THE NEW INDIA ASSURANCE CO. LTD.

REGISTERED & HEAD OFFICE: 87, MAHATMA GANDHI ROAD, MUMBAI 400001

NEW INDIA FLOATER MEDICLAIM POLICY- PROSPECTUS

We welcome You as Our Customer. This document explains how the NEW INDIA FLOATER
MEDICLAIM POLICY could provide value to You. In the document the word ‘You’, ‘Your’ means the
all the members covered under the Policy. ‘We’, ‘Our’, ‘Us’ means The New India Assurance Co.
Ltd.

New India Floater Mediclaim is a Policy designed to cover Hospitalisation expenses.

1. WHO CAN TAKE THIS POLICY?

This insurance is available to persons between the age of 18 years and 65 years. Children from
3 months up to 25 years can be covered provided they are financially dependent on the
parents and one or both parents are covered simultaneously. The upper age limit will not
apply to a mentally challenged children and an unmarried daughter(s). The persons beyond
65 years can continue their insurance provided they are insured under the Policy with us
without any break.
Midterm inclusion is allowed for newly married spouse by charging pro-rata premium for the
remaining period of the policy.

2. CAN I COVER MY FAMILY MEMBERS IN ONE POLICY?

Yes. You can cover the entire family under a Single Sum Insured. The members of the family
who could be covered under the Policy are:
a) Proposer
b) Proposer’s Spouse
c) Proposer’s Dependent Children
d) Proposer’s Parents (parents less than equal to 60 years of age will be covered only
if they are dependent on the proposer)
e) Proposer’s Brother/Sister
f) Proposer’s Ward
g) Employers can cover their Employees

Minimum two members are required in this policy. This policy cannot be given to a single
person. Maximum six members can be covered in a single policy.

Note:

i. Brother/Sister can only be covered when they are financially dependent on the
proposer.

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NEW INDIA FLOATER MEDICLAIM POLICY
 ii. For the relations Employer-Employee/Brother/Sister/Ward 80D certificate shall not be
given.

3. WHAT IS NEW BORN BABY COVER?

A New Born Baby to an insured mother, who has 24 months of Continuous Coverage, is
covered for any Illness or Injury from the date of birth till the expiry of the Policy, within the
terms of the Policy, without any additional Premium. Any expenses incurred towards post-
natal care, pre-term or pre-mature care or any such expense incurred for delivery of the New
Born Baby would not be covered. Congenital External Anomaly of the New Born Baby is also
not covered under the policy.

No coverage for the New Born Baby would be available during subsequent renewals until the
child is declared for insurance and covered as an Insured Person.

4. WHAT DOES THE POLICY COVER?

This Policy is designed to give You and Your family, protection against unforeseen
Hospitalisation expenses.

5. WHAT ARE THE EXPENSES COVERED UNDER THIS POLCY?

Our liability for all claims admitted during the Period of Insurance in respect of all Insured Persons shall
not exceed the aggregate of the Sum Insured and the Cumulative Bonus. Subject to this, for each claim
We will reimburse the following Reasonable and Customary and Medically Necessary Expenses admissible
as per the terms and conditions of the Policy:

Room rent, Boarding, DMO / RMO / CMO / RMP Charges, Nursing (Including Injection / Drugs and
(a)
Intra venous fluid administration expenses), not exceeding 1% of the Sum Insured per day.

Intensive Care Unit (ICU) / Intensive Cardiac Care Unit (ICCU), Intensivist charges, Monitor and
(b)
Pulse Oxymeter expenses, not exceeding 2% of the Sum Insured per day.

Associate Medical Expenses; such as Professional fees of Surgeon, Anaesthetist, Consultant,

(c) Specialist; Anaesthesia, Blood, Oxygen, Operating Theatre Charges and Procedure Charges such as
Dialysis, Chemotherapy, Radiotherapy & similar medical expenses related to the treatment.

(d) Cost of Pharmacy and Consumables, Cost of Implants and Medical Devices and Cost of Diagnostics.

(e) Pre-Hospitalization Medical Expenses, not exceeding thirty days

(f) Post-Hospitalization Medical Expenses, not exceeding sixty days

Proportionate Deduction is applicable on the Associate Medical Expenses, if the Insured Person
opts for a higher Room than his eligible category. It shall be effected in the same proportion as the
eligible rate per day bears to the actual rate per day of Room Rent. However, it is not applicable
(g) on

1. Cost of Pharmacy and Consumables

2. Cost of Implants and Medical Devices
3. Cost of Diagnostics.
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NEW INDIA FLOATER MEDICLAIM POLICY
 Proportionate Deduction shall also not be applied in respect of Hospitals which do not follow
differential billing or for those expenses in which differential billing is not adopted based on the
room category, as evidenced by the Hospital’s schedule of charges / tariff.

MEDICAL EXPENSES INCURRED UNDER TWO POLICY PERIODS:

If the claim event falls within two policy periods, the claims shall be paid taking into consideration the
available Sum Insured of the expiring Policy only. Sum Insured of the Renewed Policy will not be available
for the Hospitalisation (including Pre & Post Hospitalisation Expenses), which has commenced in the
expiring Policy. Claim shall be settled on per event basis.

MEDICAL EXPENSES FOR ORGAN TRANSPLANT:

If treatment involves Organ Transplant to Insured Person, then We will also pay Hospitalisation Expenses
(excluding cost of organ) incurred on the donor, provided Our liability towards expenses incurred on the
donor and the insured recipient shall not exceed the aggregate of the Sum Insured, if any, of the Insured
Person receiving the organ.

i. LIMIT ON PAYMENT FOR CATARACT

Our liability for payment of any claim within the Period of Insurance, relating to Cataract for each eye
shall not exceed 10% of the Sum Insured or Rs.50,000, whichever is less.

The limit mentioned above shall be applicable per event for all the Policies of Our Company including
Group Policies. Even if two or more Policies of New India are invoked, sublimit of the Policy chosen by
Insured shall prevail and our liability is restricted to stated sublimit.

ii. NEW BORN BABY COVERAGE

A New Born Baby is covered for any Illness or Injury from the date of birth till the expiry of this Policy,
within the terms of this Policy. Any expense incurred towards post-natal care, pre-term or pre-mature
care or any such expense incurred in connection with delivery of such New Born Baby would not be
covered.

Congenital External Anomaly of the New Born Baby is covered only after 48 months Waiting Period.

Waiting Period for Congenital Internal Disease would not apply to a New Born Baby during the year of
Birth and also subsequent renewals, if Premium is paid for such New Born Baby and the renewals are
effected before or within thirty days of expiry of the Policy.

No coverage for the New Born Baby would be available during subsequent renewals unless the child is
declared for insurance and covered as an Insured Person.

Note: New Born Baby means a baby born during the Policy Period to a female Insured Person, who has
twenty-four months of Continuous Coverage with Us.

iii. TREATMENTS UNDER AYURVEDIC/HOMEOPATHIC/UNANI SYSTEMS

Our liability for expenses incurred for Ayurvedic/Homeopathic/Unani treatments shall not exceed 25%
of the Sum Insured in respect of all such treatments admitted during the Period of Insurance, provided
the treatment for Illness or Injury, is taken in any AYUSH Hospital.

