National Insurance Company Limited

Regd. Office 3, Middleton Street, Post Box 9229, Kolkata 700 071
CIN - U10200WB1906GOI001713 IRDA Regn. No. - 58

Naini National Health Mediclaim Insurance Policy

1 Recital clause
Whereas the insured designated in the schedule hereto has by a proposal dated as stated in the schedule, 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 Nainital, and their eligible
family members, named in the schedule hereto (hereinafter called, the insured person) and has paid premium as consideration for
such insurance.

2 Operative clause
Now this policy witnesses that subject to the terms, definition, exclusions and conditions contained herein or endorsed, or
otherwise expressed here on the company undertakes that if during the policy period stated in the schedule or during the
continuance of this policy by renewal any insured person shall suffer from any illness or disease (hereinafter called disease) or
sustain any bodily injury due to an accident (hereinafter called injury) and if such disease or injury shall require any such insured
person, upon the advice of a duly qualified medical practitioner to be hospitalised for treatment at any nursing home/ hospital
(hereinafter called hospital) in India, Nepal or Bhutan as an in-patient, the company shall pay to the hospital or reimburse the
insured person the amount of such reasonable, customary and medically necessary expenses described below incurred in respect
thereof by or on behalf of such insured person but not exceeding the sum insured per family stated in the schedule hereto¸ in
respect of all such claims, during the policy period.

Coverage
2.1Room charges and Intensive care unit charges as provided by the hospital.

2.2 Nursing expenses.

2.3 Surgeon, anaesthetist, medical practitioner, consultants, specialist’s fees.

2.4 Anaesthesia, blood, oxygen, operation theatre charges, surgical appliances, medicines & drugs, diagnostic materials and X-
ray, dialysis, chemotherapy, radiotherapy cost of pacemaker, artificial limbs and similar expenses.

2.5 Ambulance charges not exceeding `1,000/- (Rupees one thousand only) per policy period.

2.6 In case of hospitalisation of children below 12 (twelve) years, a lump sum amount of `1,000/- (Rupees one thousand only) per
policy period towards the out-of-pocket expenses.

2.7 Maternity and baby care expenses

Maternity & baby care expenses, subject to the conditions hereunder.
i. Cover is available up to a limit of 5% of sum insured.
ii. A waiting period of 9 (nine) months is applicable for payment of any claim relating to normal delivery or caesarean section or
abdominal operation for extra uterine pregnancy. The waiting period may be relaxed only in case of delivery, miscarriage or
abortion induced by accident or other medical emergency.
iii. Claim in respect of delivery for only first two children and/or operations associated therewith will be considered under the
policy or any renewal thereof. Those insured persons who are already having two or more living children will not be eligible
for this benefit.
iv. Expenses incurred in connection with voluntary medical termination of pregnancy during the first 12 (twelve) weeks from the
date of conception are not covered.
v. Pre-natal and post-natal expenses are not covered unless admitted in hospital and treatment is taken there.

2.8 In case of death in hospital, funeral expenses are reimbursed up to `1,000/- (Rupees one thousand only) over and above the
sum insured subject to the hospitalisation claim being admissible under the policy.

2.9 Treatment of Non Resident Indians (NRIs) in hospital in India.

2.10 Treatment in hospitals in Nepal and Bhutan covered in Indian currency.

2.11 Good health incentive

2.11.1 Cost of health checkup

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Expenses of health checkup will be reimbursed once at the end of a block of three continuous policy periods provided no claims
are reported during the block and the policy has been continuously renewed with the company without a break. Expenses payable
is a maximum of 1% of the average sum insured of the block.

3. Definition

3.1 Accident means a sudden, unforeseen and involuntary event caused by external, visible and violent means.

3.2 Any one illness means continuous period of illness and it includes relapse within 45 (forty five) days from the date of last
consultation with the hospital where treatment has been taken.

3.3 Break in policy occurs at the end of the existing policy period when the premium due on a given policy is not paid on or
before the renewal date or within grace period.

3.4 Cashless facility means a facility extended to the insured person where the payment of the cost of treatment undergone by the
insured person in accordance with the policy terms and conditions, is directly made to the network provider by the company to the
extent of pre-authorization approval

3.5 Condition precedent means a policy term or condition upon which the company’s liability under the policy is conditional
upon.

3.6 Congenital anomaly means a condition which is present since birth, and which is abnormal with reference to form, structure
or position.
i. Internal congenital anomaly means congenital anomaly which is not on the visible and accessible parts of the body
ii. External congenital anomaly means congenital anomaly which is on the visible and accessible parts of the body

3.7 Contribution means the right of an company to call upon other insurers, liable to the same insured, to share the cost o f an
indemnity claim on a ratable proportion.

3.8 Day care treatment means medical treatment, and/or surgical procedure which is:
i. undertaken under General or Local Anesthesia in a hospital/day care centre in less than 24 (twenty four) hrs because of
technological advancement, and
ii. which would have otherwise required a hospitalisation o f more than 24 (twenty four) hours.
Treatment normally taken on an out-patient basis is not included in the scope of this definition.

