LOAN SECURE INSURANCE POLICY
Universal Sompo General Insurance Company Limited (“the Company”), having received a Proposal and the premium from the Proposer named in the Schedule referred to herein below, and the said Proposal and declaration together with any statement, report or other document leading to the issue of this Policy and referred to therein having been accepted and agreed to by the Company and the Proposer as the basis of this contract do, by this Policy agree, in consideration of and subject to the due receipt of the subsequent premiums, as set out in the Schedule with all its Parts, and further, subject to the terms and conditions contained in this Policy, as set out in the Schedule with all its Parts that on proof to the satisfaction of the Company of the Compensation having become payable as set out in Part I of the Policy to the title of the said person or persons claiming payment or upon the happening of an event upon which one or more benefits become payable under this Policy, the Sum Insured/ appropriate benefit will be paid by the Company.
For the purposes of this Policy and endorsements, if any, the terms mentioned below shall have the meaning set forth:
Where the context so requires, references to the singular shall also include references to the plural and references to any gender shall include references to all genders.
1.Accidentmeans a sudden unforeseen and involuntary event caused by external, visible and violent means.
2.Bank means a banking Company which transacts the business of banking in India and is regulated by the policies of Reserve Bank of India and other banking laws.
3.Beneficiary: In case of Death of the Insured Person, the Beneficiary means, unless stipulated otherwise by the Insured Person, the surviving Spouse or immediate blood relative of the Insured Person, mentally capable and not divorced, followed by the children recognized or adopted followed by the Insured Person‟s legal heirs. For all other benefits, the Beneficiary means the Insured Person himself unless stipulated otherwise.
4.Civil War means armed opposition, whether declared or not, between two or more parties belonging to the same country where the opposing parties are of different ethnic, religious or ideological groups. Included in the definition: armed rebellion, revolution, sedition, insurrection, Coup d‟état, and the consequences of Martial law.
5.Compensation means Sum Insured, Total Sum Insured or percentage of the Sum Insured, as appropriate.
6.Confirmation means Confirmation of Availability of Insurance issued by the Company to the insured confirming that the Insured is entitled to insurance coverage under this Policy.
7.Contribution is essentially the right of an insurer to call upon other insurers liable to the same insured to share the cost of an indemnity claim on a rateable proportion of Sum Insured. This clause shall not apply to any Benefit offered on fixed benefit basis.
8.EMI or EMI Amount1 means and includes the amount of monthly payment required to repay the principal amount of Loan and Interest by the Insured as set forth in the amortization chart referred to in the loan agreement (or any amendments thereto) between the Bank/Financial Institution and the Insured prior to the date of occurrence of the Insured Event under this Policy. For the purpose of avoidance of doubt, it is clarified that any monthly payments that are overdue and unpaid by the Insured prior to the occurrence of the Insured Event will not be considered for the purpose of this Policy and shall be deemed as paid by the Insured.
EMI refers to the EMI or Pre EMI on the loan or the Sum Insured, whichever is lower, on the date of the Insured Event.
9.Financial Institution shall have the same meaning assigned to the term under section 45 I of the Reserve Bank of India Act, 1934 and shall include a Non-Banking Financial Company as defined under section 45 I of the Reserve Bank of India Act, 1934
10.Illness means a sickness or a disease or pathological condition leading to the impairment of normal physiological function which manifests itself during the Policy Period and requires medical treatment.
- Acute Condition is a disease, Illness or Injury that is likely to respond quickly to treatment which aims to return the person to his or her state of health immediately before suffering the disease/Illness/Injury which leads to full recovery.
- Chronic condition is defined as a disease, Illness, or Injury that has one or more of the following characteristics
- it needs on-going or long-term monitoring through consultations, examinations, check-ups, and/or tests
- it needs on-going or long-term control or relief of symptoms
- it requires Your rehabilitation or for You to be specially trained to cope with it
- it continues indefinitely
- it comes back or is likely to come back.
11. Injury means accidental physical bodily harm excluding Illness or disease solely and directly caused by external, violent and visible and evident means which is verified and certified by a Medical Practitioner.
12. Insured means the Individual(s) whose name(s) are specifically appearing as such in Section 1 of the Schedule to this Policy and are referred to as “You”/”Your”/”Yours”/”Yourself”. For the purpose of avoidance of doubt it is clarified that the heirs, executors, administrators, successors or legal representatives of the Insured may present a claim on behalf of the Insured to the Company.
13. Insured Eventmeans any event specifically mentioned as covered under this Policy.
14. Loan means the sum of money lent at interest or otherwise to the Insured by any Bank/Financial Institution as identified by the Loan Account Number referred to in Section 1 of this Policy
15. Medical Advices Any consultation or advice from a Medical Practitioner including the issue of any prescription or repeat prescription.
16. Medical Practitioneris a person who holds a valid registration from the Medical Council of any State or Medical Council of India or Council for Indian Medicine or for Homeopathy set up by the Government of India or a State Government and is thereby entitled to practice medicine within its jurisdiction; and is acting within the scope and jurisdiction of licence and is not a member of the Insured Person‟s Family.
17. Nomineemeans the person(s) nominated by the Insured to receive the insurance benefits under this Policy payable on the death of the Insured. For the purpose of avoidance of doubt it is clarified that if the Insured is a minor, his guardian shall appoint the Nominee.
18. Permanent Total Disablement means disablement, as the result of a Bodily Injury, which:
- continues for a period of twelve (12) consecutive months, and
- is confirmed as total, continuous and permanent by a Medical Practitioner after the twelve (12) consecutive months, and
- entirely prevents an Insured Person from engaging in or giving attention to gainful occupation of any and every kind for the remainder of his/her life.
