Delighted to inform you that we have gone LIVE at the PAYTM platform with the “MOTOR RENEWAL” instance where on the fore-front, Private Car & Two wheeler would be available there for the renewal.
Customer Care : 1800 22 4030, 1800 200 4030
24x7

Individual Health Insurance


Health Insurance policy of Universal Sompo is offered to individual and/or his family. The policy designed to pay the Insured person(s) the hospitalization expenses as well as domiciliary hospitalization benefits if he/she suffers an illness or accidental injury during the policy period.

  • Treatments only in the Hospitals / Nursing homes in India are covered
  • The coverage includes expenses incurred towards room, boarding expenses, nursing expenses, surgeon / specialist fees, charges for blood, oxygen etc
  • Domiciliary hospitalization benefit means Medical treatment for a period exceeding 3 days for such illness which in the normal course require treatment in a hospital but actually taken whilst confined at home in India since

    (1) the condition of the patient is such that he cannot be removed to a hospital or

    (2) the patient cannot be removed to the hospital for lack of accommodation

  • The indemnity provided by the policy is restricted to sum insured and the sub-limits provided in the schedule
  • Premium is calculated depending on the age of the insured and the sum insured selected
  • If Your age or Your dependant's age is more than 45 years , You /Your dependents shall have to undergo medical tests as prescribed by Us and the cost of such expenses shall be borne by You
  • The entry age under the policy should be less than 55 years
  • Maximum coverage is Rs.5 lacs
  • As per Income Tax Act, the premium paid for this cover is exempted from tax under Section 80 D

The Policy can be extended to cover certain Critical Illness

The Policy covers loss or damage to the Insured Person arising out of:

  • Pre-existing diseases are not covered
  • Any expense on hospitalization or domiciliary hospitalization incurred on account of any illness contacted during first 30 days from the date of commencement of an insurance cover is not covered. However, this exclusion shall not be applicable if Hospitalization is required on account of an accident
  • During the first year of the cover, the expense of treatment of diseases such as Cataract, Benign Prostatic Hypertrophy, Hysterectomy, Piles, Sinusitis and related disorders not payable
  • Injury or disease directly or indirectly attributable to War, invasion, Act of Foreign enemy not payable
  • Circumcision unless necessary for treatment of a disease is excluded
  • Cost of spectacles, contact lenses, hearing aids are excluded
  • Dental treatment or surgery of any kind unless hospitalization is required is excluded
  • Venereal diseases, intentional self-injury and use of intoxicating drugs/alcohol are excluded
  • Any treatment directly or indirectly for treatment associated with AIDS
  • Cosmetic or aesthetic treatment is excluded
  • Voluntary termination of Pregnancy
  • Pregnancy and Child-birth
  • Naturopathy Treatment

Group Health Insurance Policy of Universal Sompo is offered to Groups comprising of employees both in trading and manufacturing sectors/ social sector and/or members of an institution/society/association/club. The Policy is designed to pay the Insured person(s) the hospitalization expenses as well as domiciliary hospitalization benefits if he/she suffers an illness or accidental injury during the policy period.

  • Treatments only in the Hospitals / Nursing homes in India are covered
  • The coverage includes expenses incurred towards room, boarding expenses, nursing expenses, surgeon / specialist fees, charges for blood, oxygen etc
  • Domicillary hospitalization benefit means Medical treatment for a period exceeding 3 days for such illness which in the normal course require treatment in a hospital but actually taken whilst confined at home in India since (1) the condition of the patient is such that he cannot be removed to a hospital or (2) the patient cannot be removed to the hospital for lack of accommodation
  • The indemnity provided by the Policy is restricted to sum insured and the sub limits prescribed
  • Premium is calculated depending on the age of the insured, family size and the sum insured selected
  • Maximum coverage is Rs.5 lacs

The following additional covers can also be opted on payment of additional premium which shall depend upon the group size & its profile.

  • Critical Illness Cover (Paralytic stroke/ Cancer/Chronic renal failure/Coronory Artery Bypass/Transplant of organs -
    • Kidney
    • Lung
    • Pancreas
    • Bone Marrow NB,
    • Liver Transplant is not covered under this extension.
  • Maternity Benefit Cover
  • Hospital Cash Cover - is in built cover
  • Pre existing
  • Family Floater
  • By choosing the add on, the coverage for such named critical illness beckons double the basic sum insured

Policy is subject to fullowing Exclusions

  • Pre-existing diseases are not covered
  • Any expense on hospitalization or domiciliary hospitalization incurred on account of any illness contacted during first 30 days from the date of commencement of an insurance cover is not covered. However, this exclusion shall not be applicable if Hospitalization is required on account of an accident
  • During the first year of the cover, the expense of treatment of diseases such as Cataract, Benign Prostatic Hypertrophy, Hysterectomy, Piles, Sinusitis and related disorders not payable
  • Injury or disease directly or indirectly attributable to War, invasion, Act of Foreign enemy not payable
  • Circumcision unless necessary for treatment of a disease is excluded
  • Cost of spectacles, contact lenses, hearing aids are excluded
  • Dental treatment or surgery of any kind unless hospitalization is required is excluded
  • Venereal diseases, intentional self-injury and use of intoxicating drugs/alcohol are excluded
  • Any treatment directly or indirectly for treatment associated with AIDS
  • Cosmetic or aesthetic treatment is excluded
  • Voluntary termination of Pregnancy
  • Pregnancy and Child-birth
  • Naturopathy Treatment

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

Universal Sompo's Personal Accident Policy provides you and your family mitigation against the financial consequences of unforeseeable accidents.

The Policy provides for defined benefits based on the nature of injury sustained, by the Insured Person in an accident during the Policy period.

The Policy covers loss or damage to the Insured Person arising out of:

  • The enrollment age under the Policy is from 5 years to 65 years. Fresh proposals for persons above 65 years till 75 years of age may be accepted with 20% loading on premium.
  • No fresh proposal beyond 75 years.
  • Proposer needs to be aged 18 years or above.
  • No maximum renewal age under the Policy

The Policy provides for three different options as under:

  • Basic Cover - covers against Death only
  • Wider Cover - covers against Death, Permanent Total Disablement Permanent Partial Disablement
  • Comprehensive Cover - covers against Death, Permanent Total Disablement Permanent Partial Disablement Temporary Total Disablement

The compensation benefits will depend upon the nature of injury and the Capital Sum Insured under the Policy.

For accidents resulting in Death or Permanent Total disablement, we will provide compensation equivalent to the full Capital Sum Insured.

For Permanent Partial Disablement the compensation will depend on the nature of injury and corresponding percentage of Capital Sum Insured as detailed in the 'Table of Benefit' under the Policy document or as per the medical advices of our appointed Medical Practioner.

In respect of Temporary Total Disablement, we will provide compensation at 1% of Capital Sum Insured or Rs 5000/- whichever is less per week for a maximum period of 104 weeks.

In addition to the Compensation benefit stated above, we also undertake to provide compensation in respect of the following:

Transportation Cost for carriage of dead body to Home including funeral charges. 1% of Capital Sum Insured or 2,500/- (Two thousand five hundred) whichever is lower.
Cost of Clothing damaged in the Accident as described above and liability for disablement is admitted by Us. Actual expenses subject to maximum of Rs 1000/
Ambulance charges for transportation of Insured person to Hospital following Accident subject to maximum of Rs 1000/
Education Fund In the event of death, permanent total disablement i.e. 1 2 of Table of Benefit of Insured Person, We will approve compensation towards Education Fund for dependent children as below -5% (Five percent) of C.S.I Subject to a maximum of Rs. 15000/-
Loss of Employment In the event of accident leading to loss of employment as a consequence of Permanent Total Disability as per the table of benefits. 2% of CSI subject to a maximum of Rs 25000/-

The Policy can be extended to cover the following by payment of additional Premium

Medical Expenses Extension: Cover the medical expenses reasonably and necessarily incurred by you towards medical expenses as a result an accident resulting in the bodily injury, death or disablement. The compensation under this extension is restricted to 40% of Personal Accident Claim or actual medical expenses whichever is less.

Hospital Confinement Allowance: Daily allowance of Rs 500/- per day to a maximum of 30 days if you or any of the insured person (s) is hospitalised as a result of an accident resulting in the bodily injury, death or disablement.

  • This Policy shall ordinarily be renewable for lifetime except on grounds of fraud, moral hazard or misrepresentation or non-cooperation by You
  • The 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 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 Death or Permanent Total Disablement claims where the Policy terminates following payment of the benefit covered
  • No loading on premium shall be applied on Your individual claims experience basis
  • The premium of the Policy may be revised subject to approval from Insurance Regulatory Development Authority

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.

The Policy shall be issued for a period of 12 months from date of commencement of Policy

Death only cover --- 10 times the yearly Income Wider Cover --- 05 times the yearly Income Comprehensive Cover --- 05 times the yearly Income (Rs 500,000/- max)`

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.

Sum Insured can be enhanced only upon renewal, subject to Our underwriter‟s approval.

We may cancel this Policy by sending 15 days notice in writing by recorded delivery to You at Your last known address. 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

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

1. The Policy shall have a free look period. The free look period shall be applicable at the inception of the Policy and:

  • 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. 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.

The premium under the Policy shall be payable in single installment

Nature of Cover Category- Normal Heavy Very Heavy
Basic 0.40% 0.60% 0.90%
Wider 0.85% 1.25% 1.95%
Comprehensive 1.40% 2.00% Not to be covered

a) Medical Expenses Extension: The additional Premium for this extension is 25% of the base PA premium.

b) Hospital Confinement Allowance: The additional premium for this extension is Rs 300/- per person.

For Renewal policies for persons above 65 years of age, a 10% loading shall be applicable. 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.

Please note:We shall issue Policy only after getting Your consent

A) Family package discount: More than 3 family Members 10.00% More than 4 family Members 12.50% More than 5 family Members 15.00% NB: Family means Proposer, spouse, dependent children and dependent parents.

B) Loyalty Discount:

Loyalty discount on the premium in respect of individual and family package cover at the following rate shall be allowed in case the Policy is renewed with Us within 7 days after the expiry of the Policy:

1st year 05%

2nd year 10%

3rd year 15%

A) Upon happening of any Accident and/or Injury 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. In case of death, written notice also of death must, unless reasonable cause is shown, be given before internment/ cremation and in any case, within one calendar month after the death, and in the event of loss of sight or amputation of limbs, written notice thereof must also be given within one calendar month after such loss of sight or amputation.
  • All certificates, information and evidence from the attending Medical Practitioner shall be provided by You.

B) On receipt of intimation from You regarding a claim under the Policy, we are entitled to carry out examination and ascertain details and in the event of death get the post-mortem examination done in respect of deceased person.

C) 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.

D) Following documents shall be required in the event of a claim.

For Death Claim

  • Duly filled up claim form
  • Death Certificate
  • Original FIR
  • Original Panchnama
  • Post mortem report

For Permanent Total disablement/Permanent Partial Disablement

  • Duly filled up claim form
  • Original FIR
  • Panchnama
  • Hospitalization Report
  • Hospital discharge card
  • Original Certificate from Doctor of Govt. Hospital stating the degree of disability

For Temporary Total Disablement

  • Duly filled up claim form
  • Original FIR
  • Panchnama
  • Hospitalization Report
  • Hospital discharge card
  • Original Certificate from Doctor of Govt. Hospital stating the degree of disability
  • Termination letter for claim under “Loss of Employment”

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.

E) Position after claim:

The maximum liability of the Company for each of the benefit opted is limited to its Sum Insured as reflected in the Schedule of the Policy and if a claim is made for more than one of the covered benefits resulting from any Accident, only one benefit amount which is the largest among the admissible benefits, will be paid. Regardless of one or more claim during the Policy period, the maximum amount payable towards any admissible benefit covered shall be restricted to Sum Insured for the Death/Permanent total disability benefit as reflected in the Schedule of the Policy.

F) 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.

In the unfortunate event of any medical contingency resulting into a claim on this Policy, please intimate the mishap IMMEDIATELY to Our Call Centre at Toll Free Numbers: 1800-200-5142, Chargeable Numbers: 022 – 39635200, Fax Toll Free Numbers: 1800-200-9134. email at contactclaims@universalsompo.com. Please note that no delay should be allowed to occur in notifying a claim on the Policy as the same may prejudice liability.

The Policy shall be directly serviced by Us. Please get in touch with Our Company's representative for complete details. For all Your service requests e-mail Us at contactus@universalsompo.com

No person shall allow or offer to allow, either directly or indirectly, as an inducement to any person to take out or renew or continue an insurance in respect of any kind of risk relating to lives or property in India, any rebate of the whole part of the commission payable or any rebate of the premium shown on the Policy nor shall any person taking out or renewing or continuing a Policy accept any rebate, except such rebates as may be allowed in accordance with the published prospectuses or tables of the Insurer. Any person making default in complying with the provisions of this section shall be punishable with fine which may extend to Ten Lakh Rupees

The prospectus contains only an indication of cover offered, for complete details on terms, conditions, coverages and exclusions please get in touch with Us or Our agent and read Policy wordings carefully before concluding a sale. Insurance is a subject matter of solicitation. 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

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

In consideration of your having paid the premium for the Policy period stated in the Schedule or for any further period of insurance for which we may accept the payment for renewal of this Policy, We undertake that in the event of accidental bodily Injury sustained by You during the Policy period, we will make payment to you or your legal representative/nominee as per the Table of Benefits set forth in the Policy provided that all the terms, conditions and exceptions of this Policy in so far as they relate to anything to be done or complied with by You have been met.

This Policy is an evidence of the contract between you and Universal Sompo General Insurance Company Limited. The information furnished by you in the Proposal form and the declaration signed by you forms the basis of this contract.

The Policy, the Schedule and any Endorsement shall be read together and any word or expression to which a specific meaning has been attached in any part of this Policy or of Schedule shall bear such meaning whenever it may appear.

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.

Accidentmeans a sudden unforeseen and involuntary event caused by external, visible and violent means.

Accidental Deathmeans Death resulting from Bodily Injury solely and independently of any other cause except Illness directly resulting from, or medical or surgical treatment rendered necessary for such Injury, occasions the Death of the Insured Person within 12 months from the date of Accident.

Adventure Sports:Participation in sports activities such as bungee jumping, sky diving, white water canoeing/rafting and engaging in racing, hunting, mountaineering, ice hockey, winter sports and the like.

Ambulancemeans any vehicle used solely for the conveyance of injured persons from Accidental location or Your residential place or Hospital to any Hospital in emergency cases.

Bodily Injurymeans accidental physical bodily Injury solely and directly caused by external, violent visible cause.

Break in Policyoccurs 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.

Capital Sum Insuredmeans the monetary amounts shown against Insured Person(s) which is the maximum limit of our liability against said Insured Person.

Cashless facilitymeans a facility extended by Us to You where the payments, of the costs of treatment undergone by You in accordance with the Policy terms and conditions, are directly made to the network provider by Us to the extent pre-authorization approved.

Condition Precedentmeans a Policy term or condition upon which the Insurer’s liability under the Policy is conditional upon.

Contributionis 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.

Disclosure to information normmeans the 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 Caremeans 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.

Hospitalizationmeans 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 24 consecutive hours.

Hospitalmeans 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 inpatient beds, in those towns having a population of less than 10, 00,000 and 15 inpatient 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 will make these accessible to Insurance company’s authorized personnel.

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.

a) 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/her state of health immediately before suffering the disease/Illness/Injury which leads to full recovery.

b) 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

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.

Inpatient Care means treatment for which the Insured Person has to stay in a Hospital for more than 24 hours for a covered event.

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

Insured Person: The person(s) named as Insured Person in the Schedule which will include you and your family inclusive of dependent parents.

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

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.

Nominee means the person(s) nominated by the Insured Person to receive the insurance benefits under this Policy payable on his/her death.

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.

Notification 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.

Period of Insurance: The time period for which the contract of insurance is valid as shown in the Policy Schedule.

Permanent Total Disablement: The bodily Injury that totally, irrecoverably and absolutely prevents you from engaging in any kind of occupation.

Permanent Partial Disability: The bodily Injury that results in total, irrevocable, absolute and continuous loss of or impairment of a body part or sensory organ specified under the Table of Benefits.

Proposal: The application form you sign for this insurance and/or any other information you give to us or which is given to us on your behalf.

Policy: Policy wording, the Schedule, the Proposal form and Endorsement / Memoranda, if any.

Renewal means 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.

Reasonable and Customary 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 .

Schedule means Schedule attached to and forming part of this Policy mentioning the details of the Insured/Insured Persons, the Sum Insured, the period and the limits to which benefits under the Policy would be payable.

Subrogation means 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.

Temporary Total Disablement: The bodily Injury that prevents you from engaging in your occupation for a period not exceeding 104 weeks since the date of Injury to the time you are fit enough to resume your occupation as certified by Medical Professional.

Terrorism/Terrorist activity: means any actual or threatened use of force or violence directed at or causing damage, Injury, harm or disruption, or commission of an act dangerous to human life or property, against any individual, property or government, with the stated or unstated objective of pursuing economic, ethnic, nationalistic, political, racial or religious interests, whether such interests are declared or not. Robberies or other criminal acts, primarily committed for personal gain and acts arising primarily from prior personal relationships between perpetrator(s) and victim(s) shall not be considered Terrorist activity. Terrorism shall also include any act, which is verified or recognized by the relevant Government as an act of terrorism.

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 mean 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 WE COVER

Accidental bodily Injury directly resulting in the death or disablement to Insured Person as per the Table of Benefits.

The scope of coverage shall depend on the benefit selected by you and as described in the Schedule

  • A) Basic Cover—Death only
  • B) Wider Cover--- Death + Permanent Total Disability + Permanent Partial Disability
  • C) Comprehensive Cover---- Death + Permanent Total Disability + Permanent Partial Disability + Temporary Total Disability

We shall pay to the Insured Person or his/her legal personal representative / assignee, the compensation set forth in Table of Benefits (as percentage of Capital Sum Insured).

WHAT WE EXCLUDE

1. Natural Death

2. Compensation under more than one of the benefits mentioned in Table of Benefits in respect of same period of disablement.

3. Any other payment after a claim under one of the benefits 1,2, 3 and 4 in Table of benefits has been admitted and becomes payable.

4. Any payment in case of more than one claim under this Policy during any one period of Insurance by which our liability in that period would exceed CSI

5 Payment of compensation in respect of death or Injury as a consequence of/resulting from

a) Committing or attempting suicide, intentional self-Injury.

b) Whilst under influence of intoxicating liquor or drugs. c) Drug addiction or alcoholism.

d) Whilst engaged in any adventurous sports and/or hazardous activities.

e) Committing any breach of law with criminal intent.

f) War, Civil War, invasion, act of foreign enemies, revolution, insurrection, mutiny, military or usurped power, seizure, capture, arrest, restraint, or detainment, confiscation, or nationalisation or requisition by or under the order of any government or public authority.

6. Consequential loss of any kind and/or any legal liability.

7. Pregnancy including child birth, miscarriage, abortion or complication arising there from.

8. Participation in any naval, military or air force operations.

9. Curative treatments or interventions.

10. Venereal or sexually transmitted diseases.

11. HIV and or related Illness.

S. No. Table of Benefits Percentage of Capital Sum Insured
1 Accidental Death: 100
2 Permanent Total Disability:
a) Loss of sight (both eyes) 100
b) Loss of two limbs 100
c) Loss of one limb and one eye 100
d) Permanent Total and absolute disablement as certified by Medical Practitioner 100
3 Partial Disability:
A Loss of sight of one eye 50
B Loss of one limb 50
C Loss of toes-all 20
D Great-both phalanges 5
E Great-one phalanx 2
F if more than one toe lost each 1
G both ears 50
H Loss of hearing – one ear 15
I Loss of Speech 50
Loss of four fingers and thumb of one hand 40
K Loss of four fingers 35
L Loss of thumb-both phalanges 25
M Loss of thumb-one phalanx 10
N Loss of index finger i) Three phalanges ii)Two phalanges iii)One phalanges 10 8 4
O Loss of middle finger i) Three phalanges ii)Two phalanges iii)One phalanges 6 4 2
P Loss of ring finger i) Three phalanges ii)Two phalanges iii)One phalanges 5 4 2
Q Loss of little finger i) Three phalanges ii)Two phalanges iii)One phalanges 4 3 2
R Loss of Metacarpals (i)First or second (additional)(ii)Third, fourth or fifth (additional) 3 2
S Any other permanent partial disablement % as assessed by Medical Practitioner appointed by us
4 Temporary Total disablement benefit at the rate per week for period of confinement or part thereof. 1% of C.S.I or Rs 5000/- whichever is lower for 104 weeks max.

Extra Benefits under the Policy in addition to capital Sum Insured, in case the liability under the Policy for Accidental Claim has been admitted.

A. Transportation cost for carriage of dead body to Home including funeral charges. 1% of Capital Sum Insured or 2,500/- (Two thousand five hundred) whichever is lower.
B. Cost of Clothing damaged in the Accident as Actual expenses subject to maximum of Rs 1000/
C. Ambulance charges for transportation of Insured person to Hospital following Accident Actual expenses subject to maximum of Rs 1000/
D. Education Fund: In the event of Death, permanent total disablement of the proposer that is the first Insured Person, We will approve compensation towards Education Fund for up to two dependent children as below 5% (Five percent) of C.S.I Subject to a maximum of Rs. 15000/-
E. Loss of Employment In the event of Accident leading to loss of employment as a consequence of Permanent Total Disability as per the table of benefits. 2% of Basic Sum Insured subject to a maximum of Rs 25000/-

Add-on Covers: (applicable only to Comprehensive Policy and on receipt of additional premium specifically shown under the Schedule)

A) Medical Expenses Extension:In consideration of payment of additional premium as shown in the Schedule, the Policy is extended to cover the Medical Expenses Reasonably and customarily incurred by you towards Medical Expenses as a result of an Accident resulting in the bodily Injury, death or disablement. The compensation under this extension is restricted to 40% of Personal Accident Claim or actual Medical Expenses whichever is less.

B) Hospital Confinement Allowance:In consideration of payment of additional premium as shown in the Schedule, we undertake to pay a daily allowance of Rs 500/- per day to a maximum of 30 days if you or any of the Insured Person(s) is hospitalised as a result of an Accident resulting in the bodily Injury, death or disablement.

We will not pay for any compensation in respect of death, Injury or disablement of the Insured Person arising out of:

1. War, invasion, act of foreign enemy, hostilities (whether war be declared or not) civil war, rebellion, revolution, ;insurrection, mutiny military or usurped power, confiscation, seizure, capture, assault, restraint, nationalization, civil commotion or loot or pillage in connection herewith.

2. Ionizing radiation or contamination by radioactivity from any nuclear fuel or from any nuclear waste from the combustion of nuclear fuel. For the purpose of this exclusion, combustion shall include any self-sustaining process of nuclear fission.

3. The radioactive, toxic, explosive or the hazardous properties of any nuclear assembly or nuclear component.

4. Air travel except as a passenger on a recognized airline operating on regular scheduled air routes and air travel by any charter aircraft duly licensed as a recognized air carrier and flown by professional crews between properly established and maintained airports.

5. Participation in any kind of motor speed contest (including trial, training and qualifying heats)

6. This Insurance does not cover any loss, damage, cost or expense directly or indirectly arising out of a) Biological or chemical contamination b) Missiles, bombs, grenades, explosives due to any act of terrorism

A) Upon happening of any Accident and/or Injury 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. In case of death, written notice also of death must, unless reasonable cause is shown, be given before internment/ cremation and in any case, within one calendar month after the death, and in the event of loss of sight or amputation of limbs, written notice thereof must also be given within one calendar month after such loss of sight or amputation.
  • All certificates, information and evidence from the attending Medical Practitioner shall be provided by You.

B) On receipt of intimation from You regarding a claim under the Policy, we are entitled to carry out examination and ascertain details and in the event of death get the post-mortem examination done in respect of deceased person.

C) 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.

D) Following documents shall be required in the event of a claim.

For Death Claim

  • Duly filled up claim form
  • Death Certificate
  • Original FIR
  • Original Panchnama
  • Post mortem report

For Permanent Total disablement/Permanent Partial Disablement

  • Duly filled up claims form
  • Original FIR
  • Panchnama
  • Hospitalization Report
  • Hospital discharge card
  • Original Certificate from Doctor of Govt. Hospital stating the degree of disability
  • Termination letter for claim under ―Loss of Employment

For Temporary Total Disablement

  • Duly filled up claims form
  • Original FIR
  • Panchnama
  • Hospitalization Report
  • Hospital discharge card
  • Original Certificate from Doctor of Govt. Hospital stating the degree of disability

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.

E) Position after claim:

The maximum liability of the Company for each of the benefit opted is limited to its Sum Insured as reflected in the Schedule of the Policy and if a claim is made for more than one of the covered benefits resulting from any Accident, only one benefit amount which is the largest among the admissible benefits, will be paid. Regardless of one or more claim during the Policy period, the maximum amount payable towards any admissible benefit covered shall be restricted to Sum Insured for the Death/Permanent total disability benefit as reflected in the Schedule of the Policy.

F) 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.

1. Notice

Every notice and communication to the Company required by this Policy shall be in writing. Initial notification can be made by telephone

2. Mis-description

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 failure on Your part to intimate us in writing and obtaining written approval from us in respect of Changes in Circumstances arising out of changes in the duty, business, occupation of the Insured Person(s).

3. Contribution and Subrogation

Subrogation and Contribution provisions are not applicable to the Policy.

4. Fraud

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.

5. Discounting under the product

We shall offer You the below mentioned discounts under the Policy

a) Family package discount: We shall offer You discount as under for covering more than two family members under the Policy

More than 3 family Members 10.00%

More than 4 family Members 12.50%

More than 5 family Members 15.00% NB:

Family means Proposer, spouse, dependent children and dependent parents.

b) Loyalty Discount:

We shall offer You loyalty discount on the premium in respect of individual and family package cover at the following rate in case the Policy is renewed with us within 7 days after the expiry of the Policy:

1st year 05%

2nd year 10%

3rd year 15%

Loading under the Policy

We shall apply a loading of 10% on Your Renewal premium if You seek Renewal of Your Policy from Us beyond 65 years of age.

