Smart Cash Plan 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 Smart Cash Plan Terms and Conditions. 

 

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, 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 General Insurance Co. Limited.

 

•  The information given to us in the Proposal form and Declaration signed by you/Proposer and/or over telephone to our tele agent by You / proposer 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 from the age of 91 days at the Commencement Date of the Policy. Dependents, who bear any legal relation to the Proposer, can also be insured. If non-dependent members are covered exemption.

 

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.

 

Accident / Accidental

 

An accident is a sudden, unforeseen and involuntary event caused by external, visible and violent means.

 

Air accident

 

Air accident shall mean an accident caused directly while boarding/travelling/alighting from an aircraft. Accident within the airport area to which the public have got no right of access is excluded

 

Alternative treatments

 

Alternative treatments are forms of treatments other than treatment “Allopathy” or “modern medicine” and includes Ayurveda, Unani, Sidha and Homeopathy in the Indian context.

 

Cancer Of Specified Severity - A malignant tumour characterized by the uncontrolled growth and spread of malignant cells with invasion and destruction of normal tissues. This diagnosis must be supported by histological evidence of malignancy & confirmed by a pathologist. The term cancer includes leukaemia, lymphoma and

sarcoma.

 

The following are excluded:

tumours showing the malignant changes of carcinoma in situ & tumours which are histologically described as premalignant or non invasive, including but not limited to: Carcinoma in situ of breasts, Cervical dysplasia CIN-1, CIN-2 & CIN-3

 

Any skin cancer other than invasive malignant melanoma

 

All tumours of the prostate unless histologically classified as having Gleason score greater than 6 or having progressed to atleast clinical

 

TNM classification T2N0M0.

 

Papillary micro-carcinoma of the thyroid less than 1cm in diameter

 

Chronic lymphocyctic leukaemia less than RAI stage 3

 

Microcarcinoma of the bladder

 

All tumours in the presence of HIV infection

 

Company/We/Our/Insurer/Us

 

Royal Sundaram General Insurance Co. Limited. (Formerly known as Royal Sundaram Alliance Insurance Company Limited)

 

Day Care Treatment

 

Day care treatment refers to medical treatment, and/or surgical procedure which is:

 

i. undertaken under General or Local Anesthesia in a hospital/day care centre in less than 24 hrs because of technological advancement, and

ii. which would have otherwise required a hospitalization of more than 24 hours.

iii. Treatment normally taken on an out-patient basis is not included in the scope of this definition.

 

Commencement date

 

Commencement date of this Policy shall be the inception date of first Insurance policy under this Hospital Cash Plan for that Insured Person, insured with Us and without any break in period of cover thereto.

 

Condition Precedent

 

Condition Precedent shall mean a policy term or condition upon which the Insurer’s liability under the policy is conditional upon.

 

Congenital Anomaly

 

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.

 

Critical Illness

 

Critical Illness means those disease/illness, which have been expressly defined under critical illness benefit.

 

Dependent Child

 

A dependent child refers to a child (natural or legally adopted), who is financially dependent on the primary insured or proposer and does not have his / her independent sources of income.

 

Diagnosis

 

Diagnosis means the identification of a disease/illness/medical condition made by a Physician, based upon such specific evidence, as required, in the definition of the particular Critical Illness concerned, or, in the absence of such specific evidence based upon radiological, clinical, histological, laboratory evidence or any other medical tests following medical advancement, acceptable to the Company.

 

Emergency Care

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

 

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.

 

First Heart Attack – of specified severity

 

The first occurrence of myocardial infarction which means the death of a portion of the heart muscle as a result of inadequate blood supply to the relevant area. The diagnosis for this will be evidenced by all of the following criteria:

 

a) history of typical clinical symptoms consistent with the diagnosis of Acute Myocardial Infarction (for e.g. typical chest pain)

b) new characteristic electrocardiogram changes

c) elevation of infarction specific enzymes, Troponins or other specific biochemical markers.

 

The following are excluded:

 

i. Non-ST-segment elevation myocardial infarction (NSTEMI) with elevation of Troponin I or T

ii. Other acute Coronary Syndromes

iii. Any type of angina pectoris

 

Family Members shall mean Spouse, parents, children and own siblings.

 

Grace Period

 

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.