3.9 Dental treatment means a treatment carried out by a dental practitioner including examinations, fillings (where appropriate),
crowns, extractions and surgery excluding any form of cosmetic surgery/implants.

3.10 Family means the Bank of Baroda account holder, spouse and two dependant children.

3.11 Grace period means 30 days immediately following the premium due date during which a payment can be made to renew
or continue the policy in force without loss of continuity benefits such as waiting period and coverage of pre-existing disease.
Coverage is not available for the period for which no premium is received.

3.12 Hospital means any institution established for in-patient care and day care treatment of illness and/or injuries and which
has been registered as a hospital with the local authorities under the Clinical Establishments (Registration and Regulation) Act,
2010 or under the enactments specified under the Schedule of Section 56(1) of the said Act OR complies with all minimum
criteria as under:
i. has qualified nursing staff under its employment round-the-clock;
ii. has at least 10 (ten) in-patient beds in towns having a population of less than 10,00,000 (ten lacs) and at least 15 (fifteen) in-
patient beds in all other places;
iii. has qualified medical practitioner(s) in charge round-the-clock;
iv. has a fully equipped operation theatre of its own where surgical procedures are carried out;
v. maintains daily records of patients and makes these accessible to the insurance company’s authorized personnel.

3.13 Hospitalisation means admission in a hospital as an in-patient for a minimum period of 24 (twenty four) consecutive hours.
However, this time limit is not applicable to
i. dialysis, chemotherapy, radiotherapy, eye surgery, dental surgery, lithotripsy (kidney stone removal), dilatation and curettage
(D&C), tonsillectomy
ii. treatment that necessitates hospitalisation and the procedure involves specialized infrastructural facilities available in
hospitals and due to technological advances hospitalisation is required for less than 24 (twenty four) hours only.

3.14 Illness means a sickness or a disease or pathological condition leading to the impairment of normal physiological function
which manifests itself during the policy period and requires medical treatment.

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i. Acute condition means a disease, illness orinjury that is likely to respons quickly to treatment which aims to return the
person to his or her state of health immediately before suffering the disease/ illness/ injury which leads to full recovery.
ii. Chronic condition means a disease, illness, or injury that has one or more of the following characteristics
a) it needs ongoing or long-term monitoring through consultations, examinations, check-ups, and / or tests
b) it needs ongoing or long-term control or relief o f symptoms
c) it requires your rehabilitation or for you to be specially trained to cope with it
d) it continues indefinitely
e) it comes back or is likely to come back.

3.15 In-patient means an insured person who is admitted in hospital upon the written advice of a duly qualified medical
practitioner for more than 24 (twenty four) continuous hours, for the treatment of covered disease/ injury during the policy period.

3.16 Intensive care unit means an identified section, ward or wing of a hospital which is under the constant supervision of a
dedicated medical practitioner(s), and which is specially equipped for the continuous monitoring and treatment of patients who are
in a critical condition, or require life support facilities and where the level of care and supervision is considerably more
sophisticated and intensive than in the ordinary and other wards.

3.17 Medical advice means any consultation or advice from a Medical Practitioner including the issue of any prescription or
repeat prescription.

3.18 Medical expenses means those expenses that an insured person has necessarily and actually incurred for medical treatment
on account of disease/ injury on the advice of a medical practitioner, as long as these are no more than would have been payable if
the Insured Person had not been insured and no more than other hospitals or doctors in the same locality would have charged for
the same medical treatment.

3.19 Medical practitioner means a person who holds a valid registration from the Medical Council of any State or Medical
Council of India or Council for Indian Medicine or for Homeopathy set up by the Government of India or a State Government and
is thereby entitled to practice medicine within its jurisdiction; and is acting within the scope and jurisdiction of licence.

3.20 Network provider means hospitals or health care providers enlisted by an insurer or by a TPA and insurer together to
provide medical services to an insured person on payment by a cashless facility.

3.21 Non- network means any hospital, day care centre or other provider that is not part of the network.

3.22 Notification of claim means the process o f notifying a claim to the company or TPA by specifying the timelines as well as
the address / telephone number to which it should be notified.

3.23 Out-patient treatment means treatment in which the insured person visits a clinic / hospital or associated facility like a
consultation room for diagnosis and treatment based on the advice of a medical practitioner and the insured person is not admitted
as a day care patient or in-patient.

3.24 Policy period means period of one year as mentioned in the schedule for which the policy is issued.

3.25 Portability means transfer by an individual health insurance policy holder (including family cover) of the credit gained for
pre-existing conditions and time bound exclusions if the policy holder chooses to switch from one insurer to another.

3.26 Preferred provider network (PPN) means a network of hospitals which have agreed to a cashless packaged pricing for
certain procedures for the insured person. The list is available with the company/TPA and subject to amendment from time to
time. Reimbursement of expenses incurred in PPN for the procedures (as listed under PPN package) shall be subject to the rates
applicable to PPN package pricing.

