Guidelines on Covid Standard Health Policy

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~ -A-... " " • .p,_,_,.., ~ 0 'lffiolq ~II-ii lcll..Ji.114cfi 3ffi 1qq,1t1 ).IIIUcR'UT cnm INSURANCE REGULATORY AND irJai DEVELOPMENT AUTHORITY OF INDIA Ref: IRDAI/HL T/REG/CIR/163 /06/2020 26th June, 2020 Guidelines on Individual Covid Standard Health Policy SI.No 1. 2. 3. 4. INDEX Item Page No. Guidelines on Covid Standard Health Policy 2-8 Annexure-1 :Policy Terms and Conditions of the Covid Standard 9-27 Health Policy Annexure-2: Format for Customer Information Sheet Annexure-3: Form for filing the Covid Standard Health Policy Sy no 115/1 , Financial District, Nanakramguda, Hyderabad 500 032 www.irda.gov.in 28-29 30-40 Page 1 of 40 To All General and Health Insurers {except ECGC & AIC) Guidelines on Covid Standard Health Policy A. Preamble: 1. In view of the global pandemic Covid 19, the Authority has decided to mandate all general and health insurers to offer Individual Covid Standard Health Policy with the following objectives: • To have a Covid specific product addressing basic health insurance needs of insuring public related to Covid. • To have a standard product with common policy wordings across the industry 2. Towards this, the following Guidelines on Covid Standard Health Policy are issued under the provisions of Section 34 (1) (a) of Insurance Act, 1938. 3. All general and health insurers shall offer the Covid Standard Health Policy by duly complying with the following guidelines. 4. The Covid Standard Health Policy shall have One Basic mandatory cover as specified in these Guidelines which shall be uniform across all General and Health Insurers. 5. One Optional Cover specified in these Guidelines, shall be offered along with the Covid Standard Health Policy within the sum insured. The total amount payable in respect of Covers B (I) (11) (12) (13) (14) (15) and B(II) (18) shall not exceed 100% of the Sum Insured during a policy period. The premium payable towards this Optional Cover shall be specified separately so as to enable policyholders to choose and pay based on the need. 6. The insurer may determine the price keeping in view the covers proposed to be offered subject to complying with the norms specified in the IRDAI (Health Insurance) Regulations, 2016 and Guidelines notified there under. 7. The Base Cover of Covid Standard Health Policy shall be offered on Indemnity basis whereas Optional Cover shall be made available on Benefit Basis. 8. The Covid Standard Health Policy shall offer a policy tenure of three and half months (3 ½ months), six and half months (6 ½ months), and nine and half months (9 ½ months) including waiting period. 9. Every General and Standalone Health Insurer, who has been issued a Certificate of Registration to transact General and/or Health Insurance Business, shall 2 mandatorily offer this product. However, if any insurer is currently not offering health insurance products at all, the above stipulation will not apply to those. 10. The Covid Standard Health Policy shall comply with all the provisions of Insurance Regulatory and Development Authority of India (IRDAI) (Health Insurance) Regulations, 2016, all other applicable Regulations, Guidelines on Standardization in Health Insurance (Ref: IRDA/HLT/REG/CIR/146/07/2016) dated 29th July, 2016, Guidelines on Product Filing in Health Insurance Business (Ref: IRDA/HL T/REG/CIR/150/07/2016) dated 29th July, 2016, Guidelines on Standardization of Exclusions in Health Insurance Contracts (Ref: IRDAI/HL T/REG/CIR/177/09/2019) dated 27thSeptember, 2019 and other applicable Guidelines as amended from time to time. B. Construct of Covid Standard Health Policy: The Covid Standard Health Policy shall offer the following: I. Base cover: 11. COVID Hospitalization Expenses: The Hospitalization expenses incurred by the insured person for the treatment of Covid on Positive diagnosis of Covid in a government authorized diagnostic centre. This section shall cover the following: a) Room, Boarding, Nursing Expenses as provided by the Hospital/ Nursing Home. b) Surgeon, Anesthetist, Medical Practitioner, Consultants, Specialist Fees (including consultation through telemedicine as per Telemedicine Practice Guideline of 25th March 2020) whether paid directly to the treating doctor / surgeon or to the hospital. c) Anesthesia, blood, oxygen, operation theatre charges, surgical appliances, ventilator charges, medicines and drugs, costs towards diagnostics, diagnostic imaging modalities, PPE Kit, gloves, mask and such other similar expenses (Expenses on Hospitalization for a minimum period of 24 hours are admissible.) d) Intensive Care Unit (ICU)/ Intensive Cardiac Care Unit (ICCU) expenses. e) Expenses incurred on road Ambulance subject to a maximum of Rs.2000/- per hospitalization. 12. Home Care Treatment Expenses: Insurer shall cover the costs of treatment of COVID incurred by the Insured person on availing treatment at home maximum up to 14 days per incident provided that: a) The Medical practitioner advices the Insured person to undergo treatment at home. b) There is a continuous active line of treatment with monitoring of the health status by a medical practitioner for each day through the duration of the home care treatment. c) Daily monitoring chart including records of treatment administered duly signed by the treating doctor is maintained. d) Insured shall be permitted to avail the services as prescribed by the medical practitioner. Cashless or reimbursement facility are offered under homecare 3 expenses subject to claim settlement policy disclosed in the website of the Insurer. e) In case the insured intends to avail the services of non-network provider, claim shall be subject to reimbursement, a prior approval from the Insurer needs to be taken before availing such services. Insurer shall respond to approval request within 2 hrs of receiving the last necessary requirement. In this benefit, the following shall be covered if prescribed by the treating medical practitioner and is related to treatment of COVID, a. Diagnostic tests undergone at home or at diagnostics centre b. Medicines prescribed in writing c. Consultation charges of the medical practitioner d. Nursing charges related to medical staff e. Medical procedures limited to parenteral administration of medicines f. Cost of Pulse oximeter, Oxygen cylinder and Nebulizer Subject to other terms, conditions and exclusions of the policy, expenses payable during the Policy period shall not in aggregate exceed the maximum Sum Insured as specified in the Policy Schedule against this Benefit. 13. AYUSH Treatment: The Medical expenses incurred on hospitalization under AYUSH (as defined in IRDAI (Health Insurance) Regulations, 2016) systems of medicine for the treatment of Covid on Positive diagnosis of Covid in a government authorized diagnostic centre shall be covered up to the Sum Insured without any sub-limits. 14. Pre-Hospitalization medical expenses incurred for a period of 15days prior to the date of hospitalization/home care treatment following an admissible claim under this policy shall be covered. Pre hospitalization expenses shall also cover the costs of diagnostics towards Covid. 15. Post-Hospitalization medical expenses incurred for a period of 30days from the date of discharge from the hospital/completion of home care treatment, following an admissible claim under this policy shall be covered. 16. No deductibles are permitted in this product. 17. The Policy shall include the cost of treatment for any comorbid condition including pre-existing comorbid condition (s)along with the treatment for Covid. 4 II.Optional cover: 18. Hospital Daily Cash: The Company will pay 0.5% of sum insured per day for each 24 hours of continuous hospitalization for treatment of Covid following an admissible hospitalization claim under this policy. The benefit shall be payable maximum up to 15 days during a policy period in respect of every insured person. C. Other Norms applicable: SI.No Particulars 1. Plan Variants 2. Distributions Channels 3. Family Floater 4. Definition of family 5. Category of Cover Norms Applicable No plan variants are allowed. Covid Standard Health Policy may be distributed across all distribution channels including Micro Insurance Agents, Point of sale persons and Common Public Service Centres. Distribution of Covid Standard Health Policy shall be governed by the regulations of concerned distribution channels. In addition to the number of products allowed to be marketed as per IRDAI circular ref: IRDAI/ INT/ CIR/ PSP/ 019/01/2020 dated 13thJanuary, 2020 "Covid Standard Health Policy" is also allowed to be marketed by Point of Sale. Covid Standard Health Policy shall be offered on family floater basis also. Family consists of the proposer and any one or more of the family members as mentioned below: (i) legally wedded spouse. (ii) Parents and Parents-in-law. (iii) dependent Children (i.e. natural or legally adopted) between the day 1 of age to 25 years. If the child above 18 years of age is financially independent, he or she shall be ineligible for coverage. The Base Cover of Covid Standard Health Policy shall be offered on indemnity basis whereas Optional Cover shall be made available on Benefit Basis. 