 

Hazardous Sports/ Activities

 

Persons whilst working in underground mines, explosives, magazines, workers whilst involved in electrical installation with high tension supply, nuclear installations, handling hazardous chemicals, circus personnel engaged in activities like racing on wheels or horseback, big game hunting, mountaineering, winter sports, Skydiving, Parachuting, Scuba Diving , Riding or Driving in Races or Rallies, Mountain Climbing, hunting or equestrian activities, rock climbing, caving, potholing, bungee jumping, skiing, ice hockey, ballooning, hang gliding, diving or under-water activity, river rafting, canoeing involving rapid waters, polo, yachting or boating outside coastal waters and persons whilst engaged in occupation / activities of similar hazard.

 

Persons whilst engaged in the following occupations are also excluded.

 

Aircraft pilots and crew, Armed Forces personnel, Artistes engaged in hazardous performances, Aerial crop sprayer, Bookmaker (for gambling), Demolition contractor, Entertainment Industry, Explosives users, Fisherman (seagoing), Jockey, Marine salvager, Miner and other occupations underground, Off-shore oil or gas rig worker, Policeman, Professional sports person, Roofing contractors and all construction, maintenance and repair workers at heights in excess of 50ft/15m, Saw miller, Scaffolder, Scrap metal merchant, Security guard (armed), Ship crew, Steeplejack, Stevedore, Structural steelworker, Tower crane operator, Tree feller.

 

Hospitalisation

 

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.

 

Hospital

 

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

 

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.

 

Day Care Centre

 

A day care centre means any institution established for day care treatment of illness and/or injuries or a medical setup within a hospital and which has been registered with the local authorities, wherever applicable, and is under the supervision of a registered and qualified medical practitioner AND must comply with all minimum

criteria as under-

- has qualified nursing staff under its employment;

- has qualified medical practitioner/s in charge;

- has a fully equipped operation theatre of its own where surgical procedures are carried out;

- maintains daily records of patients and will make these accessible to the insurance company’s authorized personnel

 

Injury

 

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.

 

Medical Advise

 

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

 

In-Patient care

 

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.

 

Insured/You/Your/Insured Person is 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.

 

Kidney Failure Requiring Regular Dialysis

 

End stage renal disease presenting as chronic irreversible failure of both kidneys to function, as a result of which either regular renal dialysis (hemodialysis or peritoneal dialysis) is instituted or renal transplantation is carried out. Diagnosis has to be confirmed by a specialist medical practitioner.

 

Maternity Expense/Treatment

 

Maternity Expense/Treatment shall include

 

(a) Medical treatment expenses traceable to childbirth (including complicated deliveries and caesarean sections incurred during hospitalization).

(b) Expenses towards lawful medical termination of pregnancy during the policy period.

 

Medical Practitioner

 

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

 

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.

 

 

Multiple Sclerosis With Persisting Symptoms

 

The definite occurrence of multiple sclerosis. The diagnosis must be supported by all of the following:

 

I. Investigations including typical MRI and CSF findings, which unequivocally confirm the diagnosis to be multiple sclerosis;

 

II. there must be current clinical impairment of motor or sensory function, which must have persisted for a continuous period of at least 6 months, and

 

III. well documented clinical history of exacerbations and remissions of said symptoms or neurological deficits with

atleast two clinically documented episodes atleast one month apart

 

IV. other causes of neurological damage such as SLE and HIV

are excluded.

 

Nuclear, Chemical, Biological Terrorism shall mean the use of any nuclear weapon or device or the emission, discharge, dispersal, release or escape of any solid, liquid or gaseous Chemical agent and/ or Biological agent during the period of this insurance by any person or group(s) of persons, whether acting alone or on behalf of or in connection with any organisation(s) or government(s), committed for political, religious or ideological purposes or reasons including the intention to influence any government and/or to put the public, or any section of the public, in fear.

 

“Chemical” agent shall mean any compound which, when suitably disseminated, produces incapacitating, damaging or lethal effects on people, animals, plants or material property.

 

“Biological” agent shall mean any pathogenic (disease producing) micro-organism(s) and/or biologically produced toxin(s) (including genetically modified organisms and chemically synthesized toxins) which cause illness and/or death in humans, animals or plants.

 

OPD treatment

 

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.

 

Open Chest CABG

 

The actual undergoing of open chest surgery for the correction of one or more coronary arteries, which is/are narrowed or blocked, by coronary artery bypass graft (CABG). The diagnosis must be supported by a coronary angiography and the realization of surgery has to be confirmed by a specialist medical practitioner.

