LIFE INSURANCE CORPORATION OF INDIA CENTRAL OFFICE Dept: Product Development Yogakshema Jeevan Bima Marg Mumbai 400

0 021 31st May, 2011

Ref: CO/PD/11 To, All HODs of Central Office All Zonal Offices All Divisional Offices All Branch Offices (through DOs) MDCs, ZTCs, STCs, NIA and Audit & Inspection Depts. of Zonal Offices.

Re: INTRODUCTION OF LICS JEEVAN AROGYA (Plan No. 903) 1. INTRODUCTION: It has been decided to introduce LICs JEEVAN AROGYA (Plan No. 903) with effect from 1st June, 2011 The Unique Identification Number (UIN) for LICs Jeevan Arogya plan is 512N266V01. This number has to be quoted in all relevant documents furnished to the policyholders and other users (public, distribution channels). An individual can take the health cover under this plan for himself / herself. This individual will be addressed as Principal Insured (PI) for the purpose of insurance under this plan. The Spouse, Children, Parents and Parents-in-law can also be covered under the same policy. This is non-linked health plan which provides fixed benefits for hospitalization and almost all types of surgical procedures irrespective of actual cost incurred and the benefit is in addition to any other health insurance cover that insured lives may have, subject to certain terms and conditions. The benefits offered under the plan are: i) Hospital Cash Benefit (HCB) ii) Major Surgical Benefit (MSB) iii) Day Care Procedure Benefit (DCPB) iv) Other Surgical Benefit (OSB) Two riders viz. Term Assurance Rider and Accident Benefit Rider shall also be available under the plan for PI and Insured Spouse only. At the time of filling up the proposal form, PI and Spouse (if insured) have to exercise an option whether to continue the policy in case of exit of PI from the policy, as per Annexure C enclosed with the proposal form. If option for continuation of policy is exercised, in case of death or expiry of cover of PI, the surviving Insured Spouse will become the Principal Insured and the Policy will continue. In such case, the premium for the Insured Spouse will change from the coinciding or following instalment premium due date and the new premium would be based on tabular premium rates applicable for PIs and the age for calculation of revised premium rate will be the age at entry of the spouse. Other details of the plan are as follows.

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2. PREMIUM: Under this plan multiple lives can be covered under one policy. For each insured life, the instalment premium shall be based on the age at entry, the Initial Daily Hospital Cash Benefit chosen, gender and whether insured life is PI or other than PI. The tabular premium rates applicable for PI (males/females) will be different from those applicable for other lives (males/females) as given in Annexure I. Thus, the level of premium for PI and other insured lives shall be different for same age, same gender and same level of cover. The instalment premium payable during the cover period in respect of each Insured will be the sum of: (i) Instalment premium for the Basic Plan (ii) Instalment premium for Accident Benefit Rider (if opted for) (iii) Instalment premium for Term Assurance Rider (if opted for) The total instalment premium payable in respect of each policy shall be the sum of instalment premiums payable in respect of each insured life covered under the policy. For example, if there are 3 lives covered under a policy- PI (male), Spouse (female) and child (for children premium does not vary with gender). PI has opted for both Term Assurance Rider & Accident Benefit Rider, Spouse has not opted for any rider benefit and the optional riders are not available for child. Thus, Instalment premium for PI is = Instalment premium for PI under the Basic Plan + Instalment premium for Accident Benefit Rider + Instalment premium for Term Assurance Rider ------------- (A) Instalment premium for Spouse = Instalment premium for Spouse under the Basic Plan ------------- (B) Instalment premium for Child = Instalment premium for Child under the Basic Plan ------------- (C) Therefore, Total Instalment Premium to be paid for this policy shall be [(A) + (B) + (C)] In respect of each insured life covered under a policy, the instalment premium for Basic Plan will be guaranteed for a period of 3 (three) years from the Date of Commencement of the policy. The instalment premiums for Basic Plan are reviewable on every third policy anniversary (defined as Automatic Renewal Date in para 5 a) below) starting from the date of commencement of policy. The premium rates for the basic plan applicable on renewal, i.e. from Automatic Renewal Date, shall be guaranteed for a further period of 3 years i.e. till next Automatic Renewal Date. If any additional member is included in the policy after the date of commencement, the premium charged in respect of that member will also be guaranteed till the next Automatic Renewal Date and hence may change even before completion of 3 years from his/her joining the policy. On any Automatic Renewal Date in the future, the instalment premium in respect of each insured will be based on the entry age of that Insured (i.e. age as on the date of commencement of policy/ age at the time of inclusion into the policy, as the case may be) and the Corporations premium rates then prevailing for this product. The Instalment premium for both the optional riders is, however, guaranteed throughout the

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term for which cover is provided. The tabular premium rates per annum for PI and Other Insured for standard lives are given in the Annexure - I. Also the rates of Class I extra premium per annum are enclosed as Annexure II to this circular. Kindly note that maximum age at entry for PI is 65 years. However, tabular premium rates and Class I extra for PI have been given up to age 79 years to cover the possibilities mentioned in para 4 b) of this circular. 3. ELIGIBILITY CONDITIONS AND FEATURES: FOR BASIC PLAN a) Minimum / There is no specific minimum and maximum premium payable. The total Maximum Premium premium payable will be the sum of premiums in respect of each individual Amount member covered under the policy. The premium in respect of each individual will be payable from the date of entry into the policy till the date of exit from the policy. b) Minimum entry age Principal Insured, Insured Spouse, Parents & Parents-in-law [18] years last birthday Insured Dependent Children [3] months (completed) c) Maximum entry age Principal Insured and Insured Spouse - [65] years last birthday Insured Parents and Parents-in-law - [75] years last birthday Insured Dependent Children [17] years last birthday d) Maximum cover Principal Insured, Insured Spouse, Insured Parents & Parents-in-law ceasing age [80] years last birthday Insured Dependent Children [25] years last birthday e) Date of cover Policy anniversary on which the Insured life attains Maximum cover ceasing expiry in respect age or as per other conditions as specified in Para 5 (g). of each Insured covered under the plan f) Premium Rate Rates will be guaranteed for first 3 years of the policy i.e. for 3 years from the Guarantee date of commencement of policy. At the end of every 3 years, i.e. on each Automatic Renewal Date (defined in Para 5 a)) the premium rates may change i.e. the policy may be treated as if it is renewed every 3 years. The rates applicable on renewal after every 3 years shall be guaranteed for a further period of 3 years i.e. till next renewal.

(i) For Hospital Cash Benefit (HCB) (under Basic Plan) Feature Principal Insured (PI) Minimum Initial Daily ` 1,000/Benefit (in a ward other than Intensive Care Unit) Maximum Initial Daily ` 4,000/Benefit Insured Spouse (if any), Insured Dependent Insured Parents & Children (if any) Parents-in-law (if any) ` 1,000/` 1,000/-

a)

b)

Insured Spouse- Less than or equal to that of PI Insured Parents/ Parents-inlaw - Less than or equal to that of Insured Spouse (PI, if there is no Insured

Less than or equal to that of Insured Spouse (PI, if there is no Insured Spouse). Further, included children shall be

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c)

Maximum annual benefit period, applicable to each insured d) Maximum Lifetime Benefit period, applicable to each insured Initial Hospital Cash Benefit shall be in multiples of ` 1000/-. (ii) For Major Surgical Benefit (MSB) (under Basic Plan) Feature

Spouse). Further, included covered for equal parents shall be covered for benefits. equal benefits. 30 days in year 1, 90 days per year thereafter, inclusive of stay in ICU. Maximum number of days in ICU is restricted to 15 days in year 1 and to 45 days thereafter. 720 days inclusive of stay in ICU. Maximum number of days in ICU is restricted to 360 days in respect of each Insured.

a)

Major Surgical Benefit Sum Assured (MSB SA)

b)

c)

Maximum annual benefit, applicable to each insured Maximum Lifetime 800% of Major Surgical Benefit Sum Assured Benefit, applicable to each insured (iii) For Day Care Procedure Benefit (DCPB) (under Basic Plan)

Principal Insured (PI) Insured Spouse (if any),Insured Parents & Parents-in-law (if any) 100 times of Insured Spouse- 100 Applicable Daily times of ADB of Benefit (ADB) of PI Insured Spouse (as specified in para Insured Parents/ 4). Parents-in-law - 100 times of ADB of each parent 100% of Major Surgical Benefit Sum Assured

Insured Dependent Children (if any)

100 times of ADB of each child

Feature

a)

b)

c)

Principal Insured (PI) Insured Spouse (if any),Insured Parents & Parents-in-law (if any) Lump sum benefit 5 times of Applicable Insured Spouse- 5 Daily Benefit (ADB) times of ADB of payable (described in Para 4) Insured Spouse of PI for each Surgical Insured Parents/ Procedure Parents-in-law - 5 times of ADB of each parent Maximum annual 3 Surgical Procedures benefit, applicable to each insured Maximum Lifetime 24 Surgical Procedures Benefit, applicable to each insured

Insured Dependent Children (if any)

5 times of ADB of each child

(iv) For Other Surgical Benefit (OSB) (under Basic Plan)

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Feature

a)

b) c)

Insured Spouse (if Insured Dependent any),Insured Parents & Children (if any) Parents-in-law (if any) Daily benefit amount Insured Spouse- 2 times of 2 times of ADB of ADB of Insured Spouse each child Insured Parents/Parents-in-law2 times of ADB of each parent Maximum annual benefit, 15 days in year 1 and 45 days per year thereafter applicable to each insured Maximum Lifetime Benefit, 360 days applicable to each insured

Principal Insured (PI) 2 times of ADB of PI

FOR TERM ASSURANCE RIDER OPTION: This rider shall be available for PI and Insured Spouse only. (a) Minimum Term Assurance Sum Assured: ` [100] in '000's

(b) Maximum Term Assurance Sum Assured: An amount equal to the Major Surgical Benefit Sum Assured (MSB SA) at the time of inception/ inclusion into the policy (i.e. 100 times of Initial Daily Hospital Cash Benefit) in respect of the insured, subject to the maximum of ` 25 lakh overall limit taking all term assurance riders under all existing policies of the Life Assured and Term Assurance Sum Assured under other proposals into consideration. The Term Assurance Sum Assured shall be in multiples of ` 25,000/-. (c) Minimum / Maximum Premium Amount: There is no specific minimum and maximum premium payable. The premium payable will depend on the Term Assurance Sum Assured. The tabular premium rates per annum for Term Rider benefit are given in the Annexure III. Also the rates of Class I extra premium per annum are given in the Annexure IV. (d) Minimum Entry Age: (e) Maximum Entry Age: (f) Maximum Benefit Ceasing Age: (g) Maximum Term: FOR ACCIDENT BENEFIT RIDER OPTION: This rider shall only be available for PI and Insured Spouse provided Term Assurance Rider has been opted for. (a) Minimum Accident Benefit Sum Assured: ` [25] in '000's (b) Maximum Accident Benefit Sum Assured: An amount equal to the Term Assurance Sum Assured at the time of inception/ inclusion into the policy in respect of the insured, subject to maximum of ` 50 lakhs overall limit considering the Accident Benefit Sum Assured in respect of all existing policies on the life of the insured including the policies [18] years (completed) [50] years (Nearest Birthday) [60] years (Nearest Birthday) [35] years

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taken from Life Insurance Corporation of India and other insurance companies and the Accident Benefit Sum Assured under new proposals into consideration. The Accident Benefit Sum Assured shall be in multiples of `5,000/-. (c) Minimum / Maximum Premium Amount: There is no specific minimum and maximum premium payable. The premium payable will depend on the Accident Benefit Sum Assured. For premium rate refer Para 6 (e) below. (d) Minimum Entry Age: (e) Maximum Entry Age: (f) Maximum age for cover: (g) Maximum Term: 4. BENEFITS: Death Benefit under the basic plan: No death benefits will be payable on the death of any Insured unless Term Assurance Rider Benefit mentioned in Para 6 f) below, along with or without Accident Benefit Rider mentioned in Para 6 e), has been opted for. On death of the Principal Insured (PI); a) The surviving Insured Spouse will become the Principal Insured provided the option is exercised at the beginning of the contract and the Policy will continue. In such case, the premium for the Insured Spouse will change from the date coinciding with or following instalment premium due date and the new premium would be based on tabular premium rates applicable for PIs and the age for calculation of revised premium rate will be the age at entry of the spouse. If the option is not exercised at the beginning of the contract, the Insured Spouse will not become PI and the policy will terminate. b) If the Insured Spouse had predeceased the Principal Insured or had not given the option to continue the policy as new PI on death of PI, then the other Insured will have the option to take a new policy and the existing Policy will terminate. In respect of these other Insured: i. The new policy will be issued without any underwriting if the new policy is bought within 90 days of the termination of the existing Policy. ii. The maximum entry age condition for the basic plan will not apply for the new policy. iii. The outstanding Waiting periods and outstanding period of any Exclusion will however apply under the new policy. iv. Other terms and conditions including premium rates will be as applicable for the new policy. In the event of death of an Insured person other than the Principal Insured, the policy will continue after removal of the Insured and change in premium will apply from the instalment premium due date coinciding with or next following the date of intimation of death of the Insured. Maturity Benefit: No benefits are payable at end of the Cover Period. Benefit payable on hospitalization: If PI or any of the Insured lives covered under the policy is hospitalized due to Accidental Bodily Injury or Sickness and the stay in hospital exceeds a continuous period of 24 hours, [18] years completed [50] years (Nearest Birthday) [60] years (Nearest Birthday) [35] years

