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Policy Coverage

Saral Suraksha Bima undertakes to pay a lump sum amount of as selected by the proposer on happening of an eventuality covered in the policy.

The policy pays one-time payment equal to the Sum Insured on diagnosis of any of the listed five Critical Illnesses, Accidental Death and Permanent Total Disablement resulting from an accident.

Who can be covered under the Policy?

The Policy is structured to target group of members of SHG’s, NGOs, MFIs, Co-operative Banks, FCIs, Shareholders of Banks/Public ltd Companies, holders of Depositor Certificate by Banks/NBFCs, Members of Registered Service Clubs and Employer - Employee relationship including dependants of the employee, etc.

The policy can also be issued to individuals upon request and acceptance of such a request by Us.

What is covered under the Policy?

The policy shall pay to you on happening of below mentioned contingencies.

Section 1 - Critical Illness

a) Stroke resulting in permanent symptoms

b) Cancer of specified severity

c) Kidney Failure requiring regular dialysis

d) Open Chest CABG

e) Major Organ /Bone Marrow Transplant

Section 2 – Personal Accident

    • Accidental Death:

The nominee gets a one-time payment equal to Capital Sum Insured (CSI) if the insured dies in an accident.

    • Permanent Total Disablement

The insured is entitled to receive the percentage of the capital sum insured as per the table of benefit if he suffers a permanent and total loss of limbs, sight in an accident.

. TABLE OF BENEFITS % OF CSI
1. Death 100
2.
  • Loss of sight (both eyes)
  • b) Physical separation of or loss of ability to use both hands or both feet
  • c) Physical separation of or loss of ability to use one hand and/ or any feet
  • d) Loss of sight of one eye and physical separation of or loss of ability to use either one hand or one foot
  • 100
  • 100
  • 100
  • 100
3 a) Loss of sight of one eye b)physical separation of or use of ability to use one hand or one foot 50 50
4 Permanent Total and absolute disablement as certified by a qualified medical practitioner 100
Eligibility
      • Entry age for you (the proposer) is 18 years and you can opt for this policy up to the age of 65 years.
      • Policy renewals will be for your lifetime.
      • Children from 10 years 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.

What is not covered under the policy:-

Exclusion specific to Critical Illness

1) 90 days Waiting Period

A waiting period of 90 days will apply to all claims unless:

i.You have been insured under this Policy continuously and without any break in the previous Policy Year, or

ii.You were insured continuously and without interruption for at least 1 year under any other Indian insurer’s individual health insurance Policy for similar risks, and You establish to Our satisfaction that You were unaware of and had not taken any advice or medication for such Illness or treatment.

iii.If You renew with Us or transfer from any other insurer and increase the Sum Insured upon Renewal with Us, then this exclusion shall only apply in relation to the amount by which the Sum Insured has been increased.

2) Pre-existing diseases

    • Pre-existing diseases will not be covered until 48 months of continuous coverage have elapsed, since inception of the first Policy with Us; but:

1.If You are presently covered and have been continuously covered without any break under:

i.An individual health insurance plan with an Indian insurer for similar health risks

    • OR

ii.Any other similar health insurance plan from Us, then, Pre-existing diseases exclusion of the Policy stands deleted and shall be replaced entirely with the following:

i.The waiting period for all Pre-existing diseases shall be reduced by the number of Your continuous preceding years of coverage under the previous health insurance Policy;

    • AND

ii.If the proposed Sum Insured for You is more than the Sum Insured applicable under the previous health insurance Policy,

    • then the reduced waiting period shall only apply to the extent of the Sum Insured under the previous health insurance Policy.

3)Death within 30 days following the diagnosis of the Critical Illness

4)Any Critical Illness which arises or is caused by any one of the following:

a.Dry addiction, alcoholism, smoking of more than 30 cigarettes/cigars or equivalent intake of tobacco in a day and any complication, consequences arising there from.

b.Any Insured person suffering from Human T.Cell Lymphotropic Virus Type III (HTLV-III) or Lymphadinopathy Associated Viruses (LAV) or the Mutant derivatives or Variations Deficiency Syndrome or any Syndrome or a condition of similar kind referred to as AIDS. The onus shall always be on Insured Person to show any event was not caused by or did not arise through AIDS or HIV.

Exclusion specific to Personal Accident

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 1,2,3 and 4 in Table of benefits has been admitted and becomes payable.