 

The following are excluded

 

I. Angioplasty and/or any other intra-arterial procedures

II. any key-hole or laser surgery.

 

Open Heart Replacement Or Repair Of Heart Valves

 

The actual undergoing of open-heart valve surgery to replace or repair one or more heart valves, as a consequence of defects in, abnormalities of, or disease affected cardiac valve(s). The diagnosis of the valve abnormality must be supported by an echocardiography and the realization of surgery has to be confirmed by a specialist medical practitioner. Catheter based techniques including but not limited to, balloon valvotomy/valvuloplasty are excluded.

 

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

 

Portability means transfer by an individual health insurance policyholder (including family cover) of the credit gained for preexisting conditions and time-bound exclusions if he/she chooses to switch from one insurer to another.

 

Pre Existing Disease

 

Any condition, ailment or injury or related condition(s) for which you had signs or symptoms and/or were diagnosed and/or received medical advise/ treatment, within 48 months prior to your first policy issued by the Insurer.

 

Proposer

 

Insured or the person who signs the Proposal form on behalf of the Insured

 

Qualified Nurse

 

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

 

Rail accident

 

Rail accident shall mean an accident caused directly while boarding/ travelling/alighting from a train, Accident within the railway area to which the public have got no right of access is excluded.

 

Renewal

 

Renewal defines the terms on which the contract of insurance canbe renewed on mutual consent with a provision of grace period for treating the renewal continuous for the purpose of all waiting periods.

 

Road Accident

 

Accidents arising out of use of vehicle (including pedal cycle) in a public place viz. road, street, way or other place, to which the public have a right of access.

 

Stroke Resulting In Permanent Symptoms

 

I. Any cerebrovascular incident producing permanent neurological sequelae. This includes infarction of brain tissue, thrombosis in an intracranial vessel, haemorrhage and embolisation from an extracranial source. Diagnosis has to be confirmed by a specialist medical practitioner and evidenced by typical clinical symptoms as well as typical findings in CT Scan or MRI of the brain. Evidence of permanent neurological deficit lasting for at least 3 months has to be produced.

 

II. The following are excluded:

 

a. Transient ischemic attach (TIA)

b. Traumatic injury of the brain

c. Vascular disease affecting only the eye or optic nerve or vestibular functions.

 

Surgery

 

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.

 

Unproven/Experimental treatment

 

Treatment including drug experimental therapy which is not based on established medical practice in India is treatment experimental or unproven.

 

Free Look in Period

 

All new individual health insurance policies except those with tenure less than a year shall have a free look period. The free look period shall be applicable at the inception of the policy.

 

Notification of Claim

 

Notification of claim is the process of notifying a claim to the Insurer by specifying the timelines as well as the address/telephone number to which it should be notified.

 

C. BENEFITS

 

Benefit Table Structure

 

S.No.	Plan/s	Benefit	Description
1	Silver/Gold/ Platinum	A	Hospital Confinement Benefit
		B	Accident Hospital Benefit - Double Benefit
		C	Convalescence Benefit
		D	Critical Illness Benefit
		E	Joint Hospitalization due to Accident
2	Gold/Platinum	F	Child Birth Benefit
		G	Pre-Existing Disease Benefit
		H	Health Check up cost reimbursement
3	Platinum	I	ICU Benefit
		J	Parental Accommodation Benefit
		K	Emergency Family Member visit

 

 

Daily benefit sum Insured shall be restricted to Rs.3000/day (as per Silver Plan) for persons above 70 years at entry.

 

Benefit A

 

Hospital Confinement Benefit:

 

In the event of hospitalisation of the Insured Person for a consecutive and completed period of more than 24 hrs during the policy period, a daily benefit as mentioned in the Schedule of the Policy is payable for each completed and consecutive period of 24 hrs subject to a maximum of 180 days per policy year.

 

Benefit B

 

Accident Hospitalisation Benefit:

 

Any hospital confinement benefit payable will be increased to double the daily benefit shown on the schedule for each completed and consecutive 24 hour period of a hospital confinement resulting from an insured person sustaining bodily injury due to road/rail/ air accident.

 

This benefit becomes payable only if the confinement is for consecutive and completed period of more than 5 days. This benefit is payable for a maximum of 15 days per policy year and for such duration no benefit shall be payable under Benefit A.

