Sampoorna Suraksha Bima (Micro Insurance Package Policy)
1. What is the Eligibility Age under the Policy?
• Entry age of the Proposer is 18 years to 65 years.
• Children from 91 days to 25 years can be covered if any one of the Parent is insured under the Policy. Unmarried children can also be covered upto maximum of 25 years of age only. In case child gets married, the child will not be covered on next renewal. The cover will continue till the natural expiry of the Policy.
2. What is covered under the Policy?
Section 1: Fire Allied perils - Contents
This section covers contents located in dwelling units excluding money and valuables under this section. The coverage under this Section is against following perils:
- Explosion / Implosion
- Aircraft Damage
- Riot, Strike, Malicious and Terrorism Damage
- Storm, Cyclone, Typhoon, Tempest, Hurricane, Tornado, Flood and Inundation
- Impact Damage
- Subsidence and Landslide including rock slide
- Bursting and/or overflowing of Water Tanks, Apparatus and Pipes
- Missile Testing operations
- Leakage from Automatic Sprinkler Installations
- Bush Fire
Sum Insured for Assets must be on Reinstatement Value basis.
Specific Exclusions to Section I
- Damage caused by pressure waves.
- Destruction or damage caused to the property by its own fermentation, natural heating or spontaneous combustion or its undergoing heating or drying process
- Burning of property insured by order of any Public Authority.
- Explosion/implosion losses to boilers (other than domestic boilers), economizers or other vessels, machinery or apparatus (in which steam is generated) including their contents.
- Destruction or damage to property caused by centrifugal forces.
- Damages caused by
- Permanent or temporary dispossession of any building resulting from the unlawful occupation by any person of such building or prevention of access to the same.
- Burglary, housebreaking, theft, larceny or any other such attempt or any omission of any kind of any person (whether or not such act is committed in connection with the disturbance of public peace) in any malicious act.
- Total or partial cessation of work or the retardation or interruption or cessation of any process or operations or omissions of any kind
- Damage by vehicle/animals belonging to or owned by You or Your Family.
- Damages caused by :-
- Normal cracking, settlement or bedding of structures.
- Settlement or movement of made up ground.
- Coastal or river erosion.
- Defective design or workmanship or use of defective material
- Demolition, construction, structural alteration or repair of any property or ground work or excavation.
- Damage caused by
- Repairs or alteration to Your Home.
- Repairs, removal or extension of the sprinkler installation.
- Defects in construction known to You.
- Damages caused to the insured property by pollution or contamination.
- Expenses necessarily incurred on Architect, Surveyor and Consulting Engineer’s fees and Debris Removal following Damage to property insured by an insured peril in excess of 3% and 1% of the claim amount respectively.
- Loss of earnings, loss by delay, loss of market or other consequential or indirect loss or damage of any kind or description whatsoever.
- Loss, destruction damage to any electrical machine, apparatus fixture or fittings arising from or occasioned by overrunning excessive pressure, short circuiting, arcing, self-heating or leakage of electricity from whatever cause (lightning included provided that this exclusion will apply only to the particular electrical machine, apparatus, fixture or fittings which may be destroyed or damaged by fire so set up.
- Livestock or pets
- Valuables as defined under the Policy, unless specifically covered.
- Loss or damage to property insured if removed to any building or place other than in which it is herein stated, except machinery and equipment temporarily removed for repairs, cleaning, renovation or other similar purposes for a period not exceeding 60 days.
- Liability in excess of First Loss Limit as stated in the Schedule
Section 2: Burglary Robbery
The Section covers loss or damage by actual or attempted burglary and/or robbery including theft during the Policy period in respect of the following:
(a) Contents or any item whilst kept in the insured premises
(b) Insured premises ( including reasonable costs for damaged locks)
There is an Option of availing the coverage under Section 1 and Section 2 on First Loss Basis i.e., the our liability shall be limited to the First Loss Limit which shall represent that percentage (25% or 50%, same under both the Sections) of total value at risk chosen by You to be insured, which shall be our maximum liability under this Section. After a loss the First Loss Limit shall have to be reinstated by payment of additional premium.
Specific Exclusions to Section 2
- Loss or damage from any yard, garden outbuilding (including sheds or garages not attached to the building) or any other property outside the confines of the premises unless specified in the Schedule
- Valuables and cash in safe/Almirah, unless specifically covered in the Schedule
- Loss or damage of motor vehicles, trailers unless mentioned as covered in the Schedule
- Loss or damage in which You, Your family members or any other person lawfully on or about Your premises is or is alleged to be in any way concerned or implicated
- Loss or damage resulting from an act of Riot, Strike, Malicious Damage and Terrorism
- Damage to glass and sign boards
- Live stock
- Loss or damage to contents or stock when the premises are left unoccupied for more than 30 consecutive days unless the same has been reported to us in writing and our written approval obtained.
