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DEFINITION:

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.

AccidentAn accident is a sudden, unforeseen and involuntary event caused by external, visible and violent means.

Age:means completed years as at the commencement of the Policy.

Ambulance:means any vehicle used solely for Your conveyance if You are injured from the Accidental location or Your residential place or Hospital to any Hospital in emergency cases.

Any one illness:means “Universal Sompo General Insurance Company Limited.”

Alternative treatmentsAlternative treatments are forms of treatments other than treatment "Allopathy" or "modem medicine" and includes Ayurveda, Unani, Sidha and Homeopathy in the Indian contex

“Break in policy”:It occurs at the end of the existing policy term, when the premium due for renewal on a given policy is not paid on or before the premium renewal date or within 30 days thereof.

Cashless facility: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.

Company:means ―Universal Sompo General Insurance Company Limited.

Condition Precedent:Condition Precedent shall mean a policy term or condition upon which the Insurer's liability under the policy is conditional upon

Congenital Anomaly:Congenital Anomaly refers to a condition(s) which is present since birth, and which is abnormal with reference to form, structure or position.

  • Internal Congenital Anomaly - Congenital anomaly which is not in the visible and accessible parts of the body
  • External Congenital Anomaly - Congenital anomaly which is in the visible and accessible parts of the body

Contribution: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.

Co-payment:A co-payment is a cost-sharing requirement under a health insurance policy that provides that the policyholder/insured will bear a specified percentage of the admissible claim amount. A co-payment does not reduce the Sum Insured

Cumulative Bonus:Cumulative Bonus shall mean any increase in the Sum Insured granted by the insurer without an associated increase in premium.

Daymeans a period of 24 consecutive hours.

Daily AllowanceMeans management for a severe illness or injury which results in symptoms which occur suddenly and unexpectedly, and requires immediate care by a Medical Practitioner to prevent death or serious long term impairment of the insured person’s health.

  • has qualified nursing staff under its employment;
  • has qualified medical practitioner/s in charge;
  • has a fully equipped operation theatre of its own where surgical procedures are carried out;
  • maintains daily records of patients and will make these accessible to the insurance company’s authorized personnel

Day care treatmentIt refers to medical treatment, and/or surgical procedure which is:

  • Undertaken under General or Local Anesthesia in a hospital/day care centre in less than 24 hrs because of technological advancement, and
  • Which would have otherwise required a hospitalization of more than 24 hours. Treatment normally taken on an out-patient basis is not included in the scope of this definition

Please see the list of such listed procedures enclosed as Appendix- A to the Policy

Dental TreatmentDental treatment is treatment carried out by a dental practitioner including examinations, fillings (where appropriate), crowns, extractions and surgery excluding any form of cosmetic surgery /implants

Domiciliary Hospitalisation:Domiciliary hospitalization means medical treatment for an illness/disease/injury which in the normal course would require care and treatment at a hospital but is actually taken while confined at home under any of the following circumstances:

  • the condition of the patient is such that he/she is not in a condition to be removed to a hospital, or
  • the patient takes treatment at home on account of non availability of room in a hospital

Disclosure to information normThe Policy shall be void and all premium paid hereon shall be forfeited to the Company, in the event of misrepresentation, mis-description or non-disclosure of any material fact.

Emergency Care:Emergency care means management for a severe illness or injury which results in symptoms which occur suddenly and unexpectedly, and requires immediate care by a medical practitioner to prevent death or serious long term impairment of the insured person’s health

Grace Period:Means the individual whose name is specifically appearing in the Schedule herein after referred as “You”/”Your”/”Yours”/”Yourself”.

HospitalA hospital means any institution established for in-patient care and day care treatment of illness and/or injuries and which has been registered as a hospital with the local authorities under the Clinical Establishments (Registration and Regulation) Act, 2010 or under the enactments specified under the Schedule of Section 56(1) of the said Act OR complies with all minimum criteria as under:

  • has qualified nursing staff under its employment round the clock;
  • has at least 10 in-patient beds in towns having a population of less than 10,00,000 and at least 15 in-patient beds in all other places;
  • has qualified medical practitioner(s) in charge round the clock;
  • has a fully equipped operation theatre of its own where surgical procedures are carried out;
  • maintains daily records of patients and makes these accessible to the insurance company’s authorized personnel

HospitalisationMeans admission in a Hospital for a minimum period of 24 In patient Care consecutive hours except for specified procedures/ treatments, where such admission could be for a period of less than 24consecutive hours.

InjuryInjury 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

IllnessIllness 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 - 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 -A chronic condition is defined as a disease, illness, or injury that has one or more of the following characteristics:—it needs ongoing or long-term monitoring through consultations, examinations, check-ups, and / or tests—it needs ongoing 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.

Insured: means the individual whose name is specifically appearing in the Schedule herein after referred as ―"You"/"Your"/"Yours"/"Yourself".

Insured Person means the individual whose name is appearing in the Schedule and is selected to You as Spouse.

Intensive Care Unit Intensive care unit means an identified section, ward or wing of a hospital which is under the constant supervision of a dedicated medical practitioner(s), and which is specially equipped for the continuous monitoring and treatment of patients who are in a critical condition, or require life support facilities and where the level of care and supervision is considerably more sophisticated and intensive than in the ordinary and other wards.