 

Benefit C

 

Convalescence Benefit:

 

For Hospital Confinement beyond 15 consecutive and completed days, a lumpsum payment of Rs.10000/- 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 shall be admissible only if there is an admissible claim under Hospital confinement Benefit.

 

Benefit D

 

Critical Illness Benefit:

 

The Policy provides for payment of Rs.10000/- (for Silver Plan), Rs.15000/- (for Gold Plan) and Rs.20000/- (for Platinum Plan), on diagnosis of any of the following Critical Illness

 

a) First Diagnosis of the below-mentioned Illnesses more specifically described below

 

1. Cancer of specified severity

2. Multiple Sclerosis with Persisting Symptoms

3. Kidney failure requiring regular dialysis.

 

b) Undergoing for the first time of the following surgical procedures, more specifically described below.

 

4. Open chest CABG,

5. Open Heart Replacement or Repair of Heart Valves.

 

c) Occurrence for the first time of the following medical events more specifically described below

 

6. Stroke resulting in permanent symptoms

7. First Heart Attack – of specified Severity,

 

This Benefit shall be admissible only if there is an admissible claim under Hospital confinement Benefit.

 

Special Exclusion for Critical Illness Benefit Section:

 

• Pre Existing Disease and any disease, illness, medical condition,injury, which is a complication of a Pre Existing    Disease.

• Critical Illness Benefit nos. 3, 4, 5, and 7 shall not be admissible in respect of Insured Persons suffering from preexisting Hypertension / Diabetes.

 

Special Condition for Critical Illness Benefit Section:

 

Only one lump sum payment shall be provided during the Insured’s lifetime regardless of the number of Critical Illness, incapacities or treatments suffered by him/her. This Critical Illness benefit under the Policy will be automatically terminated after payment under this Section and shall not be available even during subsequent renewals.

 

Benefit E

 

Joint Hospitalisation due to an Accident: If two or more Insured Persons covered under the same policy are hospitalised concurrently as inpatients during the Policy Period due to an Accident then we shall pay double the Daily Benefit as mentioned in the Schedule under Benefit A, for a maximum period of 5 completed days per policy year per insured person and for such duration no benefit shall be payable under Benefit A.

 

Benefit F

 

Child Birth Benefit:

 

We will pay a lumpsum of Rs.10000/- (for Gold Plan) and Rs.20000/- (for Platinum Plan), in the event of hospitalisation resulting in Child Birth.

 

Special Condition for Child Birth Section:

 

• This benefit is applicable only under Gold & Platinum plans and applicable only for female insured person

• This benefit is payable maximum twice during the lifetime of the Insured Person.

• A waiting period of 2 years from inception is applicable for this benefit.

• This benefit shall not be applicable for ectopic pregnancy and termination of pregnancy for whatsoever reason.

 

Benefit G

 

Pre-existing disease benefit:

 

Under Gold & Platinum plans, pre-existing disease shall be covered upto a maximum of 5 days per person per policy year, for the chosen daily benefit or Rs.5000/- per day whichever is lower,

 

This benefit shall be payable only after 4 years of continuous insurance from the commencement date of the first Policy issued by Us.

 

Whenever pre-existing disease benefit is admissible under the Policy, we will not pay for any other Benefit for the period pre-existing disease benefit is payable.

 

Benefit H

 

Health Check up cost reimbursement:

 

We will reimburse expenses towards Master Health Check up for the Insured Person/s, after a block of 4 consecutive claim free years with us, up to a maximum of 50% of the average daily benefit chosen of the respective block, per Insured Person. This benefit is applicable only under Gold & Platinum plans.

 

Benefit I

 

Intensive Care Benefit:

 

We will pay double the Hospital Confinement Benefit chosen for each completed and consecutive period of 24 hours that the Insured Person is admitted in an ICU, subject to a maximum of 5 days per policy year. Whenever Intensive care benefit is admissible under the Policy, we will not pay for Hospital Confinement Benefit or Accident Hospitalization Benefit for the period when the Insured Person is in Intensive Care unit. This benefit is applicable only under Platinum plan.

 

Benefit J

 

Parental Accommodation Benefit:

 

In the event of hospitalisation of Insured Person aged 12 years or less and the hospitalisation period exceeds a completed and consecutive period of 72 hours parental accommodation benefit shall be payable subject to the following:

• We will pay the chosen daily benefit upto a maximum of 5 days per policy year in addition to hospital confinement benefit for the insured hospitalized, provided the claim is admissible under Benefit A. This benefit is applicable only under Platinum plan.

