LICs Health Plus is an awesome plan in line with other ULIPs of LIC. It is specially designed to cater the ever growing need of covering hospitalization and major surgeries, etc. Any person, male or female, aged between 18 & 55 years, called Principal Insured (PI), can take policy under this plan, cover him/herself and/or his/her spouse and/or one or all dependent children. The point should be noted here that if existing spouse and/or one or more dependent children are eligible for inclusion and not covered at the inception itself, they will not be allowed to be covered in future. On the other hand, if they are not eligible for Inclusion at the time of inception, can be included from the first anniversary of the policy
As mentioned earlier, the very purpose of this plan is to cover health related expenses rather than life Insurance. As result, this plan provides 3 benefits for health risks i.e.,
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Hospital Cash Benefit (HCB)
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Major Surgical Benefit (MSB)
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Domiciliary Treatment Benefit (DTB)
These benefits are inbuilt in the plan. First two benefits are chargeable and the third one is payment from the unit fund of the policy. Hence, charges for the first two benefits are recovered alongwith usual charges like in any other ULIP by cancelling appropriate number of units as on the particular date based on NAV. The details of these benefits, relative charges, conditions and exclusions are explained in the subsequent parts
There’s only one type of fund available, the pattern of investment of which is as follows
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Fund Type
Health Plus
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Fund Investment
a. Govt/Govt guaranteed securities/corp. debt
Not less than 50%
b. Short term investments, ie, money market instruments (including govt. securities and corp. debt)
Not more than 90%
c. Investment in listed securities
Not less than 10% and not more than 50%
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Objective of fund for risk/return
Income & Growth at Low Risk
Minimum Premium
Single life of PI
6 times HCB of PI but subject to minimum of Rs 5000 pa
2 lives
6 times HCB of PI plus 3 times HCB of another insured but subject to minimum of Rs 7500 pa
More than 2 lives
6 times HCB of PI plus 3 times HCB of each of other insureds but subject to minimum of Rs 10000 pa
*Annualized premium shall be in multiples of Rs 500
Maximum Premium
No limit
Minimum Age at Entry
PI & Insured Spouse
18 years (last birthday)
Insured dependent children
3 months completed
Maximum Age at Entry
PI & Insured Spouse
55 years (nearer birthday)
Insured dependent children
17 years (nearer birthday)
Policy Term
65 years (nearer birthday) minus age at entry of PI
Benefits on death (When all the due premiums have been paid)
On Single Life
In case of death of the PI, Policy Fund value will be paid to the nominee or legal heir
If one or more insured lives (Other than PI) covered
On death of PI before completion of 3 years from Date of Commencement (DOC)
Policy will be terminated and Fund Value in the Policy Fund will be paid to the nominee
After completion of 3 years from DOC
The payment of premiums shall cease & the cover shall continue for the surviving lives till the maximum benefit ceasing age or till the fund is sufficient to recover the charges for HCB & MSB, whichever is earlier
On death of Other insured members
Payment of premiums and cover for PI & other insured members, if any, will continue
On death of PI & spouse (whether insured or not under the policy)
The benefits of the children, if any, shall continue and can be claimed by the eldest major child covered under the policy. If all children are minor, benefits will be claimed by the legal guardian
Hospital Cash Benefit (HCB)
It is based on per day basis. Charges of Rs. 100 per day HCB is prescribed. The amount of daily benefit due to hospitalisation as prescribed in the policy schedule is Initial Daily Benefit (IDB) amount & it will be in multiples of Rs 50. This will increase by 5% every polIcy year commencing at policy anniversary after the first anniversary till it reaches 1.5 times the IDB. It is called as applicable daily benefit for that policy year. This benefit is payable by LIC, subject to exclusions, in the event of accidental bodily injury or sickness first occurring or manifesting itself after the date of cover commencement. The following points should be noted carefully
Minimum IDB (Non-ICU Ward*)
Rs 250 for each insured
Maximum IDB
For PI
Rs 2500
For Insured Spouse, if any
Less than or equal to PI, but maximum of Rs. 1500
For Insured Dependent Children
Less than or equal to Insured Spouse (PI, if there is no insured Spouse), but maximum Rs 1500
*In case of ICU Ward, it is 2 times the Non-ICU benefit
Maximum Cover Ceasing Age
For PI & Insured Spouse
65 years (nearer birthday)
For Dependent Children
25 years (nearer birthday)
Maximum Annual Benefit Period
For PI, Insured Spouse & Dependent Children, if any
18 days in 1st year, 60 days per year thereafter inclusive of stay at ICU