Inpatient CareInpatient care means treatment for which the insured person has to stay in a hospital for more than 24 hours for a covered event.

Insured Eventmeans any event specifically mentioned as covered under this Policy.

Medical AdviceAny consultation or advice from a Medical Practitioner including the issue of any prescription or repeat prescription.

Medical expenses Medical Expenses means those expenses that an Insured Person has necessarily and actually incurred for medical treatment on account of Illness or Accident on the advice of a Medical Practitioner, as long as these are no more than would have been payable if the Insured Person had not been insured and no more than other hospitals or doctors in the same locality would have charged for the same medical treatment.

Pre-hospitalization Medical ExpensesMedical Expenses incurred immediately before the Insured Person is Hospitalised, provided that:

  • Such Medical Expenses are incurred for the same condition for which the Insured Person’s Hospitalisation was required, and
  • The In-patient Hospitalization claim for such Hospitalization is admissible by the Insurance Company

Post Hospitalisation Medical Expenses: Medical Expenses incurred immediately after the insured person is discharged from the hospital provided that:

  • Such Medical Expenses are incurred for the same condition for which the insured person’s hospitalization was required and
  • The inpatient hospitalization claim for such hospitalization is admissible by the insurance company

Medically Necessary Medically necessary treatment is defined as any treatment, tests, medication, or stay in hospital or part of a stay in hospital which

  • is required for the medical management of the illness or injury suffered by the insured;
  • must not exceed the level of care necessary to provide safe, adequate and appropriate medical care in scope, duration, or intensity;
  • must have been prescribed by a medical practitioner,
  • must conform to the professional standards widely accepted in international medical practice or by the medical community in India.

Medical Practitioner A Medical Practitioner is 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 close member of Insured’s family

Network Provider "Network Provider" means hospitals or health care providers enlisted by an insurer or by a TPA and insurer together to provide medical services to an insured on payment by a cashless facility

Nominee means the person(s) nominated by You to receive the insurance benefits under this Policy payable on Your death.

Non- Network Any hospital, day care centre or other provider that is not part of the network.

Notification of ClaimNotification of claim is the process of notifying a claim to the insurer or TPA by specifying the timelines as well as the address / telephone number to which it should be notified.

OPD treatment OPD treatment is one in which the Insured visits a clinic/ hospital or associated facility like a consultation room for diagnosis and treatment based on the advice of a Medical Practitioner. The Insured is not admitted as a day care or in-patient.

Policymeans the document evidencing the contract of insurance and includes endorsements issued thereto, changing either the scope of cover, terms and conditions, or any other narration made in the Policy.

Policy Periodmeans the period commencing at the Policy Period Start Date and ending at the Policy Period End Date, as specifically stated in the Schedule and for which the insurance cover will remain valid.

Portability Portability means transfer by an individual health insurance policyholder (including family cover) of the credit gained for pre-existing conditions and time-bound exclusions if he/she chooses to switch from one insurer to another.

Pre-Existing Disease 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 insurer.

Qualified Nurse Qualified nurse is a person who holds a valid registration from the Nursing Council of India or the Nursing Council of any state in India.

Reasonable and Customary Charges Reasonable charges means the charges for services or supplies, which are the standard charges for the specific provider and consistent with the prevailing charges in the geographical area for identical or similar services, taking into account the nature of the illness/ injury involved .

Room Rent Means the amount charged by a hospital for the occupancy of a bed on per day (24 hours) basis and shall include associated medical expenses.

Renewal Renewal defines 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.

Spouse Means the person whose name is specifically appearing in the Schedule and is related to You as husband or wife as per the Indian Law

Sum Insured means the sum as mentioned in the Schedule against the respective benefit(s) which represents Our maximum liability for any or all claims under this Policy during the Policy Period.

Subrogation Subrogation shall mean the right of the insurer to assume the rights of the insured person to recover expenses paid out under the policy that may be recovered from any other source.

Surgery 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.

Unproven/Experimental treatment: Treatment including drug experimental therapy which is not based on established medical practice in India, is treatment experimental or unproven.

You/Your/Yours/Yourself means the person(s) that We insure and is/are specifically named as Insured in the Schedule.

We/Our/Ours/Us means Universal Sompo General Insurance Company Limited.

War means war, whether declared or not, or any warlike activities, including use of military force by any sovereign nation to achieve economic, geographic, nationalistic, political, racial, religious or other ends.