5 The minimum sum insured under Covid Standard Health Policy shall be Rs 50,000/- (Fifty Thousand only) 6. Minimum and Maximum Sum Insured Maximum limit shall be Rs 5,00,000/-(5 Lakh) (in the multiples of fifty thousand) Covid Standard Health Policy shall be offered with a policy 7 Policy Period term of three and half months (3 ½ months), six and half months (6 ½ months) and nine and half months (9 ½ months) including waiting period. Modes of premium Single premium 8 payment Minimum entry age shall be 18 years for principal insured and maximum age at entry shall not be less than 65 years 9. Entry age for all the insured members including principal insured. Dependent Child/ children shall be covered from Day 1 of age to 25 years subject to the definition of 'Family'. The benefit pay out should be explicitly disclosed in the 10. Benefit Structure format of application (Form - IRDAI-UNF-SCHP) along with other relevant documents. The insurer shall specify the non-medical limit and relevant details explicitly in the format specified. 11. Underwriting 5% discount in premium shall be provided to health care workers. Renewal, Portability Lifelong renewability, migration and portability stipulated 12. and Migration under Regulation 13 and 17 of IRDAI (Health Insurance) Regulations, 2016 respectively are not applicable. The premium under this product shall be pan India basis Pricing and no geographic location / zone based pricing is 13. allowed. 14. The Policy shall include the cost of treatment for any Comorbid Conditions comorbid condition including pre-existing comorbid condition(s) along with the treatment for Covid. D: Construct of Terms and Conditions for Covid Standard Health Policy: 19. The Policy Terms and Conditions of the Covid Standard Health Policy shall be in the format specified in Annexure - 1. Insurer may suitably modify the definitions and other clauses of the policy contract prospectively based on the Regulations or Guidelines that may be issued by the Authority from time to time. 6 E: Other Norms: 20. The nomenclature of the product shall be Corona Kavach Policy, succeeded by name of insurance company, (Corona Kavach Policy, <name of insurer>). No other name is allowed in any of the documents. 21. The Proposal Form used for the product shall be subject to the norms specified under the Guidelines on Product Filing in Health Insurance. 22. Insurers shall mandatorily issue Customer Information Sheet as per the format specified in Annexure-2. 23. The Covid Standard Health Policy may be offered as MICRO Insurance Product subject to Sum Insured limits specified in IRDAI (Micro Insurance) Regulations, 2015, and other circulars/ guidelines issued in this regard by the Authority from time to time. 24. The Covid Standard Health Policy shall be launched without prior approval of the Authority subject to complying with the following conditions. a. The product shall be approved by the Product Management Committee. b. Insurers shall obtain UIN for the Covid Standard Health Policy by filing the relevant particulars in Form - IRDAI-UNF-SCHP (as specified in Annexure - 3 of these Guidelines) along with a certificate from Chief Compliance Officer that the product filed is in compliance with the norms specified under these guidelines. c. On review of the application, the Authority may call for such further information as may be required and may issue suitable directions which shall be retrospectively effected in respect of all contracts issued under this product. 25. General and Health Insurers shall ensure that this product is compulsorily offered on or before 10th July, 2020. 26. In terms of the provisions of Regulation 4(iii) of IRDAI (Issuance of e-lnsurance Policies) Regulations, 2016 providing policy document in physical form is mandatory when policies are issued in electronic form directly to the policyholders. Since features of Corona Kavach Policy shall be common across the industry and as the terms and conditions of the policy are specified by the Authority, with the objective of reducing the operating costs and to pass on this benefit of reduced operational cost to the policyholders by way of affordable premiums, insurers are allowed to issue the policy contract of Corona Kavach Policy in electronic/ digital format. The digital form of the policy contract may be forwaded through email or a link shall be provided in the certificate of insurance.However, where policyholder specifically seeks the physical form of the policy contract, the same shall be provided by the insurer. 7 27. Every insurer offering Corona Kavach Policy shall provide a certificate of insurance to the policyholder indicating the availability of health insuarnce coverage.The certificate shall have a reference to access detailed terms and conditions of the policy contract. Insurers shall also clearly mention policy period (Policy Start Date to Policy End Date), effective policy period (from end of waiting period to end of policy period), waiting period (policy start date to end of policy period) in the Certificate of Insurance. 28. In terms of Clause 5 of Guidelines on short term health insurance policies Ref: IRDAI/HL T/REG/CIR/156/05/2020 dated 23rd June, 2020, the policies issued under these guidelines will remain valid till 31st March, 2021. 29. This has the approval of Competent Authority. (DVS Ramesh) General Manager 8 Corona Kavach Policy, [Company Name] 1. PREAMBLE Annexure-1 This Policy is a contract of insurance issued by [name of the Company] (hereinafter called the 'Company') to the proposer mentioned in the schedule (hereinafter called the 'Insured') to cover the person(s) named in the schedule (hereinafter called the 'Insured Persons'). The policy is based on the statements and declaration provided in the proposal Form by the proposer and is subject to receipt of the requisite premium. 2. OPERATIVE CLAUSE If during the policy period one or more Insured Person (s) is required to be hospitalized for treatment of Covid at a Hospital or given Home Care Treatment following Medical Advice of a duly qualified Medical Practitioner, the Company shall indemnify medically necessary expenses towards the Coverage mentioned in the policy schedule. Provided further that, any amount payable under the policy shall be subject to the terms of coverage exclusions, conditions and definitions contained herein. Maximum liability of the Company under all such Claims during the Policy Period shall be the Sum Insured (Individual or Floater) opted and specified in the Schedule. 3. DEFINITIONS The terms defined below and at other junctures in the Policy have the meanings ascribed to them wherever they appear in this Policy and, where, the context so requires, references to the singular include references to the plural; references to the male includes the female and references to any statutory enactment includes subsequent changes to the same. 3.1. Age means age of the Insured person on last bi1thday as on date of commencement of the Policy. 3.2. AYUSH Treatment refers to hospitalization treatments given under Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy systems. 3.3. An A YUSH Hospital is a healthcare facility wherein medical/surgical/para-surgical treatment procedures and interventions are carried out by A YUSH Medical Practitioner(s) comprising of any of the following: a. Central or State Government A YUSH Hospital or b. Teaching hospital attached to A YUSH College recognized by the Central Government/Central Council of Indian Medicine/Central Council for Homeopathy; or c. A YUSH Hospital, standalone or co-located with in-patient healthcare facility of any recognized system of medicine, registered with the local authorities, wherever applicable, and is under the supervision of a qualified registered A YUSH Medical Practitioner and must comply with all the following criterion: 1. Having at least 5 in-patient beds; 11. Having qualified A YUSH Medical Practitioner in charge round the clock; 111. Having dedicated A YUSH therapy sections as required and/or has equipped operation theatre where surgical procedures are to be carried out; 9 1v. Maintaining daily records of the patients and making them accessible to the insurance company's authorized representative. 3.4. Cashless Facility means a facility extended by the insurer to the insured where the payments, of the costs of treatment undergone by the insured person in accordance with the Policy terms and conditions, are directly made to the network provider by the insurer to the extent pre-authorization is approved. 3.5. Condition Precedent means a Policy term or condition upon which the Company's liability under the Policy is conditional upon. 3.6. COVID: For the purpose of this Policy, Coronavirus Disease means COVID-19 as defined by the World Health Organization (WHO) and caused by the virus SARS-CoV2. 3.7. Day Care Treatment means medical treatment, and/or surgical procedure which is: 1. undertaken under general or local anesthesia in a hospital/day care centre in less than twenty-four hours because of technological advancement, and 11. which would have otherwise required a hospitalization of more than twenty-four hours. 111. Treatment normally taken on an out-patient basis is not included in the scope of this definition. 3.8. Disclosure to information norm: The policy shall be void and all premiums paid thereon shall be forfeited to the Company in the event of misrepresentation, mis-description or non-disclosure of any material fact by the policyholder. 3.9. Emergency Care: Emergency care means management for an illness or injury which results in symptoms which occur suddenly and unexpectedly, and requires immediate care by a medical practitioner to prevent death or serious long term impairment of the insured person's health. 3.10.Family means, the Family that consists of the proposer and any one or more of the family members as mentioned below: i. Legally wedded spouse. ii. Parents and Parents-in-law. iii. Dependent Children (i.e. natural or legally adopted) between the day 1 of age to 25 years. If the child above 18 years of age is financially independent, he or she shall be ineligible for coverage 3.11. Health care worker for the purpose of this policy shall mean doctors, nurses, midwives, dental practitioners and other health professionals including laboratory assistants, pharmacists, physiotherapists, technicians and people working in hospitals. 