Group Assurance Health Plan

Plan Structure

Individual sum insured

Family floater sum insured

Plan Types

Individual Plan
Covers either self, spouse or dependent child. Only one person can be covered
under this plan and coverage would be on individual sum insured basis.

Family Plan
Covers self, spouse and upto 4 dependent children. Policy will have the
same Sum Insured for all the members and coverage would be on floater
basis

Parents Plan
Covers either set of dependent Parents or parent’s in law of Self on family
floater sum insured basis
Eligibility Criteria

Age at entry (Min) Age at entry (Max)

Self 18 years 70 years

Adult Dependent 18 years 70 years

Child Dependent 91 days 25 years

▪ There is no cover ceasing age on continuous renewals

▪ Family definition includes Self, Spouse and dependent children
▪ Either set of dependent parents or parents in laws.
▪ Dependent children between the age of 91 days and 5 years can ONLY be
covered if either of the parents are covered under the policy.
Sum Insured (Rs.)
2 Lakhs

3 Lakhs

4 Lakhs

Sum Insured (Rs.)

5 Lakhs

7.5 Lakhs

10 Lakhs

15 Lakhs
Product Benefits
Benefits Sum Insured
Sum Insured Options 2L, 3L, 4L, 5L, 7.5L, 10L, 15L
In-patient hospitalisation Upto Sum Insured
Pre-hospitalisation 90 days
Post-hospitalisation 180 days
Day care procedures 183 day Care Procedures
Domiciliary Treatment Upto Sum Insured
Organ Donor Upto Sum Insured
Ayush Benefit Upto Sum Insured
Double Restore Benefit Instant addition of 100% of basic SI
1% of sum insured per policy at each renewal irrespective of claim
Preventive Health Check-up
subject to max of Rs. 7500
Ambulance Cover Rs. 2000/- per hospitalisation
Double Sum Insured for Critical
4 listed CI’s
Illness
Cumulative Bonus 10% for every claim free year subject to max 100% of the base SI
Hospital Daily Cash Rs. 1000 per day; max 15 days
E-Opinion in respect of Critical
Offered
Illness
In-patient Treatment

Medical expenses for-

▪ Room rent, boarding expenses,
▪ Nursing,
▪ Intensive care unit,
▪ Medical practitioner(s),
▪ Anesthesia, blood, oxygen, operation theatre charges, surgical
appliances,
▪ Medicines, drugs and consumables,
▪ Diagnostic procedures,
▪ The cost of prosthetic and other devices or equipment if implanted
internally during a surgical procedure.
Pre & Post Hospitalisation
Medical expenses incurred for consultations, investigations and medicines

Pre – Hospitalisation Post- Hospitalisation

upto 90 days immediately upto 180 days immediately
before the insured person after the insured person was
was hospitalised discharged from hospital

Provided that
▪ Such costs are incurred in respect of the same condition for
which the insured person’s earlier hospitalisation was
required, and
▪ We have accepted an in-patient hospitalisation claim under
In-patient treatment or domiciliary hospitalisation.
Daycare Procedures

Medical treatment or surgical procedure which is undertaken under general

or local anaesthesia, which require admission in a Hospital/Day Care Centre
for stay less than 24 hours because of technological advancement. Treatment
normally taken on out-patient basis is not included in the scope of this
definition.

Indicative list of Day Care Treatments/Procedures

Cancer Chemotherapy, Liver biopsy, Coronary angiography, Haemodialysis,
Operation of cataract, Nasal sinus aspiration

Benefit excludes
• Treatment that can be and is usually taken on an out-patient basis is
not covered.
• Treatment NOT taken at a Hospital or a Day Care centre.

Note: Pre & Post hospitalization expenses are covered under Day Care
Procedures also

Please refer to Annexure 1 for complete list of day care procedures

Domiciliary Treatment
Medical treatment for an Illness/disease/injury which in the normal course
would require care and treatment at a Hospital but is actually taken while
confined at home under any of the following circumstances:

• The condition of the patient is such that he/she is not in a

condition to be removed to a Hospital or,
• The patient takes treatment at home on account of non availability
of room in a Hospital

Pre Hospitalisation and Post Hospitalisation expenses for consultations,

investigations and medicines covered.

