HDFC ERGO General Insurance Company Limited

HDFC Group Health Insurance - Prospectus

Key features of the policy: (namely a sudden, urgent, unexpected occurrence or event, bodily
1. Entry age limit of 65 years with lifetime renewal alteration or occasion requiring immediate medical attention)
2. Various optional covers available such as Hospital Cash, Cumulative ii. or from one Hospital to another Hospital
Bonus etc. iii. or from Hospital to Home (within same City) following
3. 100% Sum Insured Restore Benefit available. Hospitalization
4. PED coverage after 48 months. 7. Organ Donor Expenses
5. Option to pay premium in monthly, quarterly and half-yearly We will pay Medical Expenses covered under Section A1 towards organ
installments donor’s Hospitalization for harvesting of the donated organ where an
Insured Person is the recipient subject to condition that;
SECTION A. GOLD PLAN i. The organ donor is any person whose organ has been made
available in accordance and in compliance with The Transplantation
We will pay under below listed Covers on Medically Necessary of Human Organ (amendment) Act, 2011, Transplantation of Human
Hospitalization of an Insured Person due to Illness or Injury sustained or Organs and Tissues Rules, 2014 and other applicable Laws and/
contracted during the Period of Insurance subject to terms and conditions or Regulations.
as listed below.
ii. Hospitalization Claim under Section A1 is admissible under the
1. In-Patient Hospitalization coverage for the Insured Person
i. Room Rent and boarding charges up to 1% of Base Sum Insured, iii. The Organ Donor’s Pre-Hospitalization and Post-Hospitalization
subject to a maximum limit of INR 3000 per day Medical Expenses are excluded under the Policy.
ii. Intensive Care Unit charges up to 2% of Base Sum Insured iv. Any other Medical Expenses or Hospitalization consequent to the
iii. Consultation fees & Nursing charges harvesting is excluded under the Policy.
iv. Anesthesia, blood, oxygen, operation theatre charges, surgical
appliances charges SECTION B. PLATINUM PLAN
v. Medicines, drugs and consumables We will pay under below listed Covers on Medically Necessary
vi. Diagnostic procedures Hospitalization of an Insured Person due to Illness or Injury sustained or
contracted during the Period of Insurance subject to terms and conditions
vii. The Cost of prosthetic and other Medical devices or equipment
as listed below.
if implanted internally during a Surgical Procedure.
1. In-Patient Hospitalization
a. Special Conditions
i. Room Rent and boarding charges
i. Room Rent & Proportionate deduction:
ii. Intensive Care Unit charges
In case of admission to a room at rates exceeding the aforesaid
limits, the reimbursement/payment of Room Rent charges iii. Consultation fees & Nursing charges
including all Associated Medical Expenses incurred at Hospital iv. Anesthesia, blood, oxygen, operation theatre charges, surgical
shall be effected in the same proportion as the admissible rate appliances charges
per day bears to the actual rate per day of Room Rent charges. v. Medicines, drugs and consumables
This condition is not applicable in respect of Hospitals where
differential billing for Associated Medical Expenses is not followed vi. Diagnostic procedures
based on Room category. vii. The Cost of prosthetic and other Medical devices or equipment
if implanted internally during a Surgical Procedure.
ii. Mental Illness
The Coverage for Mental illness is applicable if done in Mental a. Special Conditions
Health Establishment and is subject to the provisions contained in i. Mental Illness
the Mental Health Care Act, 2017, as amended from time to time The Coverage for Mental illness is applicable if done in Mental
and other applicable laws and Regulations. Health Establishment and is subject to the provisions contained in
2. Pre-Hospitalization Medical Expenses Cover the Mental Health Care Act, 2017, as amended from time to time
and other applicable laws and Regulations.
We will pay for the Pre-Hospitalization Medical Expenses incurred
during the 60 days immediately before Hospitalization of an Insured 2. Pre-Hospitalization Medical Expenses cover
Person. We will pay for the Pre-Hospitalization Medical Expenses incurred
3. Post-Hospitalization Medical Expenses Cover during the 60 days immediately before Hospitalization of an Insured
Person.
We will pay for the Post-Hospitalization Medical Expenses incurred
upto 90 days from the date Insured Person is discharged from Hospital. 3. Post-Hospitalization Medical Expenses cover
4. Day Care Procedures We will pay for the Post- Hospitalization Medical Expenses incurred
upto 180 days from the date Insured Person is discharged from
We will pay for the Medical Expenses under Section A1 on Hospital.
Hospitalization of Insured Person in Hospital or Day Care Centre for
Day Care Treatment. 4. Day Care Procedures
5. Domiciliary Hospitalization We will pay for the Medical Expenses under Section B1 on
Hospitalization of Insured Person in Hospital or Day Care Centre for
We will pay the Medical Expenses incurred on Domiciliary Day Care Treatment.
Hospitalization of the Insured Person presecribed by treating Medical
Practitioner. 5. Domiciliary Hospitalization
6. Road Ambulance Cover We will pay the Medical Expenses incurred on Domiciliary
Hospitalization of the Insured Person presecribed by treating Medical
For each admissible Claim under Section A1 and A4, We will pay for Practitioner.
expenses incurred on Road Ambulance Services if Insured Person is
required; 6. Road Ambulance Cover
i. to be transferred to the nearest Hospital following an emergency For each admissible Claim under Section B1 and B4, We will pay for

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No. 146. CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, 165-166 Backbay Reclamation,
H. T. Parekh Marg, Churchgate, Mumbai – 400 020. For more details on the risk factors, terms and conditions, please read the policy document carefully before concluding a sale. Trade Logo 1
displayed above belongs to HDFC Bank Ltd and ERGO International AG and used by the Company under license. UIN: HDFC Group Health Insurance - HDFHLGP21116V012021.
 HDFC ERGO General Insurance Company Limited

HDFC Group Health Insurance - Prospectus

expenses incurred on Road Ambulance Services if Insured Person is ii. Cumulative Bonus will be reduced at the same rate as accrued in
required; the event of admissible Claim under the Coverage.
i. to be transferred to the nearest Hospital following an emergency iii. Cumulative Bonus can be accumulated upto the limit mentioned
(namely a sudden, urgent, unexpected occurrence or event, bodily on the Schedule of Coverage in the Policy Schedule/Certificate
alteration or occasion requiring immediate medical attention) of Insurance.
ii. or from one Hospital to another Hospital iv. Cumulative Bonus applied will be applicable only to Insured
iii. or from Hospital to Home (within same City) following Person(s) covered under the expiring Coverage and who continue
Hospitalization to remain insured on Renewal.

