1. Who can take the 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.
3. What is covered under the Policy?
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|
(i)Room, Boarding expenses a provided by the Hospital/Nursing Home
|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|
|Knee Ligament Reconstruction Surgery||Rs 40,000|
|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.
Additional Benefits under the Policy
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.
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|
|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|
|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|
|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|
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
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:
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.
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.
4. Sum Insured Enhancement
Sum Insured can be enhanced only upon renewal, subject to
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:
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:
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
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.
What is not covered under the Policy?
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:
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:
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:
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
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. 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 email@example.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.
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.
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 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.
In-House Claim Management
Click to view In-House Claim Management Process