AAPAT SURAKSHA BIMA POLICY

A. SCHEDULE
Policy Number:

Issuing Office:

Date of Proposal /
Declaration

Statistical Code

Name of the Proposer

Profession /
Occupation / Business

Address

Phone No.

Fax No.

E-mail ID
Details of Nominee

a) Name of the Nominee under the Policy

b) Relationship with the Insured

Period of Insurance From _____AM/PM of ________ To midnight of ________

Type of Policy Single Premium
BENEFITS COVERED Name of persons CSI/Sum Insured per TOTAL PREMIUM
covered person
Personal Accident List attached Rs……………….. Rs.
Section (Death and
Permanent Total
Disability Only)
Rs.
Critical Illness
List attached Rs…………..
Applicable
discounting/ loading ( if
any)
Rs.
TOTAL

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 Rs.
Service Tax
Rs.
Premium + Service Tax
Note: In the event of dishonour of cheque, this policy document automatically stands cancelled from
inception, irrespective of whether a separate communication is sent or not.

IN WITNESS WHEREOF THIS Policy has been signed at _________ this _______ day of
______20__.

For UNIVERSAL SOMPO GENERAL INSURANCE CO. LTD

Duly Constituted Attorney

Agency Details
Agency Code: ___________________________________________________________
Agency Name: ___________________________________________________________
Contact Number: _________________________________________________________
TPA: The Policy will be serviced directly by the Company. Please get in touch with Our representative
for complete details.

B. PREAMBLE
In consideration of you having paid the premium for the policy period stated in the Schedule
or for any further period of insurance for which we may accept the payment for renewal of
this policy 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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 C. DEFINITION

C.1. STANDARD DEFINITIONS:

Accident means a sudden unforeseen and involuntary event caused by external, visible and violent
means.

Condition Precedent means a Policy term or condition upon which the Insurer's liability under the
Policy is conditional upon.
Congenital Anomaly means a condition(s) which is present since birth, and which is abnormal with
reference to form, structure or position.
a) Internal Congenital Anomaly: means which is not in the visible and accessible parts of the body
b) External Congenital Anomaly: means which is in the visible and accessible parts of the body

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.
Grace period means the specified period of time immediately following the premium due date
during which a payment can be made to renew or continue a Policy in force without loss of
continuity benefits such as waiting periods and coverage of Pre-Existing Diseases. Coverage is not
available for the period for which no premium is received.
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 in-patient beds in towns having a population of less than 10,00,000 and at least
15 in-patient 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 makes these accessible to the insurance Company’s
authorized personnel.
Illness means 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 is a disease, Illness or Injury that is likely to respond quickly to treatment which
aims to return the person to his or her state of health immediately before suffering the
disease/Illness/Injury which leads to full recovery.
b) Chronic condition is defined as a disease, Illness, or Injury that has one or more of the following
characteristics
• it needs on-going or long-term monitoring through consultations, examinations, check-ups,
and/or tests
• it needs on-going or long-term control or relief of symptoms

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 • 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.

In-patient Care means treatment for which the Insured Person has to stay in a Hospital for more than
24 hours for a covered event.

Intensive Care Unit means an identified section, ward or wing of a Hospital which is under the
constant supervision of a dedicated Medical Practitioner(s), and which is specially equipped for the
continuous monitoring and treatment of patients who are in a critical condition, or require life support
facilities and where the level of care and supervision is considerably more sophisticated and intensive
than in the ordinary and other wards.

Medical Advice Medical Advice means any consultation or advice from a Medical Practitioner
including the issuance of any prescription or follow-up 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.

Medically Necessary means any treatment, tests, medication, or stay in Hospital or part of a stay in
Hospital which
• is required for the medical management of the Illness or Injury suffered by the insured;
• must not exceed the level of care necessary to provide safe, adequate and appropriate medical
care in scope, duration, or intensity;
• must have been prescribed by a Medical Practitioner,
• must conform to the professional standards widely accepted in international medical practice or
by the medical community in India.

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.

Pre- Existing Diseases

Pre-existing Disease means any condition, ailment, injury or disease:

a. That is/are diagnosed by a physician within 48 months prior to the effective date of the policy
issued by the insurer or its reinstatement or

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 b. For which medical advice or treatment was recommended by, or received from, a physician
within 48 months prior to the effective date of the policy issued by the insurer or its
reinstatement

Qualified Nurse means a person who holds a valid registration from the Nursing Council of India or
the Nursing Council of any state in India.