19. Period of Insurance means the period commencing from the Policy start date of the first Major Medical IllnessesProcedures Policy with the Company, under which the Insured is covered, subject to the Insured continuously renewing such Major Medical IllnessesProcedures Policy with the Company without any break and terminating at midnight on the Policy end date as UNIVERSAL SOMPO GENERAL INSURANCE COMPANY LIMITED 3 Policy Wordings – Loan Secure Insurance Policy specified in the Schedule to this Policy. No benefit shall accrue to the Insured on account of the Period of Insurance unless the dates are evidenced in writing against the caption of “Period of Insurance” of this Policy. For the purpose of avoidance of doubt it is clarified that if no dates are evidenced in writing against the caption “Period of Insurance” as mentioned above, then the Period of Insurance shall mean the Policy Period.
20. Physical Separation means as regards the hand actual separation at or above the wrists, and as regards the foot means actual separation at or above the ankle.
21. Policy means the Policy booklet, the Schedule, any Extension and applicable endorsements under the Policy. The Policy contains details of the extent of cover available to the Insured, the exclusions under the cover and the terms and conditions of the issue of the Policy
22. Policyholder means the entity or person named as such in the Schedule
23. Policy Period means the period commencing from Policy start date and hour as specified in the Schedule and terminating at midnight on the Policy end date as specified in of the Schedule to this Policy.
24. Portability means transfer by You, an individual health insurance Policy holder (including Family cover) of the credit gained for pre-existing conditions and time bound exclusions if You choose to switch from other insurer to Us.
25. Pre-Existing Disease means any condition, ailment or Injury or related condition(s) for which You had signs or symptoms, and / or were diagnosed, and / or received Medical Advice / treatment within 48 months to prior to the first Policy issued by the Company.
26. Principal Outstanding means the principal amount of the Loan outstanding as on the date of occurrence of Insured Event less the portion of principal component included in the EMIs payable but not paid from the date of the loan agreement till the date of the Insured Event/s. For the purpose of avoidance of doubt, it is clarified that any EMIs that are overdue and unpaid to the Bank prior to the occurrence of the Insured Event will not be considered for the purpose of this Policy and shall be deemed as paid by the Insured.
27. Professional Sports means a sport, which would remunerate a player in excess of 50% of his or her annual income as a means of their livelihood.
28. Public Authority means any governmental, quasi-governmental organization or any statutory body or duly authorized organization with the power to enforce laws, exact obedience, and command, determine or judge.
29. Renewal means defining the terms on which the contract of insurance can be renewed on mutual consent with a provision of grace period for treating the Renewal continuous for the purpose of all waiting periods.
30. Schedule means this Schedule and parts thereof, and any other annexure(s) appended, attached and / or forming part of this Policy.
31. Scheduled Airlinemeans any civilian aircraft operated by a civilian scheduled air carrier holding a certificate, license or similar authorization for civilian scheduled air carrier transport issued by the country of the aircraft‟s registry, and which in accordance therewith flies, maintains and publishes tariffs for regular passenger service between named cities at regular and specified times, on regular or chartered flights operated by such carrier and is flown by authorized licensed pilot.
32. Spousemeans an Insured Person‟s husband or wife who is recognized as such by the laws of the jurisdiction in which they reside.
33. Subrogation means Our rights to assume Your rights to recover expenses paid out under the policy that may be recovered from any other source.
34. Sum Insured means and denotes the amount of cover available to the Insured subject to the terms and conditions of this Policy and as stated in the Table of Benefits given in the Schedule of this Policy which is the maximum liability of the Company under this Policy.
35. Surgery or Surgical Procedure means manual and / or operative procedure(s) required for treatment of an Illness or Injury, correction of deformities and defects, diagnosis and cure of diseases, relief of suffering or prolongation of life, performed in a hospital or day care centre by a Medical Practitioner
36. Terrorism means activities against persons, organizations or property of any nature:
- A. that involve the following or preparation for the following:
a) use or threat of force or violence; or
b) commission or threat of a dangerous act; or
c) commission or threat of an act that interferes with or disrupts an electronic, communication, information or mechanical system; and
- B.when one or both of the following applies:
a) the effect is to intimidate or coerce a government or the civilian population or any segment thereof, or to disrupt any segment of the economy; or
b) It appears that the intent is to intimidate or coerce a government, or to further political, ideological, religious, social or economic objectives or to express (or express opposition to) a philosophy or ideology.
32. Spousemeans an Insured Person‟s husband or wife who is recognized as such by the laws of the jurisdiction in which they reside.
32. Spousemeans an Insured Person‟s husband or wife who is recognized as such by the laws of the jurisdiction in which they reside.
SCOPE UNDER THE POLICY
WHAT WE COVER
The Hospitalization expenses of the insured when he/she sustains any injury or contracts any disease and is advised hospitalization by a Medical Practitioner
We will pay Reasonable and Customary charges of the following Hospitalization expenses:
1.The Medical Expenses incurred on Room, Boarding and Nursing Expense as provided in the Hospital/ Nursing Home
2.The Medical Expenses incurred on Medical Practitioner/ Anesthetist, Consultant fees, Surgeons fees and similar expenses
3.The Medical Expenses incurred on Anesthesia, Blood, Oxygen, Operation Theatre, Surgical Appliances, Medicines and Drugs, Diagnostic Materials and X-ray, Dialysis, Chemotherapy, Radiotherapy, Cost of Pacemaker, Artificial Limbs, Cost of Organs and similar expenses.
