In consideration of Your having paid the premium for the period stated in the Schedule or for any further period for which We may accept the payment for Renewal of this Policy, We undertake that in the event of Death or Permanent Total Disablement sustained by the Insured Person(s) solely due to an Accidental Injury during the Policy Period, We will make payment to them or to their legal representative/Nominee as per the Table of Benefits set forth in the Policy provided that all the terms, conditions and exceptions of this Policy in so far as they relate to anything to be done or complied with by them have been met.
This Policy is an evidence of the contract between You and Universal Sompo General Insurance Company Limited. The information furnished by You in the Proposal Form and the declaration signed by You forms the basis of this contract.
The Policy, the Schedule and any Endorsement shall be read together and any word or expression to which a specific meaning has been attached in any part of this Policy or of Schedule shall bear such meaning whenever it may appear.
For the purposes of this Policy and endorsements, if any, the terms mentioned below shall have the meaning set forth:
Where the context so requires, references to the singular shall also include references to the plural and references to any gender shall include references to all genders.
Accident means a sudden unforeseen and involuntary event caused by external, visible and violent means.
Accidental Death means Death resulting from Bodily Injury solely and independently of any other cause except Illness directly resulting from, or medical or surgical treatment rendered necessary for such Injury, occasions the Death of the Insured Person within 12 months from the date of Accident.
Adventure Sports: Participation in sports activities such as bungee jumping, sky diving, white water canoeing/rafting and engaging in racing, hunting, mountaineering, ice hockey, winter sports and the like.
Ambulance means any vehicle used solely for the conveyance of injured persons from Accidental location or Your residential place or Hospital to any Hospital in emergency cases.
Bodily Injury means accidental physical bodily Injury solely and directly caused by external, violent visible cause.
Break in Policy occurs at the end of the existing Policy term, when the premium due for Renewal on a given Policy is not paid on or before the premium Renewal date or within 30 days thereof.
Capital Sum Insured means the monetary amounts shown against Insured Person(s) which is the maximum limit of our liability against said Insured Person.
Cashless facility means a facility extended by Us to You where the payments, of the costs of treatment undergone by You in accordance with the Policy terms and conditions, are directly made to the network provider by Us to the extent pre-authorization approved.
Condition Precedent means a Policy term or condition upon which the Insurer’s liability under the Policy is conditional upon.
Contribution is essentially the right of an insurer to call upon other insurers liable to the same Insured to share the cost of an indemnity claim on a rateable proportion of Sum Insured. This clause shall not apply to any Benefit offered on fixed benefit basis.
Disclosure to information norm means the Policy shall be void and all premium paid hereon shall be forfeited to the Company, in the event of misrepresentation, mis-description or non-disclosure of any material fact.
Emergency Care means management for a severe Illness or Injury which results in symptoms which occur suddenly and unexpectedly, and requires immediate care by a Medical Practitioner to prevent death or serious long term impairment of the Insured Person’s health.
Hospitalization means admission in a Hospital for a minimum period of 24 In-patient Care consecutive hours except for specified procedures/ treatments, where such admission could be for a period of less than 24 consecutive hours.
Hospital means any institution established for In- patient care and Day Care treatment of Illness and/ or Injuries and which has been registered as a Hospital with the local authorities under the Clinical Establishments (Registration and Regulation) Act, 2010, or under the enactments specified under the Schedule of Section 56(1) of the said Act OR complies with all minimum criteria as under:
- has qualified nursing staff under its employment round the clock,
- has at least 10 inpatient beds, in those towns having a population of less than 10, 00,000 and 15 inpatient beds in all other places,
- has qualified Medical Practitioner (s) in charge round the clock,
- has a fully equipped operation theatre of its own where surgical procedures are carried out,
- maintains daily records of patients and will make these accessible to Insurance company’s authorized personnel.
Illnessmeans a sickness or a disease or pathological condition leading to the impairment of normal physiological function which manifests itself during the Policy Period and requires medical treatment.
a) Acute condition - Acute condition is a disease, Illness or Injury that is likely to respond quickly to treatment which aims to return the person to his/her state of health immediately before suffering the disease/Illness/Injury which leads to full recovery.
b) Chronic condition - A chronic condition is defined as a disease, Illness, or Injury that has one or more of the following characteristics:
- it needs ongoing or long-term monitoring through consultations, examinations, check-ups, and / or tests
- it needs ongoing or long-term control or relief of symptoms
- it requires Your rehabilitation or for you to be specially trained to cope with it
- it continues indefinitely
- it comes back or is likely to come back
Injury means accidental physical bodily harm excluding Illness or disease solely and directly caused by external, violent and visible and evident means which is verified and certified by a Medical Practitioner.
