Hospital Cash Terms & Conditions Page
Hospital Cash Insurance Policy Terms & Conditions
We request you to carefully read and understand the Terms and Conditions, before you buy the Policy. All claims are processed strictly according to it. Please speak or chat with our Customer Support Team, if you need any clarifications.
Click Here to download the Hospital Cash Policy Terms and Conditions.
Click here to download the Customer Information Sheet of Hospital Cash Policy.
IMPORTANT NOTES ABOUT THIS INSURANCE
- Please read and check the details of this Policy carefully to ensure its accuracy and see that it meets your requirements. Please inform us immediately of any change in your address, occupation, state of health, or of any other changes affecting any Insured Person.
- The Policy is an evidence of the contract between You and Royal Sundaram Alliance Insurance Company Limited.
- The information given to us in the Proposal form and Declaration electronically signed by you, forms the basis of this Contract.
- The Policy, Schedule and any Endorsement thereon shall be considered as one document and any word or expression to which a specific meaning has been attached in any of them shall bear such meaning throughout.
- Provided that You pay the premium for all the persons intended to be Insured under this Policy and We receive and accept it, We will provide the insurance described in the Policy.
- Insurance under this Policy is given subject to the Endorsements if any, exclusions, terms and conditions shown below and failure in compliance may result in the claim being denied.
A. PERSONS WHO CAN BE INSURED
This insurance is available to persons between the age of 1 year and 65 years at the Commencement Date of the Policy. This insurance also provides cover for family comprising of the Insured and any one or more of the following:
- Dependent Children
- Dependent Parents
B. DEFINITIONS & INTERPRETATIONS
In this Policy the singular will be deemed to include the plural, the male gender includes the female where the context permits, and the following words or phrases shall have the meanings attributed to them wherever they appear in this Policy.
An accident is a sudden, unforeseen and involuntary event caused by external, visible and violent means.
Alternative treatments are forms of treatments other than treatment "Allopathy" or "modern medicine" and includes Ayurveda, Unani, Sidha and Homeopathy in the Indian context.
Royal Sundaram Alliance Insurance Company Limited.
Commencement date of this Policy shall be the inception date of first health Insurance policy under this Hospital Cash Plan for that Insured Person, insured with Us, with out any break in period of cover.
Condition Precedent shall mean a policy term or condition upon which the Insurer's liability under the policy is conditional upon.
Congenital Anomaly refers to a condition(s) which is present since birth, and which is abnormal with reference to form, structure or position.
a. Internal Congenital Anomaly
Congenital anomaly which is not in the visible and accessible parts of the body.
b. External Congenital Anomaly
Congenital anomaly which is in the visible and accessible parts of the body.
Emergency care means management for a severe 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.
Endorsement means written evidence of change to Your Policy including but not limited to increase or decrease in the period, extent and nature of the cover agreed by Us in writing.
Grace period means the specified period of time immediately following the premium due date during which a payment can be made to renew or continue a policy in force without loss of continuity benefits such as waiting periods and coverage of pre existing diseases. Coverage is not available for the period for which no premium is received.
Hospitalisation means admission in a Hospital for a minimum period of 24 In-patient Care consecutive hours except for specified procedures/ treatments, where such admission could be for a period of less than 24 consecutive hours.
A 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:
– has qualified nursing staff under its employment round the clock;
– has at least 10 in-patient beds in towns having a population of less than 10,00,000 and at least 15 in-patient beds in all other places;
– has qualified medical practitioner(s) in charge round the clock;
– has a fully equipped operation theatre of its own where surgical procedures are carried out;
– maintains daily records of patients and makes these accessible to the insurance company's authorized personnel.
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.
a. Acute condition - Acute condition is a disease, illness or injury that is likely to respond 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
b. Chronic condition - A chronic condition is defined as a disease, illness, or injury that has one or more of the following characteristics:
- it needs ongoing or long-term monitoring through consultations, examinations, check-ups, and/or tests.
- it needs ongoing or long-term control or relief of symptoms.
- it requires your rehabilitation or for you to be specially trained to cope with it.
- it continues indefinitely.
- it comes back or is likely to come back.
