Name of Insurance Product /Policy

Shri Criticare Insurance

Policy number

Type of Insurance Product / Policy

Benefit Based –This insurance pays a fixed amount under the policy on the occurrence of a covered event

8. Part E: Coverage

Sum Insured (Basis) (Along with amount)

Individual Sum insured ₹

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

While this Policy is in force, the Company shall provide the benefit in one lump sum as stated in the Schedule of Benefits subject to the provisions, conditions and limitations contained herein or which may be endorsed hereinafter if the Insured is diagnosed to be suffering from a Critical Illness as defined hereinabove and if all of the following conditions are satisfied.

• a. The Insured Person experiences a Critical Illness specifically listed and defined in this Policy; and
• b. The Critical Illness experienced by the Insured is the first incidence of that Critical Illness; and
• c. The signs or symptoms of the Critical Illness experienced by the Insured Person commenced more than Ninety (90) days following the Issue Date of the Certificate of Insurance or the last Commencement Date, whichever is later; and
• d. None of the General or Specific Limitations or Exclusions specifically contained in this Policy applies. contained in this Policy applies.
• e. The person has to survive the illness by thirty (30) days or more, from the date of diagnosis. Only one lump sum payment shall be provided during the Insured‟s lifetime regardless of the number of Critical Illness, incapacities or treatments suffered by him/her. This Benefit will be terminated after the lump sum payment. If a Critical Illness is diagnosed within Ninety (90) days following the effective date or the date of its last reinstatement of this Policy, whichever is later, the Company‟s liability shall be limited to the refund of premiums paid under this Policy.

Type of Plan - Advance

• 1. Cancer of specified severity
• 2. Myocardial Infarction (First heart attack - of specified severity)
• 3. Open chest CABG
• 4. Open heart replacement or repair of heart valves
• 5. Kidney failure requiring regular dialysis
• 6. Stroke resulting in permanent symptoms
• 7. Major organ /bone marrow transplant
• 8. Permanent paralysis of limbs
• 9. Multiple sclerosis with persisting symptoms
• 10. Primary (Idiopathic) Pulmonary Hypertension
• 1. Coma Of Specified Severity
• 1. End Stage Liver Failure
• 13. Loss Of Limbs
• 14. Major Head Trauma
• 15. Angioplasty
• 16. Benign Brain Tumor
• 17. Blindness
• 18. Deafness
• 19. End Stage Lung Failure
• 20. Loss Of Speech
• 21. Third Degree Burns
• 22. Motor Neuron Disease With Permanent Symptoms

Clause 8 Part E – Coverage

Exclusions (what the policy does not cover)

This entire Policy does not provide benefits for any loss resulting in whole or in part from, or expenses incurred, directly or indirectly in respect of:

• Pre-Existing Diseases - Code- Excl01

  • Expenses related to the treatment of a pre-existing Disease (PED) and its direct complications shall be excluded until the expiry of 48 months of continuous coverage after the date of inception of the first policy with insurer.
  • In case of enhancement of sum insured the exclusion shall apply afresh to the extent of sum insured increase.
  • If the Insured Person is continuously covered without any break as defined under the portability norms of the extant IRDAI (Health Insurance) Regulations, then waiting period for the same would be reduced to the extent of prior coverage.
  • Coverage under the policy after the expiry of 48 months for any pre-existing disease is subject to the same being declared at the time of application and accepted by Insurer
• Any Illness, sickness or disease, other than specified as Critical Illness, as mentioned in the policy schedule, or
• Any Critical Illness resulting from a physical or mental condition which existed before the Policy Issue Date or the last Commencement Date which was not disclosed, or
• Intentionally self-inflicted Injury or illness, 0or sexually transmitted conditions, mental or nervous disorder, anxiety, stress or depression, Acquired Immune Deficiency Syndrome (AIDS), Human Immune-deficiency Virus (HIV) infection; suicide, or
• War, civil war, invasion, insurrection, revolution, act of foreign enemy, hostilities (whether War be declared or not), rebellion, mutiny, use of military power or usurpation of government or military power; or
• Ionising radiation or contamination by radioactivity from any nuclear fuel or from any nuclear waste from burning nuclear fuel; or
• The radioactive, toxic, explosive or other dangerous properties of any explosive nuclear equipment or any part of that equipment; or
• Participation in winter sports, skydiving/parachuting, hang gliding, bungee jumping, scuba diving, mountain climbing (where ropes or guides are customarily used), riding or driving in races or rallies using a motorized vehicle or bicycle, caving or pot-holing, hunting or equestrian activities, skin diving or other underwater activity, rafting or canoeing involving white water rapids, yachting or boating outside coastal waters (2 miles), participation in any Professional Sport, any bodily contact sport or any other hazardous or potentially dangerous sport for which you are trained or untrained; or
• Any loss resulting directly or indirectly, contributed or aggravated or prolonged by childbirth or from pregnancy, or
• Any Critical Illness based on a Diagnosis made by the Insured or his/her Immediate Family Member or anyone who is living in the same household as the Insured or by a herbalists, acupuncturist or other non-traditional health care provider; and
• Cosmetic or plastic surgery or any elective surgery or cosmetic procedure that improve physical appearance, surgical and non-surgical treatment of obesity (including morbid obesity) and weight control programs, or treatment of an optional nature;
• Special nursing care, routine health checks or convalescence, Custodial Care, general debility, lethargy, rest cure;
• In respect of the existing diseases, disclosed by the insured and mentioned in the policy schedule policyholder is not entitled to get the coverage for specified ICD codes.
• Any investigation(s) or treatments not directly related to a Covered Illness or Covered Injury or the conditions or diagnosis necessitating hospital admission;

Clause 5 Part B General Exclusions

Waiting period

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

Initial Waiting Period –

• Critical Illness operates after a three-month waiting period from inception of the policy. Waiting period clause will not be operative for subsequent years.

Initial Waiting Period –

• Pre-Existing Disease – 48 Month

Clause 4 Policy Tenure Clause 5 Part B General Exclusion 5.14

coverage

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

• i. No sub limits
• ii. No co-payment
• iii. No Deductible

Claims/ Claims Procedure

Claims Procedure

• Notice of claim/loss:

It is a condition precedent to Our liability hereunder that written notice of claim must be given by You to Us within 7 days after an actual or potential loss begins or as soon as reasonably possible and, in any event, not later than 30 Days after an actual or potential loss begins.

• Time for filing claim forms and evidence:

  Completed claim forms and written evidence of loss must be furnished to Us within thirty (30) Days after the date of such loss. Failure to furnish such evidence within the time required shall not invalidate nor reduce any claim if You can satisfy us that it was not reasonably possible for You to give proof within such time. However, no proof will be accepted if furnished later than one (1) year from the time the loss occurred.

• Claim Settlement

  Benefits payable under this Policy will be paid within a reasonable time upon receipt of due written evidence of such loss and any other documentation, information and assistance that We may request You pursuant to Uniform Provision

Clause 6.9

Clause 6.11

Clause 6.12

Policy Servicing

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

Phone: +91-141-3928400, 3951111,

Fax: +91-141-2770692, 2770693

Website: : www.shriramgi.com

E-mail: customer.feedback@shriramgi.in

Grievances/Complaints

Contact Address: Shriram General Insurance Co. Ltd. E-8, EPIP, RIICO Industrial Area, Sitapura, Jaipur – 302022

Grievance Cell No tell1800-103-3009, 1800-300-30000

E-mail: md@shriramgi.com

Fax No.: md@91-141-2770693

Clause 9

Things to remember

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

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

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

After completion of eight continuous years under the policy no look back to be applied. This period of eight years is called as moratorium period. The moratorium would be applicable for the sums insured of the first policy and subsequently completion of 8 continuous years would be applicable from date of enhancement of sums insured only on the enhanced limits. After the expiry of Moratorium Period no health insurance claim shall be contestable except for proven fraud and permanent exclusions specified in the policy contract. The policies would however be subject to all limits, sub limits, co-payments, deductibles as per the policy contract.

Your Obligations

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