3.12. Home Care Treatment means treatment availed by the Insured Person at home for Covid on positive diagnosis of Covid in a Government authorized diagnostic Centre, which in normal course would require care and treatment at a hospital but is actually taken at home provided that: a) The Medical practitioner advices the Insured person to undergo treatment at home. b) There is a continuous active line of treatment with monitoring of the health status by a medical practitioner for each day through the duration of the home care treatment. c) Daily monitoring chart including records of treatment administered duly signed by the treating doctor is maintained. 3.13.Hospital means any institution established for in-patient care and day care treatment of disease/ 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 Schedule of Section 56( 1) of the said Act, OR complies with all minimum criteria as under: 1. has qualified nursing staff under its employment round the clock; 10 11. has at least ten inpatient beds, in those towns having a population of less than ten lakhs and fifteen inpatient beds in all other places; 111. has qualified medical practitioner (s) in charge round the clock; 1v. has a fully equipped operation theatre of its own where surgical procedures are carried out v. maintains daily records of patients and shall make these accessible to the Company's authorized personnel. For the purpose of this policy any other set-up designated by the Government as hospital for the treatment of Covid shall also be considered as hospital. 3.14.Hospitalization means admission in a hospital for a minimum period of twenty-four (24) hours consecutive 'In-patient care' provided it will not include procedures/ treatments, where such admission could be for a period of less than twenty-four (24) consecutive hours. 3.15. In-Patient Care means treatment for which the insured person has to stay in a hospital for more than 24 hours for a covered event. 3.16. Insured Person means person(s) named in the schedule of the Policy. 3.17.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. 3.18. ICU (Intensive Care Unit) Charges means the amount charged by a Hospital towards ICU expenses on a per day basis which shall include the expenses for ICU bed, general medical suppo1t services provided to any ICU patient including monitoring devices, critical care nursing and intensivist charges. 3.19.Medical Advice means any consultation or advice from a Medical Practitioner including the issue of any prescription or follow up prescription. 3.20. Medical Expenses means those expenses that an insured person has necessarily and actually incurred for medical treatment on account of illness or accident on the 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. 3.21. Medical Practitioner means a person who holds a valid registration from the Medical Council of any state or Medical Council oflndia 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 the licence. 3.22. Medically Necessary Treatment means any treatment, tests, medication, or stay in hospital or pa1t of a stay in hospital which 1. is required for the medical management of illness or injury suffered by the insured; 11. must not exceed the level of care necessary to provide safe, adequate and appropriate medical care in scope, duration, or intensity; u1. must have been prescribed by a medical practitioner; 1v. must conform to the professional standards widely accepted in international medical practice or by the medical community in India. 3.23. Network Provider means hospitals enlisted by insurer, TPA or jointly by an insurer and TPA to provide medical services to an insured by a cashless facility. 11 3.24. Non- Network Provider means any hospital that is not pa1t of the network. 3.25. Notification of Claim means the process of intimating a claim to the Insurer or TPA through any of the recognized modes of communication. 3.26. Out-Patient (OPD) Treatment means treatment in which the insured visits a clinic/ hospital or associated facility like a consultation room for diagnosis and treatment based on the advice of a medical practitioner. The insured is not admitted as a day care or in-patient 3.27. Pre-hospitalization Medical Expenses means medical expenses incurred during the period of 15 days preceding the hospitalization/home care treatment of the Insured Person, provided that: 1. Such Medical Expenses are incurred for the same condition for which the Insured Person's Hospitalization//home care treatment was required, and 11. The In-patient Hospitalization claim//home care treatment claim for such hospitalization/home care treatment is admissible by the Insurance Company. 3.28.Post-hospitalization Medical Expenses means medical expenses incurred during the period of 30 days immediately after the insured person is discharged from the hospital/ completion of home care treatment provided that: 1. Such Medical Expenses are for the same condition for which the insured person's hospitalization/home care treatment was required, and 11. The inpatient hospitalization/home care treatment claim for such hospitalization/home care treatment is admissible by the Insurance Company. 3.29.Policy means these Policy wordings, the Policy Schedule and any applicable endorsements or extensions attaching to or forming pait thereof. The Policy contains details of the extent of cover available to the Insured person, what is excluded from the cover and the terms & conditions on which the Policy is issued to the Insured person. 3.30. Policy period means period of three and half months (3 ½ months), six and half months (6 ½ months), nine and half months (9 ½ months) as mentioned in the schedule for which the Policy is issued. 3.31.Policy Schedule means the Policy Schedule attached to and forming pait of Policy 3.32. Qualified Nurse means a person who holds a valid registration from the Nursing Council oflndia or the Nursing Council of any state in India. 3.33. Room Rent means the amount charged by a hospital towards Room and Boarding expenses and shall include the associated medical expenses. 3.34. Sub-limit means a cost sharing requirement under a health insurance policy in which an insurer would not be liable to pay any amount in excess of the pre-defined limit 3.35. Sum Insured means the pre-defined limit specified in the Policy Schedule. Sum Insured represents the maximum, total and cumulative liability for any and all claims made under the Policy, in respect of that Insured Person (on Individual basis) or all Insured Persons (on Floater basis) during the Policy Period. 3.36. Surgery or Surgical Procedure means manual and / or operative procedure (s) required for treatment of an illness or injury, correction of deformities and defects, diagnosis and cure of diseases, relief of suffering and prolongation of life, performed in a hospital or day care centre by a medical practitioner. 12 3.37. Third Party Administrator (TPA) means a Company registered with the Authority, and engaged by an insurer, for a fee or by whatever name called and as may be mentioned in the health services agreement, for providing health services. 3.38. Waiting Period means a period from the inception of this Policy during which Covid 1s not covered. 4. Base Cover: The cover listed below is in-built Policy benefit and shall be available to all Insured Persons in accordance with the procedures set out in this Policy. 4.1. Covid Hospitalization Cover The Company shall indemnify medical expenses incurred for Hospitalization of the Insured Person during the Policy period for the treatment of Covid on Positive diagnosis of Covid in a government authorized diagnostic centre including the expenses incurred on treatment of any comorbidity along with the treatment for Covid up to the Sum Insured specified in the policy schedule, for, 1. Room Rent, Boarding, Nursing Expenses as provided by the Hospital/ Nursing Home. 11. Intensive Care Unit (ICU)/ Intensive Cardiac Care Unit (lCCU) expenses. 111. Surgeon, Anesthetist, Medical Practitioner, Consultants, Specialist Fees whether paid directly to the treating doctor I surgeon or to the hospital 1v. Anesthesia, blood, oxygen, operation theatre charges, surgical appliances, ventilator charges, medicines and drugs, costs towards diagnostics, diagnostic imaging modalities, PPE Kit, gloves, mask and such similar other expenses. v. Road Ambulance subject to a maximum of Rs.2000/- per hospitalization for the Ambulance services offered by a Hospital or by an Ambulance service provider, provided that the Ambulance is availed only in relation to Covid Hospitalization for which the Company has accepted a claim under section This also includes the cost of the transportation of the Insured Person from a Hospital to the another Hospital as prescribed by a Medical Practitioner. Note: I. Expenses of Hospitalization for a minimum period of 24 consecutive hours only shall be admissible. 