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.

Surgery or Surgical Procedure means manual and / or operative procedure (s) required for
treatment of an Illness or Injury, correction of deformities and defects, diagnosis and cure of diseases,
relief of suffering or prolongation of life, performed in a Hospital or day care centre by a Medical
Practitioner.

Unproven/Experimental Treatment means a treatment, including drug Experimental therapy, which

is not based on established medical practice in India, is treatment experimental or unproven.

C.2. SPECIFIC DEFINITIONS:

Adventure Sports means 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.

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.

Company means “Universal Sompo General Insurance Company Limited.”

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.

Dental Treatment means a treatment carried out by a dental practitioner including examinations,
fillings (where appropriate), crowns, extractions and Surgery excluding any form of cosmetic
Surgery/implants.

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Insured means the individual whose name is specifically appearing in the Schedule herein after
referred as “You”/”Your”/”Yours”/”Yourself”.

Nominee means the person(s) nominated by the Insured Person to receive the insurance benefits
under this Policy payable on his/her death.

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.

Policy means Our contract of insurance with the Insured providing cover as detailed in this document.

Policy Period means the Policy Period as set out in the Schedule for which the insurance cover will
remain valid.

Policy Year means a year following Policy Period Start Date and its subsequent annual anniversary.

Proposal form The application form You sign for this insurance and any other information You give
to us or which is given to us on Your behalf.

Portability means transfer by an individual health insurance Policy Holder (including family cover) of
the credit gained for pre-existing conditions and time-bound exclusions if he/she chooses to switch
from one insurer to another.

Service Providers means any person, institution or organisation that has been empanelled by the
Company to provide services to the Insured Person specified in the Policy.

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.

Sum Insured means the Monetary Amounts shown against insured person(s) which will be our
maximum liability during the policy period.

Subrogation means 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.

TPA means the third party administrator that the Company appoints from time to time as specified
in the Schedule.

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.

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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.

D. COVERAGES:

Section I Critical Illness

It means the following major diseases, which You have been diagnosed during the Policy Period to
have suffered from and which requires Hospitalisation and are specifically defined as below.

1. Stroke resulting in permanent symptoms

Any cerebrovascular incident producing permanent neurological sequelae. This includes infarction of
brain tissue, thrombosis in an intracranial vessel, haemorrhage and embolisation from an extracranial
source. Diagnosis has to be confirmed by a specialist medical practitioner and evidenced by typical
clinical symptoms as well as typical findings in CT Scan or MRI of the brain. Evidence of permanent
neurological deficit lasting for at least 3 months has to be produced.

2. Cancer of specified severity

A malignant tumour characterised by the uncontrolled growth & spread of malignant cells with
invasion & destruction of normal tissues. This diagnosis must be supported by histological evidence of
malignancy & confirmed by a pathologist. The term cancer includes leukemia, lymphoma and
sarcoma.

3. Kidney Failure requiring regular dialysis (Renal failure)

End stage renal disease presenting as chronic irreversible failure of both kidneys to function, as a
result of which either regular renal dialysis (hemodialysis or peritoneal dialysis) is instituted or renal
transplantation is carried out. Diagnosis has to be confirmed by a specialist medical practitioner.

4. First Heart Attack of specified severity (Coronary Artery Disease)

The first occurrence of myocardial infarction which means the death of a portion of the heart muscle
as a result of inadequate blood supply to the relevant area. The diagnosis for this will be evidenced
by all of the following criteria:
i. history of typical clinical symptoms consistent with the diagnosis of Acute Myocardial Infarction
(for e.g. typical chest pain) ii. new
characteristic electrocardiogram changes
iii. elevation of infarction specific enzymes, Troponins or other specific biochemical markers.

5. Major Organ /Bone Marrow Transplant The

actual undergoing of a transplant of:
i. One of the following human organs: lung, kidney, pancreas, bone marrow that resulted from
irreversible end-stage failure of the relevant organ, or
ii. Human bone marrow using haematopoietic stem cells. The undergoing of a transplant has to be
confirmed by a specialist medical practitioner.
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Coverage
WHAT WE COVER
The Sum Insured under the section shall become payable, if the Insured Person is detected/
diagnosed for the first time during the policy period as suffering from a Critical Illness or Surgical
Procedure defined under the Policy.

