Every DETAIL Matters To Your HEALTH.: Policy Contract

POLICY CONTRACT
Every DETAIL matters

to your HEALTH.
Find them listed in your
POLICY TERMS & CONDITIONS
Health Insurance
Cigna TTK ProHealth Insurance

Customer Information Sheet
Title
Description
Please refer to the Plan and Sum Insured you have opted to understand the available
benefits under your plan in brief
Your Coverage
Details:
Identify your Plan
Basic Cover
Identify your
Opted Sum
Insured
This section
lists the Basic
benefits available
in your plan
Inpatient
Hospitalisation
(When you are
hospitalized)
Pre-hospitalization
Post hospitalization
Protect
Plus
` 2.5 Lacs,
` 3.5 Lacs,
` 4.5 Lacs
`
`
`
`
Covered upto
Shared Room
4.5 Lacs,
5.5 Lacs,
7.5 Lacs,
10 Lacs
Covered upto
Single Private
Room
Preferred
Premier
` 15 Lacs,
` 30 Lacs,
` 50 Lacs,
` 100 Lacs
Covered upto
Single Private
Room
Covered upto
Single Private
Room
Medical Expenses Covered up to 60 days before date of hospitalisation

Medical Expenses
Covered up to 90
days post discharge
from hospital
Medical Expenses Covered up to 180 days post

discharge from hospital
Refer to the following

Policy Section number
in the Policy Wording
for more details on
each cover
II.1
II.2
II.3
Day Care
Treatment
Covered up to the limit of Sum Insured opted
II.4
Domiciliary
Treatment
II.5
(Treatment at Home)
Ambulance Cover Up to ` 2000 paid

(Reimbursement per hospitalization
of Ambulance
event
Expenses)
Restoration of
Sum Insured (when
opted Sum Insured
is insufficient due
to claim)
Health
Maintenance
Benefit
(Treatment that
does not require
hospitalization
and can be
carried out in an
Out Patient
Department )
Covered up to the limit Sum Insured

once in a Policy Year
Covered up to
` 500
Not Available
First Year
Vaccinations
Covered up to
` 2000
Covered upto
` 15,000 for
normal delivery
and ` 25,000 for
C- Section per
event, after a
Waiting Period
of 48 months
II.6
II.7
Covered upto a maximum of ` 10 Lacs

in a Policy Year
Available once in a Policy Year for unrelated illnesses

in addition to the Sum Insured opted
Maternity
Expenses
New Born Baby

Expenses
Actual incurred expenses paid

per hospitalization event
Donor Expenses
(Hospitalisation
Expenses of the
donor providing
the organ)
Worldwide
Emergency Cover
(Outside India)
Up to ` 3000 paid
per hospitalization
event
Not Available
Covered up to ` 15000
per policy year.
Covered upto ` 50,000 for normal

delivery and ` 100,000 for C-Section
per event, after awaiting Period
of 48 months
II.8
II.9
II.10
II.11
Covered for the inpatient hospitalisation expenses of a

new born up to the limit provided under Maternity Expenses
II.12
Covered as per national immunization programme over

and above Maternity Sum Insured
II.13
Health Insurance
Description
Title
Your Coverage
Details:
Identify your Plan
Protect
Value Added
Covers
Health Check-Up
Available once
every 3rd Policy
year to all insured
persons who have
completed 18 years
of Age
This section lists

the additional
value added
benefits that are
available along
with your plan
Preferred
Premier
Available at each renewal, to all insured persons who

have completed 18 years of Age
Available once during the Policy Year
Expert Opinion on
Critical illness
(By a Specialist)
Cumulative Bonus
5% Increase in
(for a Claim Free
Sum Insured,
Policy)
maximum upto 50%
Healthy Rewards
Plus
10% Increase in Sum Insured,

maximum upto 50%

for more details on
each cover
III.1
III.2
Not Available
III.3
Reward Points to be earned for each year of premium paid and accumulated
for 2 years. Rewards can also be earned from enrolling and completing Our
Online Wellness Programs.
III.4
These earned Reward Points can be used to get a discount in premium

from the 3rd Annual Premium OR they can be redeemed for equivalent value of
Health Maintenance Benefit.
Optional
Covers
This section lists
the available
optional covers
under your plan
and the limits
under each of
these options
Deductible
Protect Plan
(Please select
the Sum Insured `2.5 Lac
N.A.
and Deductible
amount as you
have opted on the `3.5 Lac `1 Lac
Policy. Deductible
is the amount
beyond which a
`1 Lac
claim will be
`4.5 Lac
payable in the
`2 Lac
Policy)
Plus Plan
`4.5 Lac
`5.5 Lac
IV.1
`1 Lac
`2 Lac
`2 Lac
`3 Lac
Not Available
`2 Lac
`7.5 Lac
`10 Lac
`3 Lac
`3 Lac
Reduction in
Maternity Waiting
Not Available
Maternity waiting period Reduced from 48 months

to 24 months
Voluntary
Co-Payment^
(The cost sharing
percentage that
you have opted
will apply on each
claim.)
10% or 20% Voluntary Co-payment

for each and every claim as opted
Not Available
IV.2
IV.3
^If you have opted

for a Deductible,
Voluntary Co-payment
does not apply
Add on cover
Critical Illness
Lump sum payment of an additional 100% of

Sum Insured Opted
Not Available
Add on policy
wordings
This section lists

the Add on cover
available under
your plan
What are the
Please note that this is an indicative list of exclusions; please refer to the Policy wording and
Major exclusions clauses for the complete list of exclusions.
in the Policy
Genetic disorder and stem cell implantation/surgery.
This section
provides a brief
list of the major
charges /
treatments which
will not be
covered under
the Policy
permanently
Dental treatment other than due to accident.
HIV/ AIDS and related complications.
Vitamins and tonics unless forming part of treatment.
Artificial life maintenance, including life support machine use.
Treatment for rehabilitation measures, private duty nursing, respite care.
Treatment from persons not registered as Medical Practitioners.
Ailment requiring treatment due to drug abuse/alcohol and treatment for de-addiction,
or rehabilitation.
Any illness resulting from the Insured committing any breach of law.
VI
Health Insurance
Description
Title
What are the
Major exclusions
in the Policy
This section
provides a brief
list of the major
charges /
treatments which
will not be
covered under
the Policy
permanently

for more details on
each cover
Treatment of any mental illness or Parkinson's or Alzheimer's disease even if caused or

aggravated by or related to an Accident or Illness.
Any cosmetic surgery unless forming part of treatment.
VI
Charges incurred primarily for diagnostic purposes.

Costs of donor screening.
Any form of Non-Allopathic treatment.
Expense for injury of insured whilst engaging any adventure sports.
Expenses caused by ionizing radiation or contamination by radioactivity from any nuclear fuel.
All expenses arising from foreign invasion & warlike operations, whether war be declared or not.
*Note: This list does not apply to coverage under Health Maintenance Benefit
Waiting
Period
a. First 30 days from the Policy start date, for all illnesses except accidents.
b. 90 days waiting period will be applicable for listed Critical Illness where Critical Illness Add on
This sections lists
cover has been opted.
the applicable
period (days/
c. Two Year Waiting Period will be applicable for specific illnesses.
months) before
you can make a
d. A 48 months of waiting period will be applicable for Maternity, New Born and First year
claim for the listed
Vaccination expenses (Except where Reduction in Maternity Waiting is opted).
diseases /
treatments
e. A Personal waiting period may apply to individuals depending upon declarations on the
proposal form and existing health conditions. Please refer to the "Special Conditions"
Column on your Policy Schedule to identify if any personal waiting period is applied to your Policy.
f.
Payout
Basis
This section lists
the manner in
which the
proceeds of the
Policy will be
paid to you
Cost
Sharing
A 48/ 36/ 24/ 24 months waiting period will be applicable for any Pre-existing disease,
for Protect, Plus, Preferred & Premier Plan respectively.
a. For all covers (excluding Critical Illness Add On Benefit) pay-out will be on reimbursement of
actual expenses either by way of Cashless to the Hospital/ Network provider when a cashless
facility is availed or directly to you as a reimbursement against the bills when you have paid for
the expenses.
b. Critical Illness Add on pay-out will be on benefit payment basis as a lump sum fixed amount.
V.2
Add on Policy
Wordings
V.3
V.4
V.5
V.1
VII.
Add on Policy
Wordings
c. Health Maintenance Benefit will be on reimbursement basis on submission of bills.
VII.15
a. A mandatory co-payment will be applicable for insured's aged 65 years and above.
VIII.11
b. A Voluntary co-payment of 10% or 20% on admissible claim amount (final payable claim amount
after assessment) will apply to each and every claim if opted under the plan.
IV.3
c. A deductible option of ` 1 Lacs, 2 Lacs and 3 Lacs as per plan selected will apply on the Policy
if opted. All payable claims up to this amount will be borne by you. Any claim over any above this
limit will become payable under the Policy. To know the applicable deductible on your Policy
please refer the Policy Schedule benefits. Co-pays under "b" above will not be applied for a
Deductible Cover.
VII.19
d. Persons opting to take treatment outside of their Zone will bear a 10% or 20% co-pay as
applicable.
VIII.19
Renewal
Conditions
a. This Policy is ordinarily renewable for lifetime on mutual consent , subject to application of
Renewal and realization of Renewal premium.
VIII.18
This section lists

the terms of
renewals under
the Policy
b. Continuity will be provided if renewed within 30 days from the date of expiry of previous policy.
If there is a break in the policy, any claim occurring within the break in period will not be
covered under the Policy.
This sections lists

the various
circumstances
under which you
will bear some
portion of the
claim out of your
pocket
c. Renewals will not be denied except on grounds of misrepresentation, fraud, non-disclosure or

non-co-operation from the Insured.
d. Alterations in the policy such as Increase/ decrease in Sum Insured or Change in Plan/Product,
addition/ deletion of members, addition deletion of Medical Condition will be allowed at the time of
Renewal of the Policy. We reserve Our right to carry out underwriting in relation to acceptance of
request for changes on renewal. The terms and conditions of the existing policy will not be altered.
Health Insurance
Title
Renewal
Benefits
This section lists
the various
benefits you can
avail/accumulate
every time you
renew a Policy
with us
Cancellation
The section
explains the
Policy
cancellation
process in brief
How to claim
This section gives
you a brief on the
procedure to
make a claim
Description

for more details on
each cover
a. Cumulative Bonus- We will provide a 5% or 10% increase in sum insured for every claim free
year, subject to a maximum of 50% accumulation. The cumulative bonus will remain intact and
not get reduced in case a claim is made during the policy.
III.3
b. Health check-up - A health check-up is provided for persons aged 18 years and above,
irrespective of the claim status of the Policy.
For Protect plan - Available once every 3rd Policy year
For Plus, Preferred and Premier Plan - Available at each renewal
III.1
c. Healthy Rewards - Reward Points are earned for each year of premium paid and accumulated for
2 years, these points can be redeemed to avail a discount in Premium from 3rd Annual Premium.
III.4
a. Cancellations may be intimated to Us by giving 15 days' notice wherein We shall refund the
premium for the unexpired term on the short period scale as mentioned in the Policy wordings
enclosed in the kit. The Premium shall only be refunded only if no claim has been made under
the Policy.
VIII.16
b. This Policy can be cancelled on grounds of misrepresentation, fraud, non-disclosure of material

fact or non-cooperation by You , upon giving 15 days' notice without refund of premium.
a. In case of Planned Hospitalization, please intimate Us at least 3 days prior to the planned date of
admission.
VII
b. In case of Emergency Hospitalization, Please intimate us within 48 hours of such admission but
not later than discharge.
c. In case of reimbursement of expenses, the requisite claim documents should reach Us not later
than 15 days of date of discharge from hospital.
For any claims related query, information or assistance you can contact our
Healthline 1-800-10-24462 or visit our website www.cignattkinsurance.in or email us at
customercare@cignattk.in. Please refer to the Policy wordings for complete process on claims.
The information mentioned above is illustrative and not exhaustive. Information must be read in conjunction with the product brochures and
Policy document. In case of any conflict between the Prospectus and the Policy document the terms and conditions mentioned in the Policy
document shall prevail.
Health Insurance
Cigna TTK ProHealth Insurance

Policy Terms and Conditions
Hospital up to limits specified in the Schedule, provided that a Claim
has been admitted under In-patient Benefit under Section II.1 and is
related to the same illness/condition
I PREAMBLE & OPERATING CLAUSE

This is a legal contract between You and Us subject to the receipt of
full premium, Disclosure to Information Norm including the
information provided by You in the Proposal Form and the terms,
conditions and exclusions of this Policy.
If any Claim arising as a result of an Illness or Injury that occurred
during the Policy Period becomes payable, then We shall pay the
Benefits in accordance with terms, conditions and exclusions of the
Policy subject to availability of Sum Insured and Cumulative Bonus
(if any).
All Claims under this benefit can be made as per the process
defined under Section VII 5.
II.4. Day Care Treatment:
We will cover payment of Medical Expenses of an Insured Person
in case of Medically Necessary Day Care Treatment or Surgery that
requires less than 24 hours Hospitalization due to advancement in
technology and which is undertaken in a Hospital/ Nursing home/
Day Care Centre on the recommendation of a Medical Practitioner.
Any treatment in an outpatient department/ OPD is not covered.
For list of Day Care Treatments refer Annexure II of the Policy.
BENEFITS UNDER THE POLICY

II BASIC COVERS
II.1. Inpatient Hospitalization:
We will cover Medical Expenses of an Insured Person in case of
Medically Necessary Hospitalization arising from Accident or
Illness provided such Medically Necessary Hospitalization is for
more than 24 consecutive hours. We will pay Medical Expenses
as shown in the Schedule for:
a. Reasonable and Customary Charges for Room Rent for
accommodation in Hospital room up to Category as per Plan
opted and specified in the Schedule to this Policy.
b. Intensive Care Unit charges for accommodation in ICU ,
c. Operation theatre charges,
d. Fees of Medical Practitioner/ Surgeon ,
e. Anaesthetist,
f. Qualified Nurses,
g. Specialists,
h. Cost of diagnostic tests,
i. Medicines,
j. Drugs and consumables, blood, oxygen, surgical appliances and
prosthetic devices recommended by the attending Medical
Practitioner and that are used intra operatively during a Surgical
Procedure.
If the Insured Person is admitted in a room category that is higher
than the one that is specified in the Schedule to this Policy then the
Policyholder/ Insured Person shall bear a ratable proportion of the
total Associated Medical Expenses (including surcharge or taxes
thereon) in the proportion of the difference between the room rent
of the entitled room category to the room rent actually incurred.
defined under Section VII 4 & 5.
II.5. Domiciliary Treatment:
We will cover Medical Expenses of an Insured Person which are
towards an Illness/accident or injury which in the normal course
would have required Hospitalisation but is taken at home on the
advice of the attending Medical Practitioner, under the following
circumstances:
i.
The condition of the Insured Person does not allow a Hospital

transfer; or
ii. A Hospital bed was unavailable;

Provided that, the treatment of the Insured Person continues for at
least 3 days, in which case the reasonable cost of any Medically
Necessary treatment for the entire period shall be payable.
(a) If a claim has been accepted under this Benefit, the payment for
Post-hospitalisation Medical Expenses shall not be payable.
(b) We will however pay for Pre-hospitalisation Medical Expenses up
to 30 days in accordance with Section II.2 above.
(c) We shall not be liable under this Policy for any Claim in
connection with or in respect of the following:
i.
Asthma, bronchitis, tonsillitis and upper respiratory tract infection

including laryngitis and pharyngitis, cough and cold, influenza,
ii. Arthritis, gout and rheumatism,

iii. Chronic nephritis and nephritic syndrome,
iv. Diarrhoea and all type of dysenteries, including gastroenteritis,
For the purpose of this Section "Associated Medical Expenses"

shall include - Room Rent, Nursing Charges, Operation Theatre
Charges, Fees of Medical Practitioner/ Surgeon/ Anaesthetist/
Specialist and Diagnostic Tests conducted within the same
Hospital where the Insured Person has been admitted.
vii. Hypertension,
ix. Pyrexia of unknown origin.
II.2. Pre - hospitalization:

We will, on a reimbursement basis cover Medical Expenses of an
Insured Person which are incurred due to an Accident, Injury or
Illness immediately prior to the Insured Person's date of
Hospitalisation up to limits specified in the Schedule, provided
that a Claim has been admitted under In-patient Benefit under
Section II.1 and is related to the same illness/condition
defined under Section VII 5.
II.3. Post - hospitalization:
We will, on a reimbursement basis cover Medical Expenses of an
Insured Person which are incurred due to an Accident, Injury or
Illness immediately post discharge of the Insured Person from the
v. Diabetes mellitus and Insipidus,

vi. Epilepsy,
viii. Psychiatric or psychosomatic disorders of all kinds,
All Claims under this benefit can be made as per the process defined
under Section VII 5.
II.6. Ambulance Cover:
a. We will provide for reimbursement of Reasonable and
Customary expenses up to limits specified in the Schedule that
are incurred towards transportation of an Insured Person by a
registered healthcare or Ambulance service provider to a
Hospital for treatment of an Illness or Injury in case of an
Emergency, necessitating the Insured Person's admission to the
Hospital. The necessity of use of an Ambulance must be certified
by the treating Medical Practitioner.
b. Reasonable and Customary expenses shall include:
(i) Costs towards transferring the Insured Person from one Hospital
to another Hospital or diagnostic centre for advanced diagnostic
Health Insurance
treatment where such facility is not available at the existing

Hospital; or
(ii) When the Insured Person requires to be moved to a better
Hospital facility due to lack of super speciality treatment in the
existing Hospital.
defined under Section VII 4 & 5..
II.7. Donor Expenses:
(c) The Restored Sum Insured will be available only for claims made
by Insured Persons in respect of future claims that become
payable under Section II of the policy and shall not apply to the
first claim in the Policy year.
(d) The Restored Sum Insured will not be considered while
calculating the Cumulative Bonus.
(e) Such restoration of Sum Insured will be available only once
during a Policy Year to each insured in case of an individual Policy
and can be utilised by Insured Persons who stand covered under
the Policy before the Sum Insured was exhausted.
We will cover In-patient Hospitalisation Medical Expenses

towards the donor for harvesting the organ up to the limits of the
Sum Insured, provided that: The organ donor is any person in
accordance with the Transplantation of Human Organs Act 1994
(amended) and other applicable laws and rules, provided that -
(g) If the Restored Sum Insured is not utilised in a Policy Year, it shall
not be carried forward to subsequent Policy Year.
a. The organ donated is for the use of the Insured Person who has
been asked to undergo an organ transplant on Medical Advise.
For any single claim during a Policy Year the maximum Claim
amount payable shall be sum of:
b. We have admitted a claim under Section II.1 towards In-patient

Hospitalization
i. The Sum Insured
c. We will not cover expenses towards the Donor in respect of:

i.
Any Pre or Post - hospitalization Medical Expenses,
(f) If the Policy is issued on a floater basis, the Restored Sum

Insured will also be available on a floater basis.
ii. No Claims Bonus

(h) During a Policy Year, the aggregate claim amount payable,
subject to admissibility of the claim, shall not exceed the sum of:
ii. Cost towards donor screening,
i The Sum Insured
iii. Cost directly or indirectly associated to the acquisition of the organ,
ii. No Claims Bonus

iii. Restored Sum Insured
iv. Any other medical treatment or complication in respect of the

donor, consequent to harvesting.
II.10. Health Maintenance Benefit:

II.8. Worldwide Emergency Cover:
We will cover Medical Expenses of the Insured Person incurred
outside India, up to limits specified in the Schedule, provided that:
(a) The treatment is Medically Necessary and has been certified as
an Emergency by a Medical Practitioner, where such treatment
cannot be postponed until the Insured Person has returned to
India and is payable under Section II.1 of the Policy.
(a) We will cover, by way of reimbursement the Reasonable and

Customary Charges incurred by the Insured Person for Medically
Necessary charges incurred on an Out Patient basis.
We will cover costs incurred towards:
i)
Diagnostic tests, drugs, prosthetics, medical aids, prescribed by

the specialist Medical Practitioner up to the limits specified in the
Schedule.
(b) The Medical Expenses payable shall be limited to Inpatient

Hospitalization only.
ii) Towards Dental Treatments and Alternative Forms of Medicines

wherever prescribed by a Medical Practitioner.
(c) Any payment under this Benefit will only be made in India, in Indian
rupees on a re-imbursement basis and subject to Sum Insured.
All Waiting Periods and Permanent Exclusions under Section V

and VI shall not apply to this section.
(d) The payment of any claim under this Benefit will be based on the
rate of exchange as on the date of payment to the Hospital
published by Reserve Bank of India (RBI) and shall be used for
conversion of foreign currency into Indian rupees for payment of
claim. You further understand and agree that where on the date of
discharge, if RBI rates are not published, the exchange rate next
published by RBI shall be considered for conversion.
defined under Section VII.14.
(e) You have given Us, intimation of such hospitalisation within 48

hours of admission.
(f) Any claim made under this Benefit will be as per the claims
procedure provided under Clause VII.5 of this Policy.
(g) Exclusion VI.22 does not apply to this benefit.
II.9. Restoration of Sum Insured:
We will provide for a 100% restoration of Sum Insured once in a
Policy Year, provided that:
(a) The Sum Insured inclusive of earned Cumulative Bonus (if any) is
insufficient as a result of previous claims in that Policy Year.
(b) The Restored Sum Insured shall not be available for claims
towards an Illness/ disease/ Injury (including its complications)
for which a claim has been paid in the current Policy Year for the
same Insured Person under In- patient hospitalization under
Section II.1, for Worldwide Emergency Cover Benefit under
Section II.8, Maternity Expenses under Section II.11.
II.11. Maternity Expenses:

We will cover Maternity Expenses up to limits for Maternity Sum
insured specified in the Schedule for the delivery of a child and /
or Maternity Expenses related to a Medically Necessary and
lawful termination of pregnancy up to maximum 2 deliveries or
terminations during the lifetime of an Insured Person between the
ages of 18 years to 45 years.
You understand and agree that:
(a) Our maximum liability per delivery or termination is subject to the
limits specified in the Schedule.
(b) The Insured Person should have been continuously covered
under this Policy for at least 48 months before availing this
Benefit, except in case of opting for 'Reduction in maternity
waiting' where the limit will be relaxed to 24 months of waiting.
(c) The cover under this Benefit shall be restricted to two live children
only.
(d) The payment towards any admitted claim under this Benefit for
any complication arising out of or as a consequence of maternity
or child birth will be restricted to limits specified in the Schedule
however any restored amount will not be available for coverage
under this section.
(e) Pre or post natal Maternity Expenses will be covered within the
Maternity Sum Insured under this Benefit however; any Pre or
Health Insurance
Post - hospitalisation Expenses paid under Section II.2 and II.3,

above will not be covered under this Benefit.
(f) Maternity Sum Insured available under Maternity Expenses will
be in addition to Sum Insured.
(g) We will not cover the following expenses under Maternity Benefit:
i)
Medical Expenses in respect of the harvesting and storage of

stem cells when carried out as a preventive measure against
possible future Illnesses.
conducted at Our Network Providers.

For Protect plan - Available once every 3rd Policy year
For Plus, Preferred and Premier Plan - Available at each renewal
(b) Original Copies of all reports will be provided to You, while a copy
of the same will be retained by Us.
Plan Name
Protect
Sum Insured Age

>18 years
` 2.5 Lacs,
` 3.5 Lacs,
` 4.5 Lacs,
Plus
`
`
`
`
4.5 Lacs,
5.5 Lacs,
7.5 Lacs,
10 Lacs
Preferred
& Premier
`
`
`
`
15 Lacs,
30 Lacs,
50 Lacs,
100 Lacs
ii) Medical Expenses for ectopic pregnancy. However, these

expenses will be covered under the In- patient Hospitalisation
under Section II.1.
under Section VII 4 & 5.
II.12. New Born Baby Expenses:
Subject to a claim being admitted under Maternity Expenses
Cover under Section II.11, We will cover.
(a) Medical Expenses towards treatment of the New Born Baby while
the Insured Person is Hospitalised as an In-patient for delivery.
(b) The Reasonable and Customary Charges incurred on the New
Born Baby during and post birth up to 90 days from the date of
delivery, within the limits specified in the Schedule under
Maternity Expenses without payment of any additional premium.
c) Subject to the terms and conditions of the Policy, We will cover
the New Born Baby beyond 90 days on payment of requisite
premium for the New Born Baby into the Policy by way of an
endorsement or at the next Renewal, whichever is earlier.
II.13. First Year Vaccinations
We will cover Reasonable and Customary charges for vaccination
expenses for the New Born Baby as per National Immunization
Scheme (India) listed below, till the baby completes 1 year (12
months) upto the limits specified in the Schedule. Any restored
Sum Insured will not be available for coverage under this section.
We will continue to provide Reasonable and Customary charges for
vaccination of the New Born Baby until it completes 12 months, if
the Policy ends before the New Born Baby has completed one year.
Time Interval
0 - 3months
Vaccinations to be done (Age)
Frequency
BCG (Birth to 2 weeks)
OPV (0610 weeks) OR

OPV + IPV1 (6,10 weeks)
3 - 6 months
3 OR 4
DPT (6 & 10 week)
Hepatitis-B (0 & 6 week)
Hib (6 & 10 week)
OPV (14 week) OR OPV + IPV2
1 or 2
DPT (14 week)
Hepatitis-B (14 week)
Hib (14 week)
9 months
Measles (+9 months)
12 months
Chicken Pox (12 months)
under Section VII. 5.
III. VALUE ADDED COVERS:
III.1. Health Check Up:
(a) If the Insured Person has completed 18 years of Age, the Insured
Person may avail a comprehensive health check-up with Our
Network Provider as per the eligibility details mentioned in the
table below. Health Check Ups will be and arranged by Us and
List of tests
MER, ECG, Total
Cholesterol, FBS, Sr.
Creatinine, CBC, Urine
Routine, SGPT
18 to 40
MER, ECG,CBC-ESR,
years
Lipid Profile, HbA1c,
Sr. Creatinine, RUA,
SGOT, SGPT, GGT,
Uric Acid
> 41
MER, ECG,CBC-ESR,
years
Sr. Creatinine, RUA,
SGOT, SGPT, GGT,
Uric Acid
For females only TSH, Pap smear,
Mammogram
For Males only - PSA
18 to 40
MER, Lipid Profile,
years
HbA1c, Sr. Creatinine,
CBC-ESR, RUA,
SGPT, ECG, SGOT,
GGT, Uric Acid
For females: Pap
smear, TSH,
Mammogram
For males: PSA
> 41
MER, CBC-ESR,
years
(For males Sr. Creatinine, RUA,
only)
SGOT, SGPT, GGT,
Uric acid, TMT, USG
Abdomen, Pelvis, PSA
> 41
MER, CBC-ESR, Lipid
years
Profile, HbA1c, Sr.
(For females Creatinine, RUA,
only)
SGOT, SGPT, GGT,
TMT, Uric acid, USG
Abdomen & Pelvis,
Pap smear,
Mammogram, TSH
Full explanation of Tests is provided here: MER - Medical

Examination Report, FBS - Fasting Blood Sugar, GGT - GammaGlutamyl Transpeptidase, ECG - Electrocardiogram, CBC-ESR Complete Blood Count-Erythrocyte Sedimentation Rate, SGPT Test Serum Glutamic Pyruvate Transaminase, HbA1C Glycosylated Haemoglobin Test, RUA - Routine Urine Analysis,
SGOT - Serum Glutamic Oxaloacetic Transaminase, TSH Thyroid Stimulating Hormone, TMT - Tread Mill Test, USG Ultrasound Sonography, PSA - Prostate Specific Antigen, Pap
smear - Papanicolaou test
(c) Coverage under this value added cover will not be available on
reimbursement basis. All Claims under this benefit can be made
as per the process defined under Section VII. 16
(d) You understand and agree that the list of medical tests covered
above are indicative and We may add, modify or amend this list
on approval from the Head of Underwriting.
Health Insurance
III.2. Expert opinion on Critical Illness:

You may choose to secure a second opinion from Our Network of
Medical Practitioners, if an Insured Person is diagnosed with the
covered Critical Illness during the Policy Period. The expert
opinion would be directly sent to the Insured Person.
You understand and agree that You can exercise the option to
secure an expert opinion, provided:
(a) We have received a request from You to exercise this option.
(b) That the expert opinion will be based only on the information and
documentation provided by the Insured Person that will be
shared with the Medical Practitioner
(c) This benefit can be availed once by an Insured Person during a
Policy Year and once during the lifetime of an Insured Person for
the same Illness.
(d) This benefit is only a value added service provided by Us and
does not deem to substitute the Insured Person's visit or
consultation to an independent Medical Practitioner.
(e) The Insured Person is free to choose whether or not to obtain the
expert opinion, and if obtained then whether or not to act on it.
(f) We shall not, in any event be responsible for any actual or alleged
errors or representations made by any Medical Practitioner or in
any expert opinion or for any consequence of actions taken or not
taken in reliance thereon.
(g) The expert opinion under this Policy shall be limited to covered
Critical Illnesses and not be valid for any medico legal purposes.
subsequent Policy Year.

(g) If the Insured Persons in the expiring Policy are covered on an
individual basis and there is an accumulated Cumulative Bonus for
each Insured Person under the expiring Policy, and such expiring
Policy has been Renewed with Us on a Family Floater basis then
the Cumulative Bonus to be carried forward for credit in such
Renewed Policy shall be the lowest among all the Insured Persons.
(h) If the Insured Persons in the expiring Policy are covered on a
Family Floater basis and such Insured Persons renew their expiring
Policy with Us by splitting the Sum Insured in to two or more Family
Floater/individual policies then the Cumulative Bonus of the
expiring Policy shall be apportioned to such Renewed Policies in
the proportion of the Sum Insured of each Renewed Policy.
(i) If the Sum Insured has been reduced at the time of Renewal, the
applicable Cumulative Bonus shall be reduced in the same
proportion to the Sum Insured.
(j) If the Sum Insured under the Policy has been increased at the
time of Renewal the Cumulative Bonus shall be calculated on the
Sum Insured of the last completed Policy Year.
(k) Any earned Cumulative Bonus shall not be available for claims
under Maternity Expenses, New Born Baby Cover, First Year
Vaccination and Worldwide Emergency Cover.
(l) The Cumulative Bonus is provisional and is subject to revision if a
Claim is made in respect of the expiring Policy Year, which is
notified after the acceptance of renewal premium. Such awarded
Cumulative Bonus shall be withdrawn only in respect of the
expiring year in which the claim was admitted.
(h) We do not assume any liability towards any loss or damage

arising out of or in relation to any opinion, advice, prescription,
actual or alleged errors, omissions and representations made by
the Medical Practitioner.
(m) This clause does not alter Our right to decline a renewal or
cancellation of the Policy for reasons as mentioned under
Section VIII.16
(i) For the purpose of this benefit covered Critical Illnesses shall
include -
III.4. Healthy Rewards
Cancer of specific severity
First Heart Attack of specified severity
Open Chest CABG
Open Heart Replacement or Repair of Heart Valves
Coma of specified severity
Kidney Failure requiring regular dialysis
Stroke resulting in permanent symptoms
Major Organ/Bone Marrow Transplant
Permanent Paralysis of Limbs
Motor Neurone Disease with permanent symptoms
Multiple Sclerosis with persisting symptoms

defined under Section VII.15.
III.3. Cumulative Bonus

We will increase Your Sum Insured as per the plan opted, at the
end of the Policy Year if the Policy is renewed with Us provided that
there are no claims paid/outstanding in the expiring Policy Year:
(a) If the Policy is a Family Floater Policy as specified in the
Schedule, then the Cumulative Bonus will accrue only if no claims
have been made in respect of all the Insured Persons in the
expiring Policy Year.
(b) No Cumulative Bonus will be added if the Policy is not renewed
with Us by the end of the Grace Period.
(c) The Cumulative Bonus will not be accumulated in excess of 50%
of the Sum Insured under the first Policy with Us.
(d) Any earned Cumulative Bonus will not be reduced for claims
made in the future.
(e) Wherever the earned Cumulative Bonus is used for payment of a
claim during a particular Policy Year, the balance Cumulative
Bonus if any will be carried forward to the next Policy Year.
(f) If the Policy Period is two years, any Cumulative Bonus that has
accrued for the first Policy Year will be credited at the end of the
first Policy Year and will be available for any claims made in the
We will provide for reward points equivalent to 1% of premium

paid for each Policy. In addition to this You can accumulate
rewards by opting for Our online wellness programs that will help
You to assess Your health status and aid in improving Your overall
well-being. Each program can be opted once by a particular
Insured Person and a maximum of 5 such online programmes
can be availed during the year to earn rewards.
Details of available online programs and rewards that can be
accrued are provided below Online
Program
Reward
Points
under
Protect Plan
Reward
Points
under
Plus Plan
Reward
Points
under
Preferred
Reward
Points to be
earned under
Premier Plan
25
40
80
120
Targeted
Risk
Assessment
(TRA)
50
80
160
240
Online
Lifestyle
Management
Program
(LMP)
50
80
160
240
Health Risk
Assessment
(HRA)
Each earned reward point will be valued at Rupee 1. All

accumulated reward points can be redeemed in the following
ways a) A discount in premium from the 3rd annual premium
b) Equivalent value of Health Maintenance Benefits (either in
physical or electronic form) from third Policy Year.
IV. OPTIONAL COVERS
The following optional covers shall apply under the Policy for an
Insured Person if specifically mentioned on the Schedule and
Health Insurance
shall apply to all Insured Persons under a single policy without

any individual selection.
IV.1. Deductible:
We will provide for a Deductible on specific Sum Insured Options.
Where ever a Deductible is selected such amounts will be applied
for each Policy Year on the aggregate of all Claims in that Policy
Year other than for claims under fixed Benefit Covers, Health
Maintenance Benefit and Health Check Ups. Any Voluntary Copay shall not apply to plans with Deductible option.
For the purpose of calculating the deductible and assessment of
admissibility all claims must be submitted in accordance with
Section VII.19 of Claims Process. All other terms, conditions,
waiting periods and exclusions shall apply.
IV.2. Reduction in Maternity Waiting:
We will provide for a waiver of waiting period for Maternity
Expenses (Section II.11) from 48 months to 24 months from the
date of inception of first Policy with Us.
New Born Baby cover and first year vaccinations will follow
reduction in waiting period under Maternity Expenses Cover.
All other terms, conditions and exclusions under Maternity
Expenses Cover (Section II.11) shall apply.
IV.3. Voluntary Co-Pay:
Irrespective of the Age and number of claims made by the Insured
Person and subject to the Co-payment option chosen by You, it is
agreed that We will only pay 90% or 80% of any amount that We
assess for the payment or reimbursement in respect of any Claim
under the Policy made by that Insured Person and the balance
will be borne by the Insured Person.
Co-pays shall not apply to fixed Benefit Covers, Health
Maintenance Benefit and Health Check-Ups.
V. WAITING PERIODS
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. All the waiting
period shall be applicable individually for each Insured Person
and claims shall be assessed accordingly.
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, Oestoarthritis and
Osteoposrosis, Joint Replacement Surgery (other than caused
by Accident), Prolapse of Intervertibral discs (other than caused
by Accident), all Vertibrae Disorders, including but not limited to
Spondylitis, Spondylosis, 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 anomoly,
vii) Fissure, Fistula in anus, Piles, all types of Hernia, Pilonidal sinus,
Hemorrhoids 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 tumors/ skin tumors, and any type of Breast
lumps(unless malignant), Polycystic Ovarian Diseases,
x) Any surgery of the genito-urinary system unless necessitated by
malignancy.
If these diseases are pre-existing at the time of proposal or
subsequently found to be pre-existing the pre-existing waiting
periods as mentioned in the Schedule to this Policy shall apply.
V.4. Maternity Waiting Period
Any treatment arising from or traceable to pregnancy, childbirth
including caesarean section until 48 months of continuous
coverage has elapsed for the particular Insured Person since the
inception of the first Policy with Us. However, this exclusion/
waiting period will not apply to Ectopic Pregnancy proved by
diagnostic means and certified to be life threatening by the
attending Medical Practitioner.
Wherever Optional Cover for 'Reduction in Maternity Waiting
Period' has been applied this limit will be reduced to 24 months of
continuous cover.
V.5. Personal Waiting period:
V.1. Pre-existing Disease Waiting Period