Benefit excludes
• Treatment of less than 3 days.
• Expenses for treatment for first three days only will be covered if treatment
period is greater than 3 days)
Organ Donor

Medical and surgical Expenses of the organ donor for harvesting the organ
where an Insured Person is the recipient.

Benefit excludes
• Claims which have NOT been admitted under 1a) for the insured
person.
• Admission not compliant under the Transplantation of Human Organs
Act, 1994 (as amended).
• The organ donor’s Pre and Post-Hospitalisation expenses.
Ambulance Cover

Expenses incurred on transportation of insured

person to a hospital for treatment in case of an
emergency, subject to Rs. 2000 per hospitalisation.
AYUSH Benefit
Medical expenses incurred for in-patient treatment taken under Ayurveda,
Unani, Sidha or Homeopathy provided that the treatment has been undergone
in
▪ Government hospital or in any institute recognized by government
and/or accredited by Quality Council of India or National
Accreditation Board on Health; or

▪ Teaching hospitals of AYUSH colleges recognised by Central Council of

Indian Medicine (CCIM) and Central Council of Homeopathy (CCH); or

▪ AYUSH Hospitals having registration with a Government authority

under appropriate Act in the State/UT and complies with the
following as minimum criteria

▪ has at least fifteen in-patient beds;

▪ has minimum five qualified and registered AYUSH doctors;
▪ has qualified paramedical staff under its employment round the clock;
▪ has dedicated AYUSH therapy sections;
▪ maintains daily records of patients and makes these accessible to the
insurance company’s authorized personnel
Preventive Health Check-up
Reimbursement of expenses incurred on a preventive a health check –up.
▪ Benefit can be availed only once during the renewed policy period.
▪ Health check-up limited is over and above the base sum insured
limit.
▪ This benefit is available ONLY to those Insured Persons who were
insured in the previous policy.
▪ This benefit is not available for expenses incurred on a preventive
health check-up in the first policy year. This benefit will NOT be
carried forward if it is not claimed and would not be provided if the
Group Assurance Health Plan Insurance Policy is not renewed further

Plan 2 - 15 lacs
Upto 1% of Sum Insured per Insured Person, at the end of every Policy Year, subject to
Individual Plan
maximum of Rs 7,500
Upto 1% of Sum Insured per Policy, at the end of every Policy Year, subject to maximum of
Family Floater Plan
Rs 7,500

Preventive Health Check-up means a package of medical test(s) undertaken for general assessment of health status, it does not
include any diagnostic or investigative medical tests for evaluation of illness or a disease.
E-Opinion with respect to Critical Illness
We shall arrange and pay for a second opinion from Our panel of Medical
Practitioners, if:
• The Insured Person suffers a Critical Illness during the Policy Period;
and
• He requests an E-opinion; and

The Insured Person can choose one of Our panel Medical

Practitioners. The opinion will be directly sent to the Insured Person
by the Medical Practitioner.

“Critical Illness” includes Cancer of specified severity, Open Chest

CABG, Myocardial Infarction (First Heart Attack of specific severity),
Kidney Failure requiring regular dialysis, Major Organ/Bone Marrow
Transplant, Multiple Sclerosis with persisting symptoms, Permanent
Paralysis of Limbs and Stroke resulting in permanent symptoms,
We will not pay for:
i) More than one claim for this benefit in a Policy Year.
ii) More than one claim for the same Critical Illness.
iii) Any other liability due to any errors or omission or representation or
consequences of any action taken in reliance of the E-opinion
provided by the Medical Practitioner.
Hospital Daily Cash

▪ In case of in-patient hospitalisation due to illness or accident a daily cash

amount shall be provided for each continuous and completed period of 24
hours
▪ Provide over and above base sum insured limit

Daily Cash per day (Rs.) for maximum

Rs. 1000
of 15 days
Double Sum Insured for Critical Illness

We will increase the Sum Insured for an insured

person by 100% if he is diagnosed as suffering from a
critical Illness under this Policy, provided that:
The insured person is first diagnosed as suffering from
a critical illness during the Policy period, and
The benefit is utilised only by the insured person
diagnosed with the critical illness, and
We have accepted an inpatient hospitalisation claim
under in-patient treatment benefit

For this benefit Critical Illness means :