- Any consequential loss or legal liability
- First Rs 2500/- under each and every claim
Section 3- Personal Accidents
This section covers Bodily injury to you and your dependants named in the Policy Schedule resulting to the death or disablement leading to following as per % mentioned in the Policy:
• Loss of sight
• Physical separation of or loss of ability to use both hands or both feet
• Physical separation of or loss of ability to use one hand and/or both feet
• Loss of sight of one eye and physical separation of or loss of ability to use either one hand or one foot
• Permanent Total disablement
Extra Benefits under the Policy in addition to capital sum Insured, in case the liability under the policy for Accidental Claim has been admitted.
|A.Transportation cost for carriage of dead body to Home including funeral charges.
||1% of Capital Sum Insured or 2,500/- (Two thousand five hundred) whichever is lower.
|B.Cost of Clothing damaged in the Accident as described above and liability is admitted by US.
||Actual expenses subject to maximum of Rs 1000/
|C.Ambulance charges for transportation of Insured person to Hospital following Accident
||Actual expenses subject to maximum of Rs 1000/
|D.Education Fund:- In the event of Death, permanent total disablement of the proposer that is the first Insured Person, We will approve compensation towards Education Fund for up to two dependent children as below
||5% (Five percent) of C.S.I @2.5% per child.
|E.Loss of Employment:- In the event of accident leading to loss of employment as a consequence of Permanent Total Disability as per the table of benefits.
||2% of Capital Sum Insured.
Specific Exclusions to Section 3
- Natural Death
- Compensation under more than one of the benefits mentioned in Table of Benefits in respect of same period of disablement.
- Any other payment after a claim under one of the benefits 1or2in Table of benefits has been admitted and becomes payable.
- Any payment in case of more than one claim under this Section during any one period of Insurance by which our liability in that period would exceed CSI
- Payment of compensation in respect of Death or injury as a consequence of/resulting from
- Committing or attempting suicide, intentional self-injury.
- Whilst under influence of intoxicating liquor or drugs.
- The abuse or the consequences of the abuse of intoxicants or hallucinogenic substances such as drugs and alcohol.
- Whilst engaged in any adventurous sports like hand gliding, mountaineering, rock climbing, sky diving, professional or amateur racing, parachuting, skiing, ice skating, ballooning, river rafting, polo playing, horse racing or sports of similar nature and/or hazardous activities like Persons working in underground mines, explosives, workers involved in electrical installations with High- tension supply, jockeys, circus Personnel or activities of similar nature
- Committing any breach of law with criminal intent.
- War, Civil War, invasion, act of foreign enemies, revolution, insurrection, mutiny, military or usurped power, seizure, capture, arrest, restraint, or detainment, confiscation, or nationalization or requisition by or under the order of any government or public authority.
- Consequential loss of any kind and/or any legal liability
- Pregnancy including child birth, miscarriage, abortion or complication arising there from.
- Participation in any naval, military or air force operations.
- Curative treatments or interventions
- Venereal or sexually transmitted diseases.
- HIV and or related illness
- Insured Person’s participation or involvement in naval, military or air force operation, racing, diving, aviation, scuba diving, parachuting, hang-gliding, rock or mountain climbing.
Section 4- Health Insurance Cover
This section covers the medical expenses incurred as an inpatient in respect of the treatment undergone by you and/or your family members – limited to self, spouse, children - due to accidental injury/illness sustained during the period of this Policy. The cover is also available for pre and post hospitalisation cover upto specified limits. There is no coverage available for any pre-existing diseases. The coverage excludes coverage of any diseases for first 30 days of the cover and specified illnesses for first year of cover.
• Inpatient Treatment :- The Policy shall cover Insured members for expenses incurred subject to limits as per below for each and every day of hospitalization under the policy.
i. Room, Boarding expenses a provided by the Hospital/Nursing Home
ii. If admitted in IC Unit
iii. Registration Charges
i)Up to 1% of Sum Insured per day
ii)Up to 2% of Sum Insured per day
||Surgeon, Anaesthetist, Medical Practitioner, Consultants, Specialists Fees, Nursing Expenses
||Up to 25% of Sum Insured per illness/ Injury
||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 40% of Sum Insured per illness/Injury
• Pre- Hospitalisation :- Relevant medical expenses incurred 30 days prior to Insured being hospitalized shall be covered under the Policy.
• I Post-Hospitalisation:- Relevant medical expenses incurred 60 days after Insured being hospitalized 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 20% of SI 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 in connection with an admissible claim limited to 1% of Sum Inured or Rs 1,000 whichever is less.s
Specific Exclusions to Section 4
- Hospitalization/Domiciliary Hospitalization expenses arising from all Diseases/ Injuries which are in Pre-existing Condition.