3.27 Pre hospitalisation means medical expenses incurred 30 (thirty) days immediately before the insured person is hospitalisation,
provided that:
i. such medical expenses are incurred for the same condition for which the insured person’s hospitalisation was required, and
ii. the in-patient hospitalisation claim for such hospitalisation is admissible by the company
Pre hospitalisation will be considered as part of hospitalisation claim.

3.28 Post hospitalisation means medical expenses incurred 60 (sixty) days immediately after the insured person is discharged from
hospital, provided that:
i. such medical expenses are incurred for the same condition for which the insured person’s hospitalisation was required, and
ii. the in-patient hospitalisation claim for such hospitalisation is admissible by the company
Post hospitalisation will be considered as part of hospitalisation claim.

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3.29 Pre-existing disease means any condition, ailment or injury or related condition(s) for which the insured person had signs
or symptoms and/or was diagnosed and/or received medical advice/ treatment within 48 (forty eight) months prior to the first
policy issued by the company.

3.30 Reasonable and customary charges means the charges for services or supplies, which are the standard charges for the
specific provider and consistent with the prevailing charges in the geographical area for identical or similar services, taking into
account the nature of the illness / injury involved.

3.31 Room rent means the amount charged by a hospital for the occupancy of a bed on per day (24 hours) basis and shall include
associated medical expenses.

3.32 Sum insured means the floater sum insured as mentioned in the schedule. The sum insured represents maximum liability for
the family, for any and all benefits claimed during the policy period.

3.33 Surgery means manual and / or operative procedure (s) required for treatment of an illness or injury, correction of
deformities and defects, diagnosis and cure of diseases, relief of suffering or prolongation of life, performed in a hospital or day
care centre by a medical practitioner.

3.34 TPA means any entity, licensed under the IRDA (Third Party Administrators - Health Services) Regulations, 2001 by the
Authority, and is engaged, for a fee by the company for the purpose of providing health services.

3.35 Qualified nurse means a person who holds a valid registration from the Nursing Council of India or the Nursing Council of
any state in India.

3.36 Waiting period means a period from the inception of the first policy during which specified diseases/treatment is not
covered. On completion of the period, diseases/treatment will be covered provided the policy has been continuously renewed
without any break.

4. Exclusions

The company shall not be liable to make any payment under this policy in respect of any expenses incurred by any insured person
in connection with or in respect of:

4.1 Pre-existing diseases

All pre-existing diseases when the cover incepts for the first time until 36 (thirty six) months of continuous coverage has
elapsed. Any complication arising from pre-existing ailment/disease/injuries will be considered as a part of the pre existing
health condition or disease.

4.2 First 30 days waiting period

Any disease contracted by the insured person during the first 30 (thirty) days from the inception of the first policy. This shall not
apply in case the insured person is hospitalised for injuries, suffered in an accident which occurred after inception of the first
policy.

4.3 One year waiting period

Following diseases/treatment are subject to one year waiting period.
i Cataract vi Internal congenital anomaly
ii Benign prostatic hypertrophy vii Fistula in anus
iii Hysterectomy for haemorrhage or fibromyoma vii Piles
iv Hernia ix Sinusitis and related disorders
v Hydrocele

4.4 Circumcision unless necessary for treatment of a disease (if not excluded otherwise) or necessitated due to an accident.

4.5 Vaccination or inoculation.

4.6 Cosmetic, plastic surgery, sex change

Cosmetic or aesthetic treatment of any description, change of life or sex change operation. Expenses for plastic surgery other than
as may be necessitated due to illness/ disease/ injury.

4.7 Spectacles, contact lens, hearing aid.

4.8 Dental treatment

Dental treatment or surgery of any kind unless requiring hospitalisation.

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4.9 General debility, external congenital anomaly
Convalescence, general debility, run down condition or rest cure, external congenital anomaly.

4.10 Sterility, venereal disease, intentional self inflicted injury.

4.11 Drug/alcohol abuse

Treatment arising out of illness/disease/injury due to misuse or abuse of drugs/alcohol or use of intoxicating substances.

4.12 AIDS
All expenses arising out of any condition directly or indirectly caused to or associated with Human T-Cell Lymph tropic Virus
Type-III (HTLV-III) or Iymphadinopathy Associated Virus (LAV) OR the Mutants Derivative or Variation Deficiency Syndrome
or any syndrome or condition of similar kind commonly referred to as AIDS.

4.13 Hospitalisation for the purpose of diagnosis and evaluation, irrelevant investigations charges
All expenses incurred at Hospital primarily for diagnostic, x -ray or laboratory examinations or other diagnostic studies
not consistent with nor incidental to the diagnosis and treatment of positive existence or presence of any ailment,
sickness or injury, for which confinement is required at a Hospital.

4.14 Vitamins, tonics

Vitamins and tonics unless forming part of treatment for illness/disease/injury as certified by the attending medical practitioner.

4.15 Maternity
No expenses will be payable for any treatment arising from or traceable to voluntary termination of pregnancy.

4.15 Naturopathy treatment.

4.16 Domiciliary hospitalisation expenses

4.17 War group perils

Injury or disease directly or indirectly caused by or arising from or attributable to war invasion act of foreign enemy, warlike
operations (whether war be declared or not) and injury or disease directly or indirectly caused by or contributed to by nuclear
weapons/materials.