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NEW INDIA FLOATER MEDICLAIM POLICY
 iv. HOSPITAL CASH
We will pay Hospital Cash at the rate of 0.1% of the Sum Insured, for each day of Hospitalisation,
admissible under the Policy. The payment under this Clause for Any One Illness shall not exceed 1% of
the Sum Insured. The payment under this Clause is applicable only where the period of Hospitalization
exceeds twenty-four hours.

v. CRITICAL CARE BENEFIT

If during the Period of Insurance any Insured Person discovers that he or she is suffering from any Critical
Illness as defined under 2.12, which results in a claim admissible under this Policy, 10% of the Sum Insured
would be paid as Critical Care Benefit along with the admissible claim amount. Critical Care Benefit is
payable only once in the life time of each Insured Person and is not applicable to any Insured Persons for
whom it is a Pre- Existing Condition/Disease. Any payment under this Clause would be in addition to the
Sum Insured and shall not deplete the Sum Insured.

vi. PAYMENT OF AMBULANCE CHARGES

We will pay You the charges for Ambulance services not exceeding 1% of the Sum Insured, Medically
Necessarily incurred for shifting any Insured Person to Hospital for admission in Emergency Ward or ICU,
or from one Hospital to another Hospitalfor better medical facilities.

vii. PAYMENTS ONLY IF INCLUDED IN HOSPITAL BILL

No payment shall be made for any Hospitalisation expenses incurred, unless they form part of the
Hospital Bill. However, the bills raised by Surgeon, Anaesthetist directly and not included in the Hospital
Bill shall be paid provided a numbered Bill is produced in support thereof, for an amount not exceeding
Rs. Ten thousand, where such payment is made in cash and for an amount not exceeding Rs. Twenty
thousand, where such payment is made by cheque.

viii. TREATMENT FOR CONGENITAL DISEASES

Congenital Internal Disease or Defects or anomalies shall be covered after twenty-four months of
Continuous Coverage.

Congenital External Disease or Defects or anomalies shall be covered after forty-eight months of
Continuous Coverage, but such cover for Congenital External Disease or Defects or anomalies shall be
limited to 10% of the average Sum Insured in the preceding four years.

ix. SPECIFIC COVERAGES:

a) Impairment of Persons’ intellectual faculties by usage of drugs, stimulants or depressants as

prescribed by a medical practitioner is covered up to 5% of Sum Insured, maximum upto Rs.
25,000 per policy period subject to it arising during treatment of covered illness.
b) Artificial life maintenance, including life support machine use, where such treatment will not
result in recovery or restoration of the previous state of Health under any circumstances
unless in a vegetative state as certified by the treating medical practitioner, is covered up to
10% of Sum Insured and for a maximum of 15 days per policy period following admission for
a covered illness. (Explanation: Expenses up to the date of confirmation by the treating doctor
that the patient is in vegetative state shall be covered as per the terms and conditions of the
policy contract).
c) Treatment of mental illness, stress or psychological disorders and neurodegenerative
disorders The Company shall indemnify the Hospital or the Insured the Medical Expenses

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 related to following and they are covered after a waiting period of 48 months with a sub-limit
up to 25% of Sum Insured per policy period.

The below covers are subject to the patient exhibiting any of the following traits and requiring
Hospitalisation as per the treating Psychiatrist’s advice
1. Major Depressive Disorder- when the patient is aggressive or violent.
2. Acute psychotic conditions- aggressive/violent behavior or hallucinations, incoherent talking
or agitation.
3. Schizophrenia- esp. Psychotic episodes.
4. Bipolar disorder- manic phase.

Treatment of any Injury due to exhibiting Suicidality shall not be covered.

Condition

Treatment shall be undertaken at a Hospital categorized as Mental Health Establishment or at a

Hospital with a specific department for Mental Illness, under a Medical Practitioner qualified as
Mental Health Professional.

Exclusions

Any kind of Psychological counselling, cognitive / family / group / behavior / palliative therapy or other
kinds of psychotherapy for which Hospitalisation is not necessary shall not be covered.

d) Puberty and Menopause related Disorders: Treatment for any symptoms, Illness,
complications arising due to physiological conditions associated with Puberty, Menopause
such as menopausal bleeding or flushing is covered only as Inpatient procedure after 24
months of continuous coverage. This cover will have a sub-limit of up to 25% of Sum Insured
per policy period.
e) Age Related Macular Degeneration (ARMD) is covered after 48 months of continuous
coverage only for Intravitreal Injections and anti – VEGF medication. This cover will have a
sub-limit of 10% of Sum Insured, maximum upto Rs. 75,000 per policy period.
f) Behavioural and Neuro developmental Disorders: Disorders of adult personality and
Disorders of speech and language including stammering, dyslexia; are covered as Inpatient
procedure after 24 months of continuous coverage. This cover will have a sub-limit of 25% of
Sum Insured per policy period.
g) Genetic diseases or disorders are covered with a sub-limit of 25% of Sum Insured per policy
period with 48 months waiting periods.

Note: For the coverages defined in 3.14, waiting period's, if any, shall be applicable afresh i.e. for both
New and Existing Policyholders w.e.f 1st October 2020. Coverage for such illness or procedures shall
only be available after completion of the said waiting periods.

x. COVERAGE FOR MODERN TREATMENTS or PROCEDURES: The following procedures will be covered
(wherever medically indicated) either as in patient or as part of day care treatment in a hospital up to the
limit specified against each procedure during the policy period.

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NEW INDIA FLOATER MEDICLAIM POLICY
S No Treatment or Procedure Limit (Per Policy Period)

Uterine Artery Embolization and HIFU (High intensity focused Upto 20% of Sum Insured subject to
1
ultrasound) a Maximum upto Rs. 2 Lakh

Upto 20% of Sum Insured subject to

2 Balloon Sinuplasty.
a Maximum upto Rs. 2 Lakh

Upto 50% of Sum Insured subject to

3 Deep Brain stimulation.
a maximum upto Rs. 5 Lakh

Upto 10% of Sum Insured subject to

4 Oral chemotherapy.
Maximum upto Rs. 1 Lakh.

Immunotherapy- Monoclonal Antibody to be given as Upto 25% of Sum Insured subject to

5
injection. a Maximum of Rs 2 Lakh.

Upto 10% of Sum Insured subject to

6 Intravitreal injections.
a Maximum of Rs.75,000.

Upto 50% of Sum Insured subject to

7 Robotic surgeries.
Maximum of Rs. 5 Lakh.

Upto 50% of Sum Insured subject to

8 Stereotactic radio surgeries.
Maximum Rs. 3 Lakh.

Upto 50% of Sum Insured subject to

9 Bronchial Thermoplasty.
Maximum of Rs. 2.5 Lakh.

Vaporisation of the prostrate (Green laser treatment or Upto 50% of Sum Insured subject to
10
holmium laser treatment). Maximum of Rs. 2.5 Lakh.

Upto 10% of Sum Insured subject to

11 IONM - (Intra Operative Neuro Monitoring).
Maximum of Rs. 50,000.

Stem cell therapy: Hematopoietic stem cells for bone marrow Upto 50% of Sum Insured subject to
12
transplant for haematological conditions to be covered. Maximum of Rs. 2.5 Lakh.

6. WHAT ARE THE OPTIONAL COVERS AVAILABLE IN THE POLICY?

Following are the optional covers available in the Policy.

OPTIONAL COVER I: NO PROPORTIONATE DEDUCTION

This cover can be opted by the Insured Person whose Sum Insured is Rs. 2,00,000 and above.

On payment of additional Premium for each Insured Person, Proportionate deduction as

mentioned in Clause 3.1 (g) of Policy Document will be deleted for such members opting for
such cover.

Policy holder shall continue to bear the differential between actual and eligible Room Rent.

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NEW INDIA FLOATER MEDICLAIM POLICY
 Premium will be charged for all the Insured persons shall be charged separately.

OPTIONAL COVER II: MATERNITY EXPENSES BENEFIT

This cover can be opted by the Insured Person whose Sum Insured is Rs. 5,00,000 and above.

On the payment of additional Premium, Clause 4.4.15 of Policy Document or sub point O of
Q. 10 below, shall be deleted for the members opting for Maternity Cover. Our liability for
claim admitted for Maternity shall not exceed 10% of the average Sum Insured of the Insured
Person in the preceding three years.