• Cancer of specified severity
• Myocardial Infarction (First Heart Attack of specific
severity)
• Stroke resulting in Permanent Symptoms
• Major Organ/Bone Marrow Transplant
Double Sum Insured for Critical Illness - Illustration
Insured with base cover of 300000 and there is a hospitalisation claim due to cancer for Rs.
500,000
Base sum
insured fully
utilized,
Step 1 Base Sum insured is utilized Full Rs. 300,000 residual claim
amount
200000
Step 2 Double SI for cancer is utilized next Rs. 2 Lac out of Rs.
3 Lac
Double Sum
Step 3 As claim occurs, Restore will trigger
Insured for
Cancer utilized
for Rs 200000
Restored sum insured available for all members under family floater policy. Double sum
insured for cancer of Rs 100000 available for any hospitalisation claim due to cancer in
that policy year.
Cumulative Bonus

▪ Available for every claim free year

▪ Sum Insured increased by 10%
▪ Maximum up to 100% of SI
▪ In the event of Claim, CB reduced by 10% of
Sum Insured
Cumulative Bonus - Illustration
Insured person having base Sum Insured of Rs 500000 and no claim is made in 3 years since
the inception of the policy. A claim is made in the 4 th policy year.

Claim Made in the Policy

Sum Insured at inception Base Sum Insured Cumulative Bonus Policy Year
Year
500000 500000 - 2017-18 -
550000 500000 50000 2018-19 No
600000 500000 100000 2019-20 No
650000 500000 150000 2020-21 Yes
600000 500000 100000 2021-22 No
Double Restore Benefit
• Instant addition of 100% Basic Sum Insured on complete or partial utilization of
Your existing Policy Sum Insured and Cumulative Bonus (if applicable) during the
Policy Year. The Total amount (Basic sum insured, Cumulative Bonus and Restore
Sum Insured when added) will be available to all Insured Persons for all claims
under In-patient Benefit during the current Policy Year and subject to the
condition that single claim in a Policy Year cannot exceed the sum of Basic Sum
Insured and the Cumulative Bonus (if applicable).
• Post complete utilization of your Basic Sum Insured and Cumulative Bonus (if
applicable), if You partially or completely utilize your Restore Sum Insured (as
given in i above), another 100% of Basic sum insured would be added to Your
Restored sum insured available to all Insured Persons for claims under In-patient
Benefit during the current Policy Year and subject to the condition that single
claim in a Policy Year cannot exceed the Basic Sum Insured.

• The Restore or Double Restore Sum Insured will be applied only once for the
Insured Person during a Policy Year
• If the Restore or Double Restore Sum Insured is not utilized in a Policy Year, it
shall not be carried forward to any subsequent Policy Year.
• In case of a Family Floater Policy, Restore or Double Restore Sum Insured will be
available on floater basis for all Insured Persons in the Policy.
• This benefit would only be offered where Base Sum Insured is 1 lac and above.
• The Restore or Double Restore Sum Insured can be used for claims made by the
Insured Person in respect all benefits except Preventive Health Checkup, Hospital
Daily Cash and E-Opinion in respect of Critical Illness
How does Double Restore Benefit work?
FIRST RESTORE TRIGGER Double
1) Now get instant 100% addition of your Basic Sum Insured at the first claim (You don’t need to Restore
consume the full Sum Insured). Sum
Insured

+
First Claim - any amount 100% instant addition Restore
3X
from your Basic SI + CB (if any) of your Sum Insured
Sum
SECOND RESTORE TRIGGER
2) Furthermore, once your Basic Sum Insured and Cumulative Bonus (if any) in the same policy year is
Insured
completely utilized AND if you partially or completely utilize your Restored Sum Insured (as
mentioned in 1 above), then we would add another 100% of your Basic Sum Insured under your policy.

+ + + Basic SI +
+ CB (if any)
100% instant addition
Basic SI + CB gets exhausted and
of your Sum Insured
What’s better is that you one can claim
utilizefurther dipsInsured
the Sum in Restore
forSIthe illness for which claim has already
been paid earlier and a single claim in a Policy Year cannot exceed the Basic Sum Insured and
Cumulative Bonus (if any).
Illustration 1 (Policy Tenure: Jan – Dec; Basic Sum Insured 5 Lacs)
Double Restore
Jan Remaining SI Restore Trigger
Trigger

