supreme-healthcare-policy-wordings (1)

SUPREME HEALTHCARE POLICY
POLICY WORDINGS
1. PREAMBLE
The proposal and declaration given by the proposer and other documents if any shall
form the basis of this Contract and is deemed to be incorporated herein. The two parties
to this contract are the Policy Holder/Insured/Insured Persons (also referred as You) and
Universal Sompo General Insurance Co Limited (also referred as Company/ We/Us),
and all the Provisions of Indian Contract Act, 1872, shall hold good in this regard. The
references to the singular include references to the plural; references to the male include
the references to the female; and references to any statutory enactment include
subsequent changes to the same and vice versa. The sentence construction and
wordings in the Policy documents should be taken in its true sense and should not be
taken in a way so as to take advantage of the Company by filing a claim which deviates
from the purpose of Insurance.
In return for premium paid, the Company will pay the Insured in case a valid claim is
made:
In consideration of the premium paid by the Policy Holder, subject to the terms &
conditions contained herein, the Company agrees to pay/indemnify the Insured
Person(s), the amount of such expenses that are reasonably and necessarily incurred up
to the limits specified against respective Benefit in any Policy Year.
Please check whether the details given by you about the insured Persons in the
proposal form (a copy of which was provided at the time of issuance of cover for the first
time) are incorporated correctly in the policy schedule. If you find any discrepancy,
please inform us within 30 days from the date of receipt of the policy, failing which the
details relating to the person/s covered would be taken as correct.
So also the coverage details may also be gone through and in the absence of any
communication from you within 30 days from the date of receipt of the policy, it would be
construed that the policy issued is correct and the claims if any arise under the policy will
be dealt with based on proposal /policy details.
For the purposes of interpretation and understanding of the product the Company has
defined, herein below some of the important words used in the product and for the
remaining language and the words the Company believes to mean the normal meaning
of the English language as explained in the standard language dictionaries. The words
and expressions defined in the Insurance Act, IRDA Act, regulations notified by the
Insurance Regulatory and Development Authority of India (“Authority”) and circulars and
guidelines issued by the Authority shall carry the meanings described therein. The terms
and conditions, insurance coverage and exclusions, other Benefits, various procedures
UIN - UNIHLIP25030V012425
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and conditions which have been built-in to the product are to be construed in accordance
with the applicable provisions contained in the product.
The terms defined below have the meanings ascribed to them wherever they appear in
this Policy and, where appropriate.
2. Definitions
2.1. Standard Definition
2.1.1. Accidental / Accident is a sudden, unforeseen and involuntary event caused

by external, visible and violent means.
2.1.2. AYUSH Hospital is a healthcare facility wherein medical/surgical/para-

surgical treatment procedures and interventions are carried out by AYUSH
Medical Practitioner(s) comprising of any of the following:
(a) Central or State Government AYUSH Hospital or

(b) Teaching hospital attached to AYUSH College recognized by the Central
Government/Central Council of Indian Medicine/Central Council for
Homeopathy ;or
(c) AYUSH Hospital, standalone or co-located with in-patient healthcare facility of
any recognized system of medicine, registered with the local authorities,
wherever applicable, and is under the supervision of a qualified registered
AYUSH Medical Practitioner and must comply with all the following criterion:
i. Having at least 5 in-patient beds;
ii. Having qualified AYUSH Medical Practitioner in charge round the clock;
iii. Having dedicated AYUSH therapy sections as required and/or has
equipped operation theatre where surgical procedures are to be carried
out;
iv. Maintaining daily records of the patients and making them accessible to
the insurance Company’s authorized representative.
2.1.3. AYUSH Day Care Centre means and includes Community Health Centre
(CHC), Primary Health Centre (PHC), Dispensary, Clinic, Polyclinic or any
such center which is registered with the local authorities, wherever applicable,
and having facilities for carrying out treatment procedures and medical or
surgical/para-surgical interventions or both under the supervision of
registered AYUSH Medical Practitioner (s) on day care basis without in-
patient services and must comply with all the following criterion:
i. Having qualified registered AYUSH Medical Practitioner(s) in charge;

ii. Having dedicated AYUSH therapy sections as required and/or has
equipped operation theatre where surgical procedures are to be carried
out;
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iii. Maintaining daily records of the patients and making them accessible to
the insurance Company’s authorized representative.
2.1.4. Cashless Facility means a facility extended by the insurer to the Insured
where the payments, of the costs of treatment undergone by the insured in
accordance with the Policy terms and conditions, are directly made to the
network Provider by the insurer to the extent pre-authorization is approved.
2.1.5. Condition Precedent shall mean a Policy term or condition upon which the
Insurer’s liability under the Policy is conditional upon.
2.1.6. Congenital Anomaly refers to a condition which is present since birth, and
which is abnormal with reference to form, structure or position :
Internal Congenital Anomaly –

Congenital anomaly which is not in the visible and accessible parts of the body
External Congenital Anomaly –
Congenital anomaly which is in the visible and accessible parts of the body
2.1.7. Co-payment is a cost-sharing requirement under a health insurance policy

that provides that the policyholder/insured will bear a specified percentage of
the admissible claim amount. A co-payment does not reduce the sum insured.
2.1.8. Cumulative Bonus mean any increase or addition in the Sum Insured
granted by the insurer without an associated increase in premium.
2.1.9. Day Care Centre means any institution established for day care treatment of
illness and/or injuries or a medical setup within a hospital and which has been
registered with the local authorities, wherever applicable, and is under the
supervision of a registered and qualified medical practitioner AND must
comply with all minimum criteria as under—
• has qualified nursing staff under its employment;

• has qualified Medical Practitioner/s in-charge;
• has a fully equipped operation theatre of its own, where Day Care Treatment
is carried out.
• maintains daily records of patients and will make these accessible to the
insurance Company’s authorized personnel.
2.1.10. Day Care Treatment means medical treatment, and/ or Surgical Procedure
which is:
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• undertaken under general or local anesthesia in a Hospital/ Day Care
Centre in less than 24 consecutive hours because of technological
advancement, and
• which would have otherwise required a Hospitalization of more than 24
hours.
• Treatment normally taken on an out-patient basis is not included in the
scope of this definition.
2.1.11. Deductible is a cost-sharing requirement under a health insurance policy that

provides that the Insurer will not be liable for a specified rupee amount in
case of indemnity policies and for a specified number of days/hours in case of
hospital cash policies which will apply before any benefits are payable by the
insurer. A deductible does not reduce the Sum Insured.
2.1.12. Dental Treatment means a treatment related to teeth or structures

supporting teeth including examinations, fillings (where appropriate), crowns,
extractions and surgery.
2.1.13. Disclosure to Information Norm: The Policy shall be void and all premium
paid thereon shall be forfeited to the Company, in the event of
misrepresentation, mis-description or non-disclosure of any material fact.
2.1.14. Domiciliary Hospitalization means medical treatment for an

illness/disease/injury which in the normal course would require care and
treatment at a Hospital but is actually taken while confined at home under any
of the following circumstances:
• The condition of the patient is such that he/she is not in a condition to be

removed to a Hospital, or
• The patient takes treatment at home on account of non-availability of room
in a Hospital.
2.1.15. Emergency Care (Emergency) means management for an 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.
2.1.16. Grace Period means the specified period of time, immediately following the
premium due date during which premium payment can be made to renew or
continue a policy in force without loss of continuity benefits pertaining to
waiting periods and coverage of pre-existing diseases. Coverage need not be
available during the period for which no premium is received. The grace
period for payment of the premium for all types of insurance policies shall be:
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fifteen days where premium payment mode is monthly and thirty days in all
other cases.
2.1.17. Hospital (not applicable for Overseas Travel Insurance) 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 Has 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.
2.1.18. Hospitalization (not applicable for Overseas Travel Insurance) means

admission in a Hospital for a minimum period of 24 consecutive ‘In-patient
Care’ hours except for specified procedures/treatments, where such
admission could be for a period of less than 24 consecutive hours.
2.1.19. Illness means a sickness or a disease or a pathological condition leading to

the impairment of normal physiological function and requires medical
treatment.
(a) Acute condition - Acute condition is a disease, illness or injury that is

likely to respond quickly to treatment which aims to return the person to his
or her state of health immediately before suffering the disease/ illness/ injury
which leads to full recovery
(b) Chronic condition - A chronic condition is defined as a disease, illness,
or injury that has one or more of the following characteristics:
• It needs ongoing or long-term monitoring through consultations,

examinations, check-ups, and /or tests;
• It needs ongoing or long-term control or relief of symptoms;
• It requires rehabilitation for the patient or for the patient to be specially
trained to cope with it;
• It continues indefinitely;
• It recurs or is likely to recur.
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2.1.20. 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.
2.1.21. In-patient Care (not applicable for Overseas Travel Insurance) means
treatment for which the Insured Person has to stay in a Hospital for more than
24 hours for a covered event.
2.1.22. Intensive Care Unit (ICU) 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.
2.1.23. ICU Charges (Intensive care Unit) means the amount charged by a Hospital
towards ICU expenses which shall include the expenses for ICU bed, general
medical support services provided to any ICU patient including monitoring
devices, critical care nursing and intensivist charges.
2.1.24. Maternity expenses shall include—
• Medical treatment expenses traceable to childbirth (including complicated

deliveries and caesarean sections incurred during hospitalization).
• Expenses towards lawful medical termination of pregnancy during the policy
period.
2.1.25. Medical Advice means any consultation or advice from a Medical

Practitioner including the issuance of any prescription or follow-up
prescription.
2.1.26. 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.
2.1.27. Medical Practitioner (not applicable for Overseas Travel Insurance) 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 license.
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2.1.28. Medically Necessary Treatment (not applicable for Overseas Travel
Insurance) 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 Person;
• 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.
2.1.29. Migration means a facility provided to policyholders (including all members

under family cover and group policies), to transfer the credits gained for pre-
existing diseases and specific waiting periods from one health insurance
policy to another with the same insurer.
2.1.30. Network Provider (not applicable for Overseas Travel Insurance) means the
Hospitals enlisted by an Insurer, TPA or jointly by an Insurer and TPA to
provide medical services to an Insured by a Cashless Facility.
2.1.31. Newborn baby means baby born during the Policy Period and is aged up to
90 days.
2.1.32. Non - Network Provider: Non-Network means any hospital, day care centre
or other provider that is not part of the Company’s network.
2.1.33. Notification of Claim means the process of intimating a Claim to the Insurer
or TPA through any of the recognized modes of communication.
2.1.34. OPD Treatment is one in which the Insured Person visits a clinic/Hospital or
associated facility like a consultation room for diagnosis and treatment based
on the advice of a Medical Practitioner. The Insured is not admitted as a day
care or In-patient.
2.1.35. Portability means a facility provided to the health insurance policyholders

