National Insurance Company Limited Regd, & Head Office : 3, Middleton Street, Kolkata - 700 071 Post Box 9228, Phone (033) 2283 1705 - 09 BARODA HEALTH POLICY lates REE 1. WHEREAS the Insured designated in the Schedule hereto has by a proposal and declaration which shall be the basis of this Contract and is deemed to be incorporated herein, has applied to NATIONAL INSURANCE COMPANY LTD. (hereinafter called the COMPANY), for the insurance hereinafter set forth in respect of Account holders of BANK OF BARODA (including their eligible family members) named in the Schedule hereto (hereinafter called the INSURED PERSON) and has paid premium as consideration for such Insurance, COVERAGE 1.4. NOW THIS POLICY WITNESSES that subject tothe terms, conditions, exclusions and definitions contained herein ~ of endorsed, or otherwise expressed hereon the Company undertakes that if during the period stated in the sehedule or during the continuance of this policy by renewal any insured person shall contract any disease or suffer from any illness (hereinafter called DISEASE) or sustain any bodly injury, through accident (hereinafter called INJURY) and if such disease or injury shall require any such insured person, upon the advice of @ duly qualified physician/Medical SpecialisMedical Practitioner (hereinafter called MEDICAL PRACTITIONER) or of {uly qualified Surgeon (hereinafter called SURGEON) to incur hospitalization/expenses for medica/surgical treatment at any Nursing Home/Hospital in India as herein defined (hereinafter called HOSPITAL) as an inpatient, the company will pay through the TPA to the Hospital/Nursing Home or Insured person the amount of such expenses as are reasonably and necessarily incurred in respect-thereof by or on behalt of such Insured Person but not exceeding the Floater Sum Insured in aggregate in anyone period of insurance stated in the schedule hereto. 1.2. Inthe event of any claim becoming admissible under this policy, the company will pay through TPA to the Hospital! Nursing Home or insured person the amount of such expenses as would fall under different heads mentioned below and as are reasonably and necessarily incurred there of by or on behalf of such insured person. A) Room, Boarding expenses as provided by the Hospital / Nursing Home. 8) Nursing expenses. ©) Surgeon, Anaesthetist, Medical Practitioner, Consultants, Specialist Fees. D) Anaesthesia, Blood, Oxygen, Operation Theatre Charges, Surgical Appliances, Medicines & Drugs, Diagnostic Materials and X Ray, Dialysis, Chemotheraphy, Radiotherapy, cost of pacemaker, Artificial Limbs and cost or organs and similar expenses, . &) Ambulance charges not exceeding Rs. 1000/- (Rupees one thousand only) per Policy period. F)__ Incase of Hospitalisation of children below 12 years, a lump sum amount of Rs. 1000/- (Rupees one thousand only) per policy period towards the out-of-pocket expenses to any of the attending parents during their stay a at hospital to attend their children upto age of 12 years who will be undergoing treatment for injuries/disease: covered by the Policy. The payment wil be made on the basis of a declaration from the parent without insisting fon any supporting bil/cash mé.no, (N.B.: Company's Liability in respect of all claims admitted during the period of Insurance shall not exoéed thé Floater Sum Insured per FAMILY as mentioned in the schedule) 5 2. DEFINITIONS : 2.4, HOSPITAL | NURSING HOME means any institution in India established for indoor care and treatment of sickness and injuries and which EITHER (@)__Has been registered either as a Hospital or Nursing Home with the local authorities and is under the ‘supervision of @ registered and qualified Medical Practitioners. OR (b) Should comply with minimum criteria as under (1) It should have at least 15* inpatient beds. (2) Fully equipped operation theatre of its own wherever surgical operations are carried out (3) Fully qualified Nursing Staff under its employment round the clock. (4) Fully qualified Doctor(s) should be in-charge round the clock. *N.B.: In class ‘C’ towns requirement of number of beds is reduced to 10. 24.1 The Term "Hospital/Nursing Home” shall not include an establishment which is-a place of rest, a place for the ~ aged, a place for drug-addicts or-place of alcoholics, hotel or a similar place. 2.4.2 “Surgical Operation” means manual and/or operative procedures for correction of deformities and defects, repair Of injuries diagnosis and cure of diseases, relief of suffering and prolongetton of Ife. 12.1.3. Expenses on Hospitaisation for minimum peried of 24 hours are admissible. However, this time tmit wil not apply for speci treatments, i. Dialysis, Chemotherephy, Radiotherapy, Eye Surgery, Dental Surgery. ithotrpsy (Kidney Stone removal), D&C, Tonsillectomy taken in the Hospital/Nursing Home and the Insured is discharged on the same day, such treatment will be considered to be taken under Hospitalization Baneft. This condition will aso not apply incase of stay in Hospital of less than 24 hours provided, 2) The treatment is such that it necessitates hospitalization and the procedure involves specialized infrastructural