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.

Please note We shall issue Policy only after getting Your consent

7. Renewal

i. This Policy shall ordinarily be renewable for lifetime except on grounds of fraud, moral hazard or misrepresentation or non-cooperation by You

ii. The 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.

iii. 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 Death or Permanent Total Disablement claims where the Policy terminates following payment of the benefit covered

iv. No loading on premium shall be applied on Your individual claims experience basis

v. The premium of the Policy may be revised subject to approval from Insurance Regulatory Development Authority

8. Free Look-up period

1. The Policy shall have a free look period. The free look period shall be applicable at the inception of the Policy and:

i. 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.If You have not made any claim during the Free Look period, You shall be entitled to

i.A refund of the premium paid less any expenses incurred by Us on Your medical examination and the stamp duty charges or;

ii.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;

iii.Where only a part of the risk has commenced, such proportionate risk premium commensurate with the risk covered during such period.

9. Cancellation

We may cancel this Policy by sending 15 days notice in writing by recorded delivery to You at Your last known address. 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

10. Arbitration

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 provided, if the Company has disputed or not accepted liability under or in respect of this Policy.

It is hereby expressly stipulated and declared that it shall be a Condition Precedent to any right of action or suit upon this Policy that the award by such arbitrator/ arbitrators of the amount of the loss or damage shall be first obtained.

11. 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.

12. Geographical Scope:

The geographical scope of this Policy will be worldwide unless otherwise stated in the Policy schedule; however the claims shall be settled in India in Indian rupees. The provisions of this Policy shall be governed by the laws of India for the time being in force. The parties hereto unconditionally submit to the jurisdiction of the courts in India.

13. Policy Disputes

It has been agreed between the parties that though the geographical scope of the Policy is Worldwide, 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.

14. Sum Insured Enhancement:

Sum Insured can be enhanced only upon renewal, subject to Our underwriter’s approval.

15. Three Months 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:

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.

16. Nomination

The Policy has provision of nomination, In absence of Your declaring Nomination at the time of Proposal, then all benefits accrued under the Policy if any, shall be given to Your legal heir/ dependants.

17. Substitute Product

In case We may decide to withdraw this product under which this Policy is issued to You or where the children have attended maximum eligibility age under the Policy, if covered, We shall provide You with an option to buy a similar substitute Accident insurance Policy from Us.

The Policy provides for three different options as under:

18. Cumulative Bonus (Applicable to Individual and Family Package)

If no claim has been made under the Policy and the Policy is renewed with Us without any break, We will apply a cumulative bonus to the next Policy Year by automatically increasing the Sum Insured for the next Policy Year by 5% of the Sum Insured for this Policy Year. The maximum cumulative bonus shall not exceed 50% of the Sum Insured in any Policy Year.

In relation to a Family Policy, the cumulative bonus so applied will only be available in respect of claims made by those Insured Persons who were Insured Persons in the claim free Policy Year and continue to be Insured Persons in the subsequent Policy Year.

The cumulative bonus % will be applied on section 1 to 3If a cumulative bonus has been applied and a claim is made, then in the subsequent Policy Year We will automatically decrease the cumulative bonus to zero in the following Policy Year.

19. Compensation:

i. In case of claim by death or permanent total disablement compensation will be made only after deleting by an endorsement the name of the deceased/ Injured person in respect of whom such sums shall become payable.

ii. In case of claim by permanent partial disablement i.e. Benefit 3 of Table of Benefits compensation will be made only after reduction of Capital Sum Insured by an endorsement by the amount admissible under the claim in respect of the Injured person.

iii. In case of Temporary Total Disablement Benefit i.e. 4 of Table of Benefits compensation will be made only upon termination of such disablement in respect of Injured Person or on the expiry of 104 weeks of disablement whichever occurs earlier.

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

Landline Numbers

(022)-27639800 or (022)-41582900 or (022)-41582999 or (022)-39133700 (Local Charges Apply)

E-mail Address

contactus@universalsompo.com.

Fax Numbers

(022) 41582929 or (022) 41582939

Note: Please include Your Policy number for any communication with us.

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.

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 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 or on chargeable numbers at (022)-39635200.

You can also visit Our Company website and click under links Grievance Notification

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 : HTTPS://www.gbic.co.in/ombudsman.html

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
RH 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

Universal Sompo's Personal Accident Policy provides you and your family mitigation against the financial consequences of unforeseeable accidents.

Janata Personal Accident Insurance is offered to cover employees of a firm/Company and members of an association/club, depositors of banks, members of cooperative society’s, NGO’s, SHG’s, Kisan Credit Card Holders, members of APL and BPL segments of society.

  • The enrollment age under the Policy is from 5 years to 65 years.
  • Proposer needs to be aged 18 years or above.

The Policy provides for defined benefits for Death and Permanent Total Disablement caused as a result of accidental injury sustained by Insured Persons,in the Accident during the Policy Period.

The compensation benefits will depend upon the nature of injury and the Capital Sum Insured under the Policy.

For accidents resulting in Death or Permanent Total disablement, we will provide compensation equivalent to the full Capital Sum Insured

Group Discount

We shall provide group discount as per below when the number of persons covered under the Policy exceeds 25. Group Discount will not be reviewed during the currency of the Policy, even if the size of the group exceeds the next slab.

Number of Persons covered Applicable discount
Upto 25 persons No discount
Between 25 and 50 persons 5% on total premium
Between 51 and 100 persons 10% on total premium
Between 101 and 300 persons 15% on total premium
Between 301 and 400 persons 20% on total premium
Between 401 and 500 persons 25% on total premium
Over 500 persons To be decided by Corporate Office
On Duty Cover Discount:

We may provide a discount up to 25% on the basic premium when Janata Personal Accident cover is only for restricted hours of duty (and not for all 24 hours of day and night) for the Insured Persons in the Policy. The restricted cover is intended only for employers who wish to cover their employees for accidents during and in the course of employment.

Off Duty Cover Discount:

We may provide a discount up to 50% on the basic premium when Janata Personal Accident cover is required only for restricted hours, when the Insured Person is not at work and/ or not on official duty.

A. Premium details:

Please get in touch with our Company representative or visit our office with complete details viz., demography of group, Sum Insured and Extensions sought under the policy and other terms and conditions for premium details.

B. Cancellation Terms

We may cancel this Policy by sending 15 days notice in writing by recorded delivery to You at Your last known address. 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:

Upto 1 month 25% of annual premium Above 1 month and upto 3 months 50% of annual premium Above 3 months and upto 6 months 75% of annual premium Above 6 months 100% of annual premium

  • This Policy shall ordinarily be renewable for lifetime except on grounds of fraud, moral hazard or misrepresentation or non-cooperation by You
  • The 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.
  • No loading on premium shall be applied on Your individual claims experience basis

The premium for renewals shall be subject to discount when group Policy issued witnesses favourable claims ratio as under:

Incurred Claim Ratio under the Group Policy Discount Percentage (%)
Up to 20 % 25
21 % - 35 % 15
36 % - 50 % 10
51 % - 60 % 5

The premium for renewals shall be subject to loading when group Policy issued witnesses adverse claims ratio as under:

Incurred Claim Ratio under the Group Policy Loading Percentage (%)
Between 80 % and 100 % 25
55
Between 126 % and 150 % 90
Between 151 % and 175 % 120
Between 176 % and 200 % 150
Over 200 % Cover to be reviewed

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.

Please note We shall issue Policy only after getting Your consent

iv. The premium of the Policy may be revised subject to approval from Insurance Regulatory Development Authority

D. Policy Term: The policy shall be viewed for a term of 12 months.

E. Installment Premium: Premium under the policy shall be payable in a single installment at inception of the policy.

F. Free look up:

1. The Policy shall have a free look period. The free look period shall be applicable at the inception of the Policy and:

  • i. 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. If You have not made any claim during the Free Look period, You shall be entitled to

  • i. A refund of the premium paid less any expenses incurred by Us on Your medical examination and the stamp duty charges or;
  • ii. 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;
  • iii. Where only a part of the risk has commenced, such proportionate risk premium commensurate with the risk covered during such period
G. 3 Month’s 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.

H. Policy Servicing:

Your policy shall be directly serviced by us..

1. Compensation under more than one of the benefits mentioned in Table of Benefits in respect of same period of disablement.

2. Any other payment after a claim under one of the benefits 1 and 2 in Table of benefits has been admitted and becomes payable.

3. Any payment in case of more than one claim in respect of one insured person under this Policy during any Period of Insurance by which Our liability in that period would exceed CSI.

4. Payment of compensation in respect of a Permanent Partial Disability or Death/disability as a consequence of/resulting from

a. Committing or attempting suicide, intentional self-injury.

b. Whilst under influence of intoxicating liquor or drugs.

c. Drug addiction or alcoholism.

d. Whilst engaged in any adventurous sports.

e. Committing any breach of law with criminal intent.

f. War, Civil War, invasion, act of foreign enemies, revolution, insurrection, mutiny, military or Usurped power,seizure, capture, arrest, restraint, or detainment, confiscation, or nationalisation or requisition by or under the order of any government or public authority.

5. Consequential loss of any kind and/or any legal liability

6. Death/disability due to pregnancy including child birth, miscarriage, abortion or complication.

7. Insured participating in any naval, military or air force operations.

8. Curative treatments or interventions.

9. Venereal or sexually transmitted diseases.

10. HIV and or related illness

11. Ionizing radiation or contamination by radioactivity from any nuclear fuel or from any nuclear waste from the combustion of nuclear fuel. For the purpose of this exclusion, combustion shall include any self sustaining process of nuclear fission.

12. The radioactive, toxic, explosive or the hazardous properties of any nuclear assembly or nuclear component.

A)happening of any Accident and/or Injury 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. In case of death, written notice also of death must, unless reasonable cause is shown, be given before internment/ cremation and in any case, within one calendar month after the death, and in the event of loss of sight or amputation of limbs, written notice thereof must also be given within one calendar month after such loss of sight or amputation.
  • All certificates, information and evidence from the attending Medical Practitioner shall be provided by You.

B) Following documents shall be required in the event of a claim.

For Death Claim

  • Duly filled up claim form
  • Death Certificate
  • Original FIR
  • Original Panchnama
  • Post mortem report

For Permanent Total disablement/Permanent Partial Disablement

  • Duly filled up claim form
  • Original FIR
  • Panchnama
  • Hospitalization Report
  • Hospital discharge card
  • Original Certificate from Doctor of Govt. Hospital stating the degree of disability

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.

C) On receipt of intimation from You regarding a claim under the Policy, we are entitled to carry out examination and ascertain details and in the event of death get the post-mortem examination done in respect of deceased person.

D) Position after claim:

We shall have no liability under this Policy, once the Sum Insured (Maximum Limit of Liability), as stated in the Policy Schedule with respect to any of the benefits, is exhausted by You.

E) 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.

Claim Disclaimer

In the unfortunate event of any medical contingency 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 (other users) or on chargeable numbers at +91-22-26748600 / +91-22-41582900 / +91-22-41582999 or email at contactclaims@universalsompo.com. Please note that no delay should be allowed to occur in notifying a claim on the policy as the same may prejudice liability.

The Policy shall be directly serviced by Us. Please get in touch with Our Company's representative for complete details.

For all Your service requests e-mail Us at contactus@universalsompo.com

No person shall allow or offer to allow, either directly or indirectly, as an inducement to any person to take out or renew or continue an insurance in respect of any kind of risk relating to lives or property in India, any rebate of the whole part of the commission payable or any rebate of the premium shown on the policy nor shall any person taking out or renewing or continuing a policy accept any rebate, except such rebates as may be allowed in accordance with the published prospectuses or tables of the Insurer. Any person making default in complying with the provisions of this section shall be punishable with fine which may extend to Ten Lakh Rupees

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

In consideration of Your having paid the premium for the period stated in the Schedule or for any further period for which We may accept the payment for Renewal of this Policy, We undertake that in the event of Death or Permanent Total Disablement sustained by the Insured Person(s) solely due to an Accidental Injury during the Policy Period, We will make payment to them or to their legal representative/Nominee as per the Table of Benefits set forth in the Policy provided that all the terms, conditions and exceptions of this Policy in so far as they relate to anything to be done or complied with by them have been met.

This Policy is an evidence of the contract between You and Universal Sompo General Insurance Company Limited. The information furnished by You in the Proposal Form and the declaration signed by You forms the basis of this contract.

The Policy, the Schedule and any Endorsement shall be read together and any word or expression to which a specific meaning has been attached in any part of this Policy or of Schedule shall bear such meaning whenever it may appear.

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.

Accident means a sudden unforeseen and involuntary event caused by external, visible and violent means.

Accidental Death means Death resulting from Bodily Injury solely and independently of any other cause except Illness directly resulting from, or medical or surgical treatment rendered necessary for such Injury, occasions the Death of the Insured Person within 12 months from the date of Accident.

Adventure Sports: Participation in sports activities such as bungee jumping, sky diving, white water canoeing/rafting and engaging in racing, hunting, mountaineering, ice hockey, winter sports and the like.

Ambulance means any vehicle used solely for the conveyance of injured persons from Accidental location or Your residential place or Hospital to any Hospital in emergency cases.

Bodily Injury means accidental physical bodily Injury solely and directly caused by external, violent visible cause.

Break in Policy 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.

Capital Sum Insured means the monetary amounts shown against Insured Person(s) which is the maximum limit of our liability against said Insured Person.

Cashless facility means a facility extended by Us to You where the payments, of the costs of treatment undergone by You in accordance with the Policy terms and conditions, are directly made to the network provider by Us to the extent pre-authorization approved.

Condition Precedent means a Policy term or condition upon which the Insurer’s liability under the Policy is conditional upon.

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.

Disclosure to information norm means the 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 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.

Hospitalization means 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 24 consecutive hours.

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 inpatient beds, in those towns having a population of less than 10, 00,000 and 15 inpatient 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 will make these accessible to Insurance company’s authorized personnel.

Illnessmeans 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.

a) 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/her state of health immediately before suffering the disease/Illness/Injury which leads to full recovery.

b) 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

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.

Inpatient Care means treatment for which the Insured Person has to stay in a Hospital for more than 24 hours for a covered event.

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

Insured Person: The person(s) named as Insured Person in the Schedule which will include you and your family inclusive of dependent parents.

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

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.

Nominee means the person(s) nominated by the Insured Person to receive the insurance benefits under this Policy payable on his/her death.

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 member of the Insured Person’s Family.

Notification 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.

Period of Insurance: The time period for which the contract of insurance is valid as shown in the Policy Schedule.

Permanent Total Disablement: The bodily Injury that totally, irrecoverably and absolutely prevents you from engaging in any kind of occupation.

Permanent Partial Disability: The bodily Injury that results in total, irrevocable, absolute and continuous loss of or impairment of a body part or sensory organ specified under the Table of Benefits.

Proposal: The application form you sign for this insurance and/or any other information you give to us or which is given to us on your behalf.

Policy: Policy wording, the Schedule, the Proposal form and Endorsement / Memoranda, if any.

Renewal means 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.

Reasonable and Customary 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 .

Schedule means Schedule attached to and forming part of this Policy mentioning the details of the Insured/Insured Persons, the Sum Insured, the period and the limits to which benefits under the Policy would be payable.

Subrogationmeans 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.

Temporary Total Disablement: The bodily Injury that prevents you from engaging in your occupation for a period not exceeding 104 weeks since the date of Injury to the time you are fit enough to resume your occupation as certified by Medical Professional.

Terrorism/Terrorist activity: means any actual or threatened use of force or violence directed at or causing damage, Injury, harm or disruption, or commission of an act dangerous to human life or property, against any individual, property or government, with the stated or unstated objective of pursuing economic, ethnic, nationalistic, political, racial or religious interests, whether such interests are declared or not. Robberies or other criminal acts, primarily committed for personal gain and acts arising primarily from prior personal relationships between perpetrator(s) and victim(s) shall not be considered Terrorist activity. Terrorism shall also include any act, which is verified or recognized by the relevant Government as an act of terrorism.

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 mean 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 We Cover

1. Bodily Injury directly resulting in death or Permanent Total Disablement of the Insured.

We shall pay to the Insured Person or his/her legal personal representative/nominee the compensation set forth in Table of Benefits (as percentage of Capital Sum Insured.)

What We exclude

1. Compensation under more than one of the benefits mentioned in Table of Benefits in respect of same period of disablement.

2. Any other payment after a claim under one of the benefits 1 and 2 in Table of benefits has been admitted and becomes payable.

3.Any payment in case of more than one claim in respect of one Insured Person under this Policy during any Period of Insurance by which Our liability in that period would exceed CSI.

4.Payment of compensation in respect of a Permanent Partial Disability or Death /disability as a consequence ;of/resulting from

a)Committing or attempting suicide, intentional self-Injury.

b)Whilst under influence of intoxicating liquor or drugs.

c)Drug addiction or alcoholism

d)Whilst engaged in any adventurous sports.

e)Committing any breach of law with criminal intent.

f)War, Civil War, invasion, act of foreign enemies, revolution, insurrection, mutiny, military or Usurped power, seizure, capture, arrest, restraint, or detainment, confiscation, or nationalisation or requisition by or under the order of any government or public authority.

5.Consequential loss of any kind and/or any legal liability.

6.Death/disability due to pregnancy including child birth, miscarriage, abortion or complication.

7.Insured participating in any naval, military or air force operations.

8.Curative treatments or interventions.

9.Venereal or sexually transmitted diseases.

10.HIV and or related Illness.

11.Ionizing radiation or contamination by radioactivity from any nuclear fuel or from any nuclear waste from the combustion of nuclear fuel. For the purpose of this exclusion, combustion shall include any self-sustaining process of nuclear fission.

12.The radioactive, toxic, explosive or the hazardous properties of any nuclear assembly or nuclear component.

TABLE OF BENEFITS
COVER FOR PERCENTAGE OF CAPITAL SUM INSURED
1.Death 100
2.Permanent Total Disability:

a. Loss of sight (both eyes)

b. Loss of two limbs

c. Loss of one limb and one eye

d. Any other Permanent Total and absolute disablement as certified by Qualified Medical Practitioner

100

100

100

100

A) Upon happening of any Accident and/or Injury 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. In case of death, written notice also of death must, unless reasonable cause is shown, be given before internment/ cremation and in any case, within one calendar month after the death, and in the event of loss of sight or amputation of limbs, written notice thereof must also be given within one calendar month after such loss of sight or amputation.
  • All certificates, information and evidence from a Medical Practitioner or otherwise required by Us as mentioned below shall be provided by You.

B) Following documents shall be required in the event of a claim.

For Death Claim
  • Duly filled up claim form
  • Death Certificate
  • Original FIR
  • Original Panchnama
  • Post mortem report

B) For Permanent Total disablement

  • Duly filled up claims form
  • Original FIR
  • Panchnama
  • Hospitalization Report
  • Hospital discharge card
  • Original Certificate from Doctor of Govt. Hospital stating the degree of disability

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. C) On receipt of intimation from You regarding a claim under the Policy, we are entitled to carry out examination and ascertain details and in the event of death get the post-mortem examination done in respect of deceased person. D) Position after claim: We shall have no liability under this Policy, once the Sum Insured (Maximum Limit of Liability), as stated in the Policy Schedule with respect to any of the benefits, is exhausted by You. E) 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.

1. Notice:

Every notice and communication to the Company required by this Policy shall be in writing. Initial notification can be made by telephone

2. Mis-description:

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 failure on Your part to intimate us in writing and obtaining written approval from us in respect of Changes in Circumstances arising out of changes in the duty, business, occupation of the Insured Person(s).

3. Contribution and Subrogation:

Subrogation and Contribution provisions are not applicable to the Policy.

4. Fraud

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.

5. Cancellation/termination

We may cancel this Policy by sending 15 days notice in writing by recorded delivery to You at Your last known address. 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:

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

6. Discount(s) under the Policy: Group Discount

We shall provide group discount as per below when the number of persons covered under the Policy exceeds 25. Group Discount will not be reviewed during the currency of the Policy, even if the size of the group exceeds the next slab.

Number of Persons covered Applicable discount
Upto 25 persons No discount
Between 25 and 50 persons 5% on total premium
Between 51 and 100 persons 10% on total premium
Between 101 and 300 persons 15% on total premium
Between 301 and 400 persons 20% on total premium
Between 401 and 500 persons 25% on total premium
Over 500 persons To be decided by Corporate Office

On Duty Cover Discount:

We may provide a discount up to 25% on the basic premium when Janata Personal Accident cover is only for restricted hours of duty (and not for all 24 hours of day and night) for the Insured Persons in the Policy. The restricted cover is intended only for employers who wish to cover their employees for accidents during and in the course of employment.

Off Duty Cover Discount:

We may provide a discount up to 50% on the basic premium when Janata Personal Accident cover is required only for restricted hours, when the Insured Person is not at work and/ or not on official duty.

7. 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.

8. Geographical Scope:

The geographical scope of this Policy will be worldwide unless otherwise stated in the Policy schedule; however the claims shall be settled in India in Indian rupees. The provisions of this Policy shall be governed by the laws of India for the time being in force. The parties hereto unconditionally submit to the jurisdiction of the courts in India.

9. Sum Insured Enhancement:

Sum Insured can be enhanced only upon renewal, subject to Our underwriter’s approval.

10. 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.

11. Three Months 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:

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 DevelopmentAuthority. 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.

12. Nomination

The Policy has provision of nomination, In absence of Your declaring Nomination at the time of Proposal, then all benefits accrued under the Policy if any, shall be given to Your legal heir/ dependants.

13. Substitute Product

In case We may decide to withdraw this product under which this Policy is issued to You or where the children have attended maximum eligibility age under the Policy, if covered, We shall provide You with an option to buy a similar substitute Accident insurance Policy from Us.

14. Free Look-up period

1.The Policy shall have a free look period. The free look period shall be applicable at the inception of the Policy and:

i.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.If You have not made any claim during the Free Look period, You shall be entitled to

i.A refund of the premium paid less any expenses incurred by Us on Your medical examination and the stamp duty charges or;

ii.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;

iii.Where only a part of the risk has commenced, such proportionate risk premium commensurate with the risk covered during such period

15. Renewal

i.This Policy shall ordinarily be renewable for lifetime except on grounds of fraud, moral hazard or misrepresentation or non-cooperation by You

ii.The 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.

iii.No loading on premium shall be applied on Your individual claims experience basis but the group as a whole

The premium for renewals shall be subject to discount when group Policy issued witnesses favourable claims ratio as under:

Incurred Claim Ratio under the Group Policy Discount Percentage (%)
Up to 20 % 25
21 % - 35 % 15
36 % - 50 % 10
51 % - 60 % 5

The premium for renewals shall be subject to loading when group Policy issued witnesses adverse claims ratio as under:

Incurred Claim Ratio under the Group Policystrong> Discount Percentage (%)
Between 80 % and 100 % 25
Between 101 % and 125 % 55
Between 126 % and 150 % 90
Between 151 % and 175 % 120
Between 176 % and 200 % 150
Over 200 % Cover to be reviewed

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.

Please note We shall issue Policy only after getting Your consent

iv.The premium of the Policy may be revised subject to approval from Insurance Regulatory Development Authority

16. Adjustment of Premium (applicable to policies issued on unnamed employees basis)

The premium payable hereon has been determined by reference to Your estimate of the number of persons and their category as stated in the Schedule. It is hereby agreed that during the Policy Period You shall maintain a proper and contemporaneous record of the actual number of persons within such category, which record shall be available for inspection by Us at any reasonable time.

Within one month from the expiry of this Policy, You shall provide Us with a written record of the actual number of persons within such category during the Policy Period and any information or supporting documentation in respect thereof at Our request. If the actual number of persons within such category ascertained after the expiry of this Policy shall differ from Your original estimate thereof, then:

if the actual number of persons within such category exceeds the estimate of the same, You shall pay Us any additional premium that We may determine by reference to the differential, or

if the actual number of persons within such category is less than the estimate of the same, We will reimburse You by reference to the differential but subject to minimum retention of premium of 50%

17. Compensation

In case of claim by Death or Permanent Total Disablement compensation will be made only after deleting by an endorsement the name of the deceased/injured person in respect of whom such sums shall become payable.

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 1-800-1024030 or 1- 800–2004030

Landline Numbers

(022)-27639800 or (022)-41582900 or (022)-41582999 or (022)-39133700 (Local Charges Apply)

E-mail Address

contactus@universalsompo.com.

Fax Numbers

(022) 41582929 or (022) 41582939

Note:Please include Your Policy number for any communication with us.

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.

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 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 or on chargeable numbers at (022)-39635200.

You can also visit Our Company website and click under links Grievance Notification

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 : HTTPS://www.gbic.co.in/ombudsman.html

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
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
RH 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

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

Universal Sompo's Group Personal Accident Policy offers protection against the consequences of unforeseeable accidents to you and your employees/members. The Policy can also be extended to cover the dependent children/parents of your employees.

The Policy provides for defined benefits based on the nature of injury sustained, in the accident during the Policy Period by the insured person.

The Policy provides for three different options as under:

  • Basic Cover - covers against Death only
  • Wider Cover - covers against Death, Permanent Total Disablement Permanent Partial Disablement
  • Comprehensive Cover - covers against Death, Permanent Total Disablement Permanent Partial Disablement Temporary Total Disablement

NB: Comprehensive cover is not available to dependent family members

The compensation benefits will depend upon the nature of injury and the Capital Sum Insured under the Policy. For accidents resulting in Death or Permanent Total disablement, we will provide compensation equivalent to the full Capital Sum Insured. For Permanent Partial Disablement the compensation will depend on the nature of injury and corresponding percentage of Capital Sum Insured as detailed in the 'table class="content-table" of Benefit' under the Policy document or as per the medical advices of our appointed Medical Practioner. In respect of Temporary Total Disablement, we will provide compensation at 1% of Capital Sum Insured or Rs 5000/- whichever is less per week for a maximum period of 104 weeks.

