwith theroposer

&ccupation %ate ofcommencementof first policy

E-cludeddiseases

I. Sum #nsured 9 Rs.

, $hreshold *eel 9 Rs.

G. eriod of #nsurance = 6rom $o

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