- Any claim occurring as a result of any condition, ailment or injury or related condition(s) for which the insured had signs or symptoms, and/or was diagnosed, and/or received medical advice/ treatment, within 48 months prior to the insured's first policy with the Company would not be payable until 48 months of continuous coverage have elapsed, since inception/reinstatement of the first policy with the Us.
- Hospitalisation/Domiciliary Hospitalisation expenses for any Disease which incepts during first 30 days of commencement of this Insurance cover.
- Hospitalization/Domiciliary Hospitalization expenses incurred in the first year of operation of the insurance cover on treatment of the following Diseases :
- Cataract; Benign Prostatic Hypertrophy; Myomectomy, Hysterectomy; Hernia, Hydrocele; Fistula in anus, Piles; Arthritis, Gout, Rheumatism; Joint replacement unless warranted due to an accident; Sinusitis and related disorders; Medical Management of tonsillitis.; Stone in the urinary and biliary systems; Dilatation and Curettage; Skin and all internal tumors/ cysts/ nodules/ polyps of any kind, including breast lumps unless malignant, adenoids and haemorrhoids; Dialysis required for renal failure; Surgery on tonsils and sinuses; Gastric and duodenal ulcers;
- Hospitalization for only Investigations and diagnosis.
- Injury or Diseases directly or indirectly caused by or arising from or attributable to war, invasion, act of foreign enemy, war like operation (whether war be declared or not).
- Circumcision unless necessary for the treatment of a Disease not otherwise excluded or required as a result of accidental bodily injury; vaccination, inoculation, cosmetic or aesthetic treatment of any description(including any complications arising thereof), plastic surgery except those relating to treatment of Injury or Disease.
- Cost of spectacles and contact lens or hearing aids.
- Dental treatment or surgery of any kind unless requiring inpatient hospitalization due to Accident.
- Convalescence, general debility, run down condition or rest cure, external congenital disease or defects or anomalies, sterility, venereal disease, intentional self-injury and use of intoxicating drugs/alcohols.
- Any expense on treatment related to HIV, AIDS and all related medical conditions.
- Expenses on Diagnostic, X-Ray, or Laboratory examinations unless related to the treatment of Disease or Injury falling within ambit of Hospitalization claim.
- Expenses on treatment arising from any infertility, sub fertility or assisted conception treatment.
- Expenses on Voluntary termination of pregnancy within first 12 Weeks.
- Injury or Diseases directly or indirectly caused by or contributed to by nuclear weapons/material.
- Any expense on treatment of Insured Person as an outpatient in a Hospital.
- Any expense on Naturopathy, non-allopathic treatment and/or any treatments not approved by Indian Medical Council any expense related to Disease/Injury suffered whilst engaged in adventurous sports.
- Expenses on treatment arising from or traceable to pregnancy, childbirth, miscarriage, an accidental abortion or complications of any of these, including caesarean section. This exclusion is not applicable to ectopic pregnancy.
- Any Expense of any treatment related to Human T-Cell Lymphotropic Viruses types III (III-LB-III) or Lymphadinopathy Associated Viruses (LAV) or the Mutant derivatives or Variations Deficiency Syndrome.
- External medical equipment of any kind used at home as post hospitalization care like wheelchairs, crutches, instruments used in treatment of Sleep Apnea Syndrome (C.P.A.P) or Continuous-Peritoneal Ambulatory Dialysis (C.P.A.D) and oxygen concentrator for bronchial asthmatic condition, etc.
- War, riots, strike, terrorism acts, nuclear weapon induced treatment section.
3. Conditions Under the Policy
- Your Policy shall ordinarily be renewable till 80 years of age except on grounds of fraud, moral hazard or misrepresentation or non‐cooperation by You/ any of the Insured Person
- The Renewal of a Policy sought by You shall not be denied arbitrarily. If denied, We shall provide You with cogent reasons for such denial of Renewal.
- The Renewal of a Policy sought by You shall not be denied arbitrarily. If denied, We shall provide You with cogent reasons for such denial of Renewal.
- We shall not deny the Renewal of the Policy on the ground that You had made a claim or claims in the previous or earlier years, except for the optional benefit covers where the coverage under the benefits viz. Personal Accident shall terminate following payment
- We shall provide for a mechanism to condone a delay in Renewal up to 30 days from the due date of Renewal without deeming such condonation as a Break in Policy. However coverage shall not be available for such period.
- If the Policy is not renewed within the Grace Period then We may agree to issue a fresh Policy subject to Our underwriting criteria and no continuing benefits shall be available from the expired Policy.
- All premiums are payable in advance of any cover under this Policy being provided.
- The basic premium applicable under the Policy may be revised at a later stage subject to approval from IRDA.