faciities available in hospitals, >) Due to technological advances hospitalization is required for less than 24 hours only, 2.1.4 Family : The size of the family shall consist of the Bank of Baroda Account holder, his/her spouse and their two dependent children only (Le. maximum 1 + 3 only) 3. ANY ONE ILLNESS : ‘Any one illness will be deemed to mean continuous period of illness and it includes relapse within 45 days from the date of discharge from the Hospital / Nursing Home from winere treatment was taken, Occurrence of same illness after a lapse Of 45 days as stated above wil be considered as fresh llness for the purpose of this policy 3.1. PRE HOSPITALISATION: Relevant medical expenses incurred during period up to 30 days prior to Hospitalization on disease/iliness/injury sustained will be considered as part of claim as mentioned under item 1.2 above. 3.2. POST HOSPITALISATION ; Relevant medical expenses incurred during period up to 0 days after Hospitalization on disease/ilnesssinjury Sustained will be considered as part of ciaim as mentioned under item 1.2 above. 3.3. MEDICAL PRACTITIONER means a person, who holds a Degree/Diploma of a recognized institution ands registered by Medical Council of respective State of India, The term Medical Practitioner would include Physician, Specialist and Surgeon, 3.4 QUALIFIED NURSE means a person who holds a certificate ofa recognized Nursing Council and who is employed (on recommendation of the attending Medical Practitioner. 3.5 TPA means a Third Party Administrator, who, for the time being, is licensed by the Insurance Regulatory and Development Authority, and Is engaged, fora fee or remuneration, by whatever name called as May be specified in the agreement with the Company, for the provision of health services. 3.6 Pre-existing Diseases : Any condition, ailment or injury or related condition(s) for which you had signs ‘or symptoms and/or were diagnosed and/or received medical advice/treatment within 48 months prior ¥ to your first policy with us. 4, EXCLUSIONS: The Company shall not be liable to make any payment under this Policy in respect of any expenses whatsoever incurred by any insured person in connection with or in respect of 4.1 Benefits for pre existing diseases will not be available for any condition(s) as defined in the policy until 36 months of continuous coverage have elapsed since inception of the first policy with us. . 4.2 Any hospitiization Expenses inurred in the first 20 days from the first commencement date of insurrence cover except In case of injury arising out of accident. + 4.3. During the period of twelve months from the date of inception of the policy, the expenses on treatment of diseases such as Cataract, Benign, Prostatic Hyperthropathy, Hysterectomy for Hemorrhagic, of Fibromyoma, Hemia, Hydrocele, congenital internal disease, Fistula in anus, Piles, Sinusitis and related disorders are not payable. These disease, if preexisting, will be covered only as per provisions of 4.1 above. 4.4 Injury disease directly or indirectly caused by or arising from or attributed to Wer, Invasion, Act of Foreign Enemy, Warlike operations (whether war be declared or not) 4.5 Circumcision unless necessary for treatment or a disease not excluded hereunder or as may be necessitated due to {an accident, vaccination or inoculation or change of life or cosmetic or aesthetic treatment of any description, plastic surgery other than as may be necessitated due to an accident or as a part of any illness. 4.8. Cost of spectacies, contact lenses, hearing aids. 4.7 Dental treatment or surgery of any kind unless requiring hospitalisation. 4.8 Convalescence, general debility, run-down condition or rest cure, congenital external disease or defects or anomalies, Sterity, Infertity, Venereal disease, intentional self injury and iliness, disease or accidents for use of or contributed by uSe of intoxication durgs/alconol. 4.9 All expenses arising out of any condition directly or indirectly caused to or associated with Human T-Cell Lymphotrophic Virus Type Ill (HTLB-I) or Lymphadinopathy Associated Virus (LAV) or the Mutants Derivative or variations Deficiency ‘Syndrome or any Syndrome or condition of similar kind commonly referred to as AIDS, 1 4.10 Charges incurred at Hospital or Nursing Home primarily for diagnosis X-ray or Laboratory exeminations or other diagnostic studies not consistent with or Incidental or the diagnosis and treatmnet of positive existence of presence of any ailment sickness or injury, for which confinement is required at a Hospital/Nursing home.4a 4.42 413 ang 415 4.18 NOTE: Frpeeaes on vitamins and tonics unless forming part of treatment for njuy or dsease as certifed by the attending physician. {nlury or Disease directly or indirectly caused by or contributed to by nuclear weaporvmateral Treatment arising from or traceable to pregnancy (including voluntary termination of Pregnancy) and child birth (including Caesarean Section) and allied maternity benefits. Naturopathy Treatment Domiciliary Hospitalization expenses. Prchenefis tke Cumulative Bonus, health check up including contiunity accrued under