Acko General Insurance Limited Acko Group Health Insurance Policy

Terms & Conditions

This is a summary of the key terms under the Acko Group Health Insurance Policyoffered by Acko General Insurance Limited (“Acko”) to Dreamplug Technologies Private Limited (“Cred”)subject to the receipt of premium in full in respect of the Insured Persons and the terms, conditions and exclusions of underlying Policy. The covers available under the Policy can be availed only by the registered customers of Cred. The insurance coverage period under this policy is valid as mentioned in the Certificate of Insurance.

1. Key Benefits

Key benefits available to the Insured person is as follows:

Benefit Details:

Benefit Table with the details of benefit wise coverage, sum insured and applicable conditions

Global Coverage applicable:-No

Currency used for Global coverage: NA

2. General Conditions:

• Acko will only be covering loan facilitated by Cred.
• We should be given immediate written notice of any event that may give rise to a claim under the Policy, in accordance with the claims procedure under the Policy.
• The policy is valid for a period of loan tenure maximum up to 5 years from the Insurance start date.The EMI Protection benefit is not applicable once the loan is repaid in full.
• All claims made under the Policy will be subject to the applicable deductible, any sub-limits and the availability of the Sum Insured.
• The Hospitalization is for Medically Necessary Treatment and is commenced and continued on the written advice of the treating Medical Practitioner.
• Any Pre-Existing diseases are not covered.

3. Cancellation/Termination of the Policy

If You have any objections to any of the terms and conditions, you have the option of cancelling the Policy stating the reasons. If you will cancel the policy within 15 days of the issuance of the Certificate of Insurance, we will refund the full premium if no claim is made.

For cancellation requests after free-look period, we shall refund the percentage of premium for the unexpired Policy Period/ Coverage Period if no claim has been made under the Policy as per the short period scale mentioned below, after deducting Our expenses.

We may at any time terminate this Policy on grounds of misrepresentation, fraud or non-disclosure of material facts by You or any Insured Person upon 30 days’ notice by sending an endorsement to Your address shown in the Schedule without refund of premium.

4. Declaration to be given by the Insured while purchasing the policy

Insured have declared the following:

• I hereby agree to buy Acko Group Health Insurance Policyand authorize Cred/Loan Provider to disburse the premium to Acko General Insurance Limitedtowards policy issuance and provide my express consent to the terms and conditions including assignment of claim payment in favour of Cred/Loan Provider.
• I hereby declare that I am in good health and do not suffer from any Pre-Existing medical conditions or critical illness covered under the policy.
• I, hereby assign and authorize Acko General Insurance Ltd. to pay any claim made by me under Acko Group Health Insurance Policyin favour of Cred/Loan Provider, for and up to the extent of the principal outstanding. I confirm that the aforesaidshall be construed as complete discharge of liability of Acko and I shall not have any right to such amount from Acko.

5. Benefit Definition

5.1. In-Patient Hospitalization (“IPD”) Indemnity Category

5.1.1 Benefits

The Section defines the Benefits under this coverage category. The following Benefits shall trigger in the event related to Hospitalization of the Insured Person on an in-patient basis. Claims under this coverage category will be admissible subject to the fulfilment of the following conditions with respect to the Insured Person’s Hospitalization:

1. The Hospitalization of the Insured Person is caused solely and directly due to an Illness contracted or an Injury sustained by the Insured Person, during the Coverage Period, as specified in the Policy Schedule / Certificate of Insurance.
2. The Date of Admission is within the Coverage Period.
3. The Hospitalization is for Medically Necessary Treatment, and commences and continues on the written advice of the treating Medical Practitioner.

5.1.1.1 EMI Protection:

If an Insured Person is unable to pay the EMI Amounts payable under his/her Loan due to an Injury or Illness specified in the Schedule / Certificate of Insurance, suffered or contracted during the Coverage Period , then We will pay an amount equal to the EMI Amount which is due on the Insured’s outstanding Loan in the number of months immediately following the date of such occurrence, as is specified in the Certificate of Insurance, subject to this amount not exceeding the amount specified in the Certificate of Insurance.

Amortization Chartmeans a complete table of periodic loan payments, showing the amount of principal loan amount and the amount of interest that comprise each payment or EMI, as the case may be, until the Loan is paid off at the end of its term.