(including all members under family cover), to transfer the credits gained for,
pre-existing diseases and specific waiting periods from one insurer to another
insurer.
2.1.36. Pre-existing Disease means any condition, ailment, injury or disease:
a) that is/are diagnosed by a physician not more than 36 months prior to the
date of commencement of the policy issued by the insurer; or
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b) for which medical advice or treatment was recommended by, or received
from, a physician, not more than 36 months prior to the date of
commencement of the policy.
Provided that the definition of the pre-existing disease shall not be applicable
for Overseas Travel Policies.
2.1.37. Pre-hospitalization Medical Expenses means Medical Expenses incurred

during pre-defined number of days preceding the hospitalization of the
Insured Person, provided that :
• Such Medical Expenses are incurred for the same condition for which
the Insured Person’s Hospitalization was required, and
• The In-patient Hospitalization claim for such Hospitalization is
admissible by the Insurance Company.
2.1.38. Post-hospitalization Medical Expenses means Medical Expenses incurred

during pre-defined number of days immediately after the Insured Person is
discharged from the Hospital provided that:
• Such Medical Expenses are incurred for the same condition for which
the Insured Person’s Hospitalization was required and
• The inpatient Hospitalization claim for such Hospitalization is
admissible by the Company.
2.1.39. Qualified Nurse (not applicable for Overseas Travel Insurance) is a person
who holds a valid registration from the Nursing Council of India or the Nursing
Council of any state in India.
2.1.40. Reasonable and Customary Charges (not applicable for Overseas Travel
Insurance) 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.
2.1.41. 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 gaining credit for pre-existing diseases,
time-bound exclusions and for all waiting periods.
2.1.42. Room Rent means the amount charged by a Hospital towards Room &
Boarding expenses and shall include the associated medical expenses.
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2.1.43. Subrogation (Applicable to other than Health Policies and health sections of
Travel and PA policies) 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.
2.1.44. Surgery/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 from suffering or prolongation
of life, performed in a Hospital or a Day Care Centre by a Medical
Practitioner.
2.1.45. 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.
2.2. Specific Definitions:
2.2.1. Age means the completed age of the Insured Person as on his/her last
birthday.
2.2.2. AYUSH Treatment refers to the medical and / or hospitalization treatments

given under Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy
systems
2.2.3. Associate Medical Expenses means those Medical Expenses as listed below
which vary in accordance with the Room Rent or Room Category applicable in
a Hospital:
(a) Room, boarding, nursing and operation theatre expenses as charged by the
Hospital where the Insured Person availed medical treatment;
(b) Fees charged by surgeon, anesthetist, Medical Practitioner;
Note:
1. The following expenses shall not be part of ‘associate medical expenses’:
a. Cost of pharmacy and consumables;
b. Cost of implants and medical devices
c. Cost of diagnostics
2. Associate Medical Expenses are not applied in respect of the hospitals which
do not follow differential billing or for those expenses in respect of which
differential billing is not adopted based on the room category.
2.2.4. Ambulance means a vehicle (Road/Air) operated by a licensed/ authorized

service provider and equipped for the transport and paramedical treatment of
persons requiring medical attention.
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2.2.5. Annexure means the document attached and marked as Annexure to this
Policy.
2.2.6. Break in Policy means the period of gap that occurs at the end of the existing
policy term/installment premium due date, when the premium due for renewal
on a given policy or installment premium due is not paid on or before the
premium renewal date or grace period
2.2.7. Claim means a demand made in accordance with the terms and conditions of
the Policy for payment of the specified Benefits in respect of the Insured
Person.
2.2.8. Claimant means a person who possesses a relevant and valid Insurance
Policy which is issued by the Company and is eligible to file a Claim in the event
of a covered loss.
2.2.9. Company (also referred as Insurer/We/Us) means Universal Sompo General

Insurance Company Limited.
2.2.10. Diagnosis means pathological conclusion drawn by a registered medical

practitioner, supported by acceptable Clinical, radiological, histological, histo-
pathological and laboratory evidence wherever applicable.
2.2.11. Excluded Providers means hospital or any other provider specifically

excluded by the Insurer.
2.2.12. Hazardous Activities (or Adventure sports) means any sport or activity,
which is potentially dangerous to the Insured whether he is trained or not. Such
sport/activity includes (but not limited to) stunt activities of any kind, adventure
racing, base jumping, biathlon, big game hunting, black water rafting, BMX
stunt/ obstacle riding, bobsleighing/ using skeletons, bouldering, boxing,
canyoning, caving/ pot holing, cave tubing, rock climbing/ trekking/
mountaineering, cycle racing, cyclo cross, drag racing, endurance testing, hand
gliding, harness racing, hell skiing, high diving (above 5 meters), hunting, ice
hockey, ice speedway, jousting, judo, karate, kendo, lugging, risky manual
labor, marathon running, martial arts, micro – lighting, modern pentathlon,
motor cycle racing, motor rallying, parachuting, paragliding/ parapenting,
piloting aircraft, polo, power lifting, power boat racing, quad biking, river
boarding, scuba diving, river bugging, rodeo, roller hockey, rugby, ski
acrobatics, ski doo, ski jumping, ski racing, sky diving, small bore target
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shooting, speed trials/ time trials, triathlon, water ski jumping, weight lifting or
wrestling of any type.
2.2.13. Indemnity/Indemnify means compensating the Insured Person up to the

extent of Expenses incurred, on occurrence of an event which results in a
financial loss and is covered as the subject matter of the Insurance Cover.
2.2.14. Insured Event means an event that is covered under the Policy; and which
is in accordance with the Policy Terms & Conditions.
2.2.15. Insured Person (Insured) means a self, legally married spouse,

dependent children, dependent parents or any other relationship having an
insurable interest and whose name specifically appears under Insured in the
Policy Schedule and with respect to whom the premium has been received by
the Company.
2.2.16. Mental Illness means a substantial disorder of thinking, mood, perception,

orientation or memory that grossly impairs judgment, behavior, capacity to
recognize, reality or ability to meet the ordinary demands of life, mental
conditions associated with the abuse of alcohol and drugs, but does not include
mental retardation which is a condition of arrested or incomplete development
of mind of a person, specially characterized by sub normality of intelligence.
2.2.17. Medical device - means any, instrument, apparatus or device including any
component, part or accessory thereof, manufactured solely for medical
purpose which intends to treatment and mitigation of a medical condition or to
physically support the function of human body.
2.2.18. Nominee means the person named in the Policy Schedule or as declared
with the Policyholder who is nominated to receive the benefits under this Policy
in accordance with the terms of the Policy, if the Insured Person is deceased.
2.2.19. Preventive Care means any kind of treatment taken as a pro-active care
measure without actual requirement or symptoms of a disease or illness.
2.2.20. Policy means these Policy terms and conditions and Annexures thereto,
the Proposal Form, Policy Schedule and Optional Cover (if applicable) which
form part of the Policy and shall be read together.
2.2.21. Policy Schedule is a certificate attached to and forming part of this Policy.
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2.2.22. Policy Year means a period of one year commencing on the Policy Period
Start Date or any anniversary thereof.
2.2.23. Policyholder (also referred as You) means the person named in the Policy
Schedule as the Policyholder.
2.2.24. Policy Period means the period commencing from the Policy Period Start
Date and ending on the Policy Period End Date of the Policy as specifically
appearing in the Policy Schedule.
2.2.25. Policy Period End Date means the date on which the Policy expires, as
specifically appearing in the Policy Schedule.
2.2.26. Policy Period Start Date means the date on which the Policy commences,
as specifically appearing in the Policy Schedule.
2.2.27. Rehabilitation means assisting an Insured Person who, following a

Medical Condition, requires assistance in physical, vocational, independent
living and educational pursuits to restore him to the position in which he was in,
prior to such medical condition occurring.
2.2.28. Sum Insured means the amount specified in the Policy Schedule, for which
premium is paid by the Policyholder
2.2.29. Single Private AC Room means an air conditioned room in a Hospital

where a single patient along with the attendant is accommodated and which
has an attached toilet (lavatory and bath). Such room type shall be the most
basic and the most economical of all accommodations available as a Single
room in that Hospital.
2.2.30. Third Party Administrator or TPA means a Company registered with the
Authority, and engaged by an insurer, for a fee or by whatever name called and
as may be mentioned in the health services agreement, for providing health
services as mentioned under IRDAI (TPA-Health Services) Regulations as
amended from time to time.
2.2.31. Therapy - A therapy is the attempted remediation of a health problem,

usually following a medical diagnosis. It means treatment to help or cure a
mental or physical illness, usually without drugs or medical operations. This
does not include any experimental therapies.
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2.2.32. Twin Sharing Room means a Hospital room where at least two patients
are accommodated at the same time. Such room shall be the most basic and
the most economical of all accommodations available as twin sharing rooms
in that Hospital
3. COVERAGES
3.1. Base Coverages
3.1.1 Hospitalization Expenses
If an Insured Person is diagnosed with an illness or suffers an injury and which requires
the Insured Person to be admitted in a Hospital in India which should be Medically
Necessary during the Policy Year and while the Policy is in force for:
(i) Benefit: In-patient Care: The Company will indemnify the Insured Person for
Medical Expenses incurred towards Hospitalization through Cashless or
Reimbursement Facility, maximum up to the Sum Insured, as specified in the Policy
Schedule, provided that the Hospitalization is for a minimum period of 24
consecutive hours and was prescribed in writing, by a Medical Practitioner, and the
Medical Expenses incurred are Reasonable and Customary Charges that were
Medically Necessary.
(ii) Benefit: Day Care Treatment: The Company will indemnify the Insured Person for
Medical Expenses incurred on all Day Care Treatments through Cashless or
Reimbursement Facility, maximum up to the Sum Insured ,as specified in the Policy
Schedule, provided that the period of treatment of the Insured Person in the
Hospital/Day Care Centre does not exceed 24 hours, which would otherwise require
an in-patient admission and such Day Care Treatments was prescribed in written,
by a Medical Practitioner, and the Medical Expenses incurred are Reasonable and
Customary Charges that were Medically Necessary.
(iii) Advance Technology Methods:

The Company will indemnify the Insured Person up to the Sum Insured, as specified
in the Policy Schedule, for expenses incurred under Benefit ‘Hospitalization
expenses’ for treatment taken through following advance technology methods:
A. Uterine Artery Embolization and HIFU
B. Balloon Sinuplasty
C. Deep Brain stimulation
D. Oral chemotherapy
E. Immunotherapy- Monoclonal Antibody to be given as injection
F. Intra vitreal injections
G. Robotic surgeries
H. Stereotactic radio surgeries
I. Bronchical Thermoplasty
J. Vaporisation of the prostrate (Green laser treatment or holmium laser treatment)
K. IONM - (Intra Operative Neuro Monitoring)
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L. Stem cell therapy: Hematopoietic stem cells for bone marrow transplant for
haematological conditions to be covered.
(iv) Pre-Hospitalization Medical Expenses
The Company will indemnify the Insured Person for Medical Expenses incurred
which are Medically Necessary, only through Reimbursement Facility, up to the
Sum Insured, as specified in the Policy Schedule, provided that the Medical
Expenses so incurred are related to the same Illness/Injury for which the
Company has accepted the Insured Person’s Claim under Benefit
‘Hospitalization Expenses’ and subject to the conditions specified below:
(i) For a period of 60 days immediately prior to the Insured Person’s date of
admission to the Hospital, provided that the Company shall not be liable to
make payment for any Pre-hospitalization Medical Expenses that were not
incurred during the Policy Year.
(v) Post-Hospitalization Medical Expenses

The Company will indemnify the Insured Person for Medical Expenses incurred
which are Medically Necessary, only through Reimbursement Facility, up to the
Sum Insured, as specified in the Policy Schedule, provided that the Medical
Expenses so incurred are related to the same Illness/Injury for which the
Company has accepted the Insured Person’s Claim under Benefit
‘Hospitalization Expenses’ and subject to the conditions specified below:
i) For a period of 180 days immediately after the Insured Person’s date of
discharge from the hospital and claim documents to be submitted within 30
days after the completion of 180 days from the date of discharge from the
hospital.
(vi) Benefit: AYUSH Treatment
1.1.1. The Company will indemnify the Insured Person, through Cashless or
Reimbursement Facility, up to the Sum Insured, as specified in the Policy
Schedule, towards Medical Expenses incurred with respect to the Insured
Person’s medical treatment undergone at any AYUSH Hospitals or health
care facilities for any of the listed AYUSH treatments namely Ayurveda, Yoga
and Naturopathy, Unani, Siddha and Homeopathy systems, subject to the
conditions specified below:
(i) A Claim will be admissible under this Benefit only if the Claim is admissible
under Benefit ‘Hospitalization Expenses’.
(ii) Medical Treatment should be rendered from a registered Medical
Practitioner who holds a valid practicing license in respect of such AYUSH
Treatments; and
(iii) Such treatment taken is within the jurisdiction of India; and
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(iv) Clause 4.2 (12) under Permanent Exclusions, is superseded to the extent
covered under this Benefit.
(vii) Benefit : Domiciliary Hospitalization
The Company will indemnify the Insured Person, only through Reimbursement
Facility, up to the Sum Insured ,as specified in the Policy Schedule, for the
Medical Expenses incurred towards Domiciliary Hospitalization, i.e., Coverage
extended when Medically Necessary treatment is taken at home (as explained in
Definition 2.1.14), subject to the conditions specified below:
(i) The Domiciliary Hospitalization continues for a period exceeding 3

consecutive days.
(ii) The Medical Expenses are incurred during the Policy Year.
(iii) The Medical Expenses are Reasonable and Customary Charges which are
necessarily incurred.
(iv) Any Pre Hospitalization Medical Expenses and Post Hospitalization Medical
Expenses shall be payable under this Benefit.
(v) Any Medical Expenses incurred for the treatment in relation to any of the
following diseases shall not be payable under this Benefit:
1. Asthma;
2. Bronchitis;
3. Chronic Nephritis and Chronic Nephritic Syndrome;
4. Diarrhoea and all types of Dysenteries including Gastro-enteritis;
5. Diabetes Mellitus and Diabetes Insipidus;
6. Epilepsy;
7. Hypertension;
8. Influenza, cough or cold;
9. All Psychiatric or Psychosomatic Disorders;
10. Pyrexia of unknown origin;
11. Tonsillitis and Upper Respiratory Tract Infection including Laryngitis and
Pharyngitis;
12. Arthritis, Gout and Rheumatism.
(viii) Benefit: Organ Donor Cover
The Company will indemnify the Insured Person, through Cashless or