 

Benefit K

 

Emergency Family Member visit from abroad:

 

In the event of admissible claim under Critical Illness Benefit (Benefit D) for hospitalisation of Insured Parents/ Spouse/Children due to Critical Illness, flight ticket charges incurred by the Insured Person for emergency travel to India from abroad within a period of 30 days from the date of diagnosis or surgery as applicable, will be payable. Reimbursement of two way flight charges in economy class upto a maximum of Rs.1 lac per Insured Person per policy year shall be payable.

 

This benefit is applicable only under Platinum plan

 

Special condition applicable to all benefits

 

In no case the maximum number of days of hospitalization covered under the policy shall together exceed 180 days per person per policy year.

 

D. GENERAL EXCLUSIONS

 

The Company shall not be liable under this Policy for any claim in connection with or in respect of:

 

1. Pre Existing Disease and any illness, medical condition, injury, which is a complication of a Pre Existing Disease.    This exclusion will also apply to any complications arising from preexisting disease. For example, if a person is suffering from diabetes or hypertension or both, then the policy would be subject to the following exclusions:

 

Diabetes	Hypertension/Diabetes
Diabetic Retinopathy	Coronary Artery Disease
Diabetic Nephropathy	Cerebro Vascular Accident
Diabetic Foot / wound	Hypertensive Nephropathy
Diabetic Angiopathy	Internal Bleeding/Haemorrhages
Diabetic Neuropathy
Hyper/Hypoglycaemic shocks

 

For Gold & Platinum Plan, the above exclusion shall be waived after 4 years of continuous insurance from the commencement date of the first Policy issued by Us as specified under benefit G.

 

2. 30 Days Waiting Period: Daily benefit in respect of hospital confinement of any disease contracted by the Insured Person during the first 30 days from the Commencement Date of the Policy. This waiting period is not applicable in case of accidents.

 

3. First Year Exclusions: During the first 12 months from the Inception date, the daily benefit for hospital confinement towards the following disease / surgical procedures are not covered unless caused by accident: Treatment of Congenital Internal Anomaly, Cataract, Benign Prostatic Hypertrophy, Hysterectomy for Menorrhagia or Fibromyoma, Hernia, Hydrocele, Fistula in anus, Piles, Sinusitis & related disorders and Knee/Hip replacement.

 

4. Treatment arising from or traceable to pregnancy (including voluntary termination), miscarriage, maternity or birth (including caesarean section) except in the case of ectopic pregnancy excepting as provided under Child Birth benefit applicable for Gold & Platinum plans.

 

5. Circumcision unless necessary for treatment of a disease, not excluded hereunder or necessitated due to an accident.

 

6. Convalescence, general debility, `Run-down’ condition or rest cure, Congenital External Disease or defects or anomalies, Venereal disease, intentional self injury or attempted suicide.

 

7. 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.

 

8. 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.

 

9. Hospitalisation for evaluation and / or diagnostic purposes.

 

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.

12.3. Nuclear, Chemical, Biological terrorism (If the Company alleges that by reason of this exclusion any loss is not covered by this insurance the burden of proving the contrary shall be(upon the Insured Person).

 

13. Any routine or preventative examinations, vaccinations, inoculation or screening.

 

14. Outpatient (OPD) treatment charges.

 

15. Sex change or treatment, which results from, or is in any way related to, sex change.

 

16. Hormone replacement therapy (including hormone replacement treatment following any disease / surgery), Cytotron Therapy, Oxymed Therapy, Arterial Clearance Therapy and similar such therapies.

 

17. Treatment of obesity (including morbid obesity) and any other weight control programs, services or supplies.

 

18. Treatment of psychiatric and psychosomatic disorders, 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 cancer, accidents and burns.

 

20. Expenses incurred towards treatment of illness/disease/injury/ condition/de addiction arising out of use / misuse or abuse of alcohol, solvents, substance or drugs.

 

21. Any treatment received in convalescent homes, convalescent hospitals, health hydros, nature cure clinics or similar establishments.

 

22. Any stay or extended stay in Hospital for any domestic reason or where there is no active regular treatment by a

Medical Practitioner. Any Hospitalisation which is not Medically Necessary.