7. Organ Donor Expenses 3. Hospital Cash

We will pay Medical Expenses covered under Section B1 towards organ If Insured Person contracts Illness or sustains Injury during Period of
donor’s Hospitalization for harvesting of the donated organ where an Insurance, which results in Medically Necessary;
Insured Person is the recipient subject to condition that; i. Hospitalization
i. The organ donor is any person whose organ has been made ii. Domiciliary Hospitalization
available in accordance and in compliance with The Transplantation iii. Hospitalization for Alternative Treatments of an Insured Person
of Human Organ (amendment) Act, 2011, Transplantation of Human within India, We will pay per day Sum Insured as specified on
Organs and Tissues Rules, 2014 and other applicable Laws and/ the Schedule of Coverage in the Policy Schedule/Certificate
or Regulations. of Insurance subject to maximum number of benefit days for
ii. Hospitalization Claim under Section B1 is admissible under the each continuous and completed period of 24 hours of such
coverage for the Insured Person Hospitalization.
iii. The Organ Donor’s Pre-Hospitalization and Post-Hospitalization 4. Restore Benefit
Medical Expenses are excluded under the Policy. Instant addition of 100% Base Sum Insured on complete or partial
iv. Any other Medical Expenses or Hospitalization consequent to the utilization of Your existing Policy Sum Insured and Cumulative Bonus
harvesting is excluded under the Policy. (if applicable) during the Policy Year. The Total amount (Base Sum
Insured, Cumulative Bonus and Restore Sum Insured) will be available
SECTION C. OPTIONAL COVER to all Insured Persons for all claims under the Coverage during the
current Policy Year and subject to the condition that single claim in
Insuring Clause a Policy Year cannot exceed the sum of Base Sum Insured and the
In consideration of payment of additional Premium or reduction in the Cumulative Bonus (if applicable).
Premium as applicable, it is hereby declared and agreed that We will Conditions for Restore benefit:
pay/restrict the expenses under below listed Covers subject to waiting
periods and limits as specified on the Schedule of Coverage in the Policy a. The Sum Insured will be restored only once in a Policy Year.
Schedule/Certificate of Insurance. b. If the Restored Sum Insured is not utilized in a Policy Year, it will
Subject to otherwise all other terms, conditions, exclusions and waiting expire.
periods applicable to the Policy. In case of a Family Floater Policy, Restore Sum Insured will be
These Covers are optional and applicable only if opted for and upto the available on floater basis for all Insured Persons in the Policy.
Sum Insured or limits mentioned on the Schedule of Coverage in the Policy 5. Waiting period Modification Option
Schedule/Certificate of Insurance. On availing this option, Waiting Periods listed under Section D.I.i shall
1. Preventive Health Check Up stand modified as mentioned in Schedule of Coverage on the Policy
Schedule/ Certificate of Insurance.
We will indemnify the Insured Person towards the cost of Preventive
Health Check – Up, up to the limit mentioned on the Schedule of All other terms and Conditions of the Policy shall remain unaltered.
Coverage in the Policy Schedule/Certifiate of Insurance. 6. Specific Illness Waiting period Modification Option
Other terms and Conditions applicable to this Coverage On availing this option, Waiting Periods listed under Section D.I.ii shall
• The Coverage will be applicable as per the eligibility as mentioned stand modified as mentioned in Schedule of Coverage on the Policy
on the Schedule of Coverage in the Policy Schedule/Certificate Schedule/Certificate of Insurance.
of Insurance. All other terms and Conditions of the Policy shall remain unaltered.
• In case of Annual Eligibility, the percentage and limit will be
7. Alternative Treatment
calculated on expiring Coverage Sum Insured and will be only
applicable to Insured Person covered under expiring Coverage, We will pay Medical Expenses covered under Section A or B as opted,
subject to no claim under Base Coverage. only on Medically Necessary In-patient care treatment of Insured
Person in Ayush Hospital upto the limit mentioned on the Schedule of
• In case of Eligibility at the end of each block of continuous years
Coverage in the Policy Schedule/Certificate of Insurance for following
(as mentioned on the Schedule of Coverage), the percentage and
Alternative Treatments prescribed by Medical Practitioner:
limit will be calculated on Average Sum Insured during block of
three years and will be only applicable to Insured Person covered • Ayurvedic
for all previous 3 years. • Unani
• Claim under this Cover does not impact the Sum Insured or the • Siddha
eligibility for Cumulative Bonus.
• Homeopathy
• The test reports received under this Coverage will not be utilized
• Yoga & Naturopathy
for re-underwriting the expiring coverage of Insured Person
Note : Alternative Treatment is no longer an optional cover. Basis CIR. Ref.
2. Cumulative Bonus IRDAI/HLT/CIR/GDL/31/01/2024 issued by IRDAI, all Insured Persons shall
On each continuous Renewal of the Coverage with Us, We will apply be covered by default for In-patient care expenses under this cover upto
10% of Base Sum Insured under expiring Cover as Cumulative Bonus Sum Insured of Gold Plan or Platinum Plan as opted.
in the Coverage provided that; Details mentioned in the Policy Schedule against this cover shall be
i. There has been no claim under the Coverage in expiring year. superceded by the above wordings.

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No. 146. CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, 165-166 Backbay Reclamation,
2 H. T. Parekh Marg, Churchgate, Mumbai – 400 020. For more details on the risk factors, terms and conditions, please read the policy document carefully before concluding a sale. Trade Logo
displayed above belongs to HDFC Bank Ltd and ERGO International AG and used by the Company under license. UIN: HDFC Group Health Insurance - HDFHLGP21116V012021.
HDFC ERGO General Insurance Company Limited