Inpatient Care means treatment for which the Insured Person has to stay in a Hospital for more than 24 hours for a covered event.
Insured means the individual whose name is specifically appearing in the Schedule herein after referred as ―You‖/‖Your‖/‖Yours‖/‖Yourself‖.
Insured Person: The person(s) named as Insured Person in the Schedule which will include you and your family inclusive of dependent parents.
Medical Advise means any consultation or advice from a Medical Practitioner including the issue of any prescription or repeat prescription.
Medical Expenses means those expenses that an Insured Person has necessarily and actually incurred for medical treatment on account of Illness or Accident on the advice of a Medical Practitioner, as long as these are no more than would have been payable if the Insured Person had not been Insured and no more than other Hospitals or doctors in the same locality would have charged for the same medical treatment.
Nominee means the person(s) nominated by the Insured Person to receive the insurance benefits under this Policy payable on his/her death.
Medical Practitioner is a person who holds a valid registration from the Medical Council of any State or Medical Council of India or Council for Indian Medicine or for Homeopathy set up by the Government of India or a State Government and is thereby entitled to practice medicine within its jurisdiction; and is acting within the scope and jurisdiction of licence and is not a member of the Insured Person’s Family.
Notification of Claim is the process of notifying a claim to the insurer or TPA by specifying the timelines as well as the address / telephone number to which it should be notified.
Period of Insurance: The time period for which the contract of insurance is valid as shown in the Policy Schedule.
Permanent Total Disablement: The bodily Injury that totally, irrecoverably and absolutely prevents you from engaging in any kind of occupation.
Permanent Partial Disability: The bodily Injury that results in total, irrevocable, absolute and continuous loss of or impairment of a body part or sensory organ specified under the Table of Benefits.
Proposal: The application form you sign for this insurance and/or any other information you give to us or which is given to us on your behalf.
Policy: Policy wording, the Schedule, the Proposal form and Endorsement / Memoranda, if any.
Renewal means the terms on which the contract of insurance can be renewed on mutual consent with a provision of Grace Period for treating the Renewal continuous for the purpose of all waiting periods.
Reasonable and Customary Charges means the charges for services or supplies, which are the standard charges for the specific provider and consistent with the prevailing charges in the geographical area for identical or similar services, taking into account the nature of the Illness / Injury involved .
Schedule means Schedule attached to and forming part of this Policy mentioning the details of the Insured/Insured Persons, the Sum Insured, the period and the limits to which benefits under the Policy would be payable.
Subrogationmeans the right of the insurer to assume the rights of the Insured Person to recover expenses paid out under the Policy that may be recovered from any other source.
Temporary Total Disablement: The bodily Injury that prevents you from engaging in your occupation for a period not exceeding 104 weeks since the date of Injury to the time you are fit enough to resume your occupation as certified by Medical Professional.
Terrorism/Terrorist activity: means any actual or threatened use of force or violence directed at or causing damage, Injury, harm or disruption, or commission of an act dangerous to human life or property, against any individual, property or government, with the stated or unstated objective of pursuing economic, ethnic, nationalistic, political, racial or religious interests, whether such interests are declared or not. Robberies or other criminal acts, primarily committed for personal gain and acts arising primarily from prior personal relationships between perpetrator(s) and victim(s) shall not be considered Terrorist activity. Terrorism shall also include any act, which is verified or recognized by the relevant Government as an act of terrorism.
You/Your/Yours/Yourself means the person(s) that We insure and is/are specifically named as Insured in the Schedule.
We/Our/Ours/Us mean Universal Sompo General Insurance Company Limited.
War means War, whether declared or not, or any warlike activities, including use of military force by any sovereign nation to achieve economic, geographic, nationalistic, political, racial, religious or other ends.