- We shall provide You with a substitute product if You have reached maximum renewable age under the Policy and suitable credits (continuity benefits) for all the previous Policy years that You have been covered shall be provided to You if the Policy has been maintained without break.
Please note: This Policy is in force for the Policy Period in Your Policy Schedule and is renewable subject to the terms provided at the time of each Renewal.We, however, are not bound to give notice that the Policy due for Renewal. Unless renewed as herein provided, this Policy shall terminate at the expiration of the period for which premium has been paid.
Cancellation We may cancel this Policy by sending 15 days notice in writing by recorded delivery to You at Your last known address. However this clause shall not be exercised except on grounds of fraud, misrepresentation, or suppression of any material fact either at the time of taking the Policy or any time during the currency of the Policy. In such circumstances you will not be entitled to any refund.
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:
|Period of Risk
||Rate of premium to be charged
|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
In the event of the Policy under which You are a covered member and which is being discontinued or not renewed or You cease to be a member of the group, You shall have the option of taking a standard individual health policy from Us in which due adjustment for the uninterrupted period in completed years for which You were covered under the Sampoorna Suraksha Bima issued by Us shall be made.
In case, where the Company may decide to withdraw Sampoorna Suraksha Bima Policy after prior approval from the Authority, option shall be available to You to migrate to nearest substitute product offered by the Company. The children, who have attended the maximum age under eligibility, can opt for nearest substitute health product offered by the Company on individual basis. Continuity benefits in all such cases shall be carried to the individual health insurance policy as per provisions mentioned above.
4. CLAIMS PROCEDURE
1. Claim Intimation
In the unfortunate event of any medical contingency/ loss resulting into a claim on this policy, please intimate the mishap IMMEDIATELY to our Call Centre at Toll Free Numbers on 1-800-22-4030 (for MTNL/BSNL users) or 1-800-102-4030 (other users) or on chargeable numbers at +91-22-26748600 / +91-22-41582900 / +91-22-41582999 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.
2. Submission of documents
Insured must submit any or all of the below mentioned document(s) as requested by us for settling Insured’s claim within 15 days ( 30 days for Hospitalisation claims) from date of intimating the claim.
Claim Documents for Section I and Section II
- Duly completed Claim form
- Copy of FIR
- Estimate of loss/repairs
- Any other details/documents called for a specific loss
Claims documents for Section III
For Death Claim
- Duly filled up claim form
- Death Certificate
- Original FIR
- Original Panchnama
- Post mortem report if conducted
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
- Termination letter for claim under “Loss of Employment”
Claim Documents for Section IVt
- Copy of the original bills
- Certificates, information and evidences from the attending Medical Practitioner/ Hospital/ Chemist/ Laboratory as required by Us.
We shall settle claim(s) as per policy terms and conditions, 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.
5. Third Party Administrator: Family Health Plan Limited
|Section 1 Fire and Allied Perils- Building Contents
Basic Rate: 0.25%
Policy on First loss:
- For 25% First loss: Limit Rate is 0.15% applicable on the 100% value at risk Total rate :0.25%
- For 50% First loss: Limit Rate is 0.21% applicable on the 100% value at risk Total rate :0.31%
|The basic rate is line with the basic rates filed by us as per the “FILE USE” guidelines for “Fire Special Perils Policy for Dwellings and household contents
|Section 2 Burglary Robbery
Rs 1.0%o for Full Value cover
Policy on First loss:
- For 25% First loss: Limit Rate is 0.25% on 100% of value at risk
- For 50% First loss: Limit Rate is 0.50% on
|---- Do -----
7. Premium chart for Section 4 – Health Cover:
|Premium - Self Only (upto 50 years of age )
For sum insured Option of Rs 30,000
||Premium in RS. for self
||Age of head of family
||Premium for Self Spouse and two dependent children
|51 to 55
||51 to 55
|56 to 60
||56 to 60
|61 to 65
||61 to 65
|66 to 70
||66 to 70
|71 to 75
||71 to 75
|75 to 80
||75 to 80
* Above Premium figures are exclusive of Service Tax
Service Tax exemption: Premium paid under Section 4 – Health Insurance is exempt from Service tax under Section 80 D of Income tax act if Premium is paid by your own cheque.
We will be creating packages of 2 or more covers from the above for offering them to the various customer groups / segments as per their specific requirements, the names of any specific package created shall be advised to IRDA prior to selling the same.
If coverage for more than one section is opted under the Policy, sectional discounts as mentioned below can be provided.
|All four sections
Sectional Discounts are not applicable for Group Policies.
|201 To 500 persons
|501 and above
||15% on total premium
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: 1-800-224030 (For MTNL/BSNL users) or 1-800-1024030.
Note: The above are only the salient features of the Policy , for complete terms and conditions please refer to Policy Wordings