4.The medical expenses on treatment arising from or traceable to pregnancy, childbirth and expenses on the treatment of the newly born child up to 5% of the sum insured, subject to such treatment not being carried out before the completion of 9 months from the commencement of the policy
5.The Medical Expenses incurred in the 30 days immediately prior before the date You were Hospitalized, provided that any Nursing expenses during Pre Hospitalisation will be considered only if Qualified Nurse is employed on the advice of the attending Medical Practitioner for the duration specified
6.The Medical Expenses incurred in the 60 days immediately after Your date of discharge from Hospital provided that any Nursing expenses during Pre Hospitalisation will be considered only if Qualified Nurse is employed on the advice of the attending Medical Practitioner for the duration specified
7.Cost of Health Checkup: Insured Person shall be entitled for reimbursement of cost of medical checkup once at the end of a block of every three claim free Policies. The reimbursement shall not exceed the amount equal to 1% of the average Basic Sum Insured during the block of four claim free Policies.
8.In case of hospitalization of children below 12 years, a lump sum amount of Rs.1000/- as Out of Expenses to any of the parents during the policy period.
9.Ambulance charges in connection with any admissible claim limited to Rupees 1000/- per policy period.
10.In case of death in hospital, funeral expenses are reimbursed up to Rs.1000/ over and above the sum insured subject to the original illness/accident claim admitted under the policy.
a)Expenses on Vitamins and Tonics only if forming part of treatment as certified by the attending Medical Practitioner.
b)The Hospitalization expenses incurred for treatment of any one illness under agreed package charges of the Hospital/Nursing Home will be restricted to 75% of the Sum Insured.
c)Cashless facility for the medical treatment carried out in Network Hospital/ Nursing home is available through our nominated Third Party Administrator (TPA)
d)A co-payment of 20% shall be applicable on each and every claim of Insured Person who is above 55 years of age under the Policy
e)If medical expenses are incurred under two Policy Periods, the total liability shall not exceed the Sum Insured of the Policy during which the Insured Person’s medical treatment commenced and the entire claim will be considered under that Policy only
f)Expenses on hospitalization for a minimum period of 24 hours are admissible. However, this time limit is not applied to specific treatments, i.e. Dialysis, Chemotherapy, Radiotherapy, Eye Surgery, Lithotripsy (Kidney stone removal), D&C, Tonsillectomy taken in the Hospital / Nursing Home and where in the insured is discharged on the same day, such treatment will be considered to have been taken under hospitalization benefit. This condition will also not apply in case of stay in Hospital for less than 24 hours provided (a) the treatment is such that it necessitates hospitalization and the procedure involves specialized infrastructural facilities available in hospitals (b) due to technological advances hospitalization is required for less than 24 hours only.
WHAT WE EXCLUDE
30 days Waiting Period
A waiting period of 30 days will apply to all claims unless:
i.You have been insured under this Policy continuously and without any break in the previous Policy Year, or
ii.You were insured continuously and without interruption for at least 1 year under any other Indian insurer’s individual health insurance Policy for the reimbursement of medical costs for inpatient treatment in a Hospital, and You establish to Our satisfaction that You were unaware of and had not taken any advice or medication for such Illness or treatment.
iii.If You renew with Us or transfer from any other insurer and increase the Sum Insured (other than as a result of the application of Cumulative Bonus upon Renewal with Us, then this exclusion shall only apply in relation to the amount by which the Sum Insured has been increased.
Pre-existing diseases will not be covered until 48 months of continuous coverage have elapsed, since inception of the first Policy with Us; but:
1.If You are presently covered and have been continuously covered without any break under:
i.An individual health insurance plan with an Indian insurer for the reimbursement of medical costs for inpatient treatment in a Hospital,
ii.Any other similar health insurance plan from Us, then, Pre-existing diseases exclusion of the Policy stands deleted and shall be replaced entirely with the following:
i.The waiting period for all Pre-existing diseases shall be reduced by the number of Your continuous preceding years of coverage under the previous health insurance Policy;
ii.If the proposed Sum Insured for You is more than the Sum Insured applicable under the previous health insurance Policy (other than as a result of the application of Cumulative Bonus), then the reduced waiting period shall only apply to the extent of the Sum Insured under the previous health insurance Policy.
2.Hospitalization expense incurred in the first year of operation of the insurance cover on treatment of the following Diseases :
- Benign Prostatic Hypertrophy
- Myomectomy, Hysterectomy
- Hernia, Hydrocele
- Fistula in anus, Piles
- Arthritis, Gout, Rheumatism
- Joint replacement unless due to accident
- Sinusitis and related disorders
- Stone in the urinary and biliary systems
- Dilatation and Curettage
- Skin and all internal tumors/cysts/nodules/polyps of any kind, including breast lumps unless malignant, adenoids and hemorrhoids
- Dialysis required for rental failure
- Surgery on tonsils and sinuses
- Gastric and duodenal ulcers
However, a waiting period of 1 year will not apply if You were insured continuously and without interruption for at least 1 year under Our or any other Indian insurer’s individual health insurance Policy for the reimbursement of medical costs for inpatient treatment in a Hospital.
NB: The reduction in the waiting period specified above shall be applied subject to the following:
i)We will only apply the reduction of the waiting period if We have received the database and claim history from the previous Indian insurance Company (if applicable);
ii)We are under no obligation to insure all Insured Persons or to insure all Insured Persons on the proposed terms, or on the same terms as the previous health insurance Policy even if You have submitted to Us all documentation
iii)We shall consider only completed years of coverage for waiver of waiting periods.
1.Injury or Diseases directly or indirectly caused by or arising from or attributable to war, invasion, act of foreign enemy, war like operation (whether war be declared or not).
2.Circumcision unless necessary for the treatment of a Disease not otherwise excluded or required as a result of accidental bodily injury; vaccination, inoculation, cosmetic or aesthetic treatment of any description(including any complications arising thereof), plastic surgery except those relating to treatment of Injury or Disease.
3.Cost of spectacles and contact lens or hearing aids.
4.Dental treatment or surgery of any kind
5.Convalescence, general debility, run down condition or rest cure, congenital external disease or defects or anomalies, sterility, venereal disease, intentional self injury and use of intoxicating drugs/alcohols.
