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 (“Policy”) offered by Acko General Insurance Limited (“Acko”) to DMI Finance Private Limited (“DMI Finance”) 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 DMI Finance customers. 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:

Sr. No.	Benefit Name	Sum Insured	Plan 1 (18-50 years)	Plan 2 (51 - 60 years)	Additional Conditions
1	Accidental Death Benefit	Principal Loan Amount (Max. up to 20 lacs)	√	√	Common Sum Insured for Accidental Death, Permanent Total Disability and Permanent Partial Disability Pay-out for Permanent Partial Disability will be according to the grid based on the nature of disability.
2	Permanent Total Disability		√	√
3	Permanent Partial Disability		√	√
4	EMI Protection	Up to 1 Monthly EMI (Max. up to 20 lacs)	√	√	EMI will be payable after 15 days of continuous hospitalization
5	Critical Illness Fixed Benefit	Principal Loan amount (Max. up to 20 lacs)	√	√	This policy will cover 15 Critical Illness as per the table of Critical Illness provided. Survival Period: 7 days Benefit is payable up to the principal Loan amount at the time of first diagnosis of Critical Illness during the Coverage Period

Note:

• Plan 1: The coverage will only be provided to the persons in the age band inclusive of 18 years – 50 years old (age last birthday)
• Plan 2: The coverage will only be provided to the persons in the age band inclusive of 51 years – 60 years old (age last birthday)

Waiting Period

Sr. No.	Condition	Waiting Period
1	Initial Waiting Period (except for accident)	None
2	Critical Illness Waiting Period	None
3	Survival Period for Critical Illness	7 Days

2. General Conditions:

• Acko will only be covering loan taken from DMI Finance. Any loan taken from other source(s) will not be covered.
• 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 as mentioned in the Certificate of Insurance or maximum period of 4 years from the Insurance start date or when the loan amount is repaid in full (whichever is earlier).
• 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 disease is 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.

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:

• Insured have declared that he is in good health and entirely free from any mental or physical impairment or deformities and he does not suffer from any Pre-Existing Critical Illness or any other illness which are covered under the policy.
• Insured has authorized us to pay directly to DMI Finance towards outstanding dues against the loan borrowed from DMI Finance out of the claims proceed or premium refund under policy issued by Acko General Insurance Limited.
• DMI Finance will disburse premium to Acko General Insurance Limited as premium towards issuance of policy for Acko Group Health Insurance Policy offered by Acko General Insurance Limited.

5. Benefit Definition

5.1 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 in the Insured Person’s death within 365 days from the date of the Accident, We will pay the Sum Insured.

5.2 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:

Nature of Permanent Total Disability
Total and irrecoverable loss of sight in both eyes
Loss by physical separation or total and permanent loss of use of both hands or both feet
Loss by physical separation or total and permanent loss of use of one hand and one foot
Total and irrecoverable loss of sight in one eye and loss of a Limb
Total and irrecoverable loss of hearing in both ears and loss of one Limb/ loss of sight in one eye
Total and irrecoverable loss of hearing in both ears and loss of speech
Total and irrecoverable loss of speech and loss of one Limb/ loss of sight in one eye
Permanent, total and absolute disability (not falling under any one the above) which results in the Insured Person being unable to engage in any employment or occupation or business for remuneration or profit, of any description whatsoever which results in Loss of Independent Living

For the purpose of this Benefit:

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

5.3 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:

Nature of Permanent Partial Disability	Percentage of the Sum Insured payable
i. Total and irrecoverable loss of sight in one eye	50%
ii. Loss of one hand or one foot	50%
iii. Loss of all toes - any one foot	10%
iv. Loss of toe great - any one foot	5%
v. Loss of toes other than great, if more than one toe lost, each	2%
vi. Total and irrecoverable loss of hearing in both ears	50%
vii. Total and irrecoverable loss of hearing in one ear	15%
viii. Total and irrecoverable loss of speech	50%
ix. Loss of four fingers and thumb of one hand	40%
x. Loss of four fingers	35%
xi. Loss of thumb- both phalanges	25%
xii. Loss of thumb- one phalanx	10%
xiii. Loss of index finger-three phalanges	10%
xiv. Loss of index finger-two phalanges	8%
xv. Loss of index finger-one phalanx	4%
xvi. Loss of middle/ring/little finger-three phalanges	6%
xvii. Loss of middle/ring/little finger-two phalanges	4%
xviii. Loss of middle/ring/little finger-one phalanx	2%

5.4 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 Chart means 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.

