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Policy Document
ROYAL SUNDARAM GENERAL INSURANCE CO. LTD
Registered office: No. 21, Patullos Road, Chennai- 600 002
Corporate Office: Vishranthi Melaram Towers, No. 2/319, Rajiv Gandhi Salai (OMR), Karapakkam, Chennai- 600
097
Part II- Policy Document
Section 1 Terms & Conditions
Preamble Clause- The insurance cover provided under this Policy to the Insured Person up to the Sum Insured is
and shall be subject to (a) the terms and conditions of this Policy and (b) the receipt of premium, and (c) Disclosure
to Information Norm (including by way of the Proposal or Information Summary Sheet) for Yourself and on behalf
of all persons to be insured. Please inform Us immediately of any change in the address, nature of job, state of health,
or of any other changes affecting You or any Insured Person.
If any Claim arising as a result of an Illness or Injury that occurred during the Policy Period becomes payable, then
We shall pay the Benefits in accordance with terms, conditions and exclusions of the Policy subject to availability of
Sum Insured and Cumulative Bonus (if any).
Section 2 Interpretations & Definitions (Operational Clause)
The terms defined below have the meanings ascribed to them wherever they appear in this Policy and, where
appropriate, references to the singular include references to the plural, references to the male include the female and
references to any statutory enactment include subsequent changes to the same:
Def. 1. Accident or Accidental means sudden, unforeseen and involuntary event caused by external, visible and
violent means.
Def. 2. Alternative Treatments are forms of treatments other than treatment "Allopathy" or "modern medicine"
and includes Ayurveda, Unani, Sidha and Homeopathy in the Indian context.
Def. 3. AYUSH Hospital:
An AYUSH Hospital is a healthcare facility wherein medical/surgical/para surgical treatment procedures
and interventions are carried out by AYUSH Medical Practitioner(s) comprising of any of the following:
a) Central or State Government AYUSH Hospital; or
b) Teaching hospital attached to AYUSH College recognized by the Central Government/Central
Council of Indian Medicine/Central Council for Homeopathy; or
c) AYUSH Hospital, standalone or co-located with in-patient healthcare facility of any recognized
system of medicine, registered with the local authorities, wherever applicable, and is under the
supervision of a qualified registered AYUSH Medical Practitioner and must comply with all the
following criterion :
i.Having at least 5 in-patient beds;
ii.Having qualified AYUSH Medical Practitioner in charge round the clock;
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iii.Having dedicated AYUSH therapy sections as required and/or has equipped operation theatre where
surgical procedures are to be carried out;
iv.Maintaining daily records of the patients and making them accessible to the insurance company’s
authorized representative.
Def.4. AYUSH Day Care Centre:
AYUSH Day Care Centre means and includes Community Health Centre (CHC), Primary Health Centre
(PHC), Dispensary, Clinic, Polyclinic or any such health centre which is registered with the local authorities,
wherever applicable and having facilities for carrying out treatment procedures and medical or surgical/para-
surgical interventions or both under the supervision of registered AYUSH Medical Practitioner (s) on day
care basis without in-patient services and must comply with all the following criterion:
i. Having qualified registered AYUSH Medical Practitioner(s) in charge;
ii. Having dedicated AYUSH therapy sections as required and/or has equipped operation theatre where
surgical procedures are to be carried out;
iii. Maintaining daily records of the patients and making them accessible to the insurance company’s
authorized representative.
Def. 5. Break in Policy means the period of gap that occurs at the end of the existing policy term, when the premium
due for renewal on a given policy is not paid on or before the premium renewal date.
Def. 6. Base Sum Insured means the amount specified as Sum Insured at the inception of a Policy Year and in the
event the Policy is upgraded or downgraded on any continuous Renewal, then exclusive of Cumulative Bonus,
if any, the Sum Insured for which premium is paid at the commencement of the Policy Year for which the
prevalent upgrade or downgrade is sought.
Def. 7. Cashless Facility means a facility extended by the insurer to the insured where the payments, of the costs
of treatment undergone by the insured in accordance with the policy terms and conditions, are directly made
to the Network Provider by the insurer to the extent pre-authorization approved.
Def. 8. Condition Precedent means a policy term or condition upon which the Insurer's liability under the policy is
conditional upon.