6.Any expense on treatment related to HIV, AIDS Human T-Cell Lymphotropic Viruses types III (III-LB-III) or Lymphadinopathy Associated viruses (LAV) or the Mutant derivatives or Variations Deficiency Syndrome and all related medical condition.
7.Expenses on Diagnostic, X-Ray, or Laboratory examinations unless related to the treatment of Disease or Injury falling within ambit of Hospitalisation or Domiciliary Hospitalisation claim.
8.Voluntary medical termination of pregnancy during first 12 weeks from the date of conception and expenses on treatment of any infertility, sub fertility or assisted conception treatment.
9.Injury or Diseases directly or indirectly caused by or contributed to by nuclear weapons/material.
10.Any expense on treatment of Insured Person as outpatient in a Hospital.
11.Any expense on Naturopathy, non allopathic treatment and/or any treatments not approved by Indian Medical council Any expense related to Disease/Injury suffered whilst engaged in adventurous sports like hand gliding, mountaineering, rock climbing, sky diving, professional or amateur racing, parachuting, skiing, ice skating, ballooning, river rafting, polo playing, horse racing or sports of similar nature.
12.External medical equipment of any kind used at home as post hospitalisation care like wheelchairs, crutches, instruments used in treatment of sleep apnea syndrome (C.P.A.P) or continuous peritoneal ambulatory dialysis (C.P.A.D) and oxygen concentrator for bronchial asthmatic condition, etc.
13.Any expense under Domiciliary Hospitalisation
14.Pre and post natal expenses are excluded unless incurred as inpatient in a hospital
15.War, riots, strike, terrorism acts, nuclear weapon induced treatment
A) Reimbursement Claims Process:
Upon happening of any injury / Disease which may give rise to a claim under this Policy
- You shall give Us a notice to Our call centre immediately and also intimate in writing to Our Policy issuing office but not later than 7 days from the date of Hospitalisation. A written statement of the claim will be required and a Claim Form will be completed and the claim must be filed within 30 days from the date of discharge from the Hospital or completion of treatment.
- You must give all original or copies of bills, receipts, certificates, post-mortem report in the event of death, information and evidences from the attending Medical Practitioner / Hospital / Chemist / Laboratory as required by Us. On receipt of intimation from You regarding a claim under the Policy, We are entitled to carry out examination and obtain information on any alleged Injury or Disease requiring Hospitalisation if and when We may reasonably require.
B) Cashless Claims:
Cashless Service: You can avail cashless hospitalisation facility at any hospital in the network of the TPA. We will provide a Cashless Service by making payment to the extent of Our liability direct to the Network
Hospital as long as We are given notice that the Insured Person wishes to avail Cashless Service accompanied by full particulars at least 48 hours before any planned treatment or Hospitalisation or within 24 hours after the treatment or Hospitalisation in the case of an emergency (namely a sudden, urgent, unexpected occurrence or event, bodily alteration or occasion requiring immediate medical attention).
In case if You want to avail cashless facility in any of the network hospital you shall follow the process as mentioned below.
- Carry the Health Card/ copy of E-cards.
- Obtain Pre Authorization form from the hospital counter.
- Fill up the form and submit it at the hospital counter.
- Ensure that hospital faxes the pre authorization form to TPA or you can fax the form to TPA yourself.
- Once the form has been faxed, TPA will send the authorization to the Hospital.
- Once cash less approval is received, patient need not pay the bill to the hospital for covered medical expenses
1.We shall settle claim(s) as per Policy terms and conditions, including its rejection, within thirty days of the receipt of the last necessary claim document
2.We shall have no liability under this Policy, once the Sum Insured (Maximum Limit of Indemnity) with respect to any of the Sections, is exhausted by You or Your Insured Family Member.
3.All admissible claims under this Policy shall be paid by Us within 7 working days from date of acceptance of such a claim.
In case of delay in the payment, We shall be liable to pay interest at a rate which is 2% above bank rate prevalent at the beginning of the financial year in which claim is reviewed by Us.
4.We shall condone delay on merit for delayed claims where the delay is proved to be beyond Your control.
Should any dispute arise between Us and You on the quantum of amount payable, liability being otherwise admitted by us, such dispute will be referred to Arbitration proceedings in accordance with Arbitration and Conciliation Act of 1996 as amended from time to time. Further the making of an award by Arbitrator(s) shall be a condition precedent to any right of action or suit by You against Us
A Co-pay of 20% on each and every claim shall be applicable if You are above 55 years of age under the policy3. Contribution
If at the time of a claim there is another insurance Policy or other contract in the Your name which covers You for the same expense or loss, We will only pay Our proportionate share of the loss. Our Proportionate share will be calculated by determining the percentage Our Policy maximum bears to the total amount of insurance in force as to the loss.4. Cancellation
We may cancel this Policy by sending 15 days’ notice in writing by recorded delivery to You at Your last known address, However this clause shall not be exercised except on grounds of fraud, misrepresentation, or suppression of any material fact either at the time of taking the policy or any time during the currency of the policy or bad moral hazard. You will then be entitled to a pro-rata refund of premium for the un-expired period of this Policy from the date of cancellation, which We are liable to pay on demand.
You may cancel this Policy by sending a written notice to Us. Retention premium for the period we were on risk will be calculated based on following short period table and the balance will be refunded to you subject to the condition that no claim has been preferred on us:
|Period Of Risk||Rate of premium to be charged|
|Upto 1 month||25% of annual premium|
|Upto 3 months||50% of annual premium|
|Upto 6 months||75% of annual premium|
|Above 6 months||100% of annual premium|
5. Three Month Notice
We shall give You notice in the event We may decide to revise, modify or withdraw the product. Such notice shall be given to You at least three months prior the date when such modification or revision or withdrawal comes into effect. We also promise You that
i.In case of modification or revision, the notice given to You shall detail the reasons for such revision or modification, in particular the reason for an increase in premium (if any) and the quantum of such increase.
ii.The product shall be withdrawn only after due approval from the Insurance Regulatory and Development Authority. However, if You do not respond to Our intimation in case of such withdrawal, the Policy shall be withdrawn on the Renewal date and We shall provide You with an option to migrate to a substitute product offered by Us, subject to portability conditions.