 

23. Any other Alternative Treatments except Allopathy (Modern Medicine).

 

24. 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.

 

25. Participation in Hazardous sports / activities of any kind.

 

26. Hospitalization advised by a Medical Practitioner which is outside of his discipline for which he is licensed.

 

27. Insured’s/Proposer’s involvement in any activities resulting in any breach of law with criminal intent.

 

28. Any claim in respect of Unproven / Experimental Treatment.

 

E. CONDITIONS

 

1. Claims Procedure

 

Claims Procedure for hospitalization claims occurring in India:

 

1. Preliminary notice of claim with particulars relating to Policy number, name of the Insured Person in respect of

whom claim is made, nature of illness/injury and name and address of Hospital/Nursing Home etc. should be given

to Us 72 hours prior to admission in case of planned hospitalisation and not later than 48 hours after admission in case of an emergency hospitalisation.

 

2. 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. Delay if any in submission of documents shall be considered based on merits of each case.

 

a)   Photocopy  of  and  discharge  certificate/card  from  the Hospital (For   maternity   claims,   Discharge   Summary mentioning LMP, EDD & Gravida).

b)  Photocopy of all investigation and lab reports.

c)   Photocopy of F.I.R. /M.L.C. copy in case of an accident.

d)  Complete set of Hospital/medical records if specifically sought by Us.

e)   Age proof of child in respect of Parental Accommodation  benefit.

f)   Copy  of  tickets/e-tickets,  Visa  Stamping  and  Passport, proof   of   relationship   with   the   person   hospitalized, health records of the person hospitalized, for claiming  under  Emergency  Family  Member  visit  from  abroad  benefit.

g)   If  required,  the  Insured /  Insured  Person  must  give  consent  to  obtain  Medical  Report  from  any  Medical Practitioner at Our expense.

h)  If required, the Insured / Insured Person must agree to  be examined by a Medical Practitioner of Our choice at Our expense.

 

Documents to be submitted if specifically sought

 

1.  Copy of indoor case records (including nurse’s notes, OT notes and anesthetists’ notes, vitals chart)

2.  Copy of bills and receipts for hospitalization expenditure

3.  Copy of extract of Inpatient Register

4.  Attendance records of employer/educational institution

5.  Complete medical records (including indoor case records and OP records) of past hospitalization/treatment if any

6.  Attending Physician’s certificate clarifying

• reason for hospitalization and duration of hospitalization

• history of any self-inflicted injury

• history of alcoholism, smoking

• history of associated medical conditions, if any

7.  Previous   master   health   check-up   records/pre-employment medical records if any

8.  Any other document necessary in support of the claim on case to case basis.

 

Documents   to   be  submitted   for   Health   Check   up   cost reimbursement:

 

• Original Health check up Bill with Money Receipt

• Photocopy of the Investigation Reports

 

Claims Procedure for hospitalization claims occurring abroad:

1.   Preliminary notice of claim with particulars relating to Policy number, name of the Insured Person in respect of whom claim is made, nature of illness/injury and name and address of  Hospital/Nursing Home etc. should be given to Us 72 hours prior  to admission in case of planned hospitalisation and not later than 48 hours after admission in case of an emergency hospitalisation.

2.   The claim form duly completed in all respects along with all documents listed below should be submitted maximum within 30 days from the date of discharge. Delay if any in submission of documents shall be considered based on merits of each case.

a) Photocopy of and discharge certificate/card from the Hospital (For maternity claims, Discharge Summary mentioning LMP, EDD & Gravida).

 

b) Photocopy of all investigation and lab reports.

 

c) Photocopy of M.L.C. copy in case of an accident.

 

d) Complete set of Hospital/medical records if specifically sought by Us.

 

e) If required, the Insured / Insured Person must give consent to obtain Medical Report from any Medical Practitioner at Our expense.

 

h) If required, the Insured / Insured Person must agree to be examined by a Medical Practitioner of Our choice at Our expense.