Special conditions applicable to Maternity Expenses Benefit:

1. These Benefits are admissible only if the expenses are incurred in Hospital as
inpatients in India.
2. A waiting period of thirty six months is applicable, from the date of opting this cover, for
payment of any claim relating to normal delivery or caesarian section or abdominal
operation for extra uterine pregnancy. The waiting period may be relaxed only in case
of delivery miscarriage or abortion induced by accident or other medical emergency.
3. Claim in respect of delivery for only first two children and / or surgeries associated
therewith will be considered in respect of any one Insured Person covered under the
Policy or any renewal thereof.
4. Expenses incurred in connection with voluntary medical termination of pregnancy
during the first 12 weeks from the date of conception are not covered.

Pre-natal and post-natal expenses are not covered unless admitted in Hospital and treatment
is taken there.

The maternity limit mentioned above shall be applicable per event for all the Policies of Our
Company including Group Policies. Even if two or more Policies of New India are invoked,
sublimit of the Policy chosen by Insured shall prevail and our liability is restricted to stated
sublimit.

Premium will be charged separately for each Insured Person opting for this cover.

OPTIONAL COVER III: REVISION IN LIMIT OF CATARACT

This cover can be opted by the Insured Person whose Sum Insured is Rs. 8,00,000 and above.

On payment of additional Premium as mentioned in Schedule, it is declared and agreed that

following additional amount for Cataract shall become payable but not exceeding the actual
expenses incurred:

Sum Insured Revised Cataract Limit

Rs. 8,00,000 Rs. 80,000
Rs. 10,00,000 Rs. 1,00,000
Rs. 12,00,000 Rs. 1,20,000
Rs. 15,00,000 Rs. 1,50,000

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NEW INDIA FLOATER MEDICLAIM POLICY
 Benefit of this cover will be available after the expiry of thirty-six months from the date of opting this
cover. Premium will be charged separately for each Insured Person opting for this cover.

7. WHAT IS HOSPITAL CASH BENEFIT?

This policy provides for payment of Hospital Cash at the rate of 0.1% of Sum Insured per day
of Hospitalisation. This benefit will be given in every case of admissible claim and for each
member. This benefit is applicable only where Hospitalisation exceeds twenty four
consecutive hours.

The total payment for Any One Illness shall not exceed 1% of the Sum Insured. This benefit
shall be directly given by TPA/underwriting office, as the case may be.

8. WHAT IS CRITICAL CARE BENEFIT?

If during the Period of Insurance any Insured Person discovers that he/she is suffering from
any Critical Illness as listed below, we will pay flat 10% of Sum Insured as additional benefit
i.e. other than the admissible claim:

1. Cancer of Specified severity

2. First Heart attack of specified severity
3. Open chest CABG
4. Open Heart replacement or repair of Heart valves
5. Coma of specified severity
6. Kidney failure requiring regular dialysis
7. Stroke resulting in permanent symptoms
8. Major organ / bone marrow transplant
9. Permanent paralysis of limbs
10. Motor neurone disease with permanent symptoms
11. Multiple sclerosis with persisting symptoms

Any payment under this clause would be in addition to the Sum Insured and shall not deplete
the Sum Insured. This benefit will be paid once in lifetime of any Insured Person. This benefit
is not applicable for those Insured Persons for whom it is a pre-existing disease.

9. IS PRE-ACCEPTANCE MEDICAL CHECK-UP REQUIRED?

i. Pre-acceptance test is required for all the members entering after the age of 50 for
the first time.
ii. However, the condition (i) shall be relaxed to 60 year’s subject to the following
conditions:
a. A minimum of 3 persons should be covered in the policy.
b. At least one of the members age should be less than 35 Years.

Irrespective of the (i) & (ii) a person needs to undergo this pre-acceptance medical check-up
if he has an adverse medical history. The cost of this check-up will be borne by the proposer.
But if the proposal is accepted, then 50% of the cost of this check-up will be reimbursed to
the proposer.

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 Note: Adverse Medical History means a person:

i. Who has undergone more than one Hospitalization in previous two years,
ii. Who is suffering from Critical Illness, Recurring Illness or Chronic Illness.
iii. Is Suffering from Hypertension / Diabetes.
iv. Is not in good health and free from Physical and mental diseases or infirmity or medical
complaints.

10. DOES IT COVER ALL CASES OF HOSPITALISATION?

No claim will be payable under this Policy for the following:

i. PRE-EXISTING DISEASES (Code- Excl01)

a. Expenses related to the treatment of a pre-existing Disease (PED) and its direct complications shall
be excluded until the expiry of 48 months of continuous coverage after the date of inception of
the first policy with us.
b. In case of enhancement of Sum Insured the exclusion shall apply afresh to the extent of Sum
Insured increase.
c. If the Insured Person is continuously covered without any break as defined under the portability
norms of the extant IRDAI (Health Insurance) Regulations then waiting period for the same would
be reduced to the extent of prior coverage.
d. Coverage under the policy after the expiry of 48 months for any pre-existing disease is subject to
the same being declared at the time of application and accepted by us.

ii. SPECIFIC WAITING PERIOD (Code- Excl02)

a. Expenses related to the treatment of the following listed conditions, surgeries / treatments shall
be excluded until the expiry of Ninety Days / 24 / 48 months of continuous coverage, as may be
the case after the date of inception of the first policy with the insurer. This exclusion shall not be
applicable for claims arising due to an accident.
b. In case of enhancement of sum insured the exclusion shall apply afresh to the extent of sum
insured increase.
c. If any of the specified disease/procedure falls under the waiting period specified for pre-existing
diseases, then the longer of the two waiting periods shall apply.
d. The waiting period for listed conditions shall apply even if contracted after the policy or declared
and accepted without a specific exclusion.
e. If the Insured Person is continuously covered without any break as defined under the applicable
norms on portability stipulated by IRDAI, then waiting period for the same would be reduced to
the extent of prior coverage.

(i) 90 Days Waiting Period

1. Diabetes Mellitus
2. Hypertension
3. Cardiac Conditions

(ii) 24 Months waiting period

1. All internal and external benign tumours, cysts, polyps of any kind, including benign breast
lumps

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NEW INDIA FLOATER MEDICLAIM POLICY
 2. Benign ear, nose, throat disorders
3. Benign prostate hypertrophy
4. Cataract and age related eye ailments
5. Gastric/ Duodenal Ulcer
6. Gout and Rheumatism
7. Hernia of all types
8. Hydrocele
9. Non Infective Arthritis
10. Piles, Fissures and Fistula in anus
11. Pilonidal sinus, Sinusitis and related disorders
12. Prolapse inter Vertebral Disc and Spinal Diseases unless arising from accident
13. Skin Disorders
14. Stone in Gall Bladder and Bile duct, excluding malignancy
15. Stones in Urinary system
16. Treatment for Menorrhagia/Fibromyoma, Myoma and Prolapsed uterus
17. Varicose Veins and Varicose Ulcers
18. Puberty and Menopause related Disorders
19. Behavioural and Neuro-Developmental Disorders:
a. Disorders of adult personality
b. Disorders of speech and language including stammering, dyslexia
20. Internal Congenital Diseases

(iii) 48 Months waiting period

1. Joint Replacement due to Degenerative Condition
2. Age-related Osteoarthritis & Osteoporosis
3. Treatment of mental illness, stress or psychological disorders and neurodegenerative
disorders.
4. Age Related Macular Degeneration (ARMD)
5. Genetic diseases or disorders
6. External Congenital Diseases

iii. FIRST THIRTY DAYS WAITING PERIOD (Code- Excl03)

a. Expenses related to the treatment of any illness within 30 days from the first policy
commencement date shall be excluded except claims arising due to an accident, provided the
same are covered.
b. This exclusion shall not, however, apply if the Insured Person has Continuous Coverage for more
than twelve months.
c. The within referred waiting period is made applicable to the enhanced sum insured in the event
of granting higher sum insured subsequently.

EXCLUSIONS
The Company shall not be liable to make any payment under the policy, in respect of any expenses
incurred in connection with or in respect of:

A. INVESTIGATION & EVALUATION (Code- Excl04)

a. Expenses related to any admission primarily for diagnostics and evaluation purposes.
b. Any diagnostic expenses which are not related or not incidental to the current diagnosis and
treatment

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 However, Treatment for any symptoms, Illness, complications arising due to physiological conditions for
which aetiology is unknown is not excluded. It is covered with a Sub-Limit of upto 10% of Sum Insured
per policy period.