6. Disclaimer Clause
In case of any claim under the Policy which is not admitted by us and such claim shall not have been made subject matter of a suit in a court of law within 12 months from the date of disclaimer, then the claim shall for all purposes be deemed to have been abandoned and shall not thereafter be recoverable under this Policy.
7. Free Look Period
We shall give Youa Free Look Period. at the inception of the Policy and:
1.You 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.
2.2. If You have not made any claim during the Free Look period, You shall be entitled to
a)A refund of the premium paid less any expenses incurred by Us on Your medical examination and the stamp duty charges or;b)where the risk has already commenced and the option of return of the Policy is exercised by You, a deduction towards the proportionate risk premium for period on cover or;
c)Where only a part of the risk has commenced, such proportionate risk premium commensurate with the risk covered during such period.
All benefit under this Policy shall be forfeited and the policy shall be treated as void in case of any fraudulent claims or if any fraudulent means are used by You or anyone acting on Your behalf to obtain any benefit under this Policy.
9. Geographical Limit
The geographical scope of this Policy will be India, Nepal and Bhutan and all claims shall be payable in Indian currency.
This Policy shall be void and premium paid shall be forfeited to Us in the event of mis-representation, mis-description or non-disclosure of any materials facts by you. Non- disclosure shall include non-intimation of any circumstances which may affect the insurance cover granted.
11. Multiple Policies
i.If two or more policies are taken by You / Insured Persons during the period for which You/ Insured Person are/is covered under this Policy from one or more insurers, the contribution clause shall not be applicable where the cover/ benefit offered:
- is fixed in nature viz. Personal Accident if available under the Policy
- does not have any relation to the treatment costs;
ii.We also agree that even if, You/ Insured Person are/is covered under multiple policies providing Personal Accident, We shall make the claim payments independent of payments received under other similar polices in respect of the covered event.
iii.We agree that even if two or more policies are taken by You/ Insured Person during the time for which You/ Insured are/is covered under this Policy from one or more insurers for indemnification of Your Hospitalisation treatment costs, We shall not apply the Contribution clause and You shall have the following rights
- You may choose to get the settlement of claim from Us as long as the claim is within the limits of and according to terms and conditions of the Policy
- If the amount to be claimed exceeds the Sum Insured under a single Policy after consideration of the deductible and co-pay, You/ Insured Person shall have the right to choose any insurers including Us by whom You/ Insured Person wish Your claim to be settled. In such cases, We shall settle the claim with contribution clause
- Except for the Personal Accident cover, in case if You/ Insured Person have taken policies from Us and one or more insurers to cover the same risk on indemnity basis , You/ Insured Person shall only be indemnified the hospitalisation costs in accordance with the terms and condition of the Policy.
You can at the inception or at any time before the expiry of the Policy, make a nomination for the purpose of payment of claims under the Policy in the event of death. In absence of Your declaring nomination at the time of proposals, all benefits accrued under the Policy shall be given to your legal heir/ dependants.
Any change of nomination shall be communicated to Us in writing and such change shall be effective only when an endorsement on the Policy is made by Us.
In case of any Insured Person other than You under the Policy, for the purpose of payment of claims in the event of death, the default nominee would be You.
Every notice and communication to the Company required by this policy shall be in writing. Initial notification can be made by telephone
14. Policy Disputes
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. The dispute on quantum on payment of losses or any other dispute explained in the paragraph shall be preferred to be dealt and resolved under the alternative dispute resolutions system including Arbitration and Conciliation Act of India.
If You were insured continuously and without a break under another Indian similar health insurance Policy with any other Indian General Insurance company or from Us, it is understood and agreed that:
a)If You wish to exercise the Portability Benefit, We should have received Your application with complete documentation at least 45 days before the expiry of Your present period of insurance;
b)This benefit is available only at the time of Renewal of the existing health insurance Policy.
c)The Portability Benefit shall be applied subject to the following:
i)You shall give Us all additional documentation and/or information We request;
ii)You pay Us the applicable premium in full;
iii)There is no obligation on Us to insure all Insured Persons or to insure all Insured Persons on the proposed terms, even if You have given Us all documentation;
iv)We have received the database and claim history from the previous insurance company for the Insured Persons’ previous health insurance Policy.
v)Your proposal shall be subject to Our medical underwriting
We reserve the right to modify or amend the terms and the applicability of the Portability Benefit in accordance with the provisions of the regulations and guidance issued by the Insurance Regulatory and Development Authority as amended from time to time.
a)Your Policy shall ordinarily be renewable till 80 years of age except on grounds of fraud, moral hazard or misrepresentation or non‐cooperation by You/ any of the Insured Person
b)The Renewal of a Policy sought by You shall not be denied arbitrarily. If denied, We shall provide You with cogent reasons for such denial of Renewal.
c)We shall not deny the Renewal of the Policy on the ground that You had made a claim or claims in the previous or earlier years, except for the optional benefit covers where the coverage under the benefits viz. Personal Accident shall terminate following payment
d)We shall provide for a mechanism to condone a delay in Renewal up to 30 days from the due date of Renewal without deeming such condonation as a Break in Policy. However coverage shall not be available for such period.
e)If You move into a higher age band, the premium will increase at the next Renewal. However, this Policy will not be subject to any alteration in premium rates generally introduced until the next Renewal.
f)If the Policy is not renewed within the Grace Period then We may agree to issue a fresh Policy subject to Our underwriting criteria and no continuing benefits shall be available from the expired Policy.
g)All premiums are payable in advance of any cover under this Policy being provided
h)The basic premium applicable under the Policy may be revised at a later stage subject to approval from IRDA.
i)We shall provide You with a substitute product if You have reached maximum renewable age under the Policy and suitable credits (continuity benefits) for all the previous policy years that You have been covered shall be provided to You if the Policy has been maintained without break
This Policy is in force for the Policy Period in Your Policy Schedule and is renewable subject to the terms provided at the time of each Renewal.We, however, are not bound to give notice that the Policy due for Renewal. Unless renewed as herein provided, this Policy shall terminate at the expiration of the period for which premium has been paid.