Injury means accidental physical bodily harm excluding illness or disease solely and directly caused by external, violent and visible and evident means which is verified and certified by a Medical Practitioner.
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.
Anybody shown on the Schedule as Insured in this Policy.
Intensive Care Unit
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.
A Medical Practitioner is 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. The registered practitioner should not be the insured or close family members.
Medically necessary treatment is defined as any treatment, tests, medication, or stay in hospital or part of a stay in hospital which
- is required for the medical management of the illness or injury suffered by the insured;
- must not exceed the level of care necessary to provide safe, adequate and appropriate medical care in scope, duration, or intensity;
- must have been prescribed by a medical practitioner,
- must conform to the professional standards widely accepted in international medical practice or by the medical community in India.
OPD treatment is one 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.
Period of Insurance
Period of Insurance means the period shown in the Schedule, for which You have paid and We have received and accepted Your premium.
Portability means transfer by an individual health insurance policyholder (including family cover) of the credit gained for pre-existing conditions and time-bound exclusions if he/she chooses to switch from one insurer to another.
Pre Existing Condition
Pre Existing Condition means any condition, ailment or injury or related condition(s) for which you had signs or symptoms and/or were diagnosed and/or received medical advice/treatment, within 48 months prior to your first Policy issued by the Insurer.
Insured or the person who signs the Proposal form on behalf of the Insured.
Qualified Nurse is a person who holds a valid registration from the Nursing Council of India or the Nursing Council of any state in India.
Renewal defines the terms on which the contract of insurance can be renewed on mutual consent with a provision of grace period for treating the renewal continuous for the purpose of all waiting periods.
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.
Treatment including drug experimental therapy which is not based on established medical practice in India, is treatment experimental or unproven.
Hospital Confinement Benefit - Disease
In the event of hospitalization of the Insured Person due to any illness for a consecutive period of more than 24 hrs, a daily benefit as mentioned in the Schedule of the Policy is payable for a maximum of 180 days during the entire policy period.
Hospital Confinement Benefit - Accident
In the event of hospital confinement arising out accidental injury due to road, rail or air accident, double the daily benefit as shown in the schedule shall be payable upto 21 days during the entire policy period in excess of first 24 hours of confinement.
Intensive Care Unit Benefit
For each 24 hour period of Hospital Confinement in an Intensive Care Unit, triple the Daily Benefit shown on the Schedule for that Insured Person is payable for a maximum of 21 days during the entire policy period.
When Intensive Care Unit benefit is admissible under the policy, hospital confinement benefit for illness and accident, shall not be payable for those days in which insured person was in Intensive Care Unit.
When Intensive Care Unit confinement is due to accident, the triple daily benefit shall be payable in excess of first 24 hours of confinement.
In no case the maximum number of days under all the above benefits put together shall exceed 180 days.
For Hospital Confinement beyond 21 consecutive days a fixed amount is payable towards convalescence, in addition to the Hospital Confinement benefit, in accordance with the plan chosen for that Insured Person. This benefit is payable only once per illness/accident /policy. This benefit is payable only if there is an admissible claim under any of the daily benefits.
Additional Features: Income Tax Relief
This insurance scheme is approved by IRDA and the premium is eligible to get exemption from income tax under section 80D subject to the relevant provisions of the Income Tax Act 1961.
The Company shall not be liable under this Policy for any claim in connection with or in respect of:
1. a) Pre Existing condition and any disease, illness, medical condition, injury, which is a complication of a Pre Existing Condition.
b) Any heart, kidney and circulatory disorders in respect of Insured Persons suffering from pre-existing Hypertension/Diabetes.
2. 30 Days Waiting Period: Any disease contracted by the Insured Person during the first 30 days from the Commencement Date of the Policy.
3. First Year Exclusions:
Treatment of Congenital Internal Anomaly , any type of Migraine Vascular head ache, Stones in the Urinary and Biliary systems, Surgery on Tonsils/Adenoids, Gastric and Duodenal Ulcer, any type of Cyst/Nodules/Polyps, any type of Breast Lumps, Spondylosis / Spondilitis any type, Inter vertebral Disc Prolapse and such other Degenerative Disorders, Cataract, Benign Prostatic Hypertrophy Hysterectomy, Fistula, Fissure in Anus, Piles, Hernia, Hydrocele, Sinusitis, Knee/Hip Joint replacement, Chronic Renal Failure or end stage Renal Failure, Heart diseases, any type of Carcinoma/Sarcoma/Blood Cancer, Osteoarthritis of any joint during the first year of the operation of the Policy with us.