4.2 Home Care Treatment Expenses: Home Care Treatment means Treatment availed by the Insured Person at home for Covid on positive diagnosis of Covid in a Government authorized diagnostic Centre, which in normal course would require care and treatment at a hospital but is actually taken at home maximum up to 14 days per incident provided that: a) The Medical practitioner advices the Insured person to undergo treatment at home. b) There is a continuous active line of treatment with monitoring of the heal.th status by a medical practitioner for each day through the duration of the home care treatment. c) Daily monitoring chart including records of treatment administered duly signed by the treating doctor is maintained. d) Insured shall be permitted to avail the services as prescribed by the medical practitioner. Cashless or reimbursement facility shall be offered under homecare expenses subject to claim settlement policy disclosed in the website. e) In case the insured intends to avail the services of non-network provider claim shall be subject to reimbursement, a prior approval from the Insurer needs to be taken before availing such services. ln this benefit, the following shall be covered if prescribed by the treating medical practitioner and is related to treatment of COY ID, 13 a. Diagnostic tests undergone at home or at diagnostics centre b. Medicines prescribed in writing c. Consultation charges of the medical practitioner d. Nursing charges related to medical staff e. Medical procedures limited to parenteral administration of medicines f. Cost of Pulse oximeter, Oxygen cylinder and Nebulizer 4.3 A YUSH Treatment The Company shall indemnify medical expenses incurred for inpatient care treatment for Covid on Positive diagnosis of COVID test in a government authorized diagnostic centre including the expenses incurred on treatment of any comorbidity along with the treatment for Covid under Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy systems of medicines during the Policy Period up to the limit of sum insured as specified in the policy schedule in any A YUSH Hospital. Covered expenses shall be as specified under Covid Hospitalization Expenses (Section 4.1) 4.4 Pre Hospitalization The company shall indemnify pre-hospitalization/home care treatment medical expenses incurred, related to an admissible hospitalization/home care treatment, for a fixed period of 15 days prior to the date of admissible hospitalization/home care treatment covered under the policy. 4.5 Post Hospitalization The company shall indemnify post hospitalization//home care treatment medical expenses incurred, related to an admissible hospitalization//home care treatment, for a fixed period of 30days from the date of discharge from the hospital, following an admissible hospitalization covered under the policy. 4.6 The expenses that are not covered in this policy are placed under List-I of Annexure-A. The list of expenses that are to be subsumed into room charges, or procedure charges or costs of treatment are placed under List-lI,List-III and List-IV of Annexure-A respectively. 5.0ptional cover: The cover listed below is Optional Policy benefit and shall be available to Insured Persons in accordance with the terms set out in the Policy, if the listed cover is opted 5.lHospital Daily Cash: The Company shall pay the Insured Person 0.5% of sum insured per day for each 24 hours of continuous hospitalization for which the Company has accepted a claim under Section- 4.1 Hospitalization Cover. The benefit shall be payable maximum up to 15 days during a policy period in respect of eve1y insured person. The total amount payable in respect of Covers 4.1,4.2, 4.3,4.4,4,4.5, 5.1 , shall not exceed I 00% of the Sum Insured during a policy period. 14 6. Waiting Period The Company shall not be liable to make any payment under the policy in connection with or in respect of following expenses till the expiry of waiting pei·iod mentioned below: 6.1. First Fifteen Days Waiting Period Expenses related to the treatment of Covid within 15 days from the policy commencement date shall be excluded. 7. EXCLUSIONS The Company shall not be liable to make any payment under the policy, in respect of any expenses incurred in connection with or in respect of: 7.1 Investigation & Evaluation(Code- Exc104) Expenses related to any admission primarily for diagnostics and evaluation purposes. Any diagnostic expenses which are not related or not incidental to the current diagnosis and treatment 7.2 Rest Cure, rehabilitation and respite care (Code- Exc105) Expenses related to any admission primarily for enforced bed rest and not for receiving treatment. This also includes: 1. Custodial care either at home or in a nursing facility for personal care such as help with activities of daily living such as bathing, dressing, moving around either by skilled nurses or assistant or non-skilled persons. 11. Any services for people who are te1'minally ill to address physical, social, emotional and spiritual needs. 7.3 Dietary supplements and substances that can be purchased without prescription, including but not limited to Vitamins, minerals and organic substances unless prescribed by a medical practitioner as part of hospitalization claim or Home care treatment. 7.4 Unproven Treatments: Expenses related to any unproven treatment, services and supplies for or in connection with any treatment. Unproven treatments are treatments, procedures or supplies that lack significant medical documentation to suppo1t their effectiveness. However, treatment authorized by the government for the treatment of COVID shall be covered. 7.5 Any claim in relation to Covid where it has been diagnosed prior to Policy Start Date. 7.6 Any expenses incurred on Day Care treatment and OPD treatment 7.7 Diagnosis /Treatment outside the geographical limits of India 7.8 Testing done at a Diagnostic centre which is not authorized by the Government shall not be recognized under this Policy 7.9 All covers under this Policy shall cease if the Insured Person travels to any country placed under travel restriction by the Government of India. 15 8. CLAIM PROCEDURE 8.1Procedure for Cashless claims: (i) Treatment may be taken in a network provider and is subject to pre authorization by the Company or its authorized TPA. (ii) Cashless request form available with the network provider and TPA shall be completed and sent to the Company/TPA for authorization. (iii) The Company/ TPA upon getting cashless request form and related medical information from the insured person/ network provider 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 Company/ 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 Company / TPA for reimbursement. 8.2 Procedure for reimbursement of claims: For reimbursement of claims the insured person may submit the necessary documents to TPA (if applicable)/Company within the prescribed time limit as specified hereunder. SI Type of Claim Prescribed Time limit No 1. Reimbursement of hospitalization and pre Within thirty days of date of discharge hospitalization expenses from hospital 2. Reimbursement of post hospitalization Within fifteen days from completion of expenses post hospitalization treatment 3 Reimbursement of Home Care expenses Within thirty days from completion home care treatment 8.3 Notification of Claim Notice with full particulars shall be sent to the Company/TPA (if applicable) as under: 1. Within 24 hours from the date of emergency hospitalization/cashless home care treatment. 11. At least 48 hours prior to admission in Hospital in case of a planned Hospitalization. 8.4 Documents to be submitted: of The claim is to be suppo1ied with the following documents and submitted within the prescribed time limit. Benefits Claims Documents Required 1. Covid I. Duly filled and signed Claim Form Hospitalization 11. Copy of Insured Person's passpo1i, if available (All pages) Cover iii. Photo Identity proof of the patient (if insured person does not own a passpo1i) IV. Medical practitioner's prescription advising admission 16 2. Home treatment expenses Care v. Original bills with itemized break-up v1. Payment receipts vii. Discharge summary including complete medical history of the patient along with other details. viii.Investigation reports including Insured Person's test reports from Authorized diagnostic centre for COVID 1x. OT notes or Surgeon's certificate giving details of the operation performed, wherever applicable x. Sticker/Invoice of the Implants, wherever applicable. x1. NEFT Details (to enable direct credit of claim amount 111 bank account) and cancelled cheque x11. KYC (Identity proof with Address) of the proposer, where claim liability is above Rs 1 Lakh as per AML Guidelines xiii.Legal heir/succession certificate, wherever applicable xiv. Any other relevant document required by Company/TPA for assessment of the claim. I. 11. Ill. IV. V. Duly filled and signed Claim Form Copy of Insured Person's passport, if available (All pages) Photo Identity proof of the patient (if insured person does not own a passport) Medical practitioners' prescription advising hospitalization A certificate from medical practitioner advising treatment at home or consent from the insured person on availing home care benefit. vi. Discharge Certificate from medical practitioner specifying date of start and completion of home care treatment. v11. Daily monitoring chart including records of treatment administered duly signed by the treating doctor is maintained. [Note: Insurer may specify the documents required in original and waive off any of above required as per their claim procedure] Note: 1. The company shall only accept bills/invoices/medical treatment related documents only in the Insured Person's name for whom the claim is submitted 2. In the event of a claim lodged under the Policy and the original documents having been submitted to any other insurer, the Company shall accept the copy of the documents and claim settlement advice, duly ce,tified by the other insurer subject to satisfaction of the Company 3. Any delay in notification or submission may be condoned on merit where delay is proved to be for reasons beyond the control of the Insured Person 8.5 Claim Settlement (provision for Penal Interest) 1. The Company shall settle or reject a claim, as the case may be, within 30 days from the date ofreceipt of last necessary document. 