1. Who can take the Policy?
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.
3. What is covered under the Policy?
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
|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
4. Additional Benefits under the Policy
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
- 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|
|> 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|
|> 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|
|> 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|
|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|
- Premium Amount (in INR) excluding Service Tax and Cess @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
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:
|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|
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
- 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,
- 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;
- 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:
- 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.
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
- 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 firstname.lastname@example.org
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
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