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then for any continuous period of 24 hours or part thereof, provided any such part stay exceeds a continuous period of 4 hours (after having completed the 24 hours as above) in a non-ICU ward/room of a hospital, an amount equal to the Applicable Daily Benefit (ADB), available under the policy during that policy year, shall be payable subject to terms and conditions mentioned in Para 5 c) & 5 i) and exclusions mentioned in Para 7. During the first year of cover commencement in respect of each insured, the Applicable Daily Benefit (ADB) shall be the Initial Daily Benefit amount (i.e. the level of HCB chosen by the insured) mentioned in the policy Schedule. The amount of Applicable Daily Benefit (ADB) for each policy year, after the first policy year, shall consist of 2 parts: An arithmetic addition of an amount equal to 5% (five percent) of the Initial Daily Benefit to the Applicable Daily Benefit of the previous Policy Year. Such increase in the Applicable Daily Benefit shall be effected on each Policy anniversary during the Cover Period and shall continue until it attains a maximum amount of 1.5 times the Initial Daily Benefit Thereafter, this amount in each Policy Year in future shall remain at that maximum level attained. Further arithmetic addition of an amount equal to No Claim Benefit (as defined below under the heading No Claim Benefit) provided the policy attracts and is eligible for it. There shall be no maximum limit for such increase which means that if this policy is eligible for No Claim Benefit, the same shall be granted throughout the Cover Period without any maximum limit. Consider an example where Initial Daily Benefit is Rs.1000 in respect of each insured life (say, PI and spouse) under a policy. There is no claim admitted under the policy during first 12 years from the policy commencement except in the 5th year when a claim is admitted in respect of spouse. In this case, year-wise Applicable Daily Benefit for each insured shall be as follows:
Year ADB 1 1000 2 1050 3 1100 4 1200* 5 1250 6 1300 7 1350** 8 1400 9 1450 10 1550* 11 1600*** 12 1600

* In years 4 and 10 No Claim Benefit is added. ** In year 7 No Claim Benefit is not added as a claim occurred in the 5th year. *** After 11th year, ADB shall not increase as it has attained the maximum level (1.5 times of Initial Daily Benefit). However the ADB shall increase due to No Claim Benefit as and when the policy shall be eligible for. For members included subsequently under the policy, the benefit in the first year shall be equal to Initial Daily Benefit amount and thereafter the Applicable Daily Benefit shall increase as above. If the member insured is required to stay in an Intensive Care Unit of a hospital, two times the Applicable Daily Benefit, for any continuous period of 24 hours or part thereof, provided any part stay exceeds a continuous period of 4 hours (after having completed the 24 hours as above), will be payable subject to terms and conditions mentioned in Para 5 (c) & 5 (i) and exclusions mentioned in Para 7. The Applicable ICU Daily Benefit amount shall be twice the Applicable Daily Benefit amount. No benefit will be payable for the first 24 hours of hospitalisation. However, for every Hospitalization that extends for a continuous period of 7 days or more, the Daily Hospital Cash

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Benefit would also be paid for first 24 hours (day one) of hospitalization, regardless of whether the Insured was admitted in a general or special ward or in an intensive care unit. It may be noted that hospitalization for 6 days and 4 hours or more will be considered as 7 days. Major Surgical Benefit: In the event of an Insured under this plan, due to medical necessity, undergoing one of the surgeries defined in Major Surgical Benefit Annexure, within the cover period in a Hospital due to Accidental Bodily Injury or Sickness, the respective benefit percentage of the Major Surgical Benefit Sum Assured, as specified against each of the eligible surgeries mentioned in Major Surgical Benefit Annexure, shall be paid subject to terms and conditions mentioned in Para 5 d) & 5 i) and exclusions mentioned in Para 7. Ambulance Benefit: In the event that a Major Surgical Benefit falling under Category 1 or Category 2 (as mentioned in the Major Surgical Benefit Annexure) is payable and emergency transportation costs by an ambulance have been incurred, an additional lump sum of `1,000 will be payable in lieu of ambulance expenses. Premium Waiver Benefit: Further, in the event that a Major Surgical Benefit falling under Category 1 or Category 2 (as mentioned in the Major Surgical Benefit Annexure) is payable in respect of any Insured, the total annualized premium i.e. total one year premium in respect of that Policy from the date of instalment premium due coinciding with or next following the date of the Surgery will be waived. Day Care Procedure Benefit: In the event of an Insured under this Plan undergoing any specified Day Care Procedure mentioned in the Day Care Procedure Benefit Annexure due to medical necessity, an amount equal to 5 (five) times the Applicable Daily Benefit shall be paid, regardless of the actual costs incurred, subject to terms and conditions mentioned in Para 5 e) & 5 i) and exclusions mentioned in Para 7. Other Surgical Benefit: In the event of an Insured under this Plan, due to medical necessity, undergoing any Surgery not listed under Major Surgical Benefit or Day Care Procedure Benefit, and the stay in hospital exceeds a continuous period of 24 hours, a Daily Benefit equal to 2 (two) times the Applicable Daily Benefit shall be paid for each continuous period of 24 hours or part thereof provided any such part stay exceeds a continuous period of 4 hours of Hospitalization, subject to terms and conditions mentioned in Para 5 f) & 5 i) and exclusions mentioned in Para 7. Other Surgical Benefit shall be payable from day one of hospitalization but the minimum stay in hospital should be atleast 24 hours. No claim benefit: A no claim benefit will be paid in the event that during the period between Date of Commencement of policy and next Automatic Renewal Date or between two Automatic Renewal Dates (described in para 5 a) below) there are no claims in respect of any Insured. The amount of the no claim benefit would be equal to 5% (five percent) of the Initial Daily Benefit in respect of each Insured and the resulting amount shall be added to arrive at the Applicable Daily Benefit in respect of each Insured for the Policy Year next following the most recent Automatic Renewal Date. 5. OTHER TERMS AND CONDITIONS: a) Automatic Renewal Date: The instalment premium will be guaranteed in respect of each Insured for a period of 3 (three) years from the Date of Commencement of the policy, i.e. for the first 3 years of the policy. Thereafter, at the end of every third policy anniversary, the premiums may be

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reviewed to take into account the Corporations experience, subject to prior approval from IRDA. These premium due dates, at the end of every third policy anniversary, starting from the date of commencement of policy till the date of cover expiry, on which the instalment premiums are reviewable, will be referred as Automatic Renewal Dates in respect of all Insured in the Policy. The premium rates applicable on Automatic Renewal Date after every 3 years shall be guaranteed for a further period of 3 years i.e. till next Automatic Renewal Date. On any Automatic Renewal Date in the future, the instalment premium will be based on the Insureds age at entry into the policy i.e. age as on the date of commencement of policy/ age at the time of inclusion into the policy, as the case may be and the Corporations premium rates then prevailing for this product. b) Removal of existing members: In the event of death or divorce, an Insured may be removed from coverage upon request by the Principal Insured in writing. This will be effective from the instalment premium due date coinciding with or next following the date of such a request. No further premiums are due in respect of that Insured from such instalment premium due date. In any other circumstances, removal of an existing Insured will be permitted at the sole discretion of the Corporation. c) Hospital Cash Benefit: In the event of Accidental Bodily Injury or Sickness first occurring or manifesting itself after the date of commencement of cover in respect of that Insured and during the Cover Period and causing an Insureds Hospitalization to exceed a continuous period of 24 hours within the Cover Period, then, subject to the terms and conditions, waiting period and exclusions of the Policy, the Daily Benefit is payable by the Corporation as follows, regardless of the actual costs incurred: In case of Hospitalisation in the general or special ward (i.e. a nonIntensive Care Unit ward/room) of a Hospital: The Applicable Daily Benefit in a Policy Year, for each continuous period of 24 hours or any part thereof (after having completed the 24 hours as above) provided any such part stay exceeds a continuous period of 4 hours of Hospitalization necessitated solely by reason of the said Accidental Bodily Injury or Sickness, shall be payable. In case of Hospitalisation in the Intensive Care Unit of a Hospital: Two times the Applicable Daily Benefit reckoned under para 4 above for each continuous period of 24 hours or part thereof (after having completed the 24 hours as above) provided any such part stay exceeds a continuous period of 4 hours of Hospitalization in the Intensive Care Unit of a Hospital during any period of Hospitalization necessitated solely by reason of the said Accidental Bodily Injury or Sickness shall be payable. Combined stay in Non-ICU and ICU ward/room: During one period of 24 continuous hours (i.e. one day) of Hospitalisation (after having completed the 24 hours as above), if the said Hospitalisation included stay in an Intensive Care Unit as well as in any other in-patient (non-Intensive Care Unit) ward of the Hospital, the Corporation shall pay benefits as if the admission was to the Intensive Care Unit provided that the period of Hospitalisation in the Intensive Care Unit was at least 4 continuous hours.

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No benefit will be payable for the first 24 hours of hospitalisation. However, for every Hospitalization that extends for a continuous period of 7 days or more, the Hospital Cash Benefit would also be paid for the first 24 hours (day one) of hospitalization, regardless of whether the Insured was admitted in a general or special ward or in an intensive care unit. The amount of Daily Benefit due to Hospitalization as specified in the Policy Schedule would be the Initial Daily Benefit amount. In the first Policy Year the Initial Daily Benefit would be the Applicable Daily Benefit amount which will be payable per day of each eligible hospitalized day. For each Policy Year commencing at a Policy anniversary on or after the first anniversary, the Applicable Daily Benefit of the previous Policy Year shall be increased by arithmetic addition of an amount equal to 5% (five percent) of the Initial Daily Benefit. This shall be further enhanced if the policy attracts and is eligible for No Claim Benefit (as defined in Para 4). And the resulting amount shall be the Applicable Daily Benefit for that Policy Year. Thus, the Applicable Daily Benefit for each policy year, after the first policy year, shall consist of 2 parts: An arithmetic addition of an amount equal to 5% (five percent) of the Initial Daily Benefit to the Applicable Daily Benefit of the previous Policy Year. Such increase in the Applicable Daily Benefit shall be effected on each Policy anniversary during the Cover Period and shall continue until it attains a maximum amount of 1.5 times the Initial Daily Benefit Thereafter, this amount in each Policy Year in future shall remain at that maximum level attained. Further arithmetic addition of an amount equal to No Claim Benefit provided the policy attracts and is eligible for it. There shall be no maximum limit for such increase which means that if this policy is eligible for No Claim Benefit, the same shall be granted throughout the Cover Period without any maximum limit. The amount of Daily Benefit in case of admission to the Intensive Care Unit shall be two times the Applicable Daily Benefit. For any new member added during the term of the policy, first policy year for that new member for the purpose of this benefit shall start from the policy anniversary on which the cover starts. A no claim benefit is payable in the event that during the period between two Automatic Renewal Dates there are no claims in respect of any Insured. The amount of the no claim benefit would be equal to 5% (five percent) of the Initial Daily Benefit in respect of each Insured and the resulting amount shall be added for arriving at the amount of Applicable Daily Benefit in respect of each Insured for that Policy Year. Such increase in the Applicable Daily Benefit shall be effective from the next following Automatic Renewal Date. Benefit Limits and Conditions: i. The Hospital Cash Benefit shall be payable only if Hospitalisation has occurred within India. ii. The total number of days for which hospital cash benefit would be payable, in respect of each Insured, in a Policy Year would be restricted to a. A maximum of 30 (thirty) days of Hospitalization out of which not more than 15 (fifteen) days shall be in an Intensive Care Unit in the first Policy Year

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following the date of commencement of cover in respect of that Insured

b. A maximum of 90 (ninety) days of Hospitalization out of which not more

than 45 (forty five) days shall be in an Intensive Care Unit in the second and subsequent Policy Years following the date of commencement of cover in respect of that Insured. iii. The total number of days of Hospitalization for which Hospital Cash Benefit is payable during the Cover Period, in respect of each and every Insured covered under the policy, shall be limited to a maximum of 720 (seven hundred and twenty) days out of which not more than 360 (three hundred and sixty) days shall be in an Intensive Care Unit. Upon attainment of this limit by an Insured, the Hospital Cash Benefit in respect of that Insured shall cease immediately. iv. The Benefit Limits specified above in respect of an Insured under this Policy, shall solely and exclusively apply to that Insured. Any unclaimed Hospital Cash Benefit of any one Insured is not transferable to any other Insured. v. The Hospital Cash Benefit shall not be payable in the event of an Insured under this Policy undergoing any specified Day Care Procedure (as mentioned in the Day Care Procedure Benefit Annexure). d) Major Surgical Benefit: In the event of an Insured under this Policy undergoing any specified Surgery (as mentioned in the Major Surgical Benefit Annexure) in a Hospital due to Accidental Bodily Injury or Sickness first occurring or manifesting itself after the date of commencement of cover in respect of that Insured and during the Cover Period then, subject to the terms and conditions, waiting period and exclusions of this Policy, a percentage (as mentioned in the Major Surgical Benefit Annexure against the specified Surgery performed) of the Major Surgical Benefit Sum Assured shall be payable by the Corporation, regardless of the actual costs incurred. In the event that a Major Surgical Benefit falling under Category 1 or Category 2 (as mentioned in the Major Surgical Benefit Annexure) is payable and emergency transportation costs by an ambulance have been incurred, an additional lump sum of ` 1,000 will be payable in lieu of ambulance expenses. In the event that a Major Surgical Benefit falling under Category 1 or Category 2 (as mentioned in the Major Surgical Benefit Annexure) is payable in respect of any Insured, the total annualized premium i.e. total one year premium in respect of that Policy from the date of instalment premium due coinciding with or next following the date of the Surgery will be waived. Benefit Limits and Conditions:
i.

ii.

iii. iv.

v.