Reimbursement Facility, up to the Sum Insured, as specified in the Policy
Schedule, for the Medical Expenses incurred in respect of the donor, for any
organ transplant surgery during the Policy Year, subject to the conditions
specified below:
(i) The Organ donor is an eligible donor in accordance with The Transplantation
of Human Organs Act, 1994 (amended) and other applicable laws and rules.
(ii) The Insured Person is the recipient of the Organ so donated by the Organ
Donor.
15
(iii) The Company will not be liable to pay the Medical Expenses incurred by the
Insured Person towards benefit ‘Pre-Hospitalization Medical Expenses and
Post Hospitalization Medical Expenses’ or any other Medical Expenses in
respect of the donor consequent to the harvesting.
(ix) Conditions applicable for Benefit “Hospitalization Expenses”:
Room, boarding and nursing expenses as charged by the Hospital where the
Insured Person availed medical treatment (Room Rent / Room Category):
i. The eligible Room Rent or Room Category applicable for the Insured
Person under the Policy is ‘No limit’, which means that there is no
separate restriction on Room Charges incurred towards stay during
Hospitalization
ii. Intensive Care Unit Charges (ICU Charges): The eligible ICU Charges
applicable for the Insured Person under the Policy is ‘No limit’, which
means that there is no separate restriction on ICU Charges incurred
towards stay in ICU during Hospitalization.
3.1.2 Road Ambulance Cover
The Company will indemnify the Insured Person, through Cashless or

Reimbursement Facility, up to the Sum Insured, provided that the Medical
Expenses so incurred are related to the Illness or Injury for which the Company
has accepted the Insured Person’s Claim under Benefit ‘Hospitalization
Expenses’ and subject to conditions as specified below:
(i) Such road ambulance transportation is offered by a Hospital or by an

Ambulance service provider for the Insured Person’s necessary transportation;
and
(ii) Such Transportation is from the place of occurrence of Medical Emergency of
the Insured Person, to the nearest Hospital; and/or
(iii) Such Transportation is from one Hospital to another Hospital for the purpose
of providing advanced/better equipped medical support/aid to the Insured
Person which is medically necessary subject to treating Medical Practitioner
certification.
3.1.3 Cumulative Bonus:
At the end of each Policy Year, the Company will enhance the Sum Insured by
50% flat, on a cumulative basis, as a Cumulative Bonus for each completed and
continuous Policy Year, and subject to the conditions specified below:
(i) In any Policy Year, the accrued Cumulative Bonus, shall not exceed 100% of
the Sum Insured available in the expiring Policy or renewed Policy, wherever
Sum Insured is lower.
16
(ii) The entire Cumulative Bonus will be forfeited if the Policy is not continued /
renewed on or before Policy Period End Date or the expiry of the Grace Period
whichever is later.
(iii) The Cumulative Bonus shall be applicable on an annual basis subject to
continuation of the Policy.
(iv) If the Insured Persons in the expiring policy are covered on Individual basis and
thus have accumulated the Cumulative Bonus for each Insured Person in the
expiring policy, and such expiring policy is renewed with the Company on a
Floater basis, then the Cumulative Bonus to be carried forward for credit in this
Policy would be the least Cumulative Bonus amongst all the Insured Persons.
(v) If the Insured Persons in the expiring policy are covered on a Floater basis and
such Insured Persons renew their expiring Policy with the Company by splitting
the Floater Sum Insured in to 2 (two) or more Individual/ Floater covers, then
the Cumulative Bonus of the expiring Policy shall be apportioned to such
renewed Policy in the proportion of the Sum Insured of each of the renewed
Policy.
(vi) In the event of a Claim there is no impact on the accrual of Cumulative Bonus.
(vii) In case Sum Insured under the Policy is reduced at the time of renewal, the
applicable Cumulative Bonus shall be reduced in proportion to the Sum
Insured.
(viii) In case Sum Insured under the Policy is increased at the time of renewal, the
Cumulative Bonus shall be calculated on the Sum Insured applicable on the
last completed Policy Year.
(ix) The ‘Unlimited Automatic Recharge’ and Optional Benefit: ‘Plus Benefit’
amount shall not be considered while calculating ‘Cumulative Bonus’.
(x) Accrued ‘Cumulative Bonus’ can be utilized for Base Benefits- ‘Hospitalization
Expenses’, ’ Road Ambulance Cover’ under the Policy.
(xi) Cumulative Bonus would be credited automatically to the subsequent Policy
year, even in case of multi-year Policies (with 2 or 3 year policy tenure).
3.1.4 Unlimited Automatic Recharge
If a Claim is payable under the Policy, then the Company agrees to automatically
make the re-instatement of up to the base Sum Insured unlimited times in a policy
year which is valid for that Policy Year only, subject to the conditions specified
below:
(i) The Recharge shall be utilized only after the base Sum Insured, applicable
Cumulative Bonus, Cumulative Bonus Super (if applicable) and Plus Benefit (if
applicable) have been completely exhausted in that Policy Year.
(ii) A Claim will be admissible under the Recharge only if the Claim is admissible
under Benefit ‘Hospitalization Expenses’.
(iii) Recharge amount can be utilized for same illness as well as different Illnesses.
(iv) The Sum Insured available under this Benefit can only be utilized for Benefits
– ‘Hospitalization Expenses’ and ‘Road Ambulance Cover’.
(v) All Insured Persons will be eligible to utilize the Recharged amount for any
illness or injury pertaining to that Policy Year.
17
(vi) Applicable ‘Cumulative Bonus’,’ Optional Benefit: Cumulative Bonus Super’ ,
Optional Benefit: Plus Benefit shall not be considered while calculating
‘Unlimited Automatic Recharge’.
(vii) Any unutilized Recharge cannot be carried forward to any subsequent Policy
Year.
3.1.5 Unlimited E-Consultation
The Company shall offer unlimited e-consultations with qualified General

Physicians at our network during the Policy Year through any mode of
communication (Voice/Video Call /Chat /Email Chat/etc.)
3.1.6 Health Services
The Company shall provide the following Services:
Health Portal: The insured may access health related information and services
such as Doctor on chat, Healthy tips reminder, Digital locker for medical records
etc. as available on Company’s website.
Discount Connect: The Insured Person may access to Special rates for OPD,
Diagnostics, maternity, Pharmacy etc. through Network as available on the
Company’s website.
3.2. OPTIONAL BENEFITS
3.2.1. Smart Select
If this Optional Benefit is opted, then Policyholder is entitled for a reduction in the total
premium (which includes premium of Base Benefits, Optional Benefits - Room Rent
Modification, PED Wait Period Modification, Named Ailment Wait Period Modification,
Instant Cover, Deductible, Co-payment, New Born Cover, Plus Benefit, Cumulative Bonus
Super, Air Ambulance cover) payable as specified in the Policy Schedule, subject to
following conditions:
(i) If the Insured Person takes Medical Treatment in hospitals other than those listed
in Annexure – III to the Policy Terms and Conditions, then the Policyholder/Insured
Person shall bear a Co-Payment of 20% on each and every Claim arising in such regard,
which will be in addition to any other co-payment (if any) applicable in the Policy.
(ii) However, no such additional co-payment shall be applicable if treatment is availed
in the hospitals listed in Annexure III to the Policy Terms and Conditions.
NOTE: For an updated list of Hospitals mentioned under Annexure – III to the Policy
Terms and Conditions, the Policyholder / Insured Person should refer to the Company’s
Website www.universalsompo.com
18
3.2.2. Room Rent Modification
Notwithstanding anything to the contrary in the Policy, if this Optional Benefit is opted, the
Company agrees to modify the Room Rent / Room Category to Single Private AC room /
Twin sharing room as specified in Policy schedule. If the Insured Person is admitted in a
Hospital room where the Room Category opted or Room Rent incurred is higher than the
eligible Room Category/ Room Rent as specified in the Policy Schedule, then, the
Policyholder/Insured Person shall bear the ratable proportion of the total Associate
Medical Expenses (including applicable surcharge and taxes thereon) in the proportion
of the difference between the Room Rent actually incurred and the Room Rent specified
in the Policy Schedule or the Room Rent of the entitled Room Category to the Room Rent
actually incurred.
i. Single Private AC Room If the Policy Schedule states ‘Single Private AC Room’ as
eligible Room Category, it means the maximum eligible Room Category in case of
Hospitalization of the Insured Person payable by the Company is limited for stay in a
Single Private AC Room.
ii. Twin Sharing Room If the Policy Schedule states ‘Twin Sharing Room’ as eligible
Room Category, it means the maximum eligible Room Category in case of
Hospitalization of the Insured Person payable by the Company is limited for stay in a
Twin Sharing Room.
Note:
1) The nomenclature of Room categories may vary from one hospital to the other.
Hence, the final consideration will be as per the definition of the Rooms mentioned in
the Policy.
2) No limit on ICU charges under this Optional Benefit.
3.2.3. PED Wait Period Modification
Notwithstanding anything to the contrary in the Policy, by choosing this Optional

Benefit, the applicable waiting period of 36 months for Claims related to Pre-existing
diseases shall be modified to specific time period as mentioned in the Policy
Schedule.
Hence all the provisions stated under Clause 4.1 (a) (i) and Definition 2.1.36 holds
good for this benefit as well, except that the claims will be admissible for any Medical
Expenses incurred for Hospitalization in respect of diagnosis/treatment of any Pre
Existing Disease after specific time period of continuous coverage has elapsed as
mentioned in the Policy Schedule, since the inception of the first Policy with the
Company.
3.2.4. Named Ailment Wait Period Modification
Notwithstanding anything to the contrary in the Policy, by choosing this Optional