B. REST CURE, REHABILITATION AND RESPITE CARE (Code- Excl05) Expenses related to any admission
primarily for enforced bed rest and not for receiving treatment. This also includes:
a. Custodial care either at home or in a nursing facility for personal care such as help with activities
of daily living such as bathing, dressing, moving around either by skilled nurses or assistant or non-
skilled persons.
b. Any services for people who are terminally ill to address physical, social, emotional and spiritual
needs.

However, Expenses related to any admission primarily for enteral feedings is not excluded, if the Oral
intake is absent for a period of at-least 5 days. It will be covered for a Maximum period of 14 days in a
Policy Period.

C. OBESITY/ WEIGHT CONTROL (Code- Excl06) Expenses related to the surgical treatment of obesity that
does not fulfil all the below conditions:
a. Surgery to be conducted is upon the advice of the Doctor
b. The surgery/Procedure conducted should be supported by clinical protocols
c. The member has to be 18 years of age or older and
d. Body Mass Index (BMI);
1. greater than or equal to 40 or
2. greater than or equal to 35 in conjunction with any of the following severe co-morbidities
following failure of less invasive methods of weight loss:
i. Obesity-related cardiomyopathy
ii. Coronary heart disease
iii. Severe Sleep Apnea
iv. Uncontrolled Type2 Diabetes

D. CHANGE-OF-GENDER TREATMENTS (Code- Excl07)

Expenses related to any treatment, including surgical management, to change characteristics of the
body to those of the opposite sex.

E. COSMETIC OR PLASTIC SURGERY (Code- Excl08)

Expenses for cosmetic or plastic surgery or any treatment to change appearance unless for
reconstruction following an Accident, Burn(s) or Cancer or as part of medically necessary treatment to
remove a direct and immediate health risk to the insured. For this to be considered a medical necessity,
it must be certified by the attending Medical Practitioner.

F. HAZARDOUS OR ADVENTURE SPORTS (Code- Excl09)

Expenses related to any treatment necessitated due to participation as a professional in hazardous or
adventure sports, including but not limited to, para-jumping, rock climbing, mountaineering, rafting,
motor racing, horse racing or scuba diving, hand gliding, sky diving, deep-sea diving.

However, Treatment related to Injury or Illness associated with Hazardous activities related to particular
line of employment or occupation (not for recreational purpose) is not excluded.

G. BREACH OF LAW (Code- Excl10)

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 Expenses for treatment directly arising from or consequent upon any Insured Person committing or
attempting to commit a breach of law with criminal intent.

H. EXCLUDED PROVIDERS (Code-Excl11)

Expenses incurred towards treatment in any hospital or by any Medical Practitioner or any other
provider specifically excluded by the Insurer and disclosed in its website / notified to the policyholders
are not admissible. However, in case of life-threatening situations or following an accident, expenses
up to the stage of stabilization are payable but not the complete claim.

I. Treatment for, Alcoholism, drug or substance abuse or any addictive condition and consequences
thereof. (Code- Excl12)

J. Treatments received in health hydros, nature cure clinics, spas or similar establishments or private
beds registered as a nursing home attached to such establishments or where admission is arranged
wholly or partly for domestic reasons. (Code- Excl13)

K. Dietary supplements and substances that can be purchased without prescription, including but not
limited to Vitamins, minerals and organic substances unless prescribed by a medical practitioner as
part of hospitalization claim or day care procedure. (Code- Excl14)

L. REFRACTIVE ERROR (Code- Excl15)

Expenses related to the treatment for correction of eye sight due to refractive error less than 7.5
dioptres.

M. UNPROVEN TREATMENTS (Code- Excl16)

Expenses related to any unproven treatment, services and supplies for or in connection with any
treatment. Unproven treatments are treatments, procedures or supplies that lack significant medical
documentation to support their effectiveness.

N. STERILITY AND INFERTILITY (Code- Excl17)

Expenses related to sterility and infertility. This includes:

a. Any type of contraception, sterilization

b. Assisted Reproduction services including artificial insemination and advanced reproductive
technologies such as IVF, ZIFT, GIFT, ICSI
c. Gestational Surrogacy
d. Reversal of sterilization

O. MATERNITY EXPENSES (Code - Excl18)

a. Medical treatment expenses traceable to childbirth (including complicated deliveries and
caesarean sections incurred during hospitalization) except ectopic pregnancy;
b. Expenses towards miscarriage (unless due to an accident) and lawful medical termination of
pregnancy during the policy period.

P. Acupressure, acupuncture, magnetic therapies.

Q. Any expenses incurred on Domiciliary Hospitalization.

R. Any kind of Service charges, Surcharges, Luxury Tax and similar charges levied by the Hospital.

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NEW INDIA FLOATER MEDICLAIM POLICY
S. Bodily Injury or Illness due to willful or deliberate exposure to danger (except in an attempt to save
human life), intentional self-inflicted Injury and attempted suicide.

However, Failure to seek or follow medical advice or failure to follow treatment is not excluded. It is
covered with a sub-limit of 10% of Sum Insured per policy period.

T. Circumcision unless necessary for treatment of an Illness not excluded hereunder or as may be
necessitated due to an accident.

U. Convalescence, General debility and Venereal disease.

V. Cost of braces, equipment or external prosthetic devices, non-durable implants, eyeglasses, Cost of
spectacles and contact lenses, hearing aids including cochlear implants, durable medical equipment.

W. Dental treatment or Surgery of any kind unless necessitated by accident and requiring Hospitalisation.

X. External and or durable Medical / Non-medical equipment of any kind used for diagnosis and or
treatment including CPAP (Continuous Positive Airway Pressure), Sleep Apnoea Syndrome, CPAD
(Continuous Peritoneal Ambulatory Dialysis), Oxygen Concentrator for Bronchial Asthmatic condition,
Infusion pump etc. Ambulatory devices i.e., walker, crutches, Belts, Collars, Caps, Splints, Slings,
Stockings, elastocrepe bandages, external orthopaedic pads, sub cutaneous insulin pump, Diabetic
foot wear, Glucometer / Thermometer, alpha / water bed and similar related items etc., and also any
medical equipment, which is subsequently used at home.

Y. Naturopathy Treatment.

Z. Nuclear, chemical or biological attack or weapons, contributed to, caused by, resulting from or from
any other cause or event contributing concurrently or in any other sequence to the loss, claim or
expense. For the purpose of this exclusion:
a. Nuclear attack or weapons means the use of any nuclear weapon or device or waste or
combustion of nuclear fuel or the emission, discharge, dispersal, release or escape of fissile/ fusion
material emitting a level of radioactivity capable of causing any Illness, incapacitating disablement
or death.
b. Chemical attack or weapons means the emission, discharge, dispersal, release or escape of any
solid, liquid or gaseous chemical compound which, when suitably distributed, is capable of causing
any Illness, incapacitating disablement or death.
c. Biological attack or weapons means the emission, discharge, dispersal, release or escape of any
pathogenic (disease producing) micro-organisms and/or biologically produced toxins (including
genetically modified organisms and chemically synthesized toxins) which are capable of causing
any Illness, incapacitating disablement or death.

AA. Stem cell implantation/Surgery for other than those treatments mentioned in Policy Clause 3.15.12

BB. Treatments such as Rotational Field Quantum Magnetic Resonance (RFQMR), External Counter
Pulsation (ECP), Enhanced External Counter Pulsation (EECP), Hyperbaric Oxygen Therapy

CC. Treatment taken outside the geographical limits of India

DD. Vaccination and/or inoculation

NIAHLIP21278V042021 Page 13 of 26
NEW INDIA FLOATER MEDICLAIM POLICY
EE. War (whether declared or not) and war like occurrence or invasion, acts of foreign enemies, hostilities,
civil war, rebellion, revolutions, insurrections, mutiny, military or usurped power, seizure, capture,
arrest, restraints and detainment of all kinds.