the previous Policy! Policies, issued by any other Insurance Company shall not be avalable under this. Policy, nditions applicable to Hospitalisation Expenses Cover 5-1 Every notice or communication tobe given or made under this Policy shall be delivered in writing atthe address of the TPA office as shown in the Schedule, 52 Uren the happening of any event which may give rise to a claim under this policy notice with ful particulars’ shall be sent to the TPA named immediately and in case of emergency within 24 hours of Hosplalsten 53 All supporting documents relating tothe claim must be fled with TPA within 30 (hity) days from the date of Gischarge from the hospital. n case of Post-hospitalization, treatment (Limited to 60 days), all claim documents Should be submitted within 30 (thirty) days after completion of such treatment ote: Walver ofthis Concltion may be considered in extreme cases of hardship where itis proved to the satisfaction Gorton eripany that under the circumstances in which the insured was placed it was not possible for him or any ater Person to give such notice or file claim within the prescribed time-limtt oe Mpa yngurad Person shall obtain and furnish the TPA with all orginal bis, eceipts and other documents upon Which @ claim is based and shall also give the TPA such additional information and assistance as the Fon ‘may require in dealing with the claim, 55 Avy medical practioner authorized by the TPA shal be allowed to examine (se Insured person in case of any alleged injury or disease requiring Hospitalization when and so often as the same may reasonably be required ‘on behalf of the Company at the cost of the Company. 5.6 If at the time when any claim arises under this Policy, there is in existence any Mediclaim/Health Insurance Policy Issued by any other Insurer (other than Cancer Insurance Policy in collaboration with indian Ceneer Society), whether It be effected by or on behalf of any Insured Person in respect of whom the claim may have arisen covering the same loss, lability, compensation, costs or expenses, the Company shall not be ligble to Pay or contribute more than its rate able proportion of any loss, liability, Compensation, Cost or expenses. The Ponefis under this Policy shal be in excess of the benefits available under the Cancer Insurance Policy subject to the Floater Sum Insured of this policy set in the schedule and also subject to admissibility of the claim under this policy 5.7 All Medical/Surgical treatments under this policy shall have to be taken in India and admissible claims thereot shall be payable in indian Currency Payment of claim shall be made through TPA tothe Hospital Nutsing Home or the Insured Person as the cas~ may be. . 1. The insured will be eligible for deduction ogder Section 80 D of the income Tax Act 1961 as amended from time to time, for the premium under this policy subject to limits specified in the Income Tax Act. 2. The Policy willbe serviced by Third Party Administrators (TPA) named in the Policy. The Baroda Health Identity Card will be Issued by the TPA. Additional Conditions :* 1, The Policy shall commence either from (a) the date of Debit of Premium from the Insured’s Bank account if the instrument with the proposal/renewal advice is dispatched to the Company on the samo date or (2) the actual date of dispatch of the instrument with proposal/renewal advice or c) the date of deposit of premium fo the Company to comply to provisions of Section 64 VB of insurance Act. The due payment cf premium and the observance and fulfillment of the terms, provisions, conditions and endorsements of this Policy by the Insured Persons in so far as they relate to anything to be done or complied with by the Insured Ferson shall be a condition precedent to any labity of the Company to make any payment under thie policy. No waiver of any terms, provisions, conditions and endorsements of this policy shall be valid unless made te writing and signed by an authorized official of the Company, The Company shail not be liable to make any payment under this policy in respect of any claim if such claim be in any manner fraudulent or supported by any fraudulent means or device whether by the Ingured Person or by any other person acting on his behalf. 3. The Policy may be renewed by mutual consent, the Company shall not however be bound to give notice {that It is due for renewal. In case the policy is not renewed in time due to any exceptional circumstances: beyond the physical control of the insured and is to the satisfaction of the Company, a grace period up to 15 days may be allowed for renewal of the policy without withdrawal of any accrued benefit under the policy.The Company may at any time cancel this policy on grounds of msrepresentation, fraud, moral hazard er non co-operation of the insured by sending the 30 days notice by registered letter at insureds last known address. in the even of the Company canceling the policy for mis-representation, fraud, moral hazard, non disclosure of material facts or non co-opeation, no refund of premium shall be made. The Company shall, however, remain liable for any claim, which arose prior to the date of cancellation, {tis furthur understood and agreed that the premium has been remitted by tho bank, on collection of the same by duly debiting the account of account holders with their prior consent. On such polley of insurance being issued, the company shall not entertain any request for cancellation and consequent refund of premium therefor on any grounds whatsoever shall not arise. ‘4. The Company shall not be bound to take notice orbe affected by any-notice of any trust, charge, len, assignment er other dealings with or relating to this policy but the receipt ofthe insured or his legal personal representatives shall in all cases be an effective discharge to the Company. 