HDFC Group Health Insurance - Prospectus

Surgical Procedures
SECTION D. WHAT IS NOT COVERED
We will not make payment for any claim in respect of any Insured Person Adenoidectomy, Tympanoplasty, Hernia
caused by, arising from or attributable to any of the following unless tonsillectomy Mastoidectomy
expressly stated to the contrary in the Policy Dilatation and Nasal concha resection Surgery for
curettage (D&C) prolapsed inter
I. Waiting Periods
vertebral disc
Claims under the Policy are covered subject to Waiting Period as
specified below: Myomectomy for Surgery of Genito Surgery for varicose
fibroids urinary system veins and varicose
i) Pre-existing Diseases – Code – Excl01 ulcers
a) Expenses related to the treatment of a pre-existing disease Surgery on Cholecystectomy Surgery for Perianal
(PED) and its direct complications shall be excluded until the prostate Abscesses
expiry of 48 months of continuous coverage after the date of
inception of the first Policy with insurer. Hydrocele/ Joint replacement Surgery for Nasal
Rectocele surgeries septum deviation
b) In case of enhancement of Sum Insured the exclusion shall
apply afresh to the extent of sum of Sum Insured increase. Ligament, Tendon Hysterectomy Fissurectomy,
and Meniscal tear Haemorrhoidectomy,
c) If the Insured Person is continuously covered without any Fistulectomy, ENT
break as defined under the portability norms of the extant surgeries
IRDAI (Health Insurance) Regulations, then waiting period for
the same would be reduced to the extent of prior coverage. Endometriosis Prolapsed Uterus Rectal Prolapse
d) Coverage under the Policy after the expiry of 48 months for Varicocele Retinal detachment Glaucoma
any pre-existing disease is subject to the same being declared
Nasal polypectomy
at the time of application and accepted by Insurer.
ii) Specified Disease/Procedure waiting period - Code - Excl02 iii) 30-day waiting period – Code – Excl03
a) Expenses related to the treatment of the listed Conditions, a) Expenses related to the treatment of any Illness within 30 days
surgeries/treatments shall be excluded until the expiry of 24 from the first Policy commencement date shall be excluded
months of continuous coverage after the date of inception of except claims arising due to an Accident, provided the same
are covered.
the first Policy with us. This exclusion shall not be applicable
for claims arising due to an Accident. b) This exclusion shall not, however, apply if the Insured Person
has continuous coverage for more than twelve months.
b) In case of enhancement of Sum Insured the exclusion shall
apply afresh to the extent of Sum Insured increase. c) The within referred waiting period is made applicable to the
enhanced Sum Insured in the event of granting higher Sum
c) If any of the specified disease/procedure falls under the
Insured subsequently.
waiting period specified for Pre-existing diseases, then the
longer of the two waiting periods shall apply. II. Permanent Exclusions
d) The waiting period for listed conditions shall apply even if We will not make any payment for any claim in respect of any Insured
contracted after the Policy or declared and accepted without Person caused by, arising from or attributable to any of the following
a specific exclusion. unless expressly stated to the contrary in this Policy:
e) If the Insured Person is continuously covered without any i. Investigation & Evaluation: Code - Excl04
break as defined under the applicable norms on portability a. Expenses related to any admission primarily for diagnostic
stipulated by IRDAI, then waiting period for the same would and evaluation purposes only are excluded.
be reduced to the extent of prior coverage.
b. Any diagnostic expenses which are not related or not
Illnesses incidental to the current diagnosis and treatment are excluded.

Diseases of gall Non infective Arthritis Pilonidal sinus ii. Rest Cure, rehabilitation and respite care: Code – Excl05:
bladder including Expenses related to any admission primarily for enforced bed
cholecystitis rest and not for receiving treatment. This also includes:
a. Custodial care either at home or in a nursing facility for
Pancreatitis calculus diseases of Benign tumors, cysts, personal care such as help with activities of daily living such
Urogenital system e.g. nodules, polyps as bathing, dressing, moving around either by skilled nurses
Kidneystone, Urinary including breast or assistant or non-skilled persons.
Bladder Stone lumps
b. Any services for people who are terminally ill to address
All forms of Ulcer and erosion Polycystic ovarian physical, social, emotional and spiritual needs.
Cirrhosis of stomach and diseases
iii. Obesity/Weight control: Code – Excl06: Expenses related to
duodenum
the surgical treatment of obesity that does not fulfil all the below
Perineal Abscesses Gastro Esophageal Sinusitis, Rhinitis conditions:
Reflux Disorder (GERD) a. Surgery to be conducted is upon the advice of the doctor
Cataract Perianal Abscesses Skin tumors b. The surgery/procedure conducted should be supported by
clinical protocols
Osteoarthritis and Fissure/fistula in anus, Tonsillitis
c. The member has to be 18 years of age or older and
osteoporosis Haemorrhoids including
Gout and rheumatism d. Body Mass Index (BMI)
i. Greater than or equal to 40 or,
Fibroids Benign Hyperplasia of
(fibromyoma) Prostate ii. 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:
HDFC ERGO General Insurance Company Limited. IRDAI Reg. No. 146. CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, 165-166 Backbay Reclamation,
H. T. Parekh Marg, Churchgate, Mumbai – 400 020. For more details on the risk factors, terms and conditions, please read the policy document carefully before concluding a sale. Trade Logo 3
displayed above belongs to HDFC Bank Ltd and ERGO International AG and used by the Company under license. UIN: HDFC Group Health Insurance - HDFHLGP21116V012021.
 HDFC ERGO General Insurance Company Limited

HDFC Group Health Insurance - Prospectus

iii. Obesity related cardiomyopathy xvi. War or any act of war (whether war be declared or not or caused
iv. coronary heart disease during service in the armed forces of any country), invasion, act
of foreign enemy, civil war, public defence, rebellion, revolution,
v. severe sleep apnoea insurrection, military or usurped acts, Nuclear, Chemical or Biological
vi. uncontrolled type2 diabetes attack or weapons, radiation of any kind.
xvii. Any Insured Person committing or attempting to commit intentional
iv. Change-of-Gender treatments: Code – Excl07: Expenses related
self-injury or attempted suicide or suicide while mentally sound or
to any treatment, including surgical management, to change
unsound.
characteristics of the body to those of the opposite sex.
xviii. Any Insured Person’s participation or involvement in naval, military
v. Cosmetic or plastic surgery: Code – Excl08: Expenses for cosmetic
or air force operation.
or plastic surgery or any treatment to change appearance unless for
reconstruction following an Accident, Burn(s) or Cancer or as part of xix. Investigative treatment for Sleep-apnoea, General debility or
Medically Necessary Treatment to remove a direct and immediate exhaustion (“run-down condition”).
health risk to the insured. For this to be considered a medical xx. Congenital external diseases, defects or anomalies,
necessity, it must be certified by the attending Medical Practitioner.
xxi. Stem cell harvesting.
vi. Hazardous or Adventure Sports: Code – Excl09– Expenses related
to any treatment necessitated due to participation as a professional xxii. Investigative treatments for analysis and adjustments of spinal
in Hazardous or Adventure sports, including but not limited to, para- subluxation, diagnosis and treatment by manipulation of the skeletal
jumping, rock climbing, mountaineering, rafting, motor racing, horse structure or for muscle stimulation by any means except treatment
racing or scuba diving, hand gliding, sky diving, deep sea diving. of fractures (excluding hairline fractures) and dislocations of the
mandible and extremities).
vii. Breach of Law: Code – Excl10 - Expenses for treatment directly
arising from or consequent upon any Insured Person committing xxiii. Circumcisions (unless necessitated by Illness or Injury and forming
or attempting to commit a breach of law with criminal intent. part of treatment).