11. WHAT IS A PRE EXISTING DISEASE?

The term Pre-existing condition/disease is defined in the Policy. It eans any condition, ailment,
Injury or Illness

a. That is/are diagnosed by a physician within 48 months prior to the effective date of the Policy
issued by Us and its reinstatement or
b. For which medical advice or treatment was recommended by, or received from, a physician within
48 months prior to the effective date of the Policy or its reinstatement.

12. IS HOSPITALISATION ALWAYS NECESSARY TO GET A CLAIM?

Yes. Unless the Insured Person is Hospitalised for a condition warranting Hospitalisation, no
claim is payable under the Policy. The Policy does not cover outpatient treatments.

13. HOW LONG DOES THE INSURED PERSON NEED TO BE HOSPITALISED?

The Policy pays only where the Hospitalisation is for more than twenty four hours. But for
certain treatments specified in the Policy, period of stay at the Hospital could be less than
twenty four hours. The 24 hours treatments are according to the table given in Point 14
below.

14. WHAT ARE THE DAY CARE TREATMENTS COVERED UNDER THIS POLICY?
Following are the day-care treatments covered under this policy (treatments done within 24
hours)
1 Stapedotomy 2 Excision And Destruction Of A Lingual Tonsil
Other Operations On The Tonsils And
3 Stapedectomy 4
Adenoids
5 Revision Of A Stapedectomy 6 Incision On Bone, Septic And Aseptic
Closed Reduction On Fracture, Luxation Or
7 Other Operations On The Auditory Ossicles 8
Epiphyseolysis With Osteosynthesis
Suture And Other Operations On Tendons
9 Myringoplasty (Type -I Tympanoplasty) 10
And Tendon Sheath
Tympanoplasty (Closure Of An Eardrum
11 Perforation/Reconstruction Of The Auditory 12 Reduction Of Dislocation Under Ga
Ossicles)
13 Revision Of A Tympanoplasty 14 Arthroscopic Knee Aspiration
Other Microsurgical Operations On The
15 16 Incision Of The Breast
Middle Ear
17 Myringotomy 18 Operations On The Nipple
Incision And Excision Of Tissue In The Perianal
19 Removal Of A Tympanic Drain 20
Region
Incision Of The Mastoid Process And Middle
21 22 Surgical Treatment Of Anal Fistulas
Ear

NIAHLIP21278V042021 Page 14 of 26
NEW INDIA FLOATER MEDICLAIM POLICY
 23 Mastoidectomy 24 Surgical Treatment Of Haemorrhoids
Division Of The Anal Sphincter
25 Reconstruction Of The Middle Ear 26
(Sphincterotomy)
27 Other Excisions Of The Middle And Inner Ear 28 Other Operations On The Anus
29 Fenestration Of The Inner Ear 30 Ultrasound Guided Aspirations
31 Revision Of A Fenestration Of The Inner Ear 32 SclerotherapyEtc
Incision (Opening) And Destruction
33 34 Incision Of The Ovary
(Elimination) Of The Inner Ear
Other Operations On The Middle And Inner
35 36 Insufflation Of The Fallopian Tubes
Ear
Excision And Destruction Of Diseased Tissue
37 38 Other Operations On The Fallopian Tube
Of The Nose
39 Operations On The Turbinates (Nasal Concha) 40 Dilatation Of The Cervical Canal
41 Other Operations On The Nose 42 Conisation Of The Uterine Cervix
43 Nasal Sinus Aspiration 44 Other Operations On The Uterine Cervix
45 Incision Of Tear Glands 46 Incision Of The Uterus (Hysterotomy)
47 Other Operations On The Tear Ducts 48 Therapeutic Curettage
49 Incision Of Diseased Eyelids 50 Culdotomy
Excision And Destruction Of Diseased Tissue
51 52 Incision Of The Vagina
Of The Eyelid
Local Excision And Destruction Of Diseased
53 Operations On The Canthus And Epicanthus 54 Tissue Of The Vagina And The Pouch Of
Douglas
Corrective Surgery For Entropion And
55 56 Incision Of The Vulva
Ectropion
57 Corrective Surgery For Blepharoptosis 58 Operations On Bartholin’S Glands (Cyst)
Removal Of A Foreign Body From The
59 60 Incision Of The Prostate
Conjunctiva
Transurethral Excision And Destruction Of
61 Removal Of A Foreign Body From The Cornea 62
Prostate Tissue
Transurethral And Percutaneous Destruction
63 Incision Of The Cornea 64
Of Prostate Tissue
Open Surgical Excision And Destruction Of
65 Operations For Pterygium 66
Prostate Tissue
67 Other Operations On The Cornea 68 Radical Prostatovesiculectomy
Removal Of A Foreign Body From The Lens Of Other Excision And Destruction Of Prostate
69 70
The Eye Tissue
Removal Of A Foreign Body From The
71 72 Operations On The Seminal Vesicles
Posterior Chamber Of The Eye
Removal Of A Foreign Body From The Orbit
73 74 Incision And Excision Of Periprostatic Tissue
And Eyeball
75 Operation Of Cataract 76 Other Operations On The Prostate
Incision Of The Scrotum And Tunica Vaginalis
77 Incision Of A Pilonidal Sinus 78
Testis

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NEW INDIA FLOATER MEDICLAIM POLICY
 Other Incisions Of The Skin And Subcutaneous
79 80 Operation On A Testicular Hydrocele
Tissues
Local Excision Of Diseased Tissue Of The Skin Excision And Destruction Of Diseased Scrotal
81 82
And Subcutaneous Tissues Tissue
Other Excisions Of The Skin And Plastic Reconstruction Of The Scrotum And
83 84
Subcutaneous Tissues Tunica Vaginalis Testis
Simple Restoration Of Surface Continuity Of Other Operations On The Scrotum And Tunica
85 86
The Skin And Subcutaneous Tissues Vaginalis Testis
87 Free Skin Transplantation, Donor Site 88 Incision Of The Testes
Excision And Destruction Of Diseased Tissue
89 Free Skin Transplantation, Recipient Site 90
Of The Testes
91 Revision Of Skin Plasty 92 Unilateral Orchidectomy
Other Restoration And Reconstruction Of The
93 94 Bilateral Orchidectomy
Skin And Subcutaneous Tissues
95 Chemosurgery To The Skin 96 Orchidopexy
Destruction Of Diseased Tissue In The Skin
97 98 Abdominal Exploration In Cryptorchidism
And Subcutaneous Tissues
Incision, Excision And Destruction Of Diseased
99 100 Surgical Repositioning Of An Abdominal Testis
Tissue Of The Tongue
101 Partial Glossectomy 102 Reconstruction Of The Testis
Implantation, Exchange And Removal Of A
103 Glossectomy 104
Testicular Prosthesis
105 Reconstruction Of The Tongue 106 Other Operations On The Testis
Surgical Treatment Of A Varicocele And A
107 Other Operations On The Tongue 108
Hydrocele Of The Spermatic Cord
Incision And Lancing Of A Salivary Gland And
109 110 Excision In The Area Of The Epididymis
A Salivary Duct
Excision Of Diseased Tissue Of A Salivary
111 112 Epididymectomy
Gland And A Salivary Duct
113 Resection Of A Salivary Gland 114 Reconstruction Of The Spermatic Cord
Reconstruction Of A Salivary Gland And A Reconstruction Of The Ductus Deferens And
115 116
Salivary Duct Epididymis
Other Operations On The Salivary Glands And Other Operations On The Spermatic Cord,
117 118
Salivary Ducts Epididymis And Ductus Deferens
External Incision And Drainage In The Region
119 120 Operations On The Foreskin
Of The Mouth, Jaw And Face
Local Excision And Destruction Of Diseased
121 Incision Of The Hard And Soft Palate 122
Tissue Of The Penis
Excision And Destruction Of Diseased Hard
123 124 Amputation Of The Penis
And Soft Palate
Incision, Excision And Destruction In The
125 126 Plastic Reconstruction Of The Penis
Mouth
127 Plastic Surgery To The Floor Of The Mouth 128 Other Operations On The Penis
129 Palatoplasty 130 Cystoscopical Removal Of Stones
131 Other Operations In The Mouth 132 Lithotripsy