If more than one Surgery is performed on the Insured, through the same incision or by making different incisions, during the same surgical session, the Corporation shall only pay for that Surgery performed in respect of which the largest amount shall become payable. The Major Surgical Benefit shall be paid as a lump sum as specified for the benefit concerned and is subject to providing proof of Surgery to the satisfaction of the Corporation. All Surgical Procedures claimed should be confirmed as essential and required, by a qualified Physician or Surgeon, to the satisfaction of the Corporation. The Major Surgical Benefit will be payable only after the Corporation is satisfied on the basis of medical evidence that the specified Surgery covered under the Policy has been performed. The Major Surgical Benefit shall be payable only if the Surgery has been performed within India.

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vi. The amount in lieu of ambulance expenses shall be payable only once in

vii.

viii.

ix.

x.

respect of each Insured in any Policy Year and is subject to providing satisfactory evidence to the Corporation. The total amount payable in respect of each Insured under the Major Surgical Benefit in any Policy Year during the Cover Period shall not exceed 100% of the Major Surgical Benefit Sum Assured in that Policy year. The total amount payable in respect of each Insured during the Cover Period under the Major Surgical Benefit shall not exceed a maximum limit of 800% of the Major Surgical Benefit Sum Assured. If the total amount paid in respect of an Insured equals this lifetime maximum limit, the Major Surgical Benefit in respect of that Insured will cease immediately. The Benefit Limits specified in the above clauses in respect of an Insured under this Policy, shall solely and exclusively apply to that Insured. Any unclaimed Major Surgical Benefit of any one Insured is not transferable to any other Insured. The Major Surgical benefit for any surgery cannot be claimed and shall not be payable more than once for the same surgery during the term of the policy.

e) Day Care Procedure Benefit: In the event of an Insured under this Policy undergoing any specified Day Care Procedure (as mentioned in the Day Care Procedure Benefit Annexure) in a Hospital due to Accidental Bodily Injury or Sickness first occurring or manifesting itself after the date of commencement of cover in respect of that Insured and during the Cover Period then, subject to the terms and conditions, waiting period and exclusions of this Policy, an amount equal to 5 (five) times the Applicable Daily Benefit, shall be payable by the Corporation, regardless of the actual costs incurred. Benefit Limits and Conditions: i. If more than one Day Care Procedure is performed on the Insured, through the same incision or by making different incisions, during the same surgical session, the Corporation shall only pay for one Day Care Surgical Procedure. ii. The Day Care Procedure Benefit shall be paid as a lump sum and is subject to providing proof of Surgery to the satisfaction of the Corporation. iii. All Surgical Procedures claimed should be confirmed as essential and required, by a qualified Physician or Surgeon, to the satisfaction of the Corporation. iv. The Day Care Procedure Benefit will be payable only after the Corporation is satisfied on the basis of medical evidence that the specified Surgical Procedure covered under the policy has been performed. v. The Day Care Procedure Benefit shall be payable only if the Surgical Procedure has been performed within India. vi. In respect of each Insured, the Day Care Procedure Benefit will be payable only up to a maximum of 3 (three) Surgical Procedures in any Policy Year during the Cover Period. vii. In respect of each Insured during the Cover Period, the Day Care Procedure Benefit will be payable only up to a maximum of 24 (twenty four) Surgical Procedures. If the number of Surgical Procedures eligible for the Day Care Procedure Benefit in respect of an Insured equals this lifetime maximum limit, the Day Care Procedure Benefit in respect of that Insured will cease immediately. viii. The Benefit Limits specified in the above clauses in respect of an Insured under this Policy, shall solely and exclusively apply to that Insured. Any unclaimed Day Care Procedure Benefit of any one Insured is not transferable to any other Insured. ix. If a Day Care Procedure Benefit is performed no Hospital Cash Benefit shall be paid.

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f)

Other Surgical Benefit: In the event of an Insured under this Policy undergoing any Surgery not listed under Major Surgical Benefit or Day Care Procedure Benefit, in a Hospital due to Accidental Bodily Injury or Sickness first occurring or manifesting itself after the date of commencement of cover in respect of that Insured and during the Cover Period then, subject to the terms and conditions, waiting period and exclusions of this Policy, a Daily Benefit equal to 2 (two) times the Applicable Daily Benefit, shall be payable by the Corporation, regardless of the actual costs incurred for each continuous period of 24 hours or part thereof provided any such part stay exceeds a continuous period of 4 hours of Hospitalization. Other Surgical Benefit shall be payable from day one of hospitalization but the minimum stay in hospital should be atleast 24 hours. Benefit Limits and Conditions: i. If more than one Surgical Procedure is performed on the Insured, through the same incision or by making different incisions, during the same surgical session, the Corporation shall only pay for one Surgical Procedure. ii. The Other Surgical Benefit shall be paid as a Daily Benefit and is subject to providing proof of Surgery to the satisfaction of the Corporation. iii. All Surgical Procedures claimed should be confirmed as essential and required, by a qualified Physician or Surgeon, to the satisfaction of the Corporation. iv. The Other Surgical Benefit will be payable only after the Corporation is satisfied on the basis of medical evidence that the specified Surgical Procedure covered under the policy has been performed. v. The Other Surgical Benefit shall be payable only if the Surgical Procedure has been performed within India. vi. The total number of days of Hospitalization for which the Other Surgical Benefit is payable during a Policy Year in respect of each and every Insured covered under the Policy shall not exceed 15 (fifteen) days in the first Policy Year following the Date of Cover Commencement in respect of that Insured and 45 (forty five) days for the second and subsequent Policy Years following the Date of Cover Commencement in respect of that Insured. vii. The total number of days of Hospitalization for which the Other Surgical Benefit is payable during the Cover Period, in respect of each and every Insured covered under the Policy shall not exceed a maximum limit of 360 (three hundred and sixty) days. Upon attainment of this lifetime maximum limit, the Other Surgical Benefit in respect of that Insured will cease immediately. viii. The Benefit Limits specified in the above clauses in respect of an Insured under this Policy, shall solely and exclusively apply to that Insured. Any unclaimed Other Surgical Benefit on any one Insured is not transferable to any other Insured.

g) Commencement And Termination Of Benefit Covers: The Hospital Cash Benefit, Major Surgical Benefit, Day Care Procedure Benefit and Other Surgical Benefit cover in respect of each Insured shall commence on the Date of Cover Commencement individually stated in the Policy Schedule. The Hospital Cash Benefit, Major Surgical Benefit, Day Care Procedure Benefit and Other Surgical Benefit cover in respect of each Insured shall terminate at the earliest of the following: i. The Date of Cover Expiry mentioned in the Policy Schedule; ii. On attaining the lifetime maximum Benefit Limits as specified above; iii. On death or Date of Cover Expiry of the Principal Insured and if the Policy does not continue with the Insured Spouse as the Principal Insured;

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On death or Date of Cover Expiry of Insured Spouse after the Policy continues with the Insured Spouse as the Principal Insured after the PI dies or reaches his/her Date of Cover Expiry. v. On death of the Insured; vi. In respect of the Insured Spouse, on divorce or legal separation from the Principal Insured; vii. On termination of the Policy due to non-payment of premium or any other reason.
iv.

h) Termination Of Policy: A) If policy is issued on single life: The policy shall terminate at the earliest of the following: i) Non-payment of premiums within the revival period described in Para 8; ii) On death; iii) On the Date of Cover Expiry mentioned in the Policy Schedule; iv) On exhausting all the lifetime maximum Benefit Limits as specified above. B) If policy is issued on more than one life: The policy shall terminate at the earliest of the following: i) Non-payment of premiums within the revival period; ii) On PI exhausting all the lifetime maximum Benefit Limits as specified above. iii) On death or Date of Cover Expiry, of the Principal Insured and if the Policy does not continue with the Insured Spouse as the Principal Insured. iv) On the death or Date of Cover Expiry, of Insured Spouse after the Policy continues with the Insured Spouse as the Principal Insured after the PI dies or reaches his/her Date of Cover Expiry. i) Waiting Period: General waiting period: There shall be no general waiting period in case Hospitalization or Surgery is due to Accidental Bodily Injury. There shall be a general waiting period during which no benefits shall be payable in the event of Hospitalization or Surgery, if the said Hospitalization or Surgery occurred due to Sickness.
i. ii.

The general waiting period shall be 90 (ninety) days from the Date of Cover Commencement in respect of each Insured. If the policy is revived after discontinuance of the Cover then the following shall apply in respect of each Insured: a. If the request for revival is received by the Corporation within 90 (ninety) days from the due date of the first unpaid premium, then there shall be a general waiting period of 45 (forty five) days from the Date of Revival in respect of each Insured. b. If the request for revival is received by the Corporation beyond 90 (ninety) days from the due date of the first unpaid premium, then there shall be a general waiting period of 90 (ninety) days from the Date of Revival in respect of each Insured.

Specific waiting period: The specific waiting period in respect of the treatments specified in the list below shall be

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as follows: The specific waiting period shall be 2 (two) years from the Date of Cover Commencement in respect of each Insured. ii. If the policy is revived after discontinuance of the Cover then the following shall apply in respect of each Insured: a. If the request for revival is received by the Corporation within 90 (ninety) days from the due date of the first unpaid premium, then the specific waiting period shall continue to be till 2 (two) years from the Date of Cover Commencement in respect of each Insured. b. If the request for revival is received by the Corporation beyond 90 (ninety) days from the due date of the first unpaid premium, then there shall be a specific waiting period of 2 (two) years from the Date of Revival in respect of each Insured.
i.

In respect of each Insured, no benefits are available hereunder and no payment will be made by the Corporation for any claim under this Policy on account of Hospitalization or Surgery directly or indirectly caused by, based on, arising out of or howsoever attributable to any of the following during the specific waiting period:
i. ii. iii. iv. v. vi. vii. viii. ix. x. xi. xii. xiii. xiv. xv. xvi. xvii.

Treatment for adenoid or tonsillar disorders Treatment for anal fistula or anal fissure Treatment for benign enlargement of prostate gland Treatment for benign uterine disorders like fibroids, uterine prolapse, dysfunctional uterine bleeding etc Treatment for Cataract Treatment for Gall stones Treatment for slip disc Treatment for Piles Treatment for benign thyroid disorders Treatment for Hernia Treatment for hydrocele Treatment for degenerative joint conditions Treatment for sinus disorders Treatment for kidney or urinary tract stones Treatment for varicose veins Treatment for Carpal tunnel syndrome Treatment for benign breast disorders e.g. fibroadenoma, fibrocystic disease etc

6. OPTIONS AVAILABLE UNDER THE PLAN: (a) Plan changes: No alterations from this plan to another plan will be allowed. (b) Insured Spouse to become Principal Insured: In case of death or expiry of cover of Principal Insured, the surviving Insured Spouse shall become the Principal Insured provided the option is exercised at the time of filling up the proposal form and the policy will continue. In such case, the premium for the Insured Spouse will change from the coinciding or following instalment premium due date and the new premium would be based on tabular premium rates applicable for Principal Insureds and the age for calculation of revised premium rate will be the age at entry of the spouse. (c) Cover to new additional members: If the PI gets married/ remarried during the term of the policy, the spouse and parents-in-law can be included in the policy within six months from the date of marriage/ remarriage, but the Cover shall start from the policy anniversary coinciding with or next following the date of inclusion. Enhanced premium shall be due from such policy anniversary.