 

i) Copy of Passport with Visa stamping with date of entry and exit (both in and out of India and abroad)

 

Documents to be submitted if specifically sought

1. Copy of indoor case records (including nurse’s notes, OT notes and anesthetists’ notes, vitals chart)

2. Copy of bills and receipts for hospitalization expenditure

3. Complete medical records (including indoor case records and OP records) of past hospitalization/ treatment if any

4. Attending Physician’s certificate clarifying

• reason for hospitalization and duration of hospitalization

• history of any self-inflicted injury

• history of alcoholism, smoking

• history of associated medical conditions, if any

5. Previous master health check-up records/pre-employment medical records if any

6. Any other document necessary in support of the claim on case to case basis.

The documents should be sent to:

 

Health Claims Department

M/s. Royal Sundaram General Insurance Co. Limited.,

Vishranthi Melaram Towers,

No.2/319, Rajiv Gandhi Salai (OMR),

Karapakkam, Chennai- 600 097.

Tel.No:044-7117 7117.

 

2. Payment of Claim:

• All claims under this Policy shall be payable in Indian Currency.

• 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 an 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.

 

3. Transfer:

Transferring of interest in this Policy to anyone else is not allowed.

 

4. Cancellation:

The Company may at any time cancel the Policy on grounds of misrepresentation, fraud, non-disclosure of material fact relating to this insurance of the insured or non-cooperation by the Insured by sending 7 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 insured may also cancel this policy by giving 7 days notice in writing to the Company, and in such event, the Company shall cancel the policy from the date of receipt of such notice and allow refund of premium if any, after retaining premium for the period on risk as per Company’s short period rate table given below, provided no claim has been reported upto the date
of cancellation of policy.

 

Period on Risk	Rate of Premium	Rate of be retained	Rate of be retained
Tenure of the Policy	1 Year	2 Year	3 Year
Up to 1 month	25% of Premium	10% of Premium	10% of Premium
Up to 3 months	50% of Premium	25% of Premium	20% of Premium
Up to 6 months	75% of Premium	40% of Premium	25% of Premium
Up to 12 months	Full Premium	50% of Premium	30% of Premium
Up to 13 months		60% of Premium	40% of Premium
Up to 15 months		75% of Premium	50% of Premium
Up to 18 months		90% of premium	60% of Premium
Up to 24 months		Full Premium	70% of Premium
Up to 25 months			75% of Premium
Up to 27 months			80% of Premium
Up to 30 months			90% of premium
Exceeding 30 months			Full Premium

 

5. Notice:

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.

 

6. Misdescription:

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 Scope:

Geographical scope of the cover is restricted to hospitalization in India. However, the policy stands extended in the event of hospitalisation of the Insured Person due to sudden and unexpected sickness or Accident, whilst on a Trip abroad due to a Holiday or Official visit.

 

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: l Take over the defense on settlement of any claim l Start legal action to get compensation from anyone else l Start legal action to get back from anyone else for payments that have already been made by Us.

 

10. Fraud:

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 inrespect of such Insured Person.

 

11. Renewals:

This policy is portable and renewable lifelong. 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 as per the underwriting guidelines of the company. The coverages, terms & conditions and the premium are guaranteed till the expiry date shown in the policy. At renewal, the coverages, terms & conditions & 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 of the policy. In the event of withdrawal of a product, Company shall offer similar alternative product from its currently marketed product suites.

 

12. Arbitration:

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 clearly agreed and understood that no difference or dispute shall be referable to Arbitration as hereinbefore provided, if the Company has disputed or not accepted liability under or in respect of this Policy. It is hereby expressly stipulated and declared that it shall be 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.

 

13. Disclaimer:

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 12 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.

 

14. Jurisdiction

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:

No midterm increase in daily benefit is allowed during the currency of the policy. On renewal the daily benefit can be increased up to a maximum of 100% of the existing Sum Insured. Eligibility for enhancement of sum insured is not automatic and is subject to the underwriting guidelines of the company. For those customers who have a pre existing disease or who have made a claim the increase in sum insured is not automatic and guaranteed. It shall be subjected to the underwriting guidelines of the company and restricted to a maximum daily benefit of Rs.3000/- or existing daily benefit as per chosen plan whichever is higher. A chosen sum insured cannot be increased after 70 years.

 

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 insured 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 insured has not made any claim during the free look period, he 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.

However, please note free look is not applicable in the case of renewals.

