1. Duty of Disclosure

 The Policy shall be null and void and no Benefit shall be payable in the event of untrue or incorrect statements including incorrect information on claims experience, misrepresentation, mis-description or non-disclosure of any material particulars in the group proposal form/ Request for Quote (RFQ) form, personal statements, declarations, medical history and connected documents, or any material information having been withheld or a Claim being fraudulent or any fraudulent means or devices being used by the Policyholder/ Insured Person/ Dependent or any one acting on their behalf, under this Policy. Under such circumstance, we may at Our sole discretion cancel the Policy and the premium paid shall be forfeited to Us.

2. Observance of Terms and Conditions

 The due observance and fulfilment of the terms and conditions of the Policy (including the realization of premium by their respective due dates and compliance with the specified procedure on all claims) in so far as they relate to anything to be done or complied with by the Policyholder or any of the Insured Persons, shall be the Condition Precedent to Our liability under this Policy.

3. Parties to the Policy

The only parties to this Policy are the Policyholder and Us.

4. No Constructive Notice

Any knowledge or information of any circumstance or condition in relation to You/Insured Person in Our possession or in the possession of any of Our officials shall not be deemed to be notice or be held to bind or prejudicially affect Us, or absolve You/Insured Person from your/her duty of disclosure, notwithstanding subsequent acceptance of any premium.

5. Eligibility

To be eligible for coverage under the Policy, the Insured Person must be -

a.Either an employee of the policyholder where there is an employer/employee relationship OR an enrolled member of a non-employer/employee group

b.The relationships which may be covered under the Policy are-

i.Self

ii.Employee/member’s legal Spouse, Life Partner (including live-in partner)

For the purpose of this section, Life Partner (including live-in partner) shall be taken as declared at the time of inception of Policy and no change would be accepted during the Policy Period. However, the Insured may request for change at the time of Renewal of the cover.

iii.The Employee/member’s children between the age of 91 days and 18 years shall be covered provided either or both parents are covered concurrently. Children above 18 years will continue to be covered along with parents up to the age of 26 years, provided they are unmarried/unemployed and dependent.

iv.Parents/Parents-in-law

v.The Employee/member’s siblings shall be covered up to the age of 26 years, provided they are unmarried/unemployed and dependent.

vi.Any other relationship as specified in the Policy Schedule

c.Minimum Group size: The Policyholder shall ensure that the minimum number of Employees/members who will form a group to avail the Benefits under this Policy shall be 7 (Seven).

d.New Born Babies will be accepted for cover (subject to the limitations of the New Born Baby Benefit Cover) from birth if mother is covered and maternity cover is opted. Acceptance of New Born Babies as Insured Persons is subject to written notification on or before the last day of the month following the birth of the child and receipt of the agreed premium. Renewals will be available for lifetime, provided the Insured Person is still employed with the Policyholder/continues to be a member of the group.

 Relationships covered under the Policy are as specified in the Policy Schedule/ Certificate of Insurance.

6. Reasonable Care

 The Insured Person understands and agrees to take all reasonable steps in order to safeguard against any Illnesses, Accident or Injury that may give rise to any claim under this Policy.

7. Premium

The premium for each Policy will be determined based on the available data of each group, coverage sought by the insured and applicable discounts and loadings. Payment of premiums will be available in Single mode. No receipt for premium shall be valid except on Our official form signed by Our duly authorized official. The due payment of premium and the observance and fulfilment of the terms, provisions, conditions and endorsements of this Policy by the Policyholder in so far as they relate to anything to be done or complied with by the Policyholder shall be a Condition Precedent to Our liability to make any payment under this Policy.

Premium will be subject to revision at the time of renewal of the Policy. Further, premium shall be paid in Indian Rupees and in favour of United India Insurance Company Ltd.

NOTE: Where Instalment facility is granted by Us for the payment of premium, it is to be in accordance with the schedule of payments agreed between the Policyholder and Us in writing.