In addition to the Compensation benefit stated above, we also undertake to provide compensation in respect of the fullowing:Optional Extension available under the PolicyThe Policy can be extended to cover the fullowing by payment of additional Premium ( applicable to Employees/Members only) Medical Expenses Extension: Covers the medical expenses reasonably and necessarily incurred by you towards medical expenses as a result of an accident resulting in the bodily injury , death or disablement. The compensation under this extension is restricted to 40% of Personal Accident Claim or actual medical expenses whichever is less. Hospital Confinement Allowance: Daily allowance of Rs 500/- per day to a maximum of 30 days if you or any of the insured person (s) is hospitalised as a result of an accident resulting in the bodily injury, death or disablement.Exclusions

Transportation Cost for carriage of dead body to Home including funeral charges. 1% of Capital Sum Insured or 2,500/- (Two thousand five hundred) whichever is lower.
Cost of Clothing damaged in the Accident as described above and liability for disablement is admitted by Us. Actual expenses subject to maximum of Rs 1000/
Ambulance charges for transportation of Insured person to Hospital fullowing Accident Actual expenses subject to maximum of Rs 1000/
Education Fund In the event of death, permanent total disablement i.e. 1 2 of table class="content-table" of Benefit of Insured Person, We will approve compensation towards Education Fund up to 2 dependent children. -5% (Five percent) of C.S.I Subject to a maximum of Rs. 15000/- in all
Loss of Employment In the event of accident leading to loss of employment as a consequence of Permanent Total Disability as per the table class="content-table" of benefits. 2% of CSI subject to a maximum of Rs 25000/-

The Policy can be extended to cover the following by payment of additional Premium ( applicable to Employees/Members only)

Medical Expenses Extension: Covers the medical expenses reasonably and necessarily incurred by you towards medical expenses as a result of an accident resulting in the bodily injury , death or disablement. The compensation under this extension is restricted to 40% of Personal Accident Claim or actual medical expenses whichever is less.

Hospital Confinement Allowance: Daily allowance of Rs 500/- per day to a maximum of 30 days if you or any of the insured person (s) is hospitalised as a result of an accident resulting in the bodily injury, death or disablement.

  • Self-injury, suicide, venereal disease or insanity
  • Influence of intoxicating liquor or drugs
  • Death due to pregnancy or childbirth
  • Breach of law with criminal intent
  • War and nuclear group of perils
  • Loss whilst on duty with armed forces
  • Injury/death while participation in adventurous sports

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

Aapat Suraksha Bima Policy provides cover on lump sum basis to support the insured and/or the nominee against a sudden and unexpected expenditure (other than the medical treatment expenses) on diagnosis of the fullowing major diseases like:

  • Paralytic Stoke
  • Cancer
  • Renal Failure
  • Coronary Artery Disease
  • Major Organ Transplant

The Policy shall also provide protection to the family against the unfortunate accidental death and/or permanent total disablement of the insured.

Aapat Suraksha Bima undertakes to pay a lump sum amount as selected by the proposer at inception on happening of an eventuality mentioned in the Policy. The Policy pays one time payment equal to the sum insured on conclusive diagnosis of existence of any of the five critical illnesses ,or occurrence of accidental death and/or permanent total disablement resulting from an accident.

The Policy provides for three different options as under:

  • Paralytic Stroke
  • Cancer
  • Renal Failure
  • Coronary Artery Disease
  • Major Organ Transplant

The nominee gets a one time payment equal to Capital Sum Insured if the insured dies in an accident.

The insured is entitled to receive the percentage of the capital sum insured as per the table of benefit if he suffers a permanent and total loss of limbs , sight in an accident.

  • Any illness diagnosed within first 90 days of the Policy taken for the first time
  • Any pre existing illness
  • Any accident resulting from intentional self injury, suicide or whilst the insured is under the influence of intoxication
  • The insured dies or suffers from permanent disablement whilst taking part in an adventure sports as a professional or whilst travelling in an aircraft in any capacity other than as a fare paying passenger in a scheduled flight
  • Death within 30 days fullowing the diagnosis of the Critical Illness

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

Universal Sompos Loan Secure Insurance Policy is a unique Policy that helps you transfer the burden of your loan in the event of an unforeseen contingency. This Policy is specially designed for customers of banks and financial Institutions. This Insurance Policy serves as safety net so that you and your near and dear ones are not worried about repayment of your loan in the event of your unfortunate diagnose of listed Major Medical Illnesses or undergoing of Surgical Procedures or witness Accidental Death, or Permanent Total Disablement on account of Accident resulting in inability to remain gainfully employed. This Policy also provides for Loss of Job and Cover of Dwelling and Content against Fire and Allied Perils.

The Policy can be taken by an individual for covering himself / herself and his/ her family i.e. spouse, dependent children up to 25 years of age and dependent parents.

  • Entry age for you (the proposer) is 18 years and you can opt for this policy up to the age of 70years.
  • Policy renewals will be for your lifetime.
  • Entry age for dependent children is 6 months.
  • No pre-acceptance medical tests up to 55 years of age, however, if you are above 55 years, then, you may require undergoing medical tests at our listed diagnostic centers, 50% cost of which will be borne by us in case of accepted proposals.

Pre -Medical Tests:Fasting Sugar Blood, BP report and ECG may be required to be submitted to us on request. Validity period of theses test 15 days or less immediately prior to the acceptance your health proposal under this policy. Any tests carried out older than 15 days prior to acceptance of this proposal would not be considered for acceptance and fresh test of the current date i.e. the date of proposal would be taken into consideration.

After the medical examination, the coverage under the product would not be refused/ declined but would be amended to exclude the coverage permanently for the ailments/ diseases & its related complications substantiated in pre-policy medical examination. These facts would be disclosed to the customers clearly and the acceptance in writing from the insured would be sought before issuing the policy and in case customer does not accept the condition for permanently excluding the coverage for the related disease, then the company would have an option for denying the coverage. USGI also confirm that no loading and discount in the premium would be extended for these cases falling in the above category.

Sum Insured Options:You have the option of choosing Sum Insured on either of the basis as mentioned below (applicable to Section I and II only).

The Policy comprises of three sections

Section 1: Hospital Confinement BenefitA Daily Allowance as under would be payable upon normal hospitalization other than an admission in ICU for a maximum number of days as opted by you when you opt for coverage under this Section. The choice would be given to you to opt for any of the following options and remittance of premium accordingly

Benefit Options
Options Option I Option II Option III Option IV Option V Option VI
Amount per day Rs 500/ - per day Rs 1000/ - per day Rs 1500/- per day Rs 2000 per day Rs 2500 per day Rs 3000 per day
Maximum Amount per Policy Period Rs 90,000 Rs 1,80,000 Rs 2,70,000 Rs 3,60,000 Rs 4,50,000 Rs 5,40,000

Section 2: Intensive Care Benefit:The amount as chosen by you from the above options shall be doubled when you/ your family member during the course of their treatment is admitted in an ICU other than normal hospitalization. Further during the course of treatment, if the hospitalization is for ICU and then shifting to the normal ward then confining therein , then ICU period of stay and normal Hospital Confinement period stay will be counted separately and Benefit will be paid separately as per the eligible amount for these this according to the no of days stayed separately.

Section 3: Convalescence Benefit:A convalescence benefit of Rs 10,000 shall become payable under the policy if your or your covered family member’s hospitalization exceeds 21 days and this benefit would not become payable if the Hospital Cash Period is opted for 30 days or more maximum upto 180 days

You can choose to cover Hospital Cash for a fixed no of 15, 30, 45, 60, 90 or 180 days as per your requirement. Other than the above mentioned prescribed no of days, the other combination of days cannot be chosen

1. Long Term Policy Discount:The Policy can be taken for a period of one, two or three years and discount as under would be provided when the policy is bought from us for longer terms by paying premium in a single installment

Duration of policy Premium to be charged
2 years 2 year premium (Double of the Annual Premium as mentioned below in the Table ) paid in advance less 10% discount
3 years 3 year premium in (Three Times of Annual Premium as mentioned below in the Table ) paid in advance less 15% discount

Even If the policy is purchased for 2years/3 years at once by paying the premium in one instalment, the Benefits will be applicable only on annual basis of the policy.

2. Family discount:Get Family discount of 5% towards total the total premium of the policy

3. Group Discount: The purpose of including group in the filed product is to the extent of issuing policy document as group in view of our Bancassurance Business Model where the premium is being collected by our Corporate Agent (Bank Partner and its associates) from their customers and remitted to USGI as a one signal amount. In the captioned cases, the policy is issued master policy as Bank Partner Name A/C Various Customer Name, but each Individual & its family member’s insured therein is treated as Individual in nature for which the product is filed and individual policy certificate is issued to each customer, hence, we have not made the provision of any Group Discount in the product filed. We further confirm that on individual basis if the family members are covered, we have extended the family member discount and the same would follow if the policy is issued as Group to Bank Partner and its associates

4. Portability If You were insured continuously and without a break under another 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.

5. Free Look-up period The Policy shall have a free look period. The free look period shall be applicable at the inception of the policy and:

  • 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. 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.

6. Conditions under the Policy

1. Premium The premium under the Policy shall be as under – Annual Policy for One Year

Hospital Cash - Premium Chart- Annual Premium
Coverage Per Day Proposer Age 15 Days 30 Days 45 Days 60 Days 90 Days 180 Days
Rs. 500/- 0.6 - 25 Years 188 375 563 750 1125 2250
26 - 40 Years 263 525 788 1050 1575 3150
41 - 50 Years 375 750 1125 1500 2250 4500
51 - 60 Years 413 825 1238 1650 2475 4950
61- 70 Years 450 900 1350 1800 2700 5400
71-80* Years 750 1500 2250 3000 4500 9000
> 80* Years 900 1800 2700 3600 5400 10800
Rs. 1000/- 0.6 - 25 Years 390 762 1134 1500 2250 4500
26 - 40 Years 540 1062 1598 2100 3150 6300
41 - 50 Years 765 1530 2264 3000 4500 9000
51 - 60 Years 833 1665 2489 3300 4950 9900
61- 70 Years 915 1809 2790 3600 5400 10800
71-80* Years 1545 3015 4658 6000 9000 18000
> 80* Years 1875 3660 5513 7200 10800 21600
Rs. 1500/- 0.6 - 25 Years 567 1140 1688 2300 3375 6750
26 - 40 Years 794 1605 2363 3240 4725 9450
41 - 50 Years 1136 2280 3375 4635 6750 13500
51 - 60 Years 1245 2505 3713 5040 7425 14850
61- 70 Years 1359 2835 4050 5511 8100 16200
71-80* Years 2310 4770 6750 9201 13500 27000
> 80* Years 2727 5517 8100 11012 16200 32400
Rs. 2000/- 0.6 - 25 Years 750 1500 2340 3000 4464 9000
26 - 40 Years 1050 2100 3321 4200 6298 12600
41- 50 Years 1500 3000 4662 6000 8998 18000
51-60* Years 1650 3300 4968 6600 10098 19800
61-70 Years 1800 3600 5480 7200 10822 21600
71 - 80 Years 3000 6000 9080 12000 18048 36000
> 80* Years 3600 7200 10879 14400 21956 43200
Rs. 2500/- 0.6 - 25 Years 938 1875 2813 3750 5625 11250
26 - 40 Years 1313 2625 3938 5250 7875 15750
41 - 50 Years 1875 3750 5625 7500 11250 22500
51 - 60 Years 2063 4125 6188 8250 12375 24750
61 - 70 Years 2250 4500 6750 9000 13500 27000
71 - 80* Years 3750 7500 11250 15000 22500 45000
> 80* Years 4500 9000 13500 18000 27000 54000
Rs. 3000/- 0.6 - 25 Years 1110 2295 3375 4500 6885 13500
26 - 40 Years 1605 3195 4725 6300 9585 18900
41 - 50 Years 2266 4545 6750 9000 13635 27000
51 - 60 Years 2510 4995 7425 9900 14985 29700
61 - 70 Years 2731 5445 8100 10800 16335 32400
71 - 80* Years 4541 9045 13500 18000 27135 54000
> 80* Years 5515 10845 16200 21600 32535 64800

Note

  • Premium Amount (in INR) excluding Service Tax and Cess Attribute at 14%
  • Premium of the Policy may be revised subject to approval from IRDA.
  • Tax Benefit :Avail of tax benefit under section 80D of Income Tax Act on the applicable premium (Tax Benefit are subject to change as per change in Tax Laws)
  • * premium for renewals only.

2. Cancellation Terms

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% 12% 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 with 30 days notice by sending an endorsement to Your address shown in the Schedule without refund of premium.

3. Claims in Two Policy Period:If the claim event falls within two policy periods, the claims shall be paid taking into consideration the available sum insured in the two policy periods, including the deductibles for each policy period. Such eligible claim amount to be payable to the insured shall be reduced to the extent of premium to be received for the renewal/due date of premium of health insurance policy, if not received earlier.

4. Contribution:The conditions of contribution shall not apply to this policy

5. 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

6. 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 subject to approval from IRDA.
  • We also agree that no loading on premium shall be applicable on your individual claims experience basis.

7. Sum Insured EnhancementSum Insured can be enhanced only upon renewal, subject to no claims under the Policy and underwriters’ approval.

8. Inclusion / Exclusion of Insured –dThis policy allows to include or exclude a member only at the time of renewal.

9. 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

10. 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.

11. What is not covered under the Policy?

We shall not be liable to make any payment for any claim directly or indirectly caused by, based on, arising out of or howsoever attributable to any of the following:

1. 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:

  • 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.

2. Treatment of following diseases within the first one year from the commencement of the Policy, will not be payable:

  • Cataract
  • Benign Prostatic Hypertrophy
  • Myomectomy, Hysterectomy unless because of malignancy
  • Hernia, Hydrocele
  • Fistula in anus, Piles
  • Arthritis, gout, rheumatism
  • Joint replacements unless due to accident
  • Sinusitis and related disorders
  • Stones 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 chronic renal failure
  • Surgery on tonsils and sinuses
  • Gastric and Duodenal ulcers

However, the waiting period of 1 year will not apply if You were insured continuously and without interruption for at least 1 year under any other Indian insurer’s similar health insurance policy from us or any of the Indian insurers.

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

3. Any Sickness that has been classified as an Epidemic by the Central or State Government.

4. General debility, nervous or other breakdown, rest cure, congenital diseases or defect or anomaly, sterility, sterilisation or infertility (diagnosis and treatment), any sanatoriums, spa or rest cures or long term care or hospitalisation undertaken as a preventive or recuperative measure

5. Sickness requiring Hospitalisation within the first 30 days from the commencement date of the Policy Period unless the Policy is renewed without interruption with the Company or the policy is a renewal of similar health insurance policy from any of the other Indian insurers and We have accepted your proposal with portability.

6. 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.

7. Payment of compensation in respect of injury, hospitalisation resulting -

  • From intentional self-injury, suicide or attempted suicide.
  • Self-exposure to needless perils except in an attempt to save human life.
  • 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, misdemeanor or civil commotion.
  • Whilst engaging in racing, hunting, mountaineering, ice hockey, winter sports and the like.
  • Due to war or ionizing 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

8. Any loss resulting directly or indirectly, contributed or aggravated or prolonged by childbirth or from pregnancy ( except Ectopic Pregnancy)

9. Any treatment not performed by a Physician or any treatment of a purely experimental nature.

10. 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).

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

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

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

14. All kind of Alternate Treatment

Senior Citizen Grievance

USGI has established a dedicated team of personnel to address the health insurance related claims and grievances of senior citizens. Direct Nos. 022-39171324, 022-39171375, 022-39171281.

Claim Intimation

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: 1800-200-5142, Chargeable Numbers. - 022–39635200,Fax Toll Free Numbers: 1800-200-9134.

Please note that no delay should be allowed to occur in notifying a claim on the policy as the same may prejudice liability.

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 Hospitalisation

In the event that a claim becomes payable under the terms of the Policy, We shall payment 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 contengency 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

Claim Documents

  • Photo copy of bills, receipt and discharge certificate/card from the Hospital.
  • Photocopy of F.I.R. copy in case of an accident.
  • Complete set of Hospital/medical records

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

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

We shall have no liability under this Policy, once the Maximum Limit of Liability (Sum Insured) as stated in the Policy Schedule with respect to any of the Sections, is exhausted by You or Your Insured Family Member.

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.

For all your service requests e-mail us at contactus@universalsompo.com

Statutory Warning:No person shall allow or offer to allow, either directly or indirectly, as an inducement to any person to take out or renew or continue an insurance in respect of any kind of risk relating to lives or property in India, any rebate of the whole part of the commission payable or any rebate of the premium shown on the policy nor shall any person taking out or renewing or continuing a policy accept any rebate, except such rebates as may be allowed in accordance with the published prospectuses or tables of the Insurer. Any person making default in complying with the provisions of this section shall be punishable with fine which may extend to Ten Lakh Rupees

Please note:The prospectus contains only an indication of cover offered, for complete details on terms, conditions, coverages and exclusions please get in touch with us or our agent and read policy wordings carefully before concluding a sale. Insurance is a subject matter of solicitation

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: 1800-200-5142, Chargeable Numbers. - 022–39635200, Fax Toll Free Numbers: 1800-200-9134.

Day Care Annexure List of expenses excluded

1. Claim Intimation

In the unfortunate event of any medical contingency 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 (other users) or on chargeable numbers at +91-22-26748600/ +91-22-41582900/ +91-22-41582999 or email at contactus@universalsompo.com Please note that no delay should be allowed to occur in notifying a claim on the policy as the same may prejudice liability.

2. Submission of documents

Insured must submit any or all of the below mentioned document(s) as requested by us for settlingInsured‟s claim within 30 days from date of intimating the claim.

Claim Documents for Section I a.Certificate from the attending Medical Practitioner of the Insured Person confirming, inter alia,

  • Name of the Insured person;
  • Name, date of occurrence and medical details of the Insured Event
  • Confirmation that the Insured Event does not relate to any Pre-Existing Illness or any Illness or Injury which existed within the first 90 days of commencement of Period of Insurance.

b.Certificate, if applicable, from the Bank/Financial Institution stating the amortization schedule, the EMI Amounts, Principal Outstanding, etc.

c.Duly completed claim forms;

d.Original Discharge Certificate/ Card from the hospital/ Medical Practitioner;

e.Original investigation test reports, indoor case papers;

f.Any other documents as may be required by the Company.

If required, You, the Insured, must agree to be examined by a Medical Practitioner of Our choice at Our expense.

Claims documents for Section II

1.Duly completed claim form;

2.Medical Practitioner‟s Report;

3.First Information Report and Final Police report, wherever necessary;

4.Death certificate/ Post Mortem Report, wherever applicable;

5.Investigation Reports like Laboratory test, X-rays and reports essential of confirmation of the Injury etc.;

6.Disability certificate from a Medical Practitioner or hospital confirming the extent and nature of disability;

7.Post mortem report, if the same was conducted;

8.Certificate, from the Insured stating the amortization schedule, the EMI Amount, Principal Outstanding, etc. ;

9.Any other supporting documents as may be required by the Company.

Claim Documents for Section III

1.Duly completed claim form;

2.Certificate if applicable from the Bank stating the amortization schedule, the EMI Amounts, Principal Outstanding, etc.

3.Certificate from the employer of the Insured person confirming the termination, dismissal, temporary suspension or retrenchment from employment of the Insured person furnishing the date of termination, dismissal, temporary suspension or retrenchment from employment of the Insured person with the reasons for the same. In case of temporary suspension the period of suspension should also be mentioned in such certificate.

4.Any other document as may be required by the Company.

Claim Documents for Section IV

1.Duly completed Claim form;

2.Copy of FIR

3.Estimate of loss / repairs

4.Invoice/ Bills/Receipts

5.FR

6.Any other details/documents called for a specific loss

The Company shall have no liability under this Policy, once the Maximum Limit of Liability (Sum Insured) with respect to any of the Sections, is exhausted by the Insured. The Company shall be relieved of its liability under the Policy once a claim has been paid under Section I and Section II of the Policy (except for Section IV)

For all your service requests e-mail us at contactus@universalsompo.com

*Cover available for Salaried Employees only

**Long Term Discount not applicable on Terrorism Risk Premium

Statutory Warning: No person shall allow or offer to allow, either directly or indirectly, as an inducement to any person to take out or renew or continue an insurance in respect of any kind of risk relating to lives or property in India, any rebate of the whole part of the commission payable or any rebate of the premium shown on the policy nor shall any person taking out or renewing or continuing a policy accept any rebate, except such rebates as may be allowed in accordance with the published prospectuses or tables of the Insurer. Any person making default in complying with the provisions of this section shall be punishable with fine which may extend to Ten Lakh Rupees

Please note: The prospectus contains only an indication of cover offered, for complete details on terms, conditions, coverages and exclusions please get in touch with us or our agent and read policy wordings carefully before concluding a sale. Insurance is a subject matter of solicitation. 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.

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.

  1. 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.
  2. 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:

  1. continues for a period of twelve (12) consecutive months, and
  2. is confirmed as total, continuous and permanent by a Medical Practitioner after the twelve (12) consecutive months, and
  3. 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.

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.

Additional benefits

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.

NB:

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.

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

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,

OR

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;

AND

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 :

  • Cataract
  • 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

Claim Processing

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.

1. Arbitration

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

2. Co-pay

A Co-pay of 20% on each and every claim shall be applicable if You are above 55 years of age under the policy

3. 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.

8. Fraud

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.

10. Mis-description

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.

12. Nominee

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.

13. Notice

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.

15. Portability

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.

16. Renewal

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

Please note:

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.

17. 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.

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

Landline Numbers

(022)-27639800 or (022)-41582900 or (022)-41582999 or (022)-39133700 (Local Charges Apply)

E-mail Address

contactus@universalsompo.com.

Fax Numbers

(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 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: 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

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
AC1: 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

Loan Period 2 3 4 5 6 7 8 9 10 11 12 14 15
Year 1 25% 45% 50% 51% 51% 51% 51% 51% 52% 52% 52% 52% 52%
Year 2 . 11% 13% 14% 14% 14% 14% 14% 15% 15% 15% 15% 15%
Policy Period 3 3 3 3 3 3 3 3 3 3 3 3 3
Loan Period 16 17 18 19 20 21 22 23 24 25 26 27 28
Year 1s 53% 53% 53% 53% 53% 53% 53% 53% 53% 53% 54% 54% 54%
Year 2 16% 16% 16% 16% 16% 16% 16% 16% 16% 16% 17% 17% 17%
Policy Period 3 3 - - - - - - - - - - -
Loan Period 29 30 - - - - - - - - - - -
Year 1 54% 54% - - - - - - - - - - -
Year 2 17% 17% - - - - - - - - - - -

b) For Fixed Sum Insured basis

% Refund Premium
. Policy Period (Years)
Year Of Cancellation 2 3
Year 1 25% 45%
Year 2 . 11%

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.”

Special conditions:

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.

PROSPECTUS

The Policy can be taken by an individual for covering himself / herself and his/ her family i.e. spouse, dependent children up to 25 years of age and dependent parents.

  • Entry age for you (the proposer) is 18 years and you can opt for this policy up to the age of 70years.
  • Policy renewals will be for your lifetime.
  • Entry age for dependent children is 6 months.
  • No pre-acceptance medical tests up to 55 years of age, however, if you are above 55 years, then, you may require undergoing medical tests at our listed diagnostic centers, 50% cost of which will be borne by us in case of accepted proposals.

Pre -Medical Tests:Fasting Sugar Blood, BP report and ECG may be required to be submitted to us on request. Validity period of theses test 15 days or less immediately prior to the acceptance your health proposal under this policy. Any tests carried out older than 15 days prior to acceptance of this proposal would not be considered for acceptance and fresh test of the current date i.e. the date of proposal would be taken into consideration.

After the medical examination, the coverage under the product would not be refused/ declined but would be amended to exclude the coverage permanently for the ailments/ diseases & its related complications substantiated in pre-policy medical examination. These facts would be disclosed to the customers clearly and the acceptance in writing from the insured would be sought before issuing the policy and in case customer does not accept the condition for permanently excluding the coverage for the related disease, then the company would have an option for denying the coverage. USGI also confirm that no loading and discount in the premium would be extended for these cases falling in the above category.

The Policy comprises of three sections

Section 1: Hospital Confinement BenefitA Daily Allowance as under would be payable upon normal hospitalization other than an admission in ICU for a maximum number of days as opted by you when you opt for coverage under this Section. The choice would be given to you to opt for any of the following options and remittance of premium accordingly

Benefit Options
Options Option I Option II Option III Option IV Option V Option VI
Amount per day Rs 500/ - per day Rs 1000/ - per day Rs 1500/- per day Rs 2000 per day Rs 2500 per day Rs 3000 per day
Maximum Amount per Policy Period Rs 90,000 Rs 1,80,000 Rs 2,70,000 Rs 3,60,000 Rs 4,50,000 Rs 5,40,000

Section 2: Intensive Care Benefit:The amount as chosen by you from the above options shall be doubled when you/ your family member during the course of their treatment is admitted in an ICU other than normal hospitalization. Further during the course of treatment, if the hospitalization is for ICU and then shifting to the normal ward then confining therein , then ICU period of stay and normal Hospital Confinement period stay will be counted separately and Benefit will be paid separately as per the eligible amount for these this according to the no of days stayed separately.