What will We Pay? (Scope of Cover)

SECTION I – HOSPITALISATION (Base Cover)

1. In-patient Treatment

We hereby agree subject to terms, conditions and exclusions herein contained or otherwise expressed hereon that, if during the Policy Period, You require Hospitalization for any Illness or Injury on the written advice of a Medical Practitioner, then We will indemnify the Medical Expenses so incurred by You as per below heads

Hospitalisation Benefits/strong Limits
A i)Room, Boarding expenses a provided by the Hospital/Nursing Home
ii)If admitted in IC Unit
i) Up to 1% of Sum Insured or actuals whichever is less per day
ii) Up to 2% of Sum Insured or actuals whichever is less per day
Overall limit:25% of the S.I. per illness/ injury or actuals whichever is less
B Surgeon, Anaesthetist, Medical Practitioner, Consultants, Specialists Fees, Nursing Expenses Up to 25% of Sum Insured per illness/ Injury or actuals whichever is less
C Anaesthesia, Blood, Oxygen, OT charges, Surgical appliances(any disposable surgical consumables subject to upper limit of 7% of Sum Insured), Medicines, drugs, Diagnostic material X-Ray, Dialysis, Chemotherapy, Radiotherapy, cost of pacemaker, artificial limbs, Cost of stent implants Up to 50% of Sum Insured per illness/Injury or actuals whichever is less

Hospitalization expenses of person donating an organ during the course of organ transplant will also be payable subject to the sub limits under ―above applicable to you.

However, our total liability under this Policy for payment of any and all Claims in aggregate during each Policy Year of the Policy Period shall not exceed the Sum Insured as stated in the Policy Schedule.

2. –Day Care Procedures/ Treatment

.We hereby agree subject to terms, conditions and exclusions herein contained or otherwise expressed hereon that, if during the Policy Period, You require Hospitalization as an inpatient for less than 24 hours in a Hospital (but not in the outpatient department of a Hospital) on the written advice of a Medical Practitioner, then We will pay You for the Medical Expenses incurred for undergoing such Day Care Procedure/Treatment or surgery, (as is mentioned in the list of Day Care Procedures/Treatments annexed to this Policy).

However, Our total liability under this cover for payment of any and all Claims in aggregate during each Policy Year of the Policy Period shall not exceed the Sum Insured as stated in the Policy Schedule.

3. Pre-Hospitalization and Post-Hospitalization Expenses

We hereby agree subject to the terms, conditions and exclusions herein contained or otherwise expressed hereon that, We will compensate You for the relevant Medical Expenses incurred by You in relation to:

  • Pre-hospitalization Medical Expenses incurred by You for a 30-day period immediately before Your date of Hospitalization; and
  • Post-hospitalization Medical Expenses incurred by You for a 60-day period immediately after the date
  • of discharge from the Hospital, provided that Your Hospitalization falls within the

Policy Period and We have accepted Your Claim under "In-patient Treatment" or "Day Care Procedures" section of the Policy.

However, Our total liability under this Policy for payment of any and all Claims in aggregate during each Policy Year of the Policy Period shall not exceed the Sum Insured as stated in the Policy Schedule.

4. Domiciliary Hospitalization

We hereby agree subject to the terms, conditions and exclusions herein contained or otherwise expressed here on that, We will compensate You for expenses incurred on availing medical treatment at home on recommendation of a Medical Practitioner, which would otherwise have required hospitalisation.

The cover under this Section will be available up to a maximum of 50% of Sum Insured opted by You or actual amount incurred whichever is less.However, Our total liability under this Policy for payment of any and all Claims in aggregate during each Policy Year of the Policy Period shall not exceed the Sum Insured as stated in the Policy Schedule.

5. Cost of Health Check-up

We hereby agree subject to the terms, conditions and exclusions herein contained or otherwise expressed here on that, We will provide for payment to You for the charges incurred for medical check-up once in a block of every 3 years up to 1.25% of the average Sum Insured or the actual charges incurred whichever is less provided there were no claims reported in this Section of the Policy during the said 3 years block period. In case, of floater policies, the above limit of 1.25% of average Sum Insured for the three years is for the two Insured Persons covered under the Policy.

However, Our total liability under this Policy for payment of any and all Claims in aggregate during each Policy Year of the Policy Period shall not exceed the Sum Insured as stated in the Policy Schedule.

6. Daily Allowance

We hereby agree, subject to the terms, exclusions and conditions herein contained or otherwise expressed hereon, to pay You 0.1% of Sum Insured or Rs 250 whichever is less, as a Daily Allowance, for each continuous and completed period of 24 hours of Hospitalisation subject to a maximum of Rs 2500 under the Policy.

However, Our total liability under this Policy for payment of any and all Claims in aggregate during each Policy Year of the Policy Period shall not exceed the Sum Insured as stated in the Policy Schedule.

7. Ambulance Charges

We hereby agree, subject to the terms, exclusions and conditions herein contained or otherwise expressed hereon, to reimburse You for the expenses incurred for transportation by ambulance to the nearest Hospital/ Nursing Home for treatment of the disease/ illness/ injury necessitating Your admission to Hospital/ Nursing Home up to 1% of Sum Insured or Rs 1500 or actual amount incurred in such transportation whichever is less.

However, Our total liability under this Policy for payment of any and all Claims in aggregate during each Policy Year of the Policy Period shall not exceed the Sum Insured as stated in the Policy Schedule.