viii. Excluded Providers: Code – Excl11- Expenses incurred towards xxiv. Any Convalescence, sanatorium treatment, private duty nursing or
treatment in any hospital or by any Medical Practitioner or any other long-term nursing care.
provider specifically excluded by the Insurer and disclosed in its xxv. Preventive care, and other nutritional and electrolyte supplements,
website/notified to the policyholders are not admissible. However, in unless certified to be required by the attending Medical Practitioner
case of life threatening situations or following an Accident, expenses as a direct consequence of an otherwise covered claim.
up to the stage of stabilization are payable but not the complete
xxvi. Vaccination including inoculation and immunisations (Except post
claim.
Animal bite treatment),
ix. Treatment for Alcoholism, drug or substance abuse or any addictive
xxvii. Non-Medical expenses such as Food charges (other than patient’s
condition and consequences thereof. Code – Excl12
diet provided by hospital), laundry charges, attendant charges,
x. Treatments received in health hydros, nature cure clinics, spas or ambulance collar, ambulance equipment, baby food, baby utility
similar establishments or private beds registered as a nursing home charges and other such items. Full list of Non-Medical expenses is
attached to such establishments or where admission is arranged available at www.hdfcergo.com.
wholly or partly for domestic reasons. Code – Excl13
xxviii. Treatment taken on Outpatient basis.
xi. Dietary supplements and substances that can be purchased without
xxix. The provision or fitting of hearing aids, spectacles or contact lenses.
prescription, including but not limited to Vitamins, minerals and
organic substances unless prescribed by a Medical Practitioner as xxx. Any treatment and associated expenses for alopecia, baldness
part of Hospitalization claim or day care procedure. Code – Excl14 including corticosteroids and topical immunotherapy wigs, toupees,
hair pieces, any non-surgical hair replacement methods, Optometric
xii. Expenses related to the treatment for correction of eye sight due
therapy.
to refractive error less than 7.5 dioptres. Code – Excl15
xxxi. Any treatment or part of a treatment that is not of a Reasonable and
xiii. Unproven Treatments: Code – Excl16 - Expenses related to any
Customary charge, not Medically Necessary; treatments or drugs
unproven treatment, services and supplies for or in connection with
not supported by a prescription.
any treatment. Unproven treatments are treatments, procedures
or supplies that lack significant medical documentation to support xxxii. Expenses for Artificial limbs or and/or device used for diagnosis
their effectiveness. or treatment (except when used intra-operatively).prosthesis,
corrective devices, external durable medical equipment of any
xiv. Sterility and Infertility: Code – Excl17 - Expenses related to sterility
kind, wheelchairs, crutches, and oxygen concentrator for bronchial
and infertility. This includes:
asthma/ COPD conditions, cost of cochlear implant(s) unless
a. Any type of contraception, sterilization necessitated by an Accident. Exhaustive list of Non-Medical
b. Assisted Reproduction services including artificial insemination Expenses also available on www.hdfcergo.com.
and advanced reproductive technologies such as IVF, ZIFT, xxxiii. Any Claim arising due to Non-disclosure of Pre-existing Illness or
GIFT, ICSI Material fact as sought to be declared on the Proposal form.
c. Gestational Surrogacy
d. Reversal of sterilization

xv. Maternity: 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.

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No. 146. CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, 165-166 Backbay Reclamation,
4 H. T. Parekh Marg, Churchgate, Mumbai – 400 020. For more details on the risk factors, terms and conditions, please read the policy document carefully before concluding a sale. Trade Logo
displayed above belongs to HDFC Bank Ltd and ERGO International AG and used by the Company under license. UIN: HDFC Group Health Insurance - HDFHLGP21116V012021.
HDFC ERGO General Insurance Company Limited

HDFC Group Health Insurance - Prospectus

SECTION E. CLAIMS PROCEDURE

1. Notification of a Claim

Procedure Cashless Hospitalization

Reimbursement Claims
Emergencies Planned

Claim Intimation
You shall intimate the Claims to us through any available mode of communication as specified in the Policy, Health Card or our Website

Within 48 hours of admission

Within 24 hours of the Emergency At least 72 hours prior to the
Claim Intimation Timelines or before discharge from the
Hospitalization planned Hospitalization
Hospital, whichever is earlier

i. The health card issued by Us

ii. KYC documents
iii. The Policy Number
iv. Name of the Policyholder
Particulars to be provided to us for v. Name and address of Insured Person
claim notification vi. Nature of the Illness/Injury and the treatment required
vii. Name and address of the attending Medical Practitioner
viii. Name of Hospital for admission/treatment
ix. Proposed /Actual Date of admission
x. MLC/FIR copy/certificate regarding abuse of Alcohol/intoxicating agent if applicable (in case of an injury).

i. Copy of Discharge Summary / Discharge Certificate along with time of admission and discharge
ii. First consultation letter from treating Medical Practitioner
iii. Certificate from treating Medical Practitioner, specifying the duration and aetiology
Hospital Cash
iv. MLC/FIR copy/certificate regarding abuse of Alcohol/intoxicating agent if applicable (in case of an injury).
v. NEFT details & cancelled cheque of Claimant or Nominee (in case claimant expired),
vi. legal heir certificate in case nominee is minor.

i. Policy Number
ii. Name of the Insured person(s)
Particulars to be provided for pre- iii. Nature of disease/Illness/Injury
Not Applicable
authorization iv. Name and address of the attending Medical Practitioner / Hospital
v. Date of admission & probable date of discharge
vi. Approximate Claim Expenses

Any other relevant information as required Not Applicable

On receipt of duly filled pre authorization form and other details, We

may;
• Issue the authorization letter specifying the sanctioned amount,
Process for pre-authorization limitation, and non-payable items, if applicable Not Applicable
Or
• Reject the request for pre-authorization specifying reasons for the
rejection.

List of Claim documents Not Applicable As enlisted below

If the claim is not notified/ or submitted to Us within the specified time limits, then We shall be provided the
Condonation of Delay reasons for the delay in writing. We will condone such delay on merits where the delay has been proved to
be for reasons beyond the claimant’s control

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No. 146. CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, 165-166 Backbay Reclamation,
H. T. Parekh Marg, Churchgate, Mumbai – 400 020. For more details on the risk factors, terms and conditions, please read the policy document carefully before concluding a sale. Trade Logo 5
displayed above belongs to HDFC Bank Ltd and ERGO International AG and used by the Company under license. UIN: HDFC Group Health Insurance - HDFHLGP21116V012021.
 HDFC ERGO General Insurance Company Limited