SPECIAL PROVISIONS
1. Each of the critical illness mentioned in the Policy must be confirmed by a Medical Practitioner
and must be supported by clinical, radiological, histological and laboratory evidence as
applicable.
2. The cover under this Policy in respect of any Insured Person shall cease upon the payment of
compensation on the happening of a critical illness or injuries defined under the policy.

Section II 1) Capital Sum Insured

a. It means the Monetary Amounts shown against insured person(s).
2) Bodily Injury
a. It shall mean Accidental Bodily Injury solely and directly caused by external, violent and
visible cause.
3) Permanent Total Disablement
a. The bodily injury that totally prevents you from engaging in any kind of occupation.

WHAT WE COVER
Bodily injury directly resulting to Your death or disablement as per the Table of Benefits.
We shall pay to You or Your legal personal representative / nominee the compensation set forth in
Table of Benefits (as percentage of Capital Sum Insured)
% OF CAPITAL
TABLE OF BENEFITS
SUM INSURED
1. Death 100
2. a) Loss of sight (both eyes) 100
b) Physical separation of or loss of ability to use both hands or both
feet 100
c) Physical separation of or loss of ability to use one hand and/ or
both feet 100
d) Loss of sight of one eye and physical separation of or loss of ability
to use either one hand or one foot 100
3. a) Loss of sight of one eye 50
b) Physical separation of or use of ability to use one hand or one 50
foot.
4. Permanent Total and absolute disablement 100

E. EXCLUSIONS:

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E.1. STANDARD EXCLUSIONS:

A) WAITING PERIOD:

1. Pre-existing diseases (Code- ExcI 01)

I. Expenses related to the treatment of a pre-existing Disease (PED) and its direct
complications shall be excluded until the expiry of 48 months of continuous coverage after
the date of inception of the first policy with us.
II. In case of enhancement of sum insured the exclusion shall apply afresh to the extent of
sum insured increase.
III. If the Insured Person is continuously covered without any break as defined under the
portability norms of the extant IRDAI (Health Insurance) Regulations then waiting period
for the same would be reduced to the extent of prior coverage.
IV. Coverage under the policy after the expiry of 48 months for any pre-existing disease is
subject to the same being declared at the time of application and accepted by us.

E.1. SPECIFIC EXCLUSIONS:

1. 90 days waiting period

A waiting period of 90 days will apply to any claim under this section 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 similar health insurance Policy for covering critical illness 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, then this
exclusion shall only apply in relation to the amount by which the Sum Insured has been increased

NB: The reduction in the waiting periods specified above shall be applied subject to the following:
i) We will only apply the reduction of the waiting period if We have received the database and
claim history from the previous Indian insurance Company (if applicable);
ii) We are under no obligation to insure all Insured Persons or to insure all Insured Persons on the
proposed terms, or on the same terms as the previous similar health insurance Policy even if You
have submitted to Us all documentation
iii) We shall consider only completed years of coverage for waiver of waiting periods. Policy
Extensions if any sought during or for the purpose of porting insurance Policy shall not be
considered for waiting period waiver
2. Death within 30 days following the diagnosis of the Critical Illness
3. 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.
4. Any claim if a critical Illness is caused directly or indirectly or contributed to by or arising from:

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 a. Ionizing Radiation or contamination by radioactivity from any nuclear fuel or from any
nuclear waste from combustion of nuclear fuel or nuclear weapon materials.
b. War, Invasion, Act of foreign enemy, Hostilities, Civil war, Rebellion, Revolution, Insurrection,
Mutiny, Military or usurped Power, Seizure, Capture, Arrest, Restraints and Detainments of
all kinds, Princes of whatever nation conditions or quality so ever.
5. Payment under Accidental Benefits arising out of the following:
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.
f) 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.
g) 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.
The radioactive, toxic, explosive or the hazardous properties of any nuclear assembly
or nuclear component.