All Pre-existing Diseases/ Illness/ Injury/ conditions as defined in
the Policy, until 24/ 36/ 48 (as specified in the Schedule) months
of continuous covers have elapsed since inception of the first
Policy with Us. This exclusion doesnt apply for Insured Person
having any health insurance indemnity policy in India at least for a
period of 12/24/36/48 months as applicable, prior to taking this
Policy and accepted under portability cover, as well as for
subsequent Renewals with Us without a break.
V.2. 30 days Waiting Period
Any disease contracted and/or Medical Expenses incurred in
respect of any Pre-existing Disease/ Illness by the Insured/
Insured Person during the first 30 days from the inception date of
the Policy will not be covered.
This exclusion doesn't apply for Insured Person having any health
insurance indemnity policy in India at least for a period of 30 days
prior to taking this Policy and accepted under portability cover, as
well as for subsequent Renewals with Us without a break.
VI PERMANENT EXCLUSIONS
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:
1. Genetic disorder and stem cell implantation/surgery, harvesting,
storage or any kind of treatment using stem cells.
2. Dental treatment, dentures or surgery of any kind unless
necessitated due to an accident and requiring minimum 24 hours
hospitalization or treatment of irreversible bone disease involving
the jaw which cannot be treated in any other way, but not if it is
related to gum disease or tooth disease or damage.
3. Circumcision unless necessary for treatment of a disease, illness
or injury not excluded hereunder or due to an accident.
A waiting period of 24 months shall apply to the treatment, of the

following, whether medical or surgical for all Medical Expenses
along with their complications on treatment towards:
4. Birth control procedures, contraceptive supplies or services

including complications arising due to supplying services,
hormone replacement therapy and voluntary termination of
pregnancy during the first 12 weeks from the date of conception,
surrogate or vicarious pregnancy.
Cataract,
5. Routine medical, eye and ear examinations, cost of spectacles,
V.3. Two year waiting period
i)
A special Waiting Period not exceeding 48 months, may be

applied to individual Insured Persons depending upon
declarations on the proposal form and existing health conditions.
Such waiting periods shall be specifically stated in the Schedule
and will be applied only after receiving Your specific consent.
Health Insurance
laser surgery for cosmetic purposes or corrective surgeries,

contact lenses or hearing aids, cochlear implants, vaccinations
except post-bite treatment or for new born baby up to 90 days,
any physical, psychiatric or psychological examinations or
testing, any treatment and associated expenses for alopecia,
baldness, wigs, or toupees and hair fall treatment & products,
issue of medical certificates and examinations as to suitability for
employment or travel.
6. Laser Surgery for treatment of focal error correction other than for
focal error of +/- 7 or more and is medically necessary.
7. All expenses arising out of any condition directly or indirectly
caused due to or associated with human T-call Lymph tropic virus
type III (HTLV-III or IITLB-III) or Lymphadinopathy Associated
Virus (LAV) and its variants or mutants, Acquired Immune
Deficiency Syndrome (AIDS) whether or not arising out of HIV,
AIDS related complex syndrome (ARCS) and all diseases /
illness / injury caused by and/or related to HIV.
8. All sexually transmitte d diseases including but not limited to
Genital Warts, Syphilis, Gonorrhoea, Genital Herpes, Chlamydia,
Pubic Lice and Trichomoniasis.
9. Vitamins and tonics unless forming part of treatment for disease,
illness or injury and prescribed by a Medical Practitioner.
10. Instrument used in treatment of Sleep Apnea Syndrome (C.P.A.P.)
and Continuous Peritoneal Ambulatory Dialysis (C.P.A.D.) and
Oxygen Concentrator for Bronchial Asthmatic condition, Infusion
pump or any other external devices used during or after treatment.
11. Artificial life maintenance, including life support machine use,
where such treatment will not result in recovery or restoration of
the previous state of health.
12. Treatment for developmental problems including learning
difficulties eg. Dyslexia, behavioural problems including attention
deficit hyperactivity disorder(ADHD)
13. Treatment for general debility, ageing, convalescence,
sanatorium treatment, rehabilitation measures, private duty
nursing, respite care, run down condition or rest cure, congenital
external anomalies or defects, sterility, fertility, infertility including
IVF and other assisted conception procedures and its
complications, subfertility, impotency, venereal disease, puberty,
menopause or intentional self-injury, suicide or attempted
suicide(whether sane or insane).
14. Certification / Diagnosis / Treatment by a family member, or a
person who stays with the Insured Person, or from persons not
registered as Medical Practitioners under the respective Medical
Councils, or from a Medical Practitioner who is practicing outside
the discipline that he is licensed for, or any diagnosis or treatment
that is not scientifically recognized or experimental or unproven,
or any form of clinical trials or any kind of self-medication and its
complications.
21. Any cosmetic surgery, aesthetic treatment unless forming part of

treatment for cancer or burns, surgery for sex change or
treatment of obesity/morbid obesity (unless certified to be life
threatening) or treatment / surgery / complications / illness arising
as a consequence thereof.
22. Treatment received outside India other than for coverage under
World Wide Emergency Cover, Expert Opinion on Critical
Illnesses.
23. Any robotic, remote surgery or treatment using cyber knife.
24. Charges incurred primarily for diagnostic, X-ray or laboratory
examinations or other diagnostic studies not consistent with or
incidental to the diagnosis and treatment even if the same
requires confinement at a Hospital.
25. Costs of donor screening or costs incurred in an organ transplant
surgery involving organs not harvested from a human body.
26. Any form of Non-Allopathic treatment, Naturopathy, hydrotherapy,
Ayurvedic, Homeopathy, Acupuncture, Reflexology, Chiropractic
treatment or any other form of indigenous system of medicine.
27. Insured Persons whilst engaging in speed contest or racing of
any kind (other than on foot), bungee jumping, parasailing,
ballooning, parachuting, skydiving, paragliding, hang gliding,
mountain or rock climbing necessitating the use of guides or
ropes, potholing, abseiling, deep sea diving using hard helmet
and breathing apparatus, polo, snow and ice sports or involving a
naval military or air force operation.
28. Insured Person whilst flying or taking part in aerial activities
(including cabin crew) except as a fare-paying passenger in a
regular scheduled airline or air Charter Company.
29. All expenses caused by ionizing radiation or contamination by
radioactivity from any nuclear fuel or from any nuclear waste from
the combustion of nuclear fuel.
30. All expenses directly or indirectly, caused by or arising from or
attributable to foreign invasion, act of foreign enemies, hostilities,
warlike operations (whether war be declared or not or while
performing duties in the armed forces of any country), civil war,
public defense, rebellion, revolution, insurrection, military or
usurped power.
31. All non-medical expenses including but not limited to
convenience items for personal comfort not consistent with or
incidental to the diagnosis and treatment of the disease/illness/
injury for which the Insured Person was hospitalized, Ambulatory
devices, walker, crutches, belts, collars, splints, slings, braces,
stockings of any kind, diabetic footwear, glucometer/
thermometer and any medical equipment that is subsequently
used at home except when they form part of room expenses.
For complete list of Non-medical expenses, Please refer to the
Annexure IV "Non Medical Expenses.
15. Ailment requiring treatment due to use, abuse or a consequence

or influence of an abuse of any substance, intoxicant, drug, alcohol
or hallucinogen and treatment for de-addiction, or rehabilitation.
32. Non-Medical Expenses including but not limited to RMO charges,

surcharges, night charges, service charges levied by the hospital
under whatever head, registration/admission charges.
16. Any illness or hospitalisation arising or resulting from the Insured

Person or any of his family members committing any breach of
law with criminal intent.
33. Any deductible amount or percentage of admissible claim under

co-pay if applicable and as specified in the Schedule to this Policy.
17. Any treatment received in convalescent homes, convalescent

hospitals, health hydros, nature cure clinics or similar
establishments.
18. Prostheses, corrective devices and medical appliances, which
are not required intra-operatively for the disease/ illness/ injury
for which the Insured Person was hospitalised.
19. Any stay in Hospital without undertaking any treatment or any
other purpose other than for receiving eligible treatment of a type
that normally requires a stay in the hospital.
20. Treatment of any mental illness or sickness or disease including a
psychiatric condition, disorganization of personality or mind, or
emotions or behaviour, including stress, Parkinsons or
Alzheimer's disease even if caused or aggravated by or related to
an Accident or Illness or general debility or exhaustion ("rundown condition").
34. Any physical, medical or mental condition or treatment or service

that is specifically excluded in the Policy Schedule under Special
Conditions.
VII. CLAIM PROCESS & MANAGEMENT
VII.1. Condition Preceding
The fulfilment of the terms and conditions of this Policy (including
the realization of premium by their respective due dates) in so far
as they relate to anything to be done or complied with by You or
any Insured Person, including complying with the following steps,
shall be the condition precedent to the admissibility of the claim.
Completed claim forms and processing documents must be
furnished to Us within the stipulated timelines for all
reimbursement claims. Failure to furnish this documentation
within the time required shall not invalidate nor reduce any claim if
10
Health Insurance
You can satisfy Us that it was not reasonably possible for You to
submit / give proof within such time.
The due intimation, submission of documents and compliance
with requirements as provided under the Claims Process under
this Section, by You shall be essential failing which We shall not
be bound to accept a claim.
Cashless and Reimbursement Claim processing and access to
network hospitals is through our service partner, details of the
same will be available on the Health Card issued by Us as well as
on our website. For the latest list of network hospitals you can log
on to our website.
VII.2. Policy Holder's / Insured Persons Duty at the time of Claim
You are required to check the applicable list of Network Providers,
at Our website or call center before availing the Cashless services.
On occurrence of an event which may lead to a Claim under this
Policy, You shall:
(a) Forthwith intimate, file and submit the Claim in accordance to the
Claim Procedure defined under Section VII.3, VII.4, VII.5 as
mentioned below.
(b) Follow the directions advice or guidance provided by a Medical
Practitioner. We shall not be obliged to make any payment(s) that
are brought about or contributed to, as a consequence of failure
to follow such directions, advice or guidance.
c) If so requested by Us, You or the Insured Person must submit
himself/ herself for a medical examination by Our nominated
Medical Practitioner as often as We consider reasonable and
necessary. The cost of such examination will be borne by Us.
(d) Allow the Medical Practitioner or any of Our representatives to
inspect the medical and Hospitalization records, investigate the
facts and examine the Insured Person.
(a) For Planned Hospitalization:

i.
ii. The Network Provider will issue the request for authorization
letter for Hospitalization in the pre-authorization form prescribed
by the IRDA.
iii. The Network Provider shall electronically send the pre authorization
form along with all the relevant details to the 24 (twenty four) hour
authorization/ cashless department along with contact details of the
treating Medical Practitioner & the Insured Person.
iv. Upon receiving the pre-authorization form and all related medical
information from the Network Provider, We will verify the eligibility
of cover under the Policy.
v. Wherever the information provided in the request is sufficient to
ascertain the authorisation We shall issue the authorisation
Letter to the Network Provider. Wherever additional information
or documents are required We will call for the same from the
Network provider and upon satisfactory receipt of last necessary
documents the authorisation will be issued. All authorisations will
be issued within a period of 4 hours from the receipt of last
complete documents.
vi. The Authorisation letter will include details of sanctioned amount,
any specific limitation on the claim, any co-pays or deductibles
and non-payable items if applicable.
vii. The authorisation letter shall be valid only for a period of 15 days
from the date of issuance of authorization.
In the event that the cost of Hospitalization exceeds the
authorized limit as mentioned in the authorization letter:
i.
(e) Assist and not hinder or prevent Our representatives in pursuance

of their duties for ascertaining the admissibility of the claim, its
circumstances and its quantum under the provisions of the Policy.
VII.3. Claim Intimation
Upon the discovery or occurrence of any Illness / Injury that may
give rise to a Claim under this Policy, You / Insured Person shall
undertake the following:
In the event of any Illness or Injury or occurrence of any other
contingency which has resulted in a Claim or may result in a claim
covered under the Policy, You / the Insured Person, must notify
Us either at the call center or in writing, in the event of:
Planned Hospitalization, You/the Insured Person will intimate such

admission at least 3 days prior to the planned date of admission.
Emergency Hospitalization, You / the Insured Person will intimate

such admission within 48 hours of such admission.
The following details are to be provided to Us at the time of
intimation of claim
The Insured Person should at least 3 days prior to admission to

the Hospital approach the Network Provider for Hospitalization
for medical treatment.
The Network Provider shall request Us for an enhancement of

authorisation limit as described under Section VII.4 (a) including
details of the specific circumstances which have led to the need
for increase in the previously authorized limit. We will verify the
eligibility and evaluate the request for enhancement on the
availability of further limits.
ii. We shall accept or decline such additional expenses within 24

(twenty-four) hours of receiving the request for enhancement
from You.
In the event of a change in the treatment during Hospitalization to
the Insured Person, the Network Provider shall obtain a fresh
authorization letter from Us in accordance with the process
described under VII.4 (a) above.
At the time of discharge:
i.
the Network Provider may forward a final request for

authorization for any residual amount to us along with the
discharge summary and the billing format in accordance with the
process described at VII.4.(a) above.
ii. Upon receipt of the final authorisation letter from us, You may be
discharged by the Network Provider.
Policy Number
(b) In case of Emergency Hospitalisation
Name of the Policyholder
i.
Name of the Insured Person in whose relation the Claim is being

lodged
Nature of Illness / Injury
Name and address of the attending Medical Practitioner & Hospital
Date of Admission
Any other information as requested by Us
VII.4. Cashless Facility

Cashless facility is available only at our Network Hospital. The
Insured Person can avail Cashless facility at the time of
admission into any Network Hospital, by presenting the health
card as provided by Us with this Policy, along with a valid photo
identification proof (Voter ID card/ Driving License/ Passport/
PAN Card/ any other identity proof as approved by Us).
The Insured Person may approach the Network Provider for

Hospitalization for medical treatment.
ii. The Network Provider shall forward the request for authorization
within 48 hours of admission to the Hospital as per the process
under Section VII.4 (a).
iii. It is agreed and understood that we may continue to discuss the
Insured Person's condition with the treating Medical Practitioner
till Our recommendations on eligibility of coverage for the Insured
Person are finalised.
iv. In the interim, the Network Provider may either consider treating
the Insured Person by taking a token deposit or treating him as
per their norms in the event of any lifesaving, limb saving, sight
saving, Emergency medical attention requiring situation.
v. The Network Provider shall refund the deposit amount to You
barring a token amount to take care of non-covered expenses
once the pre-authorization is issued.
11
Health Insurance
Note: Cashless facility for Hospitalization Expenses shall be

limited exclusively to Medical Expenses incurred for treatment
undertaken in a Network Hospital for Illness or Injury which are
covered under the Policy and shall not be available to the Insured
Person for coverage under Worldwide Emergency Cover (Section
II.8) For all Cashless authorisations, You will, in any event, be
required to settle all non-admissible expenses, Co-payment and/
or De.ductibles (if applicable), directly with the Hospital.
The Network Provider will send the claim documents along with the
invoice and discharge voucher, duly signed by the Insured Person
directly to us. The following claim documents should be submitted
to Us within 15 days from the date of discharge from Hospital -
In case You/ Insured Person delay submission of claim

documents as specified in 5.(a) above, then in addition to the
documents mentioned in VII.5. (a) above, You are also required
to provide Us the reason for such delay in writing.
We will accept such requests for delay up to an additional period
of 30 days from the stipulated time for such submission. We will
condone delay on merit for delayed Claims where the delay has
been proved to be for reasons beyond Your/Insured Persons
control.
VII.6. Scrutiny of Claim Documents
Claim Form Duly Filled and Signed
Original pre-authorisation request
a. We shall scrutinize the claim and accompanying documents. Any

deficiency of documents, shall be intimated to You and the Network
Provider, as the case may be within 5 days of their receipt.
b.
Copy of pre-authorisation approval letter (s)
Copy of Photo ID of Patient Verified by the Hospital
Original Discharge/Death Summary
Operation Theatre Notes(if any)
Original Hospital Main Bill and break up Bill
Original Investigation Reports, X Ray, MRI, CT Films, HPE
Doctors Reference Slips for Investigations/Pharmacy
Original Pharmacy Bills
MLC/FIR Report/Post Mortem Report (if applicable and conducted)

We may call for any additional documents as required based on
the circumstances of the claim
There can be instances where We may deny Cashless facility for
Hospitalization due to insufficient Sum Insured or insufficient
information to determine admissibility in which case You/Insured
Person may be required to pay for the treatment and submit the
claim for reimbursement to Us which will be considered subject to
the Policy Terms &Conditions.
We in our sole discretion, reserves the right to modify, add or
restrict any Network Hospital for Cashless services available
under the Policy. Before availing the Cashless service, the
Policyholder/Insured Person is required to check the applicable/
latest list of Network Hospital on the Company's website or by
calling our call centre.
VII.5. Claim Reimbursement Process

(a) Collection of Claim Documents
i.
Wherever You have opted for a reimbursement of expenses, You

may submit the following documents for reimbursement of the
claim to Our branch or head office at your own expense not later
than 15 days from the date of discharge from the Hospital. You
can obtain a Claim Form from any of our Branch Offices or
download a copy from our website www.cignattkinsurance.in
ii. List of necessary claim documents to be submitted for

reimbursement are as following:
Claim form duly signed
Copy of photo ID of patient
Hospital Discharge summary
Operation Theatre notes
Hospital Main Bill
Hospital Break up bill
Investigation reports
Original investigation reports, X Ray, MRI, CT films, HPE, ECG
Doctors reference slip for investigation
Pharmacy Bills
MLC/FIR report, Post Mortem Report if applicable and conducted

We may call for any additional documents/ information as
required based on the circumstances of the claim.
a. Our branch offices shall give due acknowledgement of collected

documents to You.
If the deficiency in the necessary claim documents is not met or

are partially met in 10 working days of the first intimation, We shall
remind You of the same and every 10 (ten) days thereafter.
c. We will send a maximum of 3 (three) reminders following which

We will send a closure letter.
d. We may at our sole discretion decide to deduct the amount of
claim for which deficiency is intimated to the insured person and
settle the claim if we observe that such a claim is otherwise valid
under the policy.
e. In case a reimbursement claim is received when a PreAuthorization letter has been issued, before approving such claim a
check will be made with the provider whether the Pre-authorization
has been utilized as well as whether the Policyholder has settled all
the dues with the provider. Once such check and declaration is
received from the Provider, the case will be processed.
VII.7. Claim Assessment
We will assess all admissible claims under the Policy in the
following progressive order a) For Plans without Deductible Option
i)
If the provisions of the Contribution Clause apply, (under Section

VIII.10), Our liability to make payment under the claim shall be
first apportioned accordingly.
ii) Where a room accommodation is opted for higher than the eligible
room category under the plan, the room rent for the applicable
accommodation will be apportioned. Such apportioned amount
will apply to all "Associated Medical Expenses".
iii) Any Voluntary or Mandatory Co-payment shall be applicable on
the amount payable after applying the Section VII.7 a (i) and (ii)
b) For Plans with Deductible Option
i)
If the claim amount is higher than the deductible, and if the

provisions of the Contribution Clause apply, (under Section
VIII.10), Our liability to make payment under the claim shall be
first apportioned accordingly. Where the claim amount is within
the Deductible we will not apply the Contribution Clause (under
Section VIII.10.)
ii) Where a room accommodation is opted for higher than the eligible
room category under the plan, the room rent for the applicable
accommodation will be apportioned. Such apportioned amount
will apply to all "Associated Medical Expenses".
iii) Arrived admissible claim amount will be assessed against the
deductible.
iv) Any Mandatory Co-payment shall be applicable on the amount
payable after applying the Section VII.7 b (i), (ii) & (iii)
c) The Claim amount assessed under Section VII.7 a) and b) will be
deducted from the following amounts in the following progressive
order i)
Deductible & Co-pays (if opted)
ii) Mandatory Copays
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Health Insurance
iii) Sum Insured

iv) Cumulative Bonus
v) Restored Sum Insured
VII.8. Re-opening of Claim
We may allow a closed claim to be reopened depending on the
validity and the circumstances of the claim.
VII.9. Claims Investigation
We may investigate claims at Our own discretion to determine the
validity of claim. Such investigation shall be concluded within 15
days from the date of assigning the claim for investigation and not
later than 6 months from the date of receipt of claim intimation.
Verification carried out, if any, will be done by individuals or
entities authorised by Us to carry out such verification/
investigation(s) and the costs for such verification/ investigation
shall be borne by the Us.
VII.10. Pre and Post-hospitalization claims
You should submit the Post-hospitalization claim documents at
Your own expense within 15 days of completion of Posthospitalization treatment or eligible post hospitalization period of
cover, whichever is earlier.
We shall receive Pre and Post- hospitalization claim documents
either along with the inpatient Hospitalization papers or
separately and process the same based on merit of the claim
derived on the basis of documents received.
VII.11. Settlement & Repudiation of a claim
We shall settle a Claim including its rejection within 30 days of the
receipt of the last "necessary" documents.
In case of suspected frauds, the last "necessary" document shall
mean the receipt of verification/ investigation report to determine
the validity of the claim as stated in VII.9.above.
In the cases of delay in the payment, We shall be liable to pay
interest at a rate which is 2% above the bank rate prevalent at the
beginning of the financial year in which the claim is reviewed by Us.
then such relapse shall be deemed to be part of the same claim

and all the limits for "Any One Illness" under this Policy shall be
applied as if they were under a single claim.
For Cashless Claims, the payment shall be made to the Network
Hospital whose discharge would be complete and final.
For Reimbursement Claims, the payment will be made to you. In
the unfortunate event of Your death, We will pay the nominee (as
named in the Policy Schedule) and in case of no nominee to the
Legal Heir who holds a succession certificate or Indemnity Bond
to that effect, whichever is available and whose discharge shall
be treated as full and final discharge of its liability under the Policy.
Claim process Applicable to the following Sections:
VII.15. Health Maintenance Benefit
(a) Submission of claim
You can send the Health Maintenance Benefit claim form along
with the invoices, treating Medical Practitioner's prescription,
reports, duly signed by You/ Insured Person as the case may be,
to Our branch office or Head Office. The Health Maintenance
Benefit can be claimed only once during the Policy Period to the
extent of limit under this benefit.
(b) Assessment of Claim Documents
We shall assess the claim documents and assess the
admissibility of claim.
(c) Settlement & Repudiation of a claim
We shall settle claims, including its rejection, within 5 (five)
working days of the receipt of the last 'necessary' document but
not later than 30 days.
VII.16. Expert Opinion on Critical Illness
(a) Receive Request for Expert Opinion on Critical Illness
You can submit Your request for a expert opinion by calling Our
call centre or register request through email.
(b) Facilitating the Process
We will schedule an appointment or facilitate delivery of Medical
Records of the Insured Person to a Medical Practitioner. The
expert opinion is available only in the event of the Insured Person
being diagnosed with Covered Critical Illness.
VII.12 Representation against Rejection:

Where a rejection is communicated by Us, the You may if so
desired within 15 days represent to Us for reconsideration of the
decision.
VII.13. Claims falling in 2 policy periods
If the claim event falls within two Policy Periods, the claims shall
be paid taking into consideration the available Sum Insured in the
two Policy Periods, including the Deductibles for each Policy
Period. The admissible claim amount shall be reduced to the
extent of premium to be received for the Renewal/due date of
premium of health insurance policy, if not received earlier. In case
of a Claim under Maternity Expenses the Maternity Sum Insured
under the first Policy will be the maximum limit available.
VII.14. Payment Terms
VII.17. Health Check up

(a) You or The Insured Person shall seek appointment by calling Our
call centre.
(b) We will facilitate Your appointment and We will guide You to the
nearest Network Provider for conducting the medical
examination. Reports of the Medical Tests can be collected
directly from the centre. A copy of the medical reports will be
retained by the medical centre which will be forwarded to Us
along with the invoice for reimbursement.
VII.18. Worldwide Emergency Cover
a) In an unlikely event of You or the Insured Person requires
Emergency medical treatment outside India, You or Insured
Person, must notify Us either at Our call centre or in writing within
48 hours of such admission.
The Sum Insured opted under the Plan shall be reduced by the
amount payable/ paid under the Benefit(s) and the balance shall
be available as the Sum Insured for the unexpired Policy Period.
b) You shall file a claim for reimbursement in accordance with

Section VII.5 of the Policy.
We are not obliged to make payment for any Claim or that part of
any Claim that could have been avoided or reduced if You/
Insured Person could reasonably have minimized the costs
incurred, or that is brought about or contributed to by You/Insured
Person failing to follow the directions, advice or guidance
provided by a Medical Practitioner.
VII.19. Deductible
If You/ Insured Person suffers a relapse within 45 days of the date

of discharge from the Hospital for which a claim has been made,
a) Any claim towards hospitalisation during the Policy Period must

be submitted to Us for assessment in accordance with the claim
process laid down under Section VII.4 and Section VII.5.towards
cashless or reimbursement respectively in order to assess and
determine the applicability of the Deductible on such claim. Once
the claim has been assessed, if any amount becomes payable
after applying the deductible, We will assess and pay such claim
13
Health Insurance
in accordance with Section VII.6. and VII. 7.b).
VIII.8. Geography
b) Wherever such hospitalisation claims as stated under VII.19. a)

above is being covered under another Policy held by You, We will
assess the claim on available photocopies duly attested by Your
Insurer / TPA as the case may be.
VIII. GENERAL TERMS AND CONDITIONS
The geographical scope of this policy applies to events within

India other than for Worldwide Emergency Cover and which are
specifically covered in the Schedule. However all admitted or
payable claims shall be settled in India in Indian rupees.
VIII.9. Subrogation
You and/ or any Insured Person will do or concur in doing or
permit to be done all such acts and things that may be necessary
or reasonably required by Us for the purpose of enforcing and/or
securing any civil or criminal rights and remedies or obtaining
relief or indemnity from any other party to which We are/ or would
become entitled upon Us making any payment of a Claim under
this Policy, whether such acts or things shall be or become
necessary or required before or after its payment. Neither You nor
any Insured Person shall prejudice these subrogation rights in
any manner and provide Us with whatever assistance or
cooperation is required to enforce such rights. Any recovery that
We make pursuant to this clause shall first be applied to the
amounts paid or payable by Us under this Policy and any costs
and expenses incurred by Us for effecting a recovery, whereafter
We shall pay any balance remaining to You. This Section does
not apply to benefit sections.
VIII.1. Duty of Disclosure

The Policy shall be null and void and no benefit shall be payable
in the event of untrue or incorrect statements, misrepresentation,
mis-description or non-disclosure of any material particulars in
the proposal form, personal statement, declaration, claim form
declaration, medical history on the claim form and connected
documents, or any material information having been withheld by
You or any one acting on Your behalf, under this Policy. You
further understand and agree that We may at Our sole discretion
cancel the Policy and the premium paid shall be forfeited to Us.
VIII.2. Material Change
Material information to be disclosed includes every matter that
You are aware of, or could reasonably be expected to know, that
relates to questions in the Proposal Form and which is relevant to
Us in order to accept the risk of insurance and if so on what terms.
You must exercise the same duty to disclose those matters to Us
before the Renewal, extension, variation, endorsement or
reinstatement of the contract.
VIII.10. Contribution
If two of more policies are taken by You during the same period
from one or more Insurers to indemnify treatment costs and the
amount of claim is within the Sum Insured limit of any of the
policies, You will have the right to opt for a full settlement of Your
claim in terms of any of Your policies.
VIII.3. Observance of Terms and Conditions

The due observance and fulfilment of the terms and conditions
of the Policy (including the realisation of premium by their
respective due dates and compliance with the specified
procedure on all Claims) in so far as they relate to anything to
be done or complied with by You or any of the Insured Persons,
shall be the condition precedent to Our liability under this
Policy.
Where the amount to be claimed exceeds the Sum Insured under

a single policy after considering Deductibles, Co-pays (if
applicable), You can choose the insurer with which You would like
to settle the claim. Wherever We receive such claims We have
the right to apply the Contribution clause while settling the claim.
VIII.11. Mandatory Co-pay
A compulsory Co-payment of 20% is applicable on all claims for
Insured Persons aged 65 years and above irrespective of age of
entry in to the Policy. Co-pay will be applied on the admissible
claim amount.
VIII.4. Reasonable Care

You/Insured Person understands and agrees to take all
reasonable steps in order to safeguard against any Accident or
Illnesses that may give rise to any claim under this Policy.
In case the Insured has selected the Voluntary co-pay (Section

IV.3), and / or if he chooses to take treatment out of Zone then the
co-pay percentages will apply in conjunction.
VIII.5. Alterations in the Policy

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 Us.
VIII.6. Change of Policyholder
The policyholder may be changed only at the time of Renewal of
the Policy. The new policyholder must be a member of the Insured
Person's immediate family. Such change would be solely subject
to Our discretion and payment of premium by You. The renewed
Policy shall be treated as having been renewed without break.
The policyholder may be changed upon request in case of his
demise, his moving out of India or in case of divorce during the
Policy Period.
VIII.12. Multiple Policies

In case of two or more policies taken by an Insured Person during
a period from one or more insurer, the Contribution Section under
VIII.10 shall not apply where the cover/benefit offered:
Is fixed in Nature
Does not have any relation to the treatment costs/same Illness

In case of multiple policies which provide fixed benefits, on
occurrence of the insured event in accordance with the terms and
conditions of the Policy, We will make the claim payment
independent of payments received under similar policies.
In case where such multiple policies are issued by Us, We will not
be liable to pay for more than the amount payable under the
highest of all such policies. All other Polices will be cancelled from
inception and full premium will be refunded.
VIII.7. No Constructive Notice

Any knowledge or information of any circumstance or condition in
relation to the Policyholder/ Insured Person which is in Our
possession and not specifically informed by the Policyholder/
Insured Person shall not be held to bind or prejudicially affect Us
notwithstanding subsequent acceptance of any premium.
VIII.13. Special Provisions

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.
14
Health Insurance
VIII.14. Records to be maintained
VIII.18. Renewal Terms
You or the Insured Person, as the case may be shall keep an

accurate record containing all relevant medical records and shall
allow Us or our representative(s) to inspect such records. You or
the Insured Person as the case may be, shall furnish such
information as may be required by Us 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.
VIII.15. Free Look period
A period of 15 days from the date of receipt of the Policy
document is available to review the terms and conditions of this
Policy. The Insured has the option of cancelling the Policy stating
the reasons for cancellation. If there are no claims reported
(paid/outstanding) under the Policy then We shall refund the full
premium. All rights under this Policy shall immediately stand
extinguished on the free look cancellation of the Policy.
Free look Period shall not be available on Renewal of this Policy
as well as to Portability Policies.
VIII.16. Cancellation
Request for Cancellation shall be intimated to Us from Your side
by giving 15 days' notice in which case we shall refund the
premium for the unexpired term as per the short period scale
mentioned below.
Premium shall be refunded only if no claim has been made under
the Policy.
1 Year
Policy in
force upto
Premium
Refund %
b. The premium payable on Renewal shall be paid to Us on or before

the Policy Period end date and in any event before the expiry of the
Grace Period. Policy would be considered as a fresh policy if there
would be break of more than 30 days between the previous policy
expiry date and current Policy start date. We, however shall not be
liable for any claim arising out of an ailment suffered or
Hospitalisation commencing or disease/ illness/ condition
contracted during the period between the expiry of previous policy
and date of inception of subsequent policy and such disease/
Illness/ condition shall be treated as a Pre-existing Condition.
c. Renewals will not be denied except on grounds of
misrepresentation, fraud, non-disclosure or non-co-operation by
You.
d. Where We have discontinued or withdrawn this product/ plan You
will have the option to renewal under the nearest substitute Policy
being issued by Us, provided however benefits payable shall be
subject to the terms contained in such other policy which has
been approved by IRDA.
e. Insured Person shall disclose to Us in writing of any material
change in the health condition at the time of seeking Renewal of
this Policy, irrespective of any claim arising or made. The terms
and condition of the existing policy will not be altered.
f.
2 year
Policy in
force upto
Premium
Refund %
1 Month
75%
1 Month
87.5%
3 months
50%
3 months
75%
6 months
25%
6 months
62.5%
More than
NIL
12 months
50%
6 months
a. This Policy will automatically terminate at the end of the Policy

Period. This Policy is ordinarily renewable on mutual consent for
life, subject to application of Renewal and realization of Renewal
premium.
15 months
37.50%
18 months
25%
Above 18 months
NIL
You further understand and agree that We may cancel the Policy
by giving 15 days' notice in writing by Registered Post
Acknowledgment Due/recorded delivery to Your last known
address on grounds of misrepresentation, fraud, non-disclosure
of material fact or for non-co-operation by You without any refund
of premium.
An individual policy with a single insured shall automatically
terminate in case of Your death or if You are no longer a resident
of India. In case of an Individual Policy with multiple Insured
Persons and in case of a floater, the Policy shall continue to be in
force for the remaining members of the family up to the expiry of
current Policy Period. The Policy may be Renewed on an
application by another adult Insured Person under the Policy
whenever such is due. In case, the Insured Person is minor, the
Policy shall be renewed only through any one of his/her natural
guardian or guardian appointed by Court. All relevant particulars
in respect of such person (including his/her relationship with You)
must be given to Us along with the Application.
VIII.17. Grace Period
The Policy may be renewed by mutual consent and in such event
the Renewal premium should be paid to Us 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. We will not be liable to pay for
any claim arising out of an Injury/Accident/Condition that occurred
during the Grace Period. The provisions of Section 64VB of the
Insurance Act shall be applicable. All policies Renewed within the
Grace Period shall be eligible for continuity of cover.
We may in Our sole discretion, revise the Renewal premium

payable under the Policy or the terms of cover, provided that the
Renewal premiums are approved by IRDA and in accordance
with the IRDA rules and regulations as applicable from time to
time. Renewal premiums will not alter based on individual claims
experience. We will intimate You of any such changes at least 3
months prior to date of such revision or modification.
g. Alterations like increase/ decrease in Sum Insured or Change in

Plan/Product, addition/deletion of members, addition deletion of
Medical Condition will be allowed at the time of Renewal of the
Policy. You can submit a request for the changes by filling the
proposal form before the expiry of the Policy. We reserve Our
right to carry out underwriting in relation to acceptance of request
for changes on renewal. The terms and conditions of the existing
policy will not be altered.
h. Any enhanced Sum Insured during any policy renewals will not
be available for an illness, disease, injury already contracted
under the preceding Policy Periods. All waiting periods as defined
in the Policy under Section V.1 to V.5 shall apply afresh for this
enhanced limit from the effective date of such enhancement.
i.
Wherever the Sum Insured is reduced on any Policy Renewals,

the waiting periods as defined under Section V.1 to V.5 shall be
waived only up to the lowest Sum Insured of the last 48/ 36/ 24
consecutive months as applicable to the relevant waiting periods
of the Plan opted.
j.
Where an Insured Person is added to this Policy, either by way of

endorsement or at the time of renewal, all waiting periods under
Section V.1 to V.5 will be applicable considering such Policy Year
as the first year of Policy with the Company.
k. Applicable Cumulative Bonus shall be accrued on each renewal

as per eligibility under the plan opted.
l.
Once an Insured Person attain age of 65 years on renewal a

compulsory co-payment of 20% will be applicable on all claims
irrespective of the age of entry in to the Policy.
m. In case of floater policies, children attaining 24 years at the time of

renewal will be moved out of the floater into an individual cover,
however all continuity benefits on the policy will remain intact.
Cumulative Bonus earned on the Policy will stay with the floater
cover.
15
Health Insurance
VIII.19. Premium calculation

Premium will be calculated based on the Sum Insured opted,
Age, gender, risk classification and Zone of Cover. Default Zone
of Cover will be based on Your City-Location based on Your
correspondence address.
Zone Classification
Sr.No.
List of Acceptable\ Medical Ailments

(subject to other co-existing conditions)
Applicable
Underwriting
Loading (In %)
Anal fistula
10
Anemia, Hemolytic
10
Asthma
15
Benign Prostatic Hyperplasia
10
Mumbai, Thane & Navi Mumbai and Delhi & NCR
Biliary stones
10
Zone II: Bangalore, Hyderabad, Chennai, Chandigarh, Ludhiana,

Kolkata, Gujarat
Cataract (if surgery not done)
10
Cholelithiasis
10
Zone I:
Zone III: Rest of India excluding the locations mentioned under

Zone I & Zone II
Identification of Zone will be based on the location-City of the
proposed Insured Persons.
(a) Persons paying Zone I premium can avail treatment all over India
without any Co-pay.
(b) Persons paying Zone II premium
i)
Deviated Nasal Septum
10
Diabetes Mellitus
20
10
Dyslipidemia
15
11
Epilepsy
15
12
Fatty Liver
10
13
Fibroadenoma breast
(non-malignant)
15
Can avail treatment in Zone II and Zone III without any Co-pay.
14
Fissure in Ano
10
ii) Availing treatment in Zone I will have to bear 10% of each and
every claim.
15
GERD (Gastric Esophageal

Reflux Disease)
15
(c) Person paying Zone III premium
16
Hematuria
10
17
Hemorrhoids
10
ii) Availing treatment in Zone II will have to bear 10% of each and
every claim.
18
Hydrocele
10
19
Hypertension
20
iii) Availing treatment in Zone I will have to bear 20% of each and
every claim.
20
Inguinal Hernia
10
21
Leiomyoma of GI tract
15
i)
Can avail treatment in Zone III, without any Co-pay.
***Option to select a Zone higher than that of the actual Zone is

available on payment of relevant premium.
Aforesaid Co-payments for claims occurring outside of the Zone
will not apply in case of Hospitalisation due to Accident.
VIII.20. Loadings & Special Conditions
We may apply a risk loading on the premium payable(excluding
Statutory Levis and Taxes) or Special Conditions on the Policy
based upon the health status of the persons proposed for
insurance and declarations made in the Proposal Form. The
maximum risk loading applicable shall not exceed The maximum
risk loading applicable shall not exceed more than 100% per
Insured Person more than 100% per Insured Person. These
loadings will be applied from inception date of the first Policy
including subsequent Renewal(s) with Us. We may apply a
specific sub-limit on a medical condition/ailment depending on
the past history or additional waiting periods on pre-existing
diseases as part of the special conditions on the Policy. Details of
applicable loadings by ailments/ medical test results are listed as
below along with the applicable sub-limits and waiting periods..
We shall inform You about the applicable risk loading or special
condition through a counter offer letter and You would need to
revert with consent and additional premium (if any), within 7
working days of the issuance of such counter offer letter.
In case, You neither accept the counter offer nor revert to Us
within 7 working days, We shall cancel Your application and
refund the premium paid. Your Policy will not be issued unless We
receive Your consent.
Following loadings may be applied on the policy for the medical
conditions listed below if they are accepted at the time of
underwriting. The loadings are applicable on individual ailments
only. Maximum Risk Loading per individual shall not exceed
100% of Premium excluding Statutory Levis and Taxes.
22
Myoma Uterine
10
23
Nasal polyp
10
24
Ovarian Cysts
15
25
Peptic Ulcer Diseases
10
26
Poliomyelitis
10
27
Polycystic Ovarian Disease (PCOD)
15
28
Renal stones
10
29
Tuberculosis
15
30
Tympanoplasty
10
31
Umbilical hernia
10
32
Undescended Testicle
15
33
Urinary Tract infection (UTI) /

kidney infection
15
34
Varicocele
10
35
Varicose Veins
15
36
Vertigo
15
Sr.
No.
Medical Test
Range of Loading Percent

(For more than 10 percentile
deviation from normal test values)
Haemogram
10
Blood Sugar
10
Urine routine
10
Kidney Function Test
10
Complete Lipid Profile
10
Liver Function Test
10
Carcino Embryonic
Antigen
In case of deviation from normal

values, proposal will be declined.
16
Health Insurance
Prostate Specific
Antigen

values, medical test to be
clinically correlated and evaluated
on a case to case basis. If
deviation is accepted then loading
will be 20
Thyroid Profile
10
10
C Reactive Protein
10
11
Tread Mill Test
12
13

will be 20
USG Abdomen & Pelvis In case of deviation from normal

will be 20
X-Ray Chest

will be 20
12
Hypertension
NA
13
Inguinal Hernia
NA
14
Leiomyoma of GI tract
NA
15
Myoma Uterine
NA
16
Ovarian Cysts
NA
17
Peptic Ulcer Diseases
NA
18
Polycystic Ovarian
Disease (PCOD)
NA
19
Renal stones
NA
20
Tuberculosis
NA
21
Umbilical hernia
NA
NA
22
Undescended Testicle
23
Urinary Tract infection