You shall do or concur in doing or permit to be done all such acts and things that may be necessary or reasonably required by Us for the purpose of enforcing and/or securing any civil or criminal rights and remedies or obtaining relief or indemnity from any other party to which We are or would become entitled upon Us making reimbursement under this Policy, whether such acts or things shall be or become necessary or required before or after Our payment. You shall not prejudice these subrogation rights in any manner and shall provide Us with whatever assistance or cooperation is required to enforce such rights. Any recovery We make pursuant to this clause shall first be applied to the amounts paid or payable by Us under this Policy and Our costs and expenses of effecting a recovery, where after We shall pay any balance remaining to You.
18. Substitute Product
In case We may decide to withdraw this product under which this Policy is issued to You or where the children have reached maximum eligibility age or where Your maximum renewable age under the Policy has been reached, We shall provide You with an option to buy a substitute health insurance Policy from Us.
You will be given the Portability credit based on the number of years of continuous and uninterrupted insurance cover under this Policy towards the waiting periods in the new substitute health insurance Policy issued by Us.
19. Sum Insured Enhancement
We shall allow you to enhance Your Sum Insured only upon Renewal, subject to Our underwriter’s approval.
20. Notices and Claims
Any notice, direction or instruction given under this Policy shall be in writing and delivered by hand, post, or facsimile to:
Universal Sompo General Insurance Co. Ltd.
Express IT Park, Plot No. EL - 94, T.T.C. Industrial Area, M.I.D.C., Mahape, Navi Mumbai-400710 Toll Free Numbers: 1-800-224030 (For MTNL/BSNL Users) or 1-800-1024030 or 1- 800–2004030
Toll Free Numbers:
1-800-224030 (For MTNL/BSNL Users) or 1-800-1024030 or 1–800-2004030
(022)-27639800 or (022)-41582900 or (022)-41582999 or (022)-39133700 (Local Charges Apply)
(022) 41582929 or (022) 41582939
Note: Please include Your Policy number for any communication with us.
In the unfortunate event of any eventuality resulting into a claim on this Policy, please intimate the mishap IMMEDIATELY to Our Call Centre at Toll Free Numbers on 1-800-22-4030 (for MTNL/BSNL users) or 1-800-102-4030 or 1-800-200-4030 (other users) or on chargeable numbers at +91-22-27639800/+91-22-41582900/+91-22-41582999/+91-22-39133700. Please note that no delay should be allowed to occur in notifying a claim on the Policy as the same may prejudice liability.
In case of any discrepancy, complaint or grievance, please feel free to contact us within 15 days of receipt of the Policy.21. Grievances
In case You are aggrieved in any way, You may register a grievance or Complaint by visiting Our website or write to us on firstname.lastname@example.org.
You may also contact the Branch from where You have bought the Policy or the Complaints Coordinator who can be reached at Our Registered Office.
You may also contact on Our Toll Free Numbers: 1-800-224030 (For MTNL/BSNL Users) or 1-800– 2004030 or on chargeable numbers at +91-22-27639800/+91-22-39133700; and also send us fax at: (022) 39171419
♦ You can also visit Our Company website and click under links Grievance Notification
♦If the issue still remains unresolved, You may, subject to vested jurisdiction, approach Insurance Ombudsman for the redressal of Your grievance.