Feb Claim 1: 2Lacs 3 Lacs + 5 Lacs ✓ X

May Claim 2: 2Lacs 1 Lacs + 5 Lacs X X

July Claim 3: 1Lac 0 + 5 Lacs X X

0 + 4.5 Lacs + 5
Aug Claim 4: 50K lacs X ✓

Dec
Illustration 2 (Policy Tenure: Jan – Dec; Basic Sum Insured 5 Lacs: CB – 50K)
Double Restore
Jan Remaining SI Restore Trigger
Trigger

3.5 Lacs + 5 Lacs

Feb Claim 1: 2Lacs (3L+50K CB) ✓ X

May Claim 2: 2.5 Lacs 1 Lacs + 5 Lacs X X

July Claim 3: 1Lac 0 + 5 Lacs X X

0 + 4.5 Lacs + 5
Aug Claim 4: 50K lacs X ✓

Dec
Waiting Periods

• Any treatment or admission within first 30 days of policy inception

except any accidental injury.
30 Days

• 24 months waiting period for specific diseases like Cataract, surgery

Specified for hernia, surgery for hydrocele etc.
Illness

• Pre-existing diseases (PED) waiting period of 36 months

Pre-existing
Diseases
General Exclusions

▪ External Congenital diseases, cosmetic surgery and weight control treatments

▪ Expense attributable directly or indirectly to pregnancy (including voluntary termination), miscarriage
(except as a result of an Accident or Illness),
▪ Abuse of intoxicant or hallucinogenic substances like intoxicating drugs and alcohol
▪ Drugs or treatments which are not supported by a prescription
▪ Hospitalization due to war or an act of war or due to a nuclear, chemical or biological weapon and
radiation of any kind

▪ Pregnancy, dental treatment, external aids and appliances

▪ Items of personal comfort and convenience
▪ Experimental, investigative and unproven treatment devices and pharmacological regimens.
▪ Plastic surgery or cosmetic surgery unless necessary as a part of medically necessary treatment.
Please refer to the Policy Wording for the complete list of exclusions.
Cancellation (on insured’s request)

Short
If no claim has been made scale *

No
If claim has been reported and settled refund

* Please refer to annexure 2 for short scale grid

Tax Benefit
As per Section 80D, deductions on health insurance premiums paid for
self/family and parents are as follows:

Persons Covered Exemption Limit

Self and Family Rs. 25,000
Rs. (25000+25000) =
Self, Family and Parents below 60yrs
Rs. 50000
Self, Family and Parents who are Sr. Citizens i.e. Rs. (25000 + 50000) =
above 60yrs Rs. 75000
Premium
 Premiums (inclusive of 18% GST)
Individual Plan – (Plan for ONE only) – Cover yourself, your spouse or your child. Coverage will be on
individual sum insured basis.
Age bands/SI 200,000 300,000 400,000 500,000 750,000 1,000,000 1,500,000
5-45 2936 3615 4379 4859 5709 6363 7954
Above 45 5721 7019 8734 9843 12092 13959 17449

Family Plan – (2 Adults) – Cover yourself and your spouse. Coverage will be on family floater sum
insured basis.
Age bands/SI 200,000 300,000 400,000 500,000 750,000 1,000,000 1,500,000
18-45 5093 6296 7618 8469 9952 11199 13999
Above 45 8637 10497 12645 14046 16562 19086 23856

Family Plan – (2 Adults + 2 Children) – Cover yourself, your spouse and upto 2 dependent children.
Coverage will be on family floater sum insured basis.
Age bands/SI 200,000 300,000 400,000 500,000 750,000 1,000,000 1,500,000
18-45 7146 8662 10338 11426 13543 15328 19159
Above 45 10880 13075 15609 17268 20396 23495 29368
Premiums (inclusive of 18% GST)

Family Plan – (2 Adults + 4 Children) – Cover yourself, your spouse and upto 4 dependent children.
Coverage will be on family floater sum insured basis.
Age bands/SI 200,000 300,000 400,000 500,000 750,000 1,000,000 1,500,000
18-45 7956 9593 11411 12591 14956 16953 21192
Above 45 11764 14089 16777 18536 21906 25231 31539

Parent’s Plan – (2 Adults) – Cover either set of parents or parents in law. Coverage will be on family
floater sum insured basis.
Age bands/SI 200,000 300,000 400,000 500,000 750,000 1,000,000 1,500,000
18-45 5093 6296 7618 8469 9952 11199 13999
Above 45 8637 10497 12645 14046 16562 19086 23856