(UTI) / kidney infection
NA
24
Varicose Veins
NA
25
Vertigo
NA
14
HIV

Additional Sub-limit applied on Special Conditions: The Policy

will pay only 75% of the Admissible claim amount arising out of the
specified illness/medical condition and its complications as
declared by the Insured Person or diagnosed at the time of preacceptance medical tests. Admissible claim amount will be
calculated after apply all the co-pays applicable under the Policy
have been accounted
15
Hepatitis B Surface
Antigen

VIII.21. Communications & Notices
16
Pap Smear

17
2D Echo

will be 20
c. No insurance agents, brokers, other person or entity is

authorised to receive any notice on the behalf of Us unless
explicitly stated in writing by Us.
Normal Test Values will be as per the medical test reports provided
in the reports.
d. Notice and instructions will be deemed served 10 days after

posting or immediately upon receipt in the case of hand delivery,
facsimile or e-mail.
Personal Waiting Periods for Ailments declared or Diagnosed at

the time of Pre-acceptance Medical Tests:
VIII.22. Electronic Transactions
Personal Waiting Periods: Applicable Plan Wise

Range of Waiting Period (in yrs) Applicable for Pre Existing
Disease for Pro Health Plan
Sr. List of Acceptable
No. Medical Ailments
Protect
Plan
Plus
Plan
Preferred/
Premier
Plan
Asthma
NA
Benign Prostatic Hyperplasia NA
Biliary stones
NA
Cataract
NA
Cholelithiasis
NA
Diabetes Mellitus
NA
Epilepsy
NA
Fibroadenoma breast
NA
Fissure in Ano
NA
10
GERD (Gastric Esophageal

Reflux Disease)
NA
Hemorrhoids
NA
11
Any communication or notice or instruction under this Policy shall

be in writing and will be sent to:
a. The policyholder's, at the address as specified in Schedule
b. To Us, at the address specified in the Schedule.
You agree to comply with all the terms, conditions as We 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, or Our other
products and services, shall constitute legally binding when done
in compliance with Our 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 You. 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 You.
VIII.23. Overriding Effect of Policy Schedule
In case of any inconsistency in the terms and conditions in this
Policy vis-a-vis the information contained in the Policy Schedule,
the information contained in the Policy Schedule shall prevail.
17
Health Insurance
VIII.24. Fraudulent Claims

If any claim is found to be fraudulent, or if any false declaration is
made, or if any fraudulent devices are used by You or the Insured
Person or anyone acting on their behalf to obtain any benefit
under this Policy then this Policy shall be void and all claims being
processed shall be forfeited for all Insured Persons. All sums paid
under this Policy shall be repaid to Us by You on behalf of all
Insured Persons who shall be jointly liable for such repayment.
VIII.25. Limitation of Liability
If a claim is rejected or partially settled and is not the subject of
any pending suit or other proceeding or arbitration, as the case
may be, within twelve months from the date of such rejection or
settlement, the claim shall be deemed to have been abandoned
and Our liability shall be extinguished and shall not be
recoverable thereafter.
VIII.26. Portability & Continuity Benefits
You can port Your existing health insurance policy from another
company to ProHealth Insurance, provided that:
a. You have been covered under an Indian retail health insurance
policy from a Non-life Insurance company registered with IRDA
without any break
b. We should have received Your application for Portability with
complete documentation at least 45 days before the expiry of
Your present period of Insurance
c. If the Sum Insured under the previous Policy is higher than the
Sum Insured chosen under this Policy, the applicable waiting
periods under Sections V.1, V.2, V.3, V.4, and V.5 shall be
reduced by the number of months of continuous coverage under
such health insurance policy with the previous insurer to the
extent of the Sum Insured and the Eligible Cumulative Bonus
under the expiring health insurance policy.
The Portability provisions will apply to You, if You wish to migrate

from this Policy to any other health insurance policy on Renewals.
In case You have opted to switch to any other insurer under
portability provisions and the outcome of acceptance of the
portability request is awaited from the new insurer on the date of
renewal,
a. We may upon Your request extend this Policy for a period of not
less than one month at an additional premium to be paid on a prorata basis.
b. If during this extension period a claim has been reported, You
shall be required to first pay the full premium so as to make the
Policy Period of full 12 calendar months. Our liability for the
payment of such claim shall commence only once such premium
is received. Alternately We may deduct the premium for the
balance period and pay the balance claim amount if any and
issue the Policy for the remaining period.
VIII.27. Complete Discharge
We will not be bound to take notice or be affected by any Notice of
any trust, charge, lien, assignment or other dealing with or relating
to this Policy. The payment made by Us to You/Insured Person or
to Your Nominee/ Legal Representative or to the Hospital, as the
case may be, of any Medical Expenses or compensation or
benefit under the Policy shall in all cases be complete, valid and
construe as an effectual discharge in favour of Us.
VIII.28. Dispute Resolution
Any and all disputes or differences under or in relation to this
Policy shall be determined by the Indian Courts and subject to
Indian law.
VIII.29. Grievances Redressal Procedure
If you have a grievance that you wish us to redress, you may
contact us with the details of the grievance through:
d. In case the proposed Sum Insured opted for under Our Policy is
more than the insurance cover under the previous policy, then all
applicable waiting periods under Sections V.1,V.2, V.3, V.4, and
V.5 shall be applicable afresh to the amount by which the Sum
Insured under this Policy exceed the total of sum insured & Eligible
Cumulative Bonus under the expiring health insurance policy;
Toll Free : 1-800-10-24462
e. All waiting periods under Sections V.1, V.2, V.3, V.4, and V.5 shall
be applicable individually for each Insured Person and Claims
shall be assessed accordingly.
Courier: Any of Our Branch office or corporate office during

business hours.
f.
If You were covered on a floater basis under the expiring Policy

and apply for a floater cover under this Policy, then the Eligible
Cumulative Bonus to be carried forward on this Policy shall also
be available on a floater basis.
g. If You were covered on an individual basis in the expiring Policy

then the Eligible Cumulative Bonus to be carried forward on this
Policy shall be available on an individual basis.
For the purpose of this provision, Eligible Cumulative Bonus shall
mean the Cumulative Bonus which You or the Insured Person
would have been eligible for had the same policy been Renewed
with the existing insurance company.
It is further agreed and understood that
a. Portability benefit will be offered to the extent of sum of previous
sum insured and accrued cumulative bonus (if opted for), and
Portability shall not apply to any other additional increased Sum
Insured.
b. We may subject Your proposal to Our medical underwriting,
restrict the terms upon which We may offer cover, the decision as
to which shall be in Our sole and absolute discretion.
c. There is no obligation on Us to insure all Insured Persons on the
proposed terms, even if You have given Us all documentation
d. We should have received the database and claim history from the
previous insurance company for Your previous policy.
Our website: www.cignattkinsurance.in

Email: customercare@cignattk.in
Fax: 022 40825222
You may also approach the grievance cell at any of Our branches
with the details of the grievance during Our working hours from
Monday to Friday.
If You are not satisfied with Our redressal of Your grievance
through one of the above methods, You may contact Our Head of
Customer Service at The Grievance Cell, CignaTTK Health
Insurance Company Limited, 10th Floor, Commerz, International
Business Park, Oberoi Garden City, Goregaon (East), Mumbai 400 063. or email at headcustomercare@cignattk.in.
If You are not satisfied with Our redressal of Your grievance
through one of the above methods, You may approach the
nearest Insurance Ombudsman for resolution of Your grievance.
The contact details of Ombudsman offices attached as Annexure
I to this Policy document.
IX Definitions
1. Accident or Accidental means a sudden, unforeseen and
involuntary event caused by external, visible and violent means.
2. Age or Aged is the age last birthday, and which means completed
years as at the Inception Date
3. Alternative Treatments are forms of treatments other than
treatment "Allopathy" or "modern medicine" and includes
Ayurveda, Unani, Sidha and Homeopathy in the Indian context
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Health Insurance
4. Any one Illness means continuous Period of illness and it

includes relapse within 45 days from the date of last consultation
with the Hospital/Nursing Home where the treatment may have
been taken.
d) Open Heart Replacement or Repair of Heart Valves

The actual undergoing of open-heart valve surgery is to replace
or repair one or more heart valves, as a consequence of defects
in, abnormalities of, or disease-affected cardiac valve(s). The
diagnosis of the valve abnormality must be supported by an
echocardiography and the realization of surgery has to be
confirmed by a specialist medical practitioner. Catheter based
techniques including but not limited to, balloon valvotomy/
valvuloplasty are excluded.
5. Ambulance means a road vehicle operated by a licenced/

authorised service provider and equipped for the transport and
paramedical treatment of the person requiring medical attention.
6. Annexure means a document attached and marked as
Annexure to this Policy
7. Cashless Facility means a facility extended by the insurer to the
insured where the payments, of the costs of treatment undergone
by the insured in accordance with the Policy terms and
conditions, are directly made to the network provider by the
insurer to the extent pre-authorization approved.
e) Coma of Specified Severity

1. A state of unconsciousness with no reaction or response to
external stimuli or internal needs.
This diagnosis must be supported by evidence of all of the following:
8. Contribution is essentially the right of an insurer to call upon

other insurers liable to the same insured to share the cost of an
indemnity claim on a ratable proportion.
ii. life support measures are necessary to sustain life; and
9. Critical Illness means the following:
iii. permanent neurological deficit which must be assessed at least

30 days after the onset of the coma.
a) Cancer of Specified Severity

A malignant tumour characterised by the uncontrolled growth &
spread of malignant cells with invasion & destruction of normal
tissues. This diagnosis must be supported by histological
evidence of malignancy & confirmed by a pathologist. The term
cancer includes leukemia, lymphoma and sarcoma.
i.
2. The condition has to be confirmed by a specialist medical

practitioner. Coma resulting directly from alcohol or drug abuse is
excluded.
f) Kidney Failure Requiring Regular Dialysis
End stage renal disease presenting as chronic irreversible failure
of both kidneys to function, as a result of which either regular
renal dialysis (haemodialysis or peritoneal dialysis) is instituted
or renal transplantation is carried out. Diagnosis has to be
confirmed by a specialist medical practitioner.
The following are excluded 1. Tumours showing the malignant changes of carcinoma in situ &
tumours which are histologically described as premalignant or
non-invasive, including but not limited to: Carcinoma in situ of
breasts, Cervical dysplasia CIN-1, CIN -2 & CIN-3.
2. Any skin cancer other than invasive malignant melanoma
no response to external stimuli continuously for at least 96 hours;
g) Stroke Resulting in Permanent Symptoms
3. All tumours of the prostate unless histologically classified as

having a Gleason score greater than 6 or having progressed to at
least clinical TNM classification T2N0M0
Any cerebrovascular incident producing permanent neurological

sequelae. This includes infarction of brain tissue, thrombosis in
an intracranial vessel, haemorrhage and embolization from an
extra cranial source. Diagnosis has to be confirmed by a
specialist medical practitioner and evidenced by typical clinical
symptoms as well as typical findings in CT Scan or MRI of the
brain. Evidence of permanent neurological deficit lasting for at
least 3 months has to be produced.
4. Papillary micro - carcinoma of the thyroid less than 1 cm in diameter

5. Chronic lymphocytic leukaemia less than RAI stage 3
6. Microcarcinoma of the bladder
7. All tumours in the presence of HIV infection.
The following are excluded:

b) First Heart Attack of Specified Severity
The first occurrence of myocardial infarction which means the
death of a portion of the heart muscle as a result of inadequate
blood supply to the relevant area. The diagnosis for this will be
evidenced by all of the following criteria:
1. a history of typical clinical symptoms consistent with the diagnosis
of Acute Myocardial Infarction (for e.g. typical chest pain)
2. new characteristic electrocardiogram changes
3. elevation of infarction specific enzymes, Troponins or other
specific biochemical markers.
1. Non-ST-segment elevation myocardial infarction (NSTEMI) with
elevation of Troponin I or T;
1. Transient ischemic attacks (TIA)

2. Traumatic injury of the brain
3. Vascular disease affecting only the eye or optic nerve or
vestibular functions.
h) Major Organ/Bone Marrow Transplant
The actual undergoing of a transplant of:
1. One of the following human organs: heart, lung, liver, kidney,
pancreas, that resulted from irreversible end-stage failure of the
relevant organ, or
2. Human bone marrow using haematopoietic stem cells. The
undergoing of a transplant has to be confirmed by a specialist
medical practitioner.
2. Other acute Coronary Syndromes

3. Any type of angina pectoris.

i.
Other stem-cell transplants
ii. Where only islets of langerhans are transplanted

c) Open Chest CABG
The actual undergoing of open chest surgery for the correction of
one or more coronary arteries, which is/are narrowed or blocked,
by coronary artery bypass graft (CABG). The diagnosis must be
supported by a coronary angiography and the realization of
surgery has to be confirmed by a specialist medical practitioner.
Excluded are:
i)

Total and irreversible loss of use of two or more limbs as a result
of injury or disease of the brain or spinal cord. A specialist medical
practitioner must be of the opinion that the paralysis will be
permanent with no hope of recovery and must be present for
more than 3 months.
1. Angioplasty and/or any other intra-arterial procedures

2. Any key-hole or laser surgery.
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Health Insurance
j)
Motor Neurone Disease with Permanent Symptoms

Motor neurone disease diagnosed by a specialist medical
practitioner as spinal muscular atrophy, progressive bulbar palsy,
amyotrophic lateral sclerosis or primary lateral sclerosis. There
must be progressive degeneration of corticospinal tracts and
anterior horn cells or bulbar efferent neurons. There must be
current significant and permanent functional neurological
impairment with objective evidence of motor dysfunction that has
persisted for a continuous period of at least 3 months.
k) Multiple Sclerosis with Persisting Symptoms

The definite occurrence of multiple sclerosis. The diagnosis must
be supported by all of the following:
1. investigations including typical MRI and CSF findings, which
unequivocally confirm the diagnosis to be multiple sclerosis;
2. there must be current clinical impairment of motor or sensory
function, which must have persisted for a continuous period of at
least 6 months, and
3. well documented clinical history of exacerbations and remissions
of said symptoms or neurological deficits with at least two
clinically documented episodes at least one month apart.
Other causes of neurological damage such as SLE and HIV are
excluded.
10. Inception Date means the Inception date of this Policy as
specified in the Schedule
11. Co-payment is a cost-sharing requirement under a health
insurance policy that provides that the policyholder/insured will
bear a specified percentage of the admissible claim amount. A
co-payment does not reduce the Sum Insured.
12. Condition Precedent shall mean a policy term or condition upon
which the Insurer's Liability under the Policy is conditional upon.
13. Cosmetic Surgery means Surgery or Medical Treatment that
modifies, improves, restores or maintains normal appearance of
a physical feature, irregularity, or defect.
14. Congenital Anomaly refers to a condition(s) which is present
since birth, and which is abnormal with reference to form,
structure or position.
a. Internal Congenital Anomaly - which is not in the visible and
accessible parts of the body is called Internal Congenital Anomaly
b. External Congenital Anomaly - which is in the visible and
accessible parts of the body is called External Congenital Anomaly
15. Covered Relationships shall include spouse, children, brother
and sister of the Policyholder who are children of same parents,
grandparents, grandchildren, parent in laws, son in law and
daughter in law.
16. Cumulative Bonus
Cumulative Bonus shall mean any increase in the Sum Insured
granted by the insurer without an associated increase in premium.
17. Day Care Treatment refers to medical treatment, and/or surgical
procedure which is:
i)
Undertaken under General or Local Anesthesia in a hospital/day

care centre in less than 24 hrs because of technological
advancement, and
ii) Which would have otherwise required a hospitalization of more

than 24 hours.
Treatment normally taken on an out-patient basis is not included in

the scope of this definition. For the list of Day Care Treatments
please refer Annexure II attached to and forming part of this Policy.
18. Day Care Centre - A day care centre means any institution
established for day care treatment of illness and / or injuries or a
medical set -u p within a hospital and which has been registered
with the local authorities, wherever applicable, and is under the
supervision of a registered and qualified medical practitioner
AND must comply with all minimum criteria as under:a. has qualified nursing staff under its employment
b. has qualified medical practitioner (s) in charge
c. has a fully equipped operation theatre of its own where surgical
procedures are carried out
d. maintains daily records of patients and will make these
accessible to the Insurance company's authorized personnel.
19. Deductible is a cost-sharing requirement under a health
insurance policy that provides that the Insurer will not be liable for
a specified rupee amount in case of indemnity policies and for a
specified number of days/hours in case of hospital cash policies,
which will apply before any benefits are payable by the insurer. A
deductible does not reduce the sum insured.
20. Dependent Child - A dependent child refers to a child (natural or
legally adopted), who is financially dependent on the Policy
Holder, does not have his / her independent source of income, is
up to the age of 23 years.
21. Dental Treatment - Dental treatment is treatment carried out by a
dental practitioner including examinations, fillings (where
appropriate), crowns, extractions and surgery excluding any form
of cosmetic surgery/implants.
22. Domiciliary Hospitalization means medical treatment for an
illness/disease/injury which in the normal course would require
care and treatment at a hospital but is actually taken while
confined at home under any of the following circumstances:
a) the condition of the patient is such that he/she is not in a condition
to be removed to a hospital, or
b) the patient takes treatment at home on account of non-availability
of room in a hospital.
23. Disclosure to Information Norm - means the Policy shall be
void and all premium paid hereon shall be forfeited to the
Company, in the event of misrepresentation, mis-description or
non-disclosure of any material fact.
24. Emergency shall mean a serious medical condition or symptom
resulting from injury or sickness which arises suddenly and
unexpectedly, and requires immediate care and treatment by a
medical practitioner, generally received within 24 hours of onset
to avoid jeopardy to life or serious long term impairment of the
insured person's health, until stabilisation at which time this
medical condition or symptom is not considered an emergency
anymore.
25. Emergency Care means management for a severe illness or
injury which results insymptoms which occur suddenly and
unexpectedly, and requires immediate care by a medical
practitioner to prevent death or serious long term impairment of
the insured person's health.
26. Family Floater means a Policy described as such in the
Schedule where under You and Your Dependents named in the
20
Health Insurance
Schedule are insured under this Policy as at the Inception Date.