Benefit, the applicable waiting period of 24 months for Claims related to Names
ailments shall be modified to specific time period as mentioned in the Policy
Schedule. Hence, all the provisions stated under Clause 4.1 (a) (ii) holds good for
this benefit as well, except that the claims will be admissible for any Medical
19
Expenses incurred for Hospitalization in respect of diagnosis/treatment of any Named
ailment Disease after specific time period of continuous coverage has elapsed as
mentioned in the Policy Schedule, since the inception of the first Policy with the
Company.
3.2.5. Instant Cover
Notwithstanding anything to the contrary in the Policy, by choosing this Optional Benefit
the Company shall waive off the applicable PED waiting period on Diabetes/
Hypertension/ Hyperlipidemia/ Asthma at the time of issuance of first Policy with the
Company.
Note: The above Optional Benefit can be opted only if this policy is issued for the first
time with the Company and on continues renewal without break in policy.
3.2.6. Deductible
If this Optional Benefit is opted, then Policyholder is entitled for a discount on the
Premium payable.
(i) The claim amount assessed by the Company for a particular claim shall be
reduced by the Deductible as specified in the Policy Schedule and the
Company shall be liable to make payment under the Policy for any Claim only
when the Deductible on that Claim is exhausted.
(ii) The Deductible shall be applicable on an aggregate basis for all Claims made
by the Insured Person in a Policy Year.
(iii) Illustration for applicability of Deductible in the same Policy Year:
(Amount in Rs.)
Cas Sum Deducti Payab Payabl Payabl
e Insured ble Claim 1 Claim 2 Claim 3 le 1 e2 e3
1 25,00,0 10,00,00 750,00 12,50,0 10,00,0 - 10,00,0 10,00,0
00 0 0 00 00 00 00
2 25,00,0 10,00,00 750,00 15,00,0 30,00,0 - 12,50,0 12,50,0
00 0 0 00 00 00 00
Claim
not
25,00,0 10,00,00 12,50,0 40,00,0 40,00,0 2,50,0 22,50,0 payable
3
00 0 00 00 00 00 00 as SI is
exhaust
ed
3.2.7. Co-payment
If this Optional Benefit is opted, then the Insured Person will have an option to bear a Co-
payment, as specified in the Policy Schedule, and the Company’s liability shall be
restricted to the balance amount payable.
20
The Co-payment shall be applicable to each claim for each Insured member as defined
in the Policy.
3.2.8. New Born cover
Notwithstanding anything to the contrary in the Policy, by choosing this Optional Benefit,
the Company will allow the addition of New Born baby from day 1.
Note: All the applicable waiting period shall stand valid for this benefit. Premium of this
optional Benefit shall be payable only at the time of addition of new born and will be pro-
rated for the exposure period.
3.2.9. Plus Benefit
An additional amount as specified in the Policy Schedule will be available to the Insured
Person for all claims (admissible under Base Benefits) during the Policy Year, subject to
the following conditions:
a. This Plus Benefit would be applied on the base Sum Insured only.
b. Any unutilized amount will not be carried forward to the subsequent Policy
Year.
b. The Plus Benefit can be utilized for any number of claims admissible under the Policy
during the Policy Year.
c. The Plus Benefit will be applicable only after exhaustion of Base Sum Insured.
‘Cumulative Bonus’, ‘Optional Benefit: Plus Benefit’, ‘Optional Benefit: Cumulative Bonus
Super’ shall not be considered while calculating amount under this Benefit.
3.2.10. Cumulative Bonus Super
“Cumulative Bonus Super” is an extension to Benefit: Cumulative Bonus and hence all
the provisions stated under Clause 3.1.3, holds good for Clause 3.2.10 as well, except
the below clauses which have been modified for the purpose of this Optional Benefit:
(i) The Insured Person would receive a flat 100% increase in the Sum Insured on a
cumulative basis as a Cumulative Bonus Super (which is over & above the Sum Insured
accrued as Cumulative Bonus), for each completed and continuous Policy Year.
(ii) In any Policy Year, the accrued Cumulative Bonus Super shall not exceed 500%
of the Sum Insured available in the expiring Policy or renewed Policy, wherever Sum
Insured is lower.
(iii) In the event of a Claim there is no impact on the accrual of Cumulative Bonus
Super.
(iv) At the time of Policy renewal if the Policyholder chooses not to renew this Optional
Benefit, then the Cumulative Bonus Super under the expiring Policy shall be forfeited.
(v) The Recharge amount (‘Unlimited Automatic Recharge’), ‘Optional Benefit: Plus
Benefit’ shall not be considered while calculating ‘Cumulative Bonus Super ’.
3.2.11. Annual Health check-up
21
(i) On the Insured Person’s request, through Cashless Facility, the Company will arrange
for the Insured Person’s Annual Health Check-up for the list of medical tests specified
below at its Network to provide the services, in India, subject to the conditions
specified below:
a) This Benefit shall be available only once during a Policy Year per Insured Person; and
b) This benefit does not reduce the Sum Insured.
(ii) Medical Tests covered in the Annual Health Check-up, applicable for Insured Persons
who are of Age below 18 years on the Policy Period Start Date
List of Medical Tests covered as a part of Annual Health Check-

up
Physical Examination (Height, Weight and Body Mass Index (BMI)), Eye
Examination, Dental Examination and Scoring, Growth Charting, Doctor
Consultation, Urine Examination (Routine and Microscopic)
(iii) Medical Tests covered in the Annual Health Check-up, applicable for Insured
Persons who are of Age 18 years or above on the Policy Period Start Date, are
as follows:-
List of Medical Tests covered Set Sum Insured

as a part of Annual Health No.
Check-up
COMPLETE BLOOD 1
COUNT(CBC), URINE ROUTINE,
ESR, ABO GROUP & RH TYPE,
BLOOD SUGAR FASTING,
CHOLESTEROL,
CHOLESTEROL DIRECT LDL,
5Lakhs-10Lakhs
CHOLESTEROL-HDL,
TRIGLYCERIDES, TOTAL
CHOLESTEROL/HDL RATIO,
CREATININE, BLOOD UREA
NITROGEN, BUN/ CREATININE
RATIO, URIC ACID
COMPLETE BLOOD 2
COUNT(CBC), URINE ROUTINE,
ESR, ABO GROUP & RH TYPE,
BLOOD SUGAR FASTING,
CHOLESTEROL,
CHOLESTEROL DIRECT LDL, Above 10 Lakhs
CHOLESTEROL-HDL,
TRIGLYCERIDES, TOTAL
CHOLESTEROL/HDL RATIO,
CREATININE, BLOOD UREA
NITROGEN, BUN/ CREATININE
22
RATIO, URIC ACID, TREADMILL
TEST
3.2.12. Be-Fit Benefit
The Insured Person, who is above 12 years of age, may avail unlimited visits to the
Fitness Centers in a Policy year at the Company’s network.
Note: The services availed would be subject to the following conditions:
a. The services will be provided through an empanelled Fitness center only. Choice of
the Insured Person in utilizing the services of Fitness Center will be entirely his/ her own
and Company will have no liability towards the quality of services provided by the
Fitness Centers.
b. The company shall not be responsible for any disputes or loss in account of availing
the services or arising between the Insured Person and the Fitness center.
3.2.13. Wellness Benefit
a) Insured Person who is covered as Adult aged 18 years and above in the Policy
can avail following, provided this benefit is opted for–
Discount on renewal Premium by accumulating Healthy days as per table given

below. One Healthy day can be accumulated by recording 10,000 steps or more
in single day through tracking apps, devices, etc.
Healthy Days discount
No. of Healthy days in a year Discount on Renewal Premium

270 30%
240 20%
180 15%
120 10%
Less than 120 0%
• The above benefit will be applicable on Individual basis. In case of floater,

average of number of Healthy days earned by all Insured Members shall be
considered for calculating renewal discount. For example,’ A’ has attained 260
Healthy days and ’ B’ has attained 230 Healthy days, average of the Healthy
days is 245 and accordingly the discount calculated is 20%. In case of multi
tenure, average of number of Healthy days earned over the policy tenure shall be
considered for discount.
• The above section of benefit is available only for Insured covered as Adults aged
18 and above in the Policy and discount calculated shall be applicable on total
premium of Policy.
23
• Responsibility of mapping device with CHIL system is of the insured/customer
• Number of days completing 10,000 steps or more that are accumulated in last 2
months of the Policy Period would not be considered for discount on renewal
premium. The same shall carry forward and will be considered in next policy
period.
• In case of instalment premium mode is opted, then discount shall be considered
only post payment of first 6 month of premium.
• Vouchers of value equivalent to renewal discount amount can also be provided to
Insured in case he/she does not wish for discount on renewal premium.
b) Access to Digital Fitness Coaching
c) Access to Artificial Intelligence Fitness Coaching
d) Access to Nutritionist/Wellness Coach
The above services (b, c, d) shall be available at Company’s Network and available to
Insured Members aged above 12 years subject to the following conditions:
a. The services will be provided through an empanelled Provider only. Choice of the
Insured Person in utilizing the services of Provider will be entirely his/ her own and
Company will have no liability towards the quality of services provided by the Provider.
b. The company shall not be responsible for any disputes arising between the Insured
Person and the empanelled Provider.
c. The network under this benefit, does not constitute medical advice of any kind and it
is not intended to be, and should not be, used to diagnose or identify treatment for a
medical or mental health condition.
3.2.14. Air Ambulance cover
The Company will indemnify the Insured Person up to the amount as specified in
Policy Schedule, for the Reasonable and Customary Charges necessarily incurred
on availing Air Ambulance services, in India, offered by a Hospital or by an
Ambulance service provider for the Insured Person’s necessary transportation,
provided that:
(i) The treating Medical Practitioner certifies in writing that the severity or the
nature of the Insured Person’s Illness or Injury warrants the Insured Person’s
requirement for Air Ambulance.
(ii) The transportation expenses under this Optional Benefit include transportation
from the place of occurrence of Medical Emergency of the Insured person, to
the nearest Hospital; and/or transportation from one Hospital to another
Hospital for the purpose of providing advanced/better equipped medical
support/aid to the Insured Person, following an Emergency;
(iii) This benefit will be extended only through Cashless Facility, if the costs are
certified and authorized by the Company in advance. In case the Insured
24
Person has a Life Threatening Medical Condition and the Insured Person (or
his representatives) arranges for the emergency Air Ambulance at their own
expense, then the Company will reimburse such costs incurred in accordance
with the terms of this Optional Benefit;
(iv) Payment under this Optional Benefit is subject to a Claim for the same Illness
or Injury being admitted by the Company under Benefit 1 (Hospitalization
Expenses);
(v) Additional Documents to be submitted for any Claim under this Benefit:
a) It is a condition precedent to the Company’s liability under this Optional
Benefit that the following information and documentation shall be submitted
to the Company immediately and in any event within 30 days of the event
giving rise to the Claim under this Benefit:
b) Medical reports and transportation details issued by the air ambulance
service provider, prescriptions and medical report by the attending Medical
Practitioner furnishing the name of the Insured Person and details of
treatment rendered along with the statement confirm the necessity of air
ambulance services.
c) Documentary proof for expenses incurred towards availing Air Ambulance
services.
3.2.15. Women care
The Company shall indemnify the Out-Patient Medical Expenses incurred by the female
Insured Person up to the limit specified in the Policy Schedule, through cashless facility
towards Diagnosis within the Policy Year for the following:
a) Mammography
b) Cervical Cancer screening
c) PCOS/PCOD diagnostic tests
Note: This benefit is available only for women insured members aged 18 years and
above.
3.2.16. Mental Health wellbeing
The Company shall indemnify the Out Patient Medical Expenses incurred by the
Insured Person up to the limit specified in the Policy Schedule, through cashless facility
towards Consultation, Counseling and rehabilitation of the Insured Person, within the
Policy Year for the following:
a) Acute depression
b) Obsessive compulsive disorder
c) Anxiety
d) Post traumatic stress disorder
3.2.17. Claim Shield
If a claim has been accepted under this benefit, then the items which are not payable as
per List-I under Annexure I related to the particular claim, will become payable. The
maximum claim payout under this benefit shall be limited to applicable Sum Insured under
the Policy.
25
Note: Coverage for any item as per List-I under Annexure I , shall be available only if the
same is not covered under any Base Benefit or Optional Benefit.
3.2.18. Inflation Shield
The Inflation Shield benefit is designed to provide additional increase in Sum Insured
under Base Policy on the basis of inflation rate in previous calendar year.
The Inflation would be computed as the change in average CPI of the entire calendar
year published by the National Statistical Office (NSO), Ministry of Statistics and
Programme Implementation. In case inflation rate of previous year is not available at
renewal, then the inflation rate available for penultimate calendar year shall be
considered.
The % increase will be applicable only on Sum Insured under the Base Policy and not
on No Claim Bonus or any other benefit which leads to increase in Sum Insured.
In case of Sum Insured is changed at the time of renewal, any accumulated sum
Insured due to Inflation Shield Benefit will be added to the applicable new Sum Insured
opted by Insured at the time of renewal.
Please Note that all the accumulated Inflation Shield benefit will lapse and your Sum
Insured under Policy will roll back to the Sum Insured opted under the Policy if this
benefit is not continued.
3.2.19. Additional Sum Insured for Defined Critical Illnesses
In case any Claim is made due to 15 listed Critical illnesses during the Policy Year, the
Company shall provide an additional Sum Insured for In-patient Care for that Insured
Person who is hospitalized, as specified in Policy Schedule, provided that:
I. This Benefit shall be utilized only after the base Sum Insured has been
completely exhausted and shall be applied only once during the Policy Year
II. The total amount payable under this Benefit shall not exceed the sum total of the
Sum Insured, Cumulative Bonus, Cumulative Bonus Super, ‘Additional Sum Insured for
CI’
III. This Benefit is applicable only if Claim is admissible under Benefit:
Hospitalization expenses
S.No CI Conditions
1 Cancer
2 Myocardial Infarction
3 Open Chest CABG
4 Stroke
26
5 Open Heart Replacement Or Repair Of
Heart Valves
6 Multiple Sclerosis
7 Major Organ /Bone Marrow Transplant
8 Permanent Paralysis Of Limbs
9 Kidney Failure Requiring Regular