Maximum number of days in ICU is restricted to 9 days in 1St year, 30 days per year thereafter within the overall limit as explained above
Maximum Lifetime Benefit Period
For PI & Insured Spouse & Dependent Children, if any
365 days (90 days until the child completes 5 years of age)
Benefit Limits
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Benefit will be paid only after 48 hours (2 days) of hospitalization, whether admited in a general ward or in ICU
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Benefit shall be payable only if hospitalization has occurred within India
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In case the insured is covered under multiple policies, benefits under all the policies should not exceed the maximum cap on benefits under the plan
Major Surgical Benefit(MSB)
It is a percentage of sum assured depending on the type of surgical procedure. Charges per Rs. 1000 SA is prescribed. This benefit is payable by LIC, subject to exclusions, in the event of an insured undergoing any surgery in a hospital due to accidental bodily injury or sickness first occurring or manifesting itself after the date of cover commencement. Various surgical procedures and the relevant percentage of SA payable is prescribed. Exclusions will also apply to this benefit. The following points should be noted carefully
Sum Assured
For PI
200 times the IDB of PI
For Insured Spouse
200 times the IDB of the Insured Spouse
Dependent Children, if any
200 times the IDB of each child
This benefit is fixed and shall not increase in subsequent year
Minimum age for commencement of cover
For PI, Insured Spouse & Dependent Children
18 years (last birthday)
Maximum cover ceasing age
For PI & Insured Spouse
65 years (nearer birthday)
For Dependent Children, if any
25 years (nearer birthday)
Maximum Annual Benefit
For PI, Insured Spouse & Dependent Children, if any
100% of SA
Maximum lifetime Benefit
For PI, Insured Spouse & Dependent Children, if any
3 times the SA
Benefit Limits
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Claim becoming eligible for payment under this benefit, will be paid regardless of the actual amount spent. It will be paid in lump sum after providing proof of surgery being carried out. If multiple surgeries performed at the same incision or by different incisions, during the same surgical session, benefit will be payable for that surgery in respect of which the largest benefit becomes payable. Claim cannot be made for the same surgery performed again during the term of the policy
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No payment shall be made for the operations performed, which are not prescribed & the surgical procedures so performed should be confirmed as essential and required, by a qualified physician or Surgeon
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Minor children, if covered, will automatically be covered for MSB from the policy anniversary on which age at last birthday is 18 years. There is no option to PI to exclude the cover
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Surgery should have been performed in the hospitals within India
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Benefits unclaimed for one Insured cannot be transferred
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In case the insured is covered under multiple policies, benefits under all the policies should not exceed the maximum cap on benefits under the plan
Benefit Termination (Applicable to HCB and MSB)
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On date of cover expiry (i.e. from the next anniversary when PI & insured spouse becoming 65 years and in case of insured child 25 years)
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When maximum lifetime claim limit of 365 days reached
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On death of Insured
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At the end of policy term
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On divorce or legal separation of the PI & Insured Spouse
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On termination of policy due to any reason
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When premiums is paid for full 3 years, till the end of auto-cover i.e. 2 years from FUP or till such period Policy Fund Value reduces to 1 annualized premium, whichever is earlier
Exclusions for HCB & MSU
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Pre-existing condition, ie, illnesses, symptoms, treatments, pains etc. arisen or arising due to these, prior to commencement of the cover. It also includes the conditions arising between signing of the application form and confirmation of acceptance
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Waiting period of 180 days from the commencement of cover and 90 days from the date of revival will apply. Not applicable in case of Accidental Bodily Injury
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Treatment/Surgery not performed by a Physician/Surgeon
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Routine medical check up or examination, diagnosis. X – ray or laboratory examinations
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An epidemic sickness as classified by State or Central Govt