SCOPE OF COVERWhat We Cover
1. Bodily Injury directly resulting in death or Permanent Total Disablement of the Insured.
We shall pay to the Insured Person or his/her legal personal representative/nominee the compensation set forth in Table of Benefits (as percentage of Capital Sum Insured.)
What We exclude
1. Compensation under more than one of the benefits mentioned in Table of Benefits in respect of same period of disablement.
2. Any other payment after a claim under one of the benefits 1 and 2 in Table of benefits has been admitted and becomes payable.
3.Any payment in case of more than one claim in respect of one Insured Person under this Policy during any Period of Insurance by which Our liability in that period would exceed CSI.
4.Payment of compensation in respect of a Permanent Partial Disability or Death /disability as a consequence ;of/resulting from
a)Committing or attempting suicide, intentional self-Injury.
b)Whilst under influence of intoxicating liquor or drugs.
c)Drug addiction or alcoholism
d)Whilst engaged in any adventurous sports.
e)Committing any breach of law with criminal intent.
f)War, Civil War, invasion, act of foreign enemies, revolution, insurrection, mutiny, military or Usurped power, seizure, capture, arrest, restraint, or detainment, confiscation, or nationalisation or requisition by or under the order of any government or public authority.
5.Consequential loss of any kind and/or any legal liability.
6.Death/disability due to pregnancy including child birth, miscarriage, abortion or complication.
7.Insured participating in any naval, military or air force operations.
8.Curative treatments or interventions.
9.Venereal or sexually transmitted diseases.
10.HIV and or related Illness.
11.Ionizing radiation or contamination by radioactivity from any nuclear fuel or from any nuclear waste from the combustion of nuclear fuel. For the purpose of this exclusion, combustion shall include any self-sustaining process of nuclear fission.
12.The radioactive, toxic, explosive or the hazardous properties of any nuclear assembly or nuclear component.
|TABLE OF BENEFITS|
|COVER FOR||PERCENTAGE OF CAPITAL SUM INSURED|
|2.Permanent Total Disability:
a. Loss of sight (both eyes)
b. Loss of two limbs
c. Loss of one limb and one eye
d. Any other Permanent Total and absolute disablement as certified by Qualified Medical Practitioner
A) Upon happening of any Accident and/or Injury which may give rise to a claim under this Policy
- You shall give us a notice to our call centre immediately and also intimate in writing to our Policy issuing office. In case of death, written notice also of death must, unless reasonable cause is shown, be given before internment/ cremation and in any case, within one calendar month after the death, and in the event of loss of sight or amputation of limbs, written notice thereof must also be given within one calendar month after such loss of sight or amputation.
- All certificates, information and evidence from a Medical Practitioner or otherwise required by Us as mentioned below shall be provided by You.
B) Following documents shall be required in the event of a claim.For Death Claim
- Duly filled up claim form
- Death Certificate
- Original FIR
- Original Panchnama
- Post mortem report
B) For Permanent Total disablement
- Duly filled up claims form
- Original FIR
- Hospitalization Report
- Hospital discharge card
- Original Certificate from Doctor of Govt. Hospital stating the degree of disability
We shall settle claim(s), including its rejection, within thirty days of the receipt of the last necessary claim document. Wherever details pertaining to happening of claim are conveyed by You to Us after reasonable period, You shall provide the reasons of such delay to Us and We may on analysis of reasons provided by You, may condone the delay in intimation of claim or delay in providing the required information/documents to Us. C) On receipt of intimation from You regarding a claim under the Policy, we are entitled to carry out examination and ascertain details and in the event of death get the post-mortem examination done in respect of deceased person. D) Position after claim: We shall have no liability under this Policy, once the Sum Insured (Maximum Limit of Liability), as stated in the Policy Schedule with respect to any of the benefits, is exhausted by You. E) Claim Payment: All admissible claims under this Policy shall be paid by Us within 7 working days from date of acceptance of such a claim. In case of delay in the payment, We shall be liable to pay interest at a rate which is 2% above bank rate prevalent at the beginning of the financial year in which claim is reviewed by Us.
STANDARD TERMS AND CONDITIONS
Every notice and communication to the Company required by this Policy shall be in writing. Initial notification can be made by telephone
This Policy shall be void and premium paid shall be forfeited to Us in the event of mis-representation, mis-description or non-disclosure of any materials facts by You.