Dialysis
10 Benign Brain Tumour
11 Blindness
12 Motor Neurone Disease
13 End Stage Lung Failure
14 Third Degree Burns
15 Coma
3.2.20. Home Modification
The Company shall indemnify the relevant expenses incurred during the Policy Year, as
specified in the Policy Schedule, for the reasonable and necessary modification of the
Insured Person’s place of residence, if Insured Person is hospitalized for a medically
necessary treatment and post discharge from the hospital requires mobility support to
facilitate the Insured Person’s movement at his/her place of residence , subject to
admissible Hospitalization, provided that such modification is carried out within 30 days
from the date of discharge from the hospital.
3.2.21. Nursing Care
The Company shall indemnify the Insured Person for the expenses incurred up to the
limit per day as specified in Policy Schedule incurred towards the hiring of a qualified
nurse. If Insured Person requires to be attended by a qualified nurse at home after the
discharge from the hospital to avail post-operative care at home during the Policy Year
subject to admissible Hospitalization, provided that:
i. Nursing care must be recommended and certified by attending Medical
Practitioner in writing.
ii. The Company shall not be liable to make payment under this Benefit for more
than 7 days per Policy Year per Insured Person.
27
iii. This Benefit does not apply to terminally ill, Palliative Care and coma patients
4. EXCLUSIONS
4.1. Standard Exclusions:
(a) Waiting Periods:
(i) Pre-Existing Diseases: Code- Excl01
a. Expenses related to the treatment of a pre-existing Disease (PED) and its direct
complications shall be excluded until the expiry of 36 months of continuous
coverage after the date of inception of the first policy with insurer.
b. In case of enhancement of sum insured the exclusion shall apply afresh to the
extent of sum insured increase.
c. 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.
d. Coverage under the policy after the expiry of 36 months for any pre-existing
disease is subject to the same being declared at the time of application and
accepted by Insurer.
(ii) Named Ailment Waiting Period: Code- Excl02

a. Expenses related to the treatment of the listed Conditions, surgeries/treatments
shall be excluded until the expiry of 24 months of continuous coverage, as may
be the case after the date of inception of the first policy with the Company. This
exclusion shall not be applicable for claims arising due to an accident.
b. In case of enhancement of sum insured the exclusion shall apply afresh to the
extent of sum insured increase.
c. If any of the specified disease/procedure falls under the waiting period specified
for pre-Existing diseases, then the longer of the two waiting periods shall apply.
d. The waiting period for listed conditions shall apply even if contracted after the
policy or declared and accepted without a specific exclusion.
e. If the Insured Person is continuously covered without any break as defined under
the applicable norms on portability stipulated by IRDAI, then waiting period for the
same would be reduced to the extent of prior coverage.
f. List of specific diseases/procedures:
1. Any treatment related to Arthritis (if non-infective), Osteoarthritis and
Osteoporosis, Gout, Rheumatism, Spinal Disorders, Joint Replacement
Surgery, Arthroscopic Knee Surgeries/ACL Reconstruction/Meniscal and
Ligament Repair
2. Surgical treatments for Benign ear, nose and throat (ENT) disorders and
surgeries (including but not limited to Adenoidectomy, Mastoidectomy,
Tonsillectomy and Tympanoplasty), Nasal Septum Deviation, Sinusitis and
related disorders
3. Benign Prostatic Hypertrophy
4. Cataract
5. Dilatation and Curettage
6. Fissure / Fistula in anus, Hemorrhoids / Piles, Pilonidal Sinus, Gastric and
Duodenal Ulcers
28
7. Surgery of Genito-urinary system unless necessitated by malignancy
8. All types of Hernia & Hydrocele
9. Hysterectomy for menorrhagia or Fibromyoma or prolapse of uterus unless
necessitated by malignancy
10. Internal tumours , skin tumours, cysts, nodules, polyps including breast
lumps (each of any kind) unless malignant
11. Kidney Stone / Ureteric Stone / Lithotripsy / Gall Bladder Stone
12. Myomectomy for fibroids
13. Varicose veins and varicose ulcers
14. Parkinson's or Alzheimer's disease or Dementia
(iii) 30-day waiting period- Code- Excl03

a. Expenses related to the treatment of any illness within 30 days from the first policy
commencement date shall be excluded except claims arising due to an accident,
provided the same are covered.
b. This exclusion shall not, however, apply if the Insured Person has Continuous
Coverage for more than twelve months.
c. The referred waiting period is made applicable to the enhanced sum insured in
the event of granting higher sum insured subsequently.
Notes:
(i) The Waiting Periods as defined above shall be applicable individually for each
Insured Person and Claims shall be assessed accordingly.
(ii) If Coverage for Optional Benefits (if applicable) are added afresh at the time of
renewal of this Policy, the Waiting Periods as defined above shall be applicable
afresh to the newly added Optional Benefits (if applicable), from the time of such
renewal.
(b) Permanent Exclusions:

Any Claim of an Insured Person arising due to any of the following shall not be
admissible unless expressly stated to the contrary elsewhere in the Policy Terms
and conditions.
1. Investigation & Evaluation: (Code- Excl04)
a) Expenses related to any admission primarily for diagnostics and evaluation
purposes only are excluded.
b) Any diagnostic expenses which are not related or not incidental to the current
diagnosis and treatment are excluded.
2. Rest Cure, rehabilitation and respite care: (Code- Excl05)

a) Expenses related to any admission primarily for enforced bed rest and not for
receiving treatment. This also includes:
i. Custodial care either at home or in a nursing facility for personal care such
as help with activities of daily living such as bathing, dressing, moving
around either by skilled nurses or assistant or non-skilled persons.
29
ii. Any services for people who are terminally ill to address physical, social,
emotional and spiritual needs.
3. Obesity/ Weight Control: (Code- Excl06)

Expenses related to the surgical treatment of obesity that does not fulfill all the
below conditions:
1) Surgery to be conducted is upon the advice of the Doctor

2) The surgery/Procedure conducted should be supported by clinical protocols
3) The member has to be 18 years of age or older and
4) Body Mass Index (BMI);
a) greater than or equal to 40 or
b) greater than or equal to 35 in conjunction with any of the following severe co-
morbidities following failure of less invasive methods of weight loss:
i. Obesity-related cardiomyopathy
ii. Coronary heart disease
iii. Severe Sleep Apnea
iv. Uncontrolled Type2 Diabetes
4. Change-of-Gender treatments: (Code- Excl07)

Expenses related to any treatment, including surgical management, to change
characteristics of the body to those of the opposite sex.
5. Cosmetic or plastic Surgery: (Code- Excl08)

Expenses for cosmetic or plastic surgery or any treatment to change appearance
unless for reconstruction following an Accident, Burn(s) or Cancer or as part of
medically necessary treatment to remove a direct and immediate health risk to
the insured. For this to be considered a medical necessity, it must be certified by
the attending Medical Practitioner.
6. Hazardous or Adventure sports: (Code- Excl09)

Expenses related to any treatment necessitated due to participation as a
professional in hazardous or adventure sports, including but not limited to, para-
jumping, rock climbing, mountaineering, rafting, motor racing, horse racing or
scuba diving, hand gliding, sky diving, deep-sea diving.
7. Breach of law: (Code- Excl10)

Expenses for treatment directly arising from or consequent upon any Insured
Person committing or attempting to commit a breach of law with criminal intent.
8. Excluded Providers: (Code- Excl11)

Expenses incurred towards treatment in any hospital or by any Medical
Practitioner or any other provider specifically excluded by the Insurer and
disclosed in its website / notified to the policyholders are not admissible.
However, in case of life threatening situations or following an accident, expenses
up to the stage of stabilization are payable but not the complete claim.
Note: Refer Annexure – II of the Policy Terms & Conditions for list of excluded
hospitals.
30
9. Treatment for Alcoholism, drug or substance abuse or any addictive condition and
consequences thereof. (Code- Excl12)
10. Treatments received in heath hydros, nature cure clinics, spas or similar
establishments or private beds registered as a nursing home attached to such
establishments or where admission is arranged wholly or partly for domestic
reasons. (Code- Excl13)
11. Dietary supplements and substances that can be purchased without prescription,
including but not limited to Vitamins, minerals and organic substances unless
prescribed by a medical practitioner as part of hospitalization claim or day care
procedure (Code- Excl14)
12. Refractive Error: (Code- Excl15)

Expenses related to the treatment for correction of eye sight due to refractive error
less than 7.5 dioptres.
13. Unproven Treatments: (Code- Excl16)

Expenses related to any unproven treatment, services and supplies for or in
connection with any treatment. Unproven treatments are treatments, procedures
or supplies that lack significant medical documentation to support their
effectiveness.
14. Sterility and Infertility: (Code- Excl17)

Expenses related to sterility and infertility. This includes:
(i) Any type of contraception, sterilization
(ii) Assisted Reproduction services including artificial insemination and
advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI
(iii) Gestational Surrogacy
(iv) Reversal of sterilization
15. Maternity: (Code Excl18)
a. Medical treatment expenses traceable to childbirth (including complicated
deliveries and caesarean sections incurred during hospitalization) except
ectopic pregnancy;
b. Expenses towards miscarriage (unless due to an accident) and lawful
medical termination of pregnancy during the policy period.
4.2. Specific Exclusions:

Any Claim of an Insured Person arising due to any of the following shall not be
admissible unless expressly stated to the contrary elsewhere in the Policy Terms
and conditions.
1. Any item or condition or treatment specified in List of Non-Medical Items (Annexure