5. Conditions

5.1 Disclosure of information

The policy shall be void and all premium paid hereon shall be forfeited to the company, in the event of mis-representation, mis-
description or non-disclosure of any material fact.

5.2 Condition precedent to admission of liability

The due observance and fulfillment of the terms and conditions of the policy, by the insured person, shall be a condition precedent
to any liability of the company to make any payment under the policy.

5.3 Communication
i. All communication should be in writing.
ii. ID card, PPN/network provider related issues to be communicated to the TPA at the address mentioned in the schedule.The
policy related issues, change in address to be communicated to the policy issuing office at the address mentioned in the
schedule.
iii. The company or TPA will communicate to the insured person at the address mentioned in the schedule.

5.4 Physical examination

Any medical practitioner authorised by the company shall be allowed to examine the insured person in case of any alleged injury
or disease requiring hospitalisation when and as often as the same may reasonably be required on behalf of the company.

5.5 Payment of premium

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 same date or (b) the actual date of dispatch of the instrument with
proposal/renewal advice or (c) the date of deposit of premium to the company to comply to provisions of Section 64 VB of
Insurance Act.
It is further understood and agreed that the premium has been remitted by the bank on collection of the same or by duly debiting
the account of account holders with prior consent. On such policy of insurance being issued, the company shall not entertain any
request for cancellation and consequent refund of premium therefore on any grounds whatsoever shall not arise.

5.6 Claim Procedure

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5.6.1 Notification of claim
In case of a claim, the insured person/insured person’s representative shall intimate the TPA in writing by letter, e-mail, fax
providing all relevant information relating to claim including plan of treatment, policy number etc. within the prescribed time
limit.

Claim notification in case of cashless facility TPA must be informed:

In case of planned hospitalisation At least 72 (seventy two) hours prior to the insured person’s
admission to network provider/PPN
In case of emergency hospitalisation Within 24 (twenty four) hours of the insured person’s admission to
network provider/PPN

Claim notification in case of reimbursement TPA must be informed:

In case of planned hospitalisation At least 72 (seventy two) hours prior to the insured person’s
admission to hospital
In case of emergency hospitalisation Within 24 (twenty four) hours of the insured person’s admission to
hospital

5.6.2 Procedure for cashless claims

i. Treatment may be taken in a network provider/PPN and is subject to pre authorization by the TPA.
ii. Cashless request form available with the network provider/PPN and TPA shall be completed and sent to the TPA for
authorization.
iii. The TPA upon getting cashless request form and related medical information from the insured person/ network provider/PPN
will issue pre-authorization letter to the hospital after verification.
iv. At the time of discharge, the insured person has to verify and sign the discharge papers, pay for non-medical and inadmissible
expenses.
v. The TPA reserves the right to deny pre-authorization in case the insured person is unable to provide the relevant medical
details.
vi. In case of denial of cashless access, the insured person may obtain the treatment as per treating doctor’s advice and submit the
claim documents to the TPA for reimbursement.

5.6.3 Procedure for reimbursement of claims

For reimbursement of claims the insured person may submit the necessary documents to TPA within the prescribed time limit.

5.6.4 Documents
The claim is to be supported with the following documents and submitted within the prescribed time limit.
i. Completed claim form
ii. Original bills, payment receipts, medical history of the patient recorded, discharge certificate/ summary from the hospital etc.
iii. Original cash-memo from the hospital (s)/chemist (s) supported by proper prescription
iv. Original payment receipt, investigation test reports etc. supported by the prescription from attending medical practitioner
v. Attending medical practitioner’s certificate regarding diagnosis and bill receipts etc.
vi. Surgeon’s original certificate stating diagnosis and nature of operation performed along with bills/receipts etc.
vii. Any other document required by company/TPA

Note
i. In the event of a claim lodged as per clause 2.6 of the policy the payment will be made on the basis of a declaration from the
parent without insisting on any supporting bill/cash memo.
ii. In the event of a claim lodged as per clause 5.9 of the policy and the original documents having been submitted to the other
insurer, the company may accept the documents listed under clause 5.6.4 of the policy and claim settlement advice duly
certified by the other insurer subject to satisfaction of the company.

Type of claim Time limit for submission of documents to TPA

Reimbursement of hospitalisation and pre Within 15 (fifteen) days of date of discharge from hospital
hospitalisation expenses
Reimbursement of post hospitalisation expenses Within 15 (fifteen) days from completion of post
hospitalisation treatment
Reimbursement of health checkup expenses (as per At least 45 (forty five) days before the expiry of the fourth
Good health incentives 2.11.1 of the policy) policy period.

5.6.5 Claim Settlement

i. On receipt of the final document(s) or investigation report (if any), as the case may be, the company shall within a period of
30 days offer a settlement of the claim to the insured person.