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Circumcision, cosmic or aesthetic treatments of any description, change of gender surgery, plastic surgery (unless it is necessary for treatment of illness or accidental bodily injury as direct result of the insured event and performed within 6 months of the same)
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Hospitalization for donation of an organ or correction of birth defects or congenital anomalies
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Dental treatment or surgery unless necessitated by Accidental Bodily Injury
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Self afflicted injuries or conditions, attempted suicide and use/misuse of alcohol or any drugs
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Sexually transmitted diseases or any condition directly or indirectly caused by HIV or commonly referred as AIDS
Domiciliary Treatment Benefit(DTB)
This is a adhoc benefit available over and above those paid through HCB & MSB incurred in respect of PI or any other insured lives at any time after atleast 3 years’ premiums have been paid and subject to availability of sufficient amount in Policy Fund. This benefit takes care of the actual amount spent for domiciliary treatment or any other medical expenses. This benefit is available for a policy as a whole and not for individual insureds. Minimum benefit claim should be Rs 2500 and maximum 50% of the Policy Fund at the time of payment and there should be a minimum balance of one annualized premium after the payment. In the last policy year, this condition will be waived. If the balance in the Policy Fund is less than Rs 2500, then the payment of entire amount shall be made in one lump sum only. Maximum number of claims allowed per policy during a policy year is 2 times. Payments shall be made subject to production of medical treatment and supporting bills for expenses incurred for treatment. Further, expenses being claimed should not be older than a year
Premium Allocation Charges
First Year- 30%
Thereafter- 6%
Increase in Premium
Allowed in multiples of Rs. 500, if requested by PI in writing. But there will not be any increase in benefit amounts under HCB & MSB
Reduction in Premium
Allowed subject to minimum premium and benefit limits required. No change in benefit amounts provided to PI & other insurds
Premium Holidays
After 3 years’ premium payment, if the policy lapses, the PI may pay all due premiums in full. He may also choose to pay atleast the latest instalment due without interest and avail premium holidays for the period for which premiums have not been paid subject to a minimum balance of one annualized premium
Loan Facility
Not available
Mode of premium payment
Yearly, Half-yearly or Monthly (only through ECS)
Other Charges
Fund Management Charge (FMC)
1.25% pa (on the date of computation of NAV only daily basis). NAV thus calculated will be net of FMC
Policy Administration Charge
Rs 75 pm during 1st policy year & Rs 25 pm thereafter
Service Tax Charge
On Health Insurance Charges @ 12.36% (present rate)
Claim Requirements
HCB & MSB should be claimed within 15 days of discharge from the hospital with written notification in the prescribed forms along with supporting evidences, if any
Discharge card with details of diagnosis & treatment received
Certificate from the Physician for being admitted to ICU with reasons & exact date, time of admission to & discharge from ICU along with confirmation from a Physician appointed by the LIC
Any otiier document that may be called in the course of claim evaluation
Medical Underwriting Required (with respect to sum assured and age)
Rs. 50,000 to 1 Lakh
Upto 35- NM
36 to 40- NM
41 to 50- NM
51 to 55- MER, FBS, RUA
Rs. 1.00,001 to 2 Lakhs
Upto 35- NM
36 to 40- NM
41 to 50- MER, FBS, RUA
51 to 55- MER, FBS, RUA, HbA1c, ECG
Rs. 2,00,001 to 3 Lakhs
Upto 35- NM
36 to 40- MER, FBS, RUA
41 to 50- MER, FBS, RUA
51 to 55- MER, FBS, RUA, HbA1c, ECG
Rs. 3,00,001 to 5 Lakh
Upto 35- MER, FBS, RUA
36 to 40- MER, FBS, RUA, HbA1c, ECG
41 to 50- MER, FBS, RUA, HbA1c, ECG
51 to 55- MER, FBS, RUA, HbA1c, TMT
Daily Hospital Cash Benefit (HCB) Charges of Rs 100 per day
Excel
Major Surgical Benefit (MSB) Charges per Rs 1000 SA
Excel
List of Surgical Procedures & Percentage of SA Payable
Cardiovascular System
Major surgery of Aorta, CABG (2 or more coronary arteries must be bypassed) via open chest surgery, Valve replacement using mechanical prosthesis via chest surgery, Pericardiotomy/Pericardectomy done in chronic constrictive pericarditis, Open chest surgery for repair of any of the heart valves- 100%
Initial implantation of permanent pacemaker in the heart- 60%
Coronary Angioplasty with stent implantation (2 or more coronary atteries must be stented)- 40%
Haemic and Lymphatic System
Bone marrow transplant (as recepient), Splenectomy for hematogical conditions- 60%
Nervous System
Surgery to remove cerebral tumors (benign or malignant) and space occupying lesions requiring ‘craniotomy’, Repair of Cerebral or Spinal Arterio-Venous Malformations and Cerebral Aneurysms, Other intra-cranial operations requring craniotomy, Excision of pineal gland, Excision of the pituitary gland- 100%
Operations on Surbaracahnoid space of brain, Intracranial transection of Cranial nerve- 60%