Where premium is payable on an instalment basis, the revival period shall be 15 days. Wherever premiums are not received within the revival period, the Policy will be terminated effective from instalment due date and all claims that fall beyond such instalment due date shall not be paid. However, we will be liable to pay in respect of all claims where the Treatment/Admission/Accident has commenced/ occurred before the date of termination of such Policy.

8. Alterations in the Policy

This Policy constitutes the complete contract of insurance. No change or alteration will be effective or valid unless approved in writing which will be evidenced by a written endorsement, signed and stamped by Us. All endorsement requests will be made by the Policyholder only.

9. Material Information for administration

The Insured Person and/ or the Policyholder must give Us all the written information that is reasonably required to work out the premium and pay any claim/ Benefit provided under the Policy. You must give Us written notification specifying the details of the Insured Persons to be deleted and the details of the eligible persons proposed to be added to the Policy as Insured Persons.

Material information to be disclosed includes every matter that the Insured Person and/or the Policyholder is aware of, or could reasonably be expected to know, that relates to questions in the proposal form and which is relevant to Us in order to accept the risk of insurance and if so on what terms. The Insured Person/ Policyholder must exercise the same duty to disclose those matters to Us before the Renewal, extension, variation or endorsement of the Policy.

10. Material Change

It is Condition Precedent to Our liability under the Policy that You shall at Your own expense immediately notify Us in writing of any material change in the risk on account of change in nature of occupation or business of any Insured Person. We may, in Our discretion, adjust the scope of cover and / or the premium paid or payable, accordingly.

11. Geographical Area

 The geographical scope of this Policy applies to events limited to India unless specified under this Policy in a particular Benefit or definition. However, all admitted or payable claims shall be settled in India in Indian rupees.

12. Free Look period

The free look period shall be applicable at the inception of the policy and:

a)The insured will be allowed a period of at least 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

b)If the insured has not made any claim during the free look period, the insured shall be entitled to

i.A refund of the premium paid less any expenses incurred by the insurer on medical examination of the insured persons and the stamp duty charges or;

 ii.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 or;

iii.Where only a part of the insurance coverage has commenced, such proportionate premium commensurate with the insurance coverage during such period.

13. Addition and Deletion of a Member

 We shall include/exclude a group member/Employee of the Policyholder and/or his/her Dependent(s) as an Insured Person under the Policy in accordance with the following procedure:

A.Additions

a.Employer – Employee Group:

i)Newly appointed employee and his/her dependents

ii)Newly wedded spouse of the employee,

iii)New born child of the employee

may be added to the Policy as an Insured Person during the Policy period provided that the application for cover has been accepted by Us, additional premium on pro-rata basis applied on the risk coverage duration for the Insured Person has been received by Us and We have issued an endorsement confirming the addition of such person as an Insured Person

b.Non-Employer – Employee Group: As specified in the Policy Schedule

B.Deletions:

a.Employer – Employee Group

i)Employee leaving the company/organization on account of resignation/retirement/termination and his/her dependents shall be deleted from the policy effective from the date of resignation/retirement/termination or till the last day of the month of resignation/retirement/termination at the option of the insured

ii)In the event of death of an employee, his/her dependents may continue to be covered until the expiry of the policy period at the option of the insured

b.Non-Employer – Employee Group: As specified in the Policy Schedule

Refund of premium shall be made on a pro-rata basis, provided that no claim is paid/outstanding in respect of that Insured Person or his/her Dependents.

Throughout the Policy period, the Policyholder will notify Us of all and any changes in the membership of the Policy occurring in a month on or before the last day of the succeeding month.

14. Nominee 

The Insured Person can, on the Effective Date or at any time before the expiry of the Policy make a nomination for the purpose of payment of claims. Any change of nomination shall be communicated to Us in writing and such change shall be effective only when an endorsement to the Policy is made by Us.