♦ The updated details are also available on: IRDA INDIA
The details of Insurance Ombudsman are available below:
|Office of the Ombudsman||Contact Details|
|AHMEDABAD||Office of the Insurance Ombudsman,6th Floor, Jeevan Prakash Bldg, Tilak Marg, Relief Road,Ahmedabad - 380001.Tel nos: 079-25501201/02/05/06 email: email@example.com|
|BHOPAL||Janak Vihar Complex,2nd Floor, 6, Malviya Nagar, Opp. Airtel, Near New Market, BHOPAL(M.P.)-462 023.Tel: 0755-2569201; Fax:0755-2769203;Email: firstname.lastname@example.org|
|BHUBANESHWAR||62, Forest Park, BHUBANESHWAR-751 009.Tel: 0674-2596455; Fax:0674-2596429; Email email@example.com|
|CHANDIGARH||S.C.O. No.101-103, 2nd Floor, Batra Building. Sector 17-D, CHANDIGARH-160 017.Tel:0172-2706468; Fax:0172-2708274; Email firstname.lastname@example.org|
|CHENNAI||Fathima Akhtar Court,4th Floor, 453 (old 312), Anna Salai, Teynampet, CHENNAI-600018.Tel:044-24333668/5284; Fax:044 24333664 ;Email email@example.com|
|NEW DELHI||2/2 A, Universal Insurance Bldg., Asaf Ali Road, NEW DELHI-110 002.Tel.:- 011-23239633; Fax : 011-23230858; Email firstname.lastname@example.org|
|GUWAHATI||―Jeevan Nivesh‖,5th Floor, Near Panbazar Overbridge, S.S. Road, GUWAHATI-781 001(ASSAM).Tel:0361-2132204/5; Fax : 0361- 2732937; Email email@example.com|
|HYDERABAD||6-2-46, 1st Floor,Moin Court, A.C. Guards, Lakdi-Ka-Pool, HYDERABAD-500 004.Tel : 040-65504123; Fax: 040-23376599; Email firstname.lastname@example.org|
|ERNAKULAM||2nd Floor, CC 27/2603,Pulinat Bldg., Opp. Cochin Shipyard, M.G. Road, ERNAKULAM-682015.Tel : 0484-2358759; Fax : 0484-2359336; Email email@example.com|
|KOLKATA||North British Bldg., 29, N.S. Road, 4th Floor, KOLKATA-700 001.Tel : 033-22134866; Fax : 033-22134868; Email firstname.lastname@example.org|
|LUCKNOW||Jeevan Bhawan, Phase-2,6th Floor, Nawal Kishore Road, Hazaratganj, LUCKNOW-226 001.Tel :0522 -2231331; Fax : 0522-2231310; Email email@example.com|
|MUMBAI||3rd Floor, Jeevan Seva Annexe,S.V. Road, Santacruz(W), MUMBAI-400 054.Tel : 022-26106928; Fax : 022-26106052; Email firstname.lastname@example.org|
ADDITIONAL CLAUSESAC1: For Reducing Sum Insured covers
Notwithstanding anything contrary stated in the Policy, the Sum Insured under the Policy on the date of the Insured Event covered under Sections III for the purpose of calculation of claim shall be the least of the following:
i)The Principal Outstanding in the books of the Bank/Financial Institution as on the date of occurrence of the Insured Event; or
ii)The Principal Outstanding as per the amortization Schedule prepared by Bank/Financial Institution. In the event the Sum Insured as appearing against Section III of the Schedule of the Policy is less than the total of the actual Loan disbursed upto the date of the occurrence of the Insured Event, then the Amortization Schedule shall be calculated as if the actual Loan disbursed was equivalent to the Sum Insured; or
iii)The Sum Insured as appearing against Section III of the Schedule
AC2: Premium Refunds:
Notwithstanding anything to the contrary contained in the Policy, the refund of premium under the Policy shall be as under
In the event of full prepayment of the Loan by the Insured, the Company shall refund a portion of the premium subject to the terms and conditions of the Policy as per the rates mentioned below:
a) For Reducing Sum Insured basis
b) For Fixed Sum Insured basis
|% Refund Premium|
|.||Policy Period (Years)|
|Year Of Cancellation||2||3|
In event of part prepayment of the Loan, no refunds of premium shall be made under this Policy. No refunds of premium will be made under the Policy during the last year of the Policy Period. Upon making any refund of premium under this Policy in accordance with the terms and conditions hereof in respect of the Insured, the cover in respect of that Insured shall forthwith terminate and the Company shall not be liable hereunder.
Notwithstanding anything contained herein or otherwise, no refunds of premium shall be made in respect of the Insured where any claim has been admitted by the Company or has been lodged with the Company.AC3: Survival Period:
Notwithstanding anything to the contrary stated herein the Company shall not be liable to make any payment arising out of any claim under Section I for any Insured if the Insured does not survive a period of at least 90 days after the date of occurrence Insured Event.
AC4: Assignment Clause - If opted to be assigned.
It is hereby declared and agreed that:
i)from the Policy Start Date, the monies payable by the Company to the Insured and all rights, title, benefits and interest of the Insured under this Policy stand assigned in favour of the "Bank / Financial Institution as named in the Schedule of this Policy";
ii)upon any monies becoming payable under this Policy the same shall be paid by the Company to the "Bank/Financial Institution as named in Schedule of this Policy" without any reference / notice to the Insured, but not exceeding the Principal Outstanding as defined under the Policy. In the event of any monies payable under this Policy exceeding the Principal Outstanding, the Company shall pay such amount as exceeding the Principal Outstanding to the Insured;
iii)the receipt of such monies in the manner aforesaid by the Bank/Financial Institution as named in the Schedule of this Policy and the Insured shall completely discharge the Company from all liability under the Policy and shall be binding on the Insured and the heirs, executors, administrators, successors or legal representatives of the Insured, as the case may be.
Endorsements – Available with Section IV on payment of additional Premium
AC 6: Earth quake (Fire and Shock) Coverage Clause
“In consideration of the payment by the Insured to the Company of the sum of __________additional premium, it is hereby agreed and declared that notwithstanding anything stated in the printed exclusions of this Policy to the contrary, this Insurance is extended to cover loss or damage (including loss or damage by fire) to any of the property Insured by this Policy occasioned by or through or in consequence of earthquake including flood or overflow of the sea, lakes, reservoirs and rivers and/or Landslide/Rockslide resulting there from.
Provided always that all the conditions of this Policy shall apply (except in so far as they may be hereby expressly varied) and that any reference therein to loss or damage by fire shall be deemed to apply also to loss or damage directly caused by any of the perils which this insurance extends to include by virtue of this endorsement.”
1. Excess clause 5% of each and every claim subject to a minimum of Rs. 10,000/-
2. Extension cover shall be granted only if the entire property in one complex/compound/location covered under the Policy is extended to cover this risk and the Sum Insured for this extension is identical to the Sum Insured against the risk covered under main Policy except for the value of the plinth and foundations of the building(s).
Onus of proof: In the event of the Insured making any claim for loss or damage under this Policy, he must (if so required by the Company) prove that the loss or damage was occasioned by or through or in consequence of earthquake.