8. Expenses of Accompanying Person

We hereby agree, subject to the terms, exclusions and conditions herein contained or otherwise expressed hereon, to reimburse You for the expenses incurred by the person who is accompanying You at the Hospital/ Nursing Home whilst You are being hospitalized. These expenses comprise of expenses on food, additional bed charges for such accompanying person being charged by the Hospital/ Nursing Home. The cover under this Section will be available up to a maximum of 1% of Sum Insured opted by You or the actual amount incurred whichever is less.However, Our total liability under this Policy for payment of any and all Claims in aggregate during each Policy Year of the Policy Period shall not exceed the Sum Insured as stated in the Policy Schedule.

9. Cumulative Bonus

Sum insured under the Policy shall be progressively increased by 5 % in respect of each claim free year of insurance subject to maximum accumulation of 10 claim free years of insurance. In case of claim under this section, the increased percentage will be reduced by 5% of Sum Insured at the next renewal. However, the basic Sum Insured will be maintained and will not be reduced. A claim under Section B- Critical Illness, if available under the Policy, shall not affect Your right to the Cumulative Bonus under this Section of the Policy.

10. Sublimit

Notwithstanding anything to the contrary in the Policy and subject to the Sum Insured Our maximum liability to make payment for the Medical Expenses incurred during any Hospitalisation (including its related Pre and Post Hospitalization expenses if applicable) due to the below mentioned Surgeries / Medical Procedures or any medical treatment pertaining to an Illness / Injury shall be limited as per the table below:

Cataract per eye Rs 10,000
Other Eye Surgery Rs 15,000
Surgeries for Tumor/ Cysts/ Nodule/ Polyp Rs 20,000
Stone in Urinary System Rs 20,000
Hernia Related Rs 20,000
Appendisectomy Rs 20,000
Knee Ligament Reconstruction Surgery Rs 40,000
Hysterectomy Rs 20,000
Fissures/ Piles/ Fistula Rs 15,000
Spine and Verebrae related Rs 40,000
Cellulites/ Abscess Rs 15,000

For the purpose of applicability of the said sub-limits, multiple Hospitalizations pertaining to the same Illness or medical procedure / surgery occurring within a period of 45 days from the date of discharge of the first Hospitalization shall be considered as one Hospitalization.

Besides the above mentioned, no other sublimit for any major surgery or procedure shall be applicable under the Policy.

SECTION B – CRITICAL ILLNESS (Optional Cover)

What will We pay? (Scope of Cover-)

We agree, subject to the terms, conditions and exclusions applicable to this Section and the terms, conditions, general exclusions stated in the Policy, to pay such Sum Insured as mentioned against Section B in the Schedule to this Policy, on the occurrence of any of the below mentioned Critical Illnesses and/ or undergoing of the below mentioned Surgical Procedure that You/ Your Spouse may suffer from or undergo provided that

  • In the event of a claim, the Critical Illness have to be diagnosed by a Medical Practitioner, supported by radiological, histological and laboratory evidence acceptable to Us and to be reconfirmed by a Medical Practitioner appointed by Us.
  • We shall compensate You/ Your Spouse only once in respect of any particular Critical Illness/ Surgical Procedure mentioned as covered in the Schedule.
  • Cover under this policy shall cease upon payment of the compensation on the happening of a Critical Illness and/ or undergoing of listed Surgical Procedure and no further payment will be made for any consequent disease or any dependent disease.
  • You should survive for 30 days post diagnosis of such Critical Illness to be able to make a claim under the Policy.

Specified Critical Illnesses and Surgical Procedures

1. Cancer of specified severity

A malignant tumour characterised by the uncontrolled growth spread of malignant cells with invasion destruction of normal tissues. This diagnosis must be supported by histological evidence of malignancy confirmed by a pathologist. The term cancer includes leukemia, lymphoma and sarcoma. The following are excluded:

  • Tumours showing the malignant changes of carcinoma in situ tumours which are histologically described as premalignant or non invasive, including but not limited to: Carcinoma in situ of breasts, Cervical dysplasia CIN-1, CIN -2 CIN-3.
  • Any skin cancer other than invasive malignant melanoma
  • All tumours of the prostate unless histological classified as having a Gleason score greater than 6 or having progressed to at least clinical TNM classification T2NOMO
  • Papillary micro - carcinoma of the thyroid less than 1 cm in diameter
  • Chronic lymphocyctic leukaemia less than RAI stage 3
  • Microcarcinoma of the bladder
  • All tumours in the presence of HIV infection.

Open Chest CABG

The actual undergoing of open chest surgery for the correction of one or more coronary arteries, which is/are narrowed or blocked, by coronary artery bypass graft (CABG). The diagnosis must be supported by a coronary angiography and the realization of surgery has to be confirmed by a specialist medical practitioner. The following are excluded:

  • Angioplasty and/or any other intra-arterial procedures
  • any key-hole or laser surgery.

3. Kidney Failure requiring regular dialysis

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.

4. Stroke resulting in permanent symptoms

Any cerebrovascular incident producing permanent neurological sequelae. This includes infarction of brain tissue, thrombosis in an intracranial vessel, haemorrhage and embolisation 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.

The following are excluded:

  • Angioplasty and/or any other intra-arterial procedures
  • Any key-hole or laser surgery.
5. Major Organ /Bone Marrow Transplant

The actual undergoing of a transplant of:

  • One of the following human organs: heart, lung, liver, kidney, pancreas, that resulted from irreversible end-stage failure of the relevant organ, or
  • Human bone marrow using haematopoietic stem cells. The undergoing of a transplant has to be confirmed by a specialist medical practitioner.