HDFC Group Health Insurance - Prospectus

2. List of documents for Reimbursement Claims We will condone such delay on merits where the delay has been
i. Completely filled claim form, duly signed (by claimant/proposer) proved to be for reasons beyond the claimant’s control
and stamped (by Hospital). 4. Payment of a Claim
ii. Photo ID & Age Proof i. If there are any deficiencies in the necessary claim documents
iii. Copy of claim intimation letter / reference of Claim Intimation which are not met or are partially met, We will send a maximum of
Number in the absence of main claim documents 3 (three) reminders following which We will send a closure letter
iv. Copy of the Hospital’s Registration Certificate/Hospital Registration or make a part-payment if We have not received the deficiency
number in case of Hospitalization in any non-network hospital of documents after 45 days from the date of the initial request for
HDFC ERGO GIC or certificate from Hospital authorities providing such documents
facilities available including number of beds. ii. The Company shall settle or reject a claim, as the case may be,
v. Discharge Card / Day Care Summary / Transfer Summary within 30 days from the date of receipt of last necessary document.
vi. Final hospital bill with all deposit and final payment receipt and iii. In the case of delay in the payment of a claim, the Company shall
refund receipt(s), if advance amount refunded be liable to pay interest to the Policyholder/Insured Person from
the date of receipt of last necessary document to the date of
vii. Invoice with payment receipt and implant stickers for all implants payment of claim at a rate 2% above the Bank Rate.
used during surgeries e.g. lens sticker and invoice in cataract
Surgery, stent invoice and sticker in Angioplasty Surgery. iv. However, where the circumstances of a claim warrant an
investigation in the opinion of the Company, it shall initiate and
viii. All previous consultation papers indicating history and treatment complete such investigation at the earliest, in any case not later
details for current Illness and advice for current hospitalization. than 30 days from the date of receipt of last necessary document.
ix. All diagnostic reports (including imaging and laboratory) along with In such cases, the Company shall settle or reject the claim within
prescription by Medical Practitioner and invoice / bill with receipt 45 days from the date of receipt of last necessary document.
from diagnostic centre v. In case of delay beyond stipulated 45 days, the Company shall be
x. All medicine / pharmacy bills along with prescription by Medical liable to pay interest to the Policyholder/Insured Person at a rate
Practitioner 2% above the Bank Rate from the date of receipt of last necessary
xi. MLC / FIR Copy – in Accidental cases only document to the date of payment of claim.
xii. History of alcohol consumption or any intoxication certified by first vi. If We, for any reason decide to reject the claim, the reasons
treating doctor in case of accidental cases. regarding the rejection shall be communicated to You in writing
within 30 days of the receipt of documents.
xiii. Copy of Death Summary and copy of Death Certificate (in death
claims only) vii. If requested by Us, at Our cost, the Insured Person must submit to
medical examination by Our Medical Practitioner as often as We
xiv. Pre and Post-Operative Imaging reports
consider reasonable and necessary and We/Our representatives
xv. Copy of indoor case papers with nursing sheet detailing medical must be permitted to inspect the medical and Hospitalization
history of the patient, treatment details, and patient’s progress (to records pertaining to the Insured Person’s treatment and to
be submitted wherever required by the insurer). investigate the circumstances pertaining to the claim.
xvi. Invoice for Vaccination and payment receipt viii. We and Our representatives must be given all reasonable co-
xvii. KYC documents (in all claims above Rs 1 lakh) - (Ration Card/ Driving operation in investigating the claim in order to assess Our liability
License/ Aadhar Card/ Passport /any other Government authorized and quantum in respect of the claim
identity proof of the Claimant carrying name, photograph &
address) and duly filled KYC form with 1 signed across passport SECTION F. GENERAL CONDITIONS
size coloured photograph of the Claimant ***
xviii. Duly filled NEFT form with cancelled blank cheque (with IFSC 1. Entry Age:
code, A/C number, and name mentioned on cheque leaf) Base Cover:
xix. Settlement letter(s), copy (-ies) of payment receipts, and entire
Proposer Adult Dependent Child/Children
certified copy of paid claims in case of partial claim settlement
from other insurer. • Minimum Entry • Minimum Entry • Minimum Entry
*** In case of death of Insured Person, the same document reuqirement Age – 18 Years Age – 18 Years Age – 91 days
would be for nominee/legal heir of Insured Person (NOC in favour of 1 • Maximum Entry • Maximum Entry • Maximum Entry
or more than 1 undisputedly selected legal heir(s) by remanining legal Age – 65 Years Age - 65 Years Age - 25 years
heir(s).
Optional covers:
3. Conditions for obtaining Cashless facility
i. Cashless facility can be availed only at Our Network Provider. Proposer Adult Dependent Child/Children
The complete list of Network Providers and empanelled Service • Minimum Entry • Minimum Entry • Minimum Entry
Providers is available on Our website and can be obtained by Age – 18 Years Age – 18 Years Age – 91 days
contacting Us.
• Maximum Entry • Maximum Entry • Maximum Entry
ii. We reserve the right to modify, add or restrict any Network Provider Age – 65 Years Age - 65 Years Age - 25 years
for Cashless Facilities at Our sole discretion. The same shall be
duly updated on Our website. You shall check the updated list of 2. Type of Policy:
Network Providers before applying for Cashless Claim.
Individual and Family Floater
iii. Pre-authorization is valid for 15 days from date of issuance and
if all the details of the Hospitalization/treatment, including dates, 3. Coverage for dependents:
Hospital and locations match with the details as per Cashless • Floater Sum Insured Option: Self, Spouse, Dependent Children*
authorized. and Dependent Parents.
iv. We will make payment for the Cashless authorized amount directly • Dependent children: A child is considered a dependent for
to the Network Provider. insurance purposes until his 25th birthday (even if not enrolled in
v. If the claim is not notified to Us within the specified time limits, an educational institution) provided he is financially dependent,
then We shall be provided the reasons for the delay in writing. on the proposer.

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No. 146. CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, 165-166 Backbay Reclamation,
6 H. T. Parekh Marg, Churchgate, Mumbai – 400 020. For more details on the risk factors, terms and conditions, please read the policy document carefully before concluding a sale. Trade Logo
displayed above belongs to HDFC Bank Ltd and ERGO International AG and used by the Company under license. UIN: HDFC Group Health Insurance - HDFHLGP21116V012021.
HDFC ERGO General Insurance Company Limited

HDFC Group Health Insurance - Prospectus

4. Policy period Guidelines for Pre Policy Check up

This policy can be issued for 1 year • Pre Policy Check-up will be conducted at our Network provider
5. Sum Insured Options • Where ever Pre Policy Check-up is conducted at our Network
provider, 100% of the Medical test charges will be reimbursed on
• 1 lac
acceptance of proposal. In case Customer Insists on a Check-up
• 2 lacs outside our Network provider, 50% of the Medical test charges
• 3 lacs will be reimbursed on acceptance of Proposal.
• 4 lacs • If Proposal is declined post Pre Policy Check-up, 50% of the
• 5 lacs Medical test charges incurred will be reimbursed

• 7.5 lacs • Medical Reports are considered valid for up to 3 months

• 10 lacs • In case of any positive health declaration on the proposal form the
relevant medical tests shall be advised in addition to the above
• 15 lacs grid tests
• 20 lacs • In case of any additional tests advised besides the ones mentioned
• 25 lacs above,100% of the cost incurred on such test will be borne by
• 50 lacs customer