Drainage of Extradural space, Drainage of Subdural space- 40%
Respiratory System
Lung Transplant or combined Heart-Lung Transplant, Isolated Heart Transplant, Pneumonectomy or Pleuropneumonectomy-total lung of one side- 100%
Pleurectomy or Pleural decortication, Thoracotoplasty, Open Lobectomy of Lung, Excision of benign medistinal mediastinal lesions (evidence of thoractomy needs to be ascertained), Partial Extripation of Bronchus, Partial or Total Pharyngectomy, Total Laryngectomy- 60%
Digestive System
Excision of esophagus & stomach- 100%
Resection & Anastomosis of any part of digestive tract, Open Surgery for treatment of Peptic Ulcer, Total excision of oesophagus, Total excision of stomach- 60%
Artificial opening into stomach- 40%
Endocrine System
Complete excision of adrenal glands, Complete excision of Thyroid gland, Complete excision of Parathyroid gland, Thyrnectomy- 60%
Partial excision of the above-40%
Eye
Any eye surgery requiring corneal or retinal repair due to accident- 40%
Liver, Gall Bladder and PancreasPartial Resection of Liver, Partial Paricreatectomy- 40%
Musculoskeletal System
Total replacement of Hip or knee joint following accident, Amputation of Arm or hand or Foot or Leg due to trauma or accident- 60%
Oro Maxillafacial Surgery
Major reconstructive oro-maxillafacial surgery due to trauma or burns and not for cosmetic purpose- 60%
Kidney & Urinary Tract
Renal transplant(recipient)-100%Nephrectomy due to medical advice (not as a transplant donor)- 60%
Other features
Method of Calculation of Unit price
Units will be allotted based on the Net Asset Value (NAV) of the respective fund as on the date of allotment. There is no Bid-Offer spread (the Bid price and Offer price of units will both be equal to the NAV). The NAV will be computed on daily basis and will be based on investment performance, Fund Management Charge and whether fund is expanding or contracting under each fund type and shall be calculated as under
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Appropriation price is applied (when fund is expanding)
Market value of investments held by the fund plus the expenses incurred in the purchase of the assets plus the value of any current assets plus any accrued income net of fund management charges less the value of any current liabilities less provisions, if any divided by the number of units existing at the valuation date (before any new units are allocated)
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Expropriation price is applied (when fund is contracting)
Market value of investments held by the fund less the expenses incurred in the sale of assets plus the value of any current assets plus any accrued income net of fund management charges less the value of any current liabilities less provisions, if any divided by the number of units existing at the valuation date (before any units redeemed)
Applicability of Net Asset Value (NAV)
The premiums received up to a particular time (presently 3 p.m.) by the servicing branch of the Corporation through ECS or by way of a local cheque or a demand draft payable at par at the place where the premium is received, the closing NAV of the day on which premium is received shall be applicable. The premiums received after such time by the servicing branch of the Corporation through ECS or by way of a local cheque or a demand draft payable at par at the place where the premium is received, the closing NAV of the next business day shall be applicable
Similarly, in respect of the valid applications received for surrender, partial withdrawal, death claim, switches etc up to such time by the servicing branch of the Corporation closing NAV of that day shall be applicable. For the valid applications received in respect of surrender, partial withdrawal, death claim, switches etc after such time by the servicing branch of the Corporation the closing NAV of the next business day shall be applicable
In respect of maturity claim, NAV of the date of maturity shall be applicable.The timing given is as per the existing guidelines and changes in this regard shall be as per the instruction from IRDA
Discontinuance of Premiums
If premiums are payable either yearly, half-yearly, quarterly or monthly (ECS) and the same have not been duly paid within the days of grace under the Policy, the Policy will lapse. A lapsed policy can be revived during the period of two years from the due date of first unpaid premium
Where atleast 3 years’ premiums have been paid
The Life Cover and Accident Benefit rider, if any, shall continue during the revival period. During this period, the charges for Mortality and Accident Benefit cover, if any, shall be taken, in addition to other charges, by cancelling an appropriate number of units out of the Policyholder’s Fund Value every month. This will continue to provide relevant risk covers for
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Two years from the due date of first unpaid premium, or
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Till the date of maturity, or
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Till such period that the Policyholder’s Fund Value reduces to Rs 5000, whichever is earlier