The following are excluded:

  • Other stem-cell transplants
  • Where only islets of langerhans are transplanted
6. Multiple Sclerosis with persisting symptoms

The definite occurrence of multiple sclerosis. The diagnosis must be supported by all of the following:

  • Investigations including typical MRI and CSF findings, which unequivocally confirm the diagnosis to be multiple sclerosis;
  • There must be current clinical impairment of motor or sensory function, which must have persisted for a continuous period of at least 6 months, and well documented clinical history of exacerbations and remissions of said symptoms or neurological deficits with at least two clinically documented episodes at least one month apart.

Exclusion

Other causes of neurological damage such as SLE and HIV

What will We not pay for? (Specific Exclusions)

  • Any Illness, sickness or disease , other than specified as Critical Illness, as mentioned in the policy schedule, or
  • Any Critical Illness of which, the signs or symptoms first occurred prior to or within Ninety (90) days following the Policy Issue Date or the last Commencement Date, whichever is later, or
  • Any Critical Illness based on a diagnosis made by You or Your immediate family member or anyone who is living in the same household as You or by a herbalists, acupuncturist or other non-traditional health care provider.

General Exclusions under the Policy

Below mentioned exclusions shall be applicable to both Section A-Hospitalisation and Section B - Critical Illness under the Policy

1. Waiting Period(s)

We are not liable for any treatment which begins during waiting periods except if You suffer an Accident

2. 30 days Waiting Period

A waiting period of 30 days will apply to all claims unless:

  • You have been insured under this Policy continuously and without any break in the previous Policy Year, or
  • 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.
  • 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.
3. Pre-existing diseases

Pre-existing diseases will not be covered until 24 months of continuous coverage have elapsed, since inception of the first Policy with Us; but:

  • If the You are presently covered and have been continuously covered without any break under:
  • an individual health insurance plan with an Indian insurer for the reimbursement of medical costs for inpatient treatment in a Hospital,

OR

  • 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:
  • 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;

AND

  • 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.
4. Specific Waiting Period

Any Medical Expenses incurred by You on treatment of following Illnesses within the first two (2) consecutive years of Period of Insurance Start Date:

  • Cataract
  • Benign Prostatic Hypertrophy
  • Myomectomy, Hysterectomy unless because of malignancy
  • All types of Hernia, Hydrocele
  • Fissures and/or Fistula in anus, hemorrhoids/piles
  • Arthritis, gout, rheumatism and spinal disorders
  • Sinusitis and related disorders
  • Stones in the urinary and billiary systems
  • Dilatation and curettage , Endometriosis

All types of Skin and internal tumors/ cysts /nodules/ polyps of any kind including breast lumps unless malignant

  • Dialysis required for chronic renal failure
  • Surgery on tonsils, adenoids and sinuses
  • Gastric and Duodenal erosions ulcers
  • Deviated Nasal Septum
  • Varicose Veins/ Varicose Ulcers
  • Joint replacements unless due to accident

However, the waiting period of 2 years will not apply if You were insured continuously and without interruption for at least 2 years under any other Indian insurer’s individual health insurance policy for the reimbursement of medical costs for inpatient treatment in a Hospital.

You will be given the Portability credit of the waiting period based on the number of years of continuous and uninterrupted insurance cover

5. Any payment in case of more than one claim under the Policy during any one period of insurance by which the maximum liability of the Company in that period exceeds the Sum Insured.

6. Payment of compensation in respect of injury, disablement or death, hospitalisation resulting

  • From intentional self-injury, suicide or attempted suicide.
  • Whilst under the influence of liquor or drugs or other intoxicants.
  • Emotional distress
  • Whilst engaging in aviation or ballooning whilst mounting into, dismounting from or travelling in any aircraft or balloon other than as a passenger (fare paying or otherwise) in any duly licensed standard type of aircraft anywhere in the world.
  • Directly or indirectly, caused by venereal disease, AIDS or insanity.
  • Arising or resulting from committing any breach of law with criminal intent or participating in an actual or attempted felony, riot, crime, misdemeanour or civil commotion.
  • Whilst engaging in racing, hunting, mountaineering, ice hockey, winter sports and the like.
  • Due to war or ionising radiation or nuclear perils.
  • Whilst working in underground mines or explosive mines, electric installation with high tension supply, or as jockey or circus personnel or any such occupations of similar hazard.
  • Congenital anomalies or any complications or conditions arising therefrom; or

7. Any loss resulting directly or indirectly, contributed or aggravated or prolonged by hormone replacement therapy,

8. Any treatment not performed by a Physician or any treatment that is purely of experimental nature/ Unproven

9. Circumcision, cosmetic or aesthetic treatments of any description change of life surgery or treatment, plastic surgery (unless necessary for the treatment of Illness or accidental Bodily Injury as a direct result of the insured event and performed within 6 months of the same).