5.5 Critical Illness Benefit:

We will pay the percentage of Sum Insured as is specified against such Critical Illness under this Benefit in the Policy Schedule / Certificate of Insurance, if the Critical Illness or Surgical Procedure is covered under the Policy for the Insured Person, and provided that:

1. The Insured Person survives the applicable Survival Period as specified in the Policy Schedule / Certificate of Insurance.
2. The Critical Illness contracted has not arisen within the applicable Waiting Period specified in the Policy Schedule / Certificate of Insurance against this Benefit (or against any Critical Illness), from the Risk Commencement Date.

Sr. No.	Critical Illness	15 CI's
1	Cancer of Specified Severity	√
2	Kidney Failure Requiring Regular Dialysis	√
3	Multiple Sclerosis with Persisting Symptoms	√
4	Major Organ / Bone Marrow Transplant	√
5	Open Heart Replacement or Repair of Heart Valves	√
6	Open Chest CABG	√
7	Permanent Paralysis of Limbs	√
8	Myocardial Infarction (First Heart Attack – of Specific Severity)	√
9	Stroke Resulting in Permanent Symptoms	√
10	Benign Brain Tumor	√
11	Parkinson’s Disease	√
12	Coma of Specified Severity	√
13	End Stage Liver Failure	√
14	Alzheimer’s Disease	√
15	Aorta Graft Surgery	√

Listing of Critical Illnesses

A. Cancer of Specific Severity

1. A malignant tumor characterized by the uncontrolled growth & 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.
2. The following are excluded
   1. 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 & CIN-3;
   2. Any non-melanoma skin carcinoma unless there is evidence of metastases to lymph nodes or beyond;
   3. Malignant melanoma that has not caused invasion beyond the epidermis;
   4. 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;
   5. All Thyroid cancers histologically classified as T1N0M0 (TNM Classification) or below;
   6. Chronic lymphocyctic leukaemia less than RAI stage 3;
   7. Non-invasive papillary cancer of the bladder histologically described as TaN0M0 or of a lesser classification;
   8. All Gastro-Intestinal Stromal Tumours histologically classified as T1N0M0 (TNM Classification) or below and with mitotic count of less than or equal to 5/50 HPFs;
   9. All tumors in the presence of HIV infection.

B. Myocardial Infraction (First Heart attack of specified severity)

1. 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:
   1. A history of typical clinical symptoms consistent with the diagnosis of acute myocardial infarction (For e.g. typical chest pain)
   2. New characteristic electrocardiogram changes
   3. Elevation of infarction specific enzymes, Troponins or other specific biochemical markers.
2. The following are excluded
   1. Other acute Coronary Syndromes
   2. Any type of angina pectoris
   3. A rise in cardiac biomarkers or Troponin T or I in absence of overt ischemic heart disease OR following an intra-arterial cardiac procedure.

C. Open Chest CABG

1. 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.
2. The following are excluded
   1. Angioplasty and/or any other intra-arterial procedures

D. Open Heart Replacement or Repair of Heart Valves

1. 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.

E. Kidney Failure Requiring Dialysis

1. End stage renal disease presenting as chronic irreversible failure of both kidneys to function, as a result of which either regular renal dialysis (hemodialysis or peritoneal dialysis) is instituted or renal transplantation is carried out. Diagnosis has to be confirmed by a specialist medical practitioner.

F. Stroke Resulting in Permanent Symptoms

1. Any cerebrovascular incident producing permanent neurological sequelae. This includes infarction of brain tissue, thrombosis in an intracranial vessel, haemorrhage and embolization from an extracranial source. Diagnosis has to be confirmed by a specialist medical practitioner and evidenced by typical clinical symptoms as well as typical findings in CT Scan or MRI of the brain. Evidence of permanent neurological deficit lasting for at least 3 months has to be produced.
2. The following are excluded
   1. Transient ischemic attacks (TIA)
   2. Traumatic injury of the brain
   3. Vascular disease affecting only the eye or optic nerve or vestibular functions.