A) OTHER EXCLUSIONS:
i. Transient ischemic attacks (TIA)
ii. Traumatic injury of the brain
iii. Vascular disease affecting only the eye or optic nerve or vestibular functions. iv. Tumours showing
the malignant changes of carcinoma in situ & tumours which are histologically described as
premalignant or non invasive, including but not limited to: Carcinoma in situ of breasts, Cervical
dysplasia CIN-1, CIN -2 & CIN-3.
v. Any skin cancer other than invasive malignant melanoma
vi. All tumours of the prostate unless histological classified as having a Gleason score greater than
6 or having progressed to at least clinical TNM classification T2NOMO vii.
Papillary micro - carcinoma of the thyroid less than 1 cm in diameter
viii. Chronic lymphocyctic leukaemia less than RAI stage 3
ix. Microcarcinoma of the bladder

x. Non-ST-segment elevation myocardial infarction (NSTEMI) with elevation of Troponin I or T

xi. Other acute Coronary Syndromes
xii. Any type of angina pectoris. xiii. Other stem-cell transplants
xiv. Where only islets of langerhans are transplanted

xvi. Compensation under more than one of the benefits mentioned in Table of Benefits in respect
of same period of disablement.
xvii. 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.
xviii. 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 xix.
Payment of compensation in respect of injury as a consequence of
a) Committing or attempting suicide, intentional self-injury.
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 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.
xx. 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.
xxi. 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.
xxii. The radioactive, toxic, explosive or the hazardous properties of any nuclear assembly or
nuclear component.

F. GENERAL CONDITIONS APPLICABLE TO BOTH THE SECTIONS

F.1. STANDARD GENERAL TERMS AND CLAUSES:

1. Claim Procedure
A) Upon happening of any disease/diagnosis/ accident 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 but not later than 7 days from the date of diagnosis/accident. Further the duly filled
in claim form with the below mentioned claim documents must be submitted within 30 days from the
date of diagnosis/accident.

In case of Death
• Policy Copy
• Post Mortem Report (certified copies) - as applicable

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• F.I.R. or Death report or Inquest Panchnama (in original or certified copies)- • Spot Panchnama
(certified copies)- if applicable
• Death certificate (in original or certified copy)

In case of Permanent Total Disablement

• Policy Copy
• Disability certificate - Authorized Medical Practitioner of the district/ units concerned, (certificate)
stating percentage of disablement
• F.I.R. and Panchnama wherever applicable (original or certified copies)
• Medical report/ Investigation reports like laboratory test, X-rays and reports essential of
confirmation of the type and percentage of disability
• Original medical bills

In case of Critical Illnesses/ Surgical Procedures

• Original Bills (including but not limited to pharmacy purchase bill, consultation bill, diagnostic bill
and any attachments thereto like receipts or prescriptions in support of any amount claimed)
• All reports, including but not limited to all medical reports, case histories, investigation reports,
treatment papers, discharge summaries.
• A precise diagnosis of the treatment for which a claim is made.
• A detailed list of the individual medical services and treatments provided and a unit price for each.
On receipt of intimation from you regarding a claim under the policy, we are entitled to:
• To carry out examination and verification of the medical report submitted as we may reasonably
require.

Our obligations

1. We shall settle claim(s), including its rejection, within thirty days of the receipt of the last
necessary claim document
2. We shall have no liability under this Policy, once the Sum Insured (Maximum Limit of Liability)
with respect to any of the Sections, is exhausted by You
3. 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.
4. We shall condone delay on merit for delayed claims where the delay is proved to be beyond
Your control

2. Position after claim

The Policy shall terminate for the Insured Person against whom claim under any of the sections
has been admitted and paid by the Us. An endorsement to this effect deleting the name of such
Insured Person shall be passed by Us.

3. Fraudulent claims lf any claim made by the insured person, is in any respect
fraudulent, or if any false statement, or declaration is made or used in support
thereof, or if any fraudulent means or devices are used by the insured person or

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 anyone acting on his/her behalf to obtain any benefit under this policy, all benefits
under this policy and the premium paid shall be forfeited.

Any amount already paid against claims made under this policy but which are found fraudulent
later shall be repaid by all recipient(s)/policyholder(s), who has made that particular claim, who
shall be jointly and severally liable for such repayment to the insurer. For the purpose of this
clause, the expression "fraud" means any of the following acts committed by the insured person
or by his agent or the hospital/doctor/any other pa(y acting on behalf of the insured person,
with intent to deceive the insurer or to induce the insurer to issue an insurance policy:

a) the suggestion, as a fact of that which is not true and which the insured person does not believe
to be true;
b) the active concealment of a fact by the insured person having knowledge or belief of the fact;
c) any other act fitted to deceive; and
d) any such act or omission as the law specially declares to be fraudulent

4. Cancellation

• The policyholder may cancel this policy by giving 15 days'written notice and in such an
event, the Company shall refund premium for the unexpired policy period as
detailed below
Period of risk expired 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

Notwithstanding anything contained herein or otheruise, no refunds of premium shall be made in

respect of Cancellation where, any claim has been admitted or has been lodged or any benefit has
been availed by the insured person under the policy.