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Any child born/legally adopted after taking the policy can be covered from the next immediate policy anniversary date following the date on which the child completes the age of 3 months. If the age of legally adopted child on the date of adoption is more than 3 months, the child can be covered from policy anniversary coinciding with or next following the date of adoption. Enhanced premiums shall be due from such policy anniversary. Inclusion of each additional member will be subject to receipt of the proof of the event and fulfillment of underwriting conditions. The eligibility conditions as mentioned in Para 3, waiting period as mentioned in Para 5 i) and exclusions mentioned in Para 7 will apply for the new Insured. Addition in any other case will not be allowed. The existing spouse, parents, parents-inlaw and children, if not covered at the time of taking policy, shall not be covered under the policy. If both of the parents (father and mother) are alive and are eligible for cover, then either both of them will have to be covered or none of them will be covered. The PI will not have any option to choose one of them. The same condition will apply for parents-in-law also. Any addition of new lives shall be allowed by the PI only. After the death of PI, no addition will be allowed. (d) Quick Cash facility: If any of the insured lives undergoes any eligible surgery covered under Category I or II of MSB in any of the listed network hospitals, the PI will have an option to avail Quick Cash facility. Under this facility, 50% of eligible MSB amount would be made available even during the period of hospitalization of any of the insured lives covered (the surgery may be either planned or emergency due to accident) instead of waiting for making a claim for the benefit after discharge. It will be only an advance payment to the PI in the event of hospitalization for any MSB defined in the surgeries listed under categories I & II and permissible under the policy conditions of the plan. This will be, however, subject to approval from the TPA (Third Party Administrator), and the advance amount will be adjusted from the final settlement of MSB claim amount. This facility of advance payment could be availed by submitting the Bank Account details of the PI in the prescribed format. The amount of advance shall be credited in the PIs bank account directly. (e) Accident Benefit Rider: For PI and Insured Spouse, Accident Benefit Rider will be available under the plan by payment of additional premium of ` 0.50 for every ` 1,000/- of the Accident Benefit Sum Assured per policy year in respect of each life to be covered. In case of accidental death, the Accident Benefit Sum Assured will be payable as lump sum along with the Term Assurance Sum Assured. The maximum aggregate limit of assurance under all policies of the Corporation and that of all insurers under individual as well as group policies on the same life to which the benefits apply shall not exceed ` 50 lakh. The additional premium for this benefit will not be required to be paid on and after the Policy anniversary on which the age nearer birthday of the Insured is 60 years. (f) Term Assurance Rider: For PI and Insured Spouse, Term Assurance as optional rider will be available under this plan. The premiums for this option are payable along with premium under the basic plan and an amount equal to Term Assurance Sum Assured will be payable on death during the term for which Term Assurance Rider is opted for. The

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maximum cover for this rider will be ` 25 lakhs under all policies of the life assured with the Corporation taken together. 7. EXCLUSIONS: No benefits are available hereunder and no payment will be made by the Corporation for any claim under this policy on account of hospitalization or surgery directly or indirectly caused by, based on, arising out of or howsoever attributable to any of the following: i. Any Pre-existing Condition unless disclosed to and accepted by the Corporation prior to the Date of Cover Commencement or the Date of Revival (if the Policy is revived after discontinuance of the Cover). ii. Any treatment or Surgery not performed by a Physician/Surgeon or any treatment including Surgery of a purely experimental nature. iii. Any routine or prescribed medical check up or examination. iv. Medical Expenses relating to any treatment primarily for diagnostic, X-ray or laboratory examinations. v. Any Sickness that has been classified as an Epidemic by the Central or State Government. vi. Circumcision, cosmetic or aesthetic treatments of any description change of gender surgery, plastic surgery (unless such plastic surgery is necessary for the treatment of Illness or accidental Bodily Injury as a direct result of the insured event and performed within 6 months of the same). vii. Hospitalisation expenses or Surgery for donation of an organ by donor. viii. Treatment for correction of birth defects or congenital anomalies. ix. Dental treatment or surgery of any kind unless necessitated by Accidental Bodily Injury. x. Convalescence, general debility, nervous or other breakdown, rest cure, congenital diseases or defect or anomaly, sterilisation or infertility (diagnosis and treatment), any sanatoriums, spa or rest cures or long term care or hospitalization undertaken as a preventive or recuperative measure. xi. Self afflicted injuries or conditions (attempted suicide), and/or the use or misuse of any drugs or alcohol and complications arising from it. xii. Any sexually transmitted diseases or any condition directly or indirectly caused to or associated with Human Immuno Deficiency (HIV) Virus or any Syndrome or condition of a similar kind commonly referred to as AIDS. xiii. Removal or correction or replacement of any material/prosthesis/medical devices that was implanted in a former surgery before Date of Cover commencement or Date of Revival (if the Policy is revived after discontinuance of the Cover). xiv. Any diagnosis or treatment or surgery arising from or traceable to pregnancy (whether uterine or extra uterine), childbirth including caesarean section, medical termination of pregnancy and/or any treatment related to pre and post natal care of the mother or the new born. xv. Hospitalisation for the sole purpose of physiotherapy or any ailment for which hospitalization is not warranted due to advancement in medical technology. xvi. War, invasion, act of foreign enemy, hostilities (whether war be declared or not), civil war, rebellion, revolution, insurrection military or usurped power of civil commotion or loot or pillage in connection herewith. xvii. Naval or military operations(including duties of peace time) of the armed forces or air force and participation in operations requiring the use of arms or which are ordered by military authorities for combating terrorists, rebels and the like. xviii. Any natural peril (including but not limited to avalanche, earthquake, volcanic eruptions or any kind of natural hazard). xix. Participation in any hazardous activity or sports including but not limited to racing, scuba diving, aerial sports, bungee jumping and mountaineering or in any criminal or illegal activities.

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xx. To any loss, damage or expense due to or arising out of, directly or indirectly,

nuclear reaction, radiation or radioactive contamination regardless of how it was caused. xxi. Hospitalisation expenses related to non-allopathic methods of treatment or surgery. xxii. Participation in any criminal or illegal activities. xxiii. Treatment arising from the Insureds failure to act on proper medical advice 8. DISCONTINUANCE OF PREMIUMS: If premiums have not been paid within the days of grace (as specified in Para 16) under the Policy, the Policy will lapse and no benefits will be payable thereafter. The Principal Insured shall have an option to revive the policy at anytime within a period of 2 (two) years from the due date of first unpaid premium subject to conditions in Para 9 below. 9. REVIVALS/REINSTATEMENT OF DISCONTINUED POLICIES: The Policy can be revived by the Principal Insured anytime during a period of 2 (two) years from the due date of first unpaid premium called the period of revival or revival period. The revival will be subject to payment of outstanding premiums with interest, underwriting and may be on terms different from those offered earlier. Waiting periods and Exclusions as described earlier will apply on revival. The Principal Insured may need to provide satisfactory evidence of good health in respect of each Insured as required by the Corporation, at his own expense. The Date of Revival will be when all requirements for revival/reinstatement are met and approved by the Corporation at its sole discretion. No benefit will be paid for an event that occurred during the lapse period till the Date of Revival when the Policy was in a discontinued state. Further, if the Automatic Renewal Date falls during the period of lapse (the revival period) and revival is done after the Automatic Renewal Date, the premium before and after the Automatic Renewal Date may be different. Revival/reinstatement will not be allowed post the revival period. 10. SURRENDER: No surrender value will be available under the policy. 11. MODES OF PREMIUM PAYMENT: Premiums can be paid regularly either in yearly or half yearly or quarterly or monthly (through ECS only) instalments. 12. REBATES: Mode Rebates: Rebates (for basic plan) are available at the following rates: Yearly mode : 2% of Tabular Premium Half-yearly mode : 1% of the tabular premium HCB Rebates: In respect of a member covered under a policy, if HCB is more than ` 1000, then the premium arrived at in respect of that member shall be reduced by an amount (`) given

- 18 -

below: HCB (`) 2000 3000 4000

For PI 500 1000 1500

For each insured member other than PI 250 500 750

CEIS Rebate: The rebate for eligible employees of the Corporation shall be 10% of the tabular premium provided the proposal is submitted directly and not through any Agent/ Corporate Agent/ Broker. 13. COMMISSION PAYABLE TO AGENTS/ DEVELOPMENT OFFICERS CREDIT: Agents & Corporate Agents: 2nd & 3rd year 1st Year 25.0% 7.5% CORPORATE AGENTS/ BROKERS &

Subsequent Years 5.0%

Bonus Commission: 40% of 1st year's commission is payable in the first year. Brokers 1st Year 30% Subsequent Years 5%

Development Officers credit: 100% of FY premium 14. LOANS: No loan shall be granted under this plan. 15. UNDERWRITING: Instructions will be issued separately by Underwriting and Reinsurance Department. 16. DAYS OF GRACE: A grace period of one calendar month but not less than 30 days will be allowed for payment of yearly or half-yearly or quarterly premiums and 15 days will be allowed if premiums are payable monthly (ECS). If the due premiums are not paid within the days of grace the policy will lapse. The provisions of para 8 (i.e. Discontinuance of Premiums) of this circular shall be applicable in that case. 17. COOLING-OFF PERIOD: If a policyholder is not satisfied with the Terms and Conditions of the policy, he/she may return the policy to the Corporation within 15 days from the date of receipt of the policy. This period will be termed as Cooling-Off Period. In case the policy is returned during the cooling-off period, Commission shall be recovered from the concerned Agent and the Development Officers credit allowed shall be withdrawn. The refund of premium to the policyholder shall be net of mortality charges and morbidity charges. It may be noted that the mortality charge shall be deducted only for such lives who opted for Term Assurance Rider cover under this plan.

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The mortality and morbidity charges will be deductible for proportionate number of days subject to a minimum for one month. 18. BACK DATING: Back dating of policy will not be allowed. 19. POLICY STAMPING: Policy Stamping will be at the rate of `.0.20 per thousand of total Major Surgical Benefit Sum Assured (i.e. sum of Major Surgical Benefit Sum Assured in respect of all the members insured (including PI) at inception. Any addition of member thereafter shall be by way of endorsement for which stamping shall be done additionally. Further, the policy stamping for Term Rider Sum Assured will be at the rate of ` 0.20 per thousand sum assured. 20. ASSIGNMENTS / NOMINATION: No Assignment will be allowed under this plan. Notice for Nomination or change of Nominations should be submitted for registration to the office of the Corporation, where this policy is serviced. In registering a nomination, the Corporation does not accept any responsibility or express any opinion as to its validity or legal effect. 21. NORMAL REQUIREMENTS FOR CLAIM: Regarding claims, the instructions shall be issued by Health Insurance Department, Central Office, separately. 22. REINSURANCE: A separate treaty has been arranged for this plan. Our retention limits are as below: Hospital Cash Benefit: ` 500 Daily Hospital Cash Benefit Major Surgical Benefit: ` 50,000 Major Surgical Benefit Sum Assured Day Care Procedure Benefit: ` 2,500 Day Care Procedure Benefit Other Surgical Benefit: ` 1,000 per day benefit Risks over and above the above retention limits shall be shared equally between LIC (i.e. 50%) and reinsurers (50%). 23. PROPOSAL FORM: The specimen Proposal form is annexed (Annexure V). 24. POLICY DOCUMENT:

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The specimen Policy document will be sent by the Corporate Communications Department, Central Office.

CHIEF (PRODUCT DEVELOPMENT) Enclosures Annexure I, II, III, IV and V

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MAJOR SURGICAL BENEFIT ANNEXURE Sl. No. LIST OF MAJOR SURGERIES % of Major Surgical Benefit Sum Assured 100% 100% 100% 100% 100% 60% 60% 60% 60% 60% 60% 40% 40% Category

I 1 2 3 4 5 6 7 8 9 10 11 12 13 II 14 15 16 III 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

CARDIOVASCULAR SYSTEM Major Surgery of Aorta CABG (two or more coronary arteries must be bypassed) via open chest surgery Heart Valve Replacement using mechanical prosthesis Heart/Heart-Lung Transplant Aortic root transplantation with coronary artery reimplantation for proximal aortic aneurysm Pericardiotomy / Pericardectomy Initial implantation of permanent pacemaker in the heart Mitral valve repair Aortic valve repair Tricuspid valve repair Pulmonary valve repair Coronary Angioplasty with stent implantation (two or more coronary arteries must be stented) Major vein repair with or without grafting for traumatic & nontraumatic lesions HAEMIC AND LYMPHATIC SYSTEM Bone Marrow transplant (as recipient) Major Excision and grafting of Lymphoedema Splenectomy NERVOUS SYSTEM Repair of Cerebral or Spinal Arterio- Venous Malformations or aneurysms Craniotomy for malignant Cerebral tumours Excision of pineal gland Excision of the pituitary gland Craniotomy for non malignant space occupying lesions Operations on Surbaracahnoid space of brain Intracranial transection of Cranial nerve Other operations on the meninges of the Brain Microvascular decompression of cranial nerves/nervectomy Craniotomy for Drainage of Extradural, subdural or intracerebral space Decompression surgery for Entrapment Syndrome Unilateral or Bilateral sympathectomy Peripheral nerve Graft Free Fascia Graft for Facial Nerve Paralysis Excision of deep seated peripheral nerve tumour 1

Category 1 Category 1 Category 1 Category 1 Category 1 Category 2 Category 2 Category 2 Category 2 Category 2 Category 2 Category 3 Category 3

100% 60% 60% 100% 100% 100% 100% 60% 60% 60% 60% 60% 40% 40% 40% 40% 40% 40%

Category 1 Category 2 Category 2 Category 1 Category 1 Category 1 Category 1 Category 2 Category 2 Category 2 Category 2 Category 2 Category 3 Category 3 Category 3 Category 3 Category 3 Category 3