4. Treatment arising from or traceable to pregnancy/childbirth.
5. Circumcision unless necessary for treatment of a disease, not excluded hereunder or necessitated due to an accident.
6. Dental treatment or surgery of any kind unless requiring Hospitalisation.
7. Convalescence, general debility, `Run-down' condition or rest cure, Congenital External Disease or defects or anomalies, Tubectomy, Vasectomy, Venereal disease, intentional self injury or attempted suicide.
8. Confinement in Hospital arising out of any condition directly or indirectly caused by or associated with Human T-Cell Lymphotropic Virus Type III (HTLB-III) or Lymphadenopathy Associated Virus (LAV) or the Mutants Derivative or variations Deficiency Syndrome or any Syndrome or condition of a similar kind commonly referred to as AIDS.
9. Confinement at Hospital or Nursing Home primarily for diagnostic, X-ray or laboratory examinations or other diagnostic studies not consistent with or incidental to the diagnosis and treatment of the positive existence or presence of any ailment, sickness or injury, for which confinement is required at a Hospital/Nursing Home.
10. Directly or indirectly caused by or contributed to by Nuclear weapons/materials or Radioactive Contamination.
11. 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).
12. Directly or indirectly caused by or arising from or attributable to:
12. 1. Ionising radiation or contamination by any Nuclear fuel or from any Nuclear waste from burning Nuclear fuel or
12. 2. Radioactive, toxic, explosive or other dangerous properties of any explosive nuclear machinery or part of it.
13. Any routine or preventative examinations, vaccinations, inoculation or screening.
14. Outpatient treatment charges.
15. Sex change or treatment, which results from, or is in any way related to, sex change.
16. Hormone replacement therapy.
17. Treatment of obesity (including morbid obesity) and any other weight control programs, services or supplies.
18. Treatment of psychiatric, mental or nervous conditions, insanity.
19. Any cosmetic, plastic surgery, aesthetic or related treatment of any description, including any complication arising from these treatments, whether or not for psychological reasons, unless medically necessary as a result of an accident.
20. Use of intoxicating drugs alcohol and the treatment of alcoholism, solvent abuse, drug abuse or any addiction and medical conditions resulting from, or related to, such abuse or addiction.
21. Any treatment received in convalescent homes, convalescent hospitals, health hydros, nature cure clinics or similar establishments.
22. Any stay in Hospital for any domestic reason or where there is no active regular treatment by a specialist.
23. Any treatment received outside India.
24. Any other Alternative Treatments except Allopathy (Modern Medicine).
25. Complication of any surgery, therapy or treatment administered on the Insured Person which is not prescribed or required by a Registered Medical Practitioner/Registered Medical Institution in their professional capacity.
26. Taking of drug unless it is taken on proper medical advice and is not for the treatment of drug addiction.
27. Any fertility, sub-fertility or assisted conception operation.
28. Any person whilst engaging in speed contest or racing of any kind
(other than on foot), bungee jumping, parasailing, ballooning, parachuting, skydiving, paragliding, hang gliding, mountain or rock climbing necessitating the use of guides or ropes, potholing, abseiling, deep sea diving using hard helmet and breathing apparatus, polo, snow and ice sports and activities of similar hazard.
29. Any claim in respect of Unproven/Experimental treatment.
1. Claims Procedure
1. The claim form duly completed in all respects along with all documents listed below should be submitted within 30 days from the date of discharge.
a) Photo copy of bills, receipt and discharge certificate/card from the Hospital.
b) Photocopy of F.I.R. copy in case of an accident.
c) Complete set of Hospital/medical records if specifically sought by Us.
d) If required, the Insured/Insured Person must give consent to obtain Medical Report from any Medical Practitioner at Our expense.
e) If required, the Insured/Insured Person must agree to be examined by a Medical Practitioner of Our choice at Our expense.