This Insuring Clause will be payable provided that:

1. Any payments that are overdue and unpaid by the Insured prior to the occurrence of the event giving rise to a claim under this Insuring Clause will not be considered for the purpose of this Policy and shall be deemed as paid by the Insured.
2. The Benefit will not apply to any voluntary and uninsurable events, which are caused by or with the knowledge of the Insured Person, or which are against public policy, criminal or fraudulent under applicable law.
3. The treatment required by the Insured Personis for Medically Necessary Treatment and is commenced and continued on the written advice of the treating Medical Practitioner.
4. For the purpose of claim settlement against any cover under this Policy, the Amortization Chart prepared by the bank/financial institution as on the date of Loan disbursement or commencement of the Coverage Period (whichever is later) shall be considered wherever applicable.
5. Any additional amounts falling due as a penalty or charge by way of a default in repayment will not be considered for the purpose of this Policy and shall be deemed as paid by the Insured.

5.1.2 Permanent Exclusions

We shall not be liable to make any payment under this Policy for this coverage category and any Benefits or Benefit Options arising from or caused by any of the following:

1. Stem cell implantation/Surgery, harvesting, storage or any kind of Treatment using stem cells except Stem cell therapy where Hematopoietic stem cells for bone marrow transplant for haematological conditions is covered.
2. Dental Treatment, dentures or Surgery of any kind unless necessitated due to an Accident and requiring minimum 24 hours Hospitalization. Treatment related to gum disease or tooth disease or damage unless related to irreversible bone disease involving the jaw which cannot be treated in any other way.
3. Circumcision unless necessary for Treatment of an Illness or Injury not excluded hereunder or due to an Accident.
4. Birth control, Sterility and Infertility: Code – Excl17:Expenses related to Birth Control, sterility and infertility. This includes:
   1. Any type of contraception, sterilization
   2. Assisted Reproduction services including artificial insemination and advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI
   3. Gestational Surrogacy
   4. Reversal of sterilization
5. Routine medical, eye examinations, cost of spectacles, laser Surgery for cosmetic purposes or corrective Surgeries or contact lenses.
6. Ear examinations, cost of hearing aids or cochlear implants.
7. Vaccinations except post-bite Treatment.
8. Refractive Error: Code-Excl15Expenses related to the treatment for correction of eye sight due to refractive error less than 7.5 dioptres.
9. Dietary supplements and substances that can be purchased without prescription, including but not limited to Vitamins, minerals and organic substances unless prescribed by a medical practitioner as part of hospitalization claim or day care procedure. Code-Excl14
10. Sleep Disorders:Treatment for any conditions related to disturbance of normal sleep patterns or behaviours such as Sleep-apnoea, snoring, etc.
11. Rest Cure, rehabilitation and respite care-Code-Excl05
    Expenses related to any admission primarily for enforced bed rest and not for receiving treatment.
    This also includes:
    1. Custodial care either at home or in a nursing facility for personal care such as help with activities of daily living such as bathing, dressing, moving around either by skilled nurses or assistant or non-skilled persons.
    2. Any services for people who are terminally ill to address physical, social, emotional and spiritual needs.
12. External Congenital Anomaly or defects
13. Intentional self-Injury, suicide or attempted suicide.
14. Unproven Treatments: Code- Excl16Expenses related to any unproven treatment, services and supplies for or in connection with any treatment. Unproven treatments are treatments, procedures or supplies that lack significant medical documentation to support their effectiveness.
15. Treatment for, Alcoholism, drug or substance abuse or any addictive condition and consequences thereof.Code-Excl12
16. Breach of law: Code-Excl10:Expenses for treatment directly arising from or consequent upon any Insured Person committing or attempting to commit a breach of law with criminal intent.
17. Treatments received in heath hydro’s, nature cure clinics, spas or similar establishments or private beds registered as a nursing home attached to such establishments or where admission is arranged wholly or partly for domestic reasons.Code-Excl13
18. Prosthetics and Other Devices:Prosthetics and other devices not implanted internally by surgery, cost of cochlear implant(s) unless necessitated by an Accident or required intra-operatively.
19. Any stay in Hospital without undertaking any Treatment or any other purpose other than for receiving eligible Treatment of a type that normally requires a stay in the Hospital.
20. Cosmetic or plastic Surgery:Code-Excl08 Expenses for cosmetic or plastic surgery or any treatment to change appearance unless for reconstruction following an Accident, Burn(s) or Cancer or as part of medically necessary treatment to remove a direct and immediate health risk to the insured. For this to be considered a medical necessity, it must be certified by the attending Medical Practitioner.
21. Change-of-Gender treatments: Code – Excl07Expenses related to any treatment, including surgical management, to change characteristics of the body to those of the opposite sex.
22. Obesity/ Weight Control: Code- Excl06:Expenses related to the surgical treatment of obesity that does not fulfil all the below conditions:
    1. Surgery to be conducted is upon the advice of the Doctor
    2. The surgery/Procedure conducted should be supported by clinical protocols
    3. The member has to be 18 years of age or older and
    4. Body Mass Index (BMI);
       1. greater than or equal to 40 or
       2. greater than or equal to 35 in conjunction with any of the following severe co-morbidities following failure of less invasive methods of weight loss:
          1. Obesity-related cardiomyopathy
          2. Coronary heart disease
          3. Severe Sleep Apnoea
          4. Uncontrolled Type2 Diabetes
23. Treatment taken outside India.
24. Investigation & Evaluation-Code-Excl04
    1. Expenses related to any admission primarily for diagnostics and evaluation purposes only are excluded.
    2. Any diagnostic expenses which are not related or not incidental to the current diagnosis and treatment are excluded.
25. Hazardous or Adventure sports: Code-Excl09:Expenses related to any treatment necessitated due to participation as a professional in hazardous or adventure sports, including but not limited to, para-jumping, rock climbing, mountaineering, rafting, motor racing, horse racing or scuba diving, hand gliding, sky diving, deep-sea diving.
26. All Illness/expenses caused by ionizing radiation or contamination by radioactivity from any nuclear fuel (explosive or hazardous form) or from any nuclear waste from the combustion of nuclear fuel nuclear, chemical or biological attack.
27. War and Exposure to Hazardous Substances:Treatment for any Injury or Illness resulting directly or indirectly from nuclear, radiological emissions, war or war like situations (whether war is declared or not), rebellion (act of armed resistance to an established government or leader), acts of terrorism, nuclear, biological or chemical emissions, rebellion, revolution, acts of terrorism.
28. For complete list of non-medical expenses, please refer to the Annexure II and also on Our website. Any opted Deductible (Per claim / Aggregate / Group) amount or percentage of admissible claim under Co-Payment, Sub Limit if applicable and as specified in the Policy Schedule / Certificate of Insurance to this Policy.
29. Any physical, or medical condition or Treatment or service that is specifically excluded in the Policy Schedule / Certificate of Insurance under special conditions.