 

19. Portability:

If proposer desires to port to this policy, application in the appropriate form should be made before 45 days from the date of renewal. The company retains the rights to underwrite proposals falling under portability as per the company’s underwriting guidelines. In the event of acceptance of proposal under portability the commencement date for the purpose of applying time bound exclusions shall be deemed from the first inception date of any Hospital Cash Insurance Policy and such rights shall be limited to the extent of the sum insured, in each of the year, provided the Policy has been continuously renewed without any break. If insured desires to port this policy with other insurers, he shall approach them well before the renewal date (at least 45 days prior to renewal date) to avoid break in the policy coverage due to possible acceptance delays. Portability shall not be applicable for Health Check up cost reimbursement, Child Birth and Critical illness benefits. For existing customers who opt for a change from Silver to Gold/Platinum plans, the waiting period for Child Birth benefit, Pre-existing disease benefit and Health check up cost reimbursement benefit, shall commence afresh.

 

20. Grievances:

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 at the addresses given in Annexure IV. For Contact Details of Insurance Ombudsman, please visit our website www.royalsundaram.in

 

OPTIONAL BENEFIT

PERSONAL ACCIDENT BENEFIT

(Applicable only if additional premium has been paid at inception itself and coverage confirmed in the policy schedule. Coverage under this section cannot be opted or cancelled once coverage under smart cash Plan section has already commenced.)

Benefits

If at any time during the currency of this Policy, the Insured Person shall sustain any bodily injury resulting solely and directly from accident caused by external, violent and visible means anywhere in the world, then the Company shall pay to the Insured or his nominee as the case may be, the sum or sums hereinafter set forth, that is to say:

I) Death

a) If such injury shall within Twelve calendar months of its occurrence be the sole and direct cause of the death of the Insured, the sum insured stated in the relevant section of the Policy Schedule shall be payable.

II) Permanent Total Disablement

b) If such injury shall within Twelve calendar months of its occurrence be the sole and direct cause of the total and irrecoverable loss of

i) sight of both eyes, or of the actual loss by physical separation of two entire hands or two entire feet, or of one entire hand and one entire foot, of such loss of sight of one eye and such loss of one entire hand or one entire foot, the sum insured stated in the relevant section of the Policy Schedule shall be payable.

ii) Use of two hands or two feet or of one hand and one foot, or of such loss of sight of one eye and such loss of use of one hand or one foot, the sum insured stated in the relevant section of the Policy Schedule shall be payable.

c) If such injury shall within Twelve calendar months of its occurrence be the sole and direct cause of the total and irrecoverable loss of

i) The sight of one eye, or of the actual loss by physical separation of one entire hand or of one entire foot, fifty percent (50%) of the sum insured stated in the relevant section of the Policy Schedule shall be payable.

ii) Total and irrecoverable loss of use of a hand or a foot without Physical separation, fifty percent (50%) of the sum insured stated in the relevant section of the Policy Schedule shall be payable.

NOTE: For the purpose of Clause (b) and Clause (c) above, physical separation’ of a hand means separation at or above the wrist and of the foot at or above the ankle.

d) If such injury shall, as a direct consequence thereof, immediately, permanently, totally and absolutely, disable the Insured Person from engaging in any employment or occupation of any description, whatsoever, then a lump sum equal to hundred percent (100%) of the sum insured stated in the relevant section of the Policy Schedule shall be payable.

III) Permanent Partial Disablement

e) If such injury shall within twelve calendar months of its occurrence be the sole and direct cause of the total and /or partial and irrecoverable loss of use or of the actual loss by physical separation of the following, then the percentage of the sum insured as indicated below shall be payable

 

Table of Benefits		Percentage of Capital Sum Insured
i) Loss of toes	all	20%
• Great	both phalanges	5%
• Great	one phalanx	2%
• Other than Great, if more than one toe lost,	for each toe	1%
ii) Loss of hearing	both ears	75%
iii) Loss of hearing	one ear	30%
iv) Loss of four fingers and thumb of one hand		40%
v) Loss of four fingers		35%
vi) Loss of thumb	both phalanges, one phalanx	25 % 10 %
vii) Loss of index finger	three phalanges ,two phalanges ,One phalanx	10%
viii)Loss of middle finger	three phalanges ,two phalanges ,One phalanx	6%
ix) Loss of ring finger	three phalanges ,two phalanges ,One phalanx	5%
x) Loss of little finger	three phalanges ,two phalanges ,One phalanx	4%
xi) Loss of metacarpals	first or second(addl) - third, fourth, or fifth (addl) }	3%
xii) Any other permanent partial disablement		Percentage of PPD as assessed by the state board’s/ neutral Medical Practioner.