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POLICY WORDING- CRITICAL ILLNESS INSURANCE POLICY 

Grace Period:

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 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 makes these accessible to the insurance company’s authorized personnel.

Hospitalisation

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.

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 or 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.

Insured

It means the individual whose name is specifically appearing in the Schedule herein after referred as "you"/"your"/"yours"/"yourself"

Injury

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

It means person whose name is specifically appearing in the Schedule and is covered under the Policy. An individual may take this Policy for his/her spouse, children and/ or parents/ parents in laws on individual Sum Insured basis.

Inpatient Care:

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

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.

Medical Advise

Any 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.

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.

Non- Network:

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

Nominee

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

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.

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:

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.

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

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 Insured

It 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.

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 that We insure and is 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 A – CRITICAL ILLNESS

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 A in the Schedule to this Policy, on the occurrence of any of the below mentioned Critical Illnesses and/ or undergoing of Surgical Procedure mentioned as being covered in the Schedule 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 accepted to Us and to be reconfirmed by a Medical Practitioner appointed by Us.
  • We shall compensate You 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 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 -

i. 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.

ii. Any skin cancer other than invasive malignant melanoma

iii. 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

iv. Papillary micro - carcinoma of the thyroid less than 1 cm in diameter

v. Chronic lymphocyctic leukaemia less than RAI stage 3

vi. Microcarcinoma of the bladder

vii. All tumours in the presence of HIV infection.

2. First Heart Attack of specified severity

The first occurrence of myocardial infarction which means the death of a portion of the heart muscle as a result of inadequate blood supply to the relevant area. The diagnosis for this will be evidenced by all of the following criteria:

i. history of typical clinical symptoms consistent with the diagnosis of Acute Myocardial Infarction (for e.g. typical chest pain)

ii. new characteristic electrocardiogram changes

iii. elevation of infarction specific enzymes, Troponins or other specific biochemical markers.

The following are excluded:

i. Non-ST-segment elevation myocardial infarction (NSTEMI) with elevation of Troponin I or T

ii. Other acute Coronary Syndromes

iii. Any type of angina pectoris.

3. 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:

i. Angioplasty and/or any other intra-arterial procedures

ii. Any key-hole or laser surgery.

4. Open Heart Replacement

The actual undergoing of open-heart valve surgery is to replace or repair one or more heart valves, as a consequence of defects in, abnormalities of, or disease-affected cardiac valve(s). The diagnosis of the valve abnormality must be supported by an echocardiography and the realization of surgery has to be confirmed by a specialist Medical Practitioner. Catheter based techniques including but not limited to, balloon valvotomy/valvuloplasty are excluded.

5. Coma of Specified Severity

A state of unconsciousness with no reaction or response to external stimuli or internal needs. This diagnosis must be supported by evidence of all of the following:

i. no response to external stimuli continuously for at least 96 hours;

ii. life support measures are necessary to sustain life; and

iii. permanent neurological deficit which must be assessed at least 30 days after the onset of the coma.

The condition has to be confirmed by a specialist Medical Practitioner. Coma resulting directly from alcohol or drug abuse is excluded.

6. 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.

7. 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:

i. Transient ischemic attacks (TIA)

ii. Traumatic Injury of the brain

iii. Vascular disease affecting only the eye or optic nerve or vestibular functions

8. Major Organ /Bone Marrow Transplant

The actual undergoing of a transplant of:

i. One of the following human organs: heart, lung, liver, kidney, pancreas, that resulted from irreversible end-stage failure of the relevant organ, or

ii. 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:

i. Other stem-cell transplants

ii. Where only islets of langerhans are transplanted

9. Permanent Paralysis of Limbs

Total and irreversible loss of use of two or more limbs as a result of Injury or disease of the brain or spinal cord. A specialist Medical Practitioner must be of the opinion that the paralysis will be permanent with no hope of recovery and must be present for more than 3 months.

10. Motor Neurone Disease with Permanent Symptoms

Motor neurone disease diagnosed by a specialist Medical Practitioner as spinal muscular atrophy, progressive bulbar palsy, amyotrophic lateral sclerosis or primary lateral sclerosis. There must be progressive degeneration of corticospinal tracts and anterior horn cells or bulbar efferent neurons. There must be current significant and permanent functional neurological impairment with objective evidence of motor dysfunction that has persisted for a continuous period of at least 3 months.