 In case of death of any Dependent of an Insured Person where such Dependent is covered under this Policy, for the purpose of payment of claims, the Nominee would be the Insured Person.

15. Endorsements 

The Policy will allow the following endorsements during the Policy period. Any request for endorsement must be made only in writing by the Policyholder. Any endorsement would be effective from the date of the request received from You, or the date of receipt of premium, whichever is later.

oRectification in name of the proposer / Insured Person.

oRectification in gender of the proposer/ Insured Person.

oRectification in relationship of the Insured Person with the proposer.

oRectification of age/ date of birth of the Insured Person

oChange in the correspondence address of the proposer.

oChange/updating in the contact details viz., phone number, E-mail ID, etc.

oUpdating of alternate contact address of the proposer.

oChange in Nominee details.

oDeletion of Insured Person on death or upon leaving the group provided no claims are paid / outstanding.

oAddition of member (New Born Baby or newly wedded Spouse).

 All endorsement requests shall be assessed by the underwriter and where required additional information/documents/ premium may be requested.

16. Multiple Policies

 In case of multiple policies which provide fixed benefits, on occurrence of the insured event in accordance with the terms and conditions of the Policies, we shall make the claim payments independent of payments received under similar policies.

If two or more policies are taken by an insured during a period from one or more insurers to indemnify treatment costs, the policyholder shall have the right to require a settlement of his/her claim in terms of any of his/her policies.

a.In all such cases where We have issued the chosen policy, we shall be obliged to settle the claim as long as the claim is within the limits of and according to the terms of the chosen policy.

b.Policyholder having multiple policies shall also have the right to prefer claims from other policy/ policies for the amount disallowed under the earlier chosen policy / policies, even if the sum insured is not exhausted. Then the Insurer(s) shall settle the claim subject to the terms and conditions of the other policy / policies so chosen.

c.If the amount to be claimed exceeds the Sum Insured under a single policy after considering the deductibles or co-pay, the policyholder shall have the right to choose insurers from whom he/she wants to claim the balance amount. 

d.Where an insured has policies from more than one insurer to cover the same risk on indemnity basis, the insured shall only be indemnified the hospitalization costs in accordance with the terms and conditions of the chosen policy.

Further, the insured, if having multiple policies, shall also have the right to prefer claims from this policy for the amounts disallowed under the earlier chosen policy/ policies, even if the Sum Insured in the earlier chosen policy is not exhausted. Then we shall settle the claim subject to the terms & conditions of the other policy/ policies so chosen.

Note: The insured person must disclose such other insurances at the time of making the claim under this policy.

17. Grace Period & Renewal 

The Policy may be renewed by mutual consent and in such event the renewal premium should be paid to Us on or before the date of expiry of the Policy and in no case later than the Grace Period of 30 days from the expiry of the Policy. If the premium is paid within the Grace Period to renew or continue the policy in force, there will be no loss of continuity benefits such as waiting periods and coverage of pre-existing diseases. However, We will not be liable to pay for any claim arising out of an Illness/Injury/ Accident/ condition that occurred during the Grace Period.

The provisions of Section 64VB of the Insurance Act, 1938 shall be applicable.

i.For Contributory Policy

We shall not be bound to give notice that such renewal premium is due. A Policy shall be ordinarily Renewable except on grounds of fraud, moral hazard, misrepresentation or non- cooperation by the Insured Person or on his behalf.

Where such behavior has been noticed on the part of an Employee/ Member, we will terminate the cover for the specific Employee/ Member and his/her Dependents including further Renewals and continue the cover for the remaining group members while bringing such instances to the knowledge of the Policyholder. Where it is found that the Policyholder is involved in such above situations, the complete Policy will be terminated.

ii.Renewal Terms

Alterations like increase/ decrease in Sum Insured or change in optional covers can be requested at the time of Renewal of the Policy. We reserve Our right to carry out assessment of the group and provide the Renewal quote in respect of the revised Policy.