AC7: Terrorism Damage Cover Endorsement (Material Damage only)
A. Insuring Clause
Subject otherwise to the terms, exclusions, provisions and conditions contained in the Policy and in consideration of the payment by the Insured to the Company of additional premium as stated in the Schedule, it is hereby agreed and declared that notwithstanding anything stated in the „Terrorism Risk Exclusion” of this Policy to the contrary, this Policy is extended to cover physical loss or physical damage occurring during the period of this Policy caused by an act of Terrorism, subject to the exclusions, limits and excess described hereinafter.
For the purpose of this cover, an act of Terrorism means an act or series of acts, including but not limited to the use of force or violence and/or the threat thereof, of any person or group(s) of persons, whether acting alone or on behalf of or in connection with any organisation(s) or government(s), or unlawful associations, recognized under Unlawful Activities (Prevention) Amendment Act, 2008 or any other related and applicable national or state legislation formulated to combat unlawful and terrorist activities in the nation for the time being in force, committed for political, religious, ideological or similar purposes including the intention to influence any government and/or to put the public or any section of the public in fear for such purposes.
This cover also includes loss, damage, cost or expense directly caused by, resulting from or in connection with any action taken in suppressing, controlling, preventing or minimizing the consequences of an act of Terrorism by the duly empowered government or Military Authority.
Provided that if the Insured is eligible for indemnity under any government Compensation plan or other similar scheme in respect of the damage described above, this Policy shall be excess of any recovery due from such plan or scheme.
For the purpose of the aforesaid inclusion clause, "Military Authority" shall mean armed forces, para military forces, police or any other authority constituted by the government for maintaining law and order.
B. Losses Excluded
This cover shall not indemnify loss of or damage to property caused by any or all of the following:-
i)loss by seizure or legal or illegal occupation;
ii)loss or damage caused by:
- voluntary abandonment or vacation,
- confiscation, commandeering, nationalisation, requisition, detention, embargo, quarantine, or any result of any order of public or government authority, which deprives the Insured of the use or value of its property;
iii)loss or damage arising from acts of contraband or illegal transportation or illegal trade;
iv)loss or damage directly or indirectly arising from or in consequence of the seepage and or discharge of pollutants or contaminants, which pollutants and contaminants shall include but not be limited to any solid, liquid, gaseous or thermal irritant, contaminant or toxic or hazardous substance or any substance the presence, existence or release of which endangers or threatens to endanger the health, safety or welfare of persons or the environment;
v)loss or damage arising directly or indirectly from or in consequence of chemical or biological emission, release, discharge, dispersal or escape or chemical or biological exposure of any kind;
vi)loss or damage arising directly or indirectly from or in consequence of asbestos emission, release, discharge, dispersal or escape or asbestos exposure of any kind;
vii)any fine, levy, duty, interest or penalty or cost or Compensation/damages and/or other assessment which is incurred by the Insured or which is imposed by any court, government agency, public or civil authority or any other person;
viii)loss or damage by electronic means including but not limited to computer hacking or the introduction of any form of computer virus or corrupting or unauthorised instructions or code or the use of any electromagnetic weapon. This exclusion shall not operate to exclude losses (which would otherwise be covered under this Policy) arising from the use of any computer, computer system or computer software programme or any other electronic system in the launch and/or guidance system and/or firing mechanism of any weapon or missile;
ix)loss or damage caused by vandals or other persons acting maliciously or by way of protest or strikes, labour unrest, riots or civil commotion
x)loss or increased cost occasioned by any public or government or local or civil authority‟s enforcement of any ordinance or law regulating the reconstruction, repair or demolition of any property insured hereunder;
xi)any consequential loss or damage, loss of use, delay or loss of markets, loss of income, depreciation, reduction in functionality, or increased cost of working;
xii)loss or damage caused by factors including but not limited to cessation, fluctuation or variation in, or insufficiency of, water, gas or electricity supplies and telecommunications or any type of service;
xiii)loss or increased cost as a result of threat or hoax;
xiv)loss or damage caused by or arising out of burglary, house - breaking, looting, theft, larceny or any such attempt or any omission of any kind of any person (whether or not such act is committed in the course of a disturbance of public peace) in any action taken in respect of an act of Terrorism;
xv)loss or damage caused by mysterious disappearance or unexplained loss;
xvi)loss or damage directly or indirectly caused by mould, mildew, fungus, spores or other micro-organism of any type, nature or description, including but not limited to any substance whose presence poses an actual or potential threat to human health;
xvii)total or partial cessation of work or the retardation or interruption or cessation of any process or operations or omissions of any kind.C. Limit of Indemnity
The limit of indemnity under this cover shall not exceed the Total Sum Insured given in the Policy Schedule or INR 7500,000,000 whichever is lower. In respect of several insurance policies within the same compound/location with one or different insurers, the maximum aggregate loss payable per compound/location by any one or all insurers shall be INR 7500,000,000. If the actual aggregate loss suffered at one compound/location is more than INR 7500,000,000, the amounts payable under individual policies shall be reduced in proportion to the Sum Insured of the policies.D. Excess
0.5% of the Sum Insured for each and every claim subject to –
i)A minimum of INR 100,000 and a maximum of INR 100,000,000 (for industrial risks)
ii)A minimum of INR 25,000 and a maximum of INR 1,000,000/- (for non-industrial risks) / a minimum of INR 10,000 and maximum of INR 500,000 (for shops and residences)E. Cancellation Clause
Notwithstanding the cancellation provisions relating to the basic insurance Policy on which this endorsement is issued, there shall be no refund of premium allowed for cancellation of the Terrorism risk insurance during the Period of Insurance except where such cancellation is done along with the cancellation of the basic insurance. Where a Policy is cancelled and rewritten mid-term purely for the purpose of coinciding with the accounting year of the Insured, pro-rate refund of the cancelled Policy premium will be allowed.
If the cancellation is for any other purpose, refund of premium will only be allowed after charging short term scale rates.
Note:The definitions, terms and conditions of main Policy save as modified or endorsed herein shall apply.