11. In the case of delay in the payment of a claim, the Company shall be liable to pay interest from the date of receipt of last necessary document to the date of payment of claim at a rate 2% above the bank rate. 111. However, where the circumstances of a claim warrant an investigation in the opinion of the Company, it shall initiate and complete such investigation at the earliest in any case not later than 30 days from the date of receipt of last necessary document. In such cases, the Company shall settle the claim within 45 days from the date of receipt of last necessary document. 17 1v. In case of delay beyond stipulated 45 days the company shall be liable to pay interest at a rate 2% above the bank rate from the date of receipt of last necessary document to the date of payment of claim. 8.6 Services Offered by TP A (To be stated where TP A is involved) Servicing of claims, i.e., claim admissions and assessments, under this Policy by way of pre-authorization of cashless treatment or processing of claims other than cashless claims or both, as per the underlying terms and conditions of the policy. The services offered by a TPA shall not include 1. Claim settlement and claim rejection; 11. Any services directly to any 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. 8.7 Payment of Claim All claims under the policy shall be payable in Indian currency only. 9. GENERAL TERMS &CONDITIONS 9.1 Disclosure of Information The Policy shall be void and all premium paid thereon shall be forfeited to the Company in the event of misrepresentation, mis-description or non-disclosure of any material fact by the policyholder. 9.2 Condition Precedent to Admission of Liability The terms and conditions of the policy must be fulfilled by the insured person for the Company to make any payment for claim(s) arising under the policy. 9.3 Records to be maintained The Insured Person shall keep an accurate record containing all relevant medical records and shall allow the Company or its representatives to inspect such records. The Policyholder or Insured Person shall furnish such information as the Company may require for settlement of any claim under the Policy, within reasonable time limit and within the time limit specified in the Policy 9.4 Complete Discharge Any payment to the policyholder, insured person or his/ her nominees or his/ her legal representative or assignee or to the Hospital, as the case may be, for any benefit under the policy shall be a valid discharge towards payment of claim by the Company to the extent of that amount for the particular claim. 9.5 Notice & Communication 1. Any notice, direction, instruction or any other communication related to the Policy should be made in writing. 11. Such communication shall be sent to the address of the Company or through any other electronic modes specified in the Policy Schedule. 111. The Company shall communicate to the Insured at the address or through any other electronic mode mentioned in the schedule. 9.6 Territorial Limit All medical treatment for the purpose of this insurance will have to be taken in India only. 9.7 Multiple Policies 18 1. In case of multiple policies taken by an insured during a period from the same or one or more insurers to indemnify treatment costs, the policyholder shall have the right to require a settlement of his/her claim in terms of any of his/her policies. In all such cases the insurer if chosen by the policy holder shall be obliged to settle the claim as long as the claim is within the limits of and according to the terms of the chosen policy. 2. Policyholder having multiple policies shall also have the right to prefer claims under this policy for the amounts disallowed under any other policy / policies, even if the sum insured is not exhausted. Then the Insurer(s) shall independently settle the claim subject to the terms and conditions of this policy. 3. If the amount to be claimed exceeds the sum insured under a single policy, the policyholder shall have the right to choose insurers from whom he/she wants to claim the balance amount. 4. Where an insured has policies from more than one insurer to cover the same risk on indemnity basis, the insured shall only be indemnified the hospitalization costs in accordance with the terms and conditions of the chosen policy. 9.8 Fraud If any claim made by the insured person, is in any respect fraudulent, or if any false statement, or declaration is made or used in support thereat: or if any fraudulent means or devices are used by the insured person or anyone acting on his/her behalf to obtain any benefit under this policy, all benefits under this policy shall be forfeited. Any amount already paid against claims made under the policy which are found fraudulent later under this policy shall be repaid by all recipient(s)/policyholder(s), who has made that particular claim, who shall be jointly and severally liable for such repayment. For the purpose of this clause, the expression "fraud" means any of the following acts committed by the Insured Person or by his agent or the hospital/doctor/any other party, with intent to deceive the insurer or to induce the insurer to issue an insurance Policy: (a) the suggestion, as a fact of that which is not true and which the Insured Person does not believe to be true; (b) the active concealment of a fact by the Insured Person having knowledge or belief of the fact; ( c) any other act fitted to deceive; and (d) any such act or omission as the law specially declares to be fraudulent The company shall not repudiate the policy on the ground of fraud, if the insured person/ beneficiary can prove that the misstatement was true to the best of his knowledge and there was no deliberate intention to suppress the fact or that such mis-statement of or suppression of material fact are within the knowledge of the insurer. 9.9 Cancellation The Company may cancel the Policy at any time on grounds of mis-represenation, non-disclosure of material facts, fraud by the Insured Person, by giving 7 days' written notice. There would be no refund of premium on cancellation on grounds of mis-represenation, non-disclosure of material facts or fraud. 9.10 Automatic change in Coverage under the policy The coverage for the Insured Person(s) shall automatically terminate: In the case of demise of the insured person. However, the cover shall continue for the remaining Insured Persons till the end of Policy Period. All relevant pa11iculars in respect of such person (including his/her relationship with the insured person) must be submitted to the company along with the application. 19 Provided no claim has been made, and termination takes place on account of death of the insured person, pro-rata refund of premium of the deceased insured person for the balance period of the policy will be effective. 9.11 Territorial Jurisdiction All disputes or differences under or in relation to the interpretation of the terms, conditions, validity, construct, limitations and/or exclusions contained in the Policy shall be determined by the Indian couit and according to Indian law. 9.12 Arbitration 1. If any dispute or difference shall arise as to the quantum to be paid by 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 here to or if they cannot agree upon a single arbitrator within thi1ty days of any patty invoking arbitration, the same shall be referred to a panel of three arbitrators, comprising two arbitrators, one to be appointed by each of the patties to the dispute/difference and the third arbitrator to be appointed by such two arbitrators and arbitration shall be conducted under and in accordance with the provisions of the Arbitration and Conciliation Act 1996, as amended by Arbitration and Conciliation (Amendment) Act, 2015 (No. 3 of 2016). 11. It is clearly agreed and understood that no difference or dispute shall be preferable to arbitration as herein before provided, if the Company has disputed or not accepted liability under or in respect of the policy. 111. It is hereby expressly stipulated and declared that it shall be a condition precedent to any right of action or suit upon the policy that award by such arbitrator/arbitrators of the amount of expenses shall be first obtained. 9.13 Endorsements (Changes in Policy) 1. This policy constitutes the complete contract of insurance. This Policy cannot be modified by anyone (including an insurance agent or broker) except the company. Any change made by the company shall be evidenced by a written endorsement signed and stamped. 11. The policyholder may be changed during the Policy Period only in case of his/her demise or him/her moving out oflndia. The new policyholder must be the legal heir/immediate family member. Such change would be subject to acceptance by the company and payment of premium (if any). 9.14 Terms and conditions of the Policy The terms and conditions contained herein and in the Policy Schedule shall be deemed to form part of the Policy and shall be read together as one document. 9.15 Nomination The policyholder is 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 of the policyholder. 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 the event of death of the policyholder, the Company will pay the nominee {as named in the Policy Schedule/Policy Ce,tificate/Endorsement (if any)} and in case there is no subsisting nominee, to the legal heirs or legal representatives of the Policyholder whose discharge shall be treated as full and final discharge of its liability under the Policy. 20 no subsisting nominee, to the legal heirs or legal representatives of the Policyholder whose discharge shall be treated as full and final discharge of its liability under the Policy. 