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ii. If the company, for any reasons, decides to reject a claim under the policy, shall communicate to the insured person in writing
and within a period of 30 (thirty) days from the receipt of the final document(s) or investigation report (if any), as the case
may be.
iii. Upon acceptance of an offer of settlement as stated above by the insured person, the payment of the amount due shall be
made within 7 (seven) days from the date of acceptance of the offer by the company.
iv. In the cases of delay in the payment, the company shall pay interest at a rate which is 2% above the bank rate prevalent at the
beginning of the financial year in which the claim is paid.

5.6.6 Services offered by a TPA

The services offered by a TPA shall not include
i. Claim settlement and rejection with respect to the policy; However, TPA may handle claims admission and recommend to the
company for the payment of the claim settlement
ii. Any services directly to the insured person or to any other person unless such service is in accordance with the terms and
conditions of the Agreement entered into with the company.

Waiver
Time limit for claim notification and submission of documents may be waived in cases where it is proved to the satisfaction of the
company, that the circumstances under which insured person was placed, it was not possible to intimate the claim/submit the
documents within the prescribed time limit.

5.7 Payment of claim

All claims under the policy shall be payable in Indian currency through NEFT/ RTGS only.

5.8 Territorial limit

All medical treatment for the purpose of this insurance will have to be taken in India, Nepal or Bhutan.

5.9 Medical expenses incurred under two policy periods

If the claim falls within two policy periods, the claims shall be paid taking into consideration the available sum insured in the two
policy periods, including the deductibles for each policy period. Such eligible claim amount to be payable to the insured person
shall be reduced to the extent of premium to be received for the renewal/due date of premium of health insurance policy, if not
received earlier.

5.10 Contribution
In the case of a claim arising under the policy, there is in existence any other policy (other than cancer insurance policy in
collaboration with Indian Cancer Society) effected by the insured person or on behalf of insured person which covers any claim in
whole or in part made under the policy then the insured person has the option to select the policy under which the claim is to be
settled. If the claimed amount, after considering the applicable co payment, exceeds the sum insured under any one policy then the
company shall pay or contribute not more than its rateable proportion of the claim.

5.11 Fraud
The company shall not be liable to make any payment under the 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 insured person or by any other person acting on his
behalf.

5.12 Cancellation
The company may at any time cancel the policy (on grounds of fraud, moral hazard, misrepresentation or noncooperation) by
sending the insured person 30 (thirty) days notice by registered letter at insured person's last known address and in such event
the company shall not allow any refund.
The insured person may at any time cancel the policy and in such an event the company shall allow refund of premium after
charging premium at company’s short period rate mentioned below provided no claim occurred up to the date of cancellation.

PERIOD OF RISK RATE OF PREMIUM TO BE CHARGED

Up to one month ¼th of the annual rate
Up to three months ½ of the annual rate
Up to six months ¾th of the annual rate
Exceeding six months Full annual rate

5.13 Disclaimer
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.

5.14 Territorial jurisdiction

All disputes or differences under or in relation to the policy shall be determined by the Indian court and according to Indian law.

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5.15 Arbitration
If any dispute or difference shall arise as to the quantum to be paid under the policy (Liability being otherwise admitted) such
difference shall independently of all other questions be referred to the decision of a sole arbitrator to be appointed in writing by
the parties or if they cannot agree upon a single arbitrator within 30 (thirty) days of any party invoking arbitration, the same shall
be referred to a panel of three arbitrators, comprising of two arbitrators, one 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
with the provisions of the 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.

5.16 Renewal
The policy may be renewed by mutual consent. The company is not bound to give notice that it is due for renewal. Renewal of
the policy cannot be denied other than on grounds of fraud, moral hazard, misrepresentation or noncooperation. In the event of
break in the policy a grace period of 30 (thirty) days is allowed.

5.17 The company shall not be bound to take notice or be affected by any notice of any trust, charge, lien, assignment or other
dealings with or relating to this policy but the receipt of the insured or his legal personal representative(s) shall in all cases be an
effective discharge to the Company.

5.18 Portability
In the event of the insured person porting to any other insurer, insured person must apply with details of the policy and claims to
the company where the insured person wants to port, at least 45 (forty five) days before the date of expiry of the policy.
Portability shall be allowed in the following cases:
i. All individual health insurance policies issued by non-life insurance companies including family floater policies.
ii. Individual members, including the family members covered under any group health insurance policy of a non-life insurance
company shall have the right to migrate from such a group policy to an individual health insurance policy or a family floater
policy with the same insurer. One year thereafter, the insured person shall be accorded the right to port to another non-life
insurance company

5.19 Withdrawal of product

In case the policy is withdrawn in future, the company shall provide the option to the insured person to switch over to a similar
policy at terms and premium applicable to the new policy.

5.20 Revision of terms of the policy including the premium rates

The company, in future, may revise or modify the terms of the policy including the premium rates based on experience. The
insured person will be notified three months before the changes are effected.

5.21 Free look period

The insured person is allowed a period of 15 (fifteen) days from date of receipt of policy to review the terms and conditions of the
policy, and to return the same if not acceptable.
If the insured person has exercised the option of free look period and has not made any claim during the free look period, the
insured person shall be entitled to-
i. a refund of the premium paid less any expenses incurred by the company on medical examination of the insured person and
the stamp duty charges; or
ii. where the risk has already commenced and the option of return of the policy is exercised by the insured person, a deduction
towards the proportionate risk premium for period on cover
The free look provision is not applicable to renewal of the policy.