– I to Policy Terms & Conditions).
2. Taking part or is supposed to participate in a naval, military, air force operation or
aviation in a professional or semi-professional nature.
31
3. Treatment taken from anyone who is not a Medical Practitioner or from a Medical
Practitioner who is practicing outside the discipline for which he is licensed or any
kind of self-medication.
4. Charges incurred in connection with routine eye examinations and ear
examinations, dentures, artificial teeth and all other similar external appliances and
/ or devices whether for diagnosis or treatment
5. Any expenses incurred on external prosthesis, corrective devices, external durable
medical equipment of any kind, like wheelchairs, walkers, glucometer, crutches,
ambulatory devices, instruments used in treatment of sleep apnea syndrome and
oxygen concentrator for asthmatic condition, cost of cochlear implants and related
surgery.
6. Alopecia wigs and/or toupee and all hair or hair fall treatment and products.
7. Screening, counseling or treatment of any external Congenital Anomaly, Illness or
defects or anomalies or treatment relating to external birth defects.
8. Treatment of mental retardation, arrested or incomplete development of mind of a
person, subnormal intelligence or mental intellectual disability.
9. Circumcision unless necessary for treatment of an Illness or as may be
necessitated due to an Accident.
10. All preventive care (except eligible and entitled for Benefit: ‘Annual Health Check-
up’), Vaccination including Inoculation and Immunizations (except in case of post-
bite treatment) and tonics.
11. Expenses incurred for Artificial life maintenance, including life support machine
use, post confirmation of vegetative state or brain dead by treating medical
practitioner where such treatment will not result in recovery or restoration of the
previous state of health under any circumstances.
12. Non-Allopathic Treatment, Hydrotherapy, Acupuncture, Reflexology, Chiropractic
treatment or treatment related to any unrecognized systems of medicine.
13. War (whether declared or not) and war like occurrence or invasion, acts of foreign
enemies, hostilities, civil war, rebellion, revolutions, insurrections, mutiny, military
or usurped power, seizure, capture, arrest, restraints and detainment of all kinds.
14. Act of self-destruction or self-inflicted Injury, attempted suicide or suicide while
sane or insane.
15. Any charges incurred to procure documents related to treatment or Illness
pertaining to any period of Hospitalization or Illness.
16. Personal comfort and convenience items or services including but not limited to
T.V. (wherever specifically charged separately), charges for access to cosmetics,
hygiene articles, body care products and bath additives, as well as similar
incidental services and supplies.
17. Expenses related to any kind of RMO charges, Service charge, Surcharge, night
charges levied by the hospital under whatever head or transportation charges by
visiting consultant.
18. Nuclear, chemical or biological attack or weapons, contributed to, caused by,
resulting from or from any other cause or event contributing concurrently or in any
other sequence to the loss, claim or expense. For the purpose of this exclusion:
a. Nuclear attack or weapons means the use of any nuclear weapon or device or
waste or combustion of nuclear fuel or the emission, discharge, dispersal,
release or escape of fissile/ fusion material emitting a level of radioactivity
capable of causing any Illness, incapacitating disablement or death.
32
b. Chemical attack or weapons means the emission, discharge, dispersal, release
or escape of any solid, liquid or gaseous chemical compound which, when
suitably distributed, is capable of causing any Illness, incapacitating
disablement or death.
c. Biological attack or weapons means the emission, discharge, dispersal,
release or escape of any pathogenic (disease producing) micro-organisms
and/or biologically produced toxins (including genetically modified organisms
and chemically synthesized toxins) which are capable of causing any Illness,
incapacitating disablement or death.
19. Impairment of an Insured Person’s intellectual faculties by abuse of stimulants or
depressants unless prescribed by a medical practitioner.
20. Any treatment taken in a clinic, rest home, convalescent home for the addicted,
detoxification center, sanatorium, home for the aged, remodeling clinic or similar
institutions.
21. Remicade, Avastin or similar injectable treatment which is undergone other than
as a part of In-Patient Care Hospitalisation or Day Care Hospitalisation is excluded.
22. Expenses related to any kind of Advance Technology Methods other than
mentioned in the Clause 3.1.1(iii).
23. Hormone replacement therapy.
24. Any Illness or Injury attributable to consumption, use, misuse or abuse of tobacco,
intoxicating drugs, alcohol, hallucinogens, smoking.
25. Any treatment or part of treatment or any expenses incurred under this Policy that
is not reasonable and customary and/or not medically necessary.
Note: In addition to the foregoing, any loss, claim or expense of whatsoever nature
arising out of, contributed to, caused by, resulting from, or in connection with any action
taken in controlling, preventing, suppressing, minimizing or in any way relating to the
above Permanent Exclusions shall also be excluded.
5. GENERAL TERMS AND CLAUSES
Standard General Terms & Clauses
5.1. Disclosure of Information

The Policy shall be void and all premium paid thereon shall be forfeited to the
Company in the event of misrepresentation, mis-description or non-disclosure of
any material fact by the policyholder.
Note:
a. “Material facts” for the purpose of this clause policy shall mean all
relevant information sought by the Company in the proposal form and
other connected documents to enable it to take informed decision in
the context of underwriting the risk.
b. In continuation to the above clause the Company may also adjust the scope
of cover and / or the premium paid or payable /reject the claim, accordingly.
33
5.2. Condition Precedent to Admission of Liability
The terms and conditions of the policy must be fulfilled by the insured person for
the Company to make any payment for claim(s) arising under the policy.
5.3. Claim Settlement (provision for Penal Interest)

i. The Company shall settle or reject a claim, as the case may be, within 15
days from the date of intimation on receipt of last necessary document.
ii. In the case of delay in the payment of a claim, the Company shall be liable
to pay interest from the date of intimation to the date of payment of claim
at a rate 2% above the bank rate .
iii. However, where the circumstances of a claim warrant an investigation in the
opinion of the Company, it shall initiate and complete such investigation at
the earliest in any case not later than 15 days from the date of intimation of
last necessary document. In such cases, the Company shall settle the claim
within 45 days from the date of intimation of last necessary document.
iv. In case of delay beyond stipulated 45 days the Company shall be liable to pay
interest at a rate 2% above the bank rate from the date of intimation of last
necessary document to the date of payment of claim.
Bank rate shall mean the rate fixed by the Reserve Bank of lndia (RBl) at the
beginning of the financial year in which claim has fallen due.
5.4. Complete Discharge

Any payment to the policyholder, Insured Person or his/ her nominees or his/ her
legal representative or Assignee or to the Hospital, as the case may be, for any
benefit under the Policy shall be valid discharge towards payment of claim by the
Company to the extent of that amount for the particular claim.
5.5. Multiple Policies

a. In case of multiple policies taken by an insured during a period from the same
or one or more insurers to indemnify treatment costs, the Insured Person shall
have the right to require a settlement of his/her claim in terms of any of his/her
policies. In all such cases the insurer chosen by the Insured Person shall be
obliged to settle the claim as long as the claim is within the limits of and
according to the terms of the chosen policy.
b. Insured Person having multiple policies shall also have the right to prefer claims
under this policy for the amounts disallowed under any other policy/ policies,
even if the sum insured is not exhausted. Then the Insurer shall independently
settle the claim subject to the terms and conditions of this policy.
c. If the amount to be claimed exceeds the sum insured under a single policy, the
Insured Person shall have the right to choose insurers from whom he/she wants
to claim the balance amount.
d. Where an Insured has policies from more than one insurer to cover the same
risk on indemnity basis, the Insured shall only be indemnified the treatment
costs in accordance with the terms and conditions of the chosen policy.
34
5.6. Fraud
If 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 anyone acting on
his/her behalf to obtain any benefit under this policy, all benefits under this policy
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 party 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
The Company shall not repudiate the claim and / or forfeit the policy benefits on
the ground of Fraud, if the Insured Person / beneficiary can prove that the
misstatement was true to the best of his knowledge and there was no deliberate
intention to suppress the fact or that such misstatement of or suppression of
material fact are within the knowledge of the insurer.
5.7. Cancellation / Termination
The Insured may cancel this Policy by giving 7 days’ written notice, and in such an event,
the Company shall refund premium for the unexpired Policy Period as per the rates
detailed below.
a) If no claim has been made during the policy period, a proportionate refund of the
premium will be issued based on the number of unexpired days. The date of cancellation
request will be considered as expiry date of coverage
b) If the claim has been made in the current policy year, the premium for the remaining
policy year(s) will be refunded on cancellation
c) The Company may cancel the Policy at any time on grounds of mis-representations,
non-disclosure of material facts, fraud by the Insured Person, by giving 7 days' written
notice. There would be no refund of premium on cancellation on grounds of mis-
representations, non-disclosure of material facts or fraud
35
5.8. Migration
The Insured Person will have the option to migrate the policy to other health
insurance products/plans offered by the Company as per IRDAI guidelines on
Migration. If such person is presently covered and has been continuously covered
without any lapses under any health insurance product/plan offered by the
Company, the Insured Person will get the accrued continuity benefits in waiting
periods as per IRDAI guidelines on migration.
The insurer may underwrite the proposal in case of migration, if the insured is not
continuously covered for 36 months.
5.9. Portability
The Insured Person will have the option to port the policy to other insurers as per
IRDAI guidelines related to portability. lf such person is presently covered and has
been continuously covered without any lapses under any health insurance policy
with an Indian General/Health insurer, the proposed Insured Person will get the
accrued continuity benefits in waiting periods as per IRDAI guidelines on
portability.
5.10. Renewal of Policy

The policy shall ordinarily be renewable except on grounds of established fraud,
or non- disclosure or misrepresentation by the Insured Person.
i. Renewal shall not be denied on the ground that the Insured Person had made
a claim or claims in the preceding policy years.
ii. Request for renewal along with requisite premium shall be received by the
Company before the end of the policy period.
iii. At the end of the policy period, the policy shall terminate and can be renewed
within the Grace Period of 30 days for Half Yearly and Quarterly mode of
payment and grace period of 15 days for monthly mode of payment to maintain
continuity of benefits without break in policy. If the premium is paid in
installments during the policy period, coverage will be available during such
Grace period.
iv. No loading shall apply on renewals based on individual claims experience
5.11. Withdrawal of Policy

i. In the likelihood of this product being withdrawn in future, the Company will
intimate the Insured Person about the same 90 days prior to expiry of the
policy.
ii. Insured Person will have the option to migrate to similar health insurance
product available with the Company at the time of renewal with all the accrued
continuity benefits such as cumulative bonus, waiver of waiting period etc as
per IRDAI guidelines, provided the policy has been maintained without a break.
5.12. Moratorium Period
36
After completion of Sixty continuous months under the policy no look back to be
applied. This period of Sixty months is called as moratorium period. The
moratorium would be applicable for the sums insured of the first policy and
subsequently completion of Sixty continuous months would be applicable from
date of enhancement of sums insured only on the enhanced limits. After the
expiry of Moratorium Period no health insurance claim shall be contestable
except for proven fraud and permanent exclusions specified in the policy contract.
The policies would however be subject to all limits, sub limits, co-payments,
deductibles as per the policy contract.
5.13. Premium payment Installment

lf the Insured Person has opted for Payment of Premium on an installment basis
i.e. Half Yearly or Quarterly or Monthly, as mentioned in the Policy Schedule/
Certificate of Insurance, the following Conditions shall apply (notwithstanding any
terms contrary elsewhere in the policy)
1. Grace Period of 30 days would be given for Half Yearly and Quarterly mode of
payment and grace period of 15 days for monthly mode of payment would be
given to pay the installment premium due for the policy.
2. If the premium is paid in installments during the policy period, coverage will be
available during such Grace period.
3. The Insured Person will get the accrued continuity benefit in respect of the
"Waiting Periods", "Specific Waiting Periods" in the event of payment of
premium within the stipulated grace Period
4. No interest will be charged lf the installment premium is not paid on due date.
5. In case of installment premium due not received within the grace period, the
policy will get cancelled
6. In the event of a claim, all subsequent premium installments shall immediately
become due and payable.(This clause will not apply to claims arising under
‘Unlimited E-consultations’ , ‘Health Services’ , ‘Annual Health Check-up’ ,
‘Be-Fit ‘ , ‘Wellness Benefit’ , ‘Women Care and ‘Mental Health wellbeing’ )
7. The Company has the right to recover and deduct all the pending installments
from the claim amount due under the policy.
Note:
Tenure Discount will not be applicable if the Insured Person has opted for
Premium Payment in Installments.
5.14. Possibility of Revision of Terms of the Policy Including the Premium Rates
The Company, with prior approval of IRDA, may revise or modify the terms of the
policy including the premium rates. The Insured Person shall be notified three
months before the changes are affected.
5.15. 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.
37
The Insured Person shall be allowed free look period of Thirty 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.
If 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;
5.16. Grievances
If You have a grievance about any matter relating to the Policy, or Our decision on
any matter, or the claim, you can address Your grievance as follows:
Step 1: Contact Us
Write to us at: E-mail Address:

contactus@universalsompo.com
Customer Service Universal Sompo General
Insurance Co. Ltd. For more details:
Unit No. 601 & 602, 6th Floor, Reliable Tech Park, www.universalsompo.com
Thane- Belapur Road, Airoli, Navi Mumbai, Toll Free Numbers: 1800-22-4030 OR
1800-200-4030
Maharashtra - 400708 Senior Citizens toll free number: 1800-267-
4030
Step 2: Grievance Cell

If the resolution you received, does not meet your expectations, you can directly write to
our Grievance Id. After examining the matter, the final response would be conveyed
within two weeks from the date of receipt of your complaint on this email id.
Customer Service Universal Sompo General E-mail Address:

Insurance Co. Ltd. grievance@universalsompo.com
Unit No. 601 & 602, 6th Floor, Reliable Tech Park,
Thane- Belapur Road, Airoli, Navi Mumbai, For more details:
Maharashtra - 400708 www.universalsompo.com
Visit Branch Grievance Redressal Officer (GRO) - Walk into any of our nearest
branches and request to meet the GRO.
38
• We will acknowledge receipt of your concern within 3 business days.
• Within 2 weeks of receiving your grievance, we will respond to you with the best
solution.
• We shall regard the complaint as closed if we do not receive a reply within 8
weeks from the date of our response.
Step 3: Chief Grievance Redressal Officer

In case, you are not satisfied with the decision/resolution of the above office or have
not received any response within 15 working days, you may write or email to:
Customer Service Universal Sompo General E-mail Address:

Insurance Co. Ltd. gro@universalsompo.com
Unit No. 601 & 602, 6th Floor, Reliable Tech Park,
Thane- Belapur Road, Airoli, Navi Mumbai, For more details:
Maharashtra - 400708 www.universalsompo.com
For updated details of grievance officer, kindly refer the link

https://www.universalsompo.com/resourse-grievance-redressal
Step 4: Insurance Ombudsman
Bima Bharosa Portal link: https://bimabharosa.irdai.gov.in/
You can approach the Insurance Ombudsman depending on the nature of grievance
and financial implication, if any.
Information about Insurance Ombudsmen, their jurisdiction and powers is available
on the website of the Insurance Regulatory and Development Authority of India
(IRDAI) at www.irdai.gov.in, or of the General Insurance Council at
https://www.gicouncil.in/, the Consumer Education Website of the IRDAI at
http://www.policyholder.gov.in, or from any of Our Offices.
The updated contact details of the Insurance Ombudsman offices can be referred by
clicking on the Insurance ombudsman official site:
https://www.cioins.co.in/Ombudsman.
Note: Grievance may also be lodged at IRDAI- https://bimabharosa.irdai.gov.in/.
Note: Please refer the Contact details of the Insurance Ombudsman as below.
Office Details Jurisdiction of Office

Union
Territory,District)
39
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: bimalokpal.ahmedabad@cioins.co.in
BENGALURU - Karnataka.
Office of the Insurance Ombudsman,
Jeevan Soudha Building,PID No. 57-27-N-19
Ground Floor, 19/19, 24th Main Road,
JP Nagar, Ist Phase,
Bengaluru – 560 078.
Tel.: 080 - 26652048 / 26652049
Email: bimalokpal.bengaluru@cioins.co.in
BHOPAL - Madhya Pradesh

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: bimalokpal.bhopal@cioins.co.in
BHUBANESHWAR - Shri Suresh Chandra Orissa.

Panda
62, Forest park,
Bhubneshwar – 751 009.
Tel.: 0674 - 2596461 /2596455
Fax: 0674 - 2596429
Email: bimalokpal.bhubaneswar@cioins.co.in
CHANDIGARH - Punjab,
Office of the Insurance Ombudsman, Haryana(excluding
S.C.O. No. 101, 102 & 103, 2nd Floor, Gurugram, Faridabad,
Batra Building, Sector 17 – D, Sonepat and
Chandigarh – 160 017. Bahadurgarh)
Tel.: 0172 - 2706196 / 2706468 Himachal Pradesh,
Fax: 0172 - 2708274 Union Territories of
Email: bimalokpal.chandigarh@cioins.co.in Jammu & Kashmir,
40
CHENNAI - Ladakh & Chandigarh.
Office of the Insurance Ombudsman, Tamil Nadu,
Fatima Akhtar Court, 4th Floor, 453, Tamil Nadu
Anna Salai, Teynampet, PuducherryTown and
CHENNAI – 600 018. Karaikal (which are part
Tel.: 044 - 24333668 / 24335284 of Puducherry).
Fax: 044 - 24333664
Email: bimalokpal.chennai@cioins.co.in
DELHI - Shri Sudhir Krishna Delhi &

Office of the Insurance Ombudsman, Following Districts of
2/2 A, Universal Insurance Building, Haryana - Gurugram,
Asaf Ali Road, Faridabad, Sonepat &
New Delhi – 110 002. Bahadurgarh.
Tel.: 011 - 23232481/23213504
Email: bimalokpal.delhi@cioins.co.in
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: bimalokpal.guwahati@cioins.co.in
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
A. C. Guards, Lakdi-Ka-Pool, Puducherry.
Hyderabad - 500 004.
Tel.: 040 - 23312122
Fax: 040 - 23376599
Email: bimalokpal.hyderabad@cioins.co.in
JAIPUR - Rajasthan.
Jeevan Nidhi – II Bldg., Gr. Floor,
Bhawani Singh Marg,
Jaipur - 302 005.
Tel.: 0141 - 2740363
Email: bimalokpal.jaipur@cioins.co.in
41
ERNAKULAM - Ms. Poonam Bodra Kerala,
Office of the Insurance Ombudsman, Lakshadweep,
2nd Floor, Pulinat Bldg., Mahe-a part of Union
Opp. Cochin Shipyard, M. G. Road, Territory of Puducherry.
Ernakulam - 682 015.
Tel.: 0484 - 2358759 / 2359338
Fax: 0484 - 2359336
Email: bimalokpal.ernakulam@cioins.co.in
KOLKATA - Shri P. K. Rath West Bengal,

Office of the Insurance Ombudsman, Sikkim,
Hindustan Bldg. Annexe, 4th Floor, Andaman & Nicobar
4, C.R. Avenue, Islands.
KOLKATA - 700 072.
Tel.: 033 - 22124339 / 22124340
Fax : 033 - 22124341
Email: bimalokpal.kolkata@cioins.co.in
LUCKNOW -Shri Justice Anil Kumar Districts of Uttar Pradesh

Srivastava :
Office of the Insurance Ombudsman, Lalitpur, Jhansi, Mahoba,
6th Floor, Jeevan Bhawan, Phase-II, Hamirpur, Banda,
Nawal Kishore Road, Hazratganj, Chitrakoot, Allahabad,
Lucknow - 226 001. Mirzapur, Sonbhabdra,
Tel.: 0522 - 2231330 / 2231331 Fatehpur, Pratapgarh,
Fax: 0522 - 2231310 Jaunpur,Varanasi,
Email: bimalokpal.lucknow@cioins.co.in Gazipur, 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.
42
MUMBAI - Goa,
Office of the Insurance Ombudsman, Mumbai Metropolitan
3rd Floor, Jeevan Seva Annexe, Region
S. V. Road, Santacruz (W), excluding Navi Mumbai
Mumbai - 400 054. & Thane.
Tel.: 69038821/23/24/25/26/27/28/28/29/30/31
Fax: 022 - 26106052
Email: bimalokpal.mumbai@cioins.co.in
NOIDA - Shri Chandra Shekhar Prasad State of Uttaranchal and

Office of the Insurance Ombudsman, the following Districts of
Bhagwan Sahai Palace Uttar Pradesh:
4th Floor, Main Road, Agra, Aligarh, Bagpat,
Naya Bans, Sector 15, Bareilly, Bijnor, Budaun,
Distt: Gautam Buddh Nagar, Bulandshehar, Etah,
U.P-201301. Kanooj, Mainpuri,
Tel.: 0120-2514252 / 2514253 Mathura, Meerut,
Email: bimalokpal.noida@cioins.co.in Moradabad,
Muzaffarnagar, Oraiyya,
Pilibhit, Etawah,
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: bimalokpal.patna@cioins.co.in
PUNE - Shri Vinay Sah Maharashtra,
Office of the Insurance Ombudsman, Area of Navi Mumbai
Jeevan Darshan Bldg., 3rd Floor, and Thane
C.T.S. No.s. 195 to 198, excluding Mumbai
N.C. Kelkar Road, Narayan Peth, Metropolitan Region.
Pune – 411 030.
Tel.: 020-41312555
Email: bimalokpal.pune@cioins.co.in
43
5.17. 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. In 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.
Specific General Terms & Clauses
5.18. Material Change

It is a condition precedent to the Company’s liability under the Policy that the
Policyholder shall immediately notify the Company in writing of any material
change in the risk on account of change in nature of occupation or business or
current residing address at his own expense. The Company may adjust the scope
of cover and / or the premium paid or payable/reject the claim, accordingly.
5.19. Records to be maintained

The Policyholder or Insured Person shall keep an accurate record containing all
relevant medical records and shall allow the Company or its representatives to
inspect such records. The Policyholder or Insured Person shall furnish such
information as the Company may require under this Policy at any time during the
Policy Period or Policy Year or until final adjustment (if any) and resolution of all
Claims under this Policy.
5.20. No constructive Notice

Any knowledge or information of any circumstance or condition in relation to the
Policyholder or Insured Person which is in possession of the Company other than
that information expressly disclosed in the Proposal Form or otherwise in writing
to the Company, shall not be held to be binding or prejudicially affect the
Company.
5.21. Policy Disputes

Any and all disputes or differences under or in relation to the validity, construction,
interpretation and effect to this Policy shall be determined by the Indian Courts
and in accordance with Indian law.
5.22. Limitation of liability

Any Claim under this Policy for which the notification or intimation of Claim is
received 12 calendar months after the event or occurrence giving rise to the Claim
shall not be admissible, unless the Policyholder proves to the Company’s
44
satisfaction that the delay in reporting of the Claim was for reasons beyond his
control.
5.23. Communication
a. Any communication meant for the Company must be in writing and be delivered
to its address shown in the Policy Schedule. Any communication meant for the
Policyholder/ Insured Person will be sent by the Company to his last known
address or the address as shown in the Policy Schedule.
b. All notifications and declarations for the Company must be in writing and sent to
the address specified in the Policy Schedule.Agents are not authorized to receive
notices and declarations on the Company’s behalf.
c. Notice and instructions will be deemed served 10 days after posting or
immediately upon receipt in the case of hand delivery, facsimile or e-mail.
5.24. Alterations in the Policy

This Policy constitutes the complete contract of insurance. No change or alteration shall
be valid or effective unless approved in writing by the Company, which approval shall be
evidenced by a written endorsement signed and stamped by the Company. However,
change or alteration with respect to increase/ decrease of the Sum Insured shall be
permissible only at the time of renewal of the Policy.
5.25. Out of all the details of the various Benefits provided in the Policy Terms and
Conditions, only the details pertaining to Benefits chosen by policyholder as per Policy
Schedule shall be considered relevant
5.26. Electronic Transactions

The Policyholder and /or Insured Person agrees to adhere to and comply with all
such terms and conditions as the Company may prescribe from time to time, and
hereby agrees and confirms that all transactions effected by or through facilities
for conducting remote transactions including the Internet, World Wide Web,
electronic data interchange, call centers, tele-service operations (whether voice,
video, data or combination thereof) or by means of electronic, computer,
automated machines network or through other means of telecommunication,
established by or on behalf of the Company, for and in respect of the Policy or its
terms shall constitute legally binding and valid transactions when done in
adherence to and in compliance with the Company’s terms and conditions for
such facilities, as may be prescribed from time to time. Any terms and conditions
related to electronic transactions shall be within the approved Policy Terms and
Conditions
6. OTHER TERMS AND CLAUSES
6.1. Claims procedure and management