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NEW INDIA FLOATER MEDICLAIM POLICY
 Transoral Incision And Drainage Of A
133 134 Coronary Angiography
Pharyngeal Abscess
135 Tonsillectomy Without Adenoidectomy 136 Haemodialysis
137 Tonsillectomy With Adenoidectomy 138 Radiotherapy For Cancer
139 Parenteral Chemotherapy

15. WHAT DO I NEED TO DO IF ANYBODY COVERED IN THE POLICY NEEDS TO GET

HOSPITALISED?
Upon the happening of any event which may give rise to a claim under the policy, please
immediately intimate the TPA or underwriting office or nearest office of “The New India
Assurance Co. Ltd.”, whichever is applicable, named in the schedule with all the details such
as name of the Hospital, details of treatment, patient name, policy number etc.

In case of emergency Hospitalisation, this information needs to be given to the TPA or

underwriting office, whichever applicable, within 24 hours from the time of Hospitalisation.

This is an important condition that you need to comply with.

16. WHAT ARE THE AMBULANCE CHARGES PAID UNDER THIS POLICY?
Company will pay ambulance charges up to 1% of SI or actual whichever is less. These charges
are available in case of emergency extraction from anywhere to Hospital or Hospital to
Hospital.

17. IN CASE OF AYURVEDIC TREATMENT, WILL THE ENTIRE AMOUNT BE PAID?

The liability of the company in case of Ayurvedic/Homoeopathic/ Unani treatment will be 25%
of the Sum Insured provided the treatment is taken in a government Hospital or in any institute
recognized by government or accredited by Quality Council Of India or National Accreditation Board
on Health, excluding centers for spas, massage and health rejuvenation procedures.

18. IS PAYMENT AVAILABLE FOR EXPENSES INCURRED BEFORE HOSPITALISATION?

Yes. Medical Expenses incurred immediately before, but not exceeding thirty days, the Insured Person
is Hospitalised will be paid, provided that:

i. Such Medical Expenses are incurred for the same condition for which the Insured Person’s
Hospitalisation was required, and
ii. The In-patient Hospitalisation claim for such Hospitalisation is admissible by Us.

19. IS PAYMENT AVAILABLE FOR EXPENSES INCURRED AFTER HOSPITALISATION?

Yes. Medical Expenses incurred immediately after, but not exceeding sixty days, the Insured
Person is discharged from the Hospital will be paid, provided that:

i. Such Medical Expenses are incurred for the same condition for which the Insured Person’s
Hospitalisation was required, and
ii. The In-patient Hospitalisation claim for such Hospitalisation is admissible by Us.

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NEW INDIA FLOATER MEDICLAIM POLICY
 20. IS THERE A LIMIT TO WHAT THE COMPANY WILL PAY FOR HOSPITALISATION?
Yes. We will pay Hospitalisation expenses upto a limit, known as Sum Insured and Cumulative
Bonus. In cases where the Insured Person was Hospitalised more than once, the total of all
amounts paid

a) for all cases of Hospitalisation,

b) expenses paid for medical expenses prior to Hospitalisation, and
c) expenses paid for medical expenses after discharge from Hospital

Shall not exceed the Sum Insured and Cumulative Bonus

The Sum Insured under the policy is available for any or all the members covered for one or
more claims during the tenure of the policy.

21. CAN I GET TREATED ANYWHERE?

Yes, but the Policy covers treatment only in India.

22. WHAT SUM INSURED SHOULD I CHOOSE?

You are free to choose any Sum Insured from Rs. 2, 3, 5, 8, 10, 12 and 15 Lakhs. The premium
payable is determined on the respective Age of the member for the respective Sum Insured.
A discount on the number of members will be applied based on the number of members
covered, which is as under:

Discount on number 2 members 3 members 4 members & above

of members 5% 10% 15%

This above discount will be given in the total premium for all the members. For example for
a family of 5 and Sum Insured of 10 lakhs the premium calculation will be as under:

Proposer (46 years) : Rs. 13,812

Spouse (42 years) : Rs. 7,274
Child 1 (15 years) : Rs. 2,895
Child 2 (10 years) : Rs. 2,895
Parent (64 years) : Rs. 29,092
------------------------------------------------------
Total : Rs. 55,968
Disc (@ 15%) : Rs. 8,395
------------------------------------------------------
Gross Premium : Rs. 47,573

You are free to choose any Sum Insured available as specified above. But it is in your own
interest to choose the Sum Insured which could satisfy your present as well as future needs.

A digital discount of 10% is offered to customer taking fresh policy online through Company’s
Customer online Portal or Customer mobile app, as per directive of the government to
promote digital transactions.

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NEW INDIA FLOATER MEDICLAIM POLICY
 23. WHAT IS CUMULATIVE BONUS ?
The Sum Insured under Policy shall be increased by 25% at each renewal in respect of each
claim free year of insurance, subject to maximum of 50%. If a claim is made in any particular
year; the cumulative bonus accrued may be reduced at the same rate at which it is accrued.

Cumulative bonus will be lost if policy is not renewed before or within 30 days from the date
of expiry. In case sum insured under the policy is reduced at the time of renewal, the
applicable Cumulative Bonus percentage shall be applied on the reduced Sum Insured.

In case the insured is having more than one policy, the Cumulative Bonus shall be reduced
from the policy/policies in which claim is made irrespective of number of policies.

Note:

a. In case where the policy is on individual basis, the CB shall be added and available individually
to the insured person who has not claimed under the expiring policy.
b. In case where the policy is on floater basis, the CB shall be added and available to the family on
floater basis, provided no claim has been reported under the policy.
c. CB shall be available only if the Policy is renewed within the Grace Period.
d. If the Insured Persons in the expiring policy are covered on an individual basis as specified in the
Policy Schedule and there is an accumulated CB for each Insured Person under the expiring
policy, and such expiring policy has been Renewed on a floater policy basis as specified in the
Policy Schedule then the CB to be carried forward for credit in such Renewed Policy shall be the
Lowest among all the Insured Persons.
e. In case of floater policies where Insured Persons Renew their expiring policy by splitting the Sum
Insured in to two or more floater policies/individual policies, the same CB of the expiring policy
shall be apportioned to each Individual of such Renewed Policies.
f. If the Sum Insured has been reduced at the time of Renewal, the applicable Cumulative Bonus
percentage shall be applied on the reduced Sum Insured.
g. If the Sum Insured under the Policy has been increased at the time of Renewal the Cumulative
Bonus shall be calculated on the Sum Insured of the last completed Policy Year.
h. If a claim is made in the expiring Policy Year, and is notified to Us after the acceptance of
Renewal premium any awarded CB shall be withdrawn

24. HOW LONG IS THE POLICY VALID?

The Policy is valid during the Period of Insurance stated in the Schedule attached to the Policy.
It is usually valid for a period of one year from the date of beginning of insurance.

25. CAN THE POLICY BE RENEWED WHEN THE PRESENT POLICY EXPIRES?
Yes. You can and to get all Continuity benefits under the Policy, you should renew the Policy
before the expiry of the present policy. For instance, if Your Policy commences from 2nd
October, 2011 date of expiry is usually on 1st October, 2012. You should renew Your Policy
by paying the Renewal Premium on or before 1st October 2012.

In case of revision including premium or modification or withdrawal of the Policy a notice will
be provided to Insured Person, 90 days before such revision or modification or withdrawal.