5.22 Nomination
The insured is mandatorily required at the inception of the Policy to make a nomination for the purpose of payment of claims
under the policy in the event of death.
Any change of nomination shall be communicated to the company in writing and such change shall be effective only when an
endorsement on the policy is made.
In case of any insured person other than the insured under the policy, for the purpose of payment of claims in the event of death,
the default nominee would be the insured.
No assignment of this policy or the benefits there under shall be permitted.

6 Redressal of grievance
In case of any grievance relating to servicing the policy, the insured person may submit in writing to the policy issuing office or
regional office for redressal. If the grievance remains unaddressed, insured person may contact Customer Relationship
Management Dept., National Insurance company Limited, Chhabildas towers, 6A, Middleton Street, Kolkata - 700071.
If the insured person is not satisfied, the grievance may be referred to “Health Insurance Management Dept.”, National Insurance
company Limited, 3 Middleton Street, Kolkata - 700071.

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The insured person may also approach the office of Insurance Ombudsman of the respective area/ region for redressal of
grievance.

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 Appendix I
Expenses Generally Excluded
List of Expenses Generally Excluded SLINGS Reasonable costs for
("Non-Medical") in Hospital Indemnity one sling in case of
Policy - upper arm fractures is
TOILETRIES/ COSMETICS/ PERSONAL COMFORT OR payable
CONVENIENCE ITEMS ITEMS SPECIFICALLY EXCLUDED IN THE POLICIES
HAIR REMOVAL CREAM Not Payable WEIGHT CONTROL PROGRAMS/ Exclusion in policy
BABY CHARGES (UNLESS Not Payable SUPPLIES/ SERVICES
SPECIFIED/INDICATED) COST OF SPECTACLES/ CONTACT Exclusion in policy
BABY FOOD Not Payable LENSES/ HEARING AIDS ETC.,
BABY UTILITES CHARGES Not Payable DENTAL TREATMENT EXPENSES Exclusion in policy
BABY SET Not Payable THAT DO NOT REQUIRE
BABY BOTTLES Not Payable HOSPITALISATION
BRUSH Not Payable HORMONE REPLACEMENT Exclusion in policy
COSY TOWEL Not Payable THERAPY
HAND WASH Not Payable HOME VISIT CHARGES Exclusion in policy
MOISTURISER PASTE BRUSH Not Payable INFERTILITY/ SUBFERTILITY/ Exclusion in policy
POWDER Not Payable ASSISTED CONCEPTION
RAZOR Payable PROCEDURE
SHOE COVER Not Payable OBESITY (INCLUDING MORBID Exclusion in policy
BEAUTY SERVICES Not Payable OBESITY) TREATMENT IF
BELTS/ BRACES EXCLUDED IN POLICY
Essential and should be
paid at least specifically PSYCHIATRIC & PSYCHOSOMATIC Exclusion in policy
for cases who have DISORDERS
undergone surgery of CORRECTIVE SURGERY FOR Exclusion in policy
thoracic or lumbar REFRACTIVE ERROR
spine TREATMENT OF SEXUALLY Exclusion in policy
BUDS Not Payable TRANSMITTED DISEASES
BARBER CHARGES Not Payable DONOR SCREENING CHARGES Payable
CAPS Not Payable ADMISSION/REGISTRATION Exclusion in policy
COLD PACK/HOT PACK Not Payable CHARGES
CARRY BAGS Not Payable HOSPITALISATION FOR Exclusion in policy
CRADLE CHARGES EVALUATION/ DIAGNOSTIC
Not Payable
PURPOSE
COMB Not Payable
EXPENSES FOR INVESTIGATION/ Exclusion in policy
DISPOSABLES RAZORS CHARGES ( Payable
TREATMENT IRRELEVANT TO THE
for site preparations)
DISEASE FOR WHICH ADMITTED OR
EAU-DE-COLOGNE / ROOM Not Payable
DIAGNOSED
FRESHNERS
ANY EXPENSES WHEN THE PATIENT Not payable
EYE PAD Not Payable
IS DIAGNOSED WITH RETRO VIRUS
EYE SHEILD Not Payable + OR SUFFERING FROM /HIV/ AIDS
EMAIL / INTERNET CHARGES Not Payable ETC IS DETECTED/ DIRECTLY OR
FOOD CHARGES (OTHER THAN Not Payable INDIRECTLY
PATIENT's DIET PROVIDED BY STEM CELL IMPLANTATION/ Not Payable except for
HOSPITAL) SURGERY AND STORAGE Bone Marrow
FOOT COVER Not Payable Transplantation
GOWN Not Payable ITEMS WHICH FORM PART OF HOSPITAL SERVICES
LEGGINGS Payable in case of WHERE SEPARATE CONSUMABLES ARE NOT PAYABLE
varicose vein surgery BUT THE SERVICE IS
LAUNDRY CHARGES Not Payable WARD AND THEATRE BOOKING Payable under OT
MINERAL WATER Not Payable CHARGES Charges, not payable
OIL CHARGES Not Payable separately
SANITARY PAD Not Payable ARTHROSCOPY & ENDOSCOPY Rental charged by the
SLIPPERS Not Payable INSTRUMENTS hospital payable.
TELEPHONE CHARGES Not Payable Purchase of
TISSUE PAPER Not Payable Instruments not
TOOTH PASTE Not Payable payable.
TOOTH BRUSH Not Payable MICROSCOPE COVER Payable under OT
GUEST SERVICES Not Payable Charges, not payable
BED PAN Not Payable separately
BED UNDER PAD CHARGES Not Payable SURGICAL BLADES,HARMONIC Payable under OT
CAMERA COVER Not Payable SCALPEL,SHAVER Charges, not payable
CLINIPLAST Not Payable separately
CREPE BANDAGE Not Payable SURGICAL DRILL Payable under OT
CURAPORE Not Payable Charges, not payable
DIAPER OF ANY TYPE Not Payable separately
DVD, CD CHARGES Not Payable ( However EYE KIT Payable under OT
if CD is specifically Charges, not payable
sought by Insurer/TPA separately