G. Major Organ/Bone Marrow Transplant

1. The actual undergoing of a transplant of:
   1. One of the following human organs: heart, lung, liver, kidney, pancreas, that resulted from irreversible end-stage failure of the relevant organ, or
   2. Human bone marrow using haematopoietic stem cells. The undergoing of a transplant has to be confirmed by a specialist medical practitioner.
2. The following are excluded
   1. Other stem-cell transplants
   2. Where only islets of langerhans are transplanted

H. Permanent Paralysis of Limbs

1. Total and irreversible loss of use of two or more limbs as a result of injury or disease of the brain or spinal cord. A specialist medical practitioner must be of the opinion that the paralysis will be permanent with no hope of recovery and must be present for more than 3 months.

I. Multiple Sclerosis with Persisting Symptoms

1. The unequivocal diagnosis of Definite Multiple Sclerosis confirmed and evidenced by all of the following:
   1. investigations including typical MRI findings which unequivocally confirm the diagnosis to be multiple sclerosis and
   2. there must be current clinical impairment of motor or sensory function, which must have persisted for a continuous period of at least 6 months.
2. Other causes of neurological damage such as SLE and HIV are excluded.

J. Coma of Specified Severity

1. 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:
   1. no response to external stimuli continuously for at least 96 hours;
   2. life support measures are necessary to sustain life; and
   3. permanent neurological deficit which must be assessed at least 30 days after the onset of the coma.
2. The condition has to be confirmed by a specialist medical practitioner. Coma resulting directly from alcohol or drug abuse is excluded.

K. Benign Brain Tumor

1. Benign brain tumor is defined as a life threatening, non-cancerous tumor in the brain, cranial nerves or meninges within the skull. The presence of the underlying tumor must be confirmed by imaging studies such as CT scan or MRI.
2. This brain tumor must result in at least one of the following and must be confirmed by the relevant medical specialist.
   1. Permanent Neurological deficit with persisting clinical symptoms for a continuous period of at least 90 consecutive days or
   2. Undergone surgical resection or radiation therapy to treat the brain tumor.
3. The following conditions are excluded:
   Cysts, Granulomas, malformations in the arteries or veins of the brain, hematomas, abscesses, pituitary tumors, tumors of skull bones and tumors of the spinal cord.

L. Parkinson’s Disease

1. The unequivocal diagnosis of progressive, degenerative idiopathic Parkinson’s disease by a Neurologist acceptable to Us.
2. The diagnosis must be supported by all of the following conditions:
   1. the disease cannot be controlled with medication;
   2. signs of progressive impairment; and
   3. inability of the Insured Person to perform at least 3 of the 6 activities of daily living as listed below (either with or without the use of mechanical equipment, special devices or other aids and adaptations in use for disabled persons) for a continuous period of at least 6 months:
3. Activities of daily living:
   1. Washing: the ability to wash in the bath or shower (including getting into and out of the shower) or wash satisfactorily by other means and maintain an adequate level of cleanliness and personal hygiene;
   2. Dressing: the ability to put on, take off, secure and unfasten all garments and, as appropriate, any braces, artificial limbs or other surgical appliances;
   3. Transferring: The ability to move from a lying position in a bed to a sitting position in an upright chair or wheel chair and vice versa;
   4. Toileting: the ability to use the lavatory or otherwise manage bowel and bladder functions so as to maintain a satisfactory level of personal hygiene;
   5. Feeding: the ability to feed oneself, food from a plate or bowl to the mouth once food has been prepared and made available.
   6. Mobility: The ability to move indoors from room to room on level surfaces at the normal place of residence
4. Parkinson’s disease secondary to drug and/or alcohol abuse is excluded.

M. End Stage Liver Failure

1. Permanent and irreversible failure of liver function that has resulted in all three of the following:
   1. Permanent jaundice; and
   2. Ascites; and
   3. Hepatic encephalopathy.
2. Liver failure secondary to alcohol or drug abuse is excluded.

N. Alzheimer’s Disease

1. Alzheimer’s disease is a progressive degenerative Illness of the brain, characterised by diffuse atrophy throughout the cerebral cortex with distinctive histopathological changes. It affects the brain, causing symptoms like memory loss, confusion, communication problems, and general impairment of mental function, which gradually worsens leading to changes in personality.
2. Deterioration or loss of intellectual capacity, as confirmed by clinical evaluation and imaging tests, arising from Alzheimer’s disease, resulting in progressive significant reduction in mental and social functioning, requiring the continuous supervision of the Insured Person. The diagnosis must be supported by the clinical confirmation of a specialist Medical Practitioner (Neurologist) and supported by Our appointed Medical Practitioner, evidenced by findings in cognitive and neuro radiological tests (e.g. CT scan, MRI, PET scan of the Brain). The disease must result in a permanent inability to perform three or more Activities with Loss of Independent Living or must require the need of supervision and permanent presence of care staff due to the disease. This must be medically documented for a period of at least 90 days
3. The following conditions are however not covered:
   1. non-organic diseases such as neurosis and psychiatric Illnesses;
   2. alcohol related brain damage; and
   3. any other type of irreversible organic disorder/dementia.