• The Company may cancel the policy at any time on grounds of misrepresentation
nondisclosure of material facts, fraud by the insured person by giving 30 days' written
notice. There would be no refund of premium on cancellation on grounds of
misrepresentation, nondisclosure of material facts or fraud.

5. Free Look Period

The Free Look Period shall be applicable on new individual health insurance policies and not on
renewals or at the time of porting/migrating the policy. The insured person shall be allowed
free look period of fifteen days from date of receipt of the policy document to review the
terms and conditions of the policy, and to return the same if not acceptable. lf the insured
has not made any claim during the Free Look Period, the insured shall be entitled to
i. a refund of the premium paid less any expenses incurred by the Company on medical
examination of the insured person and the stamp duty charges or ii. where the risk has already
commenced and the option of return of the policy is exercised by the
insured person, a deduction towards the proportionate risk premium for period of cover or
iii. Where only a part of the insurance coverage has commenced, such proportionate premium
commensurate with the insurance coverage during such period;
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6. Nomination
The policyholder is required at the inception of the policy to make a nomination for the purpose of payment
of claims under the policy in the event of death of the policyholder. Any change of nomination shall be
communicated to the company in writing and such change shall be effective only when an endorsement on the
policy is made. ln the event of death of the policyholder, the Company will pay the nominee {as named in the
Policy Schedule/Policy Certificate/Endorsement (if any)} and in case there is no subsisting nominee, to the
legal heirs or legal representatives of the policyholder whose discharge shall be treated as full and final
discharge of its liability under the policy.

7. Redressal of Grievances ln case of any grievance the insured person may

contact the company through website o [email protected].

Toll Free Numbers: 1-800-224030 (For MTNL / BSNL Users) or 1-800–2004030 or on chargeable
numbers at +91-22-41659800/+91-22-41659900.
E-mail: [email protected]

Insured person may also approach the grievance cell at any of the company’s branches with the
details of grievance

If Insured person is not satisfied with the redressal of grievance through one of the above methods,
insured person may contact the grievance officer at [email protected]

 You can also visit our Company website and click under links Grievance Notification

If the issue still remains unresolved, You may, subject to vested jurisdiction, approach Insurance
Ombudsman for the redressal of Your grievance.

F.2. SPECIFIC TERMS AND CONDITIONS:

1. Mis-description
This Policy shall be void and premium paid shall be forfeited to Us in the event of misrepresentation,
mis-description or non-disclosure of any materials facts sought by us in our proposal form. Non-
disclosure shall include non-intimation of any change of circumstances which may affect the insurance
cover granted.

2. Contribution and Subrogation

The contribution and Subrogation clauses shall not be applicable to this Policy.

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3. Sum Insured enhancement
The Sum Insured under the Policy can only be enhanced on renewal subject to approval from
underwriter.

4. Loading/ Discounting under the Policy (Applicable only under group policies)
Group Discount under the Policy:- We will provide Group discounts as mentioned below under
group policies when numbers of persons covered exceeds 25.

Total No. of members Group Discount

25 to 100 5%
Up to 300 10%
Up to 500 12.50%
> 1000 15%

Low Claim Ratio Discount (Bonus):- We will provide you with Low Claims discount as mentioned
below under group policies when claims ratio experience of the group is as per below
Incurred Claims ratio under the Policy Discount %
Not exceeding 60% 5
Not exceeding 50% 15
Not exceeding 40% 25
Not exceeding 30% 35
Not exceeding 25% 40

High Claim Ratio Loading (Malus):- We will apply loading as mentioned below when the claims
experience of the group is as per below

Incurred Claims Ratio under the Policy Loading %

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

5. Arbitration clause
The parties to the contract may mutually agree and enter into a separate Arbitration Agreement to
settle any and all disputes in relation to this policy.
Arbitration shall be conducted under and in accordance with the provisions of the Arbitration and
Conciliation Act, 1996.
(This clause does not apply to Group policies where premium is paid by members)

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6. 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.