Sl. No. LIST OF MAJOR SURGERIES

32 33 IV 34 35 36 37 38 39 40 41 42 43 44 45 46 V 47 48 49 50 51 52 53 VI 54 55 56 57 58 59 VII 60 61 62 63 VIII 64

Multiple Miscrosurgical Repair of digital nerve Bur-hole Drainage of Extradural, subdural or intracerebral space RESPIRATORY SYSTEM Lung Transplantation Unilateral Pneumonectomy Diaphragmatic/Hiatus Hernia Repair Thoracotoplasty Open Lobectomy of Lung Excision of benign mediastinal lesions Partial Extirpation of Bronchus Partial Pharyngectomy Total Pharyngectomy Total Laryngectomy Excision of Diaphragmatic tumours Pleurectomy or Pleural decortication Tracheal reconstruction for various lesion DIGESTIVE SYSTEM Excision of esophagus and stomach Abdominal-Perineal Pull Through Resection of rectum with Colo-Anal Anastomosis Total excision of oesophagus Total excision of stomach Resection and Anastomosis of any part of digestive tract Open Surgery for treatment of Peptic Ulcer Artificial opening into stomach ENDOCRINE SYSTEM Complete excision of adrenal glands Complete excision of Thyroid gland Complete excision of Parathyroid gland Partial excision of adrenal glands Partial excision of Thyroid gland Partial excision of Parathyroid gland ENT Total ear amputation with reconstruction Transmastoid removal cholesteatoma with extended Mastoidectomy Total Nasal Reconstruction due to Traumatic lesions Labyrinthotmy for various lesions ORAL Wide excision and Major reconstruction of malignant Oro-pharyngeal tumours

% of Major Surgical Benefit Sum Assured 40% 20%

Category

Category 3 Category 4

100% 60% 60% 60% 60% 60% 60% 60% 60% 60% 60% 40% 40% 100% 100% 60% 60% 40% 40% 20% 60% 60% 60% 40% 40% 40% 60% 60% 60% 40% 60%

Category 1 Category 2 Category 2 Category 2 Category 2 Category 2 Category 2 Category 2 Category 2 Category 2 Category 2 Category 3 Category 3 Category 1 Category 1 Category 2 Category 2 Category 3 Category 3 Category 4 Category 2 Category 2 Category 2 Category 3 Category 3 Category 3 Category 2 Category 2 Category 2 Category 3 Category 2

Sl. No. LIST OF MAJOR SURGERIES

65 66 IX 67 68 69 X 70 71 72 73 XI 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98

Total Glossectomy Wide local Excision for oral leukoplakia EYE Orbit Tumour Exenteration /Flap reconstruction Corneal or Retinal Repair for Traumatic eye injuries Penetrating injuries of the eye or repair of ruptured globe LIVER, GALL BLADDER & PANCREAS Liver Transplantation Partial Resection of Liver Partial Pancreatectomy Cholecystectomy /Choledochotomy for various Gall bladder lesions MUSCULOSKELETAL SYSTEM (due to accident only) Replantation of upper limb Replantation of lower limb Total prosthetic replacement of hip joint using cement Total prosthetic replacement of hip joint not using cement Other total prosthetic replacement of hip joint Total prosthetic replacement of knee joint using cement Total prosthetic replacement of knee joint not using cement Other total prosthetic replacement of knee joint Total prosthetic replacement of other joint using cement Total prosthetic replacement of other joint not using cement Other total prosthetic replacement of other joint Prosthetic replacement of head of femur using cement Prosthetic replacement of head of femur not using cement Other prosthetic replacement of head of femur Prosthetic replacement of head of humerus using cement Prosthetic replacement of head of humerus not using cement Other prosthetic replacement of head of humerus Prosthetic replacement of any other bone using cement Prosthetic replacement of any other bone not using cement Other prosthetic replacement of any other bone Prosthetic interposition reconstruction of joint Other interposition reconstruction of joint Excision reconstruction of joint Other reconstruction of joint Implantation of prosthesis for limb

% of Major Surgical Benefit Sum Assured 40% 20% 40% 20% 20% 100% 60% 60% 40%

Category

Category 3 Category 4 Category 3 Category 4 Category 4 Category 1 Category 2 Category 2 Category 3

60% 60% 40% 40% 40% 40% 40% 40% 40% 40% 40% 40% 40% 40% 40% 40% 40% 40% 40% 40% 40% 40% 40% 40% 40%

Category 2 Category 2 Category 3 Category 3 Category 3 Category 3 Category 3 Category 3 Category 3 Category 3 Category 3 Category 3 Category 3 Category 3 Category 3 Category 3 Category 3 Category 3 Category 3 Category 3 Category 3 Category 3 Category 3 Category 3 Category 3

Sl. No. LIST OF MAJOR SURGERIES

99 100 101 102 103 104 105 106 107 XII 108 109 XIII 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132

Amputation of arm Amputation of leg Fixation of fracture of spine Elevation, Exploration and Fixation of fractured Zygoma Amputation of hand Amputation of foot Therapeutic endoscopic operations on cavity of knee joint Replantation of finger following traumic amputation Surgical Drainage and Curettage for osteomyelitis ORO-MAXILLOFACIAL SURGERY Major reconstructive oro-maxillafacial surgery due to trauma or burns and not for cosmetic purpose Osteotomy including segmental resection with bone grafting for Mandibular and maxillary lesions KIDNEY/URINARY TRACT/REPRODUCTIVE SYSTEM Renal transplant (recipient) Hysterectomy for malignant conditions Radical prostatovesiculectomy Microvascular reattachment of penis following traumatic amputation Total nephrectomy due to medical advice (not as a transplant donor) Partial excision of kidney Open extirpation of lesion of kidney Excision of ureter Total excision of bladder Kidney injury repair Pyloplasty / Ureterocalcycostomy for pelvic ureteric junction obstruction Amputation of penis Excision of vagina Unilateral or Bilateral excision of adnexa of uterus Partial excision of bladder Therapeutic ureteroscopic operations on ureter Urinary diversion Replantation of ureter Unilateral or Bilateral excision of testes Other operations on Scrotum and tunica vaginalis testis Reconstruction of the testis Open surgical excision and destruction of prostate tissue Extirpation of lesion of vulva

% of Major Surgical Benefit Sum Assured 40% 40% 40% 40% 20% 20% 20% 20% 20% 60% 60%

Category

Category 3 Category 3 Category 3 Category 3 Category 4 Category 4 Category 4 Category 4 Category 4 Category 2 Category 2

100% 60% 60% 60% 40% 40% 40% 40% 40% 40% 40% 40% 40% 40% 20% 20% 20% 20% 20% 20% 20% 20% 20%

Category 1 Category 2 Category 2 Category 2 Category 3 Category 3 Category 3 Category 3 Category 3 Category 3 Category 3 Category 3 Category 3 Category 3 Category 4 Category 4 Category 4 Category 4 Category 4 Category 4 Category 4 Category 4 Category 4

Sl. No. LIST OF MAJOR SURGERIES

133 XIV 134 135 XV 136 137 138 139 140

Excision of vulva Operations on the sinuses Operations on frontal sinus Operations on maxillary antrum using sublabial approach Others Radical Mastectomy Malignant soft tissue tumour excision and reconstruction Excision and Major Flap Repair of skin and Subcutaneous tissue due to Major Burns Simple Mastectomy TIPS procedure for portal Hypertension

% of Major Surgical Benefit Sum Assured 20% 40% 20% 60% 40% 40% 20% 20%

Category

Category 4 Category 3 Category 4 Category 2 Category 3 Category 3 Category 4 Category 4

DAY CARE PROCEDURE BENEFIT ANNEXURE S.No. DAY CARE SURGERIES Microsurgical Operations on the middle ear 1 Stapedotomy 2 Stapedectomy 3 Revision of Stapedectomy 4 Other operations on the auditory Ossicles 5 Myringoplasty (Type-I Tympanoplasty) 6 Tympanoplasty (Closure of Eardrum Perforation / reconstruction of the Auditory Ossicles) 7 Myringotomy with grommet insertion 8 Closure of Mastoid fistula 9 Revision of a Tympanoplasty 10 Other microsurgical operations on the Middle Ear Other Operations on the Middle and Internal Ear 11 Myringotomy 12 Benign Tumour removal from the external ear 13 Incision of the mastiod process and Middle ear 14 Simple Mastoidectomy 15 Reconstruction of the middle ear 16 Other excisions of the middle and inner ear 17 Fenestration of the inner ear 18 Revision of fenestration of the inner ear 19 Petrous Apicectomy 20 Other microsurgical operations on the inner Ear Operations on the nose and nasal sinuses 21 Excision and destruction of diseased tissue of the nose 22 Operation on Nasal Turbinates 23 Septoplasty (medically necessitated) 24 Functional Endoscopic Sinus Surgery 25 Endoscopic placement /removal of stents Operations on the Eyes 26 Dacrocystorhinostomy 27 Other Operations for tear gland/ duct lesions 28 Tarsorraphy 29 Excision of the diseased tissue of the eyelid 30 Operations of canthus and epicanthus when done for adhesions due to chronic infections 31 Corrective surgery of entropion 32 Corrective surgery for blepharoptosis 33 Excision of lacrimal sac and passage 34 Removal of a deep or embedded foreign body from cornea 35 Corrective surgery of ectropion 36 Operations for Pterygium with or without grafting 37 Other operations on the cornea 38 Removal of a foreign body from the lens of the eye

S.No. 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76

DAY CARE SURGERIES Removal of a foreign body from posterior chamber of the eye Removal of a foreign body from orbit and eyeball Cataract Surgery ( ECCE or Phacoemulsification with or without intraocular lens implant) Operation for glaucoma Repair of corneal laceration or wound with conjunctival flap Operations on the skin and subcutaneous tissues Surgery for pilonidal sinus Surgical wound toilet (Wound debridement) and removal of diseased tissue of the skin and subcutaneous tissues under anaesthesia Local excision or destruction of diseased tissue of skin and subcutaneous tissues under anaesthesia Surgery for pilonidal cyst Free skin transplantation, recipient site Revision of skin plasty Chemosurgery for skin cancer Operations on the tongue Incision, excision and destruction of diseased tissue of the tongue. Partial glossectomy Reconstruction of the tongue Other Operations on the tongue Incision and lancing of salivary glands and Salivary ducts Excision of a diseased tissue of salivary glands and Salivary ducts Resection of a salivary gland with or without salivary duct Reconstruction of a salivary gland and salivary duct Open Sialolithotomy Other operations on the mouth and face External incision and drainage in the region of the mouth, jaw and face Excision of the diseased hard and soft palate Excision biopsy and/or destruction of diseased structures from the oropharynx. Palatoplasty Other operations in the mouth Operations on the tonsils and adenoids Transoral incision and drainage of a pharyngeal abscess Tonsillectomy without adenoidectomy Tonsillectomy with adenoidectomy Excision and destruction of a lingual tonsil Drainage of tonsillar abscess/quinsy Trauma surgery and orthopaedics Incision and Drainage of the bone for septic and aseptic conditions Closed reduction of fracture Closed reduction of sub-luxation Epiphyseolysis with osteosynthesis Suture and other Operations on tendons and tendon sheath Reduction of dislocation under GA Arthoscopic knee aspiration

S.No. DAY CARE SURGERIES Operations on the breast 77 Incision and Drainage of breast abscess 78 Operations on the nipple except congenitally inverted nipples Operations on the digestive tract 79 Incision and excision of tissue in the perianal region 80 Surgical treatment of anal fistulas 81 Surgical treatment of Haemorrhoids. 82 Division of the anal sphincter (sphincterotomy) 83 Other operations of the anus 84 Ultrasound guided aspiration of deep seated rectal abscess 85 Sclerotherapy 86 Dilation of digestive tract strictures 87 Endoscopic gastrotomy 88 Endoscopic decompression of colon 89 Endoscopic Polypectomy Operations on the female reproductive organs 90 Incision of the ovary 91 Other operations on the Fallopian tubes 92 Dilatation of the cervical canal 93 Conisation of the uterine cervix 94 Incision of the Uterus (Hysterotomy) not done as a part of MTP 95 Therapeutic / diagnoistic dilatation and curettage ( not done as part of MTP) 96 Culdotomy 97 Hymenectomy 98 Local excision and destruction of diseased tissue of the vagina and the pouch of Douglas 99 Incision and drainage of the Vulva 100 Operations on the Bartholin's glands(cyst) 101 Hysteroscope guided biopsy of uterus 102 Suprapubic cytostomy Operations on the prostate and seminal vesicles 103 Drainage of Prostatic abscess 104 Transurethral excision and destruction of prostate tissue 105 Percutaneous excision and destruction of prostate tissue 106 Excision of seminal vesicle 107 Incision and excision of periprostatic tissue Operations on the Scrotum and tunica vaginalis testis 108 Incision and Drainage of the Scrotum and tunica vaginalis testis 109 Operations on testicular hydrocele 110 Excision or Eversion of Hydrocele Operations on the testis 111 Incision and drainage of the testis 112 Excision or destruction of testicular lesion 113 Unilateral orchidectomy 114 Other operations on the testis Operations on the spermatic cord,Epididymis and ductus deferens 115 Surgical treatment of a varicocele and hydrocele of a spermatic cord