6. Sum Insured for Optional Covers 8. Non - Disclosure or Misrepresentation

i. If at the time of issuance of Policy or during continuation of the
1% of Base Sum Insured, max upto INR 2000 Policy, the information provided to Us in the Proposal Form or
Preventive during block of 3 years otherwise, by You or the Insured Person or anyone acting on behalf
Health Check of You or an Insured Person, is found to be incorrect, incomplete,
Up 1% of Base Sum Insured, max upto INR 7500 for
every claim free year suppressed or not disclosed, wilfully or otherwise, the Policy shall
be:
Cumulative 10% max up to a) cancelled ab initio from the inception date or the Renewal
10% max up to 100%
Bonus 50% date (as the case may be), or the Policy may be modified by
Per day Sum Us at Our sole discretion, upon 30 day notice by sending an
Hospital Cash 500 1000 endorsement to Your address shown in the Policy Schedule/
Insured in `
Certificate of Insurance, and
Restore Benefit 100% of Basic Sum Insured b) the claim under such Policy if any, shall be prejudiced.
Waiting Period ii. We may also exercise any of the below listed options for the
Modification 3 years 2 years 1 year purpose of continuing the health insurance coverage in case
Option of Non-Disclosure/ Misrepresentation of Pre-existing Diseases
subject to your prior consent;
Specific Illness
1 Year a) Permanently exclude the disease/condition and continue with
Waiting Period
the Policy
10% of Base Sum Insured b) Incorporate additional waiting period of not exceeding 4 years
for the said undisclosed disease or condition from the date
Alternative 25% of Base Sum Insured
the non-disclosed condition was detected and continue with
Treatment 50% of Base Sum Insured the Policy.
c) Levy underwriting loading from the first year of issuance of
100% of Base Sum Insured
Policy or renewal, whichever is later.
7. Pre-Policy Check Up The above options will not prejudice the rights of the Company
The PPC tests required will be as per the below PPC grid. This grid to invoke cancellation under clause 1 i above.
may be subject to change based on the company policy in future &
9. Disclosure of Information
will be guided by our experience
The Policy shall be void and all premium paid thereon shall be forfeited
PED/BMI SI Upto 55 years > 55 years to the Company in the event of misrepresentation, mis description or
non- disclosure of any Material Fact by the Policyholder.
Tele MER followed
Tele MER and PPC 10. Condition Precedent to Admission of Liability
1-3 Lac by PPC (if Required)
(Set 3)
(Set 2) The terms and conditions of the Policy must be fulfilled by the Insured
Yes Person for the Company to make any payment for claim(s) arising
Tele MER followed
under the Policy.
>4 Lac by PPC (if Required) PPC (Set 3)
(Set 2) 11. Complete Discharge
Tele MER and PPC Any payment to the Policyholder, Insured Person or his/ her nominees
1-3 Lac STP or his/ her legal representative or assignee or to the Hospital, as the
NO (Set 2)
case may be, for any benefit under the Policy shall be a valid discharge
>4 Lac STP PPC (Set 2) towards payment of claim by the Company to the extent of that amount
for the particular claim.
Set 1: ME, RUA, CBC, Sr Creatinine, Lipid Profile, SGPT, GGTP, SGOT,
HBA1C, ECG 12. Multiple Policies
Set 2: ME, RUA, CBC, Sr Creatinine, Lipid Profile, SGPT, GGTP, SGOT, i. In case of multiple policies taken by an Insured Person during a
HBA1C, ECG, HBsAg, TMT/2D Echo, USG Abdomen & Pelvis, period from one or more insurers to indemnify treatment costs,
Chest X ray, CEA the Insured Person shall have the right to require a settlement of
his/her claim in terms of any of his/her policies. In all such cases
Set 3: Set 2, PSA (Males), Pap Smear & Sonomamography (Females),
the Insurer chosen by the Insured Person shall be obliged to settle
Micro albumin, BUN, Sr Uric Acid, ANA
HDFC ERGO General Insurance Company Limited. IRDAI Reg. No. 146. CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, 165-166 Backbay Reclamation,
H. T. Parekh Marg, Churchgate, Mumbai – 400 020. For more details on the risk factors, terms and conditions, please read the policy document carefully before concluding a sale. Trade Logo 7
displayed above belongs to HDFC Bank Ltd and ERGO International AG and used by the Company under license. UIN: HDFC Group Health Insurance - HDFHLGP21116V012021.
 HDFC ERGO General Insurance Company Limited

HDFC Group Health Insurance - Prospectus

the claim as long as the claim is within the limits of and according Insured. We will not apply any additional loading on YourPolicy
to the terms of the chosen Policy. premium at Renewal based on claim experience in YourPolicy.
ii. Insured Person having multiple policies shall also have the right to iv. We will inform You about the proposed loading with time bound
prefer claims under this Policy for the amounts disallowed under exclusion (if any) through a counter offer letter and will issue the
any other Policy / policies even if the sum insured is not exhausted. Policy only on Your acceptance within 15 days of the receipt of such
Then the Insurer shall independently settle the claim subject to counter offer letter. In case, You neither accept the counter offer
the terms and conditions of this Policy. nor revert to Us within 15 days, We shall cancel Your application
iii. If the amount to be claimed exceeds the Sum Insured under a and refund the premium paid within next 7 days.
single Policy, the Insured Person shall have the right to choose 17. Renewal of Policy
Insurer from whom he/she wants to claim the balance amount.
The Company shall be under no obligation to renew the Policy/
iv. Where an Insured Person has policies from more than one Insurer Coverage on expiry of the period for which premium has been
to cover the same risk on indemnity basis, the Insured Person shall paid. The Company reserves the right to offer revised rates, terms
only be indemnified the treatment costs in accordance with the and conditions at renewal based on claim experience and a fresh
terms and conditions of the chosen Policy. assessment of the risk. This Policy may be renewed only by mutual
13. Moratorium Period consent and subject to payment in advance of the total premium at
the rate in force at the time of renewal. The Company, however, shall
After completion of eight continuous years under the Policy, no look not be bound to give notice that the Policy is due for Renewal or to
back to be applied. This period of eight years is called as Moratorium accept any Renewal premium. Unless renewed as herein provided, this
Period. The moratorium would be applicable for the Sums Insured of Policy shall automatically terminate at the expiry of the Policy Period/
the first Policy and subsequently completion of 8 continuous years Coverage Period.
would be applicable from date of enhancement of Sums Insured
only on the enhanced limits. After the expiry of Moratorium Period 18. Grace Period
no health insurance claim shall be contestable except for proven i. A Grace Period of 30 days is available for Renewal of the Coverage.
fraud and permanent exclusions specified in the Policy contract. The Any Illness, disease or condition contracted during Grace Period
policies would however be subject to all limits, sub limits, co-payments, will not be covered and will be treated as Pre-existing diseases.
deductibles as per the Policy contract.
ii. For Renewal received after completion of Grace Period, the
14. Fraud Coverage would be considered as fresh without any Renewal
If any claim made by the Insured Person, is in any respect fraudulent, benefits
or if any false statement, or declaration is made or used in support iii. For Policies on instalment basis, Grace Period is available as given
thereof, or if any fraudulent means or devices are used by the Insured below.
Person or anyone acting on his/her behalf to obtain any benefit under
this Policy, all benefits under this Policy and the premium paid shall Instalment Premium Option Grace Period applicable
be forfeited. Half Yearly 30 days
Any amount already paid against claims made under this Policy but
Quarterly 30 days
which are found fraudulent later shall be repaid by all recipient(s)/
policyholder(s), who has made that particular claim, who shall be jointly Monthly 15 days
and severally liable for such repayment to the Insurer.
For the purpose of this clause, the expression “fraud” means any of 19. Free look period
the following acts committed by the Insured Person or by his agent The Free Look Period shall be applicable on new individual health
or the Hospital/doctor/any other party acting on behalf of the Insured insurance policies and not on renewals or at the time of porting/
Person, with intent to deceive the Insurer or to induce the Insurer to migrating the Policy.
issue an insurance Policy: The Insured Person shall be allowed Free Look period of fifteen days
a) the suggestion, as a fact of that which is not true and which the from date of receipt of the Policy document to review the terms and
Insured Person does not believe to be true; conditions of the Policy, and to return the same if not acceptable.
b) the active concealment of a fact by the Insured Person having If the Insured has not made any claim during the Free Look Period,
knowledge or belief of the fact; the Insured shall be entitled to
c) any other act fitted to deceive; and i. a refund of the premium paid less any expenses incurred by the
d) any such act or omission as the law specially declares to be Company on medical examination of the Insured Person and the
fraudulent stamp duty charges or

