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.
1. Who can take the Policy?
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
- 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.
3. What is covered under the Policy?
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
4. What is covered under the Policy?
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
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.
5. Conditions under the Policy
i. Premium: The premium# under the Policy shall be as under
|> 80 years*||8213||14783||20326||26609||31931||36587||42574||47896|
Two Year Policy
|> 80 years*||15605||28088||38619||50557||60669||69515||80891||91002|
Three Year Policy
|> 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.
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.
|Occupational Loading||Loading (%)|
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.
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
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 months 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 upon 30 days notice by sending an endorsement to Your address shown in the Schedule without refund of premium.
v. Renewal Terms
1. The policy shall ordinarily be renewable except on grounds of fraud, moral hazard or misrepresentation or non‐cooperation by You.
2. The renewal of policy sought by You shall not be denied arbitrarily. If denied, We shall provide You with cogent reasons for such denial of renewal.
3. As it is a benefit based policy, the policy shall terminate following payment of the benefit covered under the Policy
4. 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 need not be available for such period.
5. Premium of the Policy may be revised subject to approval from IRDA.
6. Sum Insured Enhancement – Sum Insured can be enhanced only upon renewal, subject to our underwriter’s approval.
vi. Special Condition(s)
Material Change: If there is a material change in occupation of any Insured Person leading to change in the risk category, the same should be intimated to us.
vii. 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
viii. 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:
- 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.
6. What is not covered under the Policy?
1. Any Illness, sickness or disease, other than specified as Critical Illness, as mentioned in the Policy schedule, or
2. 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
3. Any Critical Illness based on a diagnosis made by the 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; and
4. 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;
5. Special nursing care, routine health checks or convalescence, Custodial Care, general debility, lethargy, rest cure;
6. Any investigation(s) or treatments not directly related to a Covered Illness or Covered Injury or the conditions or diagnosis necessitating hospital admission;
7. Pre-existing diseases will not be covered until 48 months of continuous coverage have elapsed, since inception of the first Policy with us; but:
A. If You are presently covered and have been continuously covered without any break under:
i) any other similar health insurance plan covering critical illness risks from Us or from any other insurer, then, Pre-existing diseases exclusion of the Policy stands deleted and shall be replaced entirely with the following:
a) 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 covering critical illness risks;
b) If the proposed Sum Insured for you is more than the Sum Insured applicable under the previous similar health insurance policy covering critical illness risks, then the reduced waiting period shall only apply to the extent of the Sum Insured under the previous similar health insurance policy.
B. 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 similar health insurance policy covering critical illness risks even if you have submitted to Us all documentation
iii. We shall consider only completed years of coverage for waiver of waiting periods. Policy Extensions if any sought during or for the purpose of porting insurance policy shall not be considered for waiting period waiver
8. Payment of compensation in respect of Illness resulting –
a. From intentional self-injury, suicide or attempted suicide.
b. Due to liquor or drugs or other intoxicants.
c. Emotional distress
d. 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.
e. Directly or indirectly, caused by venereal disease, AIDS or insanity.
f. 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.
g. Due to war or ionising radiation or nuclear perils.
h. 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.
i. Congenital Anomalies or any complications or conditions arising therefrom; or
9. Any treatment not performed by a Physician or that is Unproven/ Experimental treatment.
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. 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.
12. All kind of Alternate Treatment
7. Claims Procedure
I. Claim Intimation
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 1800-200-5142 or on chargeable numbers at +(022) - 39635200 or email at firstname.lastname@example.org. Please note that no delay should be allowed to occur in notifying a claim on the policy as the same may prejudice liability.
II. 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.
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.
a. Copy of 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)
b. All reports, including but not limited to all medical reports, case histories, investigation reports, treatment papers, discharge summaries.
c. A precise diagnosis of the treatment for which a claim is made.
d. 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 email@example.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 liable for a penalty which may extend to ten lakhs 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.