S.No. 116 117 118

119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140

DAY CARE SURGERIES Excision of epididymal cyst Epididymectomy Other operations on the spermatic cord, epididymis and ductus deferens (other than vasectomy) Operations on the Penis Circumcision and other Operations on the foreskin (if medically necessitated) Local excision and destruction of diseased tissue of the penis Other operations on the penis Operations on the Urinary system Cystoscopic removal of stones Lithotripsy Other Operations Coronary angiography Bronchoscopic treatment of bleeding lesion Bronchoscopic treatment of fistula/stenting Bronchoalveolar lavage and biopsy Pericardiocentesis Insertion of filter in Inferior Vena cava Insertion of gel foam in artery or vein Carotid angioplasty Renal angioplasty Tumor embolisation Endoscopic drainage of pseudo pancreatic cyst Varicose vain stripping or ligation Excision of dupuytren's contracture Carpal tunnel Decompression PCNS (Percutaneous neprostomy) PCNL(Percutaneous nephro lithotomy) Nail bed deformity/resection and reconstruction

Annexure-I

LIC's Jeevan Arogya (Plan No. 903)

Tabular Premium Rate per ` 1000/- HCB For PI PPT = 80 - Age at Entry Age ( LBD) 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 Male 1866.25 1895.80 1922.65 1948.90 1976.85 2005.75 2036.85 2066.10 2094.15 2124.70 2159.85 2199.75 2242.90 2286.40 2331.25 2376.75 2424.40 2475.85 2530.75 2591.10 2656.10 2725.45 2799.70 2878.70 2962.55 3051.30 3139.75 3229.75 3324.65 3428.40 3538.75 3651.60 3768.00 3881.85 4001.50 4127.45 4254.60 4383.85 4509.40 4647.95 4769.70 4897.05 5027.50 5159.60 5285.85 5398.40 5538.30 5686.80 5852.65 6001.20 6155.85 6331.10 6473.65 6621.35 6741.95 6964.70 7270.00 7764.90 8431.25 9437.7 11404.85 20221.65 Female 1672.15 1698.30 1723.65 1750.00 1778.75 1807.15 1835.75 1864.95 1898.65 1934.05 1969.70 2005.50 2044.50 2084.70 2127.75 2172.35 2219.90 2269.15 2320.45 2373.15 2427.85 2480.85 2538.65 2597.15 2654.85 2706.90 2758.25 2812.95 2870.40 2933.10 2995.65 3067.30 3134.70 3202.00 3261.10 3315.80 3378.15 3442.60 3516.75 3592.35 3671.40 3744.45 3818.60 3903.65 3979.70 4053.45 4099.10 4167.95 4241.25 4314.85 4390.20 4455.15 4555.75 4646.30 4796.65 4997.15 5283.80 5583.65 5963.15 6718.25 8369.5 15864.3 For Other Major Members PPT = 80 - Age at Entry Age ( LBD) 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 Male 1532.50 1563.65 1592.15 1620.05 1649.65 1680.25 1713.00 1743.90 1773.65 1805.90 1842.70 1884.30 1929.05 1974.25 2020.70 2067.85 2117.10 2170.15 2226.65 2288.55 2355.10 2425.95 2501.70 2582.15 2667.45 2757.55 2847.35 2938.60 3034.75 3139.70 3251.15 3365.05 3482.40 3597.20 3717.65 3844.30 3972.10 4101.85 4227.80 4366.65 4488.45 4615.70 4745.80 4877.35 5002.70 5114.10 5252.40 5398.95 5562.30 5707.55 5858.10 6028.30 6164.45 6303.95 6414.00 6622.50 6908.10 7374.00 Female 1338.35 1366.15 1393.15 1421.15 1451.60 1481.65 1511.90 1542.75 1578.15 1615.20 1652.50 1690.05 1730.65 1772.50 1817.20 1863.45 1912.60 1963.45 2016.35 2070.60 2126.85 2181.35 2240.60 2300.60 2359.70 2413.15 2465.80 2521.85 2580.50 2644.35 2708.05 2780.75 2849.10 2917.30 2977.25 3032.70 3095.65 3160.65 3235.15 3311.05 3390.15 3463.10 3536.90 3621.35 3696.55 3769.15 3813.20 3880.10 3950.90 4021.20 4092.45 4152.30 4246.55 4328.95 4468.65 4655.00 4921.95 5192.70 For Children PPT = 25 - Age at Entry Age ( LBD) 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 Child 792.00 792.00 792.00 792.50 793.40 794.75 796.70 799.25 802.60 806.90 812.35 819.35 828.15 839.15 853.05 870.75 893.85 924.20

Annexure-II

LIC's Jeevan Arogya (Plan No. 903)

Class-I Extra Premium rate per ` 1000/-HCB For PI PPT = 80 - Age at Entry Age ( LBD) 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 Male 283.83 292.21 299.93 307.51 315.51 323.78 332.59 340.94 349.00 357.69 367.51 378.56 390.39 402.33 414.59 427.04 439.99 453.90 468.68 484.83 502.11 520.49 540.08 560.84 582.83 606.00 629.10 652.56 677.26 704.15 732.65 761.76 791.74 821.08 851.80 884.10 916.66 949.73 981.81 1017.11 1048.16 1080.55 1113.65 1147.09 1178.96 1207.34 1242.43 1279.55 1320.84 1357.58 1395.61 1438.51 1472.84 1507.93 1535.55 1587.61 1658.71 1774.49 1927.98 2154.94 2586.29 4442.74 Female 235.29 242.83 250.18 257.79 266.00 274.13 282.31 290.64 300.11 310.01 319.96 330.00 340.78 351.90 363.71 375.93 388.88 402.24 416.13 430.33 445.04 459.33 474.80 490.46 505.88 519.91 533.73 548.39 563.70 580.30 596.86 615.69 633.41 651.10 666.70 681.19 697.55 714.43 733.65 753.21 773.59 792.39 811.43 833.09 852.44 871.10 882.63 899.83 917.99 935.99 954.20 969.51 993.36 1014.19 1049.20 1095.74 1162.19 1229.16 1310.94 1475.08 1827.46 3353.41 For Other Major members PPT = 80 - Age at Entry Age ( LBD) 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 Male 283.81 292.21 299.93 307.51 315.51 323.76 332.59 340.94 349.00 357.68 367.51 378.55 390.40 402.31 414.59 427.04 439.99 453.90 468.68 484.83 502.11 520.49 540.08 560.84 582.81 606.00 629.10 652.58 677.26 704.14 732.65 761.76 791.75 821.08 851.80 884.11 916.68 949.73 981.81 1017.10 1048.16 1080.54 1113.65 1147.08 1178.96 1207.34 1242.43 1279.55 1320.84 1357.58 1395.63 1438.51 1472.83 1507.94 1535.54 1587.63 1658.71 1774.49 Female 235.29 242.83 250.18 257.79 265.99 274.11 282.31 290.65 300.11 310.03 319.98 329.99 340.79 351.90 363.71 375.91 388.88 402.24 416.13 430.33 445.04 459.33 474.80 490.46 505.88 519.90 533.73 548.38 563.70 580.31 596.86 615.69 633.43 651.10 666.70 681.19 697.55 714.41 733.65 753.21 773.59 792.39 811.43 833.09 852.44 871.09 882.63 899.81 917.99 935.99 954.20 969.51 993.36 1014.18 1049.21 1095.74 1162.18 1229.16 For Children PPT = 25 - Age at Entry Age ( LBD) 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 Child 119.98 120.65 121.49 122.35 123.30 124.38 125.55 126.91 128.44 130.19 132.20 134.60 137.40 140.73 144.74 149.64 155.81 163.69

Annexure-III

LIC's Jeevan Arogya (Plan No. 903)

Term Rider Premium Rates per `1000/- Sum Assured Term = Minimum ( 60-age at entry, 35 ) Age 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 Term 35 35 35 35 35 35 35 35 34 33 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 16 15 14 13 12 11 10 Premium (Rs.) 2.16 2.25 2.36 2.47 2.60 2.74 2.90 3.07 3.27 3.49 3.74 4.01 4.31 4.49 4.68 4.89 5.11 5.35 5.61 5.88 6.17 6.48 6.80 7.15 7.51 7.90 8.33 8.78 9.11 9.62 10.15 10.72 11.32

Annexure-IV

LIC's Jeevan Arogya (Plan No. 903)

Term Rider Class I Extra Premium rates per `1000/- Sum Assured Age 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 Term 35 35 35 35 35 35 35 35 34 33 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 16 15 14 13 12 11 10 Premium (Rs.) 0.45 0.47 0.50 0.53 0.56 0.59 0.62 0.66 0.71 0.76 0.81 0.87 0.94 0.98 1.03 1.08 1.14 1.19 1.26 1.32 1.40 1.47 1.55 1.64 1.73 1.83 1.93 2.05 2.13 2.26 2.39 2.53 2.68

Inward Number___________________ Proposal Number__________________ Date of receipt of Proposal _________ Policy Number_________________ Risk Date/DOC____________________

Plan Name. ________________________ Plan No. ________________________

Pol. Term /PPT _____________________ Premium Mode _____________________ Installment Premium ________________

PROPOSAL FORM FOR HEALTH INSURANCE POLICY

Branch Office. Divisional Office.R/U/F/S.. Agents Name Code No...Licence NoLicence expiry date Development Officers name.........................................................Development Officers Code... ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

1. PROPOSER (Principal Insured) DETAILS: Full Name (Max 40 Char) Fathers Name Name for printing on Health card (Max 40 char)

Nationality Initial Daily Cash Benefit chosen Date of Birth Age Rs.

Age Proof Address City/Town State Telephone E-Mail id Residence Proof Qualification Occupation Name of Employer Nature of Duty PAN Number Height (cms) Previous Health Policy no. with LIC

Sex

Male/Female

STD code Phone No...

District PIN Code Mobile If NRI, Country of Residence Annual Income Income Proof Designation Length of Service

Rs.

Weight (Kgs) Initial Daily Cash Benefit availed (Sum assured)

Rs.

Medical Code Lapsed/In-force

M/G/S

Term Assurance Rider sum proposed 2. PROPOSAL DEPOSIT DETAILS: Cheque No. Transaction/BOC No. 3. NOMINATION DETAILS: Dated Dated Cash

Accident Benefit Rider sum proposed Cheque Drawn on Amount Rs.

======================================================================================== For Office Use only (Details to be given separately for each life for Sl. Nos. 1, 2, 3, 4, 5) 1. Underwriting decision ......
2. Restrictive conditions/Restrictive clauses . 3. Installment premium. 4. IDCB allowed .. 5. Extra charged if any.. 6. Date of decision 1

Nominees Full Name Age Appointees Name (if Nominee is minor) Appointees address 4. BANK DETAILS: IFSC (11 digits) Account Number (As given on the cheque leaf) Bank Name
5.

Relationship Appointees Signature

(Please enclose a cancelled cheque) MICR Number (As given on the cheque leaf) Account Type (Savings/Current) Bank Branch

NO. OF LIVES TO BE COVERED UNDER THE POLICY (INCLUDING PRINCIPAL INSURED): DETAILS OF OTHER MEMBERS TO BE INSURED:

6.

Other Member to be Insured (1) Full Name (Max 40 char) Name for printing on Health card (Max 40 char) Initial Daily Cash Benefit chosen Date of Birth Relationship to the Proposer Occupation Designation Name of the School/ Class studying Medical Code Lapsed/In force Age Rs.

Age Proof Nationality & country of residence Educational qualification Name of Employer Nature of Duty and Length of Service Height (cms) Previous Health Policy no. with LIC

Sex

Male/Female

Weight (kgs) IDCB Rs. availed/SA Other Member to be Insured (2)

M/G/S

Full Name (Max 40 char) Name for printing on health card (Max 40 char)

Initial Daily Cash Benefit chosen Date of Birth Relationship to the Proposer Occupation Designation Age

Rs.

Age Proof Nationality & country of residence Educational qualification Name of Employer Nature of Duty and Length of Service Height (cms) Previous Health Policy no. with LIC Full Name(max 40 char) Name for printing on health card (Max 40 char)

Sex

Male/Female

Weight (kgs) IDCB availed/SA

Rs.

Name of the School/ Class studying Medical Code Lapsed/In force

M/G/S

Other Member to be Insured (3) Initial Daily Cash Rs.

Proposal Form for LIC Health Insurance policy

Benefit chosen Age Proof Nationality & country of residence Educational qualification Name of Employer Nature of Duty and Length of Service Height (cms) Previous Health Policy no. with LIC Date of Birth Relationship to the Proposer Occupation Designation Name of the School/ Class studying Medical Code Lapsed/In force Age Sex Male/Female

Weight( Kgs) IDCB availed/SA

M/G/S

Rs.