Non-disclosure shall include failure on Your part to intimate us in writing and obtaining written approval from us in respect of Changes in Circumstances arising out of changes in the duty, business, occupation of the Insured Person(s).
3. Contribution and Subrogation:
Subrogation and Contribution provisions are not applicable to the Policy.
All benefit under this Policy shall be forfeited and the Policy shall be treated as void in case of any fraudulent claims or if any fraudulent means are used by You or anyone acting on Your behalf to obtain any benefit under this Policy.
We may cancel this Policy by sending 15 days notice in writing by recorded delivery to You at Your last known address. You will then be entitled to a pro-rata refund of premium for the un-expired period of this Policy from the date of cancellation, which We are liable to pay on demand.
You may cancel this Policy by sending a written notice to Us. Retention premium for the period We were on risk will be calculated based on following short period table and the balance will be refunded to You subject to the condition that no claim has been preferred on Us:
|Upto 1 month||25% of annual premium|
|Upto 3 months||50% of annual premium|
|Upto 6 months||75% of annual premium|
|Above 6 months||100% of annual premium|
6. Discount(s) under the Policy: Group Discount
We shall provide group discount as per below when the number of persons covered under the Policy exceeds 25. Group Discount will not be reviewed during the currency of the Policy, even if the size of the group exceeds the next slab.
|Number of Persons covered||Applicable discount|
|Upto 25 persons||No discount|
|Between 25 and 50 persons||5% on total premium|
|Between 51 and 100 persons||10% on total premium|
|Between 101 and 300 persons||15% on total premium|
|Between 301 and 400 persons||20% on total premium|
|Between 401 and 500 persons||25% on total premium|
|Over 500 persons||To be decided by Corporate Office|
On Duty Cover Discount:
We may provide a discount up to 25% on the basic premium when Janata Personal Accident cover is only for restricted hours of duty (and not for all 24 hours of day and night) for the Insured Persons in the Policy. The restricted cover is intended only for employers who wish to cover their employees for accidents during and in the course of employment.
Off Duty Cover Discount:
We may provide a discount up to 50% on the basic premium when Janata Personal Accident cover is required only for restricted hours, when the Insured Person is not at work and/ or not on official duty.
7. Arbitration clause
If any dispute or difference shall arise as to the quantum to be paid under this Policy (liability being otherwise admitted) such difference shall independently of all other questions be referred to the decision of a sole arbitrator to be appointed in writing by the parties to the dispute/difference, or if they cannot agree upon a single arbitrator within 30 days of any party invoking arbitration, the same shall be referred to a panel of three arbitrators, comprising of two arbitrators, one to be appointed by each of the parties to the dispute/difference and the third arbitrator to be appointed by such two arbitrators.
Arbitration shall be conducted under and in accordance with the provisions of the Arbitration and Conciliation Act, 1996.
It is clearly agreed and understood that no difference or dispute shall be referable to arbitration, as herein before provided, if the Company has disputed or not accepted liability under or in respect of this Policy.
8. Geographical Scope:
The geographical scope of this Policy will be worldwide unless otherwise stated in the Policy schedule; however the claims shall be settled in India in Indian rupees. The provisions of this Policy shall be governed by the laws of India for the time being in force. The parties hereto unconditionally submit to the jurisdiction of the courts in India.
9. Sum Insured Enhancement:
Sum Insured can be enhanced only upon renewal, subject to Our underwriter’s approval.
10. Disclaimer Clause
In case of any claim under the Policy which is not admitted by us and such claim shall not have been made subject matter of a suit in a court of law within 12 months from the date of disclaimer, then the claim shall for all purposes be deemed to have been abandoned and shall not thereafter be recoverable under this Policy.
11. Three Months Notice: We shall give You notice in the event We may decide to revise, modify or withdraw the product. Such notice shall be given to You at least three months prior the date when such modification or revision or withdrawal comes into effect. We shall adhere to the following:
i)In case of modification or revision, the notice given to You shall detail the reasons for such revision or modification, in particular the reason for an increase in premium (if any) and the quantum of such increase.
ii)The product shall be withdrawn only after due approval from the Insurance Regulatory and DevelopmentAuthority. However, if You do not respond to Our intimation in case of such withdrawal, the Policy shall be withdrawn on the renewal date and We shall provide You with an option to migrate to a substitute product offered by Us.
