Universal Sompo Health Insurance

Features of Universal Sompo Health Insurance Plans

• This Policy covers persons in the age group 91 days to 70 years, with the proposer necessarily being an adult.
• In-patient treatment includes Hospital room rent or boarding expenses, nursing, Intensive Care Unit charges Operation Theatre charges, Medical Practitioner’s charges, fees of Surgeon, Anaesthetist, Qualified Nurse, Specialists, the cost of diagnostic tests, medicines, drugs, blood, oxygen, the cost of prosthetics and other devices or equipment if implanted internally during a Surgical Procedure. A minimum period of 24 consecutive hours hospitalization as in-patient is must.
• Pre & Post Hospitalization Cover : Covers relevant medical expenses incurred upto 30 days before hospitalization or day care treatment and 60 days post hospitalization for treatment of Disease, Illness contracted or Injury sustained.
• Organ Donor Expenses : Covers hospitalization expenses for Medical treatment of the organ donor for harvesting the organ
• AYUSH Treatment Expenses
• Automatic Restoration of Sum Insured upto 100% of Base Sum insured
• Domiciliary Treatment - Coverage of Medical treatment actually taken at home for a period of more than 3 days under the following compelling circumstances, which in the normal course would require Hospitalization of Insured Person
• Critical-illness Coverage (Add on/ Optional)
  • In case you have opted for additional cover against following 5 named Critical Illness and have paid additional premium.Your Sum insured for the treatment of the said disease/medical condition becomes double.
    • First Heart Attack - Of Specified Severity
    • Cancer of specified severity
    • Open Chest CABG
    • Open Heart Replacement Or Repair Of Heart Valves
    • Coma Of Specified Severity
    • Kidney Failure requiring regular dialysis
    • Major Organ /Bone Marrow Transplant
    • Stroke resulting in permanent symptoms
    • Kidney Failure requiring regular dialysis
    • Permanent Paralysis Of Limbs
    • Motor Neurone Disease With Permanent Symptoms
• Emergency Ambulance - Coverage of Emergency Medical expenses upto 1% of Basic Sum Insured subject to Maximum of Rs 1000.
• Health Check-up - Medical checkup expenses can be reimbursed once at the end of a block of every four claim free Policies bought from USGIC. The reimbursement shall not exceed the amount equal to 1% of the average Basic Sum Insured for the block of 4 years.
• Hospital Cash - When you avail this option, we shall provide you with daily cash for each day that you are hospitalised when your hospitalisation exceeds 3 days.
• Maternity with New Born Baby Cover
• This benefit is available only under a Family Floater Policy
• This benefit is available for Insured / Insured’s spouse provided both are covered under the same Policy.

Why Should a customer opt for Universal Sompo General ?

• Their Mission
  • World class services and products to all their Customers
  • Growth along with Customer Centric Approach
  • Highly efficient post claim services to all our customers.
• Value Added Services
  • Wellness is a lifelong path, and the journey is different for each individual — whether they are healthy, at risk of disease or injury, managing a chronic condition or experiencing a major health event.
• Policy Issuance Support
  • Policy will be delivered right to one’s email and whats app number. In case of any problem in policy issuance, they will take care of resolving the issue and delivering the policy right away in your inbox and get everything ready for you.
• Claim Assistance
  • Get full claim assistance, Just call them on our Toll-free 1800 22 4030 / 1800 200 4030 and they will take care of the rest.
• Policy Vault
  • All your policies in one place - Universal Sompo is the way ahead on the Digital Insurance journey. They take care of all one’s insurance needs.

Cashless Hospitalization Process

Reimbursement Claim Process

Claim process to be followed to avail services through TPA (Third Party Administrator)

• Cashless Service" at all our Network Providers for all eligible ailments/conditions.
• Processing and settlement of claims under the MEDICLAIM policy with a time bound approach.
• 24 hours Call Centre Service.

• Your Contact Numbers
• Policy Number and Membership ID number (as reflecting on the Health Card)
• Name of Insured person who is Sick or Injured,
• Nature of Sickness/Accident,
• Date & Time of Loss in case of accident, commencement date of symptom of disease in case of sickness,
• Location of Loss,
• Place & contact details of the Insured Person.