Section 3: Convalescence Benefit:A convalescence benefit of Rs 10,000 shall become payable under the policy if your or your covered family member’s hospitalization exceeds 21 days and this benefit would not become payable if the Hospital Cash Period is opted for 30 days or more maximum upto 180 days

You can choose to cover Hospital Cash for a fixed no of 15, 30, 45, 60, 90 or 180 days as per your requirement. Other than the above mentioned prescribed no of days, the other combination of days cannot be chosen

1. Long Term Policy Discount:The Policy can be taken for a period of one, two or three years and discount as under would be provided when the policy is bought from us for longer terms by paying premium in a single installment

Duration of policy Premium to be charged
2 years 2 year premium (Double of the Annual Premium as mentioned below in the Table ) paid in advance less 10% discount
3 years 3 year premium in (Three Times of Annual Premium as mentioned below in the Table ) paid in advance less 15% discount

Even If the policy is purchased for 2years/3 years at once by paying the premium in one instalment, the Benefits will be applicable only on annual basis of the policy.

2. Family discount:Get Family discount of 5% towards total the total premium of the policy

3. Group Discount: The purpose of including group in the filed product is to the extent of issuing policy document as group in view of our Bancassurance Business Model where the premium is being collected by our Corporate Agent (Bank Partner and its associates) from their customers and remitted to USGI as a one signal amount. In the captioned cases, the policy is issued master policy as Bank Partner Name A/C Various Customer Name, but each Individual & its family member’s insured therein is treated as Individual in nature for which the product is filed and individual policy certificate is issued to each customer, hence, we have not made the provision of any Group Discount in the product filed. We further confirm that on individual basis if the family members are covered, we have extended the family member discount and the same would follow if the policy is issued as Group to Bank Partner and its associates

4. Portability If You were insured continuously and without a break under another 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.

5. Free Look-up period The Policy shall have a free look period. The free look period shall be applicable at the inception of the policy and:

  • 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. 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.

6. Conditions under the Policy

1. Premium The premium under the Policy shall be as under – Annual Policy for One Year

Hospital Cash - Premium Chart- Annual Premium
Coverage Per Day Proposer Age 15 Days 30 Days 45 Days 60 Days 90 Days 180 Days
Rs. 500/- 0.6 - 25 Years 188 375 563 750 1125 2250
26 - 40 Years 263 525 788 1050 1575 3150
41 - 50 Years 375 750 1125 1500 2250 4500
51 - 60 Years 413 825 1238 1650 2475 4950
61- 70 Years 450 900 1350 1800 2700 5400
71-80* Years 750 1500 2250 3000 4500 9000
> 80* Years 900 1800 2700 3600 5400 10800
Rs. 1000/- 0.6 - 25 Years 390 762 1134 1500 2250 4500
26 - 40 Years 540 1062 1598 2100 3150 6300
41 - 50 Years 765 1530 2264 3000 4500 9000
51 - 60 Years 833 1665 2489 3300 4950 9900
61- 70 Years 915 1809 2790 3600 5400 10800
71-80* Years 1545 3015 4658 6000 9000 18000
> 80* Years 1875 3660 5513 7200 10800 21600
Rs. 1500/- 0.6 - 25 Years 567 1140 1688 2300 3375 6750
26 - 40 Years 794 1605 2363 3240 4725 9450
41 - 50 Years 1136 2280 3375 4635 6750 13500
51 - 60 Years 1245 2505 3713 5040 7425 14850
61- 70 Years 1359 2835 4050 5511 8100 16200
71-80* Years 2310 4770 6750 9201 13500 27000
> 80* Years 2727 5517 8100 11012 16200 32400
Rs. 2000/- 0.6 - 25 Years 750 1500 2340 3000 4464 9000
26 - 40 Years 1050 2100 3321 4200 6298 12600
41- 50 Years 1500 3000 4662 6000 8998 18000
51-60* Years 1650 3300 4968 6600 10098 19800
61-70 Years 1800 3600 5480 7200 10822 21600
71 - 80 Years 3000 6000 9080 12000 18048 36000
> 80* Years 3600 7200 10879 14400 21956 43200
Rs. 2500/- 0.6 - 25 Years 938 1875 2813 3750 5625 11250
26 - 40 Years 1313 2625 3938 5250 7875 15750
41 - 50 Years 1875 3750 5625 7500 11250 22500
51 - 60 Years 2063 4125 6188 8250 12375 24750
61 - 70 Years 2250 4500 6750 9000 13500 27000
71 - 80* Years 3750 7500 11250 15000 22500 45000
> 80* Years 4500 9000 13500 18000 27000 54000
Rs. 3000/- 0.6 - 25 Years 1110 2295 3375 4500 6885 13500
26 - 40 Years 1605 3195 4725 6300 9585 18900
41 - 50 Years 2266 4545 6750 9000 13635 27000
51 - 60 Years 2510 4995 7425 9900 14985 29700
61 - 70 Years 2731 5445 8100 10800 16335 32400
71 - 80* Years 4541 9045 13500 18000 27135 54000
> 80* Years 5515 10845 16200 21600 32535 64800

Note

  • Premium Amount (in INR) excluding Service Tax and Cess Attribute 14%
  • Premium of the Policy may be revised subject to approval from IRDA.
  • Tax Benefit :Avail of tax benefit under section 80D of Income Tax Act on the applicable premium (Tax Benefit are subject to change as per change in Tax Laws)
  • * premium for renewals only.

2. Cancellation Terms

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% 12% 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 with 30 days notice by sending an endorsement to Your address shown in the Schedule without refund of premium.

3. Claims in Two Policy Period:If the claim event falls within two policy periods, the claims shall be paid taking into consideration the available sum insured in the two policy periods, including the deductibles for each policy period. Such eligible claim amount to be payable to the insured shall be reduced to the extent of premium to be received for the renewal/due date of premium of health insurance policy, if not received earlier.

4. Contribution:The conditions of contribution shall not apply to this policy

5. 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

6. 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 subject to approval from IRDA.
  • We also agree that no loading on premium shall be applicable on your individual claims experience basis.

7. Sum Insured EnhancementSum Insured can be enhanced only upon renewal, subject to no claims under the Policy and underwriters’ approval.

8. Inclusion / Exclusion of Insured –dThis policy allows to include or exclude a member only at the time of renewal.

9. 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

10. 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.

11. What is not covered under the Policy?

We shall not be liable to make any payment for any claim directly or indirectly caused by, based on, arising out of or howsoever attributable to any of the following:

1. 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:

  • 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.

2. Treatment of following diseases within the first one year from the commencement of the Policy, will not be payable:

  • Cataract
  • Benign Prostatic Hypertrophy
  • Myomectomy, Hysterectomy unless because of malignancy
  • Hernia, Hydrocele
  • Fistula in anus, Piles
  • Arthritis, gout, rheumatism
  • Joint replacements unless due to accident
  • Sinusitis and related disorders
  • Stones 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 chronic renal failure
  • Surgery on tonsils and sinuses
  • Gastric and Duodenal ulcers

However, the waiting period of 1 year will not apply if You were insured continuously and without interruption for at least 1 year under any other Indian insurer’s similar health insurance policy from us or any of the Indian insurers.

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

3. Any Sickness that has been classified as an Epidemic by the Central or State Government.

4. General debility, nervous or other breakdown, rest cure, congenital diseases or defect or anomaly, sterility, sterilisation or infertility (diagnosis and treatment), any sanatoriums, spa or rest cures or long term care or hospitalisation undertaken as a preventive or recuperative measure

5. Sickness requiring Hospitalisation within the first 30 days from the commencement date of the Policy Period unless the Policy is renewed without interruption with the Company or the policy is a renewal of similar health insurance policy from any of the other Indian insurers and We have accepted your proposal with portability.

6. 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.

7. Payment of compensation in respect of injury, hospitalisation resulting -

  • From intentional self-injury, suicide or attempted suicide.
  • Self-exposure to needless perils except in an attempt to save human life.
  • 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, misdemeanor or civil commotion.
  • Whilst engaging in racing, hunting, mountaineering, ice hockey, winter sports and the like.
  • Due to war or ionizing 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

8. Any loss resulting directly or indirectly, contributed or aggravated or prolonged by childbirth or from pregnancy ( except Ectopic Pregnancy)

9. Any treatment not performed by a Physician or any treatment of a purely experimental nature.

10. 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).

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

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

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

14. All kind of Alternate Treatment

Senior Citizen Grievance

USGI has established a dedicated team of personnel to address the health insurance related claims and grievances of senior citizens. Direct Nos. 022-39171324, 022-39171375, 022-39171281.

Claim Intimation

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: 1800-200-5142, Chargeable Numbers. - 022–39635200,Fax Toll Free Numbers: 1800-200-9134.

Please note that no delay should be allowed to occur in notifying a claim on the policy as the same may prejudice liability.

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 Hospitalisation

In the event that a claim becomes payable under the terms of the Policy, We shall payment 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 contengency 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

Claim Documents

  • Photo copy of bills, receipt and discharge certificate/card from the Hospital.
  • Photocopy of F.I.R. copy in case of an accident.
  • Complete set of Hospital/medical records

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

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

We shall have no liability under this Policy, once the Maximum Limit of Liability (Sum Insured) as stated in the Policy Schedule with respect to any of the Sections, is exhausted by You or Your Insured Family Member.

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.

For all your service requests e-mail us at contactus@universalsompo.com

Statutory Warning:No person shall allow or offer to allow, either directly or indirectly, as an inducement to any person to take out or renew or continue an insurance in respect of any kind of risk relating to lives or property in India, any rebate of the whole part of the commission payable or any rebate of the premium shown on the policy nor shall any person taking out or renewing or continuing a policy accept any rebate, except such rebates as may be allowed in accordance with the published prospectuses or tables of the Insurer. Any person making default in complying with the provisions of this section shall be punishable with fine which may extend to Ten Lakh Rupees

Please note:The prospectus contains only an indication of cover offered, for complete details on terms, conditions, coverages and exclusions please get in touch with us or our agent and read policy wordings carefully before concluding a sale. Insurance is a subject matter of solicitation

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: 1800-200-5142, Chargeable Numbers. - 022–39635200, Fax Toll Free Numbers: 1800-200-9134.

Day Care Annexure List of expenses excluded

In-House Claim Management

Click to view In-House Claim Management Process

HOSPITAL CASH INSURANCE

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.

Alternative treatments:Means treatments other than treatment "Allopathy" or "modern medicine" and includes Ayurveda, Unani, Sidha and Homeopathy in the Indian context

Company:means “Universal Sompo General Insurance Company Limited.”

Condition PrecedentFamily means Your spouse and Your dependent children ordinarily residing with You.

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.

Day:means a period of 24 consecutive hours.

Daily Allowance:is the amount specified as such in the Schedule

Day care centre:A day care centre means any institution established for day care treatment of illness and/or injuries or a medical setup within a hospital and which has been registered with the local authorities, wherever applicable, and is under the supervision of a registered and qualified medical practitioner AND must comply with all minimum criteria as under

  • 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

Dental Treatment:Dental 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.

Dependent Children:Means a child (natural or legally adopted) up to 25 years of age, who is financially dependent on the primary Insured or proposer and does not have his/her independent sources of income.

Dependent Parents:Means a parent who is financially dependent on You and does not have his / her independent sources of income.

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

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.

Family Member:Means person(s) whose name are specifically appearing in the Schedule and are related to You as spouse and/or Dependent Children or Dependent Parents

Grace Period:Means the specified period of time immediately following the premium due date during which a payment can be made to renew or continue a policy in force without loss of continuity benefits such as waiting periods and coverage of Pre Existing Diseases Coverage is not available for the period for which no premium is received

Hospital:A 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.

Means 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.

Illness: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 -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 Family MembersMeans the individuals whose name is appearing in the Schedule and shall include Your Spouse, Dependent Children and Dependent Parents.

Intensive Care Unit:Means an identified section, ward or wing of a Hospital which is under the constant supervision of a dedicated Medical Practitioner 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.

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

Insured Event: Means any event specifically mentioned as covered under this Policy.

Insured Persons: Means person(s) whose name is/ are specifically appearing in the Schedule and are covered under the Policy.

Medical Advice : Means any consultation or advice from a Medical Practitioner including the issue of any prescription or repeat prescription.

Medical expenses: Means those expenses that You have 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 You had not been insured and no more than other hospitals or doctors in the same locality would have charged for the same medical treatment.

Medically Necessary: Means any treatment, tests, medication, or stay in Hospital or part o f a stay in Hospital which

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

Medical Practitioner:Means a person who holds a valid registration from the medical council of any state of India and is thereby entitled to practice medicine within its jurisdiction; and is acting within the scope and jurisdiction of his license and is not a member of your family.

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

Notification of Claim:Notification 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.

Policy:Means 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 Period:Means 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:Means a person who holds a valid registration from the Nursing Council of India or the Nursing Council of any state in India.

Reasonable 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

Inpatient Care:Inpatient care is the care of patients whose condition requires admission to a hospital. Progress in modern medicine and the advent of comprehensive out-patient clinics ensure that patients are only admitted to a hospital when they are extremely ill or are have severe physical trauma.

RenewalRenewal 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.

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.

Sum InsuredMeans 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.

The policy will cover all the benefits opted by the insured, preferred by the insured in one claim or in multiple claims during the policy period subject to the limit of maximum amount per policy period as per the option opted by the insured.

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.

We hereby agree, subject to the terms, exclusions and conditions herein contained or otherwise expressed hereon, to pay You

Section1: Hospital Confinement Benefit:A Daily Allowance, as mentioned in the Schedule, for each continuous and completed period of 24 hours of Hospitalisation for a maximum number of X days as mentioned in the Schedule.

Section 2: Intensive Care Benefit :Two times the Daily Allowance, subject to maximum of X days as mentioned in the Schedule, for each continuous and completed period of 24 hours required to be spent by You/ Your Insured Family Member in the Intensive Care Unit of a Hospital during any period of Hospitalisation.

Section 3: Convalescence Benefit:If Hospital Confinement continues for a period of more than 21 consecutive days, the benefit payable will be as specified in the Schedule against this benefit. This benefit is paid once in a year for each insured event

For purpose of avoidance of doubt, it is clarified that, if the claim becomes admissible under category II, benefit under category I would not be payable.

However Our total liability, under this Section, for payment of all claims in aggregate for the Policy Period shall not exceed the Sum Insured as stated in the Schedule.

We shall not be liable to make any payment for any claim directly or indirectly caused by, based on, arising out of or howsoever attributable to any of the following:

  • 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:
    • 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.
  • Treatment of following diseases within the first one year from the commencement of the Policy, will not be payable:
    • Cataract
    • Benign Prostatic Hypertrophy
    • Myomectomy, Hysterectomy unless because of malignancy
    • Hernia, Hydrocele
    • Fistula in anus, Piles
    • Arthritis, gout, rheumatism
    • Joint replacements unless due to accident
    • Sinusitis and related disorders
    • Stones 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 chronic renal failure
    • Surgery on tonsils and sinuses
    • Gastric and Duodenal ulcers

      However, the waiting period of 1 year will not apply if You were insured continuously and without interruption for at least 1 year under any other Indian insurer’s similar health insurance policy from us or any of the Indian insurers.

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

  • Any Sickness that has been classified as an Epidemic by the Central or State Government.
  • General debility, nervous or other breakdown, rest cure, congenital diseases or defect or anomaly, sterility, sterilisation or infertility (diagnosis and treatment), any sanatoriums, spa or rest cures or long term care or hospitalisation undertaken as a preventive or recuperative measure
  • Sickness requiring Hospitalisation within the first 30 days from the commencement date of the Policy Period unless the Policy is renewed without interruption with the Company or the policy is a renewal of similar health insurance policy from any of the other Indian insurers and We have accepted your proposal with portability.
  • 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.
  • Payment of compensation in respect of injury, hospitalisation resulting -
    • From intentional self-injury, suicide or attempted suicide.
    • Self-exposure to needless perils except in an attempt to save human life.
    • 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, misdemeanor or civil commotion.
    • Whilst engaging in racing, hunting, mountaineering, ice hockey, winter sports and the like.
    • Due to war or ionizing 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
  • Any loss resulting directly or indirectly, contributed or aggravated or prolonged by childbirth or from pregnancy (except Ectopic Pregnancy)
  • Any treatment not performed by a Physician or any treatment of a purely experimental nature.
  • 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).
  • Dental treatment or surgery of any kind unless necessitated by Accidental Bodily Injury.
  • Hospitalisation for the sole purpose of traction, physiotherapy or any ailment for which hospitalisation is not warranted due to advancement in medical technology
  • Naval or military operations of the armed forces or air force and participation in operations requiring the use of arms or which are ordered by military authorities for combating terrorists, rebels and the like.
  • All kind of Alternate Treatment

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 Hospitalisation

In the event that a claim becomes payable under the terms of the Policy, We shall make such payment 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

    Claim Documents

    • Photo copy of bills, receipt and discharge certificate/card from the Hospital.
    • Photocopy of F.I.R. copy in case of an accident
    • Complete set of Hospital/medical records

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

      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

We shall have no liability under this Policy, once the Maximum Limit of Liability (Sum Insured) as stated in the Policy Schedule with respect to any of the Sections, is exhausted by You or Your Insured Family Member.

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 POLICY

STANDARD TERMS AND CONDITIONS

1. Material change

You shall immediately notify Us in writing of any material change in the risk and cause at Your own expense.

2. Fraudulent claims

If any claim is in any respect fraudulent, or if any false statement, or declaration is made or used in support thereof, or if any fraudulent means or devices are used by You or anyone acting on Your behalf to obtain any benefit under this Policy, or if a claim is made and rejected and no court action or suit is commenced within twelve months after such rejection or, in case of arbitration taking place as provided therein, within twelve (12) calendar months after the Arbitrator or Arbitrators have made their award, all benefits under this Policy shall be forfeited.

3. Claims in Two Policy Period:

If the claim event falls within two policy periods, the claims shall be paid taking into consideration the available sum insured in the two policy periods, including the deductibles for each policy period. Such eligible claim amount to be payable to the insured shall be reduced to the extent of premium to be received for the renewal/ due date of premium of health insurance policy, if not received earlier.

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. 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 orinterpreted 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.

6. Discount(s) under the Policy

6. Long term discount:

We shall provide long term policy discount as under when Policy is bought from Us for period greater than an year by payment of premium in a single installment.

Number of Years % Discount
2 year policy 2 year premium (Double of the Annual Premium as mentioned below in the Table) paid in advance less 10% discount
3 year policy 3 year premium in (Three Times of Annual Premium as mentioned below in the Table) paid in advance less 15% discount

Even If the policy is purchased for 2 years/ 3 years at once by paying the premium in one instalment, the Benefits will be applicable only on annual basis of the policy

Family discount:

We shall provide a discount of 5% on the total premium of the policy including the family members.

Group Discount:The purpose of including group in the filed product is to the extent of issuing policy document as group in view of our Bancassurance Business Model where the premium is being collected by our Corporate Agent (Bank Partner and its associates) from their customers and remitted to USGI as a one signal amount. In the captioned cases, the policy is issued master policy as Bank Partner Name A/C Various Customer Name, but each Individual & its family member’s insured therein is treated as Individual in nature for which the product is filed and individual policy certificate is issued to each customer, hence, we have not made the provision of any Group Discount in the product filed. We further confirm that on individual basis if the family members are covered, we have extended the family member discount and the same would follow if the policy is issued as Group to Bank Partner and its associates.

7. 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.

8. Free Look-up period

  • 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.

9. 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.

10. Contribution: The conditions of contribution shall not apply to this Policy.

11. Subrogation:Y ou 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.

12. 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.

15. 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.

16. 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.

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

18.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.

19. 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: 1800-200-5142

Landline Numbers: 022–39635200

E-mail Address: contactus@universalsompo.com.

Fax Numbers: 1800-200-9134

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.

20. 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, Chargeable Numbers. - 022–39635200,Fax Toll Free Numbers: 1800-200-9134.

  • You can also visit our Company website and click under links Grievance Notification
  • 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: HTTPS://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

Day Care Annexure List of expenses excluded

Saral Suraksha Bima undertakes to pay a lump sum amount of as selected by the proposer on happening of an eventuality covered in the policy.

The policy pays one-time payment equal to the Sum Insured on diagnosis of any of the listed five Critical Illnesses, Accidental Death and Permanent Total Disablement resulting from an accident.

The Policy is structured to target group of members of SHG’s, NGOs, MFIs, Co-operative Banks, FCIs, Shareholders of Banks/Public ltd Companies, holders of Depositor Certificate by Banks/NBFCs, Members of Registered Service Clubs and Employer - Employee relationship including dependants of the employee, etc.

The policy can also be issued to individuals upon request and acceptance of such a request by Us.

The policy shall pay to you on happening of below mentioned contingencies.

Section 1 - Critical Illness

a) Stroke resulting in permanent symptoms

b) Cancer of specified severity

c) Kidney Failure requiring regular dialysis

d) Open Chest CABG

e) Major Organ /Bone Marrow Transplant

Section 2 – Personal Accident

    • Accidental Death:

The nominee gets a one-time payment equal to Capital Sum Insured (CSI) if the insured dies in an accident.

    • Permanent Total Disablement

The insured is entitled to receive the percentage of the capital sum insured as per the table of benefit if he suffers a permanent and total loss of limbs, sight in an accident.

. TABLE OF BENEFITS % OF CSI
1. Death 100
2.
  • Loss of sight (both eyes)
  • b) Physical separation of or loss of ability to use both hands or both feet
  • c) Physical separation of or loss of ability to use one hand and/ or any feet
  • d) Loss of sight of one eye and physical separation of or loss of ability to use either one hand or one foot
  • 100
  • 100
  • 100
  • 100
3 a) Loss of sight of one eye b)physical separation of or use of ability to use one hand or one foot 50 50
4 Permanent Total and absolute disablement as certified by a qualified medical practitioner 100
Eligibility
      • Entry age for you (the proposer) is 18 years and you can opt for this policy up to the age of 65 years.
      • Policy renewals will be for your lifetime.
      • Children from 10 years to 25 years can be covered if any one of the Parent is insured under the Policy. Unmarried children can also be covered upto maximum of 25 years of age only. In case child gets married, the child will not be covered on next renewal. The cover will continue till the natural expiry of the Policy.

Exclusion specific to Critical Illness

1) 90 days Waiting Period

A waiting period of 90 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 similar risks, 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 upon Renewal with Us, then this exclusion shall only apply in relation to the amount by which the Sum Insured has been increased.

2) Pre-existing diseases

    • 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 similar health risks

    • OR

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;

    • AND

ii.If the proposed Sum Insured for You is more than the Sum Insured applicable under the previous health insurance Policy,

    • then the reduced waiting period shall only apply to the extent of the Sum Insured under the previous health insurance Policy.

3)Death within 30 days following the diagnosis of the Critical Illness

4)Any Critical Illness which arises or is caused by any one of the following:

a.Dry addiction, alcoholism, smoking of more than 30 cigarettes/cigars or equivalent intake of tobacco in a day and any complication, consequences arising there from.

b.Any Insured person suffering from Human T.Cell Lymphotropic Virus Type III (HTLV-III) or Lymphadinopathy Associated Viruses (LAV) or the Mutant derivatives or Variations Deficiency Syndrome or any Syndrome or a condition of similar kind referred to as AIDS. The onus shall always be on Insured Person to show any event was not caused by or did not arise through AIDS or HIV.

Exclusion specific to Personal Accident

1)Compensation under more than one of the benefits mentioned in Table of Benefits in respect of same period of disablement.

2)Any other payment after a claim under one of the benefits 1,2,3 and 4 in Table of benefits has been admitted and becomes payable.

3)Any payment in case of more than one claim under this section during any one period of Insurance by which our liability in that period would exceed CSI.

4)Payment of compensation in respect of injury as consequence of

a) Committing or attempting suicide, intentional self injury

b) Whilst under influence of intoxicating liquor

c) Drug addiction or alcoholism

d) Whilst engaged in any adventurous sports

e) Committing any breach of law with criminal intent

General Exclusions under the Policy

We will not pay for any compensation in respect of death, Illness, Injury or disablement of the Insured Person arising out of:

1)War, invasion, act of foreign enemy, hostilities (whether war be declared or not) civil war, rebellion, revolution, insurrection, mutiny military or usurped power, confiscation, seizure, capture, assault, restraint, nationalization, civil commotion or loot or pillage in connection herewith.

2)Ionizing radiation or contamination by radioactivity from any nuclear fuel or from any nuclear waste from the combustion of nuclear fuel. For the purpose of this exclusion, combustion shall include any self sustaining process of nuclear fission.

3)The radioactive, toxic, explosive or the hazardous properties of any nuclear assembly or nuclear component.

What are the conditions under the Policy?

A. Sum Insured Premium Options

Sum Insured for CI Rs 10,000 Rs 20,000 Rs 25,000
Sum Insured for PA Rs 20,000 Rs 40,000 Rs 50,000
Premium excluding tax* Rs 141 Rs 246 Rs 290

* Applicable Service Tax and Cess is subject to change as per change in Tax Laws

What are the conditions under the Policy?

a.Your Policy shall ordinarily be renewable for lifetime except on grounds of fraud, moral hazard or misrepresentation or non‐cooperation by You/ any of the Insured Persons

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 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.

d.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.

e.The Policy shall terminate on payment under any of the covered benefits viz. Personal Accident or Critical Illness/ Surgical Procedure

f.The basic premium applicable under the Policy may be revised at a later stage subject to approval from IRDA.

F.Free Look-up period

1.The Policy shall have a free look period. The free look period shall be applicable at the inception of the Policy and:

i. 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.If You have not made any claim during the Free Look period, You shall be entitled to

i.A refund of the premium paid less any expenses incurred by Us on Your medical examination and the stamp duty charges or;

ii.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;

iii.Where only a part of the risk has commenced, such proportionate risk premium commensurate with the risk covered during such period.

G. Three Months 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:

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.

H. Nomination

The Policy has provision of nomination, In absence of Your declaring Nomination at the time of Proposal, then all benefits accrued under the Policy if any, shall be given to Your legal heir/ dependants.