10. Dental treatment or surgery of any kind unless necessitated by Accidental Bodily Injury.

11. Hospitalisation for the sole purpose of traction, physiotherapy or any ailment for which hospitalisation is not warranted due to advancement in medical technology

12. Naval or military operations of the armed forces or airforce and participation in operations requiring the use of arms or which are ordered by military authorities for combating terrorists, rebels and the like.

13. All kind of Alternate Treatment

14. Cosmetic or plastic surgery or any elective surgery or cosmetic procedure that improve physical appearance, surgical and non-surgical treatment of obesity (including morbid obesity) and weight control programs, or treatment of an optional nature;

15. Special nursing care, routine health checks or convalescence, Custodial Care, general debility, lethargy, rest cure;

16. Outpatient expenses except the pre-hospitalisation and post-hospitalisation expenses as covered under the policy.

17. Any investigation(s) or treatments not directly related to a Covered Illness or Covered Injury or the conditions or diagnosis necessitating hospital admission;

CLAIMS PROCEDURE

1. Method of Assessment and Payment of claim

For a Policy with Policy Period greater than one year, the Sum Insured considered for assessment of claim shall be the Sum Insured mentioned against the Policy Year of the occurrence of the Accident or Illness. In the event that a claim becomes payable under the terms of the Policy, We shall make such payment as incurred by You and accepted by Us by way of cheque or electronic fund transfer or demand draft at Our option

.

2. Limitation Period

We shall not be liable for any loss or damage after expiry of 12 months from happening of the medical contingency unless claim is subject of pending action of court or arbitration.

3. The steps for lodging the claim shall be as under:

  • Notify us immediately on occurrence of a claim and in any case within 7 days giving full description of the medical treatment undertaken and the cause.
  • Submit the completed and signed claim form, provide all the relevant documents as mentioned below in support of Your claim not later than 30 days from the date of intimation.

1. Claim Documents:

  • Duly filled in Claim Form signed by You
  • Copy of the Original Bills (including but not limited to pharmacy purchase bill, consultation bill, diagnostic bill and any attachments thereto like receipts or prescriptions in support of any amount claimed)
  • All reports, including but not limited to all medical reports, case histories, investigation reports, treatment papers, discharge summaries.
  • A precise diagnosis of the treatment for which a claim is made.
  • A detailed list of the individual medical services and treatments provided and a unit price for each.

If required, You/ Your Spouse must agree to be examined by a Medical Practitioner of Our choice at Our expense.

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We shall settle claim(s), including its rejection, within thirty days of the receipt of the last necessary claim document.

Wherever details pertaining to happening of claim are conveyed by You to Us after reasonable period, You shall provide the reasons of such delay to Us and We may on analysis of reasons provided by You, may condone the delay in intimation of claim or delay in providing the required information/documents to Us.

4. Position after claim

    • In cases of claim under Section A- Hospitalization ,

For Individual Policies: We shall reduce the Sum Insured in respect of Insured Person to whom such sum shall become payable, by the amount admissible under the claim and paid by Us.

For floater Policies: the floater Sum Insured shall be reduced by the amount admissible and paid by Us irrespective of which of the Insured Person(s) claimed under the Policy.

  • In case of a claim under Section B- Critical Illness cover, on admissibility and payment of a claim by Us, We shall delete the name of the Insured Person in respect of whom such sums shall become payable by passing an endorsement to this effect and that person shall be no longer be covered under the Section B- Critical Illness cover and consequently no further benefit under the section shall accrue to such Insured Person. We shall however, continue to cover the said Insured Person for the risks covered under Section A- Hospitalisation
  • We shall have no liability under the Policy, once the Sum Insured (Maximum Limit of Liability), as stated in the Policy Schedule with respect to any of the Sections, is exhausted by You or Your Spouse

5. Claim Payment:

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.

PART III OF THE POLICY

STANDARD TERMS AND CONDITIONS

Below mentioned conditions shall be applicable to Section A-Hospitalisation and Section B - Critical Illness

1. Material change

You shall immediately notify Us in writing of any material change in the risk and cause at Your own expense .If there is change in the Your health status known to You, You shall intimate about the same to Us.

2. Fraudulent claims

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.

3. Policy Disputes

It has been agreed between the parties that any dispute concerning the interpretation of the terms, conditions, limitations and/or exclusions contained herein is understood and agreed to be adjudicated or interpreted in accordance with Indian Laws and only competent Indian courts shall have the exclusive jurisdiction to try all or any matters arising hereunder. The matter shall be determined or adjudicated in accordance with the law and practice of such Court.

4. Cancellation/termination

By You

You may terminate this Policy at any time by giving Us written notice, and the Policy shall terminate when such written notice is received. If no claim has been made under the Policy, then We will refund premium in accordance with the table below:

Cancellation Period
Cover Period Within 1 month From 1 month to 3 months From 3 month to 6 months From 6 months to 1 year During 2nd Year During 3rd Year
1 year 75% 50% 25% 0% NA NA
2 year 75% 65% 50% 25% 0% NA
3 Year 75% 70% 60% 45% 11% 0%
By Us

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

5. Discounts and Loadings:

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1. Long Term Policy Discount- Policy terms 1 year to 3 years are available under the policy. The following discounts will be offered if the Policy is taken by paying the appropriate premium for 2 years/ 3 years at once. No installment facility in payment of premium is available to you if you choose to opt for a long term policy, Duration of policy Premium to be charged

Duration of policy Premium to be charged
2 years 2 year premium in advance less 10% discount
3 year 3 year premium in advance less 15% discount

2. Family discount: A family discount of 10% shall be applicable on hospitalisation premium when an individual opts for covering his/ her spouse under the policy on individual Sum Insured basis. This discount shall not be applicable when Your Spouse is covered under the Policy on Floater Sum Insured basis.