The Company shall not repudiate the claim and / or forfeit the Policy ii. where the risk has already commenced and the option of return of
benefits on the ground of fraud, if the Insured Person / beneficiary can the Policy is exercised by the Insured Person, a deduction towards
prove that the misstatement was true to the best of his knowledge the proportionate risk premium for period of cover or
and there was no deliberate intention to suppress the fact or that iii. Where only a part of the insurance coverage has commenced,
such misstatement of or suppression of Material fact are within the such proportionate premium commensurate with the insurance
knowledge of the Insurer. coverage during such period.

15. Geography 20. Migration

This Policy only covers Medical Treatment taken within India. The Insured Person will have the option to migrate the Policy to other
health insurance products/plans offered by the Company by applying
16. Loadings for Migration of the Policyatleast30 days before the Policy renewal
i. We may apply loading on the premium, based on the declarations date as per IRDAI guidelines on Migration. If such person is presently
made in the proposal form and the health status, habits and covered and has been continuously covered without any lapses under
lifestyle, past medical records, and the results of the Pre-Policy any health insurance product/plan offered by the Company, the Insured
medical examination of the persons proposed for insurance. Person will get the accrued continuity benefits in waiting periods as
ii. The maximum Medical Underwriting loading shall not exceed 100% per IRDAI guidelines on Migration.
for each condition and a total of 150% for each Insured Person For Detailed Guidelines on Migration, kindly refer the link
iii. Loadings will be applied from Commencement date of the Policy https://www.irdai.gov.in/ADMINCMS/cms/frmGuidelines_Layout.
including subsequent Renewal(s) with Us or on increased Sum aspx?page=PageNo3987

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No. 146. CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, 165-166 Backbay Reclamation,
8 H. T. Parekh Marg, Churchgate, Mumbai – 400 020. For more details on the risk factors, terms and conditions, please read the policy document carefully before concluding a sale. Trade Logo
displayed above belongs to HDFC Bank Ltd and ERGO International AG and used by the Company under license. UIN: HDFC Group Health Insurance - HDFHLGP21116V012021.
HDFC ERGO General Insurance Company Limited

HDFC Group Health Insurance - Prospectus

21. Portability ii. The Company may cancel the Policy at any time on grounds
The Insured Person will have the option to port the Policy to other of misrepresentation non-disclosure of Material Facts, Fraud
insurers by applying to such Insurer to port the entire Policy along by the Insured Person by giving 15 days’ written notice. There
with all the members of the family, if any, at least 45 days before, but would be no refund of premium on cancellation on grounds of
not earlier than 60 days from the Policy renewal date as per IRDAI misrepresentation, non-disclosure of Material Facts or Fraud.
guidelines related to Portability. If such person is presently covered 24. Premium Payment in Instalments
and has been continuously covered without any lapses under any
If the Insured Person has opted for Payment of Premium on an
health insurance Policy with an Indian General/Health insurer, the
instalment basis i.e. Half Yearly, Quarterly or Monthly, as mentioned
proposed Insured Person will get the accrued continuity benefits in
in the Policy
waiting periods as per IRDAI guidelines on Portability.
Schedule/Certificate of Insurance, the following Conditions shall apply
For Detailed Guidelines on Portability, kindly refer the link (notwithstanding any terms contrary elsewhere in the Policy)
https://www.irdai.gov.in/ADMINCMS/cms/frmGuidelines_Layout.
aspx?page=PageNo3987 i. Grace Period as mentioned in the table below would be given to
pay the instalment premium due for the Policy.
22. Endorsements
Options Installment Grace Period
The following endorsements are permissible during the Policy Period:
Premium Option applicable
Non-Financial Endorsements – which do not affect the premium
Option 1 Half Yearly 30 days
i. Minor rectification/correction in name of the Proposer / Insured
Person (and not the complete name change) Option 2 Quarterly 30 days
ii. Rectification in gender of the Insured Person Option 3 Monthly 15 days
iii. Rectification in relationship of the Insured Person with the Proposer ii. During such Grace Period, coverage will not be available from the
iv. Rectification of date of birth of the Insured Person (if this does not due date of instalment premium till the date of receipt of premium
impact the premium) by Company.
v. Change in the correspondence address of the Insured Person/ iii. The Insured Person will get the accrued continuity benefit in
Proposer(if this does not impact the premium) respect of the “Waiting Periods”, “Specific Waiting Periods” in the
vi. Change in Nominee Details event of payment of premium within the stipulated Grace Period.

