'ËĘ ÁflÁŸĸĘ∑§ •ı⁄U Áfl∑§Ę‚ Ž˝ĘÁœ∑§⁄UáĘ - IRDA

end-user sectionirda journal October 2012premium by the due dates mentioned inthe schedule) in so far as they relate toanything to be done or complied with byyou or any insured person shall beconditions precedent to our liability.After:We will be liable to pay under this policyonly if:1. you perform all your obligations underthis policy, and2. you have paid, and we have receivedthe premium.Example 2.Before:WHEREAS the insured … has by a proposaland declaration …., which shall be thebasis of this contract …, has applied toXYZ Insurance Company for the insurance…. … the company undertakes if insuredperson shall contract any illness, … to payor reimburse …After:(The policy begins:)The policy-holder made a proposal anddeclaration dated _____ and requested forinsurance under this policy for his healthand the health of other insured persons.The insured persons have also madedeclarations concerning their health.Based on the truth of the statements inthe proposal and declarations, we giveinsurance under this policy.(and later, the policy explains theobligation of disclosure and its effect. Forexample, see below in this Article‘Obligations of the Insured’)Example 3.Before:If at the time when any claim arises underthis policy, there is in existence any otherinsurance … … covering the same loss,liability, compensation, costs or expenses,the company shall not be liable to pay orcontribute more than its ratableproportion of any loss, liability,compensation, costs or expenses.After:If you have another insurance policy …covering the illness or injury, in respect ofwhich you have made a claim with us orany part of expenses forming part of yourclaim, we will not pay your entire claimeven if eligible. We will pay only ratableproportion of the claim. Thus, if you have apolicy from another insurance company,we will pay only part of your claim.Example 4.Before:(In a policy for a Sum Insured of `8 lacs, adeductible of `2 lacs, period from 1 Jan to31 Dec.)The Company shall not be liable for theDeductible amount as specified in Part I ofthe Schedule. The Deductible amountshall be applicable to each and everyclaim separately.After:We will pay medical charges that exceedthe Deductible amount. The Deductibleshall apply separately to each claim madeduring the period of insurance.Example: This table illustrates the amountwe will pay in excess of the deductibleamount ( `)Arrangement of exclusionsEvery Health policy excludes cover forsome expenses. The following might beexcluded:1. Specified expenses incurred for anillness that is otherwise not covered;2. Expenses for equipment;3. Expenses incurred for certain types oftreatment;4. Expenses incurred for treatment ofcertain illnesses;5. Expenses incurred for treatment ofillness arising from some activities orevents.These provisions in the policy affectadversely the interests of an insured.Hence the policy must mention them in aclear manner. The fact that certainexpenses are excluded must be statedprominently in such a manner as wouldattract his attention. The order of statingthese expenses in the list is alsoimportant.Some items of expenses would begenerally incurred in most cases ofhospitalisation. These must be stated first.For example: pre- and posthospitalisationexpenses, expenses ofnurses, tonics, X-Ray, laboratoryexamination (all these, if not covered).Treatments that are taken more oftenmust be stated before those that are rare.For example: Dental treatment can bestated before plastic surgery. Treatmentarising from war, terrorism etc. can bestated in the end.Summary of policy provisionsA summary of all policy provisions at thebeginning of the policy will guide theinsured about the entire contents. Thisgives the big picture, and makes it easy tograsp details that follow. The insured willalso figure out the connections betweenthe different provisions of the policy. Thesummary can also give reference to theparas that give details. A sample of such asummary can, for example, state:1. We promise to pay you under thispolicy the expenses that you incur forIllness occurs on Medical Expenses You pay We pay1st claim 21 January 1.5 lacs 1.5 lacs nil2nd claim 15 March 2 lacs 2 lacs nil3rd claim 30 October 3.5 lacs 2 lacs 1.5 lacs34