11. Multiple Sclerosis with persisting symptoms

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

i. investigations including typical MRI and CSF findings, which unequivocally confirm the diagnosis to be multiple sclerosis;

ii. there must be current clinical impairment of motor or sensory function, which must

iii. have persisted for a continuous period of at least 6 months, and well documented clinical history of exacerbations and remissions of said symptoms or neurological deficits with at least two clinically documented episodes at least one month apart.

Exclusion

Other causes of neurological damage such as SLE and HIV

What will We not pay for? (Exclusions under the Policy)

1) Any Illness, sickness or disease or procedure, other than specified as Critical Illness/Procedure, 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 nontraditional 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;

AND

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

i. Any treatment not performed by a Physician or that is Unproven/ Experimental treatment.

ii. 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).

iii. 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.

iv. All kind of Alternate Treatment

CLAIMS PROCEDURE

1. Method of Assessment and Payment of claim

For a Policy with Policy Period greater than one year, the Sum Insured considered for assessment of claim shall be the Sum Insured mentioned against the Policy Year of the occurrence of the Critical Illness or Surgical Procedure.

In the event that a claim becomes payable under the terms of the Policy, We shall make such payment to You by way of cheque or electronic fund transfer or demand draft at Our option.

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

1. 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

2. 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:

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 your claim)

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.

If required, You 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.

3. 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 is exhausted by You or any members of Your family mentioned as Insured Person in the Schedule. An endorsement to this effect, deleting the name of the Insured Person against whom claim was accepted and paid by Us will be issued to You.4. Claim Payment:

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.

PART III OF THE 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. If there is material change in the Your occupation leading to change in the risk category, the same shall be intimated to the Company.

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. 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 months 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.

4. 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.

5. Discount(s)/Loading(s) under the Policy:

i) 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,

Number of Years Discount
2 year Policy 2 year premium in advance less 10% discount
3 year Policy 3 year premium in advance less 15% discount

ii) Occupational Loadings:

An occupational loading as under may be done if You / any other person proposed for insurance under the policy fall into the following risks categories.

Occupational Loading 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%

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%

The maximum loading under the Policy shall not exceed 20% and the maximum discount under the Policy shall not exceed 15%.

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.

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 We have disputed or not accepted liability under or in respect of this Policy

7. Subrogation and Contribution

Subrogation and Contribution provisions are not applicable to the Policy.

8. Free Look period

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

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. Renewal

i) The policy shall ordinarily be renewable except on grounds of fraud, moral hazard or misrepresentation or non‐cooperation by You.

ii) 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.

iii) As it is a benefit based policy, the policy shall terminate following payment of the benefit covered under the Policy

iv) 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.

v) Premium of the Policy may be revised subject to approval from IRDA.

10. 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:

1. Your proposal shall be subject to Our medical underwriting

2. 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.

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 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.

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. Region of cover

We shall pay benefits under the Policy when incurred in India only.

14. Sum Insured Enhancement

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

15. Medical Examination

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
Sr. 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 ; Rs 7,50,000 and Rs 10,00,000
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 Rs 15,00,000
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 Rs 20,00,000

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.

16. 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 Number: 1800-200-5142

Landline Number:(022) - 39635200

E-mail Address: contactus@universalsompo.com

Toll Free Fax Number:1800-200-9134

Note:

Please include Your Policy number for any communication with 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 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 or on chargeable numbers at 022- 39635200.; and also send us fax on toll free number: 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 rajiv.kumar@universalsompo.com

If the issue still remains unresolved, You may, approach: -

  • IRDAI- IGMS - http://igms.irda.gov.in for grievances redressal
  • Insurance Ombudsman for the redressal of Your grievance.