10. REDRESSAL OF GRIEVANCE In case of any grievance the insured person may contact the company through Website: Toll free: E-mail: Fax: Courier: Insured person may also approach the grievance cell at any of the company's branches with the details of grievance. If Insured person is not satisfied with the redressal of grievance through one of the above methods, insured person may contact the grievance officer at ... ...... ... . For updated details of grievance officer, kindly refer the link ......... . (Link having details of grievance officer on website to be provided) Grievance may also be lodged at IRDAI Integrated Grievance Management System - https://igms.irda.gov.in/ Insurance Ombudsman -If Insured person is not satisfied with the redressal of grievance through above methods, the insured person may also approach the office of Insurance Ombudsman of the respective area/region for redressal of grievance. The contact details of the Insurance Ombudsman offices have been provided as Annexure-B.1 [Insurers to take note of the change in domain of the email ids mentioned at Annexure - B, the domain may be changed from gbic.co.in to ecoi.co.in. Insurers are fu1ther advised to note the revised details of insurance ombudsman as and when amended as available in the website http://ecoi.co.in/ombudsman.html and ensure that updated details are prospectively incorporated in the policy documents for the information of the policyholders.] 21 11. TABLE OF BENEFITS Name Covid Standard Health Policy,[Company Name] Product Type Individual/ Floater Category of Cover Indemnity/Benefit Rs 50,000/- (Fifty Thousand) to 5,00,000/- (Five Lakh) (in the multiples of fifty Sum insured thousand) On Individual basis - SI shall apply to each individual family member On Floater basis - SI shall apply to the entire family Policy Period Three and Half Months (3 ½ months), Six and Half Months (6 ½ months),, Nine and Half Months (9 ½ months) including waiting period. Policy can be availed by persons between the age of 18 years up to .. .. years (to be filled by insurers), as Proposer. Proposer with higher age can obtain policy for family, without covering self. Policy can be availed for Self and the following family members Eligibility i. legally wedded spouse. ii. Parents and Parents-in-law. iii. Dependent Children (i.e. natural or legally adopted) between the day 1 of age to 25 years. If the child above 18 years of age is financially independent, he or she shall be ineligible. Hospitalization Medical Expenses of Hospitalization for Covid for a m1111mum period of 24 Expenses consecutive hours only shall be admissible Pre Hospitalization For 15days prior to the date of hospitalization/home care treatment Post For 30days from the date of discharge from the hospital/completion of home care Hospitalization treatment Hospital Daily Cash: 0.5% of Sum Insured per day subject to maximum of 15 days Sub-limits in a policy period for every insured member Home care treatment: Maximum up to 14 days per incident Medical Expenses incurred for Inpatient Care treatment for Covid under Ayurveda, AYUSH Yoga and Naturopathy, Unani, Siddha and Homeopathy systems of medicines shall be covered upto sum insured during the Policy period as specified in the policy schedule. The Company shall indemnify costs of treatment incurred by the Insured person Home Care on availing treatment at home for Covid on Positive diagnosis of Covid in a Treatment government authorized diagnostic centre maximum up to 14 days per incident , Expenses which in the normal course would require care and treatment at a hospital but is actually taken while confined at home subject to policy terms and conditions. Page 22 of 40 Annexure-A List I - Items for which coverage is not available in the policy SI Item No 1 BABY FOOD 2 BABY UTILITIES CHARGES 3 BEAUTY SERVICES 4 BEL TS/ BRACES 5 BUDS 6 COLD PACK/HOT PACK 7 CARRY BAGS 8 EMAIL/ INTERNET CHARGES 9 FOOD CHARGES (OTHER THAN PATIENT's DIET PROVIDED BY HOSPITAL) 10 LEGGINGS 11 LAUNDRY CHARGES 12 MINERAL WATER 13 SANITARY PAD 14 TELEPHONE CHARGES 15 GUEST SERVICES 16 CREPE BANDAGE 17 DIAPER OF ANY TYPE 18 EYELET COLLAR 19 SLINGS 20 BLOOD GROUPING AND CROSS MATCHING OF DONORS SAMPLES 21 SERVICE CHARGES WHERE NURSING CHARGE ALSO CHARGED 22 TELEVISION CHARGES 23 SURCHARGES 24 ATTENDANT CHARGES 25 EXTRA DIET OF PATIENT (OTHER THAN THAT WHICH FORMS PART OF BED CHARGE) 26 BIRTH CERTIFICATE 27 CERTIFICATE CHARGES 28 COURIER CHARGES 29 CONVEYANCE CHARGES 30 MEDICAL CERTIFICATE 31 MEDICAL RECORDS 32 PHOTOCOPIES CHARGES 33 MORTUARY CHARGES 34 WALKING AIDS CHARGES 35 SPIROMETRE 36 STEAM INHALER 37 ARMSLING 38 THERMOMETER 39 CERVICAL COLLAR 40 SPLINT 41 DIABETIC FOOT WEAR 42 KNEE BRACES (LONG/ SHORT/ HINGED) 43 KNEE IMMOBILIZER/SHOULDER IMMOBILIZER 44 LUM BO SACRAL BELT 45 NIMBUS BED OR WATER OR AIR BED CHARGES 23 46 AMBULANCE COLLAR 47 AMBULANCE EQUIPMENT 48 ABDOMINAL BINDER 49 PRIVATE NURSES CHARGES- SPECIAL NURSING CHARGES 50 SUGAR FREE TABLETS 51 CREAMS POWDERS LOTIONS (Toiletries are not payable, only prescribed medical pharmaceuticals payable) 52 ECG ELECTRODES 53 ANY KIT WITH NO DETAILS MENTIONED [DELIVERY KIT, ORTHOKIT, RECOVERY KIT, ETC] 54 KIDNEY TRAY 55 OUNCE GLASS 56 PELVIC TRACTION BELT 57 PAN CAN 58 TROLL Y COVER 59 UROMETER, URINE JUG List 11 - Items that are to be subsumed into Room Charges SI Item No 1 BABY CHARGES (UNLESS SPECIFIED/INDICATED) 2 HAND WASH 3 CRADLE CHARGES 4 COMB 5 EAU-DE-COLOGNE / ROOM FRESHNERS 6 GOWN 7 SLIPPERS 8 TISSUE PAPER 9 TOOTH PASTE 10 TOOTH BRUSH 11 BED PAN 12 FLEXIMASK 13 HAND HOLDER 14 SPUTUM CUP 15 DISINFECTANT LOTIONS 16 LUXURY TAX 17 HVAC 18 HOUSE KEEPING CHARGES 19 AIR CONDITIONER CHARGES 20 IM IV INJECTION CHARGES 21 CLEAN SHEET 22 BLANKET/WARMER BLANKET 23 ADMISSION KIT 24 DIABETIC CHART CHARGES 25 DOCUMENTATION CHARGES/ ADMINISTRATIVE EXPENSES 26 DISCHARGE PROCEDURE CHARGES 27 DAILY CHART CHARGES 28 ENTRANCE PASS/ VISITORS PASS CHARGES 29 EXPENSES RELATED TO PRESCRIPTION ON DISCHARGE 30 FILE OPENING CHARGES 31 INCIDENTAL EXPENSES/ MISC. CHARGES (NOT EXPLAINED) 32 PATIENT IDENTIFICATION BAND/ NAME TAG 33 PULSEOXYMETERCHARGES 24 List Ill - Items that are to be subsumed into Procedure Charges SI Item No. 1 HAIR REMOVAL CREAM 2 DISPOSABLES RAZORS CHARGES (for site preparations) 3 EYE PAD 4 EYE SHEILD 5 CAMERA COVER 6 DVD, CD CHARGES 7 GAUSE SOFT 8 GAUZE 9 WARD AND THEATRE BOOKING CHARGES 10 ARTHROSCOPY AND ENDOSCOPY INSTRUMENTS 11 MICROSCOPE COVER 12 SURGICAL BLADES, HARMONICSCALPEL,SHAVER 13 SURGICAL DRILL 14 EYE KIT 15 EYE DRAPE 16 X-RAY FILM 17 BOYLES APPARATUS CHARGES 18 COTTON 19 COTTON BANDAGE 20 SURGICAL TAPE 21 APRON 22 TORNIQUET 23 ORTHOBUNDLE, GYNAEC BUNDLE List IV - Items that are to be subsumed into costs of treatment SI Item No. 1 ADMISSION/REGISTRATION CHARGES 2 HOSPITALISATION FOR EVALUATION/ DIAGNOSTIC PURPOSE 3 URINE CONTAINER 4 BLOOD RESERVATION CHARGES AND ANTE NATAL BOOKING CHARGES 5 BIPAP MACHINE 6 CPAP/ CAPO EQUIPMENTS 7 INFUSION PUMP- COST 8 HYDROGEN PEROXIDE\SPIRIT\ DISINFECTANTS ETC 9 NUTRITION PLANNING CHARGES - DIETICIAN CHARGES- DIET CHARGES 10 HIVKIT 11 ANTISEPTIC MOUTHWASH 12 LOZENGES 13 MOUTH PAINT 14 VACCINATION CHARGES 15 ALCOHOL SWABES 16 SCRUB SOLUTION,lSTERILLIUM 17 Glucometer& Strips 18 URINE BAG 25 The contact details of the Insurance Ombudsman offices are as below- Areas of .Jurisdiction Gujarat , UT of Dadra and Nagar 1-laveli, Daman and Diu Karnataka Madhya Pradesh and Chhattisgarh Odisha Pu1~jab Haryana, 1-limachal Pradesh, .lammu and Kashmir, UT of Chandigarh Tamil Nadu, UT- Pondichcrry Town and Karaikal (which arc part of UT of Pondicherry) Delhi Assam Manipur, Arunachal Meghalaya, Mizoram, Pradesh, Nagaland and Tripura Office of the Insurance Ombudsman Office of the Insurance Ombudsman, .leevanPrakash Building, 6th noor, TilakMarg, Relief Road, Ahmedabad - 380 00 I. Tel.: 079 - 25501201 /02/05/06 Email: bimalokpal.ahmedabad (@,ecoi.co. in Office of the Insurance Ombudsman, .leevanSoudhaBuilding,PID No. 57-27-N-19, Ground Floor, 19/ 19, 24th Main Road,.IP Nagar, Isl Phase, Bengaluru - 560 078. Tel.: 080 - 26652048 / 26652049 Email: bimalokpal.bengaluru@e coi.co.in Office of the Insurance Ombudsman, .lanakVihar Complex, 2nd Floor, 6, Malviya Nagar, Opp. Airtel Office, Near New Market, Bhopal - 462 003. Tel.: 0755 - 2769201 / 2769202 Fax: 0755 - 2769203 Email: bimalokpal.bhopal@ecoi .co.in Office of the Insurance Ombudsman, 62, Forest park, Bhubneshwar - 75 I 009. Tel.: 0674 - 2596461 /2596455 Fax: 0674 - 2596429 Email: bimalokpal.bhubaneswar (@,ccoi.co.in Office of the Insurance Ombudsman, S.C.O. No. IOI , 102 & 103, 2nd Floor, Batra Building, Sector 17 - D, Chandigarh - 160 017. Tel.: 0172 - 2706196 / 2706468 Fax: 0172 - 2708274 Email: bimalokpal.chandigarh@ ecoi.co.in Office of the Insurance Ombudsman, Fatima Akhtar Court, 4th Floor, 453, Anna Salai, Teynampet, CHENNAI - 600 018. Tcl.:044-24333668/24335284 Fax: 044 - 24333664 Email: bimalokpal.chennai@ec oi.co.in Office of the Insurance Ombudsman, 2/2 A, Universal Insurance Building, Asaf Ali Road, New Delhi - 110 002. Tel.: 011 - 23232481 /23213504 Email: bimalokpal.delhi@ecoi.c o.in Office of the Insurance Ombudsman, .leevanNivesh, 5th Floor, Nr. Panbazar over bridge, S.S. Road, Guwahati - 78100 I (ASSAM). Andhra Pradesh, Tclangana and UT of Yanam - a part of the UT of Pondicherry Rajasthan Kerala , UT of (a) Lakshadweep, (b) Mahe - a part of UT of Pondicherry West Bengal, UT of Andaman and Nicobar Islands, Sikkim Districts of Uttar Pradesh Laitpur, .lhansi, Mahoba, Hamirpur, Banda, Chitrakoot, Allahabad, M irzapur, Sonbhabdra, Fatehpur, Pratapgarh, .launpur, Varanasi, Gazipur, .lalaun, Kanpur, Lucknow, Unnao, Sitapur, Lakhimpur, Bahraich, Barabanki, Raebarel i, Sravasti, Gonda, Faizabad, Amethi, Kaushambi, Balrampur, Basti, Ambedkamagar, Sultanpur, Maharajgang, Santkabirnagar, Azamgarh, Kushinagar, Gorkhpur, Deoria, Mau, Ghazipur, Chandauli, Ballia, Sidharathnagar. Goa, Mumbai Metropolitan Region excluding Navi Mumbai & Thane Annexure-B Tel.: 0361 - 2632204 / 2602205 Email: bimalokpal.guwahati@e coi.co.in Office of the Insurance Ombudsman, 6-2-46, 1st noor, "Moin Court", Lane Opp. Saleem Function Palace, A. C. Guards, Lakdi-Ka-Pool, Hyderabad - 500 004. Tel.: 040 - 67504123 / 23312122 Fax: 040 - 233 76599 Email: bimalokpal.hyderabad@ ccoi.co.in Office of the Insurance Ombudsman, .leevanNidhi - II Bldg., Gr. Floor, Bhawani Jaipur - Tel.: 0141 Singh 302 Marg, 005. 