5. Hany dispute or lference shall arise as to the quantum to be pad under the policy (Liability being otherwise <2dmitted) such difference shall independently of all other questions be referred to the decision of a sole aritator {o be appointed in writing by the parties or if they cannot agree upon a single arbitrator within 30 days of any Party invoking arbitration, the same shall be referred toa panel of three arbitrators, comprising of io arbitrators, fone to be appointed by each of the parties to the dispute / difference and the third arbitrator to be appointed by such two arbitrators and arbitration shall be conducted under/in accordance withthe provisions ofthe Arbitration ‘and Conciliation Act 1996. It is clearly agreed and understood that no difference or dispute shall be referable to arbitration as herein before provided If the Company has disputed or not accepted liability under or in respect of this Policy, It is hereby expressly stipulated and declared that it shall be condition precedent to any right of action or Suit upon this Policy that award by such arbitrator/arbitrators of the amount of the loss or damage shall be first obtained, It's also hereby further expressly agreed and declared that if the Company/TPA shall disclaim liability to the Insured for any claim hereunder and such claims shall not within 12 calendar months from the date of such disclaimer have been made the subject matter of a suit in court of law, then the claim shall for all purposes be deemed to have been abandoned and shall not thereafter be recoverable hereunder. 7 __ No sum payable under this Policy shall carry interest except in accordance with IRDA Regulations. 6. COST OF HEALTH CHECK UP {he insured shal be entitled for reimbursement of the cost of medical check up once atthe end of block of every three underwriting Yyears/policy periods provided there areno claims reported during the block. The cost so reimbursable shall not exceed the amount equal to 1% of the amount of average sum insured during the block of three underwriting years/policy periods. IMPORTANT For Health Check-up provision as aforesaid Is applicable only in respect of continuous insurance without break under this Scheme, Health Check-up benefit will be accrued after completion of Three years continuous claim free insurance. Procedure for availing Cashless Access Services in Network Hospital/ Nursing Home. ; Claims in respect of Cashless Access Services will be through the list of the network of Hospitals/Nursing Homes and is subject to pre admission authorization. The TPA shal, upon getting the related medical information from the insured persons! network provider, verify that the person is eligible to claim under the policy and after satisfying itself wll Issue a pre-authorisation letter/ guarantee of payment letter to the Hospital/Nursing Home mentioning the sum guaranteed as payable, also the ailment for which the person is seeking to be admitted as a patient, The TPA reserves the right to deny pre-authorisation In case the insured person is unable to provide the relevant medical details a8 required by the TPA. The TPA will make it clear to the Insured person that denial of Cashless Access is in no way construed t0 be denial of treatment. The insured person may obtain the treatment as per hislher treating doctors advice and later on submit the full claim papers to the TPA for reimbursement. ‘The TPA may repudiate the clalm, giving reasois, if not covered under the terms of the policy. The Insured person shall have ‘ight of ap peal to the insurance company if he/she feels that the caim is payable. The insurance company's decision in this regard wil be final and binding on TPA, Grievance Redressal Procedure in compliance to IRDA (Protection of Policy Holders’ Interest) Regulations, 2002, the Company has opened grievance cell at Divisional, Regional as well as Head Office. The policyholder may submit his compliant / grievance to the sald grievance cell of the Company for remedial action. The policy holder has also the option to approach the office of Insurance Ombudsman with complaints in repsect of (a) any efspute on partial or total repudiation of claim (b) any dispute in regard to premium pald or payable in erp of paliey (e) any dispute on the legal construction ofthe poliey In so far as euch disputes relate to clas (0) delay in settlement of claims and (e) non-issue of insurance document after receipt of premium,