QUESTIONS APPLICABLE FOR SPOUSE ONLY:

Term Assurance Rider sum proposed Accident Benefit Rider sum proposed

QUESTIONS APPLICABLE FOR FEMALE LIVES ONLY:

Principal Insured i) Are you Pregnant now? If yes, please state the Expected Date of Delivery ii) Have you ever had an abortion or miscarriage or caesarian Section? (If so give details in a separate sheet) iii) Are you suffering from any Gynaecological disorders? If Yes, please provide details in a separate sheet. iv) Date of last delivery & Date of last menstruation v) Husbands Full Name vi) Husbands existing health insurance cover (SA amount) vii) Husbands Occupation and Annual Income Yes No Yes Yes No No Other Insured 1 Yes No Yes Yes No No Other Insured 2 Yes No .. Yes Yes No No Other Insured 3 Yes No Yes Yes No No

7. INVESTMENT PATTERN OF THE FUND: (TO BE FILLED IN RESPECT OF UNIT LINKED HEALTH POLICIES)
Fund Type Investments in Govt. / Govt. securities Short term investments such as Money market investments etc., Investment listed equity shares Details and objective of the fund

8.
i) ii)

QUESTIONS IN CASE OF SERVICES IN ARMED FORCES: (PI Principal Insured; OI Other Insured)
PI Wing to which you belong & Rank therein Place of current posting & Nature of duties OI 1 OI 2 OI 3 OI 4 OI 5 OI 6

iii) Are you presently in Category 1

9.

DETAILS OF PREVIOUS POLICIES: Give details of previous policies as per Annexure B in respect of each life to be Insured under this proposal.

Proposal Form for LIC Health Insurance policy

10. HEALTH DETAILS AND MEDICAL INFORMATION

(Annexure A is to be used if the total number of members to be insured including PI exceeds 4 in this proposal)

DETAILS
1.Does the life to be insured consume Alcohol/cigarettes/bidis or tobacco in any form? 2. Is the life to be insured currently taking any medication or drug? 3. During the past 5 years, has the life to be insured ever suffered from any illness, disorder, disability or injury which has required any form of medical or specialized examination (including X-ray, blood tests, ECG, USG, CT/MRI, gynaecological investigations), Consultation, hospitalization or surgery? 4. Has the life to be insured been absent from work/school/college for more than 7 continuous days in the last two years due to Health reasons? 5. Does the life to be insured have a parent, brother or sister who was or has been diagnosed with heart disease, stroke, diabetes, cancer, neurolgical/mental disorders or any hereditary disorder under the age of 65? If yes, please provide name of condition, age at diagnosis and relationship with the life to be insured. 6. Has the life to be insured planned for a surgery or is currently aware of any medical condition that might require medical Advice/surgery in near future? 7. Has the life to be insured ever suffered or is suffering from i) Hypertension/high blood pressure ii) Diabetes or raised blood sugar iii) Cardiovascular disease, Palpitations, Heart attack, stroke, chest pain iv) Genitourinary diseases e.g. Kidney disorder, Bladder disorder, Urine abnormality, renal stones or genital organ disorder v) Cancer of any type or a cyst or growth of any kind vi) Mental Disorder e. g Depression, anxiety, schizophrenia or any other mental or nervous disorder vii) Endocrine diseases e.g.: Thyroid or any other hormonal disorder viii) Digestive disease e.g.: Liver and gall bladder disorder, gastric ulcer, bleeding from intestine or any other disorder of the digestive tract ix) Respiratory diseases e.g.: Asthma, pneumonia, bronchitis, tuberculosis, persistent cough, or any other disorder of the chest or lungs. x) Musculoskeletal diseases e.g.: Osteoporosis, prolapsed disc, back or neck complaint, any physical disability or other disorder of the bones, joints, arthritis, gout etc xi) Neurological diseases e.g.: Fits, epilepsy, recurrent headache, paralysis, any other disease or disorder of the brain, spinal cord or nerves xii) Congenital Disorders xiii) Blood disorder e.g. Anemia, hemophilia, thalassemia xiv) Eye, Ear, Nose, Throat or Skin disorders 8. Has the life to be insured ever been tested positive for HIV / AIDS, hepatitis B or C or any sexually transmitted disease? 9. Does the life to be insured wear glasses? If so, power of glasses 10) Is the life to be insured currently covered under any health insurance policy with LIC or any other company? 11)Has any proposal/ application for revival for life, medical, health, accident, disability or critical illness cover been postponed, declined or accepted on special terms? (If yes, Give details) 12) Has the life to be insured lost more than 5 Kgs. 0f weight in the last 12 months except due to exercise or weight loss programmes< If yes, please state the reason for the weight loss. 13) Is any proposal for life or health insurance on the life to be insured pending in any of LIC offices? 14) Has the life to be insured ever been involved or is planning to pursue any dangerous sport or hobby e.g., Diving, Mountaineering, Parachuting, private aviation and racing

Principal Insured
Yes Yes Yes No No No

Other Insured 1
Yes Yes Yes No No No

Other Insured 2
Yes Yes Yes No No No

Other Insured 3
Yes Yes Yes No No No

Yes Yes

No No

Yes Yes

No No

Yes Yes

No No

Yes Yes

No No

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

No No No No No No No No No No No No

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

No No No No No No No No No No No No

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

No No No No No No No No No No No No

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

No No No No No No No No No No No No

Yes Yes Yes Yes Yes

No No No No No

Yes Yes Yes Yes Yes

No No No No No

Yes Yes Yes Yes Yes

No No No No No

Yes Yes Yes Yes Yes

No No No No No

Yes No R L Yes No Yes No

Yes No R L Yes No Yes No

Yes No R L Yes No Yes No

Yes No R L Yes No Yes No

Yes

No

Yes

No

Yes

No

Yes

No

Yes Yes

No No

Yes Yes

No No

Yes Yes

No No

Yes Yes

No No

IMPORTANT: If answer to any of the above question is Yes, please provide details (precise diagnosis, past and current treatment, current status, treatment plan for future) in a separate sheet of paper and submit copies of hospital/consultation/investigation reports available with you). For juvenile lives aged below 5 years, please submit immunization records and for ages above 5, please provide latest school/college progress report.

Proposal Form for LIC Health Insurance policy

DECLARATION BY THE PROPOSER AND OTHER MAJOR MEMBERS TO BE INSURED

I / We _____________________ declare that we are fully aware of the statements / contents etc. given by us in this proposal form along with Annexure B & C and confirm that they are true and complete in all respects and the same shall form the basis of the contract . I / We do hereby give our consent to treat the policy as null and void in case any of our statements are incorrect and I/We agree that the money paid by us shall be forfeited to the Corporation. I / We further agree that any change / addition / deletion / alteration related to my/our health, occupation, or any other adverse circumstance (including dropping, deferrment, acceptance at terms other than as proposed of any proposal/ revival of policy made to the Corporation or any other insurance company) after the submission of this proposal to the Corporation shall be conveyed before the issuance of the First Premium Receipt. Any omission on my part to do so shall render this assurance invalid. I/We hereby give my consent for undergoing medical examination/tests including test for HIV as required by the Corporation. I / We authorize the Corporation to make any enquiry to anyone concerning our health. In consultation with the agent / intermediary, I have taken a personal and independent decision in an informed manner to go for the Plan. I understand that the application money deposited by me is a token consideration under this proposal for insurance. I / We do hereby accept the policy terms and conditions, exceptions / exemptions etc. as prescribed in the policy. I/We have read and understood: Sec 41 - Prohibition of Rebates : No person shall allow or offer to allow, either directly or indirectly as an inducement to any person to take out or renew or continue Insurance in respect of any kind of risk relating to lives or property in India, any rebate of the whole or part of the commission payable or any rebate of the premium shown on the policy, nor shall any person taking out or renewing or continuing a policy, accept any rebate, except such rebate as may be allowed in accordance with the published prospectus or tables of the insurer. Provided that acceptance by an insurance agent of commission in connection with a policy of life insurance taken out by himself on his own life shall not be deemed to be an acceptance of a rebate of premium within the meaning of this sub-section if at the time of such acceptance the insurance agent satisfied the prescribed conditions establishing that he is a bonafide insurance agent employed by the insurer. Any person making default in complying with the provisions of this section shall be punishable with fine which may extend to 500 rupees. Sec 45 Indisputability Clause.: No policy of life insurance shall, after the expiry of two years from the date on which it was effected, be called in question by an Insurer on the ground that a statement made in the proposal for insurance or any report of a medical officer or referee or friend of the insurer or in any other document leading to the issue of the policy, was inaccurate or false, unless the insurer shows such statements was on material matter or suppressed facts which it was material to disclose and that it was fraudulently made by the policyholder and that the policyholder knew at the time of making it that the statement was false or that it suppressed facts which it was material to disclose. Note: Material shall mean and include all important, essential and relevant information in the context of underwriting the risk to be covered by the Corporation. Dated at .. On the Day of 20

Witness: Signature of the Proposer (Signature, Name & Address) Signatures of other Major Members to be insured i). ii). iii) . In case form is filled up / signed in a language different from that of the Proposal Form: Declaration by the person filling in the form: I hereby declare that I have fully explained the above questions to the proposer in _________ language and I have truthfully recorded the answers given by the proposer. Name &Address of the declarant ______________________ Declaration by the Proposer/Other Major Member to be insured: I certify that the contents of the form and documents have been fully explained to me by Mr/ Ms:___________________ and I have understood the significance of the proposed contract. Signature of the Proposer:_________ Signatures of other Major Members to be Insured i)ii)iii) Signature of the declarant:__________________________

FOR MEDICAL CASES ONLY I certify that the MEMBER TO BE INSURED has signed /in my presence after admitting that all answers to questions under Section 6 in this proposal form are properly recorded. i). ii). iii).. (Signatures of the members to be insured) i)ii) iii) .(Signatures of the Medical Examiners)

Proposal Form for LIC Health Insurance policy

AGENTS CONFIDENTIAL REPORT/MORAL HAZARD REPORT

Agents Name & Code Club Membership License No. Licence expiry date Occupation Nature of duties 1. (a) Acquaintance with the proposer (No. of Years): (b) Relationship with the proposer : (c) Educational qualification of the Life Proposed: 2. Annual Income: Rs.. Income Source.. Proof of Income. Verified: Yes/No PAN. 3. Physical Measurements and Identification Marks of the Proposer and other Members (beneficiaries) to be insured under the proposal. Member To Be Insured PRINCIPAL INSURED OTHER INSURED 1 OTHER INSURED 2 OTHER INSURED 3 OTHER INSURED 4 OTHER INSURED 5 OTHER INSURED 6 4. Declaration by the Agent I do hereby declare that I have personally seen the proposer / the members covered and I do hereby confirm that there is no physical deformity / impaired sight / hearing problem / mental retardation or any other diseases and am personally satisfied about his / her financial condition. I further inform that no proposal / revival has been deferred / declined / dropped / accepted with extra premium. I am fully aware that the policy shall be issued based on my above declaration that if any information given above is incorrect, it would attract penalty under Regulation 16 and other provisions of (Agents) Regulations, 1972, besides the other provisions of law applicable. Dated at on the day of 20 Signature of the Agent Name Height (cms) Weight (kgs) Abdomen (cms) Chest (exp/ins) cms 1. 2. 1. 2. 1. 2. 1. 2. 1. 2. 1. 2. 1. 2. Identification Marks Development Officer Code Branch Code

Name of Life Proposed

Age

Agents Address & Phone No. _____________________________ I am fully aware and endorse the above contents; I recommend the proposal for acceptance.

Development Officer

Assistant Branch Manager (Sales)/Chief/Sr./Branch Manager.

Proposal Form for LIC Health Insurance policy

PROPOSAL FOR HEALTH INSURANCE POLICY

PHOTO ADDENDUM FOR PREPARATION OF HEALTH IDENTITY CARDS
Members to be Insured (In the same Sequence as given in question Number 6) Proposer (affix stamp size Photo only) Other Insured 1 (affix stamp size Photo only) Other Insured 2 (affix stamp size Photo only) Other Insured 3 (affix stamp size Photo only)

Plan No. -------------

i) Name ii) DOB iii) Sex

(Mention male /Female)

iv) Relationship

Members to be Insured (In the same Sequence as given in Question No. 10) Other Insured 4 (affix stamp size Photo only) Other Insured 5 (affix stamp size Photo only) Other Insured 6 (affix stamp size Photo only)

i)

Name

ii) DOB iii) Sex

(Mention Male or Female)

iv) Relationship Specimen Signature of the Proposer:

For Office Use:

Policy Number.. Total Number of Lives Covered. Division Name and Code.. Branch Name & Code.

Check list:

1. Age Proof(s) of all the Members to be insured 3. Signature of the proposer

2. Photographs of all the Members to be insured

Proposal Form for LIC Health Insurance policy

PROPOSAL FOR HEALTH INSURANCE POLICY

ANNEXURE A

HEALTH DETAILS AND MEDICAL INFORMATION (IN RESPECT OF OTHER MEMBERS TO BE INSURED)
(To be used if the total number of members to be insured excluding PI (in the proposal form) exceeds 3)

Name of the Member to be Insured: Proposal No. Relationship with the Principal Insured:... 1. DETAILS OF OTHER MEMBERS TO BE INSURED Other Member to be Insured (4)
Full Name (Max 40 char) Name for printing on Health card (Max 40 char) Age Proof Nationality & country of residence Educational qualification Name of Employer Nature of Duty and Length of Service (if in armed forces give details) Height (cms) Previous Health Policy no. with LIC Date of Birth Relation to the proposer Occupation Designation Initial Daily Cash Benefit chosen Age Rs.

Sex

Male/Female

Weight( Kgs) IDCB availed/SA

Rs.