The documents should be sent to:
Health Claims Department
M/s. Royal Sundaram Alliance Insurance Company Limited,
Vishranthi Melaram Towers,
No.2/319,Rajiv Gandhi Salai(OMR),
2. Payment of Claim
- All claims under this Policy shall be payable in Indian Currency. All medical treatments for the purpose of this insurance will have to be taken in India only.
- Benefits payable under this policy will be paid within 30 days of the receipt of last necessary document.
- The Company shall be liable to pay any interest at 2% above the bank rate prevalent at the beginning of the financial year in which the claim is reviewed, for sums paid or payable under this Policy, upon acceptance of an offer of settlement by the insured but there is delay in payment beyond 7 days from the date of acceptance.
- At the time of claim settlement, Company may insist on KYC documents of the Proposer as per the relevant AML guidelines in force.
- In the event of hospitalisation falling within two policy periods, the sum insured considered for such claim shall be the available sum insured under both policy periods.
Transferring of interest in this Policy to anyone else is not allowed.
The Company may at any time, cancel the policy on grounds of misrepresentation, fraud, non disclosure of material facts, relating to this insurance of the Insured or non-cooperation by the insured by sending seven days notice, in writing by Registered A/D to the Insured at his last known address in which case the Company shall not refund to the Insured any portion of the premium. The Policy of Insurance may also be cancelled at any time by the Proposer by giving notice in writing. Provided no claim has arisen under the within mentioned policy prior to the receipt of such notice by the Company, the Proposer would be entitled to a return of premium less premium at Company's Short period scales as mentioned below for the period, the Policy of Insurance had been in force. If any claim is lodged after cancellation of the Policy of Insurance for hospitalization during the period in which the policy was in force, then the premium refunded will be collected back prior to settlement of the admissible claim. But the policy will still be considered as cancelled.
Short Period Scales
|For a period not exceeding||15 days||10% of the Annual Premium|
|-do-||1 month||15% of the Annual Premium|
|-do-||2 months||30% of the Annual Premium|
|-do-||3 months||40% of the Annual Premium|
|-do-||4 months||50% of the Annual Premium|
|-do-||5 months||60% of the Annual Premium|
|-do-||6 months||70% of the Annual Premium|
|-do-||7 months||75% of the Annual Premium|
|-do-||8 months||80% of the Annual Premium|
|-do-||9 months||85% of the Annual Premium|
|For a period exceeding||9 months||Full Annual Premium|
Every notice and communication to the Company required by this Policy shall be in writing to the office of the Company, through which this insurance is effected. However Initial notification of claim can be
made by telephone.
This Policy shall be void and all premium paid hereon shall be forfeited to the Company, in the event of misrepresentation, misdescription or non-disclosure of any material fact.
7. Geographical Area
The cover granted under this insurance is valid for treatments taken in India only.
8. Continuation of Terms and Conditions
The Insured has to renew the policy without any break to ensure continuity of cover from the commencement. A grace period of 30 days is allowed to renew the policy and maintain continuity of coverage.
However during such grace period, the company shall not be liable for hospitalisation, if any, occurring after the expiry of the policy and before the date of actual receipt of premium for renewal.
9. Insurer's rights
We have the right to do the following, in Insured Person's name at Our expense:
Take over the defence on settlement of any claim.
Start legal action to get compensation from anyone else.
Start legal action to get back from anyone else for payments that have already been made by Us.
If any claim is in any respect fraudulent, or if any fraudulent means or devices are used by the Insured Person or anyone acting on his behalf to obtain any benefit under this Policy, all benefits under this Policy will be forfeited and the Company may choose to void the Policy and reclaim all benefits paid in respect of such Insured Person.
This policy is portable. This Policy may be renewed by mutual consent every year and in such event, the renewal premium shall be paid to the Company on or before the date of expiry of the Policy or of the subsequent renewal thereof.
Policy must be renewed within the Grace Period of thirty days of expiry to maintain the continuity of Coverage. However no coverage shall be available during the period of such break. A policy that is sought to be renewed after the Grace Period of 30 days will be underwritten as a fresh policy at the discretion of Us.