3)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.

4)Payment of compensation in respect of injury as consequence of

a) Committing or attempting suicide, intentional self injury

b) Whilst under influence of intoxicating liquor

c) Drug addiction or alcoholism

d) Whilst engaged in any adventurous sports

e) Committing any breach of law with criminal intent

General Exclusions under the Policy

We will not pay for any compensation in respect of death, Illness, Injury or disablement of the Insured Person arising out of:

1)War, invasion, act of foreign enemy, hostilities (whether war be declared or not) civil war, rebellion, revolution, insurrection, mutiny military or usurped power, confiscation, seizure, capture, assault, restraint, nationalization, civil commotion or loot or pillage in connection herewith.

2)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.

3)The radioactive, toxic, explosive or the hazardous properties of any nuclear assembly or nuclear component.

What are the conditions under the Policy?

A. Sum Insured Premium Options

Sum Insured for CI Rs 10,000 Rs 20,000 Rs 25,000
Sum Insured for PA Rs 20,000 Rs 40,000 Rs 50,000
Premium excluding tax* Rs 141 Rs 246 Rs 290

* Applicable Service Tax and Cess is subject to change as per change in Tax Laws

What are the conditions under the Policy?

a.Your Policy shall ordinarily be renewable for lifetime except on grounds of fraud, moral hazard or misrepresentation or non‐cooperation by You/ any of the Insured Persons

b.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.

c.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.

d.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.

e.The Policy shall terminate on payment under any of the covered benefits viz. Personal Accident or Critical Illness/ Surgical Procedure

f.The basic premium applicable under the Policy may be revised at a later stage subject to approval from IRDA.

F.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.

G. 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.

H. 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.

I. 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

J. Sum Insured Enhancement:

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

K. 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.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:

i.You shall give Us all additional documentation and/or information We request;

ii.You pay Us the applicable premium in full;

iii.There is no obligation on Us to insure all Insured Persons or to insure all Insured Persons on the proposed terms, even if You have given Us all documentation;

iv.We have received the database and claim history from the previous insurance company for the Insured Persons’ previous health insurance Policy.

iv.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.

L. Contribution and Subrogation

These clauses shall not apply to this Policy.

Claims Procedure

i.Upon happening of any accident and/or injury which may give rise to a claim under this Policy.

a.Your representative shall give the notice to Our call centre immediately and also intimate in writing to Our Policy issuing office unless reasonable cause is shown, the notice be given before internment/ cremation and in any case, within one calendar month after the Death.

b.All certificates, information and evidence from a Medical Practitioner or otherwise required by Us shall be provided.

Critical illness Claims:

i.Certificate from the attending Doctor of the Insured confirming,

a.Name of the Insured;

b.Name, date of occurrence and medical details of the Insured Event

c.Confirmation that the Insured Event does not relate to any Pre-Existing Illness or an Illness or Injury which existed within the first 90 days of commencement of Policy Period.

ii.Duly completed claim form;

iii.Original Discharge Certificate/ Card from the hospital/ Doctor;

iv.Original investigation test reports, indoor case papers.

Death Claims:

a)Duly filled up claim form

b)Death Certificate and Original FIR

c)Original Panchnama

d)Post mortem report

Permanent Total Disablement Claims:

a)Duly filled original Claim Form

b)Claim Intimation

c)FIR – Attested or Original

d)Final Police Report / Original Panchnama

e)Certificate of from government hospital doctor confirming the nature and degree of disability

f)Discharge summary of the treating hospital clearly indicating the Hospital Registration No.

g)Diagnostic reports

h)Photograph of the injured reflecting disablement

Our obligation

We shall settle the claims, including its rejection, within 30 days of 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.

Position after claim:

We shall not be liable for any claim payment once the Maximum Limit of Liability (Sum Insured) is exhausted under the Policy by You.

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.

Claim Disclaimer

In the unfortunate event of any medical contingency resulting into a claim on this policy, please intimate the mishap, 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 contactus@universalsompo.com Please note that no delay should be allowed to occur in notifying a claim on the policy as the same may prejudice liability.

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.

In consideration of Your having paid the premium for the Policy Period stated in the Schedule We hereby agree, subject to the terms, conditions and exclusions stated in the Policy, to pay the Sum Insured on the occurrence of any of the insured events as mentioned under the item “What We cover” during the Policy Period.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 wherever it may appear.
 
 

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