The Sum Insured for a Family Floater means the sum shown in
the Schedule which represents Our maximum liability for any and
all claims made by You and/or all of Your Dependents during each
Policy Period.
27. Grace Period means the specified period of time immediately
following the premium due date during which a payment can be
made to renew or continue a policy in force without loss of
continuity benefits such as waiting periods and coverage of preexisting diseases. Coverage is not available for the period for
which no premium is received.
28. Hospital means any institution established for inpatient care and
day care treatment o f illness and/or injuries and which has been
registered as a hospital with the local authorities, under the Clinical
Establishments (Registration and Regulation) Act, 2010 or under
the enactments specified under the Schedule of Section 56 (1) of
the said Act OR complies with all minimum criteria as under:
has at least 10 in-patient beds, in towns having a population of

less than 10,00,000 and at least 15 in-patient beds in all other
places;
has qualified nursing staff under its employment round the clock;
has qualified medical practitioner(s) in charge round the clock;
has a fully equipped operation theatre of its own where surgical

procedures are carried out
maintains daily records of patients and makes these accessible

to the Insurance company's authorized personnel.
29. Hospitalisation or Hospitalised means admission in a hospital

for a minimum period of 24 in patient care consecutive hours
except for specified procedures / treatments, where such
admission could be for a period of less than 24 consecutive hours.
30. Illness means sickness or disease or pathological condition leading
to the impairment of normal physiological function which manifests
itself during the policy period & requires medical treatment.
31. a) Acute condition- Acute condition is a disease, illness or injury
that is likely to respond quickly to treatment which aims to return
the person to his or her state of health immediately before
suffering the disease/illness/injury which leads to full recovery
b) Chronic condition- A chronic condition is defined as a
disease, illness or injury that has one or more of the following
characteristics:-it needs ongoing or long-term monitoring through
consultations, examinations, check-ups, and/ or tests- it needs
on-going or long term control or relief of symptoms- it requires
your rehabilitation or for you to be specially trained to cope with itit continues indefinitely-it comes back or is likely to come back.
32. Intensive Care Unit means an identified section, ward or wing of
a Hospital which is under the constant supervision of a dedicated
medical practitioner(s), and which is specially equipped for the
continuous monitoring and treatment of patients who are in a
critical condition, or require life support facilities and where the
level of care and supervision is considerably more sophisticated
and intensive than in the ordinary and other wards.
33. Injury means accidental physical bodily harm excluding illness or
disease solely and directly caused by external, violent and visible
and evident means which is verified and certified by a Medical
Practitioner.
34. In-patient means an Insured Person who is admitted to hospital
and stays for at least 24 hours for the sole purpose of receiving
treatment.
35. In-patient Care means treatment for which the Insured Person
has to stay in a hospital for more than 24 hours for a covered event.
36. Insured Person means the person(s) named in the Schedule to
this Policy, who is / are covered under this Policy, for whom the
insurance is proposed and the appropriate premium paid.
37. Maternity Expense shall include the following:
i.
Medical treatment expenses traceable to childbirth (including

complicated deliveries and caesarean sections incurred during
Hospitalisation);
ii. Expenses towards lawful medical termination of pregnancy

during the Policy Period
38. Maternity Sum Insured means the sum specified in the
Schedule against the Benefit
39. Medical Advice means any written consultation or advise from a
Medical Practitioner including the issue of any prescription or
repeat prescription.
40. Medical Expenses means those expenses that an Insured
Person has necessarily and actually incurred for medical
treatment on account of Illness or Accident on the advise of a
Medical Practitioner, as long as these are no more than would
have been payable if the Insured Person had not been insured
and no more than other hospitals or doctors in the same locality
would have charged for the same medical treatment.
41. Medically Necessary means any treatment, tests, medication,
or stay in Hospital or part of a stay in Hospital which
Is required for the medical management of the Illness or injury

suffered by the Insured;
Must not exceed the level of care necessary to provide safe,

adequate & appropriate medical care in scope, duration or intensity.
Must have been prescribed by a Medical Practitioner.
Must conform to the professional standards widely accepted in

international medical practice or by the medical community in India.
42. Medical Practitioner - A Medical practitioner is a person who holds

a valid registration from the medical council of any state or Medical
Council of India or Council for Indian Medicine or for Homeopathy
set up by Government of India or a State Governement and is
thereby entitled to practice medicine within its jurisdiction; and is
acting within the scope and jurisdiction of license.
43. New Born Baby means baby born during the Policy Period and is
Aged between 1 day and 90 days, both days inclusive.
44. Network Provider means hospitals or health care providers
enlisted by an insurer or by a TPA and insurer together to provide
medical services to an insured on payment by a cashless facility.
45. Non- Network Provider Any hospital, day care centre or other
provider that is not part of the network.
46. Notification of Claim is the process of notifying a claim to the
insurer or TPA by specifying the timelines as well as the address /
telephone number to which it should be notified.
47. OPD Treatment - Out Patient Treatment (OPD) is one in which
the Insured visits a clinic/ hospital or associated facility like a
consultation room for diagnosis and treatment based on the
21
Health Insurance
advice of a Medical Practitioner. The Insured is not admitted as a

day care or In-Patient.
period for treating renewal continuous for the purpose of all

waiting periods.
48. Policy means this Terms & Conditions document, the Proposal
Form, Policy Schedule, Add-On Benefit Details (if applicable) and
Annexures which form part of the Policy contract including
endorsements, as amended from time to time which form part of
the Policy Contract and shall be read together.
59. Restored Sum Insured means the amount restored in

accordance with Section 2.1.10 of this Policy
49. Policy Period means the period between the inception date and
the expiry date of the policy as specified in the Schedule to this
Policy or the date of cancellation of this policy, whichever is earlier.
50. Policy Year means a period of 12 consecutive months
commencing from the Inception Date.
51. Policy Schedule means Schedule attached to and forming part
of this Policy mentioning the details of the Insured Persons, the
Sum Insured, the period and the limits to which benefits under the
Policy are subject to, including any annexures and/ or
endorsements, made to or on it from time to time, and if more than
one, then the latest in time.
52. Pre-existing Disease is any condition, ailment or injury or
related condition(s) for which you had signs or symptoms, and / or
were diagnosed, and/ or received medical advice/ treatment
within 48 months to prior to the first policy issued by the insurer.
60. Room Rent - Room Rent shall mean the amount charged by a
hospital for the occupancy of a bed on per day (24 hours) basis
and shall include associated medical expenses.
61. Schedule means schedule issued by Us, attached to and
forming part of this Policy mentioning the details of the Policy
Holder, Insured Persons, Sum Insured, Policy Period, Premium
Paid(including taxes) and if more than one, then the latest in time.
62. Shared Room means a Hospital room with two or more in-patient
beds with/without air-conditioning facility.
63. Single Private Room means a Hospital room with/without airconditioning facility where a single patient is accommodated and
which has an attached toilet (lavatory and bath). The room should
have the provision for accommodating an attendant.
64. Sum Insured means, subject to terms, conditions and
exclusions of this Policy, the amount representing Our maximum
liability for any or all claims during the Policy Period specified in
the Schedule to this Policy separately in respect of that Insured
Person.
i.
53. Pre-hospitalization Medical Expenses are Medical Expenses

incurred immediately before the Insured Person is Hospitalised,
provided that:
i.
Such Medical Expenses are incurred for the same condition for
which the Insured Person's Hospitalisation was required, and
ii. The In-patient Hospitalization claim for such Hospitalization is

admissible by the Insurance Company.
54. Post-hospitalization Medical Expenses
Medical Expenses incurred immediately after the Insured Person
is discharged from the hospital, provided that:
i.
Such Medical Expenses are incurred for the same condition for
which the Insured Person's Hospitalisation was required, and
ii. The In-patient Hospitalization claim for such Hospitalization is

admissible by the insurance company.
55. Portability means transfer by an individual health insurance
policyholder (including family cover) of the credit gained for preexisting conditions and time- bound exclusions if he/she chooses
to switch from one insurer to another.
56. Qualified Nurse is a person who holds a valid registration from
the Nursing Council of India or the Nursing Council of any state in
India.
57. Reasonable and Customary Charges means the charges for
services or supplies, which are the standard charges for the
specific provider and consistent with the prevailing charges in the
geographical area for identical or similar services, taking into
account the nature of the illness / injury involved by comparable
providers only.
58. Renewal means the terms on which the contract of insurance
can be renewed on mutual consent with a provision of grace
In case where the Policy Period for 2 years, the Sum Insured
specified on the Policy is the limit for the first Policy Year. These
limits will lapse at the end of the first year and the fresh limits up to
the full Sum Insured as opted will be available for the second year.
ii. In the event of a claim being admitted under this Policy, the Sum
Insured for the remaining Policy Period shall stand
correspondingly reduced by the amount of claim paid (including
'taxes') or admitted and shall be reckoned accordingly.
65. Surgery or Surgical Procedure means manual and / or operative
procedure (s) required for treatment of an illness or injury,
correction of deformities and defects, diagnosis and cure of
diseases, relief of suffering or prolongation of life, performed in a
hospital or day care centre by a medical practitioner
66. Subrogation shall mean the right of the insurer to assume the
rights of the insured person to recover expenses paid out under
the policy that may be recovered from any other source.
67. TPA means any person who is licenses under the IRDA (Third
Party Administrators - Health Services) Regulations 2001 by the
Authority, and is engaged, for a fee or remuneration by an
insurance company, for the purposes of providing health services.
68. Unproven/ Experimental Treatment - Unproven/ Experimental
treatment is treatment, including drug Experimental therapy,
which is not based on established medical practice in India, is
treatment experimental or unproven.
69. We/ Our/ Us/ Insurer means CignaTTK Health Insurance
Company Limited
70. You/ Your/ Policy Holder means the person named in the
Schedule as the policyholder and who has concluded this Policy
with Us.
22
Health Insurance
ANNEXURE - I:
Ombudsmen
Office of the
Ombudsman
Name of the
Ombudsman
Contact Details
Areas of
Jurisdiction
CV of the
Ombudsman
AHMEDABAD
Shri P. Ramamoorthy
Insurance Ombudsman,
Office of the Insurance Ombudsman,
2nd Floor, Ambica House, Nr. C.U. Shah College,
Ashram Road, AHMEDABAD-380 014.
Tel.:- 079-27546840
Fax : 079-27546142
Email: ins.omb@rediffmail.com
Gujarat , UT of
Dadra & Nagar
Haveli, Daman
and Diu
CV of Shri P.
Ramamoorthy
Janak Vihar Complex, 2nd Floor, 6, Malviya Nagar,
Opp. Airtel, Near New Market,
BHOPAL(M.P.)-462 023.
Tel.:- 0755-2569201
Fax : 0755-2769203
Email: bimalokpalbhopal@airtelmail.in
Madhya Pradesh
& Chhattisgarh
BHOPAL
BHUBANESH
WAR
Shri B. P. Parija
62, Forest Park, BHUBANESHWAR-751 009.
Tel.:- 0674-2596455
Fax : 0674-2596429
Email: ioobbsr@dataone.in
Orissa
CV of
Shri B. P. Parija
CHANDIGARH
Shri Manik Sonawane
S.C.O. No.101-103, 2nd Floor, Batra Building.
Sector 17-D, CHANDIGARH-160 017.
Tel.:- 0172-2706468
Fax : 0172-2708274
Email: ombchd@yahoo.co.in
Punjab , Haryana,
Himachal Pradesh,
Jammu & Kashmir,
UT of Chandigarh
CV of Shri Manik
Sonawane
Fathima Akhtar Court, 4th Floor, 453 (old 312),
Anna Salai, Teynampet, CHENNAI-600 018.
Tel.:- 044-24333668 /5284
Fax : 044-24333664
Email: chennaiinsuranceombudsman@gmail.com
Tamil Nadu,
UT-Pondicherry
Town and Karaikal
(which are part of
UT of Pondicherry)
CHENNAI
NEW DELHI
Shri Surendra Pal

Singh
Shri Surendra Pal Singh

2/2 A, Universal Insurance Bldg., Asaf Ali Road,
NEW DELHI-110 002.
Tel.:- 011-23239633
Fax : 011-23230858
Email: iobdelraj@rediffmail.com
Delhi & Rajasthan
GUWAHATI
Shri D. C. Choudhury
Shri D.C. Choudhury,

Jeevan Nivesh, 5th Floor, Near Panbazar Overbridge,
S.S. Road, GUWAHATI-781 001 (ASSAM).
Tel.:- 0361-2132204/5
Fax : 0361-2732937
Email: ombudsmanghy@refiffmail.com
Assam, Meghalaya, CV of Shri

Manipur, Mizoram, D. C. Choudhury
Arunachal Pradesh,
Nagaland and
Tripura
6-2-46, 1st Floor, Moin Court, A.C. Guards,
Lakdi-Ka-Pool, HYDERABAD-500 004.
Tel : 040-65504123
Fax: 040-23376599
Email: insombudhyd@gmail.com
Andhra Pradesh,
Karnataka and UT
of Yanam - a part
of the UT of
Pondicherry
HYDERABAD
CV of Shri
Surendra Pal
Singh
23
Health Insurance
ANNEXURE - I:
Ombudsmen
Office of the
Ombudsman
Name of the
Ombudsman
Contact Details
Areas of
Jurisdiction
CV of the
Ombudsman
KOCHI
Shri R.
Jyothindranathan
2nd Floor, CC 27/2603, Pulinat Bldg., Opp. Cochin
Shipyard, M.G. Road, ERNAKULAM-682 015.
Tel : 0484-2358759
Fax : 0484-2359336
Email: iokochi@asianetindia.com
Kerala, UT of (a)
Lakshadweep,
(b) Mahe - a part of
UT of Pondicherry
CV of Shri R.
Jyothindranathan
KOLKATA
Ms. Manika Datta
Ms. Manika Datta

4th Floor, Hindusthan Bldg. Annexe, 4, C.R.Avenue,
KOLKATTA - 700 072.
Tel: 033 22124346/(40)
Fax: 033 22124341
Email: iombsbpa@bsnl.in
West Bengal, Bihar, CV of

Jharkhand and UT Ms. Manika Datta
of Andeman &
Nicobar Islands,
Sikkim
LUCKNOW
Shri G. B. Pande
Jeevan Bhawan, Phase-2, 6th Floor, Nawal Kishore
Road, Hazaratganj, LUCKNOW-226 001.
Tel.: 0522 -2231331
Fax.: 0522-2231310
Email: insombudsman@rediffmail.com
Uttar Pradesh and

Uttaranchal
S.V. Road, Santacruz(W), MUMBAI-400 054.
Tel : 022-26106928
Fax : 022-26106052
Email: ombudsmanmumbai@gmail.com
Maharashtra, Goa
MUMBAI
ANNEXURE - II:
17.
Other operations on the middle ear
List of Day Care Treatments/Surgeries/Procedures covered under

Section 2.1.4 including but not limited to the following:
18.
Removal of Keratosis Obturans
CV of Shri
G. B. Pande
Operations on the nose & the nasal sinuses

Microsurgical Operations on the middle ear
19.
Excision and destruction of diseased tissue of the nose
20.
Operations on the turbinates (nasal concha)
1.
Stapedotomy to treat various lesions in the middle ear
2.
Revision of Stapedotomy
3.
Other operations of the auditory ossicles
4.
Myringoplasty (post-aura/ endural approach as well as simple

Type - I Tympanoplasty)
5.
Tympanoplasty (closure of an eardrum perforation/

reconstruction of the auditory ossicle)
Operations on the eyes
6.
Revision of a Tympanoplasty
24.
7.
Other microsurgical operations on the middle ear
Other operations on the middle & internal ear

8.
Myringotomy
9.
Removal of a tympanic drain
10.
Incision of the mastoid process and middle ear
11.
Mastoidectomy
12.
Reconstruction of the middle ear
13.
Other excisions of the middle and inner ear
14.
Fenestration of the inner ear
15.
Revision of a fenestration of the inner ear
16.
Incision (opening) and destruction (elimination) of the inner ear
21.
Other operations on the nose
22.
Nasal sinus aspiration
23.
Foreign body removal from nose
Incision of tear glands
25.
Other operations on the tear ducts
26.
Incision of diseased eyelids
27.
Correction of Eyelids Ptosis by Levator Palpebrae Superioris

Resection (bilateral)
28.
Correction of Eyelids Ptosis by Fascia Lata Graft (bilateral)
29.
Excision and destruction of diseased tissue of the eyelid
30.
Operations on the canthus and epicanthus
31.
Corrective surgery for entropion and ectropion
32.
Corrective surgery for blepharoptosis
33.
Removal of a foreign body from the conjunctiva
34.
Removal of a foreign body from the cornea
35.
Incision of the cornea
24
Health Insurance
36.
Operations for pterygium
73.
Incision, excision and destruction in the mouth
37.
Other operations on the cornea
74.
Palatoplasty
75.
Other operations in the mouth
38.
Removal of a foreign body from the lens of the eye
39.
Removal of a foreign body from the posterior chamber of the

eye
40.
Removal of a foreign body from the orbit and eyeball
41.
Operation of cataract
42.
Diathermy/ Cryotherapy to treat retinal tear
43.
Anterior chamber Pancentesis/ Cyclodiathermy/

Cyclocryotherapy / goniotomy/ Trabeculotomy and Filtering
and Allied operations to treat glaucoma
80.
Other operations on the tonsil and adenoids
44.
Enucleation of the eye without implant
81.
Traumasurgery and orthopaedics
45.
Dacryocystorhinostomy for various lesions of Lacrimal Gland
82.
Incision on bone, septic and aseptic
Laser photocoagulation to treat Retinal Tear
83.
Closed reduction on fracture, luxation or epiphyseolysis with

osteosynthesis
84.
Suture and other operations on tendons and tendon sheath
46.
Operations on the skin & subcutaneous tissues

47.
Incision of a pilonidal sinus
48.
Other incisions of the skin and subcutaneous tissues
49.
Surgical wound toilet (wound debridement) and removal of

diseased tissue of the skin and subcutaneous tissues
Operations on tonsils and adenoids

76.
Transoral incision and drainage of pharyngeal abscess
77.
Tonsillectomy without adenoidectomy
78.
Tonsillectomy with adenoidectomy
79.
Excision and destruction of a lingual tonsil
85.
Reduction of dislocation under GA
86.
Adenoidectomy
Operations on the breast

87.
Incision of the breast
50.
Local excision of diseased tissue of the skin and subcutaneous

tissues
88.
Operations on the nipple
51.
Other excisions of the skin and subcutaneous tissues
89.
Excision of single breast lump
52.
Simple restoration of surface continuity of the skin and

subcutaneous tissues
53.
Free skin transplantation, donor site
54.
Free skin transplantation, recipient site
55.
Revision of skin plasty
56.
Other restoration and reconstruction of the skin and

subcutaneous tissues
93.
Division of the anal sphincter (sphincterotomy)
57.
Chemosurgery to the skin
94.
Other operations on the anus
58.
Destruction of diseased tissue in the skin and subcutaneous

tissues
95.
Ultrasound guided aspirations
96.
Sclerotherapy etc.
Reconstruction of deformity/ defect in NailBed
97.
Laprotomy for grading Lymphoma with Splenectomy/ Liver/

Lymph Node Biopsy
Operations on the tongue
98.
Therapeutic laproscopy with Laser
60.
Incision, excision and destruction of diseased tissue of the

tongue
99.
Cholecystectomy and choledocho - jejunostomy/ Duodenostomy/

Gastrostomy/ Exploration Common Bile Duct
61.
Partial glossectomy
100. Esophagoscopy, gastroscopy, dudenoscopy with polypectomy/

removal of foreign body/ diathermy of bleeding lesions
59.
62.
Glossectomy
63.
Reconstruction of the tongue
64.
Other operations on the tongue
Operations on the salivary glands & salivary ducts

65.
Incision and lancing of a salivary gland and a salivary duct
66.
Excision of diseased tissue of a salivary gland and a salivary duct
67.
Resection of a salivary gland
68.
Reconstruction of a salivary gland and a salivary duct
69.
Other operations on the salivary glands and salivary ducts
Other operations on the mouth & face

70.
External incision and drainage in the region of the mouth, jaw

and face
71.
Incision of the hard and soft palate
72.
Excision and destruction of diseased hard and soft palate
Operations on the digestive tract, Kidney and bladder

90.
Incision and excision of tissue in the perianal region
91.
Surgical treatment of anal fistulas
92.
Surgical treatment hemorrhoids
101. Lithotripsy/ Nephrolithotomy for renal calculus