Def. 9. Congenital Anomaly refers to a condition (s) which is present since birth, and which is abnormal with
reference to form, structure or position.
a) Internal Congenital Anomaly : Which is not in the visible and accessible parts of the body
b) External Congenital Anomaly: Which is in the visible and accessible parts of the body
Def. 10. Co-payment means a cost-sharing requirement under a health insurance policy that provides that the
Policyholder/insured will bear a specified percentage of the admissible claim amount. A co-payment does
not reduce the Sum Insured.
Def. 11. Critical Illness means the following:
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1. CANCER OF SPECIFIED SEVERITY
I. A malignant tumor characterized by the uncontrolled growth and spread of malignant cells with
invasion and destruction of normal tissues. This diagnosis must be supported by histological
evidence of malignancy. The term cancer includes leukemia, lymphoma and sarcoma.
II. The following are excluded –
i. All tumors which are histologically described as carcinoma in situ, benign,
pre-malignant, borderline malignant, low malignant potential, neoplasm of
unknown behavior, or non-invasive, including but not limited to: Carcinoma in
situ of breasts, Cervical dysplasia CIN-1, CIN 2 and CIN-3.
ii. Any non-melanoma skin carcinoma unless there is evidence of metastases to
lymph nodes or beyond;
iii. Malignant melanoma that has not caused invasion beyond the epidermis;
iv. All tumors of the prostate unless histologically classified as having a Gleason
score greater than 6 or having progressed to at least clinical TNM
classification T2N0M0
v. All Thyroid cancers histologically classified as T1N0M0 (TNM
Classification) or below;
vi. Chronic lymphocytic leukaemia less than RAI stage 3
vii. Non-invasive papillary cancer of the bladder histologically described as
TaN0M0 or of a lesser classification,
viii. All Gastro-Intestinal Stromal Tumors histologically classified as T1N0M0
(TNM Classification) or below and with mitotic count of less than or equal to
5/50 HPFs;
ix. All tumors in the presence of HIV infection.
2. MYOCARDIAL INFARCTION (First Heart Attack of specific severity)
I. The first occurrence of heart attack or myocardial infarction, which means the death of a portion of the
heart muscle as a result of inadequate blood supply to the relevant area. The diagnosis for Myocardial
Infarction should be evidenced by all of the following criteria:
i. A history of typical clinical symptoms consistent with the diagnosis of acute myocardial infarction (For
e.g. typical chest pain)
ii. New characteristic electrocardiogram changes
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iii. Elevation of infarction specific enzymes, Troponins or other specific biochemical markers.
II. The following are excluded:
i. Other acute Coronary Syndromes
ii. Any type of angina pectoris
iii. A rise in cardiac biomarkers or Troponin T or I in absence of overt ischemic heart disease OR
following an intra-arterial cardiac procedure.
3. OPEN CHEST CABG
I. The actual undergoing of heart surgery to correct blockage or narrowing in one or more coronary
artery(s), by coronary artery bypass grafting done via a sternotomy (cutting through the breast bone) or
minimally invasive keyhole coronary artery bypass procedures. The diagnosis must be supported by a
coronary angiography and the realization of surgery has to be confirmed by a cardiologist.
II. The following are excluded:
i. Angioplasty and/or any other intra-arterial procedures
4. OPEN HEART REPLACEMENT OR REPAIR OF HEART VALVES
I. The actual undergoing of open-heart valve surgery is to replace or repair one or more heart valves, as a
consequence of defects in, abnormalities of, or disease affected cardiac valve(s). The diagnosis of the valve
abnormality must be supported by an echocardiography and the realization of surgery has to be confirmed
by a specialist medical practitioner. Catheter based techniques including but not limited to, balloon
valvotomy/valvuloplasty are excluded.
5. COMA OF SPECIFIED SEVERITY
I. A state of unconsciousness with no reaction or response to external stimuli or internal needs. This
diagnosis must be supported by evidence of all of the following:
i. no response to external stimuli continuously for at least 96 hours;
ii. life support measures are necessary to sustain life; and
iii. permanent neurological deficit which must be assessed at least 30 days after the onset of the coma.
II. The condition has to be confirmed by a specialist medical practitioner. Coma resulting directly from
alcohol or drug abuse is excluded.
6. KIDNEY FAILURE REQUIRING REGULAR DIALYSIS
I. End stage renal disease presenting as chronic irreversible failure of both kidneys to function, as a result
of which either regular renal dialysis (haemodialysis or peritoneal dialysis) is instituted or renal
transplantation is carried out. Diagnosis has to be confirmed by a specialist medical practitioner.
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