then payable) EYE DRAPE Payable under OT
EYELET COLLAR Not Payable Charges, not payable
separately
FACE MASK Not Payable
X-RAY FILM Payable under
FLEXI MASK Not Payable
Radiology Charges, not
GAUSE SOFT Not Payable
as consumable
GAUZE Not Payable
SPUTUM CUP Payable under
HAND HOLDER Not Payable Investigation Charges,
HANSAPLAST/ ADHESIVE Not Payable not as consumable
BANDAGES BOYLES APPARATUS CHARGES Part of OT Charges,
INFANT FOOD Not Payable
 not seperately PREPARATION CHARGES Not Payable
BLOOD GROUPING AND CROSS Part of Cost of Blood, PHOTOCOPIES CHARGES Not Payable
MATCHING OF DONORS SAMPLES not payable PATIENT IDENTIFICATION BAND / Not Payable
ANTISEPTIC OR DISINFECTANT Not Payable-Part of NAME TAG
LOTIONS Dressing Charges WASHING CHARGES Not Payable
BAND AIDS, BANDAGES, STERLILE Not Payable - Part of MEDICINE BOX Not Payable
INJECTIONS, NEEDLES, SYRINGES Dressing charges MORTUARY CHARGES Payable upto 24 hrs,
COTTON Not Payable-Part of shifting charges not
Dressing Charges payable
COTTON BANDAGE Not Payable- Part of MEDICO LEGAL CASE CHARGES Not Payable
Dressing Charges (MLC CHARGES)
MICROPORE/ SURGICAL TAPE Not Payable-Payable by EXTERNAL DURABLE DEVICES
the patient when WALKING AIDS CHARGES Not Payable
prescribed, otherwise BIPAP MACHINE Not Payable
included as Dressing COMMODE Not Payable
Charges CPAP/ CAPD EQUIPMENTS Device not payable
BLADE Not Payable INFUSION PUMP - COST Device not payable
APRON Not Payable -Part of OXYGEN CYLINDER (FOR USAGE Not Payable
Hospital Services/ OUTSIDE THE HOSPITAL)
Disposable linen to be PULSEOXYMETER CHARGES Device not payable
part of OT/ICU chatges SPACER Not Payable
TORNIQUET Not Payable (service is SPIROMETRE Device not payable
charged by hospitals, SPO2 PROBE Not Payable
consumables cannot be
NEBULIZER KIT Not Payable
separately charged)
STEAM INHALER Not Payable
ORTHOBUNDLE, GYNAEC BUNDLE Part of Dressing
ARMSLING Not Payable
Charges
THERMOMETER Not Payable
URINE CONTAINER Not Payable
CERVICAL COLLAR Not Payable
ELEMENTS OF ROOM CHARGE
SPLINT Not Payable
LUXURY TAX Actual tax levied by
government is payable. DIABETIC FOOT WEAR Not Payable
Part of room charge for KNEE BRACES ( LONG/ SHORT/ Not Payable
sub limits HINGED)
HVAC Part of room charge not KNEE IMMOBILIZER/SHOULDER Not Payable
payable separately IMMOBILIZER
HOUSE KEEPING CHARGES Part of room charge not LUMBO SACRAL BELT Payable for cases who
payable separately have undergone
SERVICE CHARGES WHERE Part of room charge not surgery of lumbar
NURSING CHARGE ALSO CHARGED payable separately spine.
TELEVISION & AIR CONDITIONER Payable under room NIMBUS BED OR WATER OR AIR Payable for any ICU
CHARGES charges not if BED CHARGES patient requiring more
separately levied than 3 days in ICU, all
patients with
SURCHARGES Part of Room Charge,
paraplegia/quadriplegia
Not payable separately
for any reason and at
ATTENDANT CHARGES Not Payable - Part of
reasonable cost of
Room Charges
approximately Rs 200/
IM IV INJECTION CHARGES Part of room charge not day
payable separately
AMBULANCE COLLAR Not Payable
CLEAN SHEET Part of
AMBULANCE EQUIPMENT Not Payable
Laundry/Housekeeping
MICROSHEILD Not Payable
not payable separately
ABDOMINAL BINDER Payable for cases who
EXTRA DIET OF PATIENT(OTHER Patient Diet provided
have undergone
THAN THAT WHICH FORMS PART OF by hospital is payable
surgery of lumbar
BED CHARGE)
spine.
BLANKET/WARMER BLANKET Not Payable- part of
ITEMS PAYABLE IF SUPPORTED BY A PRESCRIPTION
room charges
BETADINE \ HYDROGEN Payable when
ADMINISTRATIVE OR NON-MEDICAL CHARGES
PEROXIDE\SPIRIT\\DETTOL\SAVLON\ prescribed for patient,
ADMISSION KIT Not Payable
DISINFECTANTS ETC not payable for hospital
BIRTH CERTIFICATE Not Payable use in OT or ward or
BLOOD RESERVATION CHARGES Not Payable for dressings in hospital
AND ANTE NATAL BOOKING
PRIVATE NURSES CHARGES- Not payable
CHARGES SPECIAL NURSING CHARGES
CERTIFICATE CHARGES Not Payable NUTRITION PLANNING CHARGES - Patient Diet provided
COURIER CHARGES Not Payable DIETICIAN CHARGES- DIET by hospital is payable
CONVENYANCE CHARGES Not Payable CHARGES
DIABETIC CHART CHARGES Not Payable SUGAR FREE TABLETS Payable -Sugar free
DOCUMENTATION CHARGES / Not Payable variants of admissible
ADMINISTRATIVE EXPENSES medicines are not
DISCHARGE PROCEDURE CHARGES Not Payable excluded
DAILY CHART CHARGES Not Payable CREAMS POWDERS LOTIONS Payable when
ENTRANCE PASS / VISITORS PASS Not Payable (Toiletries are not payable, only prescribed prescribed
CHARGES medical pharmaceuticals payable)
EXPENSES RELATED TO Payable under Post DIGESTION GELS Payable when
PRESCRIPTION ON DISCHARGE Hosp prescribed
FILE OPENING CHARGES Not Payable ECG ELECTRODES Upto 5 electrodes are
INCIDENTAL EXPENSES / MISC. Not Payable required for every case
CHARGES (NOT EXPLAINED) visiting OT or ICU. For
MEDICAL CERTIFICATE Not Payable longer stay in ICU, may
MAINTAINANCE CHARGES Not Payable require a change and at
MEDICAL RECORDS Not Payable least one set every