The Policy has provision of nomination, In absence of Your declaring Nomination at the time of Proposal, then all benefits accrued under the Policy if any, shall be given to Your legal heir/ dependants.
13. Substitute Product
In case We may decide to withdraw this product under which this Policy is issued to You or where the children have attended maximum eligibility age under the Policy, if covered, We shall provide You with an option to buy a similar substitute Accident insurance Policy from Us.
14. Free Look-up period
1.The Policy shall have a free look period. The free look period shall be applicable at the inception of the Policy and:
i.You will be allowed a period of at least 15 days from the date of receipt of the Policy to review the terms and conditions of the Policy and to return the same if not acceptable
2.If You have not made any claim during the Free Look period, You shall be entitled to
i.A refund of the premium paid less any expenses incurred by Us on Your medical examination and the stamp duty charges or;
ii.Where the risk has already commenced and the option of return of the Policy is exercised by You, a deduction towards the proportionate risk premium for period on cover or;
iii.Where only a part of the risk has commenced, such proportionate risk premium commensurate with the risk covered during such period
i.This Policy shall ordinarily be renewable for lifetime except on grounds of fraud, moral hazard or misrepresentation or non-cooperation by You
ii.The Renewal of the Policy sought by You shall not be denied arbitrarily. If denied, We shall provide You with cogent reasons for such denial of Renewal.
iii.No loading on premium shall be applied on Your individual claims experience basis but the group as a whole
The premium for renewals shall be subject to discount when group Policy issued witnesses favourable claims ratio as under:
|Incurred Claim Ratio under the Group Policy||Discount Percentage (%)|
|Up to 20 %||25|
|21 % - 35 %||15|
|36 % - 50 %||10|
|51 % - 60 %||5|
The premium for renewals shall be subject to loading when group Policy issued witnesses adverse claims ratio as under:
|Incurred Claim Ratio under the Group Policystrong>||Discount Percentage (%)|
|Between 80 % and 100 %||25|
|Between 101 % and 125 %||55|
|Between 126 % and 150 %||90|
|Between 151 % and 175 %||120|
|Between 176 % and 200 %||150|
|Over 200 %||Cover to be reviewed|
We will inform You about the applicable risk loading through a counter offer letter. You have to revert to Us with consent and additional premium (if any) within 15 days of issuance of such counter letter. In case, You neither accept the counter letter from Us nor revert to Us within 15 days, We shall cancel Your application and refund the premium within next 7 days.
Please note We shall issue Policy only after getting Your consent
iv.The premium of the Policy may be revised subject to approval from Insurance Regulatory Development Authority
16. Adjustment of Premium (applicable to policies issued on unnamed employees basis)
The premium payable hereon has been determined by reference to Your estimate of the number of persons and their category as stated in the Schedule. It is hereby agreed that during the Policy Period You shall maintain a proper and contemporaneous record of the actual number of persons within such category, which record shall be available for inspection by Us at any reasonable time.
Within one month from the expiry of this Policy, You shall provide Us with a written record of the actual number of persons within such category during the Policy Period and any information or supporting documentation in respect thereof at Our request. If the actual number of persons within such category ascertained after the expiry of this Policy shall differ from Your original estimate thereof, then:
if the actual number of persons within such category exceeds the estimate of the same, You shall pay Us any additional premium that We may determine by reference to the differential, or
if the actual number of persons within such category is less than the estimate of the same, We will reimburse You by reference to the differential but subject to minimum retention of premium of 50%
In case of claim by Death or Permanent Total Disablement compensation will be made only after deleting by an endorsement the name of the deceased/injured person in respect of whom such sums shall become payable.
18. Notices and Claims
Any notice, direction or instruction given under this Policy shall be in writing and delivered by hand, post, or facsimile to:
Universal Sompo General Insurance Co. Ltd.
Express IT Park, Plot No. EL - 94, T.T.C. Industrial Area, M.I.D.C., Mahape, Navi Mumbai-400710 Toll Free Numbers: 1-800-224030 (For MTNL/BSNL Users) or 1-800-1024030 or 1- 800–2004030
(022)-27639800 or (022)-41582900 or (022)-41582999 or (022)-39133700 (Local Charges Apply)
(022) 41582929 or (022) 41582939
Note:Please include Your Policy number for any communication with us.