3. Loading based on location: We may load premium up by 10% if You are a

resident of any one for the Tier 1 cities viz. Delhi/NCR, Mumbai, Bengaluru, Chennai, Pune, Hyderabad, Kolkata, Ahmedabad.

4. Health status loading: We may load premium up to 100% as under the policy depending on Your health status.

Health Status Indicators
S.N. Health Indicators Normal Borderline Level High
1 Blood Sugar Levels 99 mg and lower 100-125 mg 126 mg and higher
2 Blood Pressure(Systolic) Below 130 130-139 140 or higher
3 Blood Pressure(Diastolic) Below 80 80-89 90 or higher
5 Cholesterol Level ( mg/dL) Below 200 200-239 240 or higher
5 Body Mass Index 18.5-24.9 25-29.9 30 or higher
Cover Period Within 1 month
Health Status Loading Loading
For Normal conditions and no co-existing disease at time of proposal Nil
For any One Borderline Level Condition 20%
For any One Borderline condition with a co-existing disease or any Two Borderline Level conditions 30%
For any Two Borderline Level Condition with a co-existing disease 40%
For all three Borderline Level Condition 50%
For any one High condition or all three Borderline Level Conditions with a co-existing disease 60%
For two or more high conditions 100%

5. Floater extension loading:A loading of 40% shall be applied on premium for Section A- Hospitalisation when the cover under section A of the policy is extended to spouse of the primary insured. Sum Insured under the section, then shall be available on floater basis. We will inform You about the applicable risk loading through a counter offer letter. You have to revert to Us with consent and additional premium (if any) within 15 days of issuance of such counter letter. In case, You neither accept the counter letter from Us nor revert to Us within 15 days, We shall cancel Your application and refund the premium within next 7 days.

p>

6. Arbitration clause

If any dispute or difference shall arise as to the quantum to be paid under this Policy (liability being otherwise admitted) such difference shall independently of all other questions be referred to the decision of a sole arbitrator to be appointed in writing by the parties to the dispute/difference, or if they cannot agree upon a single arbitrator within 30 days of any party invoking arbitration, the same shall be referred to a panel of three arbitrators, comprising of two arbitrators, one to be appointed by each of the parties to the dispute/difference and the third arbitrator to be appointed by such two arbitrators.

Arbitration shall be conducted under and in accordance with the provisions of the Arbitration and Conciliation Act, 1996.

It is clearly agreed and understood that no difference or dispute shall be referable to arbitration, as herein before provided, if the Company has disputed or not accepted liability under or in respect of this Policy.

7. Free Look-up periodp>

  • 1. The Policy shall have a free look period. The free look period shall be applicable at the inception of the policy and:
    • a) 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
  • If You have not made any claim during the free look period, You shall be entitled to
    • A refund of the premium paid less any expenses incurred by Us on Your medical examination and the stamp duty charges or;
    • 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;
    • Where only a part of the risk has commenced, such proportionate risk premium commensurate with the risk covered during such period.

8. Renewal

  • This policy shall ordinarily be renewable for lifetime except on grounds of fraud, moral hazard or misrepresentation or non‐cooperation by You
  • Renewal of the policy sought by You shall not be denied arbitrarily. If denied, We shall provide You with cogent reasons for such denial of renewal.
  • We also agree that We shall not deny the renewal of the policy on the ground that You made a claim or claims in the previous or earlier .
  • 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.
  • Premium of the Policy may be revised if subject to approval from IRDA.
  • We also agree that no loading on premium shall be applicable on Your individual claims experience basis.

9. Contribution:

The conditions of contribution shall not apply to this Policy.

10. Subrogation:

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.

11. Portability

If You were insured continuously and without a break under another similar Indian retail health insurance policy with Us or any other Indian General Insurance company, it is understood and agreed that:

  • 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;
  • This benefit is available only at the time of renewal of the existing health insurance policy.
  • The Portability Benefit shall be applied subject to the following:
    • Your proposal shall be subject to Our medical underwriting
    • Any modification or amendment in 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, shall apply as on the date of proposal.

12. Nomination

The Policy has provision of nomination, in absence of Insured’s declaring Nomination at the time of proposal, then all benefits accrued under the Policy if any, shall be given to the legal heir/ dependants.