102. Excision of renal cyst
103. Drainage of Pyonephrosis/ Perinephric Abscess
104. Appendicectomy with/ without Drainage
Operations on the female sexual organs
105. Incision of the ovary
106. Insufflation of the Fallopian tubes
107. Other operations on the Fallopian tube
108. Dilatation of the cervical canal
109. Conisation of the uterine cervix
110. Therapeutic curettage with Colposcopy/ Biopsy/ Diathermy/
Cryosurgery
111. Laser therapy of cervix for various lesions of Uterus
112. Other operations of the Uterine cervix
25
Health Insurance
113. Incesion of the uterus (hysterectomy)

114. Local incision and destruction of diseased tissue of the vagina
and the pouch of Douglas
115. Incision of the vagina
116. Incision of vulva
117. Culdotomy
Operations on the spermatic cord, epididymis and ductus

deferens
143. Surgical treatment of a varicocele and a hydrocele of the
spermatic cord
144. Excision in the area of the epididymis
145. Epididymectomy
118. Operations on Bartholin's glands (cyst)

119. Salpino-Oophorectomy via Laproscopy
Operations on the penis

146. Operations on the foreskin
Operations on the prostate & seminal vesicles

120. Incision of the prostate
121. Transurethral excision and destruction of prostate tissue
147. Local excision and destruction of diseased tissue of the penis

148. Amputation of the penis
149. Other operations on the penis
122. Transurethral and percutaneous destruction of prostate tissue

123. Open surgical excision and destruction of prostate tissue
124. Radical prostatovesiculectomy
125. Other excision and destruction of prostate tissue
Operations on the urinary system

150. Cystoscopical removal of stones
151. Catheterisation of bladder
126. Operations on the seminal vesicles

127. Incision and excision of periprostatic tissue
128. Other operations on the prostate
Other Operations
152. Lithotripsy
153. Coronary angiography
Operations on the scrotum & tunica vaginalis testis

129. Incision of the scrotum and tunica vaginalis testis
130. Operation on a testicular hydrocele
131. Excision and destruction of diseased scrotal tissue
132. Other operations on the scrotum and tunica vaginalis testis
154. Biopsy of Temporal Artery for Various lesions

155. External Arterio-venus shunt
156. Haemodialysis
157. Radiotherapy for Cancer
158. Cancer Chemotherapy
159. Endoscopic polypectomy
Operations on the testes

133. Incision of the testes
134. Excision and destruction of diseased tissue of the testes
135. Unilateral orchidectomy
136. Bilateral orchidectomy
137. Orchidopexy
138. Abdominal exploration in cryptorchidism
139. Surgical repositioning of an abdominal testis
140. Reconstruction of the testis
141. Implantation, exchange and removal of a testicular prosthesis
142. Other operations on the testis
Operation of bone and joints

160. Surgery for ligament tear
161. Surgery for meniscus tear
162. Surgery for hemoarthrosis/ pyoarthrosis
163. Removal of fracture pins/ nails
164. Removal of metal wire
165. Closed reduction on fracture, luxation
166. Reduction of dislocation under GA
167. Epiphyseolysis with Osteosynthesis
168. Excision of Bursitis
169. Tennis elbow release
170. Excision of various lesions in Coccyx
171. Arthroscopic knee aspiration
26
Health Insurance
ANNEXURE - III:
Plan Benefit Schedule
Cigna TTK ProHealth Insurance Plan- Benefit Structure
Basic
Sum Insured
Protect
Plus
Preferred
Premier
` 2.5 Lac,
` 4.5 Lac,
` 15 Lac,
` 100 Lac
` 3.5 Lac,
` 5.5 Lac,
` 30 Lac,
` 4.5 Lac
` 7.5 Lac,
` 50 Lac,
In-patient Hospitalization
Covered up to
Shared room
Covered up to
Single Private room
Pre - Hospitalization
Covered up to 60 days before date of hospitalisation
Post - Hospitalization
Covered up to 90
days post discharge
from hospital
Day Care Treatment
Covered up to full Sum Insured
Covers
` 10 Lac
Value
added
covers
Covered up to Single
Private room
Covered up to Single
Private room
Covered up to 180 days post discharge from hospital
Domiciliary Treatment
Covered up to full Sum Insured
Ambulance Cover
Up to ` 2000 per
hospitalization event
Donor Expenses
Covered upto full Sum Insured
Worldwide Emergency
Cover
Covered upto full Sum Insured

(once in a policy year)
Restoration Of Sum
Insured
Available once in a policy year for unrelated

illnesses in addition to the Sum Insured opted
Health Maintenance
Benefit
Covered up to ` 500
Covered up to ` 2000
Covered upto `15000 per policy year
Maternity Expenses
Not Available
Covered upto ` 15,000

for normal delivery &
` 25,000 for C- Section
per event After a Waiting
Period of 48 months
Covered upto ` 50,000 for normal delivery

and ` 100,000 for C-Section per event after a
waiting Period of 48 months
Up to ` 3000 per
hospitalization event
Actual expenses paid per hospitalization

event
Covered upto a maximum of `10 Lacs
Not Available
New Born Baby Expenses
Not Available
Covered upto Limit under Maternity Expenses
First Year Vaccinations
Not Available
Covered as per national immunization programme over and above

Maternity Expenses
Health Check-Up
Available once every

3rd Policy year to all
insured persons who
have completed 18
years of Age
Available at each renewal, to all insured persons who have completed

18 years of Age
Expert Opinion on
Critical illness
Available once during the Policy Year
Cumulative Bonus
5% Increase in Sum
Insured, maximum
upto 50%.
Healthy Rewards
Reward Points to be earned for each year of premium paid and accumulated for 2 years.
Rewards can also be earned for enrolling and completing Our Online Wellness Programs.
These earned Reward Points can be used to get a discount in premium from the 3rd Annual
Premium OR they can be redeemed for equivalent value of Health Maintenance Benefits.
Optional Deductible*
covers
Deductible Options
for Protect Plan
` 2.5 Lac
NA
` 3.5 Lac
1 Lac
` 4.5 Lac
1 Lac
2 Lac
10% Increase in Sum Insured, maximum

upto 50%
Deductible Options
for Plus Plan
` 4.5 Lac
` 1 Lac
` 2 Lac
` 5.5 Lac
` 2 Lac
` 3 Lac
` 7.5 Lac
` 2 Lac
` 3 Lac
` 10 Lac
` 3 Lac
Not Available
Not Available
Not available
* Voluntary Co-pay and Deductible cannot be taken under a single plan

Reduction in Maternity
Waiting
Not Available
Maternity waiting period Reduced to 24 months
Voluntary Co-Payment*
10% or 20% voluntary co-payment for each

and every claim as opted on the Policy
Not Available
Not Available
27
Health Insurance
Annexure IV:
List of Non-Medical Expenses
SNO
List of Expenses Generally Excluded ("Non-Medical")

in Hospital Indemnity Policy
SUGGESTIONS
TOILETRIES/ COSMETICS/ PERSONAL COMFORT OR CONVENIENCE ITEMS

1
HAIR REMOVAL CREAM
Not Payable
BABY CHARGES (UNLESS SPECIFIED/INDICATED)
Not Payable
BABY FOOD
Not Payable
BABY UTILITES CHARGES
Not Payable
BABY SET
Not Payable
BABY BOTTLES
Not Payable
BRUSH
Not Payable
COSY TOWEL
Not Payable
HAND WASH
Not Payable
10
M01STUR1SER PASTE BRUSH
Not Payable
11
POWDER
Not Payable
12
RAZOR
Payable
13
SHOE COVER
Not Payable
14
BEAUTY SERVICES
Not Payable
15
BELTS/ BRACES
Essential and may be paid specifically for cases who

have undergone surgery of thoracic or lumbar spine.
16
BUDS
Not Payable
17
BARBER CHARGES
Not Payable
18
CAPS
Not Payable
19
COLD PACK/HOT PACK
Not Payable
20
CARRY BAGS
Not Payable
21
CRADLE CHARGES
Not Payable
22
COMB
Not Payable
23
DISPOSABLES RAZORS CHARGES ( for site preparations)
Payable
24
EAU-DE-COLOGNE / ROOM FRESHNERS
Not Payable
25
EYE PAD
Not Payable
26
EYE SHEILD
Not Payable
27
EMAIL / INTERNET CHARGES
Not Payable
28
FOOD CHARGES (OTHER THAN PATIENT'S DIET PROVIDED

BY HOSPITAL)
Not Payable
29
FOOT COVER
Not Payable
30
GOWN
Not Payable
31
LEGGINGS
Essential in bariatric and varicose vein surgery and

should be considered for these conditions where
surgery itself is payable.
32
LAUNDRY CHARGES
Not Payable
33
MINERAL WATER
Not Payable
34
OIL CHARGES
Not Payable
28
Health Insurance
SNO

SUGGESTIONS
35
SANITARY PAD
Not Payable
36
SLIPPERS
Not Payable
37
TELEPHONE CHARGES
Not Payable
38
TISSUE PAPER
Not Payable
39
TOOTH PASTE
Not Payable
40
TOOTH BRUSH
Not Payable
41
GUEST SERVICES
Not Payable
42
BED PAN
Not Payable
43
BED UNDER PAD CHARGES
Not Payable
44
CAMERA COVER
Not Payable
45
CLINIPLAST
Not Payable
46
CREPE BANDAGE
Not Payable/ Payable by the patient
47
CURAPORE
Not Payable
48
DIAPER OF ANY TYPE
Not Payable
49
DVD, CD CHARGES
Not Payable ( However if CD is specifically sought by

Insurer/TPA then payable)
50
EYELET COLLAR
Not Payable
51
FACE MASK
Not Payable
52
FLEXI MASK
Not Payable
53
GAUSE SOFT
Not Payable
54
GAUZE
Not Payable
55
HAND HOLDER
Not Payable
56
HANSAPLAST/ADHESIVE BANDAGES
Not Payable
57
INFANT FOOD
Not Payable
58
SLINGS
Reasonable costs for one sling in case of upper arm

fractures should be considered
ITEMS SPECIFIC ALL Y EXCLUDED IN THE POLICIES

59
WEIGHT CONTROL PROGRAMS/ SUPPLIES/ SERVICES
Exclusion in policy unless otherwise specified
60
COST OF SPECTACLES/ CONTACT LENSES/ HEARING

AIDS ETC.
61
DENTAL TREATMENT EXPENSES THAT DO NOT REQUIRE

HOSPITALISATION
62
HORMONE REPLACEMENT THERAPY
63
HOME VISIT CHARGES
64
INFERTILITY/ SUBFERTILITY/ ASSISTED CONCEPTION

PROCEDURE
65
OBESITY (INCLUDING MORBID OBESITY) TREATMENT IF

EXCLUDED IN POLICY
66
PSYCHIATRIC & PSYCHOSOMATIC DISORDERS
67
CORRECTIVE SURGERY FOR REFRACTIVE ERROR
68
TREATMENT OF SEXUALLY TRANSMITTED DISEASES
69
DONOR SCREENING CHARGES
29
Health Insurance
SNO

SUGGESTIONS
70
ADMISSION/REGISTRATION CHARGES
71
HOSPITALISATION FOR EVALUATION/ DIAGNOSTIC PURPOSE
72
EXPENSES FOR INVESTIGATION/ TREATMENT IRRELEVANT

TO THE DISEASE FOR WHICH ADMITTED OR DIAGNOSED
Not Payable - Exclusion in policy unless otherwise

specified
73
ANY EXPENSES WHEN THE PATIENT IS DIAGNOSED WITH

RETRO VIRUS + OR SUFFERING FROM /HIV/ AIDS ETC IS
DETECTED/ DIRECTLY OR INDIRECTLY
Not payable as per HIV/AIDS exclusion
74
STEM CELL IMPLANTATION/ SURGERY and STORAGE
Not Payable except Bone Marrow Transplantation

where covered by policy
ITEMS WHICH FORM PART OF HOSPITAL SERVICES WHERE SEPARATE CONSUMABLES ARE NOT PAYABLE BUT
THE SERVICE IS
75
WARD AND THEATRE BOOKING CHARGES
Payable under OT Charges, not payable separately
76
ARTHROSCOPY & ENDOSCOPY INSTRUMENTS
Rental charged by the hospital payable.

Purchase of Instruments not payable.
77
MICROSCOPE COVER
Payable under OT Charges, not separately
78
SURGICAL BLADES,HARMONIC SCALPEL,SHAVER
79
SURGICAL DRILL
80
EYE KIT
81
EYE DRAPE
82
X-RAY FILM
Payable under Radiology Charges, not as consumable
83
SPUTUM CUP
Payable under Investigation Charges, not as consumable
84
BOYLES APPARATUS CHARGES
Part of OT Charges, not separately
85
BLOOD GROUPING AND CROSS MATCHING OF DONORS

SAMPLES
Part of Cost of Blood, not payable
86
ANTISEPTIC or DISINFECTANT LOTIONS
Not Payable -Part of Dressing Charges
87
BAND AIDS, BANDAGES, STERLILE INJECTIONS,

NEEDLES, SYRINGES
88
COTTON
89
COTTON BANDAGE
90
MICROPORE/ SURGICAL TAPE
Not Payable-Payable by the patient when prescribed,

otherwise included as Dressing Charges
91
BLADE
Not Payable
92
APRON
Not Payable -Part of Hospital Services/ Disposable linen

to be part of OT/ICU charges
93
TORNIQUET
Not Payable (service is charged by hospitals,

consumables can not be separately charged)
94
ORTHOBUNDLE, GYNAEC BUNDLE
Part of Dressing Charges
95
URINE CONTAINER
Not Payable
ELEMENTS OF ROOM CHARGE

96
LUXURY TAX
Actual tax levied by government is payable.

Part of room charge for sub limits
97
HVAC
Part of room charge not payable separately
98
HOUSE KEEPING CHARGES
99
SERVICE CHARGES WHERE NURSING CHARGE ALSO

CHARGED
30
Health Insurance
SNO

SUGGESTIONS
100
TELEVISION & AIR CONDITIONER CHARGES
Payable under room charges not if separately levied
101
SURCHARGES
Part of Room Charge , Not payable separately
102
ATTENDANT CHARGES
Not Payable - Part of Room Charges
103
IM IV INJECTION CHARGES
Part of nursing charges, not payable
104
CLEAN SHEET
Part of Laundry/Housekeeping not payable separately
105
EXTRA DIET OF PATIENT(OTHER THAN THAT WHICH

FORMS PART OF BED CHARGE)
Patient Diet provided by hospital is payable
BLANKET/WARMER BLANKET
Not Payable- part of room charges
106
ADMINISTRATIVE OR NON-MEDICAL CHARGES

107
ADMISSION KIT
Not Payable
108
BIRTH CERTIFICATE
Not Payable
109
BLOOD RESERVATION CHARGES AND ANTE NATAL

BOOKING CHARGES
Not Payable
110
CERTIFICATE CHARGES
Not Payable
111
COURIER CHARGES
Not Payable
112
CONVENYANCE CHARGES
Not Payable
113
DIABETIC CHART CHARGES
Not Payable
114
DOCUMENTATION CHARGES / ADMINISTRATIVE EXPENSES
Not Payable
115
DISCHARGE PROCEDURE CHARGES
Not Payable
116
DAILY CHART CHARGES
Not Payable
117
ENTRANCE PASS / VISITORS PASS CHARGES
Not Payable
118
EXPENSES RELATED TO PRESCRIPTION ON DISCHARGE
To be claimed by patient under Post Hosp where admissible
119
FILE OPENING CHARGES
Not Payable
120
INCIDENTAL EXPENSES / MISC. CHARGES (NOT EXPLAINED)
Not Payable
121
MEDICAL CERTIFICATE
Not Payable
122
MAINTENANCE CHARGES
Not Payable
123
MEDICAL RECORDS
Not Payable
124
PREPARATION CHARGES
Not Payable
125
PHOTOCOPIES CHARGES
Not Payable
126
PATIENT IDENTIFICATION BAND / NAME TAG
Not Payable
127
WASHING CHARGES
Not Payable
128
MEDICINE BOX
Not Payable
129
MORTUARY CHARGES
Payable upto 24 hrs, shifting charges not payable
130
MEDICO LEGAL CASE CHARGES (MLC CHARGES)
Not Payable
EXTERNAL DURABLE DEVICES

131
WALKING AIDS CHARGES
Not Payable
132
BIPAP MACHINE
Not Payable
133
COMMODE
Not Payable
134
CPAP/ CAPD EQUIPMENTS
Device not Payable
135
INFUSION PUMP - COST
Not Payable
31
Health Insurance
SNO

SUGGESTIONS
136
OXYGEN CYLINDER (FOR USAGE OUTSIDE THE HOSPITAL)
Device not Payable
137
PULSEOXYMETER CHARGES
Device not Payable
138
SPACER
Not Payable
139
SPIROMETRE
Device not Payable
140
SP 02 PROBE
Not Payable
141
NEBULIZER KIT
Not Payable
142
STEAM INHALER
Not Payable
143
ARMSLING
Not Payable
144
THERMOMETER
Not Payable (paid by patient)
145
CERVICAL COLLAR
Not Payable
146
SPLINT
Not Payable
147
DIABETIC FOOT WEAR
Not Payable
148
KNEE BRACES ( LONG/ SHORT/ HINGED)
Not Payable
149
KNEE IMMOBILIZER/SHOULDER IMMOBILIZER
Not Payable
150
LUMBOSACRAL BELT
Essential and should be paid specifically for cases

who have undergone surgery of lumbar spine.
151
NIMBUS BED OR WATER OR AIR BED CHARGES
Payable for any ICU patient requiring more than 3 days

in ICU, all patients with paraplegia / quadripiegia for any
reason & at reasonable cost of approximately Rs 200/ day
152
AMBULANCE COLLAR
Not Payable
153
AMBULANCE EQUIPMENT
Not Payable
154
MICROSHEILD
Not Payable
155
ABDOMINAL BINDER
Essential an d should be paid in post surgery patients of

major abdominal surgery including TAH, LSCS, incisional
hernia repair, exploratory laparotomy for intestinal
obstruction, liver transplant etc.
ITEMS PA YABLE IF SUPPORTED BY A PRESCRIPTION

156
BETADINE \ HYDROGEN PEROXIDE\SPIRIT\

DSINFECTANTS ETC
May be payable when prescribed for patient, not payable

for hospital use in OT or ward or for dressings in hospital
157
PRIVATE NURSES CHARGES- SPECIAL NURSING CHARGES
Post hospitalization nursing charges not Payable
158
NUTRITION PLANNING CHARGES - DIETICIAN CHARGES DIET CHARGES
Patient Diet provided by hospital is payable
159
SUGAR FREE Tablets
Payable -Sugar free variants of admissable medicines

are not excluded
160
CREAMS POWDERS LOTIONS (Toileteries are not payable,only

prescribed medical pharmaceuticals payable)
Payable when prescribed
161
Digestion gels
162
ECG ELECTRODES
Upto 5 electrodes are required for every case visiting

OT or ICU. For longer stay in ICU, may require a change
and at least one set every second day must be payable.
163
GLOVES
Sterilized Gloves payable/unsterilized gloves not payable
164
HIV KIT
Payable - payable Pre-operative screening
165
LISTERINE/ ANTISEPTIC MOUTHWASH
166
LOZENGES
32
Health Insurance
SNO

SUGGESTIONS
167
MOUTH PAINT
168
NEBULISATION KIT
If used during hospitalization is payable reasonably
169
NOVARAPID
170
VOLINI GEL/ ANALGESIC GEL
171
ZYTEE GEL
172
VACCINATION CHARGES
Routine Vaccination not Payable/ Post Bite

