Family Health Cover: Policy Wording

1. Definitions

Hospitalisation means admission to a hospital for at least 24 consecutive hours.

Pre-existing disease means any condition diagnosed or treated within 36 months before the policy start date.

2. What we cover

We will pay the reasonable and customary charges for hospitalisation of an insured person, up to the Sum Insured shown in the Schedule, for each policy year.

We will also pay for day-care procedures that need less than 24 hours in hospital because of medical advances.

3. Room rent

Room rent is covered up to 1% of the Sum Insured per day.

If you choose a room above this limit, all associated expenses will be paid in the same proportion as the eligible room rent bears to the actual room rent.

4. Exclusions

We will not pay for any claim arising from a pre-existing disease until 36 months of continuous coverage have passed.

We will not pay for cosmetic or aesthetic treatment, unless it is needed because of an accident.

Treatment outside India is not covered.

5. Waiting periods

Any illness first diagnosed within 30 days of the policy start date is not covered, except claims arising from an accident.

Cataract, hernia and joint replacement surgery are covered only after 24 months of continuous coverage.

6. Co-payment

Each admissible claim is subject to a co-payment of 10%, which the insured person must pay.

Where the insured person is aged 61 or above at the time of admission, the co-payment is 20%.

7. Making a claim

For a planned hospitalisation, you must tell us at least 48 hours before admission.

For an emergency, you must tell us within 24 hours of admission.

Reimbursement claims must be submitted with all documents within 30 days of discharge.

Cashless treatment is available only at network hospitals listed on our website.

To make a claim, call 1800 000 0000 or write to claims@example.com.

8. Renewal

This policy is renewable for life, provided the premium is paid before the end of the grace period of 30 days.

We may revise the premium at renewal with prior approval of the regulator.

9. Free-look period

You have 30 days from receipt of the policy document to review its terms.

If you cancel within this period, we will refund the premium after deducting the cost of any medical tests and a proportionate risk premium.

10. Cancellation

You may cancel this policy at any time by giving us written notice.

We will refund premium for the unexpired period according to the short-period scale in the Schedule.

We may cancel this policy only on grounds of established fraud, by giving 15 days’ written notice.

11. Complaints

If you have a complaint, write to grievance@example.com.

If you are not satisfied with our response within 15 days, you may approach the Insurance Ombudsman.

12. Law and jurisdiction

This policy is governed by the laws of India, and any dispute is subject to the jurisdiction of the courts of Mumbai.