I. Substitute Product

In case We may decide to withdraw this product under which this Policy is issued to You or where the children have attended maximum eligibility age under the Policy, if covered, We shall provide You with an option to buy a similar substitute Accident insurance Policy from Us

J. Sum Insured Enhancement:

Sum Insured can be enhanced only upon renewal, subject to Our underwriter’s approval.

K. Portability-

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.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.

iv.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.

L. Contribution and Subrogation

These clauses shall not apply to this Policy.

i.Upon happening of any accident and/or injury which may give rise to a claim under this Policy.

a.Your representative shall give the notice to Our call centre immediately and also intimate in writing to Our Policy issuing office unless reasonable cause is shown, the notice be given before internment/ cremation and in any case, within one calendar month after the Death.

b.All certificates, information and evidence from a Medical Practitioner or otherwise required by Us shall be provided.

Critical illness Claims:

i.Certificate from the attending Doctor of the Insured confirming,

a.Name of the Insured;

b.Name, date of occurrence and medical details of the Insured Event

c.Confirmation that the Insured Event does not relate to any Pre-Existing Illness or an Illness or Injury which existed within the first 90 days of commencement of Policy Period.

ii.Duly completed claim form;

iii.Original Discharge Certificate/ Card from the hospital/ Doctor;

iv.Original investigation test reports, indoor case papers.

Death Claims:

a)Duly filled up claim form

b)Death Certificate and Original FIR

c)Original Panchnama

d)Post mortem report

Permanent Total Disablement Claims:

a)Duly filled original Claim Form

b)Claim Intimation

c)FIR – Attested or Original

d)Final Police Report / Original Panchnama

e)Certificate of from government hospital doctor confirming the nature and degree of disability

f)Discharge summary of the treating hospital clearly indicating the Hospital Registration No.

g)Diagnostic reports

h)Photograph of the injured reflecting disablement

Our obligation

We shall settle the claims, including its rejection, within 30 days of 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.

Position after claim:

We shall not be liable for any claim payment once the Maximum Limit of Liability (Sum Insured) is exhausted under the Policy by You.

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.

Claim Disclaimer

In the unfortunate event of any medical contingency resulting into a claim on this policy, please intimate the mishap, 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 (other users) or on chargeable numbers at +91-22-26748600 / +91-22-41582900 / +91-22-41582999 or email at contactus@universalsompo.com Please note that no delay should be allowed to occur in notifying a claim on the policy as the same may prejudice liability.

Statutory Warning:No person shall allow or offer to allow, either directly or indirectly, as an inducement to any person to take out or renew or continue an insurance in respect of any kind of risk relating to lives or property in India, any rebate of the whole part of the commission payable or any rebate of the premium shown on the policy nor shall any person taking out or renewing or continuing a policy accept any rebate, except such rebates as may be allowed in accordance with the published prospectuses or tables of the Insurer. Any person making default in complying with the provisions of this section shall be punishable with fine which may extend to Ten Lakh Rupees

Please note:The prospectus contains only an indication of cover offered, for complete details on terms, conditions, coverages and exclusions please get in touch with us or our agent and read policy wordings carefully before concluding a sale. Insurance is a subject matter of solicitation. 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.

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.

Accidentmeans a sudden unforeseen and involuntary event caused by external, visible and violent means.

Adventure Sportsmeans participation in sports activities such as bungee jumping, sky diving, white water canoeing/rafting and engaging in racing, hunting, mountaineering, ice hockey, winter sports and the like.

Bodily InjuryIt shall mean accidental bodily injury solely and directly caused by external, violent and visible cause.

Cashless Facilitymeans a facility extended by the insurer to the insured where the payments, of the costs of treatment undergone by the insured in accordance with the Policy terms and conditions, are directly made to the Network Provider by the insurer to the extent pre-authorization approved.

Companymeans “Universal Sompo General Insurance Company Limited.

Condition Precedentmeans a Policy term or condition upon which the Insurer’s liability under the Policy is conditional upon.

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

a) Internal Congenital Anomaly:means which is not in the visible and accessible parts of the body b) External Congenital Anomaly:means which is in the visible and accessible parts of the body.

Contributionis 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.

ChildrenMeans a child (natural or legally adopted) from 10 to 25 years of age, who is financially dependent on You and does not have his / her independent sources of income.

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

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

Domiciliary Treatmentmeans 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.

Grace periodmeans the specified period of time immediately following the premium due date during which a payment can be made to renew or continue a Policy in force without loss of continuity benefits such as waiting periods and coverage of Pre-Existing Diseases. Coverage is not available for the period for which no premium is received.

Hospitalmeans 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.

Hospitalizationmeans 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 24 consecutive hours.

Insured Personsmeans the individual(s) whose name is/are appearing in the Schedule and shall include his/her spouse, dependent children and/ or parents.

InjuryMeans 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. The same has been referred to as “Bodily Injury ” in the Policy.

In-patient Caremeans treatment for which the Insured Person has to stay in a Hospital for more than 24 hours for a covered event.

Intensive Care Unitmeans 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.

Medically Necessarymeans 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 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 license and is not a member of theInsured Person’s Family.

Network Providermeans 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.

Nomineemeans the person(s) nominated by the Insured Person to receive the insurance benefits under this Policy payable on his/her death.

Non- Networkmeans any Hospital, day care centre or other provider that is not part of the network.

Notification of Claimis 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.

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.

Permanent Total DisablementMeans the bodily injury that totally prevents You from engaging in any kind of occupation.

Pre- Existing Diseasesmeans 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.

Portabilitymeans transfer by an individual health insurance Policy Holder (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.

Renewalmeans 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.

Surgery or Surgical Proceduremeans 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.

Sum InsuredMeans 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. For Section II, the Sum Insured has also been referred to as “Capital Sum Insured (CSI)” in the Policy.

SubrogationMeans Our rights to assume Your rights to recover expenses paid out under the policy that may be recovered from any other source.

TPAMeans a Third Party Administrator, who, for the time being, is licensed by the Insurance Regulatory and Development Authority, and is engaged, for a fee or remuneration, by whatever name called as may be specified in the agreement with Us, for the provision of health services.

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

We/Our/Ours/Usmean Universal Sompo General Insurance Company Limited.

Warmeans 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.

Section I :- Critical Illness

Critical Illness:It means the following major diseases, which You have been diagnosed during the Policy Period to have suffered from and which requires Hospitalization and are specifically defined as below:

1. 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 extra cranial 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:

  • Transient ischemic attacks (TIA)
  • Traumatic injury of the brain
  • Vascular disease affecting only the eye or optic nerve or vestibular functions

2. 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 leukaemia, 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.

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. 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.

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

Coverage:-

WHAT WE COVER
We shall pay Sum Insured as mentioned in the schedule to the Insured(s) upon his/ her first diagnosis of Critical Illness / Surgical Procedure as defined under the Policy
WHAT WE EXCLUDE

1) 90 days Waiting Period

A waiting period of 90 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 similar risks, 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 upon Renewal with Us, then this exclusion shall only apply in relation to the amount by which the Sum Insured has been increased.

2) Pre-existing diseases

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 similar health risks

OR

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;

AND

ii) If the proposed Sum Insured for You is more than the Sum Insured applicable under the previous health insurance Policy, then the reduced waiting period shall only apply to the extent of the Sum Insured under the previous health insurance Policy.

3) Death within 30 days following the diagnosis of the Critical Illness

4) Any Critical Illness which arises or is caused by any one of the following:

a. Dry addiction, alcoholism, smoking of more than 30 cigarettes/cigars or equivalent intake of tobacco in a day and any complication, consequences arising there from.

b. Any Insured person suffering from Human T.Cell Lymphotropic Virus Type III (HTLV- III) or Lymphadinopathy Associated Viruses (LAV) or the Mutant derivatives or Variations Deficiency Syndrome or any Syndrome or a condition of similar kind referred to as AIDS. The onus shall always be on Insured Person to show any event was not caused by or did not arise through AIDS or HIV.

Special Provisions

1.The existence of the Critical illness mentioned in the Policy must be confirmed by a Medical Practitioner and must be supported by clinical, radiological, histological and laboratory evidence as applicable.

2.The cover under this Policy in respect of any Insured Person shall cease upon the payment of compensation on the happening of a Critical illness or injuries defined under the Policy.

Section II:- Personal Accident

Capital Sum Insured:It means the Monetary Amounts shown against insured person(s).

Bodily InjuryIt shall mean accidental bodily injury solely and directly caused by external,violent and visible cause.

Coverage:-

WHAT WE COVER
We shall pay to You or Your legal heir / Nominee, as the case may be, the compensation ( as percentage of Capital Sum Insured), as set forth in Table of Benefits upon occurrence of Bodily Injury to You resulting in Your Death or disablement.
WHAT WE EXCLUDE

1)Compensation under more than one of the benefits mentioned in Table of Benefits in respect of same period of disablement.

2)Any other payment after a claim under one of the benefits 1,2,3 and 4 in Table of benefits has been admitted and becomes payable.

3)Any payment in case of more than one claim under this section during any one period of Insurance by which our liability in that period would exceed CSI.

4)Payment of compensation in respect of injury as consequence of.

  • Committing or attempting suicide, intentional self injury
  • Whilst under influence of intoxicating liquor
  • Drug addiction or alcoholism
  • Whilst engaged in any adventurous sports
  • Committing any breach of law with criminal intent
. TABLE OF BENEFITS % OF CSI
1. Death 100
2.
  • Loss of sight (both eyes)
  • b) Physical separation of or loss of ability to use both hands or both feet
  • c) Physical separation of or loss of ability to use one hand and/ or any feet
  • d) Loss of sight of one eye and physical separation of or loss of ability to use either one hand or one foot
  • 100
  • 100
  • 100
  • 100
3 a) Loss of sight of one eye b)physical separation of or use of ability to use one hand or one foot 50 50
4 Permanent Total and absolute disablement as certified by a qualified medical practitioner 100

GENERAL EXCLUSIONS UNDER THE POLICY

We will not pay for any compensation in respect of death, Illness, Injury or disablement of the Insured Person arising out of:

1.War, invasion, act of foreign enemy, hostilities (whether war be declared or not) civil war, rebellion, revolution, insurrection, mutiny military or usurped power, confiscation, seizure, capture, assault, restraint, nationalization, civil commotion or loot or pillage in connection herewith.

2.Ionizing radiation or contamination by radioactivity from any nuclear fuel or from any nuclear waste from the combustion of nuclear fuel. For the purpose of this exclusion, combustion shall include any self sustaining process of nuclear fission.

3.The radioactive, toxic, explosive or the hazardous properties of any nuclear assembly or nuclear component.

i.Upon happening of any injury/disease which may give rise to a claim under this Policy

a) Your representative shall give the notice to Our call centre immediately and also intimate in writing to Our Policy issuing office unless reasonable cause is shown, the notice be given before internment/ cremation and in any case, within one calendar month after the Death.

b) All certificates, information and evidence from a Medical Practitioner or otherwise required by Us shall be provided. ii.On receipt of intimation regarding a claim under the Policy, We are entitled to carry out examination and ascertain details and in the event of Death get the post-mortem examination done in respect of deceased person.

iii.Following documents shall be required in the event of a Claim.

Critical illness Claims:

i.Certificate from the attending Doctor of the Insured confirming,

a) Name of the Insured;

b) Name, date of occurrence and medical details of the Insured Event

c) Confirmation that the Insured Event does not relate to any Pre-Existing Illness or an Illness or Injury which existed within the first

90 days of commencement of Policy Period.

ii.Duly completed claim form;

iii.Original Discharge Certificate/ Card from the hospital/ Doctor;

iv.Original investigation test reports, indoor case papers.

Death Claims:

a)Duly filled up claim form

b)Death Certificate and Original FIR

c)Original Panchnama

d)Post mortem report

Permanent Total Disablement Claims:

a)Duly filled original Claim Form

b)Claim Intimation

c)FIR – Attested or Original

d)Final Police Report / Original Panchnama

e)Certificate of from government hospital doctor confirming the nature and degree of disability

f)Discharge summary of the treating hospital clearly indicating the Hospital Registration No.

g)Diagnostic reports

h)Photograph of the injured reflecting disablement

Our obligation

We shall settle the claims, including its rejection, within 30 days of 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.

Position after claim:

We shall not be liable for any claim payment once the Maximum Limit of Liability (Sum Insured) is exhausted under the Policy by You.

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.

GENERAL CONDITIONS APPLICABLE TO BOTH THE SECTIONS:-

1) Notice:

Every notice and communication to the Company required by this Policy shall be in writing. Initial notification can be made by telephone

2) Mis-description:

This Policy shall be void abinitio and premium paid shall be forfeited by Us in the event of misrepresentation, mis-description or non-disclosure of materials facts by You. Non- disclosure shall include non-intimation of any circumstances which may affect the acceptance of the proposal and Insurance cover granted.

3) Contribution and Subrogation

These clauses shall not apply to this Policy.

4) Fraud

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.

5) Portability

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

W

e 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.

6) 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:

Expired Period % Premium Retained
Upto 1 month 25% of the Annual Premium
Above 1 month and upto 3 months 50% of Annual Premium
Above 3 months and upto 6 months 75% of annual premium
Above 6 months 100% of annual premium
By Us

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 . You will then be entitled to a pro-rata refund of premium for the unexpired Period of this Policy from the date of cancellation, which We are liable to pay on demand.

7) Renewal

a)Your Policy shall ordinarily be renewable till lifetime 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.

s

8) Free Look Period

We shall give You 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.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.

9) 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 provided, if the Company has disputed or not accepted liability under or in respect of this Policy

It is hereby expressly stipulated and declared that it shall be a condition precedent to any right of action or suit upon this Policy that the award by such arbitrator/ arbitrators of the amount of the loss or damage shall be first obtained.

10) 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.

11) Geographical Limit:

The geographical scope of this Policy will be India and all claims shall be payable in Indian currency only.

12) Policy Disputes

It has been agreed between the parties that though the geographical scope of the Policy is Worldwide, 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.

13) Sum Insured Enhancement:

Sum Insured can be enhanced only upon renewal, subject to Our underwriter’s approval.

14) Three Months 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:

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.

15) Nomination

The Policy has provision of nomination, In absence of Your declaring Nomination at the time of Proposal, then all benefits accrued under the Policy if any, shall be given to Your legal heir/ dependants.

16) Substitute Product

In case We may decide to withdraw this product under which this Policy is issued to You or where the children have attended maximum eligibility age under the Policy, if covered, We shall provide You with an option to buy a similar substitute Accident insurance Policy from Us.

17) 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

Landline Numbers

(022)-27639800 or (022)-41582900 or (022)-41582999 or (022)-39133700 (Local Charges Apply)

E-mail Address

contactus@universalsompo.com.

Fax Numbers

(022) 41582929 or (022) 41582939

Note: Please include Your Policy number for any communication with us.

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.

18. 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 visit our Company website and click under links Grievance Notification

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 : HTTPS://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

Retail - SAMPOORNA SURAKSHA BIMA

In consideration of Your having paid the premium for the Policy Period stated in the Schedule We hereby agree, subject to the terms, conditions and exclusions stated in the Policy, to pay the Sum Insured on the occurrence of any of the insured events as mentioned under the item “What We cover” during the Policy Period.

This Policy is an evidence of the contract between You and Universal Sompo General Insurance Company Limited. The information furnished by You in the Proposal Form and the declaration signed by You forms the basis of this contract.

The Policy, the Schedule and any Endorsement shall be read together and any word or expression to which a specific meaning has been attached in any part of this Policy or of Schedule shall bear such meaning wherever it may appear.

Accidentmeans a sudden unforeseen and involuntary event caused by external, visible and violent means.

Accidental Death:Accidental death means death resulting from Bodily Injury solely and independently of any other cause except illness directly resulting from medical or surgical treatment rendered necessary for such injury, occasions the death of the insured person within 12 months from the date of accident.

Deductible:Deductible is a cost-sharing requirement under a health insurance policy that provides that the insurer will not be liable for a specified rupee amount in case of indemnity policies and for a specified number of days/hours in case of hospital cash policies which will apply before any benefits are payable by the insurer. A deductible does not reduce the Sum Insured.

Market Value:This is the basis of Sum Insured for household goods other than electrical, mechanical and electronic machines/gadgets under this Policy. Market value for household goods means the procurement value of goods from the same or similar source at the time of damage or Loss less appropriate depreciation

Family:Family means Your spouse and Your dependent children ordinarily residing with You.

First Loss Limit:The amount mentioned in the Schedule which represents the specified percentage of the full value at risk .The First Loss Limit represents our maximum liability in event of any one claim.

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.

Insured Premises:The place(s) named in the Schedule where You normally reside.

Market Value:This is the basis of Sum Insured for household goods other than electrical, mechanical and electronic machines/gadgets under this Policy. Market value for household goods means the procurement value of goods from the same or similar source at the time of damage or Loss less appropriate depreciation

Period of Insurance:The time period for which the contract of insurance is valid as shown in the Policy Schedule.

Permanent Furniture, Fixtures Fittings:Permanent furniture, fixtures and fittings include false ceiling glass /wooden partitions, wooden/steel cupboards fixed to the walls, electrical tube lights and fans only.

Permanent Total Disablement:Means the bodily injury that totally prevents You from engaging in any kind of occupation.

Policy:Policy wordings, the Schedule, the Proposal form and Endorsement / Memoranda if any.

Proposal:The application form You sign for this insurance and/or any other information You give to us or which is given to us on Your behalf.

Reinstatement Value:This is the basis of Sum insured for building and permanent furniture, fixtures and fittings and electrical/ mechanical/electronic machines/ gadgets under this Policy. Reinstatement Value represents the replacement value of the asset as New at time of Damage or Loss.

Schedule:The document which describes You, the cover that applies the Period of Insurance and other details of Your Policy.

Sum Insured:It means the amount stated against each item in each Section of the Schedule which shall be our maximum liability under this Policy for any one claim or in the aggregate for all claims under each Section during the Policy period.

Terrorism:Terrorism means an act, including but not limited to, the use of force or violence and/or the threat thereof, of any person/ group(s) of persons, whether acting alone or on behalf of or in connection with any organization(s) or government(s) committed for political, religious, ideological or similar purpose, including the intention to influence any government and/or to put the public or any Section of the public in fear.

Valuables:Valuables means (a) gold or silver or any precious metals or articles made from any precious metals (b) watches/ Jewellery/ precious stones/ models/ coins/ curios, sculptures, manuscripts, stamps, collection of stamps, rare books, medals, moulds, designs or any other collectibles (c) deeds, ATM cards, credit cards, bonds, bills of exchange, bank notes, treasury/ promissory notes, cheques, money, securities/any other negotiable instrument (d) works of art

We/Us/Our:Universal Sompo General Insurance Company Limited

You/YourThe person (s) named as Insured in the Schedule

Section 1 - Fire and Allied perils -Household Structure and Contents

WHAT WE COVER

Loss or Damage directly caused to Household Contents by insured perils listed hereunder and subject to its not being otherwise excluded.

1. Fire

2. Lightning

3. Explosion / Implosion.

4. Damage caused by an aircraft, other aerial or space devices and articles dropped there from.

5. Riot, Strike and Malicious Damage: - Visible physical Damage by external violent means directly caused to the property insured.

6. Strom, Cyclone, Typhoon, Tempest, Hurricane, Tornado, Flood and Inundation.

7. Impact Damage by any rail/road vehicle or animal by direct contact.

8. Subsidence and Landslide including Rockslide: Damage caused by subsidence of the part of site on which the insured property stands or landslide /rockslide.

9. Bursting and overflowing of water tank, apparatus and pipes.

10. Missile testing operations.

11. Leakage from automatic sprinkler installations

12. Bush Fire.

13. Earthquake– Damage to property insured including by fire occasioned by or in consequence of earthquake including flood or overflow of the sea, lakes, reservoirs and rivers and/or landslide/rockslide resulting there from.

14. Terrorism

WHAT WE EXCLUDE

1 Damage caused by pressure waves.

2 Destruction or damage caused to the property by its own fermentation, natural heating or spontaneous combustion or its undergoing heating or drying process

3 Burning of property insured by order of any Public Authority.

4 Explosion/implosion losses to boilers (other than domestic boilers), economizers or other vessels, machinery or apparatus (in which steam is generated) including their contents.

5 Destruction or damage to property caused by centrifugal forces.

6 Damages caused by

a. Permanent or temporary dispossession of any building resulting from the unlawful occupation by any person of such building or prevention of access to the same.

b. Burglary, housebreaking, theft, larceny or any other such attempt or any omission of any kind of any person (whether or not such act is committed in connection with the disturbance of public peace) in any malicious act.

c. Total or partial cessation of work or the retardation or interruption or cessation of any process or operations or omissions of any kind

7 Damage by vehicle/animals belonging to or owned by You or Your Family.

8 Damages caused by :-

a) Normal cracking, settlement or bedding of structures.

b) Settlement or movement of made up ground.

c) Coastal or river erosion.

d) Defective design or workmanship or use of defective material

e) Demolition, construction, structural alteration or repair of any property or ground work or excavation.\

9 Damage caused by

a) Repairs or alteration to Your Home.

b) Repairs, removal or extension of the sprinkler installation.

c) Defects in construction known to You.

10 Damages caused to the insured property by pollution or contamination.

11 Expenses necessarily incurred on Architect, Surveyor and Consulting Engineer‟s fees and Debris Removal following Damage to property insured by an insured peril in excess of 3% and 1% of the claim amount respectively.

12. Loss of earnings, loss by delay, loss of market or other consequential or indirect loss or damage of any kind or description whatsoever.

13. Loss, destruction damage to any electrical machine, apparatus fixture or fittings arising from or occasioned by overrunning excessive pressure, short circuiting, arcing, self-heating or leakage of electricity from whatever cause (lightning included provided that this exclusion will apply only to the particular electrical machine, apparatus, fixture or fittings which may be destroyed or damaged by fire so set up.

14. Livestock or pets

15. Valuables as defined under the Policy, unless specifically covered.

16. Loss or damage to property insured if removed to any building or place other than in which it is herein stated, except machinery and equipments temporarily removed for repairs, cleaning, renovation or other similar purposes for a period not exceeding 60 days.

17. Liability in excess of First Loss Limit as stated in the Schedule

If the property hereby insured shall at the breaking out of any fire or at the commencement of destruction of or damage by any of the insured perils be collectively of greater value than the 100% of total value at risk (as based on the first loss percentage chosen), then You shall be considered as Your own insurer for the difference and shall bear a rateable proportion of the loss in same proportion as insured value at risk bears to actual value at risk Provided, however, that if the sum insured hereby on the property insured shall at the event of such fire or at the commencement of such destruction damage be not less than 85% of the collective value of the property insured, this condition shall be of no purpose and effect if the Policy has been taken on Full Value Basis (100% First Loss Limit).

Definitions:

Burglary:Burglary means the unforeseen and unauthorized entry to or exit from the insured premises by aggressive and detectable means with the intent to steal the contents there from.

Theft:ITheft means the illegal taking of property belonging to another person without his consent with the intention of permanently depriving the other of it.

Household Goods:Household goods mean the personal belongings to You and Your family members who permanently reside with You which includes all mechanical and electrical gadgets for personal use and specified in the Schedule.

First Loss Limit:The amount mentioned in the Schedule which represents the specified percentage of the full value at risk . The First Loss Limit represents our maximum liability in event of any one claim.

WHAT WE COVER
Loss or Damage directly caused to

1. Contents‟ or any part thereof whilst kept in the insured premises

2. Damage to Insured premises (including reasonable costs for damaged locks at the entry and/or exit points) caused by actual or attempted burglary and/or theft during the Policy Period. In any case the cost of repair or replacement of locks shall not exceed 5% of the sum insured

WHAT WE EXCLUDE

1. Loss or damage from any yard, garden outbuilding (including sheds or garages not attached to the building) or any other property outside the confines of the premises unless specified in the Schedule

2. Valuables and cash in safe/Almirah, unless specifically covered in the Schedule

3. Loss or damage of motor vehicles, trailers unless mentioned as covered in the Schedule

4. Loss or damage in which You, Your family members or any other person lawfully on or about Your premises is or is alleged to be in any way concerned or implicated

5. Loss or damage resulting from an act of Riot, Strike, Malicious Damage and Terrorism

6. Damage to glass and sign boards

7. Live stock

8. Loss or damage to contents or stock when the premises are left unoccupied for more than 30 consecutive days unless the same has been reported to us in writing and our written approval obtained.

9. Any consequential loss or legal liability

10. First Rs 2500/- under each and every claim

Special Condition applicable to Section 2

Reinstatement of Sum Insured

Immediately upon happening of loss or damage under the Policy, the Sum Insured stated in the Schedule shall be reduced by the amount of loss or damage and such reduced sum insured shall be limit in respect of any further damage occurring during the current period of insurance unless We give our consent upon payment of additional premium to reinstate the said sum insured.

Basis of Settlement

Subject to Special Condition above and deductible stated in the Schedule, We may at our option reinstate, replace or repair the assets covered under this Policy which are lost or damaged or pay the amount of Loss/Damage or may join with any other insurer(s) in doing so.

We shall not be bound to reinstate exactly or completely but only as circumstances permit and in reasonably sufficient manner and in no case We shall be bound to spend more in reinstatement than it would cost to reinstate the assets as it was at the time of occurrence of such damage, nor more than the limit of liability mentioned under the Schedule.

All claims settlement under this Policy are subject to the following conditions

1) When the Sum Insured represents the full value of the assets covered:

If actual value of the assets insured under this Policy shall at the time of loss be collectively of greater value than the sum insured opted by You, then You will be considered as being Your own insurer for the difference and shall bear a ratable proportion of the loss accordingly. Every item, if more, than one in the Policy shall be separately subject to this condition.