We may in Our sole discretion, revise the premiums payable under the Policy or the terms of the cover, provided that all such changes are in accordance with the IRDAI rules and regulations as applicable from time to time.

18. Cancellation by You

The policyholder may request for cancellation of the policy at any time by giving 15 days’ notice in writing. In such case We shall refund the percentage of premium for the unexpired Policy Period on short period scale as per the table below:

The grid is applicable for single premium Policy

For installment premium, we will refund premium on pro rata basis after deducting Our expenses.

Premium shall be refunded for all lives which have not registered a claim with Us under the Policy upto the date of cancellation.

19. Our Right of Termination

A.Termination of Policy:

 Prior to the expiry of the Policy as shown in the Policy Schedule/ Certificate of Insurance, cover will end immediately for all Insured Persons, if:

i.there is misrepresentation, fraud, non-disclosure of material fact by You / Insured Person without any refund of premium, by giving 15 days’ notice in writing by Registered Post Acknowledgment Due / recorded delivery to Your last known address.

ii.there is non-cooperation by You/ Insured person, with refund of premium on pro rata basis for all lives which have not registered a claim with Us, after deducting Our expenses, by giving 15 days’ notice in writing by Registered Post Acknowledgment Due/ recorded delivery to Your last known address.

iii.the Policyholder does not pay the premiums owed under the Policy within the Grace Period.

Upon termination, cover and services under the Policy shall end immediately. Treatment and costs incurred after the date of termination shall not be paid. If Treatment has been authorized or an approval for Cashless facility has been issued, we will not be held responsible for any Treatment costs if the Policy ends. However, we will be liable to pay in respect of all claims where the Treatment/admission has commenced before the date of termination of such Policy.

B.Termination for Insured Person’s cover:

Cover will end for a Member or dependent:

i.If the Policyholder stops paying premiums for the Insured Person(s) and their Dependents (if any);

ii.When this Policy terminates at the expiry of the period shown in the Policy Schedule/ Certificate of Insurance.

iii.If he or she dies;

iv.When a dependent insured person ceases to be a Dependent; unless otherwise agreed specifically for continuation till end of policy period;

v.If the Insured Person ceases to be a member of the group.

20. Limitation of Liability

If a claim is rejected or partially settled and is not the subject of any pending suit or other proceeding or arbitration, as the case may be, within twelve months from the date of such rejection or settlement, the claim shall be deemed to have been abandoned and Our liability shall be extinguished and shall not be recoverable thereafter.

21. Portability

Where We have discontinued or withdrawn this product or where the Insured Person is not eligible to Renew as he/she ceases to be a member of the group, such Insured Person will have the option to migrate to an approved retail health insurance policy available with Us in accordance with the Portability guidelines issued by the IRDAI, provided that:

Portability benefit will be offered to the extent of Sum Insured under this policy, and Portability shall not apply to any other additional/ increased Sum Insured

a.All waiting periods under Sections IV shall be applicable individually for each Insured Person and claims shall be assessed accordingly.

b.We should have received Your application for Portability with complete documentation at least 45 days before ceasing to be an Employee of the Policyholder/ member of the group.

c.Portability benefit will be offered to the nearest Sum Insured, in case exact Sum Insured option is not available.

d.We may subject Your proposal to Our medical underwriting, restrict the terms upon which We may offer cover, the decision as to which shall be as per our underwriting practices and underwriting policy of the Company.

22. Operation of Policy & Certificate of Insurance

The Policy shall be issued for the duration as specified in the Policy Schedule/ Certificate of Insurance. The Policy takes effect on the Inception Date stated in the Policy Schedule and/or the Certificate of Insurance and ends on the date of expiry of the Policy. For specific groups, upon request, all additions thereto by way of Certificate/s of Insurance shall be valid up to the Policy Period commencing from the actual date of addition to the Policy, it being agreed and understood that We shall continue to extend the benefit of coverage of insurance to the Insured Person(s) in the same manner on Renewal of the Policy or until expiry of the Certificate of Insurance, whichever is later.