NIAHLIP21278V042021 Page 19 of 26
NEW INDIA FLOATER MEDICLAIM POLICY
 You can choose to migrate to any of our existing Policy, subject to Regulations of IRDAI
(Protection of Policyholders’ Interest) Regulations, 2017 and the Guidelines of IRDAI on
Portability of Health Insurance Policies, as amended from time to time.

26. WHAT IS CONTINUITY BENEFIT?

There are certain treatments which are payable only after the Insured Person is continuously
covered for a specified period. For example, Cataract is covered only after twenty four months
of Continuous Coverage. If an Insured took a Policy in October, 2008, does not renew it on
time and takes a Policy only in December 2009, and renewed it on time in December 2010,
any claim for Cataract would not become payable, because the Insured Person was not
continuously covered for twenty four months. If, he had renewed the Policy in time in
October 2009 and then in October 2010, then he would have been continuously covered for
twenty four months and therefore his claim for Cataract in the Policy beginning from October
2010 would be payable. For other benefits under the Policy such as cost of health checkup,
Continuous Coverage is necessary. Therefore, you should always ensure that you pay your
renewal Premium before Your Policy expires.

27. IS THERE ANY GRACE PERIOD FOR RENEWAL OF THE POLICY?

Yes. If Your Policy is renewed within thirty days of the expiry of the previous Policy, then the
Continuity Benefits would not be affected. But even if You renew Your Policy within thirty
days of expiry of previous Policy, any Illness contracted or Injury sustained or Hospitalisation
commencing during the break in insurance is not covered. Therefore, it is in your own interest
to see that you renew the Policy before it expires.

28. CAN THE SUM INSURED BE INCREASED AT THE TIME OF RENEWAL?

Yes. You may seek enhancement of Sum Insured in writing before payment of premium for
renewal, which may be granted at Our discretion. Before granting such request for
enhancement of Sum Insured, We have the right to have You examined by a Medical
Practitioner authorized by Us or the TPA (50% of Medical examination cost will be reimbursed
to the Insured Person). Our consent for enhancement of Sum Insured is dependent on the
recommendation of the Medical Practitioner.

Enhancement of Sum Insured shall be allowed based on the following table:

Age<=50 years Enhancement up to Sum Insured of 15 lakhs without Medical Examination.

Age 51-60 Years Enhancement by two slabs without Medical Examination
Age 61-65 Years Enhancement by one slab with Medical Examination

Enhancement of Sum Insured will not be considered for:

1) Insured Persons over 65 years of age.

2) Insured Person who had undergone Hospitalization in the preceding two years.
3) Insured Persons suffering from one or more of the following Illnesses/Conditions:
a) Diabetes
b) Hypertension
NIAHLIP21278V042021 Page 20 of 26
NEW INDIA FLOATER MEDICLAIM POLICY
 c) Any chronic Illness/ Ailment
d) Any recurring Illness/ Ailment
e) Any Critical Illness

In respect of any increase in Sum Insured, exclusion 4.1, 4.2, 4.3.1 and 4.3.2 would apply to
the additional Sum Insured from the date of such increase.

29. IS THERE AN AGE LIMIT UPTO WHICH THE POLICY WOULD BE RENEWED?
No. Your Policy can be renewed, as long as you pay the Renewal Premium before the date of
expiry of the Policy. There is an age limit for taking a fresh Policy, but there is no age limit for
renewal.

Children between 18 years to 25 years can be continue to be covered in the Policy provided
they are financially dependent on the parents and one or both parents are covered
simultaneously. On attaining the age of 18 years or ceasing to be financially dependent on the
parents, they can, on renewal take a separate Policy. In such an event the benefits on
Continuous Coverage can be ported to the new Policy. The upper age limit will not apply to a
mentally challenged children and an unmarried dependent daughter(s).

If you do not renew Your Policy before the date of expiry or within thirty days of the date of
expiry, the Policy may not be renewed, and only a fresh Policy could be issued, subject to our
underwriting rules. In such cases, it is possible that a fresh Policy could not be issued by us. It
is therefore in your interest to ensure that Your Policy is renewed before expiry.

30. CAN THE INSURANCE COMPANY REFUSE TO RENEW THE POLICY?

We may refuse to renew the Policy only on rare occasions such as fraud, misrepresentation
or non-disclosure of material facts or non-cooperation being committed by You or any one
acting on Your behalf in obtaining insurance or subsequently in relation thereto. If we
discontinue selling this Policy, it might not be possible to renew this Policy on the same terms
and conditions. In such a case you shall, however, have the option for renewal under any
similar Policy being issued by the Company, provided the benefits payable shall be subject to
the terms contained in such other Policy.

31. CAN I MAKE A CLAIM IMMEDIATELY AFTER TAKING A POLICY?

Claims for Illnesses cannot be made during the first thirty days of a fresh Insurance policy.
However, claims for Hospitalisation due to accidents occurring even during the first thirty days
are payable. There are certain treatments where the waiting period is two years or four years.

32. WHAT IS THIRD PARTY ADMINISTRATOR (TPA)?

Third Party Administrator (TPA) is a service provider to facilitate service to you for providing
Cashless facility for all Hospitalisation that come under the scope of the policy. The TPA also
settles reimbursement claims within the scope of the Policy.

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NEW INDIA FLOATER MEDICLAIM POLICY
 33. WHAT IS CASHLESS HOSPITALISATION?
Cashless Hospitalisation is service provided by the TPA on Our behalf whereby you are not
required to settle the Hospitalisation expenses at the time of discharge from Hospital. The
settlement is done directly by the TPA on Our behalf. However those expenses which are not
admissible under the Policy would not be paid and you would have to pay such inadmissible
expenses to the Hospital. Cashless facility is available only in Networked Hospitals. Prior
approval is required from the TPA before the patient is admitted into the Networked Hospital.
You may visit our Website at http://newindia.co.in/listofhospitals.aspx. The list of Networked
Hospitals can also be obtained from the TPA or from their website. You will have full freedom
to choose the hospitals from the Networked Hospitals and avail Cashless facility on
production of proof of Insurance and Your identity, subject to the claim being admissible. The
TPA might not agree to provide Cashless facility at a Hospital which is not a Network Hospital.
In such cases you may avail treatment at any Hospital of Your choice and seek reimbursement
of the claim subject to the terms and conditions of the Policy. In cases where the admissibility
of the claim could not be determined with the available documents, even if the treatment is
at a Network Hospital, the TPA may refuse to provide Cashless facility. Such refusal may not
necessarily mean denial of the claim. You may seek reimbursement of the expenses incurred
by producing all relevant documents and the TPA may pay the claim, if it is admissible under
the terms and conditions of the Policy.

34. CAN I CHANGE HOSPITALS DURING THE COURSE OF MY TREATMENT?

Yes, it is possible to shift to another hospital for reasons of requirement of better medical
procedure. However, this will be evaluated by the TPA on the merits of the case and as per
policy terms and conditions.

35. HOW TO GET REIMBURSEMENTS IN CASE OF TREATMENT IN NON- NETWORK HOSPITALS

OR DENIAL OF CASHLESS FACILITY?
In case of treatment in a non-Network Hospital, TPA will reimburse You the amount of bills
subject to the conditions of the Policy. You must ensure that the Hospital where treatment is
taken fulfills the conditions of definition of Hospital in the Policy. Within twenty four hours of
Hospitalisation the TPA should be intimated. The following documents in original should be
submitted to the TPA within seven days from the date of Discharge from the Hospital:

i. Claim Form duly filled and signed by the claimant.

ii. Discharge Certificate from the hospital.
iii. All documents pertaining to the illness starting from the date it was first detected i.e.
Doctor's consultation reports/history.
iv. Bills, Receipts, Cash Memos from hospital supported by proper prescription.
v. Receipt and diagnostic test report supported by a note from the attending medical
practitioner/surgeon justifying such diagnostics.
vi. Surgeon's certificate stating the nature of the operation performed and surgeon's bill
and receipt.
vii. Attending doctor’s / consultant’s / specialist’s / anesthetist's bill and receipt, and
certificate regarding diagnosis.
NIAHLIP21278V042021 Page 22 of 26
NEW INDIA FLOATER MEDICLAIM POLICY
 viii. Details of previous policies, if the details are not already with TPA or any other
information needed by the TPA for considering the claim.