2) When the „Sum Insured‟ represents a fixed proportion of the value of the assets covered referred to as First Loss Limit:

If the fixed proportion of value of the assets is insured under this Policy and at the time of loss the full value at risk is greater value than the 100% value at risk as implied by the First Loss Limit chosen, then You will be considered as being Your own insurer for the difference and shall bear a rate able proportion of the loss accordingly. Every item, if more, than one in the Policy shall be separately subject to this condition.

WHAT WE COVER

Accidental bodily injury directly resulting in the Death or disablement to insured person as per the Table of Benefits.

The scope of coverage shall depend on the benefit selected by you and as described in the Schedule

a) Basic Cover- Death only

b) Wider Cover- Death + Permanent Total Disability.

We shall pay to the insured person or his/her legal personal representative / assignee, the compensation set forth in Table of Benefits (as percentage of Capital Sum Insured)

Geographical eligibility:Worldwide

WHAT WE EXCLUDE

1. Natural Death

2. Compensation under more than one of the benefits mentioned in Table of Benefits in respect of same period of disablement.

3. Any other payment after a claim under one of the benefits 1or 2 in Table of benefits has been admitted and becomes payable.

4. Any payment in case of more than one claim under this Section during any one period of Insurance by which our liability in that period would exceed CSI

5. Payment of compensation in respect of Death or injury as a consequence of/resulting from

a) Committing or attempting suicide, intentional self-injury.

b) Whilst under influence of intoxicating liquor or drugs.

c) The abuse or the consequences of the abuse of intoxicants or hallucinogenic substances such as drugs and alcohol.

d) Whilst engaged in any 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 and/or hazardous activities like Persons working in underground mines, explosives, workers involved in electrical installations with High tension supply, jockeys, circus Personnel or activities of similar nature

e) Committing any breach of law with criminal intent.

f) War, Civil War, invasion, act of foreign enemies, revolution, insurrection, mutiny, military or usurped power, seizure, capture, arrest,

restraint, or detainment, confiscation, or nationalization or requisition by or under the order of any government or public authority.

6. Consequential loss of any kind and/or any legal liability

7. Pregnancy including child birth, miscarriage, abortion or complication arising there from.

8. Participation in any naval, military or air force operations.

9. Curative treatments or interventions

10. Venereal or sexually transmitted diseases.

11. HIV and or related illness

12. Insured Person‟s participation or involvement in naval, military or air force operation, racing, diving, aviation, scuba diving, parachuting, hang-gliding, rock or mountain climbing.

. Table of Benefits % of Capital Sum Insured
1. Accidental Death 100%
2. Permanent Total Disability:

a) Loss of sight (both eyes) or Loss of two limbs or Loss of one limb and one eye

b) Total Loss of sight of one eye or loss of use of one hand or foot

c) Any other Permanent Total and absolute disablement as certified by Medical Practitioner

100% 50% 100%

Extra Benefits under the Policy in addition to capital sum Insured, in case the liability under the policy for Accidental Claim has been admitted.

A. Transportation cost for carriage of dead body to Home including funeral charges. 1% of Capital Sum Insured or 2,500/- (Two thousand five hundred) whichever is lower.
B. Cost of Clothing damaged in the Accident as described above and liability is admitted by US. Actual expenses subject to maximum of Rs 1000/
C. Ambulance charges for transportation of Insured person to Hospital following Accident Actual expenses subject to maximum of Rs 1000/
D. Education Fund:- In the event of Death, permanent total disablement of the proposer that is the first Insured Person, We will approve compensation towards Education Fund for up to two dependent children as below 5% (Five percent) of C.S.I Attribute at 2.5% per child.
E. Loss of Employment: In the event of accident leading to loss of employment as a consequence of Permanent Total Disability as per the table of benefits. 2% of Capital Sum Insured.

a) Upon happening of any accident and/or injury which may give rise to a claim under this policy

  • You shall give the notice to our call center immediately and also intimate in writing to our policy issuing office. In case of Death, written notice also of Death must, unless reasonable cause is shown, be given before internment/ cremation and in any case, within one calendar month after the Death. In the event of loss of sight or amputation of limbs, written notice thereof must also be given within one calendar month after such loss of sight or amputation.
  • All certificates, information and evidence from a Medical Practitioner or otherwise required by us shall be provided by you.

b) On receipt of intimation from you regarding a claim under the policy, we are entitled to carry out examination and ascertain details and in the event of Death get the post-mortem examination done in respect of deceased person.

c) Following documents shall be required in the event of a claim.

For Death Claim

  • Duly filled up claim form
  • Death Certificate
  • Original FIR
  • Original Panchnama
  • Post mortem report if conducted

For Permanent Total Disablement

  • Duly filled up claims form
  • Original FIR
  • Panchnama
  • Hospitalization Report
  • Hospital discharge card
  • Original Certificate from Doctor of Govt. Hospital stating the degree of disability
  • Termination letter for claim under “Loss of Employment”

Definition

Any one illness:means continuous Period of illness and it includes relapse within 45 days from the date of last consultation with the Hospital/Nursing Home where treatment may have been taken.

Day Care Treatment/ Procedures:means any institution established for Day Care Treatment of Illness and/or Injuries or a medical setup within a Hospital and which has been registered with the local authorities, wherever applicable, and is under the supervision of a registered and qualified Medical Practitioner AND must comply with all minimum criteria as under

  • 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

Domiciliary Treatment: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.

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.

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.

a) Acute Conditionis 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.

b) Chronic conditionis 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.

Dependent Child:A dependent child refers to a child (natural or legally adopted), up to age 25 years, who is financially dependent on the primary insured or proposer and does not have his/her independent sources of income.

Grace Period:means the specified period of time immediately following the premium due date during which a payment can be made to renew or continue a Policy in force without loss of continuity benefits such as waiting periods and coverage of Pre-Existing Diseases. Coverage is not available for the period for which no premium is received.

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.

Hospitalization:means 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 24 consecutive hours.

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.

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 Care:means treatment for which the Insured Person has to stay in a Hospital for more than 24 hours for a covered event.

Medical expensesmeans 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.

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 member of the Insured Person‟s Family.

Medically Necessary:means 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.

Network Providers: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.

Non-Network:means any Hospital, day care centre or other provider that is not part of the network.

Pre-Hospitalization Medical Expenses:means the Medical 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 Inpatient Hospitalization claim for such Hospitalization is admissible by the Insurance Company.
Post Hospitalization Medical Expenses:means the 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.

Pre-existing Diseases: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 insurer.

Qualified Nurse:means 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: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.

Surgery or Surgical Proceduremeans 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.

WHAT WE COVER

The Hospitalization expenses incurred by 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. Room, Boarding and Nursing Expense as provided in the Hospital/Nursing Home subject to following limits.

a) Sub limit per day for Normal Room

b) Expenses: 1.0% of Basic Sum Insured.

c) Sub limit per day for Intensive Care/Therapeutic Unit expenses: 2% of Basic Sum Insured

d) Registration Charges of Hospital/Nursing Home : Actual

2. Medical Practitioner/ Anesthetist, Consultant fees, Surgeons fees and similar expenses subject to a limit of 25% of Basic Sum Insured (excluding sum insured for Critical Illness).

3. Expenses 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 subject to a limit of 40% of Basic Sum Insured .

4. Expenses on Vitamins and Tonics only if forming part of treatment as certified by the attending Medical Practitioner.

5. Expenses incurred for Domiciliary Hospitalization will be paid up to a maximum aggregate sub-limit of 20% of the Basic Sum Insured.

6. Additional Benefits

a) An additional Daily Allowance amount equivalent to 0.1% of the Basic Sum Insured or Rs. 250/- per day whichever is less, for the duration of Hospitalization towards miscellaneous expenses. The maximum amount payable under this extension is limited to Rs 2500/- in a year

b) Ambulance charges in connection with any admissible claim limited to 1.0% of the Basic Sum Insured or Rupees 1000/- whichever is less for each claim.

Note

1. Pre-Hospitalisation medical expenses up to 30 days and Post Hospitalization medical expenses up to 60 days will also be reimbursed along with the aforesaid Hospitalization expenses subject to the overall Sum Insured limit of the Insured Person. Any Nursing expenses during Pre and Post Hospitalization will be considered only if Qualified Nurse is employed on the advice of the attending Medical Practitioner for the duration specified.

2. If medical expenses are incurred under two Policy Periods, Our 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.

WHAT WE EXCLUDE

1. Hospitalization/ Domiciliary Hospitalization expenses arising from all Diseases/ Injuries which are in Pre-existing Condition.

a) Any claim occurring as a result of any condition, ailment or injury or related condition(s) for which the insured had signs or symptoms, and/or was diagnosed, and/or received medical advice/ treatment, within 48 months prior to the insured's first policy with the Company would not be payable until 48 months of continuous coverage have elapsed, since inception/ reinstatement of the first policy with the Us.

2. Hospitalisation/Domiciliary Hospitalisation expenses for any Disease which incepts during first 30 days of commencement of this Insurance cover.

3. Hospitalization/Domiciliary Hospitalization expenses incurred in the first year of operation of the insurance cover on treatment of the following Diseases :

  • Cataract
  • Benign Prostatic Hypertrophy
  • Myomectomy, Hysterectomy
  • Hernia, Hydrocele
  • Fistula in anus, Piles
  • Arthritis, Gout, Rheumatism
  • Joint replacement unless warranted due to an accident
  • Sinusitis and related disorders
  • Medical Management of tonsillitis.
  • 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 renal failure
  • Surgery on tonsils and sinuses
  • Gastric and duodenal ulcers

4. Hospitalization for only Investigations and diagnosis.

5. 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).

6. Circumcision unless necessary for the treatment of a Disease not otherwise excluded or required as a result of accidental bodily injury;

vaccination, except as may be requested for post animal bite treatment inoculation, cosmetic or aesthetic treatment of any description (including any complications arising thereof), plastic surgery except those relating to treatment of Injury or Disease.

7. Cost of spectacles and contact lens or hearing aids.

8. Dental treatment or surgery of any kind unless requiring inpatient hospitalization due to Accident.

9. Convalescence, general debility, run down condition or rest cure, external congenital disease or defects or anomalies, sterility, venereal disease, intentional self-injury and use of intoxicating drugs/alcohols.

10. Any expense on treatment related to HIV, AIDS and all related medical conditions.

11. Expenses on Diagnostic, X-Ray, or Laboratory examinations unless related to the treatment of Disease or Injury falling within ambit of Hospitalization claim.

12. Expenses on treatment arising from any infertility, sub fertility or assisted conception treatment.

13. Expenses on Voluntary termination of pregnancy within first 12 Weeks.

14. Injury or Diseases directly or indirectly caused by or contributed to by nuclear weapons/material.

15. Any expense on treatment of Insured Person as an outpatient in a Hospital.

16. 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.

17. Expenses on treatment arising from or traceable to pregnancy, childbirth, miscarriage, an accidental abortion or complications of any of these, including caesarean section. This exclusion is not applicable to ectopic pregnancy.

18. Any Expense of any treatment related to Human T-Cell Lymphotropic Viruses types III (III-LB-III) or Lymphadinopathy Associated Viruses (LAV) or the Mutant derivatives or Variations Deficiency Syndrome.

19. External medical equipment of any kind used at home as post hospitalization 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.

20. War, riots, strike, terrorism acts, nuclear weapon induced treatment section.

1. Claim Procedure:

Health Hospitalization Claims Procedure

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 at Our call center immediately and also intimate in writing to Our Policy issuing office but not later than 7 days from the date of Hospitalization. A written statement of the claim will be required , a Claim Form will have to be completed and the claim must be filed within 30 days from the date of discharge from the Hospital or completion of treatment and in case of Post hospitalization expenses being incurred , within 90 days from the date of discharge from Hospital
  • You must give all original bills, receipts, certificates, 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 Hospitalization if and when We may reasonably require.

B - Cashless Claims Process:

Cashless service: You can avail cashless hospitalization facility at a 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 12 Policy Wordings – Sampoorna Suraksha Bima (Micro Insurance)(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 also fax the form to TPA
  • Once the Form has been faxed. TPA will send the authorization to the Hospital On receipt of cash less approval patient need not pay the bill to the hospital for covered expenses.
  • For any queries, designated TPA can be contacted. Contact details of the TPA are as mentioned on the card issued to you. You can alternatively call our Call Centre for guidance and assistance.

1) Radioactive contamination

Any loss, damage or legal liability directly or indirectly caused by:

  • ionising radiation or radioactive contamination from nuclear fuel or nuclear waste arising from burning nuclear fuel; or
  • the radioactive, poisonous, explosive or other dangerous properties of any nuclear equipment or nuclear part of that equipment.

2) War Risks

Any consequence whatsoever resulting directly or indirectly from or in connection with any of the following regardless of any other contributing cause or event. War, invasion, act of foreign enemy hostilities or a warlike operation or operations (whether war be declared or not) civil war rebellion revolution insurrection civil commotion assuming the proportions of or amounting to an uprising military or usurped power.

3) Sonic bangs

Any loss, damage or legal liability directly or indirectly caused by pressure waves caused by aircraft and other flying objects traveling at or above the speed of sound.

4) Pollution and/or Contamination

Loss, destruction or damage caused to the insured property by pollution or contamination excluding

  • Pollution or contamination which itself results from a peril hereby insured against
  • Any peril hereby insured against which itself results from pollution or contamination

5) Gradually occurring losses

Loss or damage by Wear and tear, depreciation, insects, vermins, moth, fungus, corrosion, rust, atmospheric or climatic conditions ingress of water, gradually operating cause, process of cleaning, dyeing, repair, alteration or restoration.

6) Wilful Act

Loss or damage caused by or arising out of wilful act of the insured or any person acting on his/her behalf including circumstance, fact or matter You are or ought to be reasonably aware prior to the commencement of this contract.

7) Accidental External

Loss or damage caused by arising out of accidental external means other than due to the perils covered

8) Consequential Losses

Loss by delay, loss of market, loss of goodwill and / or any other consequential or indirect loss or damage not covered under the Policy.

9) Public Authority

  • Loss, destruction or damage caused to the property insured by burning by order of any Public Authority
  • Permanent or temporary dispossession resulting from confiscation, commandeering, requisition or destruction by order of the Government or any lawfully constituted Authority

10) Liability

(a) Liability more specifically insured elsewhere

(b) Liability arising out of Asbestosis or any matter related to or arising out of the sale, manufacture, production, distribution or the like of asbestos.

1. Reasonable care

You must take all reasonable steps to protect the property insured, prevent damage or accidents and maintain the property insured in a sound condition.

2. Mis-description

This Policy shall be void and premium paid shall be forfeited in the event of mis-representation, mis- description or non-disclosure of any materials facts as sought to be declared on the Proposal Form by You or Your representative.

3. Alteration of Risk

The cover afforded under this Policy shall be suspended and no payment shall be made hereunder if there is any material changes in the facts and matters stated in the proposal

The ownership of the building, stocks/contents/any other insured property passes from You to any other person or entity otherwise than by the operation of the law of succession as applicable.

4(A) Claims Procedure

I. In the event of any circumstances likely to give rise to a claim You must:

(a) Intimate us as soon as reasonably possible, but in any event within 15 days of the date the incident.

However in respect of loss or damage under Section 2 (Burglary and Theft) the loss must be reported within 24 hours of the happening of any insured event. 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.

(b) Lodge complaint with the local police immediately in case of fire, theft, burglary, riot strike, malicious damage or any other criminal act.

(c) Take all reasonable steps to recover any property which has been lost and protect /safe guard damaged property from further loss or damage.

(d) Provide without expense to us, all proofs, certificates, evidence, assistance or information which We may reasonably require

II.The documents normally required to be submitted in the event of a claim for Section 1 and Section 2 are :

a. Duly completed Claim form

b. Copy of FIR

c. Estimate of loss / repairs

d. Invoice/ Bills/Receipts

e. FR

f. Any other details/documents called for a specific loss

III.Rights and Responsibilities

On the happening of loss or damage to any of the property insured by this Policy, the Company may

1. Enter and take and keep possession of the building or premises where the loss or damage has happened.

2. Take possession of or require to be delivered to it any property of the Insured in the building or on the premises at the time of the loss or damage.

3. Keep possession of any such property and examine, sort, arrange, remove or otherwise deal with the same.

4. Sell any such property or dispose of the same for account of whom it may concern.

The powers conferred by this condition shall be exercisable by the Company at any time until notice in writing is given by the insured that he makes no claim under the Policy, or if any claim is made, until such claim is finally determined or withdrawn, and the Company shall not by any act done in the exercise or purported exercise of its powers hereunder, incur any liability to the Insured or diminish its rights to rely upon any of the conditions of this Policy in answer to any claim.

If the insured or any person on his behalf shall not comply with the requirements of the Company or shall hinder or obstruct the company, in the exercise of its powers hereunder, all benefits under this Policy shall be forfeited.

The Insured shall not in any case be entitled to abandon any property to the Company whether taken possession of by the Company or not.

4(B) Basis Of Claims Settlement

Unless otherwise specifically stated under the respective Section, the basis of settlement shall be as under:

For Claims under Section 1 and Section 2

Where a damaged item can be repaired or reinstated at a cost less than the replacement cost then We will indemnify You in respect of expenses necessarily incurred to restore the affected item to its state immediately prior to the happening of the insured event.

In case of a total loss of contents, We will pay You in respect of restoration or replacement costs. We shall not be bound to reinstate or restore exactly or completely but only as permitted by the circumstances and in a reasonably sufficient manner and to the state that existed immediately prior to the happening of the insured event.

1. Condition of Average

Unless otherwise expressly stated in particular Section, if the value of the insured property shall at the time of any insured event be collectively of greater value than the sum insured (if insured on full value basis) thereon then You shall be considered as Your own insurer of the difference and shall bear a rateable proportion of the loss or damage. Each item if more than one shall be separately subject to this condition.

2. Modified Condition of Average

In case of the coverage being taken under Sections1 and 2 on First Loss Basis our liability shall be limited to the sum insured chosen (25% or 50% of full value at risk).However in case the full value at risk is found to be higher than that deemed declared on basis of the First Loss Limit chosen a modified condition of average shall apply. Our liability shall stand reduced to the same extent as the insured value at risk bears to the actual value at risk.

For Claims under Section 3

In case of claim by Death or Permanent Total Disablement compensation will be made only after deleting by an endorsement the name of the deceased/ injured person in respect of whom such sums shall become payable.

We shall have no liability under this Policy, once the Sum Insured (Maximum Limit of Liability), as stated in the Policy Schedule with respect to this Section, is exhausted by You or Your Insured Family Member.

For Claims under Section 4

In the event that a claim becomes payable under the terms of this Section, We shall make such payment as incurred by You and accepted by Us towards the Medical Expenses during Hospitalisation within the Policy Period.

We shall have no liability under this Policy, once the Sum Insured (Maximum Limit of Indemnity), as stated in the Policy Schedule with respect to any of the Sections, is exhausted by You or Your Insured Family Member.

3. Condoning Delay in Claim Intimation

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. 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.

5. 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. In such circumstances you will not be entitled to any refund.

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. In such circumstances you will not be entitled to any refund.

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:

Expired Period % Premium Retained
Upto 1 month 25% of the Annual Premium
Above 1 month and upto 3 months 50% of Annual Premium
Above 3 months and upto 6 months 75% of annual premium
Above 6 months 100% of annual premium

6. Fraud

If the claim be in any respect fraudulent, or if any false declaration be made or used in support thereof or if any fraudulent means or devices are used by You or anyone acting on Your behalf to obtain any benefits under the Policy or if loss or damage be occasioned by the willful act or with Your connivance, all benefits under this Policy shall be forfeited.

7. Contribution (This clause is not applicable to Section 3 – Personal Accident)

If at the time of any loss or damage happening to any property hereby insured there be any other subsisting insurance or insurances, whether effected by You or by any other person on Your behalf covering the same property We shall not be liable to pay or contribute more than its rateable proportion of such loss.

8. Subrogation (This clause is not applicable to Section 3 – Personal Accident)

You shall at our expense 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 any rights and remedies or obtaining relief or indemnify from the other parties to which We shall be or would become entitled or subrogated upon our paying or making good any loss or damage under this Policy whether such acts and things shall be or become necessary or required before or after We indemnify Your loss or damage.

9. Arbitration

If any dispute or difference shall arise as to the quantum to be paid under the policy (liability) being otherwise admitted) such difference shall independently of all other questions be referred to the decision of the sole arbitrator to be appointed in writing by the parties to 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 3 arbitrators, comprising of 2 arbitrators, 1 to be appointed by each of the parties to the dispute/difference and the 3rd arbitrator to be appointed by 2 such arbitrators and arbitration shall be conducted under and in accordance with the provisions of the Indian 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. It is understood, however, that the Insured shall have the right at all times during currency of the Policy to communicate only, with the leading or issuing office in all matters pertaining to this insurance . Subject otherwise to the terms, exceptions, conditions and limitations of this policy.

10. Disclaimer Clause

If We shall disclaim Our liability in any claim, and such claim shall not have been made the 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.

11. Geographical Limits:

The Geographical Limit of this Policy and jurisdiction shall be India. All claims under this Policy shall be settled in Indian Rupees only.

12. Renewal

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 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.

f. All premiums are payable in advance of any cover under this Policy being provided.

g. The basic premium applicable under the Policy may be revised at a later stage subject to approval from IRDA.

h. 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.

Please note: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.

13. Continuity

In the event of the Policy under which You are a covered member and which is being discontinued or not renewed or You cease to be a member of the group, You have the option of taking a standard individual health policy from Us without any benefit of continuity of cover for any additional benefits that You may have enjoyed under this policy and for which additional premium has been charged. In such an event, all the waiting periods as stipulated under the individual health insurance policy will be applicable with due adjustment for the uninterrupted period in completed years for which You were covered under the Sampoorna Suraksha Bima issued by Us. However, any such benefit would be restricted to the maximum of Your eligibility of Sum Insured under the individual health insurance policy or the Sum Insured enjoyed by You under Hospitalisation Section under this Policy whichever is lower. Also, all the underwriting rules and regulations of our individual health insurance policy would be applicable for acceptance of such risk.

In case, where the Company may decide to withdraw Sampoorna Suraksha Bima Policy after prior approval from the Authority, option shall be available to You to migrate to nearest substitute product offered by the Company. The children, who have attended the maximum age under eligibility, can opt for nearest substitute health product offered by the Company on individual basis. Continuity benefits in all such cases shall be carried to the individual health insurance policy as per provisions mentioned above.

14. Discounts under the Policy

Sectional Discounts:

We will be creating packages of 2 or more covers from the above for offering them to the various customer groups / segments as per their specific requirements, the names of any specific package created shall be advised to IRDA prior to selling the same.

If coverage for more than one section is opted under the Policy, sectional discounts as mentioned below can be provided.

All four sections 10% discount

Sectional Discounts are not applicable for Group Policies.

Group Discount:

201 To 500 persons 10% discount
501 and above 15% on total premium

15) 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

Landline Numbers

(022)-27639800 or (022)-41582900 or (022)-41582999 or (022)-39133700 (Local Charges Apply)

E-mail Address

contactus@universalsompo.com.

Fax Numbers

(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 T oll 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.

18. 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: 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: 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

Sales Literature

1. What is the Eligibility Age under the Policy?

• Entry age of the Proposer is 18 years to 65 years.

• Children from 91 days to 25 years can be covered if any one of the Parent is insured under the Policy. Unmarried children can also be covered upto maximum of 25 years of age only. In case child gets married, the child will not be covered on next renewal. The cover will continue till the natural expiry of the Policy.

2. What is covered under the Policy?

Section 1: Fire Allied perils - Contents

This section covers contents located in dwelling units excluding money and valuables under this section. The coverage under this Section is against following perils:

  • Fire
  • Lightning
  • Explosion / Implosion
  • Aircraft Damage
  • Riot, Strike, Malicious and Terrorism Damage
  • Storm, Cyclone, Typhoon, Tempest, Hurricane, Tornado, Flood and Inundation
  • Impact Damage
  • Subsidence and Landslide including rock slide
  • Bursting and/or overflowing of Water Tanks, Apparatus and Pipes
  • Missile Testing operations
  • Leakage from Automatic Sprinkler Installations
  • Bush Fire
  • Earthquake
  • Terrorism

Sum Insured for Assets must be on Reinstatement Value basis.

Specific Exclusions to Section I

  • Damage caused by pressure waves.
  • Destruction or damage caused to the property by its own fermentation, natural heating or spontaneous combustion or its undergoing heating or drying process
  • Burning of property insured by order of any Public Authority.
  • Explosion/implosion losses to boilers (other than domestic boilers), economizers or other vessels, machinery or apparatus (in which steam is generated) including their contents.
  • Destruction or damage to property caused by centrifugal forces.
  • Damages caused by
    • Permanent or temporary dispossession of any building resulting from the unlawful occupation by any person of such building or prevention of access to the same.
    • Burglary, housebreaking, theft, larceny or any other such attempt or any omission of any kind of any person (whether or not such act is committed in connection with the disturbance of public peace) in any malicious act.
    • Total or partial cessation of work or the retardation or interruption or cessation of any process or operations or omissions of any kind
  • Damage by vehicle/animals belonging to or owned by You or Your Family.
  • Damages caused by :-
    • Normal cracking, settlement or bedding of structures.
    • Settlement or movement of made up ground.
    • Coastal or river erosion.
    • Defective design or workmanship or use of defective material
    • Demolition, construction, structural alteration or repair of any property or ground work or excavation.
  • Damage caused by
    • Repairs or alteration to Your Home.
    • Repairs, removal or extension of the sprinkler installation.
    • Defects in construction known to You.
  • Damages caused to the insured property by pollution or contamination.
  • Expenses necessarily incurred on Architect, Surveyor and Consulting Engineer’s fees and Debris Removal following Damage to property insured by an insured peril in excess of 3% and 1% of the claim amount respectively.
  • Loss of earnings, loss by delay, loss of market or other consequential or indirect loss or damage of any kind or description whatsoever.
  • Loss, destruction damage to any electrical machine, apparatus fixture or fittings arising from or occasioned by overrunning excessive pressure, short circuiting, arcing, self-heating or leakage of electricity from whatever cause (lightning included provided that this exclusion will apply only to the particular electrical machine, apparatus, fixture or fittings which may be destroyed or damaged by fire so set up.
  • Livestock or pets
  • Valuables as defined under the Policy, unless specifically covered.
  • Loss or damage to property insured if removed to any building or place other than in which it is herein stated, except machinery and equipment temporarily removed for repairs, cleaning, renovation or other similar purposes for a period not exceeding 60 days.
  • Liability in excess of First Loss Limit as stated in the Schedule

Section 2: Burglary Robbery

The Section covers loss or damage by actual or attempted burglary and/or robbery including theft during the Policy period in respect of the following:

(a) Contents or any item whilst kept in the insured premises

(b) Insured premises ( including reasonable costs for damaged locks)

There is an Option of availing the coverage under Section 1 and Section 2 on First Loss Basis i.e., the our liability shall be limited to the First Loss Limit which shall represent that percentage (25% or 50%, same under both the Sections) of total value at risk chosen by You to be insured, which shall be our maximum liability under this Section. After a loss the First Loss Limit shall have to be reinstated by payment of additional premium.