7. Claim Procedure
A) Upon happening of any disease/diagnosis/ accident 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 but not later than 7 days from the date of diagnosis/accident. Further the duly filled
in claim form with the below mentioned claim documents must be submitted within 30 days from the
date of diagnosis/accident.

In case of Death
• Policy Copy
• Post Mortem Report (certified copies) - as applicable
• F.I.R. or Death report or Inquest Panchnama (in original or certified copies)- • Spot Panchnama
(certified copies)- if applicable
• Death certificate (in original or certified copy)

In case of Permanent Total Disablement

• Policy Copy
• Disability certificate - Authorized Medical Practitioner of the district/ units concerned, (certificate)
stating percentage of disablement
• F.I.R. and Panchnama wherever applicable (original or certified copies)
• Medical report/ Investigation reports like laboratory test, X-rays and reports essential of
confirmation of the type and percentage of disability
• Original medical bills

In case of Critical Illnesses/ Surgical Procedures

• Original Bills (including but not limited to pharmacy purchase bill, consultation bill, diagnostic bill
and any attachments thereto like receipts or prescriptions in support of any amount claimed)
• All reports, including but not limited to all medical reports, case histories, investigation reports,
treatment papers, discharge summaries.
• A precise diagnosis of the treatment for which a claim is made.
• A detailed list of the individual medical services and treatments provided and a unit price for each.
On receipt of intimation from you regarding a claim under the policy, we are entitled to:
• To carry out examination and verification of the medical report submitted as we may reasonably
require.

Our obligations

5. We shall settle claim(s), including its rejection, within thirty days of the receipt of the last
necessary claim document

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 6. We shall have no liability under this Policy, once the Sum Insured (Maximum Limit of Liability)
with respect to any of the Sections, is exhausted by You
7. 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.
8. We shall condone delay on merit for delayed claims where the delay is proved to be beyond
Your control

8. Position after claim

The Policy shall terminate for the Insured Person against whom claim under any of the sections
has been admitted and paid by the Us. An endorsement to this effect deleting the name of such
Insured Person shall be passed by Us.

9. Renewal
a. Your Policy shall ordinarily be renewable till 65 years of age 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 You move into a higher age band, the premium will increase at the next Renewal. However, this
Policy will not be subject to any alteration in premium rates generally introduced until the next
Renewal.
e. 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.
f. All premiums are payable in advance of any cover under this Policy being provided.
g. The basic premium applicable under the Policy may be revised at a later stage subject to approval
from IRDA.
h. We shall provide You with a substitute similar health insurance 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.

10. Substitute Product

In case We may decide to withdraw this product under which this Policy is issued to You or where
You have reached the maximum renewal age under the Policy or where You cease to be member
of group when You are covered under a group policy issued by Us, We shall provide You with an
option to buy a substitute health insurance Policy from Us.
Aapat Suraksha Bima, Universal Sompo General Insurance Company
UIN- UNIHLIP08002V020708 Page 17 of 23
You will be given the Portability credit based on the number of years of continuous and uninterrupted
insurance cover under this Policy towards the waiting periods in the new substitute health insurance
Policy issued by Us

11. Portability
If You were insured continuously and without a break under another Indian retail health insurance
policy covering critical illness risks with Us or any other Indian General Insurance company, it is
understood and agreed that:
a) 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;
b) This benefit is available only at the time of renewal of the existing similar health insurance policy.
c) The Portability Benefit shall be applied subject to the following:
1. Your proposal shall be subject to Our medical underwriting
2. 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

12. 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 also promise You that
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, subject to portability conditions.

13. 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.

Unit No. 601 & 602, 6th Floor, Reliable Tech Park, Cloud City Campus; Gut No-31, Mouje Elthan,
Thane- Belapur Road, Airoli, Navi Mumbai- 400708

Toll Free Numbers: 1-800-224030 (For MTNL/BSNL Users) or 1-800–2004030 Senior Citizen1800-
267-4030

Landline Numbers: (022)-41659800 or (022)-41659900 (Local Charges Apply)

E-mail Address: [email protected].

Note: Please include your policy number for any communication with us.