At renewal, the coverages, terms & conditions and premium may change, in which case a three months notice shall be sent to the Proposer at his last known address as recorded in the policy. Any change in premium on account of change of age will not require any prior notice.
The product/plan may be withdrawn at any time, by giving a notice of 3 months to the Proposer at the address recorded/updated in the policy. When the policy is withdrawn, the product/plan shall not be available for renewal at the due date. However, the cover under such policy shall continue till the expiry date shown in the schedule/Certificate of the policy. In the event of withdrawal of a product, Company shall offer similar alternative product from its currently marketed product suites.
If any dispute or difference shall arise as to the quantum to be paid under this 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 to difference or, if they cannot agree upon a single Arbitrator within 30 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 and in accordance with the provisions of the Arbitration and Conciliation Act, 1996. It is hereby expressly stipulated and declared that it shall be a condition precedent to any right of action or suit upon this Policy that the award by such Arbitrator/Arbitrators of the amount of the loss or damage shall be first obtained.
It is also hereby further expressly agreed and declared that if the Company shall disclaim liability to the Insured for any claim hereunder and such claim shall not within 3 calendar months from the date of such disclaimer have been made the subject matter of a suit in a Court of law or pending reference before Ombudsman, then the claim shall for all purposes be deemed to have been abandoned and shall not thereafter be recoverable hereunder.
The Policy is subject to the laws of India and the jurisdiction of its Courts.
15. Change of Address
The Insured must inform in writing of any change in his/her address.
16. Change in Daily Benefit
Any change in Sum Insured can be considered only at the time of renewal. Eligibility for enhancement of Sum Insured is not automatic and is subject to the discretion of the Company. When the Company is admitting liability for disease/illnesses/medical condition/injury contracted by the Insured Person during the previous period of Insurance(s) with Us, then We shall pay either the Daily Benefit
for that Insured Person during the first occurrence of such disease/illness/medical condition/burns or the available daily benefit under the current Policy, whichever is less.
17. Compliance with Policy Provisions
Failure to comply with any of the provisions contained in this Policy shall invalidate all claims hereunder.
18. Free Look-in
At the inception of the policy you will be allowed a period of 15 days from the date of receipt of the policy to review the terms and conditions of the policy and to return the same if not acceptable. If you have not made any claim during the free look period, you will be entitled to the following, provided no claim has been settled or lodged for the period the policy has been in force:
a. A refund of the premium paid less stamp duty charges or;
b. where the risk has already commenced and the option of return of the policy is exercised, a deduction towards the proportionate risk premium for period on cover or;
c. Where only a part of the risk has commenced, such proportionate risk premium commensurate with the risk covered during such period.
In case the Insured Person is aggrieved in any way, the Insured Person may contact the Company at the specified address, during normal business hours for the following grievances:
a. Any partial or total repudiation of claims by the Company.
b. Any dispute regard to premium paid or payable in terms of the policy.
c. Any dispute on the legal construction of the policies in so far as such disputes relate to claims.
d. Delay in settlement of claims.
e. Non-issue of any insurance document to customer after receipt of the premium.
f. any other grievance.
The Insured Person may approach the Insurance Ombudsman, within whose jurisdiction the branch or office of Royal Sundaram Alliance Insurance Company Limited is located. The Insurance Ombudsman's offices are located at Ahmedabad, Bhubaneshwar, Bhopal, Chandigarh, Chennai, Guwahati, Kochi, Kolkatta, Lucknow, Hyderabad, Mumbai and Delhi. For Contact Details of Insurance Ombudsman, please visit our website www.royalsundaram.in
WHAT IF I EVER NEED TO COMPLAIN?
We hope, of course, that you will never feel the need to complain. Nevertheless, sometimes things do go wrong. When they do, we want to know straight away, so we can put them right as quickly as possible, and take steps to make sure they don't happen again.
In all instances, call our Customer Services at our Chennai office at 1860 425 0000 or e-mail at firstname.lastname@example.org or write us to Royal Sundaram Alliance Insurance Company Limited, Vishranthi Melaram Towers, No.2/319, Rajiv Gandhi Salai(OMR), Karapakkam, Chennai 600097.