Specific Exclusions to Section 2

  • Loss or damage from any yard, garden outbuilding (including sheds or garages not attached to the building) or any other property outside the confines of the premises unless specified in the Schedule
  • Valuables and cash in safe/Almirah, unless specifically covered in the Schedule
  • Loss or damage of motor vehicles, trailers unless mentioned as covered in the Schedule
  • Loss or damage in which You, Your family members or any other person lawfully on or about Your premises is or is alleged to be in any way concerned or implicated
  • Loss or damage resulting from an act of Riot, Strike, Malicious Damage and Terrorism
  • Damage to glass and sign boards
  • Live stock
  • Loss or damage to contents or stock when the premises are left unoccupied for more than 30 consecutive days unless the same has been reported to us in writing and our written approval obtained.
  • Any consequential loss or legal liability
  • First Rs 2500/- under each and every claim

Section 3- Personal Accidents

This section covers Bodily injury to you and your dependants named in the Policy Schedule resulting to the death or disablement leading to following as per % mentioned in the Policy:

• Loss of sight

• Physical separation of or loss of ability to use both hands or both feet

• Physical separation of or loss of ability to use one hand and/or both feet

• Loss of sight of one eye and physical separation of or loss of ability to use either one hand or one foot

• Permanent Total disablement

Extra Benefits under the Policy in addition to capital sum Insured, in case the liability under the policy for Accidental Claim has been admitted.

A.Transportation cost for carriage of dead body to Home including funeral charges. 1% of Capital Sum Insured or 2,500/- (Two thousand five hundred) whichever is lower.
B.Cost of Clothing damaged in the Accident as described above and liability is admitted by US. Actual expenses subject to maximum of Rs 1000/
C.Ambulance charges for transportation of Insured person to Hospital following Accident Actual expenses subject to maximum of Rs 1000/
D.Education Fund:- In the event of Death, permanent total disablement of the proposer that is the first Insured Person, We will approve compensation towards Education Fund for up to two dependent children as below 5% (Five percent) of C.S.I at 2.5% per child.
E.Loss of Employment:- In the event of accident leading to loss of employment as a consequence of Permanent Total Disability as per the table of benefits. 2% of Capital Sum Insured.

Specific Exclusions to Section 3

  • Natural Death
  • Compensation under more than one of the benefits mentioned in Table of Benefits in respect of same period of disablement.
  • Any other payment after a claim under one of the benefits 1or2in Table of benefits has been admitted and becomes payable.
  • Any payment in case of more than one claim under this Section during any one period of Insurance by which our liability in that period would exceed CSI
  • Payment of compensation in respect of Death or injury as a consequence of/resulting from
    • Committing or attempting suicide, intentional self-injury.
    • Whilst under influence of intoxicating liquor or drugs.
    • The abuse or the consequences of the abuse of intoxicants or hallucinogenic substances such as drugs and alcohol.
    • Whilst engaged in any 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 and/or hazardous activities like Persons working in underground mines, explosives, workers involved in electrical installations with High- tension supply, jockeys, circus Personnel or activities of similar nature
    • Committing any breach of law with criminal intent.
    • War, Civil War, invasion, act of foreign enemies, revolution, insurrection, mutiny, military or usurped power, seizure, capture, arrest, restraint, or detainment, confiscation, or nationalization or requisition by or under the order of any government or public authority.
  • Consequential loss of any kind and/or any legal liability
  • Pregnancy including child birth, miscarriage, abortion or complication arising there from.
  • Participation in any naval, military or air force operations.
  • Curative treatments or interventions
  • Venereal or sexually transmitted diseases.
  • HIV and or related illness
  • Insured Person’s participation or involvement in naval, military or air force operation, racing, diving, aviation, scuba diving, parachuting, hang-gliding, rock or mountain climbing.

Section 4- Health Insurance Cover

This section covers the medical expenses incurred as an inpatient in respect of the treatment undergone by you and/or your family members – limited to self, spouse, children - due to accidental injury/illness sustained during the period of this Policy. The cover is also available for pre and post hospitalisation cover upto specified limits. There is no coverage available for any pre-existing diseases. The coverage excludes coverage of any diseases for first 30 days of the cover and specified illnesses for first year of cover.

Inpatient Treatment :- The Policy shall cover Insured members for expenses incurred subject to limits as per below for each and every day of hospitalization under the policy.

. Hospitalisation Benefits Limits
A

i. Room, Boarding expenses a provided by the Hospital/Nursing Home

ii. If admitted in IC Unit

iii. Registration Charges

i)Up to 1% of Sum Insured per day

ii)Up to 2% of Sum Insured per day

iii)At actuals

B Surgeon, Anaesthetist, Medical Practitioner, Consultants, Specialists Fees, Nursing Expenses Up to 25% of Sum Insured per illness/ Injury
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 40% of Sum Insured per illness/Injury

Pre- Hospitalisation :- Relevant medical expenses incurred 30 days prior to Insured being hospitalized shall be covered under the Policy.

I Post-Hospitalisation:- Relevant medical expenses incurred 60 days after Insured being hospitalized shall be covered under the Policy.

Domiciliary Hospitalisation :- expenses incurred on availing medical treatment at home which otherwise would have required hospitalisation .The Sum Insured under this benefit shall be limited to 20% of SI under the Policy.

Daily Allowance:- 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 shall be covered under the Policy.

Ambulance Charges:- Ambulance charges incurred in connection with an admissible claim limited to 1% of Sum Inured or Rs 1,000 whichever is less.s

Specific Exclusions to Section 4

  • Hospitalization/Domiciliary Hospitalization expenses arising from all Diseases/ Injuries which are in Pre-existing Condition.
    • Any claim occurring as a result of any condition, ailment or injury or related condition(s) for which the insured had signs or symptoms, and/or was diagnosed, and/or received medical advice/ treatment, within 48 months prior to the insured's first policy with the Company would not be payable until 48 months of continuous coverage have elapsed, since inception/reinstatement of the first policy with the Us.
  • Hospitalisation/Domiciliary Hospitalisation expenses for any Disease which incepts during first 30 days of commencement of this Insurance cover.
  • Hospitalization/Domiciliary Hospitalization expenses incurred in the first year of operation of the insurance cover on treatment of the following Diseases :
    • Cataract; Benign Prostatic Hypertrophy; Myomectomy, Hysterectomy; Hernia, Hydrocele; Fistula in anus, Piles; Arthritis, Gout, Rheumatism; Joint replacement unless warranted due to an accident; Sinusitis and related disorders; Medical Management of tonsillitis.; 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 haemorrhoids; Dialysis required for renal failure; Surgery on tonsils and sinuses; Gastric and duodenal ulcers;
  • Hospitalization for only Investigations and diagnosis.
  • 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).
  • 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.
  • Cost of spectacles and contact lens or hearing aids.
  • Dental treatment or surgery of any kind unless requiring inpatient hospitalization due to Accident.
  • Convalescence, general debility, run down condition or rest cure, external congenital disease or defects or anomalies, sterility, venereal disease, intentional self-injury and use of intoxicating drugs/alcohols.
  • Any expense on treatment related to HIV, AIDS and all related medical conditions.
  • Expenses on Diagnostic, X-Ray, or Laboratory examinations unless related to the treatment of Disease or Injury falling within ambit of Hospitalization claim.
  • Expenses on treatment arising from any infertility, sub fertility or assisted conception treatment.
  • Expenses on Voluntary termination of pregnancy within first 12 Weeks.
  • Injury or Diseases directly or indirectly caused by or contributed to by nuclear weapons/material.
  • Any expense on treatment of Insured Person as an outpatient in a Hospital.
  • 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.
  • Expenses on treatment arising from or traceable to pregnancy, childbirth, miscarriage, an accidental abortion or complications of any of these, including caesarean section. This exclusion is not applicable to ectopic pregnancy.
  • Any Expense of any treatment related to Human T-Cell Lymphotropic Viruses types III (III-LB-III) or Lymphadinopathy Associated Viruses (LAV) or the Mutant derivatives or Variations Deficiency Syndrome.
  • External medical equipment of any kind used at home as post hospitalization 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.
  • War, riots, strike, terrorism acts, nuclear weapon induced treatment section.

3. Conditions Under the Policy

Renewal

  • 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
  • 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.
  • 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.
  • 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
  • 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.
  • 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.
  • All premiums are payable in advance of any cover under this Policy being provided.
  • The basic premium applicable under the Policy may be revised at a later stage subject to approval from IRDA.
  • 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.

Please note: 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.

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. In such circumstances you will not be entitled to any refund.

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

Continuity

In the event of the Policy under which You are a covered member and which is being discontinued or not renewed or You cease to be a member of the group, You shall have the option of taking a standard individual health policy from Us in which due adjustment for the uninterrupted period in completed years for which You were covered under the Sampoorna Suraksha Bima issued by Us shall be made.

In case, where the Company may decide to withdraw Sampoorna Suraksha Bima Policy after prior approval from the Authority, option shall be available to You to migrate to nearest substitute product offered by the Company. The children, who have attended the maximum age under eligibility, can opt for nearest substitute health product offered by the Company on individual basis. Continuity benefits in all such cases shall be carried to the individual health insurance policy as per provisions mentioned above.

4. CLAIMS PROCEDURE

1. Claim Intimation

In the unfortunate event of any medical contingency/ loss 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 (other users) or on chargeable numbers at +91-22-26748600 / +91-22-41582900 / +91-22-41582999 or email at contactclaims@universalsompo.com. Please note that no delay should be allowed to occur in notifying a claim on the policy as the same may prejudice liability.

2. Submission of documents

Insured must submit any or all of the below mentioned document(s) as requested by us for settling Insured’s claim within 15 days ( 30 days for Hospitalisation claims) from date of intimating the claim.

Claim Documents for Section I and Section II

  • Duly completed Claim form
  • Copy of FIR
  • Estimate of loss/repairs
  • Invoice/Bills/Receipts
  • FR
  • Any other details/documents called for a specific loss

Claims documents for Section III

For Death Claim

  • Duly filled up claim form
  • Death Certificate
  • Original FIR
  • Original Panchnama
  • Post mortem report if conducted

For Permanent Total Disablement

  • Duly filled up claims form
  • Original FIR
  • Panchnama
  • Hospitalization Report
  • Hospital discharge card
  • Original Certificate from Doctor of Govt. Hospital stating the degree of disability
  • Termination letter for claim under “Loss of Employment”

Claim Documents for Section IVt

  • Copy of the original bills
  • Receipts
  • Certificates, information and evidences from the attending Medical Practitioner/ Hospital/ Chemist/ Laboratory as required by Us.

Claims Settlement

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

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.

5. Third Party Administrator: Family Health Plan Limited

6. Premium

Section Rates Remarks
Section 1 Fire and Allied Perils- Building Contents

Basic Rate: 0.25%

Earthquake: 0.05%

Terrorism: 0.10%

Policy on First loss:

  • For 25% First loss: Limit Rate is 0.15% applicable on the 100% value at risk Total rate :0.25%
  • For 50% First loss: Limit Rate is 0.21% applicable on the 100% value at risk Total rate :0.31%
The basic rate is line with the basic rates filed by us as per the “FILE USE” guidelines for “Fire Special Perils Policy for Dwellings and household contents
Section 2 Burglary Robbery

Rs 1.0%o for Full Value cover

Policy on First loss:

  • For 25% First loss: Limit Rate is 0.25% on 100% of value at risk
  • For 50% First loss: Limit Rate is 0.50% on
---- Do -----

7. Premium chart for Section 4 – Health Cover:

Premium - Self Only (upto 50 years of age )
Sum Insured 10,000 20,000 30,000
Premium 268 384 537
Sum Insured 10,000 20,000 30,000
Premium 658 940 1316

For sum insured Option of Rs 30,000

Up to Premium in RS. for self Age of head of family Premium for Self Spouse and two dependent children
51 to 55 600/- 51 to 55 1400/-
56 to 60 660/- 56 to 60 1540/-
61 to 65 730/- 61 to 65 1700/-
66 to 70 840/- 66 to 70 1955/-
71 to 75 965/- 71 to 75 2248/-
75 to 80 1110/- 75 to 80 2585/-

* Above Premium figures are exclusive of Service Tax

Service Tax exemption: Premium paid under Section 4 – Health Insurance is exempt from Service tax under Section 80 D of Income tax act if Premium is paid by your own cheque.

8. Discounts:

Sectional Discounts:

We will be creating packages of 2 or more covers from the above for offering them to the various customer groups / segments as per their specific requirements, the names of any specific package created shall be advised to IRDA prior to selling the same.

If coverage for more than one section is opted under the Policy, sectional discounts as mentioned below can be provided.

All four sections 10% discount

Sectional Discounts are not applicable for Group Policies.

201 To 500 persons 10% discount
501 and above 15% on total premium

Statutory Warning: No person shall allow or offer to allow, either directly or indirectly, as an inducement to any person to take out or renew or continue an insurance in respect of any kind of risk relating to lives or property in India, any rebate of the whole part of the commission payable or any rebate of the premium shown on the policy nor shall any person taking out or renewing or continuing a policy accept any rebate, except such rebates as may be allowed in accordance with the published prospectuses or tables of the Insurer. Any person making default in complying with the provisions of this section shall be punishable with fine which may extend to Ten Lakh Rupees

Please note: The prospectus contains only an indication of cover offered, for complete details on terms, conditions, coverages and exclusions please get in touch with us or our agent and read policy wordings carefully before concluding a sale. Insurance is a subject matter of solicitation. 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.

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

SENIOR CITIZEN HEALTH INSURANCE POLICY

The Policy can be taken by a Senior Citizen who is above 60 years of age for covering himself/ herself and his/her spouse.

The following conditions shall apply for seeking coverage under the Policy

  • You must be above 60 years of age on last birthday for taking a policy.
  • Must be a permanent resident of India
  • Maximum entry age under the Policy for you and your spouse is restricted to 70 years. The renewals under the Policy shall, however, be provided for lifetime.

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

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 Rs. 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

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.

The Policy comprises of below two sections

Section – A- Hospitalisation

This Section is mandatory to be taken under the Policy.

The following benefits shall become payable under this section. The cover shall be available to both the Insured and his/ her spouse if covered under the Policy.

Benefits under Section A

Inpatient Treatment:- The Policy shall cover you for expenses incurred subject to limits as per below for each and every day of hospitalization under the policy.

S. No Hospitalisation Sum Insured 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 per day or actuals whichever is less

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

Day Care Procedures/ Surgeries:- Specified Procedures / Surgeries requiring less than 24 hours of hospitalization would be covered under the Policy.( Please see annexure for complete details)

Pre- Hospitalisation: - Relevant medical expenses incurred 30 days prior to your being hospitalized shall be covered under the Policy.

Post-Hospitalisation:- Relevant medical expenses incurred 60 days after your being discharged from hospital shall be covered under the Policy.

Domiciliary Hospitalisation: - expenses incurred on availing medical treatment at home which otherwise would have required hospitalisation .The Sum Insured under this benefit shall be limited to 50% of SI or the actual amount incurred whichever is less under the Policy.

Cost of Health Check-up: - the charges incurred for medical check-up once in a block of every 3 claims free years up to 1.25% of the average Sum Insured or the actual amount incurred whichever is less. In case of floater policies, the limit of 1.25% shall be for the two family members covered under the Policy.

Daily Allowance:- 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 shall be covered under the Policy.

Ambulance Charges: - Ambulance charges incurred for engaging an ambulance for transferring yourself to a hospital to the extent of 1% of SI or Rs. 1500 or the actual amount incurred in such transportation shall be payable under the Policy.

Expenses of accompanying person: - Expenses incurred up to 1% of Sum Insured or the actual amount incurred whichever is less for the person accompanying you shall be payable under the policy.

Sublimits under the Policy:

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.

No other sublimits for any major surgery or procedure other than the ones mentioned above shall be applicable under the policy.

Section B- Critical Illness (Optional)

You also have the option of covering listed Critical Illnesses and/ or Surgical Procedures under the Policy.

On diagnosis or undergoing of below mentioned Critical Illness or Surgical Procedure, the Sum Insured opted under this section shall become payable under the Policy. The Sum Insured under this section shall be in addition to hospitalisation sum insured.

  • Cancer of specified severity
  • Open Chest CABG
  • Kidney Failure requiring regular dialysis
  • Stroke resulting in permanent symptoms
  • Major Organ /Bone Marrow Transplant
  • Multiple Sclerosis with persisting symptoms

Provided that, we will not cover

1. Any Illness, sickness or disease , other than the above specified Critical Illness.

Any Critical Illness of which, the signs or symptoms first occurred prior to or within Ninety (90) days following the Policy Issue Date unless due credit for such time bound exclusion has been accrued in previous similar health insurance policy from us or any of Indian insurers.

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.

Extensions/ Endorsement under the Policy

Floater Benefit: With this extension, the Sum Insured under the mandatory section A- Hospitalisation shall be available on floater basis.

1. Cumulative Bonus

Subject to no claims and continuous renewal of the Policy with us, the Sum Insured under the Policy under Section A “Hospitalisation” shall be increased by 5% subject to maximum of 10 such non claim years.

In case of claim under this section, the increased percentage will be reduced by 5% of sum insured at the next renewal. However, basic sum insured will be maintained and will not be reduced. Cumulative Bonus incurred in previous health insurance policies held by you with us or any of the Indian Insurers shall be allowed to be carried forward to this Policy.

2. Long Term Policy: 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 is available for payment of premium under the Policy.

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

3. Family discount: A family discount of 10% shall be applicable on hospitalisation premium when you opt for covering your 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.

4. Sum Insureds Options: The Policy provides Sum Insured starting from 1 Lakh to 5 Lakhs Rupees for each section Hospitalisation and Critical Illness.

5. Portability

1. If You were insured continuously and without a break under another 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
  • 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

6. Free Look –up Period:

1. We shall provide you a free look period under the policy. The free look period shall be applicable at the inception of the policy and:

  • 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. 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

7. Conditions under the Policy

Options available to you

1. You can opt for any Sum Insured under both the sections of the Policy, in other words, the Sum Insured under both the sections need not be identical.

2. You may choose to cover your spouse under individual Sum Insured basis or on floater basis. When you choose to cover your spouse under the Policy on individual SI under the Policy, we shall provide you a discount of 10% on your total hospitalisation premium.

3. The cover under Section B- Critical Illness shall be available only on individual Sum Insured.

Premium for Hospitalisation ( Individual Plan/ 1 Adult)
Age/ Sum Insured 1,00,000 2,00,000 3,00,000 4,00,000 5,00,000
60-65 years 4358 8820 13493 16196 18848
66-70 years 5403 10937 16731 20083 23371
71-75 years 5796 11731 17946 21541 25068
76-80 years 7130 14429 22072 26496 30832
80-85 years 7628 15438 23618 28350 32991
86-90 years 9383 18989 29049 34871 40578
90 years 11259 22787 34859 41845 48694
Premium for Hospitalisation ( 1+ 1 Adult Plan on Individual Sum Insured basis)
Age/ Sum Insured 1,00,000 2,00,000 3,00,000 4,00,000 5,00,000
60-65 years 8279 16758 25636 30773 35810
66-70 years 10266 20780 31789 38158 44405
71-75 years 11012 22288 34097 40928 47629
76-80 years 13546 27416 41937 50342 58582
80-85 years 14494 29333 44874 53865 62683
86-90 years 17827 36080 55193 66254 77098
90 years 21393 43296 66232 79505 92519
Premium for Hospitalisation ( 1 + 1 Adult Plan on Floater Sum Insured basis)
Age/ Sum Insured 1,00,000 2,00,000 3,00,000 4,00,000 5,00,000
60-65 years 6101 12348 18890 22675 26387
66-70 years 7564 15311 23423 28117 32719
71-75 years 8114 16423 25123 30157 35095
76-80 years 9981 20201 30900 37094 43166
80-85 years 10680 21613 33065 39690 46187
86-90 years 9383 26585 40669 48819 56809
90 years 15763 31902 48803 58583 68171
Premium for Critical Illness Insurance ( Applicable for each Insured person on Individual SI basis only)
Age/ Sum Insured 1,00,000 2,00,000 3,00,000 4,00,000 5,00,000
60-65 years 2179 4410 6746 8099 9424
66-70 years 2702 5468 8365 10042 11685
71-75 years 2898 5865 8973 10771 12534
76-80 years 3565 7215 11037 13248 15416
80-85 years 3815 7720 11809 14175 16496
86-90 years 4691 9495 14525 17435 20289
90 years 5630 11394 17430 20922 24347

Note

1 Rates are excluding all taxes, cess and duties ( as applicable)

The Hospitalisation premium can be opted for the spouse either on Individual SI basis or floater basis

The cover for optional Section B- Critical Illness shall be available on individual Sum Insured basis only

4. Avail of tax benefit under section 80D of Income Tax Act, 1961 on the premium payable under the Policy ( Tax benefits are subject to change as per change in Tax Laws)

1. Cancellation Terms

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.

2. Co-pay

Co-Payment means a cost-sharing requirement applicable under this Policy in which you shall bear the percentage of the admissible claim amount which is specified in the table below. A Co-Payment does not reduce or otherwise affect the Sum Insured. This is applicable for all roll-over cases (cases of portability) as well.

Admissible on all hospitalisation claims under the Policy 10% shall apply
Arising out of pre-existing diseases (including for roll-over cases) 20% shall apply except for claims arising under Section B- Critical Illness
Day Care Procedures 15% shall apply
Packaged Charges by Hospital No co-pay shall be applicable on packaged charges by Hospital
  • 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 years except for Section B- Critical Illness where the cover under the section, if available, shall terminate for the Insured Person on whose behalf We have admitted and paid claim under the Section. The Policy for hospitalisation for you and your spouse, if covered, shall however continue to exist.
  • 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 subject to approval from IRDA. We also agree that no loading on premium shall be applicable on your individual claims experience basis.

4. 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.

5. 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

6. 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.

7. Multiple Policies

i. If two or more policies are taken by you during the period for which you are 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 i.e. Section B- Critical Illness Cover, if opted in the Policy;
  • does not have any relation to the treatment costs;
  • We also agree that even if, you are covered under multiple policies providing Critical Illness cover, we shall make the claim payments independent of payments received under other similar polices in respect of the covered event.
  • We agree that even if two or more policies are taken by you during the time for which you are 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 the deductible and co-pay, You shall have the right to choose any insurers including us by whom the claim to be settled. In such cases, We shall settle the claim with contribution clause
  • Except for the benefit Section B- Critical Illness, in case if you have taken policies from us and one or more insurers to cover the same risk on indemnity basis , you shall only be indemnified the hospitalisation costs in accordance with the terms and condition of the Policy.

8. 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.

9. Loadings under the Policy:

a) 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.

b) Health status loading: We shall load premium up to 100% under the Policy as under depending on the 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
4 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
6 Any disease co-existing with any of the above
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%

c) 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(s) 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.

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

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:

1. 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 similar health insurance policy;
  • AND
  • b) 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 health insurance policy from Us or any other insurer 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;

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. Claim Intimation

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: 1800-200-5142, Chargeable Numbers. - 022–39635200, Fax Toll Free Numbers: 1800-200-9134 or email at contactclaims@universalsompo.com. Please note that no delay should be allowed to occur in notifying a claim on the policy as the same may prejudice liability.

2. Submission of documents

Details as given in claim form should be submitted to the Company with a period of 30 days from date of intimation.

Claim Documents:

You must submit any or all of the below mentioned document(s) as requested by us for settling your claim within 30 days from date of intimating the claim.

  • 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.

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

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.

For all your service requests e-mail us at contactus@universalsompo.com

Statutory Warning:No person shall allow or offer to allow, either directly or indirectly, as an inducement to any person to take out or renew or continue an insurance in respect of any kind of risk relating to lives or property in India, any rebate of the whole part of the commission payable or any rebate of the premium shown on the policy nor shall any person taking out or renewing or continuing a policy accept any rebate, except such rebates as may be allowed in accordance with the published prospectuses or tables of the Insurer. Any person making default in complying with the provisions of this section shall be punishable with fine which may extend to Ten Lakh Rupees

Please note: The prospectus contains only an indication of cover offered, for complete details on terms, conditions, coverages and exclusions please get in touch with us or our agent and read policy wordings carefully before concluding a sale. Insurance is a subject matter of solicitation. 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: 1800-200-5142, Chargeable Numbers. - 022–39635200, Fax Toll Free Numbers: 1800-200-9134.

In-House Claim Management

Click to view In-House Claim Management Process

1. What is the Eligibility Age under the Policy?

• Entry age of the Proposer is 18 years to 65 years.

• Children from 91 days to 25 years can be covered if any one of the Parent is insured under the Policy. Unmarried children can also be covered upto maximum of 25 years of age only. In case child gets married, the child will not be covered on next renewal. The cover will continue till the natural expiry of the Policy.