Exclusions under Universal Sompo Health Plan

• Specific Waiting Periods : The Illnesses and treatments listed below will be covered subject to a waiting period of 1 years as long as in the second Policy Year has been insured under this Policy continuously and without any break:
  • Illnesses
    • Arthritis if non-infective; calculus diseases of gall bladder and urogenital system; cataract; fissure/fistula in anus, hemorrhoids, pilonidal sinus, gastric and duodenal ulcers; gout and rheumatism; internal tumors, cysts, nodules, polyps including breast lumps (each of any kind unless malignant); osteoarthritis and osteoporosis if age related; polycystic ovarian diseases; sinusitis and related disorders and skin tumors unless malignant.
    • Treatments
      • Benign ear, nose and throat (ENT) disorders and surgeries (including but not limited to adenoidectomy, mastoidectomy, tonsillectomy and tympanoplasty); dilatation and curettage (D&C); hysterectomy for menorrhagia or fibromyoma or prolapse of uterus unless necessitated by malignancy; joint replacement; myomectomy for fibroids; Surgery of gallbladder and bile duct unless necessitated by malignancy; Surgery of genito urinary system unless necessitated by malignancy; Surgery of benign prostatic hypertrophy; Surgery of hernia; Surgery of hydrocele; Surgery for prolapsed inter vertebral disk; Surgery of varicose veins and varicose ulcers; Surgery on tonsils and sinuses; Surgery for nasal septum deviation.
• However, a waiting period of 1 year will not apply if You were insured continuously and without interruption for at least 1 year under any Our or other Indian insurer’s individual health insurance Policy for the reimbursement of medical costs for inpatient treatment in a Hospital.
  • Maternity and Childcare Benefit Waiting Period of 3 years
    • The expenses covered under benefit n) Maternity and Childcare benefit shall be excluded for a period of 3 years unless You were insured continuously and without interruption for at least 3 years under any other Indian insurer’s or Our individual health insurance Policy for reimbursement of medical costs for delivery of child in a Hospital.
    • Out-patient Treatment Waiting Period of 3 years : The expenses covered under benefit l) Out – Patient treatment shall be excluded for a period of 3 years unless You were insured continuously and without interruption for at least 3 years under any other Indian insurer’s or Our individual health insurance Policy for reimbursement of medical costs incurred by You as an Out-patient in a Hospital or Out-patient Treatment centre.
• If You renew with Us or transfer from any other insurer and increase the Sum Insured (other than as a result of the application of Cumulative Bonus) upon Renewal with Us), then this exclusion shall only apply in relation to the amount by which the Sum Insured has been increased.
• You will be given the Portability credit of the waiting period based on the number of years of continuous and uninterrupted insurance cover
• Pre-existing diseases, illness, or injury. Health insurance benefits will not be available for any condition(s) as defined in the policy, until 48 months of continuous coverage have elapsed, since the inception of the first policy with the Company
• Any benefit under critical illness within the first 30 days of inception of the policy for the first year. This exclusion doesn't apply for subsequent renewals with the Company without a break.
• Medical expenses incurred for treatment undertaken for disease or illness and/or for critical illness within 30 days of the inception date of health insurance policy. This exclusion doesn't apply for subsequent renewals with the Company without a break.
• Routine medical, eye and ear examinations, cost of spectacles, laser surgery, contact lenses or hearing aids, vaccinations and inoculation of any kind, issuing of medical certificates and examinations as to suitability for employment or travel.
• Vitamins and tonics unless forming part of treatment for the disease, illness, or injury.
• Any stay in Hospital without undertaking any treatment or where there is no active regular treatment by the Medical Practitioner
• Prostheses, corrective devices, and medical appliances, which are not required intra-operatively or for the disease/ illness/ injury for which the Insured / Insured Person was hospitalized
• Charges incurred primarily for diagnostic, X-ray or laboratory examinations or other diagnostic studies not consistent with or incidental to the diagnosis and treatment.
• Costs of donor screening or treatment, unless specifically covered and specified in the Schedule to this Policy.
• Naturopathy treatment.
• Any treatment received outside India.