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UIN- UNIHLIP08002V020708 Page 18 of 23
Claims Disclaimer
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-
22-4030 (for MTNL/BSNL users) or 1-800-200-4030 (other users) or on chargeable numbers at
+91-22-41659800/+91-22-41659900. 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.

14. Notice
Every notice and communication to the Company required by this policy shall be in writing. Initial
notification can be made by telephone.

15. Geographical Limit

The geographical scope of this Policy will be India and all claims shall be payable in Indian currency
except for Accidental claims for which the scope of the Policy shall be on worldwide basis.

The updated details are also available on: http://www.irdaindia.org/ins_ombusman.htm

The details of Insurance Ombudsman are available below:-

Jurisdiction of Office
Office Details
Union Territory,District)
AHMEDABAD - Shri Kuldip Singh Gujarat,
Office of the Insurance Ombudsman, Dadra & Nagar Haveli,
Jeevan Prakash Building, 6th floor, Daman and Diu.
Tilak Marg, Relief Road,
Ahmedabad – 380 001.
Tel.: 079 - 25501201/02/05/06
Email: [email protected]
BENGALURU -
Office of the Insurance Ombudsman,
Jeevan Soudha Building,PID No. 57-27-N-19
Ground Floor, 19/19, 24th Main Road,
Karnataka.
JP Nagar, Ist Phase,
Bengaluru – 560 078.
Tel.: 080 - 26652048 / 26652049
Email: [email protected]
BHOPAL - Madhya Pradesh
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UIN- UNIHLIP08002V020708 Page 19 of 23
 Office of the Insurance Ombudsman, Chattisgarh.
Janak Vihar Complex, 2nd Floor,
6, Malviya Nagar, Opp. Airtel Office,
Near New Market, Bhopal
– 462 003.
Tel.: 0755 - 2769201 / 2769202
Fax: 0755 - 2769203
Email: [email protected]
BHUBANESHWAR - Shri Suresh Chandra Panda
Office of the Insurance Ombudsman,
Orissa.
62, Forest park,
Bhubneshwar – 751 009.

Tel.: 0674 - 2596461 /2596455

Fax: 0674 - 2596429
Email: [email protected]
CHANDIGARH - Punjab,
Office of the Insurance Ombudsman, Haryana(excluding
Gurugram, Faridabad,
Sonepat and Bahadurgarh)
S.C.O. No. 101, 102 & 103, 2nd Floor, Himachal Pradesh, Union
Territories of Jammu &
Kashmir,
Batra Building, Sector 17 – D, Chandigarh Ladakh & Chandigarh.
– 160 017.
Tel.: 0172 - 2706196 / 2706468
Fax: 0172 - 2708274
Email: [email protected]
CHENNAI - Tamil Nadu,
Office of the Insurance Ombudsman, Tamil Nadu
Fatima Akhtar Court, 4th Floor, 453, PuducherryTown and
Anna Salai, Teynampet, Karaikal (which are part of
Puducherry).
CHENNAI – 600 018.
Tel.: 044 - 24333668 / 24335284
Fax: 044 - 24333664
Email: [email protected]
DELHI - Shri Sudhir Krishna Delhi &

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UIN- UNIHLIP08002V020708 Page 20 of 23
 Office of the Insurance Ombudsman,
2/2 A, Universal Insurance Building, Following Districts of
Asaf Ali Road, Haryana - Gurugram,
New Delhi – 110 002. Faridabad, Sonepat &
Tel.: 011 - 23232481/23213504 Bahadurgarh.
Email: [email protected]
GUWAHATI - Assam,
Office of the Insurance Ombudsman, Meghalaya,
Jeevan Nivesh, 5th Floor, Manipur,
Nr. Panbazar over bridge, S.S. Road, Mizoram,
Guwahati – 781001(ASSAM). Arunachal Pradesh,
Tel.: 0361 - 2632204 / 2602205 Nagaland and Tripura.
Email: [email protected]
HYDERABAD - Andhra Pradesh,
Office of the Insurance Ombudsman, Telangana,
6-2-46, 1st floor, "Moin Court", Yanam and
Lane Opp. Saleem Function Palace, part of Union Territory of
Puducherry.
A. C. Guards, Lakdi-Ka-Pool, Hyderabad
- 500 004.
Tel.: 040 - 23312122
Fax: 040 - 23376599
Email: [email protected]
JAIPUR - Rajasthan.