2. What is covered under the Policy?

Section 1: Fire Allied perils - Contents

This section covers contents located in dwelling units excluding money and valuables under this section. The coverage under this Section is against following perils:

  • Fire
  • Lightning
  • Explosion / Implosion
  • Aircraft Damage
  • Riot, Strike, Malicious and Terrorism Damage
  • Storm, Cyclone, Typhoon, Tempest, Hurricane, Tornado, Flood and Inundation
  • Impact Damage
  • Subsidence and Landslide including rock slide
  • Bursting and/or overflowing of Water Tanks, Apparatus and Pipes
  • Missile Testing operations
  • Leakage from Automatic Sprinkler Installations
  • Bush Fire
  • Earthquake
  • Terrorism

Sum Insured for Assets must be on Reinstatement Value basis.

Specific Exclusions to Section I

  • Damage caused by pressure waves.
  • Destruction or damage caused to the property by its own fermentation, natural heating or spontaneous combustion or its undergoing heating or drying process
  • Burning of property insured by order of any Public Authority.
  • Explosion/implosion losses to boilers (other than domestic boilers), economizers or other vessels, machinery or apparatus (in which steam is generated) including their contents.
  • Destruction or damage to property caused by centrifugal forces.
  • Damages caused by
    • Permanent or temporary dispossession of any building resulting from the unlawful occupation by any person of such building or prevention of access to the same.
    • Burglary, housebreaking, theft, larceny or any other such attempt or any omission of any kind of any person (whether or not such act is committed in connection with the disturbance of public peace) in any malicious act.
    • Total or partial cessation of work or the retardation or interruption or cessation of any process or operations or omissions of any kind
  • Damage by vehicle/animals belonging to or owned by You or Your Family.
  • Damages caused by :-
    • Normal cracking, settlement or bedding of structures.
    • Settlement or movement of made up ground.
    • Coastal or river erosion.
    • Defective design or workmanship or use of defective material
    • Demolition, construction, structural alteration or repair of any property or ground work or excavation.
  • Damage caused by
    • Repairs or alteration to Your Home.
    • Repairs, removal or extension of the sprinkler installation.
    • Defects in construction known to You.
  • Damages caused to the insured property by pollution or contamination.
  • Expenses necessarily incurred on Architect, Surveyor and Consulting Engineer’s fees and Debris Removal following Damage to property insured by an insured peril in excess of 3% and 1% of the claim amount respectively.
  • Loss of earnings, loss by delay, loss of market or other consequential or indirect loss or damage of any kind or description whatsoever.
  • Loss, destruction damage to any electrical machine, apparatus fixture or fittings arising from or occasioned by overrunning excessive pressure, short circuiting, arcing, self-heating or leakage of electricity from whatever cause (lightning included provided that this exclusion will apply only to the particular electrical machine, apparatus, fixture or fittings which may be destroyed or damaged by fire so set up.
  • Livestock or pets
  • Valuables as defined under the Policy, unless specifically covered.
  • Loss or damage to property insured if removed to any building or place other than in which it is herein stated, except machinery and equipment temporarily removed for repairs, cleaning, renovation or other similar purposes for a period not exceeding 60 days.
  • Liability in excess of First Loss Limit as stated in the Schedule

Section 2: Burglary Robbery

The Section covers loss or damage by actual or attempted burglary and/or robbery including theft during the Policy period in respect of the following:

(a) Contents or any item whilst kept in the insured premises

(b) Insured premises ( including reasonable costs for damaged locks)

There is an Option of availing the coverage under Section 1 and Section 2 on First Loss Basis i.e., the our liability shall be limited to the First Loss Limit which shall represent that percentage (25% or 50%, same under both the Sections) of total value at risk chosen by You to be insured, which shall be our maximum liability under this Section. After a loss the First Loss Limit shall have to be reinstated by payment of additional premium.

Specific Exclusions to Section 2

  • Loss or damage from any yard, garden outbuilding (including sheds or garages not attached to the building) or any other property outside the confines of the premises unless specified in the Schedule
  • Valuables and cash in safe/Almirah, unless specifically covered in the Schedule
  • Loss or damage of motor vehicles, trailers unless mentioned as covered in the Schedule
  • Loss or damage in which You, Your family members or any other person lawfully on or about Your premises is or is alleged to be in any way concerned or implicated
  • Loss or damage resulting from an act of Riot, Strike, Malicious Damage and Terrorism
  • Damage to glass and sign boards
  • Live stock
  • Loss or damage to contents or stock when the premises are left unoccupied for more than 30 consecutive days unless the same has been reported to us in writing and our written approval obtained.
  • Any consequential loss or legal liability
  • First Rs 2500/- under each and every claim

Section 3- Personal Accidents

This section covers Bodily injury to you and your dependants named in the Policy Schedule resulting to the death or disablement leading to following as per % mentioned in the Policy:

• Loss of sight

• Physical separation of or loss of ability to use both hands or both feet

• Physical separation of or loss of ability to use one hand and/or both feet

• Loss of sight of one eye and physical separation of or loss of ability to use either one hand or one foot

• Permanent Total disablement

Extra Benefits under the Policy in addition to capital sum Insured, in case the liability under the policy for Accidental Claim has been admitted.

A.Transportation cost for carriage of dead body to Home including funeral charges. 1% of Capital Sum Insured or 2,500/- (Two thousand five hundred) whichever is lower.
B.Cost of Clothing damaged in the Accident as described above and liability is admitted by US. Actual expenses subject to maximum of Rs 1000/
C.Ambulance charges for transportation of Insured person to Hospital following Accident Actual expenses subject to maximum of Rs 1000/
D.Education Fund:- In the event of Death, permanent total disablement of the proposer that is the first Insured Person, We will approve compensation towards Education Fund for up to two dependent children as below 5% (Five percent) of C.S.I at 2.5% per child.
E.Loss of Employment:- In the event of accident leading to loss of employment as a consequence of Permanent Total Disability as per the table of benefits. 2% of Capital Sum Insured.

Specific Exclusions to Section 3

  • Natural Death
  • Compensation under more than one of the benefits mentioned in Table of Benefits in respect of same period of disablement.
  • Any other payment after a claim under one of the benefits 1or2in Table of benefits has been admitted and becomes payable.
  • Any payment in case of more than one claim under this Section during any one period of Insurance by which our liability in that period would exceed CSI
  • Payment of compensation in respect of Death or injury as a consequence of/resulting from
    • Committing or attempting suicide, intentional self-injury.
    • Whilst under influence of intoxicating liquor or drugs.
    • The abuse or the consequences of the abuse of intoxicants or hallucinogenic substances such as drugs and alcohol.
    • Whilst engaged in any 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 and/or hazardous activities like Persons working in underground mines, explosives, workers involved in electrical installations with High- tension supply, jockeys, circus Personnel or activities of similar nature
    • Committing any breach of law with criminal intent.
    • War, Civil War, invasion, act of foreign enemies, revolution, insurrection, mutiny, military or usurped power, seizure, capture, arrest, restraint, or detainment, confiscation, or nationalization or requisition by or under the order of any government or public authority.
  • Consequential loss of any kind and/or any legal liability
  • Pregnancy including child birth, miscarriage, abortion or complication arising there from.
  • Participation in any naval, military or air force operations.
  • Curative treatments or interventions
  • Venereal or sexually transmitted diseases.
  • HIV and or related illness
  • Insured Person’s participation or involvement in naval, military or air force operation, racing, diving, aviation, scuba diving, parachuting, hang-gliding, rock or mountain climbing.

Section 4- Health Insurance Cover

This section covers the medical expenses incurred as an inpatient in respect of the treatment undergone by you and/or your family members – limited to self, spouse, children - due to accidental injury/illness sustained during the period of this Policy. The cover is also available for pre and post hospitalisation cover upto specified limits. There is no coverage available for any pre-existing diseases. The coverage excludes coverage of any diseases for first 30 days of the cover and specified illnesses for first year of cover.

Inpatient Treatment :- The Policy shall cover Insured members for expenses incurred subject to limits as per below for each and every day of hospitalization under the policy.

. Hospitalisation Benefits Limits
A

i. Room, Boarding expenses a provided by the Hospital/Nursing Home

ii. If admitted in IC Unit

iii. Registration Charges

i)Up to 1% of Sum Insured per day

ii)Up to 2% of Sum Insured per day

iii)At actuals

B Surgeon, Anaesthetist, Medical Practitioner, Consultants, Specialists Fees, Nursing Expenses Up to 25% of Sum Insured per illness/ Injury
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 40% of Sum Insured per illness/Injury

Pre- Hospitalisation :- Relevant medical expenses incurred 30 days prior to Insured being hospitalized shall be covered under the Policy.

I Post-Hospitalisation:- Relevant medical expenses incurred 60 days after Insured being hospitalized shall be covered under the Policy.

Domiciliary Hospitalisation :- expenses incurred on availing medical treatment at home which otherwise would have required hospitalisation .The Sum Insured under this benefit shall be limited to 20% of SI under the Policy.

Daily Allowance:- 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 shall be covered under the Policy.

Ambulance Charges:- Ambulance charges incurred in connection with an admissible claim limited to 1% of Sum Inured or Rs 1,000 whichever is less.s

Specific Exclusions to Section 4

  • Hospitalization/Domiciliary Hospitalization expenses arising from all Diseases/ Injuries which are in Pre-existing Condition.
    • Any claim occurring as a result of any condition, ailment or injury or related condition(s) for which the insured had signs or symptoms, and/or was diagnosed, and/or received medical advice/ treatment, within 48 months prior to the insured's first policy with the Company would not be payable until 48 months of continuous coverage have elapsed, since inception/reinstatement of the first policy with the Us.
  • Hospitalisation/Domiciliary Hospitalisation expenses for any Disease which incepts during first 30 days of commencement of this Insurance cover.
  • Hospitalization/Domiciliary Hospitalization expenses incurred in the first year of operation of the insurance cover on treatment of the following Diseases :
    • Cataract; Benign Prostatic Hypertrophy; Myomectomy, Hysterectomy; Hernia, Hydrocele; Fistula in anus, Piles; Arthritis, Gout, Rheumatism; Joint replacement unless warranted due to an accident; Sinusitis and related disorders; Medical Management of tonsillitis.; 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 haemorrhoids; Dialysis required for renal failure; Surgery on tonsils and sinuses; Gastric and duodenal ulcers;
  • Hospitalization for only Investigations and diagnosis.
  • 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).
  • 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.
  • Cost of spectacles and contact lens or hearing aids.
  • Dental treatment or surgery of any kind unless requiring inpatient hospitalization due to Accident.
  • Convalescence, general debility, run down condition or rest cure, external congenital disease or defects or anomalies, sterility, venereal disease, intentional self-injury and use of intoxicating drugs/alcohols.
  • Any expense on treatment related to HIV, AIDS and all related medical conditions.
  • Expenses on Diagnostic, X-Ray, or Laboratory examinations unless related to the treatment of Disease or Injury falling within ambit of Hospitalization claim.
  • Expenses on treatment arising from any infertility, sub fertility or assisted conception treatment.
  • Expenses on Voluntary termination of pregnancy within first 12 Weeks.
  • Injury or Diseases directly or indirectly caused by or contributed to by nuclear weapons/material.
  • Any expense on treatment of Insured Person as an outpatient in a Hospital.
  • 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.
  • Expenses on treatment arising from or traceable to pregnancy, childbirth, miscarriage, an accidental abortion or complications of any of these, including caesarean section. This exclusion is not applicable to ectopic pregnancy.
  • Any Expense of any treatment related to Human T-Cell Lymphotropic Viruses types III (III-LB-III) or Lymphadinopathy Associated Viruses (LAV) or the Mutant derivatives or Variations Deficiency Syndrome.
  • External medical equipment of any kind used at home as post hospitalization 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.
  • War, riots, strike, terrorism acts, nuclear weapon induced treatment section.

3. Conditions Under the Policy

Renewal

  • 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
  • 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.
  • 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.
  • 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
  • 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.
  • 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.
  • All premiums are payable in advance of any cover under this Policy being provided.
  • The basic premium applicable under the Policy may be revised at a later stage subject to approval from IRDA.
  • 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.

Please note: 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.

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. In such circumstances you will not be entitled to any refund.

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

Continuity

In the event of the Policy under which You are a covered member and which is being discontinued or not renewed or You cease to be a member of the group, You shall have the option of taking a standard individual health policy from Us in which due adjustment for the uninterrupted period in completed years for which You were covered under the Sampoorna Suraksha Bima issued by Us shall be made.

In case, where the Company may decide to withdraw Sampoorna Suraksha Bima Policy after prior approval from the Authority, option shall be available to You to migrate to nearest substitute product offered by the Company. The children, who have attended the maximum age under eligibility, can opt for nearest substitute health product offered by the Company on individual basis. Continuity benefits in all such cases shall be carried to the individual health insurance policy as per provisions mentioned above.

4. CLAIMS PROCEDURE

1. Claim Intimation

In the unfortunate event of any medical contingency/ loss 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 (other users) or on chargeable numbers at +91-22-26748600 / +91-22-41582900 / +91-22-41582999 or email at contactclaims@universalsompo.com. Please note that no delay should be allowed to occur in notifying a claim on the policy as the same may prejudice liability.

2. Submission of documents

Insured must submit any or all of the below mentioned document(s) as requested by us for settling Insured’s claim within 15 days ( 30 days for Hospitalisation claims) from date of intimating the claim.

Claim Documents for Section I and Section II

  • Duly completed Claim form
  • Copy of FIR
  • Estimate of loss/repairs
  • Invoice/Bills/Receipts
  • FR
  • Any other details/documents called for a specific loss

Claims documents for Section III

For Death Claim

  • Duly filled up claim form
  • Death Certificate
  • Original FIR
  • Original Panchnama
  • Post mortem report if conducted

For Permanent Total Disablement

  • Duly filled up claims form
  • Original FIR
  • Panchnama
  • Hospitalization Report
  • Hospital discharge card
  • Original Certificate from Doctor of Govt. Hospital stating the degree of disability
  • Termination letter for claim under “Loss of Employment”

Claim Documents for Section IVt

  • Copy of the original bills
  • Receipts
  • Certificates, information and evidences from the attending Medical Practitioner/ Hospital/ Chemist/ Laboratory as required by Us.

Claims Settlement

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

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.

5. Third Party Administrator: Family Health Plan Limited

6. Premium

Section Rates Remarks
Section 1 Fire and Allied Perils- Building Contents

Basic Rate: 0.25%

Earthquake: 0.05%

Terrorism: 0.10%

Policy on First loss:

  • For 25% First loss: Limit Rate is 0.15% applicable on the 100% value at risk Total rate :0.25%
  • For 50% First loss: Limit Rate is 0.21% applicable on the 100% value at risk Total rate :0.31%
The basic rate is line with the basic rates filed by us as per the “FILE USE” guidelines for “Fire Special Perils Policy for Dwellings and household contents
Section 2 Burglary Robbery

Rs 1.0%o for Full Value cover

Policy on First loss:

  • For 25% First loss: Limit Rate is 0.25% on 100% of value at risk
  • For 50% First loss: Limit Rate is 0.50% on
---- Do -----

7. Premium chart for Section 4 – Health Cover:

Premium - Self Only (upto 50 years of age )
Sum Insured 10,000 20,000 30,000
Premium 268 384 537
Sum Insured 10,000 20,000 30,000
Premium 658 940 1316

For sum insured Option of Rs 30,000

Up to Premium in RS. for self Age of head of family Premium for Self Spouse and two dependent children
51 to 55 600/- 51 to 55 1400/-
56 to 60 660/- 56 to 60 1540/-
61 to 65 730/- 61 to 65 1700/-
66 to 70 840/- 66 to 70 1955/-
71 to 75 965/- 71 to 75 2248/-
75 to 80 1110/- 75 to 80 2585/-

* Above Premium figures are exclusive of Service Tax

Service Tax exemption: Premium paid under Section 4 – Health Insurance is exempt from Service tax under Section 80 D of Income tax act if Premium is paid by your own cheque.

8. Discounts:

Sectional Discounts:

We will be creating packages of 2 or more covers from the above for offering them to the various customer groups / segments as per their specific requirements, the names of any specific package created shall be advised to IRDA prior to selling the same.

If coverage for more than one section is opted under the Policy, sectional discounts as mentioned below can be provided.

All four sections 10% discount

Sectional Discounts are not applicable for Group Policies.

201 To 500 persons 10% discount
501 and above 15% on total premium

Statutory Warning: No person shall allow or offer to allow, either directly or indirectly, as an inducement to any person to take out or renew or continue an insurance in respect of any kind of risk relating to lives or property in India, any rebate of the whole part of the commission payable or any rebate of the premium shown on the policy nor shall any person taking out or renewing or continuing a policy accept any rebate, except such rebates as may be allowed in accordance with the published prospectuses or tables of the Insurer. Any person making default in complying with the provisions of this section shall be punishable with fine which may extend to Ten Lakh Rupees

Please note: The prospectus contains only an indication of cover offered, for complete details on terms, conditions, coverages and exclusions please get in touch with us or our agent and read policy wordings carefully before concluding a sale. Insurance is a subject matter of solicitation. 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.

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

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.

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.

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;

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.

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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:

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 : HTTPS://www.gbic.co.in/ombudsman.html

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

While it is important for you to adopt a healthy lifestyle, it is also important to have a Complete Health insurance plan which will take care of most of the medical expenses that you may incur.

The Complete Healthcare Insurance comes with comprehensive plans that reimburse medical expenses incurred in a hospital and also the out-patient charges and various value added services

3 Easy Steps choose your plan type:

  • Individual Basis or Family Floater
  • Choose your plan option: Basic or Essential or Privilege
  • Choose the Sum Insured and product options steps Down To Own Your Plan

Plans that fits every need, lifestyle and budget

What‘s more!!! Your dependent children can be covered upto 25 years of age under all our plans.

Please click on the relevant link below to view its detailed information .

Prospectus
Policy Wordings
Day Care Annexure
List of expenses excluded
Prospectus
Policy Wording
Prospectus
Policy Wording
Endorsement and Extensions Wordings
Prospectus
Policy Wording
Prospectus
Policy Wording
PROSPECTUS

With the many uncertainties that we are faced with in life, we would want to secure it by preparing for the unexpected. Critical Illness Insurance can help remove many of your financial worries and concentrate on getting better if you became critically ill.

The Policy can be taken by an Individual for covering himself/herself, his/her spouse, his/her and/ or parents/ parents-in-law

The Sum Insured under the Policy shall be available on individual basis only

For Proposer

  • You must be a resident of India
  • Entry age for you (the proposer) is 18 years and you can opt for this policy up to the age of 65 years.
  • Other eligibility conditions for all persons proposed for insurance under the Policy
  • Minimum Entry age: 5 years as on last birthday
  • Maximum Entry age Policy : 65 years as on last birthday

We may ask you or any person proposed for insurance under the Policy to undergo below mentioned medical tests for purpose of consideration of your proposal under following circumstances

  • You/ Your family member are/is above 55 years of age as on the last birthday
  • On basis of Your declaration in the Proposal Form of Your/ Your family member’s medical conditions
S.No. List of Medical tests that You may require to undergo Sum Insured limits
1. Complete Blood Sugar, Urine, Routine Blood Group, ESR, Fasting Blood, Glucose, S Cholestrol, SGPT, Creatinine Rs 2,50,000
2. Complete Blood Sugar, Urine, Routine Blood Group, ESR, Fasting Blood, Glucose, S Cholestrol, SGPT, Creatinine, ECG Rs 5,00,000 ; Rs7,50,000 and Rs10,00,000
3. Complete Blood Sugar, Urine, Routine Blood Group, ESR, Fasting Blood, Glucose, S Cholestrol, SGPT, Creatinine, ECG, Lipid Profile, Complete Physical test by a physician Rs 12,50,000 and Rs15,00,000
4. Complete Blood Sugar, Urine, Routine Blood Group, ESR, Fasting Blood, Glucose, S Cholestrol, SGPT, Creatinine, ECG, Lipid Profile, Stress test or 2D Echo , Kidney Function Test Complete Physical test by a physician Rs 17,50,000 and Rs20,00,000

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 borne by us.

If you or any person insured by you suffer any of the listed Critical Illness or undergoes a listed Surgical Procedure during the policy period and while the policy is in force, we will pay the Sum Assured specified as opted by you provided that:

1. Such Critical Illness first occurs or manifests itself during the policy period; and

2. The signs or symptoms of such Critical illness commence after 90 days from the date of commencement of the Policy and

3. You/the Insured Person survives for a minimum period of at least 30 days from the date of diagnosis of such Critical Illness for the claim to be admissible

Critical Illnesses and Surgical Procedure

The coverage shall be up to the Sum Insured as selected by you under the Policy.

  • Cancer of specified severity
  • First Heart Attack of specified severity
  • Open Chest CABG
  • Open Heart Replacement
  • Coma of Specified Severity
  • Kidney Failure requiring regular dialysis
  • Stroke resulting in permanent symptoms
  • Major Organ /Bone Marrow Transplant
  • Motor Neurone Disease with Permanent Symptoms
  • Permanent Paralysis of Limbs
  • Multiple Scelerosis with persisting symptoms

i .Long Term Policy: 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
2 Years 2 year premium in advance less 10% discount
3 Years 3 year premium in advance less 15% discount

ii .Wide range of Sum Insureds: The Policy provides for a wide range of Sum Insured starting from 2.5 Lakh to 20 Lakh Rupees

iii .Portability:

1. If You were insured continuously and without a break under another Indian retail health insurance policy with Us or any other Indian General Insurance company, 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) The Portability Benefit shall be applied subject to the following:

i) Your proposal shall be subject to Our medical underwriting

ii) 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.

iv. Free Look-up Period:

1. The Policy shall have a free look period. The free look period shall be applicable at the inception of the policy and:

i. 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. If You have not made any claim during the free look period, You shall be entitled to

i. A refund of the premium paid less any expenses incurred by Us on Your medical examination and the stamp duty charges or;

ii. 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;

iii. Where only a part of the risk has commenced, such proportionate risk premium commensurate with the risk covered during such period.

i. Premium: The premium# under the Policy shall be as under

Age Band 250000 500000 750000 1000000 1250000 1500000 1750000 2000000
5-25 Yrs 902 1624 2233 2924 3509 4020 4678 5263
26-35 Yrs 1096 1973 2713 3551 4261 4883 5682 6392
36-45 Yrs 1643 2957 4065 5322 6386 7317 8515 9579
46-55 Yrs 1889 3400 4675 6119 7343 8414 9791 11015
56-65 Yrs 3459 6226 8560 11206 13447 15408 17930 20171
66-75 Yrs* 5353 9635 13248 17343 20812 23847 27749 31218
76-80 Yrs* 6844 12319 16938 22174 26609 30489 35478 39913
> 80 years* 8213 14783 20326 26609 31931 36587 42574 47896

Two Year Policy

Age Band 250000 500000 750000 1000000 1250000 1500000 1750000 2000000
5-25 Yrs 1714 3086 4243 5556 6667 7638 8888 10000
26-35 Yrs 2082 3749 5155 6747 8096 9278 10796 12145
36-45 Yrs 3122 5618 7724 10112 12133 13902 16179 18200
46-55 Yrs 3589 6460 8883 11626 13952 15987 18603 20929
56-65 Yrs 6572 11829 16264 21291 25549 29275 34067 38325
66-75 Yrs* 10171 18307 25171 32952 39543 45309 52723 59314
76-80 Yrs* 13004 23406 32182 42131 50557 57929 67408 75835
> 80 years* 15605 28088 38619 50557 60669 69515 80891 91002

Three Year Policy

Age Band 250000 500000 750000 1000000 1250000 1500000 1750000 2000000
5-25 Yrs 2571 4628 6364 8333 10001 11457 13332 15000
26-35 Yrs 3124 5623 7732 10120 12144 13917 16194 18217
36-45 Yrs 4683 8427 11585 15168 18200 20853 24268 27300
46-55 Yrs 5384 9690 13324 17439 20928 23980 27904 31393
56-65 Yrs 9858 17744 24396 31937 38324 43913 51101 57487
66-75 Yrs* 15256 27460 37757 49428 59314 67964 79085 88971
76-80 Yrs* 19505 35109 48273 63196 75836 86894 101112 113752
> 80 years* 23407 42132 57929 75836 91003 104273 121336 136504

# Premium is exclusive of Service Tax and Education Cess as applicable

* Premium applicable for renewals only

Tax Benefit** : Avail of tax benefit under section 80D of Income Tax Act on the premium paid under the Policy

**Tax Benefit are subject to change as per change in Tax Laws.

ii. Loading on premiumAn occupational loading as under may be done if you/ any other person proposed for insurance under the policy fall into following risks categories.

Occupation Loading (%)

Medium Risks:

Builders, Contractors, Engineers engaged in superintending functions only, Veterinary Doctors, Paid Drivers and Persons engaged in occupations of similar hazard and not engaged in manual labour. All persons engaged in manual labour (except those falling under heavy risk), cash carrying employees, Garage and Motor Mechanics, Machine Operators, Drivers of Heavy Vehicles, Professional Athletes and Sportsmen and Wood working Machinist and persons engaged in any occupations of similar hazard.

15%
Occupational Loading Loading (%)

Heavy Risks

Persons working in underground Mines, Explosive, Magazines, Workers involved in electrical installation with High-tension supply, jockeys, Circus personal, persons engaged in activities like racing on wheels or Horse back, big game hunting, Mountaineering, Winter Sports, Skiing Ice Skating, Ballooning, Hang gliding, River Rafting, Polo playing and persons engaged in occupations/activities of similar hazards.

20%

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.

iii. Survival Period: You need to survive for 30 days before benefits under the Policy shall become payable to you.

iv. Cancellation Terms

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 months to 6 months From 6 months to 1 year During 2nd Year