The benefits payable under the policy in different contingencies during this period shall be as under
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In case of Death
Higher of Sum Assured under the Basic Plan or the Policyholder’s Fund Value. The Sum Assured shall be subject to provisions of Partial Withdrawals made, if any
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In case of Death due to accident
Accident Benefit Sum Assured in addition to the amount under A above, if Accident Benefit is opted for
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On Maturity
The Policyholder’s Fund Value
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In case of Surrender (including Compulsory Surrender)
The Policyholder’s Fund Value. The Surrender value, however, shall be paid only after the completion of 3 policy years
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In case of Partial Withdrawals
For 2 years period from the date of withdrawal, the sum assured under the basic plan shall be reduced to the extent of the amount of partial withdrawals made
Where the policy lapses without payment of at least 3 years’ premiums
The Life Cover and Accident Benefit rider cover, if any, shall cease and no charges for these benefits shall be deducted. However, deduction of all the other charges shall continue. The benefits under such a lapsed policy shall be payable as under
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In case of Death
The Policyholder’s Fund Value
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In case of death due to accident
Only, the amount as under previous point
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In case of Surrender (including Compulsory Surrender)
Policyholder’s Fund Value / monetary value as the case may be, shall be payable after the completion of the third policy anniversary. No amount shall be payable within 3 years from the date of commencement of policy
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In case of Partial withdrawal
Partial Withdrawals shall not be allowed under such a policy even after completion of 3 years period
Compulsory Surrender
The policy shall be surrendered compulsorily in following cases
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Where the policy is not revived during the period of revival, the policy shall be terminated after completion of 3 years from the date of commencement of the policy or on expiry of revival period, whichever is later. However, if the date of maturity falls before the expiry of revival period, then the policy shall be terminated on the date of maturity
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Where premiums have been paid for less than 3 years and the balance in policyholder’s fund value is not sufficient to recover the relevant charges
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Where premiums have been paid for at least 3 years and the balance in policyholder’s fund value falls below Rs 5000
The conversion in monetary value shall be as under
The NAV on the date of application for surrender or on the date when revival period is over (in case of compulsory surrender), as the case may be, multiplied by the number of units in the Policyholder’s Fund as on that date
Revival
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If due premium is not paid within the days of grace, the policy lapses. A lapsed policy can be revived during the period of two years from the due date of first unpaid premium or before maturity, whichever is earlier. The period during which the policy can be revived will be called “Period of revival” or “revival period”
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If premiums have not been paid for at least 3 full years, the policy may be revived within two years from the due date of first unpaid premium. The revival shall be made on submission of proof of continued insurability to the satisfaction of the Corporation and the payment of all the arrears of premium without interest
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If atleast 3 full years’ premiums have been paid and subsequent premiums are not paid, the policy may be revived within two years from the due date of first unpaid premium but before the date of maturity. No proof of continued insurability shall be required but all arrears of premium without interest shall be required to be paid
The Corporation reserves the right to accept the revival at its own terms or decline the revival of a lapsed policy. The revival of a lapsed policy shall take effect only after the same is approved by the Corporation and is specifically communicated in writing to the Proposer/Life Assured
Irrespective of what is stated above, if less than 3 years’ premiums have been paid and the Policyholder’s Fund Value is not sufficient to recover the charges, the policy shall be terminated and thereafter revival will not be entertained. If 3 years’ or more than 3 years’ premiums have been paid and the Policyholder’s Fund Value reduces to Rs. 5000/-, the policy shall terminate and Policyholder’s Fund Value as on such date shall be refunded to the Life Assured and thereafter revival will not be allowed
Assignment
Allowed
Nomination
Compulsory
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