vii. Change in Height, weight, marital status (if this does not impact iv. No interest will be charged If the instalment premium is not paid
the premium) on due date.
v. In case of instalment premium due not received within the Grace
viii. Change in bank details
Period, the Policy will get cancelled.
ix. Any other non-financial endorsement
vi. In the event of a claim, all subsequent premium installments shall
Financial Endorsements – which result in alteration in premium immediately become due and payable.
i. Change in Age/date of birth vii. The Company has the right to recover and deduct all the pending
ii. Change in Height, weight installments from the claim amount due under the Policy.
iii. Addition of Insured Person (New Born Baby or newly wedded 25. Possibility of Revision of Terms of the Policy Including the Premium
spouse) Rates
iv. Deletion of Insured Person on death or Marital separation The Company, with prior approval of IRDAI, may revise or modify the
v. Any other financial endorsement terms of the Policy including the premium rates. The Insured Person
shall be notified three months before the changes are effected.
The Policyholder/Insured Person shall apply in a proposal form along
with birth Certificate / marriage certificate as the case may be for 26. Withdrawal of Policy
addition of Insured person. i. In the likelihood of this product being withdrawn in future, the
23. Cancellation Company will intimate the Insured Person about the same 90
days prior to expiry of the Policy.
i. The Policholder may cancel this Policy by giving 15days’ written
notice and in such an event, the Company shall refund premium ii. Insured Person will have the option to migrate to similar
for the unexpired Policy Period as detailed below. health insurance product available with the Company at the
time of Renewal with all the accrued continuity benefits such
For Policies where instalment option is not availed, We will refund as Cumulative Bonus, waiver of waiting period as per IRDAI
premium in accordance with the table below: guidelines, provided the Policy has been maintained without a
break.
Month % Refund
Up to 1 month 85.0% 27. Nomination
The Policyholderis required at the inception of the Policy to make a
Up to 3 month 70.0%
nomination for the purpose of payment of claims under the Policy in
Up to 6 month 45.0% the event of death of the Policyholder. Any change of nomination shall
be communicated to the Company in writing and such change shall
Up to 12 month 0.0%
be effective only when an endorsement on the Policy is made. In the
For Policies where Premium is paid by instalment, 50% of current event of death of the Policyholder, the Company will pay the nominee
instalment premium will be refunded when the current period is {as named in the PolicySchedule/PolicyCertificate/Endorsement (if
less than 6 months in to the Policy Year. For instalment after 6 any)} and in case there is no subsisting nominee, to the legal heirs
months, no refund will be payable. or legal representatives of the Policyholderwhose discharge shall be
treated as full and final discharge of its liability under the Policy.
Notwithstanding anything contained herein or otherwise, no
refunds of premium shall be made in respect of Cancellation 28. Claim Settlement (provision for Penal Interest)
where, any claim has i. The Company shall settle or reject a claim, as the case may be,
been admitted or has been lodged or any benefit has been availed within 30 days from the date of receipt of last necessary document.
by the Insured Person under the Policy. ii. In the case of delay in the payment of a claim, the Company shall
HDFC ERGO General Insurance Company Limited. IRDAI Reg. No. 146. CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, 165-166 Backbay Reclamation,
H. T. Parekh Marg, Churchgate, Mumbai – 400 020. For more details on the risk factors, terms and conditions, please read the policy document carefully before concluding a sale. Trade Logo 9
displayed above belongs to HDFC Bank Ltd and ERGO International AG and used by the Company under license. UIN: HDFC Group Health Insurance - HDFHLGP21116V012021.
 HDFC ERGO General Insurance Company Limited

HDFC Group Health Insurance - Prospectus

be liable to pay interest to the Policyholder from the date of receipt Annexure I – Plan Chart
of last necessary document to the date of payment of claim at a
rate 2% above the Bank Rate. Base Hospitalisation Group Health Product
Cover
iii. However, where the circumstances of a claim warrant an Gold Plan Platinum Plan
investigation in the opinion of the Company, it shall initiate and
In-Patient Covered Up-to Sum Covered Up-to Sum
complete such investigation at the earliest, in any case not later
Hospitalisation Insured Insured
than 30 days from the date of receipt of last necessary document.
In such cases, the Company shall settle or reject the claim within Room Rent Limit (Per 1% of Base SI, max At Actuals
45 days from the date of receipt of last necessary document. Day) 3,000
iv. In case of delay beyond stipulated 45 days, the Company shall be ICU Limit (Per Day) 2% of Base SI At Actuals
liable to pay interest to the Policyholder at a rate 2% above the
Bank Rate from the date of receipt of last necessary document Pre Hospitalisation 60 60
to the date of payment of claim. (Days)
Post Hospitalisation 90 180
29. Disclaimer applicable to HDFC ERGO Mobile App and associated
(Days)
services
It is agreed and understood that Our HDFC ERGO Mobile App intention Day Care Procedures All Day Care All Day Care
is not to provide specific medical advice but rather to provide users Treatments covered Treatments covered
with information to better understand their health and their diagnosed Domiciliary Treatment Covered Up-to Sum Covered Up-to Sum
disorders. The information is not a substitute for professional medical Insured Insured
care by a qualified doctor or other health care professional.
Organ Donor Covered Up-to Sum Covered Up-to Sum
The information provided is general in nature and is not specific to
Expenses Insured Insured
you. You must never rely on any information obtained using this app
for any medical diagnosis or recommendation for medical treatment Ambulance Cover Upto 2,000/ Upto 2,000/
or as an alternative to medical advice from your physician or other hospitalisation hospitalisation
professional healthcare provider. If you think you may be suffering from
any medical condition you should seek immediate medical attention.
Reliance on any information on this App is solely at your own risk. Optional Covers
HDFC EGRO General Insurance Company Limited do not assume 1% of Base Sum Insured, max upto INR 2000
any liability towards any loss or damage arising out of or in relation to Preventive during block of 3 years
any opinion, actual or alleged errors, omissions and representations, Health Check
any decision made or action taken or not taken in reliance upon the Up 1% of Base Sum Insured, max upto INR 7500 for
information. every claim free year

30. Communication & Notice Cumulative 10% max up to

10% max up to 100%
Bonus 50%
Policy and any communication related to the Policy shall be sent to
through electronic modes or to the address of the Insured as recorded Per day Sum
Hospital Cash 500 1000
in the Policy. Insured in `

Section 41 of Insurance Act 1938 (Prohibition of Rebates): Up to maximum number of 30 days

1. No person shall allow or offer to allow, either directly or indirectly, as an Restore Benefit 100% of Basic Sum Insured
inducement to any person to take or renew or continue an insurance
Waiting Period
in respect of any kind of risk relating to lives or property in India, any
Modification 3 years *2 years *1 year
rebate of the whole or part of the commission payable or any rebate
Option
of premium shown on the policy, nor shall any person taking out or
renewing or continuing a policy accept any rebate, except such rebate Specific Illness
1 Year
as may be allowed in accordance with the prospectus or tables of the Waiting Period*
insurers.
10% of Base Sum Insured
2. Any person making default in complying with the provision of this
section shall be punishable with fine which may extend to Ten Lakh Alternative 25% of Base Sum Insured
Rupees. Treatment 50% of Base Sum Insured
IRDAI Regulation no 5 - This policy is subject to regulation 5 of IRDAI 100% of Base Sum Insured
(Protection of Policyholder’s Interests).
*Only applicable for Sum Insured greater than INR 4 lacs

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No. 146. CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, 165-166 Backbay Reclamation,
10 H. T. Parekh Marg, Churchgate, Mumbai – 400 020. For more details on the risk factors, terms and conditions, please read the policy document carefully before concluding a sale. Trade Logo
displayed above belongs to HDFC Bank Ltd and ERGO International AG and used by the Company under license. UIN: HDFC Group Health Insurance - HDFHLGP21116V012021.