13. Medical Examination

We may ask You or Your spouse (if proposed for insurance under the Policy) to undergo below mentioned medical tests for purpose of consideration of Your proposal on basis of Your medical conditions/ health status declaration in the Proposal Form

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S. No List of Medical tests Sum Insured limits
1 Complete Blood Sugar, Urine, Routine Blood Group, ESR, Fasting Blood, Glucose, S Cholesterol, SGPT, Creatinine Rs 1,00,000
2 Complete Blood Sugar, Urine, Routine Blood Group, ESR, Fasting Blood, Glucose, S Cholesterol, SGPT, Creatinine, ECG Rs 2,00,000 and Rs 3,00,000
3 Complete Blood Sugar, Urine, Routine Blood Group, ESR, Fasting Blood, Glucose, S Cholesterol, SGPT, Creatinine, ECG, Lipid Profile, Stress test or 2D Echo, Kidney Function Test Complete Physical test by a physician Rs 4,00,000 and 5,00,000

It is agreed and understood that details in the table above, including the list of medical tests is indicative and We reserve the right to add, to modify or amend these details.

If your proposal is accepted by Us, then 50% of the costs incurred in conducting the above mentioned medical tests shall be reimbursed by Us.

We may waive Medical Examination for You or Your spouse under the Policy

If You or Your spouse have been continuously covered under a health insurance policy from Us or any other insurers for a period of three years and have had no claims under the policy

14. Region of Cover

We shall pay for treatment confined to the Hospitals in India only. All benefits under the Policy shall be come payable when incurred in India.

15. Sum Insured Enhancement

Sum Insured can be enhanced only upon renewal, subject to

  • No claim under the previous policy with Us
  • Our underwriter’s approval.

16.TPA and Our Network Providers:

For assisting you during claims related services, we have engaged a Third Party Administrator and we have also tied-up with a lot of hospitals all over India for securing you a cashless claims processing if you so desire. The details of the TPA and the list of such hospitals empanelled by us (the Network Providers) can be found at our website www.universalsompo.com

17.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 shall adhere to the following:

  • 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.
  • 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.

18. 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 1-800-2004030

Landline Numbers:(022)27639800 or (022)39133700 (Local Charges Apply)

E-mail Address:contactus@universalsompo.com. Fax Numbers: (022)39171419

We/Our/Ours/Us:Please include your policy number for any communication with us.

We/Our/Ours/Us:

Claims Disclaimer

In the unfortunate event of any loss or damage to the insured property resulting into a claim on this policy, please intimate the mishap IMMEDIATELY to our Call Centre at Toll Free Numbers on 1800-200-5142 (other users) or on chargeable numbers at (022)-39635200. 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.

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 contactus@universalsompo.com.

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: 1800-200-5142 (For MTNL/BSNL Users) or on chargeable numbers

at (022)-39635200

You can also send direct mail to the concerned authorities at grievance@universalsompo.com

If the issue still remains unresolved, You may, subject to vested jurisdiction, approach Insurance Ombudsman for the redressal of Your grievance.

The details of Insurance Ombudsman are available below and are also available on : http://www.gbic.co.in/ombudsman.html

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: bimalokpal.ahmedabad@gbic.co.in
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: bimalokpalbhopal@airtelmail.in
BHUBANESHWAR 62, Forest Park, BHUBANESHWAR-751 009.Tel: 0674-2596455; Fax:0674-2596429; Email ioobbsr@dataone.in
CHANDIGARH S.C.O. No.101-103, 2nd Floor, Batra Building. Sector 17-D, CHANDIGARH-160 017.Tel:0172-2706468; Fax:0172-2708274; Email ombchd@yahoo.co.in
CHENNAI Fathima Akhtar Court,4th Floor, 453 (old 312), Anna Salai, Teynampet, CHENNAI-600018.Tel:044-24333668/5284; Fax:044 24333664 ;Email insombud@md4.vsnl.net.in
NEW DELHI 2/2 A, Universal Insurance Bldg., Asaf Ali Road, NEW DELHI-110 002.Tel.:- 011-23239633; Fax : 011-23230858; Email iobdelraj@rediffmail.com
GUWAHATI ―Jeevan Nivesh‖,5th Floor, Near Panbazar Overbridge, S.S. Road, GUWAHATI-781 001(ASSAM).Tel:0361-2132204/5; Fax : 0361- 2732937; Email ombudsmanghy@rediffmail.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 insombudhyd@gmail.com
ERNAKULAM 2nd Floor, CC 27/2603,Pulinat Bldg., Opp. Cochin Shipyard, M.G. Road, ERNAKULAM-682015.Tel : 0484-2358759; Fax : 0484-2359336; Email iokochi@asianetindia.com
KOLKATA North British Bldg., 29, N.S. Road, 4th Floor, KOLKATA-700 001.Tel : 033-22134866; Fax : 033-22134868; Email iombsbpa@bsnl.in
LUCKNOW Jeevan Bhawan, Phase-2,6th Floor, Nawal Kishore Road, Hazaratganj, LUCKNOW-226 001.Tel :0522 -2231331; Fax : 0522-2231310; Email insombudsman@rediffmail.com
MUMBAI 3rd Floor, Jeevan Seva Annexe,S.V. Road, Santacruz(W), MUMBAI-400 054.Tel : 022-26106928; Fax : 022-26106052; Email ombudsmanmumbai@gmail.com

Note: The above are only the salient features of the Policy , for complete terms and conditions please refer to Policy Wordings


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