Office of the Insurance Ombudsman,

Jeevan Nidhi – II Bldg., Gr. Floor,
Bhawani Singh Marg,
Jaipur - 302 005.
Tel.: 0141 - 2740363
Email: [email protected]

ERNAKULAM - Ms. Poonam Bodra Kerala,

Office of the Insurance Ombudsman, Lakshadweep,
2nd Floor, Pulinat Bldg., Mahe-a part of Union
Territory of Puducherry.
Opp. Cochin Shipyard, M. G. Road, Ernakulam
- 682 015.
Tel.: 0484 - 2358759 / 2359338
Fax: 0484 - 2359336
Email: [email protected]
KOLKATA - Shri P. K. Rath West Bengal,
Office of the Insurance Ombudsman, Sikkim,

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UIN- UNIHLIP08002V020708 Page 21 of 23
 Hindustan Bldg. Annexe, 4th Floor, Andaman & Nicobar
Islands.
4, C.R. Avenue,
KOLKATA - 700 072.
Tel.: 033 - 22124339 / 22124340
Fax : 033 - 22124341
Email: [email protected]
LUCKNOW -Shri Justice Anil Kumar Srivastava Districts of Uttar Pradesh :
Office of the Insurance Ombudsman, Lalitpur, Jhansi, Mahoba,
6th Floor, Jeevan Bhawan, Phase-II, Hamirpur, Banda,
Nawal Kishore Road, Hazratganj, Lucknow Chitrakoot, Allahabad,
- 226 001. Mirzapur, Sonbhabdra,
Tel.: 0522 - 2231330 / 2231331
Fatehpur, Pratapgarh,
Fax: 0522 - 2231310
Jaunpur,Varanasi, Gazipur,
Email: [email protected] Jalaun, Kanpur, Lucknow,
Unnao, Sitapur, Lakhimpur,
Bahraich, Barabanki,
Raebareli, Sravasti, Gonda,
Faizabad, Amethi,
Kaushambi, Balrampur,
Basti, Ambedkarnagar,
Sultanpur, Maharajgang,
Santkabirnagar, Azamgarh,
Kushinagar, Gorkhpur,
Deoria, Mau, Ghazipur,
Chandauli, Ballia,
Sidharathnagar.
MUMBAI - Goa,
Office of the Insurance Ombudsman, Mumbai Metropolitan
Region
3rd Floor, Jeevan Seva Annexe, excluding Navi Mumbai &
Thane.
S. V. Road, Santacruz (W),
Mumbai - 400 054.
Tel.:
69038821/23/24/25/26/27/28/28/29/30/31
Fax: 022 - 26106052
Email: [email protected]
NOIDA - Shri Chandra Shekhar Prasad State of Uttaranchal and the
following Districts of Uttar
Pradesh:

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UIN- UNIHLIP08002V020708 Page 22 of 23
 Office of the Insurance Ombudsman, Agra, Aligarh, Bagpat,
Bhagwan Sahai Palace Bareilly, Bijnor, Budaun,
4th Floor, Main Road, Bulandshehar, Etah, Kanooj,
Naya Bans, Sector 15, Distt: Mainpuri, Mathura, Meerut,
Gautam Buddh Nagar, U.P- Moradabad,
201301. Muzaffarnagar, Oraiyya,
Tel.: 0120-2514252 / 2514253 Pilibhit, Etawah,
Email: [email protected] Farrukhabad, Firozbad,
Gautambodhanagar,
Ghaziabad, Hardoi,
Shahjahanpur, Hapur,
Shamli, Rampur, Kashganj,
Sambhal, Amroha, Hathras,
Kanshiramnagar,
Saharanpur.

PATNA - Shri N. K. Singh Bihar,

Office of the Insurance Ombudsman, Jharkhand.
2nd Floor, Lalit Bhawan,
Bailey Road, Patna
800 001.
Tel.: 0612-2547068
Email: [email protected]
PUNE - Shri Vinay Sah Maharashtra,
Office of the Insurance Ombudsman, Area of Navi Mumbai and
Thane
Jeevan Darshan Bldg., 3rd Floor, excluding Mumbai
Metropolitan Region.
C.T.S. No.s. 195 to 198,
N.C. Kelkar Road, Narayan Peth, Pune
– 411 030.
Tel.: 020-41312555
Email: [email protected]

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UIN- UNIHLIP08002V020708 Page 23 of 23