Name of the School/ Class studying Medical Code Lapsed/In force

M/G/S

Other Member to be Insured (5)

Full Name (Max 40 char) Name for printing on health card (Max 40 char) Age Proof Nationality & country of residence Educational qualification Name of Employer Nature of Duty and Length of Service (if in armed forces give details) Height (cms) Previous Health Policy no. with LIC Date of Birth Initial Daily Cash Benefit chosen Age Rs.

Sex

Male/Female

Relation to the proposer Occupation

Designation Name of the School/ Class studying Medical Code Lapsed/In force

Weight( Kgs) IDCB availed/SA

M/G/S

Rs.

Other Member to be Insured (6)

Full Name (max 40 char) Name for printing on health card (Max 40 char) Initial Daily Cash Benefit chosen Date of Birth Age Rs.

Age Proof Nationality & country of residence Educational qualification Name of Employer Nature of Duty and Length of Service (if in armed forces give details) Height (cms) Previous Health Policy no. with LIC

Sex

Male/Female

Relation to the proposer

Occupation Designation Name of the School/ Class studying Medical Code Lapsed/In force

Weight( Kgs) IDCB availed/SA

M/G/S

Rs.

QUESTIONS APPLICABLE FOR SPOUSE ONLY:

Term Assurance Rider sum proposed Accident Benefit Rider sum proposed

Proposal Form for LIC Health Insurance policy

QUESTIONS APPLICABLE FOR FEMALE LIVES ONLY:

Other Insured 4 i) Are you Pregnant now? If yes, please state the Expected Date of Delivery ii) Have you ever had an abortion or miscarriage or Caesarian Section? (If so give details in a separate sheet) iii) Are you suffering from any Gynaecological disorders? If Yes, please provide details in a separate sheet. iv) Date of last delivery/ Date of last menstruation v) Husbands Full Name vi) Husbands existing health insurance cover (SA amount) vii) Husbands Occupation and Annual Income Yes No Yes Yes No No Other Insured 5 Yes No .. Yes Yes No No Other Insured 6 Yes No Yes Yes No No

2. HEALTH DETAILS AND MEDICAL INFORMATION

DETAILS
1.Does the life to be insured consume any form of Alcohol/cigarettes/bidis or tobacco in any other form? 2. Is the life to be insured currently taking any medication or drug? 3. During the past 5 years, has the life to be insured ever suffered from any illness, disorder, disability or injury which has required any form of medical or specialized examination (including X-ray, blood tests, ECG, USG, CT/MRI, gynaecological investigations), Consultation, hospitalization or surgery? 4. Has the life to be insured been absent from work/school/college for more than 7 continuous days in the last two years due to Health reasons? 5. Does the life to be insured have a parent, brother or sister who was or has been diagnosed with heart disease, stroke, diabetes, cancer, neurolgical/mental disorders or any hereditary disorder under the age of 65? If yes, please provide name of condition, age at diagnosis and relationship with the life to be insured. 6. Has the life to be insured planned for a surgery or is currently aware of any medical condition that might require medical Advice/surgery in near future? 7. Has the life to be insured ever suffered or is suffering from ii) Hypertension/high blood pressure ii) Diabetes or raised blood sugar iii) Cardiovascular disease, Palpitations, Heart attack, stroke, chest pain v) Genitourinary diseases e.g. Kidney disorder, Bladder disorder, Urine abnormality, renal stones or genital organ disorder v) Cancer of any type or a cyst or growth of any kind vi) Mental Disorder e. g Depression, anxiety, schizophrenia or any other mental or nervous disorder vii) Endocrine diseases e.g.: Thyroid or any other hormonal disorder viii) Digestive disease e.g.: Liver and gall bladder disorder, gastric ulcer, bleeding from intestine or any other disorder of the digestive tract ix) Respiratory diseases e.g.: Asthma, pneumonia, bronchitis, tuberculosis, persistent cough, or any other disorder of the chest or lungs. x) Musculoskeletal diseases e.g.: Osteoporosis, prolapsed disc, back or neck complaint, any physical disability or other disorder of the bones, joints, arthritis, gout etc xi) Neurological diseases e.g.: Fits, epilepsy, recurrent headache, paralysis, any other disease or disorder of the brain, spinal cord or nerves xii) Congenital Disorders xiii) Blood disorder e.g. Anemia, hemophilia, thalassemia

Other Insured 4
Yes Yes Yes No No No

Other Insured 5
Yes Yes Yes No No No

Other Insured 6
Yes Yes Yes No No No

Yes Yes

No No

Yes Yes

No No

Yes Yes

No No

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

No No No No No No No No No No No No No No No

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

No No No No No No No No No No No No No No No

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

No No No No No No No No No No No No No No No

Proposal Form for LIC Health Insurance policy

xiv) Eye, Ear, Nose, Throat or Skin disorders

Yes

No

Yes

No

Yes

No

8. Has the life to be insured ever been tested positive for HIV / AIDS, hepatitis B or C or any Yes No Yes No Yes No sexually transmitted disease? 9. Does the life to be insured wear glasses? Yes No Yes No Yes No If so, power of glasses R L R L R L 10) Is the life to be insured currently covered under any health insurance policy with LIC or any Yes No Yes No Yes No other company? 11)Has any proposal/ application for revival for life, medical, health, accident, disability or Yes No Yes No Yes No critical illness cover been postponed, declined or accepted on special terms? (If yes, Give details) 12) Has the life to be insured lost more than 5 Kgs. 0f weight in the last 12 months except due to Yes No Yes No Yes No exercise or weight loss programmes< If yes, please state the reason for the weight loss. 13) Is any proposal for life or health insurance on the life to be insured pending in any of LIC Yes No Yes No Yes No offices? 14) Has the life to be insured ever been involved or is planning to pursue any dangerous sport Yes No Yes No Yes No or hobby e.g., Diving, Mountaineering, Parachuting, private aviation and racing IMPORTANT: If answer to any of the above question is Yes, please provide details (precise diagnosis, past and current treatment, current status, treatment plan for future) in a separate sheet of paper and submit copies of hospital/consultation/investigation reports available with you). For juvenile lives aged below 5 years, please submit immunization records and for ages above 5, please provide latest school/college progress report.

3. DETAILS OF PREVIOUS POLICIES: Give details of previous policies as per Annexure B in respect of each life

to be Insured under this proposal.

DECLARATION BY THE PROPOSER AND OTHER MAJOR MEMBERS TO BE INSURED
I / We _____________________ declare that we are fully aware of the statements / contents etc. given by us in this proposal form along with Annexure B & C and confirm that they are true and complete in all respects and the same shall form the basis of the contract . I / We do hereby give our consent to treat the policy as null and void in case any of our statements are incorrect and I/We agree that the money paid by us shall be forfeited to the Corporation. I / We further agree that any change / addition / deletion / alteration related to my/our health, occupation, or any other adverse circumstance (including dropping, deferrment, acceptance at terms other than as proposed of any proposal/ revival of policy made to the Corporation or any other insurance company) after the submission of this proposal to the Corporation shall be conveyed before the issuance of the First Premium Receipt. Any omission on my part to do so shall render this assurance invalid. I/We hereby give my consent for undergoing medical examination/tests including test for HIV as required by the Corporation. I / We authorize the Corporation to make any enquiry to anyone concerning our health. In consultation with the agent / intermediary, I have taken a personal and independent decision in an informed manner to go for the Plan. I understand that the application money deposited by me is a token consideration under this proposal for insurance. I / We do hereby accept the policy terms and conditions, exceptions / exemptions etc. as prescribed in the policy. I/We have read and understood: Sec 41 - Prohibition of Rebates : No person shall allow or offer to allow, either directly or indirectly as an inducement to any person to take out or renew or continue Insurance in respect of any kind of risk relating to lives or property in India, any rebate of the whole or part of the commission payable or any rebate of the premium shown on the policy, nor shall any person taking out or renewing or continuing a policy, accept any rebate, except such rebate as may be allowed in accordance with the published prospectus or tables of the insurer. Provided that acceptance by an insurance agent of commission in connection with a policy of life insurance taken out by himself on his own life shall not be deemed to be an acceptance of a rebate of premium within the meaning of this sub-section if at the time of such acceptance the insurance agent satisfied the prescribed conditions establishing that he is a bonafide insurance agent employed by the insurer. Any person making default in complying with the provisions of this section shall be punishable with fine which may extend to 500 rupees. Sec 45 Indisputability Clause.: No policy of life insurance shall, after the expiry of two years from the date on which it was effected, be called in question by an Insurer on the ground that a statement made in the proposal for insurance or any report of a medical officer or referee or friend of the insurer or in any other document leading to the issue of the policy, was inaccurate or false, unless the insurer shows such statements was on material matter or suppressed facts which it was material to disclose and that it was fraudulently made by the policyholder and that the policyholder knew at the time of making it that the statement was false or that it suppressed facts which it was material to disclose. Note: Material shall mean and include all important, essential and relevant information in the context of underwriting the risk to be covered by the Corporation.

Proposal Form for LIC Health Insurance policy

10

Dated at .. On the Day of 20

Witness: Signatures of other Major Members to be insured

Signature of the Proposer 4).5),. 6)..

In case form is filled up / signed in a language different from that of the Proposal Form: Declaration by the person filling in the form: I hereby declare that I have fully explained the above questions to the proposer in _________ language and I have truthfully recorded the answers given by the proposer. Name &Address of the declarant ______________________ Declaration by the Proposer/Other Major Member to be insured: I certify that the contents of the form and documents have been fully explained to me by Mr/ Ms:___________________ and I have understood the significance of the proposed contract. Signature of the Proposer:_________ Signatures of other Major Member to be Insured 4)..5).., 6) FOR MEDICAL CASES ONLY I certify that the MEMBER TO BE INSURED has signed /in my presence after admitting that all answers to questions under Section 6 in this proposal form are properly recorded. 4).5) 6).. (Signatures of the members to be insured) 4)5) 6) .(Signatures of the Medical Examiners) Signature of the declarant:__________________________

Proposal Form for LIC Health Insurance policy

11

ANNEXURE B (To be attached with proposal form for a health insurance plan) Name of the Member to be insured __________________________________ Proposal Number ______________________________ A. DETAILS OF EXISTING HEALTH INSURANCE POLICIES INCLUDING (A) POLICIES SURRENDERED/LAPSED (DURING LAST 3 YEARS) (B) IN FORCE HEALTH INSURANCE POLICIES ( C) POLICIES ACCEPTED WITH MODIFIED TERMS OR WITH EXTRA PREMIUM
(If No. of policies are more, please attach a separate sheet)
Policy No. Insurance cos. from where the previous policy/ies have been purchased with address (if purchased from LIC, give name of BO/DO) Table & Term Sum Assured Term assurance Rider Sum Assured Amount of Accident Benefit taken Year of issue a. Whether accepted as proposed at ordinary rates. a. Whether in full force for full sum assured.

YES/NO
b. If not in force, give due date of last premium paid or date of surrender

YES/NO
b. If not, mention terms of acceptance (mention extra premium charged)

B. DETAILS OF EXISTING LIFE INSURANCE POLICIES INCLUDING (A) POLICIES SURRENDERED/LAPSED (DURING LAST 3 YEARS) (B) IN FORCE POLICIES ( C) POLICIES ACCEPTED WITH MODIFIED TERMS OR WITH EXTRA PREMIUM
(If No. of policies are more, please attach a separate sheet)
Policy No. Insurance cos. from where the previous policy/ies have been purchased with address (if purchased from LIC, give name of BO/DO) Table & Term Sum Assured Term assurance Rider Sum Assured Amount of Accident Benefit taken a. Whether accepted as proposed at ordinary rates. a. Whether in full force for full sum assured.

Year of issue

YES/NO
b. If not, mention terms of acceptance (mention extra premium charged)

YES/NO
b. If not in force, give due date of last premium paid or date of surrender

Note: The above information is required in respect of each of the member to be insured under this proposal.

Signature of Principal Insured Proposal Form for LIC Health Insurance policy

Signature of the other Member to be Insured, proposed for insurance by the PI 12

ANNEXURE C

LICs JEEVAN AROGYA

ADDENDUM TO PROPOSAL FORM (To be filled in if spouse of Principal Insured is also to be covered in the policy)
Answer (a) or (b) as may be appropriate: In case of benefit ceasing / unfortunate death of Principal Insured, the policy will: (a) Terminate

(b) Continue with Insured Spouse acting as new Principal Insured

Note: The level of premium for Principal Insured and the other insured members are different for same age and same level of cover. If the policy is continued after exit of Principal Insured, the premium for the Insured Spouse will change from the coinciding or following instalment premium due date and the new premium would be calculated based on tabular premium rates applicable for Principal Insureds and the age for calculation of revised premium rate will be the age of spouse at the time of purchasing/ entering into this policy. The option exercised now shall form the basis of continuing the policy with the Insured Spouse as Principal Insured and no consent shall be taken before revision of premium and making Insured Spouse as Principal Insured, if applicable. Dated at .. On the Day of 20

Signature of Proposer (Principal Insured)

Signature of Insured Spouse..

Proposal Form for LIC Health Insurance policy

13