5.2 Personal Accident Category

5.2.1. Benefits

The Section defines the Benefits under this coverage category. The following Benefits shall trigger in the event of the Insured Person suffering an Injury due to an Accident. Claims under this coverage category will be admissible subject to the fulfilment of the following conditions with respect to the Insured Person’s Injury:

1. The date of Accident is within the Coverage Period as specified in the Policy Schedule / Certificate of Insurance
2. The Hospitalization is certified as Medically Necessary by the treating Medical Practitioner

5.2.1.1 Accidental Death Benefit

If an Insured Person suffers an Injury due to an Accident that occurs during the Coverage Period and that Injury solely and directly results inthe Insured Person’s death within 365 days from the date of the Accident, We will pay the Sum Insured.

If a claim is accepted under this Benefit in respect of an Insured Person and the amount due under this Benefit and claims already admitted under Benefit (Accidental Death Benefit), Benefit (Permanent Total Disability), Benefit (Permanent Partial Disability) and Benefit (Temporary Total Disability) in respect of the Insured Person will cumulatively exceed the Common Death or Disability Sum Insured, thenOur maximum, total and cumulative liability under any and all such claims will be limited to the Common Death or Disability Sum Insured.

On the acceptance of a claim under this Benefit and payment being made under any applicable Cover Options, all cover under this Policy shall immediately and automatically cease in respect of that Insured Person.