2740363 Email: Bimalokpal.jaipur@ecoi. co.in Office of the Insurance Ombudsman, 2nd Floor, Pulinat Bldg., Opp. Cochin Shipyard, M. G. Road, Ernakulam-682015. Tel.: 0484 - 2358759/2359338 Fax: 0484-2359336 Email: bimalokpal.ernakulam@ ecoi.co.in Office of the Insurance Ombudsman, Hindustan Bldg. Annexe, 4th Floor, 4, C.R. Avenue, KOLKA TA - 700 072. Tel.: 033 - 22124339 / 22124340 Fax 033 - 22124341 Email: binrnlokpal.kolkata@eco i.co.in Office of the Insurance Ombudsman, 6th Floor, .leevanBhawan, Phase-II, Nawal Kishore Road, Hazratganj, Lucknow - 226 001. Tel.: 0522 - 2231330 / 2231331 Fax: 0522 - 2231310 Email: bimalokpal.lucknow@ec oi.co.in Office of the Insurance Ombudsman, 3rd Floor, .leevanSevaAnnexe, S. V. Road, Santacruz (W), Mumbai - 400 054. Tel.: 022 - 26106552 / 26106960 Fax: 022 - 26106052 Email: bimalokpal.mumbai@ec oi.co.in Page 26 of 40 State of Uttaranchal and Office of the Insurance the following Districts of Uttar Pradesh: Agra, Aligarh, Bagpnt, Bareilly, Bijnor, Budaun, Bulandshehar, Etah, Kanooj, Mainpuri, Mathura, Meerut, Moradabad, Muzaffarnagar, Oraiyya, Pilibhit, Etawah, Farrukhabad, Firozbad, Gautambodhanagar, Ghaziabad, Hardoi, Shahjalrnnpur, Hapur, Shamli, Rampur, Kashganj, Sambhal, Amroha, Hathras, Kanshiramnagar, Saharanpur. Bihar, Jharkhand. Maharashtra, Area of Navi Mumbai and Thane excluding Mumbai Metropolitan Region Ombudsman, BhagwanSahai 4th Floor, Main Nay a Bans, Sector Palace Road, 15, Disll: GautamBuddh Nagar, U.P-201301. Tel.: 0120-2514250 / 2514252 / 2514253 Email: bimalokpal.noida@ecoi. co.in Office of the Insurance Ombudsman, I st Floor,Kalpana Arcade Building,, Bazar Samiti Road, Bahadurpur, Patna Tel.: 800 006. 0612-2680952 Email: bimalokpal.patna@ecoi. co.in Office of the Insurance Ombudsman, JeevanDarshan Bldg., 3rd Floor, C.T.S. No.s. I 95 to 198, N.C. Kelkar Road, Narayan Peth, Pune Tel.: 41 l 030. 020-41312555 Email: bimalokpal.pune@ecoi.c O.lll [Note to Insurers: Insurers are advised to mention the correct address, e mail Id, phone number etc. of insurance ombudsmen while issuing policy contracts] 27 Annexure-2 Customer Information Sheet (Description is illustrative and not exhaustive) No Refer to TITLE DESCRIPTION policy clause number 1. Product Corona Kava ch Policy ,<name of the Insurer>. Name 2. What am I a. Hospitalization expenses- Medical expenses incurred on hospitalization for 4.1,4.4,4 covered.for Covid for minimum period of 24 hours including pre-hospitalization .5 expenses for a period ofl 5 days and post hospitalization expenses for a period of 30days. b. Ambulance Charges: Expenses on road Ambulance subject to a maximum 4.1 of Rs.2000/- per hospitalization. C. Home Care treatment expenses-Costs of treatment incurred by the insured 4.2 person on availing treatment at home maximum up to 14 days per admission as per policy terms and conditions including pre-hospitalization expenses for a period of 15 days and post hospitalization expenses for a period of 30 days. d. A YUSH Coverage- Medical expenses incurred on hospitalization for 4.3 Covid under A YUSH Treatment e. Hospital Daily Cash 5.1 3. What are the Following is a pa1tial list of the policy exclusions. Please refer to the policy Major document for the complete list of exclusions: exclusions in the policy a. Admission primarily for investigation & evaluation 7.1 b. Admission primarily for rest Cure, rehabilitation and respite care 7.2 C. Any claim in relation to Covid where it has been diagnosed prior to 7.5 Policy Statt Date. d. Day Care treatment and OPD treatment 7.6 4. Waiting Expenses related to the treatment of Covid within 15 days from the policy 6.1 period commencement date shall be excluded 5. Payment The Base Cover is on indemnity basis and Optional Cover is on Benefit Basis. basis 6. Cancellation The Company may cancel the policy at any time on grounds of 9.9 misrepresentation, non-disclosure of material facts fraud by the Insured Person by giving 7 days' written notice. 8. Claims a. For Cashless Service: 8.1 ,8.2 (Insurer to provide the details /web link.from where Hospital Network details can be obtained) b. For Reimbursement of Claim: For reimbursement of claims the insured person may submit the necessary documents to TPA/Company within the prescribed time limit as specified hereunder. 28 SI Type of Claim Prescribed Time limit No I Reimbursement of Within thirty days of date of discharge hospitalization and pre from hospital hospitalization expenses 2 Reimbursement of post Within fifteen days from completion of hospitalization expenses post hospitalization treatment 3 Reimbursement of Home Within thirty days from completion of Care expenses home care treatment For details on claim procedure please refer the policy document. 9 Policy Insurer to provide the details of company officials. Servicin~ Grievances/ a. Details of Grievance redressal officer (Insurer to provide the link) 10 Complaints b. IRDAI Integrated Grievance Management System - https://igms.irda.gov.in/ C. Insurance Ombudsman - The contact details of the Insurance Ombudsman offices have been provided as Annexure-8 of Policy document. 10 Insured's Insurer to specify the norms on TAT for Pre-Auth and Settlement of Rights reimbursement. 11 Insured's Please disclose all pre-existing disease/s or condition/s before buying a policy. Obligations Non-disclosure may result in claim not being paid. Legal Disclaimer Note: The information must be read in conjunction with the product brochure and policy document. In case of any conflict between the CIS and the policy document, the terms and conditions mentioned in the policy document shall prevail. 29 S No Annexure-3 Form IRDAI-UNF-SCHP [All the items should be filled in properly and carefully. No item must be left blank.] Item Particulars (to be filled in by insurer) Section I: General Information 1.1 Name of Health I General Insurer 1.2 Registration No.allotted by IRDAI 1.3 Name of Appointed Actuary [Please note that his/her appointment should be in force as on the date of this application] 1.4 Brand Name [Give the name of the product which will be printed Corona Kavach Policy , <Name of the insurer> in Sales Literature and known in the market. This name should not be altered/modified in any form after launching in the market. This name shall appear in all returns etc. which would be submitted to IRDAI 1.5 Date of approval by PMC Section II: Underwriting 2. Underwriting -Selection of Risks [This section should discuss how the different segments of the population will be dealt with for the purpose of underwriting (to the extent they are relevant and a briefdetail of procedure adopted for assessment of various risk classes may be given.) 2.1 Specify Non-medical Limit [Where no pre-medical examination is asked for] 2.2 Specify when and what classes of lives would be subject to medical examination 2.3 Whether any loading based Yes/ No on the health status are applicable 2.4 Whether any loading based Yes/ No on the occupation are applicable 30 2.5 Specify, any other underwritinq criteria 2.6 Whether Underwriting of the Yes/ No product aligned to the Board Approved Underwriting policy of the Company 2.7 Whether full costs of pre policy Yes/ No medical check up are borne by the Insurer 2.8 If no, specify the percentage proposed to be borne by the Insurer. Section Ill - Distribution Channels 3 Distribution channels: 3.1 Specify the various distribution channels to be used for distributing the product- [reply shall be specific and can not refer to the replies like "as approved by IRDAI] 3.1 Commission scales to distribution channels- specify the rates which are to be paid-[reply shall be specific] 3.2 Expected proportions of Distribution Fy business to be procured by Channel 20- each channel shall be 21 indicated 1.lndividual Agents 2. Corporate Agents 3. Insurance Brokers 4.Web Aggregators 5.Micro Insurance Agents 6.CSC 7.PoS 8.Direct - Only Online 31 9.Direct Marketing - Others (Incorporate separate line for each distribution channel) 10. Others- specify 11. Total Section IV - Reinsurance arrangements 4.1 Retention limit 4.2 Name of the reinsurer (s) 4.3 Terms of reinsurance(type of reinsurance, commissions, etc.). 4.4 Any recapture provisions shall be described. 4.5 Reinsurance rates provided 4.6 Whether a copy of the reinsurance program and a copy Yes/No of the Treaty is submitted to the Authority. 4.6.1 Whether reinsurance Yes/No program and a copy of the treaty enclosed (required only if these are not filed with the Authority previously) 4.6.2 Whether the reinsurance Yes/ No proposed for the product is in line with the Board approved reinsurance program filed with the Authority 4.6.3 If no, furnish the particulars Section V: Pricing 5 Premium Loadings & Discounts (Please provide objective and transparent criteria to offer discounts/rebate/Loadings And complete financial justifications by AA to every item referred hereunder. 