In the unfortunate event of any loss or damage to the insured property resulting into a claim on this policy, please intimate the mishap IMMEDIATELY to our Call Centre at Toll Free Numbers on 1800-200-5142 (other users) or on chargeable numbers at (022)-39635200. Please note that no delay should be allowed to occur in notifying a claim on the policy as the same may prejudice liability.
In case of any discrepancy, complaint or grievance, please feel free to contact us within 15 days of receipt of the Policy.
In case You are aggrieved in any way, You may register a grievance or Complaint by visiting our website or write to us on firstname.lastname@example.org.
You may also contact the Branch from where You have bought the Policy or the Complaints Coordinator who can be reached at Our Registered Office.
You may also contact on Our Toll Free Numbers: 1800-200-5142 or on chargeable numbers at (022)-39635200.
♦ You can also visit Our Company website and click under links Grievance Notification
♦ You can also send direct mail to the concerned authorities at email@example.com
♦If the issue still remains unresolved, You may, subject to vested jurisdiction, approach Insurance Ombudsman for the redressal of Your grievance.
♦ The details of Insurance Ombudsman are available below and are also available on : http://www.gbic.co.in/ombudsman.html
The details of Insurance Ombudsman are available below:
|Office of the Ombudsman||Contact Details|
|AHMEDABAD||Office of the Insurance Ombudsman,6th Floor, Jeevan Prakash Bldg, Tilak Marg, Relief Road,Ahmedabad - 380001.Tel nos: 079-25501201/02/05/06 email: firstname.lastname@example.org|
|BHOPAL||Janak Vihar Complex,2nd Floor, 6, Malviya Nagar, Opp. Airtel, Near New Market, BHOPAL(M.P.)-462 023.Tel: 0755-2569201; Fax:0755-2769203;Email: email@example.com|
|BHUBANESHWAR||62, Forest Park, BHUBANESHWAR-751 009.Tel: 0674-2596455; Fax:0674-2596429; Email firstname.lastname@example.org|
|CHANDIGARH||S.C.O. No.101-103, 2nd Floor, Batra Building. Sector 17-D, CHANDIGARH-160 017.Tel:0172-2706468; Fax:0172-2708274; Email email@example.com|
|CHENNAI||Fathima Akhtar Court,4th Floor, 453 (old 312), Anna Salai, Teynampet, CHENNAI-600018.Tel:044-24333668/5284; Fax:044 24333664 ;Email firstname.lastname@example.org|
|NEW DELHI||2/2 A, Universal Insurance Bldg., Asaf Ali Road, NEW DELHI-110 002.Tel.:- 011-23239633; Fax : 011-23230858; Email email@example.com|
|GUWAHATI||―Jeevan Nivesh‖,5th Floor, Near Panbazar Overbridge, S.S. Road, GUWAHATI-781 001(ASSAM).Tel:0361-2132204/5; Fax : 0361- 2732937; Email firstname.lastname@example.org|
|HYDERABAD||6-2-46, 1st Floor,Moin Court, A.C. Guards, Lakdi-Ka-Pool, HYDERABAD-500 004.Tel : 040-65504123; Fax: 040-23376599; Email email@example.com|
|ERNAKULAM||2nd Floor, CC 27/2603,Pulinat Bldg., Opp. Cochin Shipyard, M.G. Road, ERNAKULAM-682015.Tel : 0484-2358759; Fax : 0484-2359336; Email firstname.lastname@example.org|
|KOLKATA||North British Bldg., 29, N.S. Road, 4th Floor, KOLKATA-700 001.Tel : 033-22134866; Fax : 033-22134868; Email email@example.com|
|LUCKNOW||Jeevan Bhawan, Phase-2,6th Floor, Nawal Kishore Road, Hazaratganj, LUCKNOW-226 001.Tel :0522 -2231331; Fax : 0522-2231310; Email firstname.lastname@example.org|
|MUMBAI||3rd Floor, Jeevan Seva Annexe,S.V. Road, Santacruz(W), MUMBAI-400 054.Tel : 022-26106928; Fax : 022-26106052; Email email@example.com|
Note: The above are only the salient features of the Policy , for complete terms and conditions please refer to Policy Wordings