5.2.1.2 Permanent Total Disability

If an Insured Person suffers an Injury due to an Accident that occurs during the Coverage Period and that Injury solely and directly results in the Permanent Total Disability of the Insured Person which is of the nature specified in the table below, within 365 days from the date of the Accident, We will pay the Sum Insured:

For the purpose of this Benefit:

1. Limbmeans a hand at or above the wrist or a foot above the ankle;
2. Physical separation of one hand or footmeans separation at or above wrist and/or at or above ankle, respectively.

This Benefit will be payable provided that:

1. The Permanent Total Disability continues for a period of at least 180 days from the commencement of the Permanent Total Disability, and the Disability Certificate issued by the treating Medical Practitionerat the expiry of the 180 daysconfirmsthat there is no reasonable medical hope of improvement
2. If the Insured Person suffers Injuries resulting in more than one of the Permanent Total Disabilities specified in the table above, then Our maximum, total and cumulative liability under this Benefit shall be limited to the Sum Insured specified against this Benefit in the Policy Schedule / Certificate of Insurance.
3. If a claim is acceptedunder this Benefit in respect of an Insured Person and the amount due under this Benefit and claims already admitted under Benefit (Accidental Death Benefit), Benefit (PermanentTotal Disability), Benefit (Permanent Partial Disability) and Benefit (Temporary Total Disability) in respect of the Insured Person will cumulatively exceed the Common Death or Disability Sum Insured then Our maximum, total and cumulative liability under any and all such claims will be limited to the Common Death or Disability SumInsured
4. If We have admitted a claim for Permanent Total Disability in accordance with this Benefit, then We shall not be liable to make any payment under the Policy on the death of the Insured Person, if the Insured Person subsequently dies;
5. On the acceptance of a claim under this Benefit, all cover under this Policy shall immediately and automatically cease in respect of that Insured Person after the payment of any other applicable Cover Options.

5.2.1.3 Permanent Partial Disability

If an Insured Person suffers an Injury due to an Accident that occurs during the Coverage Period and that Injury solely and directly results in the Permanent Partial Disability of the Insured Person which is of the nature specified in the table below within 365 days from the date of the Accident, We will pay the amount specified in the table below:

This Benefit will be payable provided that:

1. The Permanent Partial Disability continues for a period of at least 180 days from the commencement of the Permanent Partial Disability and the Disability Certificate issued by the treating Medical Practitionerat the expiry of the 180 daysconfirmsthat there is no reasonable medical hope of improvement;
2. If the Insured Person suffers a loss that is not of the nature of Permanent Partial Disability specified in the table above, then the independent medical advisors will determine the degreeand percentage ofsuchdisability
3. We will not make any payment under this Benefit if We have already paid or accepted any claims under the Policy in respect of the Insured Person and the total amount paid or payable under the claims is cumulatively greater than or equalto the Sum Insured for that Insured Person;
4. If a claim is accepted under this Benefit in respect of an Insured Person and the amount due under this benefit and claims already admitted under Benefit (Accidental Death Benefit),Benefit (PermanentTotal Disability), Benefit (Permanent Partial Disability) and Benefit (Temporary Total Disability) in respect of the Insured Person will cumulatively exceed the Common Death or Disability Sum Insured then Our maximum, total and cumulative liability under any and all such claims will be limited to the Common Death or Disability Sum Insured
5. On the acceptance of a claim under this Benefit, the Insured Person’s insurance cover under this Policy shall continue, subject to the availability of the Sum Insured and the Common Death or Disability Sum Insured.

5.2.2 Permanent Exclusions:

We shall not be liable to make any payment for any claim under the Policy in respect of an Insured Person, arising from or caused by any of the following:

1. Any Pre-Existing Disease unless disclosed to Us in advance, and coverage for such Pre-Existing Disease is expressly extended and endorsed by Us on the Certificate of Insurance.
2. Suicide or attempted suicide, intentional self-inflicted Injury or acts of self-destruction, whether the Insured Person is medically sane or insane.
3. Any change of profession after inception of the Policy which results in the enhancement of Our risk under the Policy, if not accepted and endorsed by Us on the Policy Schedule / Certificate of Insurance.
4. Medical or surgical treatment except as necessary solely and directly as a result of an Accident.
5. Certification of disability by a family member, or a person who stays with the Insured Person, or from persons not registered as Medical Practitioners under the respective Medical Councils, or from a Medical Practitioner who is practicing outside the discipline that he is licensed for.
6. Death or disability arising from or caused due to use, abuse or a consequence or influence of an abuse of any substance, intoxicant, drug, alcohol or hallucinogenby the Insured Person.
7. Death or disability arising or resulting from the Insured Person committing any breach of law or participating in an actual or attempted felony, riot, crime, misdemeanour or civil commotion with criminal intent.
8. Death or disability resulting directly or indirectly, contributed or aggravated or prolonged by childbirth or from pregnancy or a consequence thereof including ectopic pregnancy unless specifically arising due to Accident.
9. Death or disability caused by participation of the Insured Person in any flying activity, except as a bona fide, fare-paying passenger of a recognized airline on regular routes and on a scheduled timetable.
10. Death or disability arising out of or attributable to foreign invasion, act of foreign enemies, hostilities, participation in any naval, military or air-force operation, civil war, public defence, rebellion, revolution, insurrection, military or usurped power.
11. Death or disability or Injury arising from or caused by ionizing radiation or contamination by radioactivity from any nuclear fuel (explosive or hazardous form) or resulting from or from any other cause or event contributing concurrently or in any other sequence to the loss, claim or expense from any nuclear waste from the combustion of nuclear fuel, nuclear, chemical or biological attack.
12. Death or disability caused other than by an Accident.
13. Chemical attack or weapons means the emission, discharge, dispersal, release or escape of any solid, liquid or gaseous chemical compound which, when suitably distributed, is capable of causing any Illness, incapacitating disability or death.
14. Biological attack or weapons means the emission, discharge, dispersal, release or escape of any pathogenic (disease producing) microorganisms and/or biologically produced toxins (including genetically modified organisms and chemically synthesized toxins) which are capable of causing any Illness, incapacitating disability or death.

6. Claim & Documents:

The Cred Customer can file a claim for any of these coverages on the Acko Website. Alternatively, he/she can reach Acko at the Contact number(s) provided below for registration of claim:

Acko:1800 266 2256

Email id:credcare@acko.com

Any claim made by the customer will be validate with Cred or its service partner to confirm the incidence.

Claims process for Cred Customer on Acko Website:

• Go to www.acko.com, login with your mobile number registered with Cred, and enter the OTP you receive.
• Select your policy in the ‘My Policies’ section.
• Click on the ‘Claim’ button below the Policy details section.
• Tell us what happened and share the necessary documents to support your claim
• Sit back and relax; we will keep you updated regarding the progress of your claim

The Insured needs to submit following documents in case of a claim:

Note: Additional documents required with respect to other coverages will be requested as and when required (if applicable).

7. Grievance Redressal:

For resolution of any query or grievance, the Insured Person may call Us at toll free number:1800 266 2256or may write an e- mail atgrievance@acko.com. In case the insured is not satisfied with the response of the office, insured may contact the Grievance Officer of the Company at the following address:

In case Insured Person is not satisfied with the resolution, the Insured Person may write to Acko’s Grievance Redressal Officer at the following address:

Grievance Redressal Officer
Grievance Redressal Officer
#36/5, Hustlehub One East, Somasandrapalya,
27th Main Rd, Sector 2, HSR Layout,
Bengaluru, Karnataka 560102
grievance@acko.com

In case Cred’s complaint is not fully addressed by Acko, You may use the Integrated Grievance Management System (IGMS) for escalating the complaint to IRDAI. Through IGMS, the insured can register the complaint online and track its status. For registration, please visit IRDAI websitewww.irdai.gov.in.

If the issue still remains unresolved, Capital Float /Insured Person may, subject to vested jurisdiction, approach the Insurance Ombudsman for the redressal of grievance.

Please note that this is only a basic description of the key terms of the Policy, and the full list of policy conditions and exclusions are available athttps://www.acko.com/download/.

Once you have opted for cover, you will receive a Certificate of Insurance from Acko which will contain complete details of your cover under the Policy, and the applicable conditions and exclusions.