32 In case of General and Health Insurers to be also furnished separately in the Technical Note) 5.1 Sum insured rebates/discounts offered, if any 5.2 Rebates/charges for different modes offered: 5.3 Premium rebates/discounts 5.4 Staff rebates 5.5 Any other discounts offered 5.6 Maximum cap on all Discounts for all variables taken together 5.7 Any loadings proposed 5.8 Maximum Cap on all Loading for all variables taken together 5.9 Subrogation (Not applicable to Health Insurance) 5.10 Pricing Assumptions and Methodology: The pricing assumptions and the methodology may vary depending on the nature of product. Give details of the following 5.11 Give the actuarial formulae, if any, used; if not, state how premiums are arrived at briefly explaining the methodology and details: 5.12 Source of data (internal/industry/ reinsurance) 5.13 Rate of morbidity [The tables whereever relevant shall be the prescribed one.] 5.14 Rates of policy terminations. [The rates used must be in accordance with insurer's experience. If such experience 33 is not available, this can be from the ind ustry/reinsu re r's experience .] 5.15 Rate of interest, if any. [The rate or rates must be consistent with the investment policy of the insurer.] 5.16 Commission scales [Give rates of commission. These are explicit items.] 5.17 Expenses - Split into First Year, and Claim related :- [Expense assumptions must be company specific. If such experience is not available, the Appointed Actuary might consider industry experience or make reasonable assumptions.] 5.17 First Year expenses by: sum assured related, premium related, per .1 policy related First Year sum assured premium related per policy related Expenses related 5.17 )ther expenses where relevant (including overhead expenses) by: sum .2 assured related, premium related, per policy related sum assured premium related per policy related related 5.17 Claim expenses .3 5.17 Future inflationary .4 increases, if any 5.18 Allowance for transfers to shareholder, if any: [Please see section 49 of the Insurance Act, 1938] 5.19 Taxation. [Please see the relevant sections of the Income Tax Act, 1961 applicable for payment of taxes by the Insurer] 5.20 Any other parameter relevant to pricing of product -specify 5.21 Reserving assumptions (please specify all the relevant details) 34 5.22 Base rate (risk premium)-furnish the rate table, if any 5.23 Gross premium- furnish the rate table, if any 5.24 Annualised Premium 5.24.1 Minimum 5.24.2 Maximum 5.25 Expected loss ratio (for the product) - 5.26 Age-wise loss ratio- S.No Age Loss ratio 5.27 Sum insured-wise- loss ratio S.No SA Loss ratio 5.28 Age and sum insured wise loss Table given below (SI band and age bands shall ratio - be increased. The format given below is indicative.) S.NO SI/Age 50000 100000 150000 200000 250000 bands 1 >=0<=2 2 >=3<=15 3 >=16<=25 4 >=26<=30 5 >=31<=35 6 >=36<=40 7 >=41<=45 8 >=46<=50 9 >=51<=55 10 >=56<=60 11 >=61<=65 12 >=66 5.29 Expected combined ratio 35 5.30 Age-wise combined ratio- 5.31 Sum insured-wise- combined ratio 5.32 Age and sum insured wise Table given below (SI band and age bands shall combined ratio - to be furnished be increased.The format given below is for each option or plan separately indicative.) S.NO SI/Age 50000 100000 150000 200000 250000 bands 1 >=0<=2 2 >=3<=15 3 >=16<=25 4 >=26<=30 5 >=31<=35 6 >=36<=40 7 >=41<=45 8 >=46<=50 9 >=51<=55 10 >=56<=60 11 >=61<=65 12 >=66 5.33 Expected cross-subsidy between age/sum insured 5.34 Experience of similar products, if any for the preceding Five Financial Years S.No Expos Premi Numb lncurr Claim Avera Bumi Loss Comb ure um - er of ed freque ge ng ratio ined Rs. claims claims ncy cost cost- ratio -Rs. per Rs. claim FY FY-1 FY-2 FY-3 36 FY-4 I I I I I I I 1. Exposure: earned life year (no of life earned during a particular financial year); 2. Premium: premium earned during the financial year; 3.Number of claims: claims occurred during the financial year; 4. Incurred claims: Incurred amount as of today for claims mentioned in "3"; 5. Claim frequency: No. of claims/ Exposure; 6. Average cost per claim: Incurred claims/ No. of claims; 7. Burning cost: Claims frequency* Average cost per claim; 8. Loss ratio: Incurred claims/ Premium; 9. Combined ratio: Loss ratio + Expense ratio; 5.35 Results of Financial Projections/Sensitivity Analysis: [The profit margins should be shown for various model points for base,optimistic and pessimistic scenarios in a tabular format below. The definition of profit margin should be taken as the present value of net profits to the p.v of premiums. Please specify assumptions made in each scenario. For terms less than one year loss ratio may be used.] 5.36 Risk discount rate used in the profit margin 5.37 Average Sum Insured Assumed 5.38 Assumptions made under pessimistic scenario 5.39 Assumptions made under optimistic scenario 5.40 Age [PM: Profit PM (base PM PM (optimistic Margin/Loss Ratio] [Age Band scenario) (pessimistic scenario) may be revisted based on the scenario) product design paratmeters] >=0<=2 >=3<=15 >=16<=25 >=26<=30 >=31<=35 >=36<=40 37 >=41<=45 >=46<=50 >=51<=55 >=56<=60 >=61<=65 >=66 Section VI: Enclosures to the Application: The following specimen documents should be enclosed: 6.1 Technical Note on Pricing 6.2 Proposal form, wherever necessary 6.3 Premium Table 6.4 Certificates by Appointed Actuary and Chief Compliance Officer Soft ware used for product design and monitoring --- (for information of the Authority) The Insurer shall enclose a certificate from the Chief Compliance Officer, Appointed Actuary, countersigned by the principal officer of the insurer, as per specimen given below:(The language of this should not be altered) Certification by Chief Compliance Officer: 1------- (Name of Chief Compliance Officer) the undersigned, on behalf of the Insurer · named below, hereby affirm and declare as follows: 1. That the details of the (Name of product) filled in above are true and correct and reflect what the policy and other documents indicate. 2. That the product complies with the various provisions of the IRDAI Health Insurance Regulations, 2016, Guidelines on Standardization of Health Insurance, Product Filing.Guidelines on Standardization of Exclusions in Health Insurance Contracts, Guidelines on Covid Standard Health Policy, issued thereon and the applicable provisions of extant IRDAI Regulations and all circulars issued by IRDAI from time to time. 3. That this application and all other documents are complete and have been verified for correctness and consistency not only in respect of each item of each document but also vis-a-vis one another. 4. I certify that the policy wordings and Customer Information sheet filed along with this application is in compliance with IRDAI (Health Insurance) Regulations, 2016, Product Filing Guidelines, Guidelines on Standardization of Health Insurance.Guidelines on Standardization of Exclusions in Health Insurance Contracts, Guidelines on Covid Standard Health Policy issued thereon. 38 5. I further certify that the Prospectus submitted is in compliance with the applicable provisions of Rules, IRDAI Regulations and Guidelines on Product Filing and Insurance Advertisements. Date: (Chief Compliance Officer) Name of Insurer Certification by Appointed Actuary: " I, (name of the appointed actuary), the appointed actuary, hereby solemnly declare that the information furnished in this Application Form is true. I also certify that, in my opinion, the premium rates, advantages, terms and conditions of the above product are workable and sound, the assumptions are reasonable and premium rates are fair." I have carefully studied the requirements of the Product Filing Procedure in relation to the design and rating of insurance products. The rates, terms and conditions of the above mentioned product are determined on technically sound basis and are sustainable on the basis of the information and claims experience available in the records of the insurer. An adequate system has been put in place for collection of data on premiums and claims based on every rating factor that will enable review of the rates and terms of the cover from time to time. It is planned to review the rates, terms and conditions of cover(--- mention periodicity of review) based on emerging experience. It is further certified that the underwriting of the product now filed shall be within the Board approved underwriting philosophy of the Company. The requirements of the Product Filing Procedure have been fully complied with in respect of this product or revision or modification of the product. I further declare that except the Sections mentioned in S.No., no other feature/benefiUclause is modified in the product (applicable only for revision or modification of the product) Place Date: Signature of the Appointed Actuary 39 Certification by Principal Officer or CEO I (name of the Principal Officer or CEO), (mention designation) hereby confirm that: 1. The rates, terms and conditions of the above-mentioned product filed with this certificate have been determined in compliance with the IRDA Act, 1999, Insurance Act, 1938, and the Regulations and guidelines issued there under, including the File and Use/ Product Filing guidelines. 2. The prospectus, sales literature, policy and endorsement documents, and the rates, terms and conditions of the product have been prepared on a technically sound basis and on terms that are fair between the insurer and the client and are set out in language that is clear and unambiguous. 3. These documents are also fully in compliance with the underwriting and rating policy approved by the Board of Directors of the insurer. 4. The statements made in the filing Form -IRDAI-UNF-SCHP are true and correct. 5. The requirements of the Product Filing Guidelines have been fully complied with in respect of this product. Date: Signature of Principal Officer or Designated Officer Place: Name and designation along with Company's seal 40