O. Aorta Graft Surgery

1. The actual undergoing of major Surgery to repair or correct aneurysm, narrowing, obstruction or dissection of the Aorta through surgical opening of the chest or abdomen. For the purpose of this cover the definition of “Aorta” shall mean the thoracic and abdominal aorta but not its branches.
2. The Insured Person understands and agrees that We will not cover:
   1. Surgery performed using only minimally invasive or intra arterial techniques.
   2. Angioplasty and all other intra arterial, catheter based techniques, "keyhole" or laser procedures
3. The Aorta is the main artery carrying blood from the heart. Aortic Graft Surgery benefit covers Surgery to the Aorta wherein part of it is removed and replaced with a graft.

6. Claim & Documents:

The DMI Finance 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: hello@acko.com

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

Claims process for DMI Finance Customer on Acko Website:

• Go to www.acko.com/ and Login with your mobile number registered on DMI Finance and enter the OTP you receive.
• Under the ‘Claims’ section, select ‘DMI Finance Claims’ which opens your ‘My Account’ page
• Select the benefit for which you want to claim insurance, which will take you to the policy detail page. Click on Initiate Claim to claim.

Select the type of claim, follow the next few steps, and your claim will be registered with Acko

The Insured needs to submit following documents in case of a clai

Sr. No.	Name of Benefit	Documents Required
	Common Documents	Our duly filled and signed Claim Form Name and address of the Insured Person in respect of whom the claim is being made; Copies of valid KYC documents of the Nominee/claimant, any other regulatory requirements, as amended from time to time;
1	Accidental Death Benefit	Copy of FIR (First Information Report)/Spot Panchnama/Inquest Panchnama-where applicable attested by issuing authorities. Death Certificate attested by issuing/ appropriate authority. Post Mortem Report where applicable- attested by issuing authorities. Original legal heir certificate (in case nomination has not been filed by deceased)
2	Permanent Total Disability (PTD)	Written intimation of the claim Investigation reports attested by Appropriate/issuing authorities Photograph of the injured with reflecting disablement FIR / MLC Copy (if MLC is done)/ Spot Panchnama-where applicable- Attested by issuing authority Disability Certificate from appropriate Government Authority Medical Certificate from treating Doctor attested by issuing authority Investigation reports Medical Any relevant claim document, post verification of submitted claim, if required
3	Permanent Partial Disability	Investigation reports Photograph of the injured with reflecting disablement FIR / MLC Copy (if MLC is done) / Spot Panchnama-where applicable- Attested by issuing authority Disability Certificate from appropriate Government Authority Medical Certificate from treating Doctor Leave certificate from the employer Details of any other related document Medical reports, case histories, investigation reports, treatment papers as applicable
4	EMI Protection	Investigation reports Photograph of the injured with reflecting disablement FIR / MLC Copy (if MLC is done) / Spot Panchnama-where applicable- Attested by issuing authority Disability Certificate from appropriate Government Authority Medical Certificate from treating Doctor Leave certificate from the employer Details of any other related document Copy of loan approval letter Medical reports, case histories, investigation reports, treatment papers as applicable EMI due statement Last EMI paid proof
5	Critical Illness Fixed Benefit	Nature of Critical Illness Medical Certificate from treating Doctor Details of any other related document Medical Bills with Prescription Medical reports, case histories, investigation reports, treatment papers as applicable Medical Investigations report with prescription First Consultation and subsequent prescription Discharge summary

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 write an e-mail at: gro@acko.com.

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
36/5, Hustlehub One East, Somasandrapalya,
27th Main Rd, Sector 2, HSR Layout,
Bengaluru, Karnataka 560102
gro@acko.com

In case DMI Finance’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 website www.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 these terms and conditions are only indicative, and the full list of policy conditions and exclusions are available at: https://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.