Insurance Ombudsman

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

The details of Insurance Ombudsman are available below: AHMEDABAD

Office of the Insurance Ombudsman, 6th Floor, Jeevan Prakash Bldg, Tilak Marg, Relief Road,Ahmedabad - 380001.Tel nos: 079-25501201/02/05/06Email: bimalokpal.ahmedabad@gbic.co.in

BENGALURU

Office of the Insurance Ombudsman, Jeevan Soudha Building, PID No. 57-27-N-19 Ground Floor, 19/19, 24th Main Road, JP Nagar, Ist Phase, Bengaluru – 560 078. Tel.: 080 - 26652048 / 26652049 Email: bimalokpal.bengaluru@gbic.co.in

BHOPAL

Office of the Insurance Ombudsman, Janak Vihar Complex, 2nd Floor, 6, Malviya Nagar, Opp. Airtel Office, Near New Market, Bhopal – 462 003. Tel.: 0755 - 2769201 / 2769202 Fax: 0755 - 2769203 Email: bimalokpal.bhopal@gbic.co.in

BHUBANESHWAR

Office of the Insurance Ombudsman, 62, Forest park, Bhubneshwar – 751 009. Tel.: 0674 - 2596461 /2596455 Fax: 0674 - 2596429 Email: bimalokpal.bhubaneswar@gbic.co.in

CHANDIGARH

Office of the Insurance Ombudsman, S.C.O. No. 101, 102 & 103, 2nd Floor, Batra Building, Sector 17 – D, Chandigarh – 160 017. Tel.: 0172 - 2706196 / 2706468 Fax: 0172 - 2708274 Email: bimalokpal.chandigarh@gbic.co.in

CHENNAI

Office of the Insurance Ombudsman, Fatima Akhtar Court, 4th Floor, 453, Anna Salai, Teynampet, CHENNAI – 600 018. Tel.: 044 - 24333668 / 24335284 Fax: 044 - 24333664 Email: bimalokpal.chennai@gbic.co.in

HYDERABAD

Office of the Insurance Ombudsman, 6-2-46, 1st floor, "Moin Court", Lane Opp. Saleem Function Palace, A. C. Guards, Lakdi-Ka-Pool, Hyderabad - 500 004. Tel.: 040 - 65504123 / 23312122 Fax: 040 - 23376599 Email: bimalokpal.hyderabad@gbic.co.in

JAIPUR

Office of the Insurance Ombudsman, Jeevan Nidhi – II Bldg., Gr. Floor, Bhawani Singh Marg, Jaipur - 302 005. Tel.: 0141 - 2740363 Email: Bimalokpal.jaipur@gbic.co.in

ERNAKULAM

Office of the Insurance Ombudsman, 2nd Floor, Pulinat Bldg., Opp. Cochin Shipyard, M. G. Road, Ernakulam - 682 015. Tel.: 0484 - 2358759 / 2359338 Fax: 0484 - 2359336 Email: bimalokpal.ernakulam@gbic.co.in

KOLKATA

Office of the Insurance Ombudsman, Hindustan Bldg. Annexe, 4th Floor, 4, C.R. Avenue, KOLKATA - 700 072. Tel.: 033 - 22124339 / 22124340 Fax : 033 - 22124341 Email: bimalokpal.kolkata@gbic.co.in

LUCKNOW

Office of the Insurance Ombudsman, 6th Floor, Jeevan Bhawan, Phase-II, Nawal Kishore Road, Hazratganj, Lucknow - 226 001. Tel.: 0522 - 2231330 / 2231331 Fax: 0522 - 2231310 Email: bimalokpal.lucknow@gbic.co.in

MUMBAI

Office of the Insurance Ombudsman, 3rd Floor, Jeevan Seva Annexe, S. V. Road, Santacruz (W), Mumbai - 400 054. Tel.: 022 - 26106552 / 26106960 Fax: 022 - 26106052 Email: bimalokpal.mumbai@gbic.co.in

NOIDA

Office of the Insurance Ombudsman, Bhagwan Sahai Palace 4th Floor, Main Road, Naya Bans, Sector 15, Distt: Gautam Buddh Nagar, U.P- 201301. Tel.: 0120-2514250 / 2514252 / 2514253, Email: bimalokpal.noida@gbic.co.in

PATNA

Office of the Insurance Ombudsman, 1st Floor,Kalpana Arcade Building,, Bazar Samiti Road, Bahadurpur, Patna 800 006. Tel.: 0612- 2680952 Email: bimalokpal.patna@gbic.co.in

PUNE

Office of the Insurance Ombudsman, Jeevan Darshan Bldg., 3rd Floor, C.T.S. No.s. 195 to 198, N.C. Kelkar Road, Narayan Peth, Pune – 411 030. Tel.: 020-41312555 Email: bimalokpal.pune@gbic.co.in

 

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.


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