XI
 second day is MENTIONED [DELIVERY KIT,
payable. ORTHOKIT, RECOVERY KIT, ETC]
GLOVES Sterilized Gloves EXAMINATION GLOVES Not payable
payable / unsterilized KIDNEY TRAY Not Payable
gloves not payable MASK Not Payable
HIV KIT Payable - Pre operative OUNCE GLASS Not Payable
screening OUTSTATION CONSULTANT'S/ Not payable
LISTERINE/ ANTISEPTIC Payable when SURGEON'S FEES
MOUTHWASH prescribed OXYGEN MASK Not Payable
LOZENGES Payable when PAPER GLOVES Not Payable
prescribed PELVIC TRACTION BELT Payable in case of PIVD
MOUTH PAINT Payable when requiring traction as
prescribed this is generally not
NEBULISATION KIT Payable reasonably if reused
used during REFERAL DOCTOR'S FEES Not Payable
hospitalisation ACCU CHECK ( Glucometery/ Strips) Not payable pre
hospitilasation or post
NOVARAPID Payable when hospitalisation /
prescribed Reports and Charts
VOLINI GEL/ ANALGESIC GEL Payable when required/ Device not
prescribed payable
ZYTEE GEL Payable when PAN CAN Not Payable
prescribed SOFNET Not Payable
VACCINATION CHARGES Not payable TROLLY COVER Not Payable
PART OF HOSPITAL'S OWN COSTS AND NOT PAYABLE UROMETER, URINE JUG Not Payable
AHD Not Payable - Part of AMBULANCE Payable
Hospital's internal Cost TEGADERM / VASOFIX SAFETY Payable - maximum of
ALCOHOL SWABES Not Payable - Part of 3 in 48 hrs and then 1
Hospital's internal Cost in 24 hrs
SCRUB SOLUTION/STERILLIUM Not Payable - Part of URINE BAG Payable where
Hospital's internal Cost medicaly necessary till
OTHERS a reasonable cost -
VACCINE CHARGES FOR BABY Not payable maximum 1 per 24 hrs
AESTHETIC TREATMENT / SURGERY Not Payable SOFTOVAC Not Payable
TPA CHARGES Not Payable STOCKINGS Payable for case like
VISCO BELT CHARGES Not Payable CABG etc..
ANY KIT WITH NO DETAILS Not Payable

The list is as per the standard list of excluded expenses stipulated by IRDA in Guidelines in Standardization in Health Insurance,
dated 20.02.2013.

XII