36. HOW TO GET REIMBURSEMENT FOR PRE AND POST HOSPITALISATION EXPENSES?
The Policy allows reimbursement of medical expenses incurred before and after admissible
Hospitalisation up to a certain number of days. For reimbursement, send all bills in original
with supporting documents along with a copy of the discharge summary and a copy of the
authorization letter to his/her TPA/underwriting office, whichever applicable. The bills must
be sent to the TPA/underwriting office within 7 days from the date of completion of
treatment. You must also provide the TPA/underwriting office with additional information
and assistance as may be required by the Company/TPA in dealing with the claim.

37. WILL THE ENTIRE AMOUNT OF THE CLAIMED EXPENSES BE PAID?

The entire amount of the claim is payable, if it is within the Sum Insured and is related with
the Hospitalisation as per Policy conditions and is supported by proper documents, except
the expenses which are excluded.

38. CAN ANY CLAIM BE REJECTED OR REFUSED?

Yes. A claim, which is not covered under the Policy conditions, can be rejected. Claims may
also be rejected in the event of misrepresentation, misdescription or nondisclosure of any material
fact/particular. In case You are not satisfied by the reasons for rejection, You can represent to
Us within 15 days of such denial. If You do not receive a response to Your representation or if
You are not satisfied with the response, You may write to our Grievance Cell, the details of
which are provided at our website at http://newindia.co.in/Content.aspx?pageid=73. You may
also call our Call Centre at the Toll free number 1800-209-1415, which is available 24x7.

You also have the right to represent Your case to the Insurance Ombudsman.

39. CAN I CANCEL THE POLICY?

Yes, You can. But the Refund that would be made in case the Policy is cancelled would not be
proportionate to the unexpired term of the Policy. Such Refund would be made only if no
claim has been made or paid under the Policy, and the Refund would be at our Short Period
rate table given below:

PERIOD ON RISK RATE OF PREMIUM TO BE CHARGED (RETAINED)

Up to one month 1/4th of the annual rate
Up to three months 1/2 of the annual rate
Up to six months 3/4th of the annual rate
Exceeding six months Full annual rate

The policy shall be null and void, and no benefits shall be payable in case of Fraud,
misrepresentation, misdescription or nondisclosure of any material fact / particular. Premium
paid shall also stand forfeited.

NIAHLIP21278V042021 Page 23 of 26
NEW INDIA FLOATER MEDICLAIM POLICY
 We may also at any time cancel the Policy on non-cooperation by You by sending fifteen days’
notice in writing by Registered A/D to You at the address stated in the Policy. Even if there
are several insured persons, notice will be sent to You.

On such cancellation, we shall allow refund of premium, if no claim has been made or paid
under the Policy, at short period rate which is tabulated above.

40. WHAT IS FREE LOOK PERIOD?

The free look period shall be applicable at the inception of first 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, then You shall be entitled to:

1) A refund of the premium paid less any expenses incurred by Us on medical examination
of the insured persons and the stamp duty charges or;
2) Where the risk has already commenced and the option of return of the policy is exercised
by the policyholder, a deduction towards the proportionate risk premium for period on
cover.

41. IS THERE ANY BENEFIT UNDER THE INCOME TAX ACT FOR THE PREMIUM PAID FOR THIS
INSURANCE?
Yes. Payments made for health insurance in any mode other than cash are eligible for
deduction from taxableincome as per Section 80 D of the Income Tax Act, 1961. For details,
please refer to the relevant Section of the Income Tax Act.

42. IS CONGENITAL DISEASES COVERED IN THE POLICY?

Yes. Congenital Internal Disease or Defects or anomalies shall be covered after twenty four
months of Continuous Coverage, if it was unknown to You or to the Insured Person at the
commencement of such Continuous Coverage. Exclusion for Congenital Internal Disease or
Defects or Anomalies would not apply to a New Born Baby during the year of Birth and also
subsequent renewals, if Premium is paid for such New Born Baby and the renewals are
effected before or within thirty days of expiry of the Policy.
Congenital External Disease or Defects or anomalies shall be covered after forty eight months
of Continuous Coverage, but such cover for Congenital External Disease or Defects or
anomalies shall be limited to 10% of the average Sum Insured in the preceding four years.

43. IF THE CLAIM EVENT FALLS WITHIN TWO POLICY PERIODS, HOW MUCH WILL BE PAID?
If the claim event falls within two policy periods, the claims shall be paid taking into
consideration the available Sum Insured of the expiring Policy only. Sum Insured of the
Renewed Policy will not be available for the Hospitalisation (including Pre & Post
Hospitalisation Expenses), which has commenced in the expiring Policy. Claim shall be settled
on per event basis.

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NEW INDIA FLOATER MEDICLAIM POLICY
 44. WHAT IS A PPN? CAN I GO FOR REIMBURSEMENT IN A PPN?
Preferred provider network (PPN) means network providers in specific cities which have agreed
to a cashless packaged pricing for specified planned procedures for the policyholders of the
Company. The list of planned procedures is available with the Company/TPA and subject to
amendment from time to time.

Yes, your claim will be admissible but Reimbursement of expenses incurred in PPN for the
procedures (as listed under PPN package) shall be subject to the rates applicable to PPN
package pricing.

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NEW INDIA FLOATER MEDICLAIM POLICY
 New India Floater Mediclaim Policy - Premium Chart
PREMIUM PER MEMBER (Excluding GST)
Sum Insured (Rs.) 2,00,000 3,00,000 5,00,000 8,00,000 10,00,000 12,00,000 15,00,000
1,380 1,731 2,183 2,686 3,040 3,281 3,509
<18
2,636 3,345 4,255 5,268 5,980 6,466 6,925
18-35
3,345 4,255 5,424 6,724 7,638 8,262 8,852
36-45
6,279 8,022 10,262 12,752 14,503 15,700 16,827
46-50
9,298 11,900 15,240 18,955 21,567 23,352 25,034
51-55
10,262 13,137 16,827 20,934 23,820 25,792 27,653
56-60
13,137 16,827 21,567 26,839 30,547 33,078 35,467
61-65

Sum Insured OPTIONAL COVER I : NO PROPORTIONATE DEDUCTION

(Rs.) <35 36-45 46-50 51-55 56-60 61-65 >65
2,00,000 1,418 1,506 2,483 3,741 4,852 6,419 9,201
3,00,000 980 1,040 1,715 2,584 3,351 4,434 6,355
5,00,000 770 817 1,348 2,031 2,634 3,485 4,995
8,00,000 646 686 1,131 1,704 2,210 2,924 4,191
10,00,000 662 703 1,159 1,747 2,265 2,997 4,296
12,00,000 644 684 1,127 1,699 2,203 2,915 4,178
15,00,000 458 487 802 1,209 1,568 2,075 2,974

OPTIONAL COVER II : MATERNITY EXPENSES BENEFIT

5,00,000 8,00,000 10,00,000 12,00,000 15,00,000
5,000 8,000 10,000 12,000 15,000

Sum Insured OPTIONAL COVER III : REVISION IN LIMIT OF CATARACT

(Rs.) <50 51-55 56-60 61-65 >65
8,00,000 444 1,049 2,269 3,645 3,893
10,00,000 555 1,311 2,836 4,556 4,866
12,00,000 666 1,573 3,404 5,467 5,839
15,00,000 832 1,967 4,255 6,834 7,299

Once the Insured Person crosses the age of 65 years, the applicable premium on renewal will be loaded
by 2.5% per year. This loading is applicable on premium for the age band of 61 years to 65 years.

Discount on number 2 members 3 members 4 members & above

of members 5% 10% 15%

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NEW INDIA FLOATER MEDICLAIM POLICY