Vaccination Payable
PART OF HOSPITAL'S OWN COSTS AND NOT PAYABLE

173
AHD
Not Payable - Part of Hospital's internal Cost
174
ALCOHOL SWABES
175
SCRUB SOLUTION/STERILLIUM
176
VACCINE CHARGES FOR BABY
Not Payable
177
AESTHETIC TREATMENT / SURGERY
Not Payable
178
TPA CHARGES
Not Payable
179
VISCO BELT CHARGES
Not Payable
180
ANY KIT WITH NO DETAILS MENTIONED [DELIVERY KIT,

ORTHOKIT, RECOVERY KIT, ETC]
Not Payable
181
EXAMINATION GLOVES
Not Payable
182
KIDNEY TRAY
Not Payable
183
MASK
Not Payable
184
OUNCE GLASS
Not Payable
185
OUTSTATION CONSULTANT'S/ SURGEON'S FEES
Not payable, except for telemedicine consultations

where covered by policy
186
OXYGEN MASK
Not Payable
187
PAPER GLOVES
Not Payable
188
PELVIC TRACTION BELT
Should be payable in case of PIVID requiring traction as

this is generally not reused
189
REFERAL DOCTOR'S FEES
Not Payable
190
ACCU CHECK ( Glucometery/ Strips)
Not payable pre hospitalisation or post hospitalisation /

Reports and Charts required / Device not payable
191
PAN CAN
Not Payable
192
SOFNET
Not Payable
193
TROLLY COVER
Not Payable
194
UROMETER, URINE JUG
Not Payable
195
AMBULANCE
Payable-Ambulance from home to hospital or inter hospital

shifts is payable/ RTA as specific requirement is payable
196
TEGADERM / VASOFIX SAFETY
Payable - maximum of 3 in 48 hrs an d then 1 in 24 hrs
197
URINE BAG
Payable where medically necessary till a reasonable

cost - maximum 1 per 24 hrs
198
SOFTOVAC
Not Payable
199
STOCKINGS
Essential for case like CABG etc. where it should

be paid.
OTHERS
33
Health Insurance
supported by a coronary angiography and the realization of

surgery has to be confirmed by a specialist medical practitioner.
Cigna TTK Critical Illness Add On Cover

Terms and Conditions
I. General Provisions
1. It is agreed and understood that the Add On Cover can only be
bought along with the Underlying Plan and cannot be bought in
isolation or as a separate product.
2. The Add On Cover is subject to the terms and conditions stated
below and the Policy terms, conditions and applicable
endorsements of the Underlying Plan.
Excluded are:
1. Angioplasty and/or any other intra-arterial procedures
2. Any key-hole or laser surgery.
d) Open Heart Replacement or Repair of Heart Valves
The actual undergoing of open-heart valve surgery is to replace
or repair one or more heart valves, as a consequence of defects
in, abnormalities of, or disease-affected cardiac valve(s). The
diagnosis of the valve abnormality must be supported by an
echocardiography and the realization of surgery has to be
confirmed by a specialist medical practitioner. Catheter based
techniques including but not limited to, balloon valvotomy/
valvuloplasty are excluded.
3. The Add On Cover shall be available under your policy only if the
same is specifically opted and specified in the Policy Schedule.
4. All applicable Terms and Conditions of the Underlying Policy shall
apply to the Add On Cover.
II. Definitions
1. Add On Cover means Cigna TTK Critical Illness Add On Cover
e) Coma of Specified Severity
2. Critical Illness means the following:
1. A state of unconsciousness with no reaction or response to

external stimuli or internal needs.
This diagnosis must be supported by evidence of all of the following:
a) Cancer of Specified Severity

A malignant tumour characterised by the uncontrolled growth &
spread of malignant cells with invasion & destruction of normal
tissues. This diagnosis must be supported by histological
evidence of malignancy & confirmed by a pathologist. The term
cancer includes leukemia, lymphoma and sarcoma.
The following are excluded 1. Tumours showing the malignant changes of carcinoma in situ &
tumours which are histologically described as premalignant or
non-invasive, including but not limited to: Carcinoma in situ of
breasts, Cervical dysplasia CIN-1, CIN -2 & CIN-3.
i.
iii. permanent neurological deficit which must be assessed at least

30 days after the onset of the coma.
2. The condition has to be confirmed by a specialist medical
practitioner. Coma resulting directly from alcohol or drug abuse is
excluded.
f) Kidney Failure Requiring Regular Dialysis
End stage renal disease presenting as chronic irreversible failure
of both kidneys to function, as a result of which either regular
renal dialysis (haemodialysis or peritoneal dialysis) is instituted
or renal transplantation is carried out. Diagnosis has to be
confirmed by a specialist medical practitioner.
2. Any skin cancer other than invasive malignant melanoma

3. All tumours of the prostate unless histologically classified as
having a Gleason score greater than 6 or having progressed to at
least clinical TNM classification T2N0M0
4. Papillary micro - carcinoma of the thyroid less than 1 cm in diameter
5. Chronic lymphocytic leukaemia less than RAI stage 3
g) Stroke Resulting in Permanent Symptoms

Any cerebrovascular incident producing permanent neurological
sequelae. This includes infarction of brain tissue, thrombosis in
an intracranial vessel, haemorrhage and embolization from an
extra cranial source. Diagnosis has to be confirmed by a
specialist medical practitioner and evidenced by typical clinical
symptoms as well as typical findings in CT Scan or MRI of the
brain. Evidence of permanent neurological deficit lasting for at
least 3 months has to be produced.
6. Microcarcinoma of the bladder

7. All tumours in the presence of HIV infection.
b) First Heart Attack of Specified Severity
The first occurrence of myocardial infarction which means the
death of a portion of the heart muscle as a result of inadequate
blood supply to the relevant area. The diagnosis for this will be
evidenced by all of the following criteria:
1. a history of typical clinical symptoms consistent with the
diagnosis of Acute Myocardial Infarction (for e.g. typical chest
pain)
no response to external stimuli continuously for at least 96 hours;
ii. life support measures are necessary to sustain life; and

1. Transient ischemic attacks (TIA)
2. Traumatic injury of the brain
2. new characteristic electrocardiogram changes
3. Vascular disease affecting only the eye or optic nerve or

vestibular functions.
3. elevation of infarction specific enzymes, Troponins or other

specific biochemical markers.
h) Major Organ/Bone Marrow Transplant

1. Non-ST-segment elevation myocardial infarction (NSTEMI) with
elevation of Troponin I or T;
2. Other acute Coronary Syndromes
3. Any type of angina pectoris.
The actual undergoing of a transplant of:

1. One of the following human organs: heart, lung, liver, kidney,
pancreas, that resulted from irreversible end-stage failure of the
relevant organ, or
2. Human bone marrow using haematopoietic stem cells. The
undergoing of a transplant has to be confirmed by a specialist
medical practitioner.
c) Open Chest CABG

The actual undergoing of open chest surgery for the correction of
one or more coronary arteries, which is/are narrowed or blocked,
by coronary artery bypass graft (CABG). The diagnosis must be

i.
Other stem-cell transplants
ii. Where only islets of langerhans are transplanted
34
Health Insurance
i)

Total and irreversible loss of use of two or more limbs as a result
of injury or disease of the brain or spinal cord. A specialist medical
practitioner must be of the opinion that the paralysis will be
permanent with no hope of recovery and must be present for
more than 3 months.
j)
Motor Neurone Disease with Permanent Symptoms

Motor neurone disease diagnosed by a specialist medical
practitioner as spinal muscular atrophy, progressive bulbar palsy,
amyotrophic lateral sclerosis or primary lateral sclerosis. There
must be progressive degeneration of corticospinal tracts and
anterior horn cells or bulbar efferent neurons. There must be
current significant and permanent functional neurological
impairment with objective evidence of motor dysfunction that has
persisted for a continuous period of at least 3 months.
k) Multiple Sclerosis with Persisting Symptoms

The definite occurrence of multiple sclerosis. The diagnosis must
be supported by all of the following:
1. investigations including typical MRI and CSF findings, which
unequivocally confirm the diagnosis to be multiple sclerosis;
2. there must be current clinical impairment of motor or sensory
function, which must have persisted for a continuous period of at
least 6 months, and
3. well documented clinical history of exacerbations and remissions
of said symptoms or neurological deficits with at least two
clinically documented episodes at least one month apart.
Other causes of neurological damage such as SLE and HIV are
excluded.
3. Underlying Policy - means the Insurance Policy or any other
insurance plan issued by Cigna TTK including its terms and
conditions, any annexure thereto and the Schedule (as amended
from time to time), the statements in the proposal form or the
Customer Information Sheet and the Policy wording (including
endorsements, if any) and to which this Add On Cover is
attached.
III. Coverage
a) We will pay a fixed lump sum amount, to the Insured Person
suffering from a disease/ Illness/ Injury or medical condition
which shall lead to the diagnosis of the named Critical Illnesses or
the performance of any of the named Surgical Procedures listed
and defined under this Add on.
i.
Cancer of specific severity
ii. First Heart Attack of specified severity

iii. Open Chest CABG
iii. The Insured Person survives for at least 30 days following the
diagnosis of Critical Illness;
iv. The Insured Person is at least 18 years of age at the time of taking
the Cover.
v. Coverage will not apply to persons between the age group of 18
to 23 years who are covered as "Child".
vi. Once a claim has been accepted and paid for a particular Critical
Illness for that particular Insured, the cover shall cease in respect
of that Insured Person.
In case of a floater policy, We will provide for a 100%
reinstatement of Sum Insured once during the lifetime of the
Policy for the other adult Insured Person in the Policy.
Reinstatement of Sum Insured for the purpose of this Policy
means the amount reinstated in accordance with the terms and
conditions as stated above under this Policy.
IV Waiting Periods
We shall not be liable to make any payment under this Add On
Cover directly or indirectly caused by, based on, arising out of or
a) First 90 days Waiting Period: Any Critical Illness or Injury which
was diagnosed or existed within the first ninety (90) days of the
Add On Cover start date will not be covered.
b) Pre-existing disease Waiting period: Any Pre-existing Critical
Illness as defined in the Policy until the specified months of
continuous covers have elapsed since inception of the first Policy
with Us. Waiting period for the specified months as mentioned in
the Schedule against this Benefit shall apply.
c) Personal Waiting Period: A special Waiting Period not exceeding
48 months, may be applied to Insured Persons depending upon
declarations on the proposal form and existing health conditions.
Such waiting periods shall be specifically stated in the Schedule
and will be applied only after receiving the Insured person's
specific consent.
V. Survival Period
The benefit payment shall be subject to survival of the Insured
Person for more than 30 days post the first diagnosis of the
Critical Illness/ undergoing for the first time of the Surgical
Procedures/ for the first time of occurrence of medical events.
VI . Cancellations
Request for Cancellation shall be intimated to Us from Your side
by giving 15 days' notice in which case We shall refund the
premium for the unexpired term as per the short period scale
mentioned below.
Premium shall be refunded only if no claim has been made under
the Policy.
1 Year
iv. Open Heart Replacement or Repair of Heart Valves

v. Coma of specified severity
vi. Kidney Failure requiring regular dialysis
vii. Stroke resulting in permanent symptoms
viii. Major Organ/Bone Marrow Transplant
ix. Permanent Paralysis of Limbs
x. Motor Neurone Disease with permanent symptoms
xi. Multiple Sclerosis with persisting symptoms
b) The Sum Insured will be payable once in a lifetime of an Insured
subject to the following conditions:
i.
The Critical Illness is specifically listed and defined in this Cover;
ii. The Critical Illness experienced by the Insured person is the first
incidence of that Critical Illness;
Policy in
force upto
Premium
Refund %
2 year
Policy in
force upto
Premium
Refund %
1 Month
75%
1 Month
87.5%
3 months
50%
3 months
75%
6 months
25%
6 months
62.5%
More than
NIL
12 months
50%
6 months
15 months
37.50%
18 months
25%
Above 18 months
NIL
You further understand and agree that We may cancel the

Policy by giving 15 days' notice in writing by Registered Post
Acknowledgment Due/ recorded delivery to Your last known
address on grounds of misrepresentation, fraud, nondisclosure of material fact or for non-co-operation by You
without any refund of premium.
35
Health Insurance
Where the Policy has been issued for two years and a claim for
Critical Illness becomes payable in the first year the cover shall
cease and any premium collected for the second year in respect
of a particular Insured Person will be refunded after deduction of
applicable discounts and commissions (if any).
VII. Permanent Exclusions
1. We shall not be liable to make any payment under this Add On
Cover, directly or indirectly caused by, based on, arising out of or
2. Any Illness, sickness or disease, other than specified as Critical
Illness, as mentioned in the Schedule;
3. Any Critical Illness directly or indirectly caused due to or
associated with human T-call Lymph tropic virus type III (HTLV-III
or IITLB-III) or Lymphadinopathy Associated Virus (LAV) and its
variants or mutants, Acquired Immune Deficiency Syndrome
(AIDS) whether or not arising out of HIV, AIDS related complex
syndrome (ARCS) and all diseases/ illness/ injury caused by
and/or related to HIV;
4. Any Critical Illness arising out of use, abuse or consequence or
influence of any substance, intoxicant, drug, alcohol or
hallucinogen;
5. Any Critical Illness directly or indirectly caused due to Intentional
self-injury, suicide or attempted suicide.
6. Any treatment/surgery for change of sex or any cosmetic surgery
or treatment/ surgery/ complications/ illness arising as a
consequence thereof;
7. All expenses directly or indirectly, caused by or arising from or
attributable to foreign invasion, act of foreign enemies, hostilities,
warlike operations (whether war be declared or not or while
performing duties in the armed forces of any country), civil war,
public defense, rebellion, revolution, insurrection, military or
usurped power;
8. Any Critical Illness caused by ionizing radiation or contamination
by radioactivity from any nuclear fuel or from any nuclear waste
from the combustion of nuclear fuel;
9. Congenital anomalies or any complications or conditions arising
therefrom;
10. Insured Persons whilst engaging in speed contest or racing of
any kind (other than on foot), bungee jumping, parasailing,
ballooning, parachuting, skydiving, paragliding, hang gliding,
mountain or rock climbing necessitating the use of guides or
ropes, potholing, abseiling, deep sea diving using hard helmet
and breathing apparatus, polo, snow and ice sports or involving a
naval military or air force operation;
11. Any loss resulting directly or indirectly, contributed or aggravated

or prolonged by childbirth or from pregnancy;
12. Any Critical Illness based on Certification/ Diagnosis/ Treatment
by a family member, or a person who stays with the Insured
Person, or from persons not registered as Medical Practitioners
under the respective Medical Councils, or from a Medical
Practitioner who is practicing outside the discipline that he is
licensed for, or any diagnosis or treatment that is not scientifically
recognized or experimental or unproven or any kind of selfmedication and its complications;
13. Cosmetic or plastic surgery or any elective surgery or cosmetic
procedure that improve physical appearance, surgical and nonsurgical treatment of obesity, including morbid obesity (unless
certified to be life threatening) and weight control programs, or
treatment of an optional nature;
14. Any critical illness arising or resulting from the Proposer or any of
his family members committing any breach of law or participating
in an actual or attempted felony, riot, crime, misdemeanor or civil
commotion;
15. In the event of death of the Insured within the stipulated survival
period applicable under each category.
Applicable exclusions of the Underlying Policy will apply in
addition to the Add On exclusions.
VIII Claim Process:
In the event of a claim arising out of any of the listed Critical
Illnesses covered under this Add on, the Insured Person shall
submit the claim documents to Us within ninety (90) days of date
of first diagnosis of the Illness/ date of surgical procedure or date
of occurrence of the medical event, as the case may be.
Insured Person shall submit the following documents in original
for assessment and upon request we will return the Original
documents.
1. Claim Form Duly Filled and Signed- Part A and B
2. Original Discharge Certificate/ Card from the hospital/ Doctor
3. Original investigation test reports confirming the diagnosis,
Indoor case papers if applicable
4. Any other documents as may be required by Us
5. In the cases where Critical Illness arises due to an accident, FIR
copy or medico legal certificate will be required.
In the unfortunate event of the death of the insured person post
the survival period, someone claiming on his behalf must inform
us in writing immediately.
36
Your Health Relationship Manager Has The Answer

Be it claims assistance or guidance, contact your Health RM anytime.
1-800-10-24462
customercare@cignattk.in
www.cignattkinsurance.in
Corporate Office: CignaTTK Health Insurance Company Limited,10th Floor, Commerz, International Business Park, Oberoi Garden City, Goregaon (East), Mumbai - 400 063.
IRDA Registration No. 151
ProHealth UIN Number: IRDA/NL-HLT/CTTK/P-HA/-I/390/13-14
Compliance Control Number - POL/0006/Feb/13-14
Critical illness UIN Number: IRDA/NL-HLT/CTTK/P-HA/-l/390/Addon(CI)13-14

Version Number: V1/Feb14

Every DETAIL Matters To Your HEALTH.: Policy Contract

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Every DETAIL Matters To Your HEALTH.: Policy Contract

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POLICY CONTRACT

Every DETAIL matters

Cigna TTK ProHealth Insurance

Identify your Plan

Medical Expenses Covered up to 60 days before date of hospitalisation

Medical Expenses Covered up to 180 days post

Refer to the following

Covered up to the limit of Sum Insured opted

Covered up to the limit of Sum Insured opted

Ambulance Cover Up to ` 2000 paid

Covered up to the limit Sum Insured

Covered upto a maximum of ` 10 Lacs

Available once in a Policy Year for unrelated illnesses

New Born Baby

Actual incurred expenses paid

Covered up to the limit of Sum Insured opted

Covered upto ` 50,000 for normal

Covered for the inpatient hospitalisation expenses of a

Covered as per national immunization programme over

Identify your Plan

This section lists

Available at each renewal, to all insured persons who

Available once during the Policy Year

10% Increase in Sum Insured,

Refer to the following

These earned Reward Points can be used to get a discount in premium

Maternity waiting period Reduced from 48 months

10% or 20% Voluntary Co-payment

^If you have opted

Lump sum payment of an additional 100% of

This section lists

Dental treatment other than due to accident.

HIV/ AIDS and related complications.

Vitamins and tonics unless forming part of treatment.

Artificial life maintenance, including life support machine use.

Treatment for rehabilitation measures, private duty nursing, respite care.

Treatment from persons not registered as Medical Practitioners.

What are the

Refer to the following

Treatment of any mental illness or Parkinson's or Alzheimer's disease even if caused or

Charges incurred primarily for diagnostic purposes.

c. Health Maintenance Benefit will be on reimbursement basis on submission of bills.

This section lists

This sections lists

c. Renewals will not be denied except on grounds of misrepresentation, fraud, non-disclosure or

Refer to the following

b. This Policy can be cancelled on grounds of misrepresentation, fraud, non-disclosure of material

Cigna TTK ProHealth Insurance

I PREAMBLE & OPERATING CLAUSE

BENEFITS UNDER THE POLICY

The condition of the Insured Person does not allow a Hospital

ii. A Hospital bed was unavailable;

Asthma, bronchitis, tonsillitis and upper respiratory tract infection

ii. Arthritis, gout and rheumatism,

For the purpose of this Section "Associated Medical Expenses"

ix. Pyrexia of unknown origin.

II.2. Pre - hospitalization:

v. Diabetes mellitus and Insipidus,