23. Electronic Transactions

The Policyholder/ Insured Person agrees to comply with all the terms and conditions as We shall prescribe from time to time, and confirms that all transactions effected facilities for conducting remote transactions such as the internet, World Wide Web, electronic data interchange, call centers, tele-service operations (whether voice, video, data or combination thereof) or by means of electronic, computer, automated machines network or through other means of telecommunication, in respect of this Policy, or Our other services, shall constitute legally binding when done in compliance with Our terms for such facilities.

Sales through such electronic transactions shall ensure that all conditions of Section 41 of the Insurance Act, 1938 prescribed for the proposal form and all necessary disclosures on terms and conditions and exclusions are made known to the Policyholder/ Insured Person. A voice recording in case of tele-sales or other evidence for sales through the World Wide Web shall be maintained and such consent will be subsequently validated / confirmed by the Policyholder/ Insured Person.

24. Communications & Notices

Any communication or notice or instruction under this Policy shall be in writing and will be sent to:

a.The Policyholder/ Insured Person, at the address as specified in the Policy Schedule/ Certificate of Insurance

b.To Us, at the address specified in the Policy Schedule/ Certificate of Insurance.

c.No insurance agents, brokers, other person or entity is authorized to receive any notice on behalf of Us unless explicitly stated in writing by Us.

25. Complete Discharge

We will not be bound to take notice or be affected by any notice of any trust, charge, lien, assignment or other dealing with or relating to this Policy. The payment made by Us to Insured Person(s) or to their Nominee/Legal Representative or to the Hospital, as the case may be, of any Medical Expenses or compensation or Benefit under the Policy shall in all cases be complete, valid and construed as an effectual discharge in favour of Us.

26. Withdrawal of Policy 

There is possibility of withdrawal of this product at any time in future with appropriate approval from IRDAI, and We reserve Our right to do so with an intimation of 3 months to all the existing insured members. In such an event of withdrawal of this product, at the time of Your seeking renewal of this Policy, You can choose, among Our available similar and closely similar Health insurance products. Upon Your so choosing Our new product, You will be charged the Premium as per Our Underwriting Policy for such chosen new product, as approved by IRDAI.

Provided however, if You do not respond to Our intimation regarding the withdrawal of the product under which this Policy is issued, then this Policy shall be withdrawn and shall not be available to You for renewal on the renewal date and accordingly upon Your seeking renewal of this Policy, You shall have to take a Policy under available new products of Us subject to Your paying the Premium as per Our Underwriting Policy for such available new product chosen by You and also subject to Portability condition.

27. Grievances Redressal Procedure

If You/ Insured Person may have a grievance that requires to be redressed, You/Insured Person may contact Us with the details of the grievance through:

Our website: www.uiic.co.in

Post/ Courier: The underwriting office or Regional Office. You/Insured Person may also approach the customer care officer at the underwriting office or Regional Office with the details of the grievance during Our working hours from Monday to Friday.

If You/Insured Person are not satisfied with Our redressal of Your grievance through one of the above methods, You/Insured Person may contact Our Officer, Uni-Customer Care Department, Head Office or email at customercare@uiic.co.in

If You/Insured Person are not satisfied with Our redressal of grievance through one of the above methods, You/Insured Person may approach the nearest Insurance Ombudsman for resolution of the grievance. The updated list of Office of Insurance Ombudsman is as per Annexure-II attached & also available on IRDA website www.irdai.gov.in and on the website of General Insurance Council www.gicouncil.in.

28. Policy Dispute & Applicable Law 

Any and all disputes or differences under or in relation to this Policy shall be determined by the Indian Courts and subject to Indian law without reference to any principle which would result in the application of the law of any other jurisdiction.