This section explains about procedures involved to file a valid Claim by the Insured
Person and related processes involved to manage the Claim by the Company.
45
6.1.1. Pre-requisite for admissibility of a Claim:
Any claim being made by an Insured Person or attendant of Insured Person during
Hospitalization on behalf of the Insured Person, should comply with the following
conditions:
(i) The Condition Precedent Clause has to be fulfilled.
(ii) The health damage caused, Medical Expenses incurred, subsequently the Claim
being made, should be with respect to the Insured Person only. The Company will
not be liable to indemnify the Insured Person for any loss other than the covered
Benefits and any other person who is not accepted by the Company as an Insured
Person.
(iii) The holding Insurance Policy should be in force at the event of the Claim. All the
Policy Terms and Conditions, wait periods and exclusions are to be fulfilled including
the realization of Premium by their respective due dates.
(iv) All the required and supportive Claim related documents are to be furnished within
the stipulated timelines. The Company may call for additional documents wherever
required.
6.1.2. Claim settlement - Facilities
(a) Facility
The Company extends Cashless Facility as a mode to indemnify the medical

expenses incurred by the Insured Person at a Network Provider. For this purpose,
the Insured Person will be issued a “Health card” at the time of Policy purchase,
which has to be preserved and produced at any of the Network Providers in the
event of Claim being made, to avail Cashless Facility. The following is the process
for availing Cashless Facility:-
(i) Submission of Pre-authorization Form: A Pre-authorization form which is

available on the Company’s Website or with the Network Provider, has to be duly
filled and signed by the Insured Person and the treating Medical Practitioner, as
applicable, which has to be submitted
electronically by the Network Provider to the Company for approval. Only upon due
approval from the Company, Cashless Facility can be availed at any Network
Hospital.
(ii) Identification Documents: The “Health card” provided by the Company under this
Policy, along with one Valid Photo Identification Proof of the Insured Person are to
be produced at the Network Provider, photocopies of which shall be forwarded to
the Company for authentication purposes. Valid Photo Identification Proof
documents which will be accepted by the Company are Voter ID card, Driving
License, Passport, PAN Card, Aadhar Card or any other identification proof as
stated by the Company.
(iii) Company’s Approval: The Company will confirm in writing, authorization or

rejection of the request to avail Cashless Facility for the Insured Person’s
Hospitalization.
46
(iv) Company’s Authorization:
a) If the request for availing Cashless Facility is authorized by the Company,

then payment for the Medical Expenses incurred in respect of the Insured
Person shall not have to be made to the extent that such Medical Expenses
are covered under this Policy and fall within the amount authorized in writing
by the Company for availing Cashless Facility.
b) An Authorization letter will include details of Sanctioned Amount, any
specific limitation on the Claim, and any other details specific to the Insured
Person, if any, as applicable.
c) In the event that the cost of Hospitalization exceeds the authorized limit, the
Network Provider shall request the Company for an enhancement of
Authorization Limit stating details of specific circumstances which have led
to the need for increase in the previously authorized limit. The Company
will verify the eligibility and evaluate the request for enhancement on the
availability of further limits.
(v) Event of Discharge from Hospital: All original bills and evidence of treatment for
the Medical Expenses incurred in respect of the Hospitalization of the Insured
Person and all other information and documentation specified under Clauses 6.1.4
and 6.1.5 shall be submitted by the Network Provider immediately and in any event
before the Insured Person’s discharge from Hospital.
(vi) Company’s Rejection: If the Company does not authorize the Cashless Facility
due to insufficient Sum Insured or insufficient information provided to the Company
to determine the admissibility of the Claim, then payment for such treatment will
have to be made by the Policyholder / Insured Person to the Network Provider,
following which a Claim for reimbursement may be made to the Company which
shall be considered subject to the Insured Person’s Policy limits and relevant
conditions. Please note that rejection of a Pre-authorization request is in no way
construed as rejection of coverage or treatment. The Insured Person can proceed
with the treatment, settle the hospital bills and submit the claim for a possible
reimbursement.
(vii) Network Provider related: The Company may modify the list of Network Providers
or modify or restrict the extent of Cashless Facilities that may be availed at any
particular Network Provider. For an updated list of Network Providers and the extent
of Cashless Facilities available at each Network Provider, the Insured Person may
refer to the list of Network Providers available on the Company’s website or at the
call center.
(viii) Claim Settlement: For Claim settlement under Cashless Facility, the payment shall
be made to the Network Provider whose discharge would be complete and final.
(b) Re-imbursement Facility
47
(i) It is agreed and understood that in all cases where intimation of a Claim has been
provided under Reimbursement Facility and/or the Company specifically states that
a particular Benefit is payable only under Reimbursement Facility, all the information
and documentation specified in Clause 6.1.4 and Clause 6.1.5 shall be submitted to
the Company at Policyholder’s / Insured Person’s own expense, immediately and in
any event within 30 days of Insured Person’s discharge from Hospital.
(ii) The Company shall give an acknowledgement of collected documents. However, in
case of any delayed submission, the Company may examine and relax the time
limits mentioned upon the merits of the case.
(iii) In case a reimbursement claim is received after a Pre-Authorization letter has been
issued for the same case earlier, before processing such claim, a check will be made
with the Network Provider whether the Pre-authorization has been utilized. Once
such check and declaration is received from the Network Provider, the case will be
processed.
(iv) For Claim settlement under reimbursement, the Company will pay the Policyholder.
In the event of death of the Policyholder, the Company will pay the nominee (as
named in the Policy Schedule) and in case of no 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.
(v) ‘Date of Loss’ under Reimbursement Facility is the ‘Date of Admission’ to Hospital
in case of Hospitalization & actual Date of Loss for non-Hospitalization related
Benefits.
6.1.3. Duties of a Claimant/ Insured Person in the event of Claim

It is agreed and understood that as a Condition Precedent for a Claim to be
considered under this Policy:
(i) The Policyholder / Insured Person shall check the updated list of Network Provider
before submission of a pre-authorization request for Cashless Facility.
(ii) All reasonable steps and measures must be taken to avoid or minimize the quantum
of any Claim that may be made under this Policy.
(iii) Intimation of the Claim, notification of the Claim and submission or provision of all
information and documentation shall be made promptly and in any event in
accordance with the procedures and within the timeframes specified in Clause 6.1
(Claims Procedure and Management) of the Policy.
(iv) The Insured Person will, at the request of the Company, submit himself / herself for
a medical examination by the Company's nominated Medical Practitioner as often
as the Company considers reasonable and necessary. The cost of such
examination will be borne by the Company.
(v) The Company’s Medical Practitioner and representatives shall be given access and
co-operation to inspect the Insured Person’s medical and Hospitalization records
and to investigate the facts and examine the Insured Person.
(vi) The Company shall be provided with complete necessary documentation and
information which the Company has requested to establish its liability for the Claim,
its circumstances and its quantum.
6.1.4. Claims Intimation
48
Upon the occurrence of any Illness or Injury that may result in a Claim under this
Policy, then as a Condition Precedent to the Company’s liability under the Policy, all
of the following shall be undertaken:
(i) If any Illness is diagnosed or discovered or any Injury is suffered or any other
contingency occurs which has resulted in a Claim or may result in a Claim under the
Policy, the Company shall be notified with full particulars within 48 hours from the
date of occurrence of event either at the Company’s call center or in writing.
(ii) Claim must be filed within 30 days from the date of discharge from the hospital in
case of hospitalization and actual date of loss in case of non-hospitalization Benefits.
Note: 6.1.4 (i) and 6.1.4 (ii) are precedent to admission of liability under the policy.
(iii) The following details are to be disclosed to the Company at the time of intimation of
Claim:
1. Policy Number;
2. Name of the Policyholder;
3. Name and address of the Insured Person in respect of whom the Claim
is being made;
4. Nature of Illness or Injury;
5. Name and address of the attending Medical Practitioner and Hospital;
6. Date of admission to Hospital or proposed date of admission to Hospital
for planned Hospitalization;
7. Any other necessary information, documentation or details requested by
the Company.
(iv) In case of an Emergency Hospitalization, the Company shall be notified either at the
Company’s call center or in writing immediately and in any event within 48 hours of
Hospitalization commencing or before the Insured Person’s discharge from Hospital.
(v) In case of an Planned Hospitalization, the Company shall be notified either at the
Company’s call center or in writing at least 48 hours prior to planned date of
admission to Hospital
6.1.5. Documents to be submitted for registration of Claim

The following information and documentation shall be submitted in accordance with
the procedures and within the timeframes specified in Clause 6.1 in respect of all
Claims and claim will be registered only on submission of below documents. The
date of submission of such information shall be deemed as date of claim registration
for the purpose of claim processing
1. Duly filled and signed Claim form by the Insured Person;

2. Copy of Photo ID and address proof of Insured Person;
3. Medical Practitioner’s first consultation paper and referral letter advising
Hospitalization;
4. Medical Practitioner’s prescription advising drugs or diagnostic tests or
consultations;
5. Original numbered bills, receipts and discharge summary from the
Hospital/Medical Practitioner;
6. Original numbered bills from licensed pharmacy/chemists;
7. Original pathological/diagnostic test reports/radiology reports and payment
receipts;
49
8. Operation Theatre Notes(if applicable);
9. Emergency Notes, Initial Assessment Sheet and Indoor case papers(if
applicable);
10. Original investigation test reports and payment receipts supported by Doctor’s
reference slip;
11. MLC/FIR report, Post Mortem Report if applicable and conducted;
12. Ambulance Receipt;
13. Any other document as required by the Company to assess the Claim, in case
fraud is suspected.
Notes:
- The Company may give a waiver to one or few of the above mentioned documents
depending upon the case.
- Additional documents as specified against any Benefit shall be submitted to the
company.
- The Company will accept bills/invoices which are made in the Insured Person’s
name only.
- The Company may seek any other document as required to assess the Claim.
- Only in the event that original bills, receipts, prescriptions, reports or other
documents have already been given to any other insurance Company, the
Company will accept properly verified photocopies of such documents attested by
such other insurance Company along with an original certificate of the extent of
payment received from such insurance Company.
However, claims filed even beyond the timelines mentioned above should be considered
if there are valid reasons for any delay.
6.1.6. Claim Assessment

a. The Company shall scrutinize the Claim and supportive documents, once received.
In case of any deficiency, the Company may call for any additional documents or
information as required, based on the circumstances of the Claim.
b. All admissible Claims under this Policy shall be assessed by the Company in the
following progressive order:
(i) If a room accommodation has been opted for where the Room Rent or Room
Category is higher than the eligible limit as applicable for that Insured Person
as specified in the Policy Schedule, then, the Associate Medical Expenses
payable shall be pro-rated as per the applicable limits in accordance with
Clause 3.1.1(ix) and 3.2.2.
(ii) The Deductible (if applicable) shall be applied to the aggregate of all Claims
that are either paid or payable under this Policy. The Company’s liability to
make payment shall commence only once the aggregate amount of all Claims
payable or paid exceed the Deductible.
(iii) Co-payment (if applicable) shall be applicable on the admissible claim amount
payable by the Company.
(iv) The balance amount, if any, subject to the applicability of sub-limits, Company’s
liability to make payment shall be limited to such extent as applicable and shall
be the Claim payable
50
c. The Claim amount assessed in Clause 6.1.6 (b) above would be deducted from the
following amounts in the following progressive order:
(i) Sum Insured;
(ii) Plus benefit , as applicable
(iii) Cumulative Bonus
(iv) Cumulative Bonus Super , as applicable
(v) Unlimited Automatic Recharge
d. All claims incurred in India are serviced by the Company directly.
6.1.7. Payment Terms

(a) This Policy covers only medical treatment taken entirely within India. All payments
under this Policy shall be made in Indian Rupees and within India.
(b) The Company shall have no liability to make payment of a Claim under the Policy in
respect of an Insured Person during the Policy Period, once the Sum Insured for that
Insured Person is exhausted.
(c) The Company shall settle or reject any Claim within 15 days of intimation on
receipt of all the necessary documents / information as required for settlement of
such Claim and sought by the Company. The Company shall provide the
Policyholder / Insured Person an offer of settlement of Claim and upon acceptance
of such offer by the Policyholder / Insured Person the Company shall make payment
within 7 days from the date of receipt of such acceptance.
(d) The Claim shall be paid only for the Policy Year in which the Insured event which
gives rise to a Claim under this Policy occurs.
(e) The Premium for the policy will remain the same for the policy period mentioned in
the Policy Schedule.
(f) The Policy covers Reasonable and Customary Charges incurred towards medical
treatment taken or any other expenses triggers under any Benefit during the Policy
Period.
(g) Under this Policy, the Company’s total, cumulative, maximum liability during the
Policy Year is maximum up to the Sum Insured unless any additional Sum Insured
available or accrued under any Benefit.
(h) For diseases or conditions or procedure that have a specified sub-limit then all
related expenses shall be covered up to the sub-limit specified for that disease or
condition or procedure. In case there is a specified sub-limit then the Company’s
total, cumulative, maximum liability during the Policy Year is maximum up to the
specified sub-limit subject to the available Sum Insured in the Policy Year.
For example- if the Policy specifies a sub-limit of Rs. 50,000 for a particular disease
then all expenses related to the treatment of that disease (including but not limited
to pre-hospitalization, hospitalization and post- hospitalization) will be covered up to
Rs. 50,000, subject to Sum Insured availability in the Policy Year even if the overall
Sum Insured is higher.
ANNEXURE 1 - List of Expenses Generally Excluded ("Non-medical") in Hospital

Indemnity Policy
51
Sr. Annexure – I List of Expenses Generally Excluded ("Non-medical") in Hospital
No. Indemnity Policy
List I – Optional Items
1 BABY FOOD
2 BABY UTILITIES CHARGES
3 BEAUTY SERVICES
4 BELTS/ BRACES
5 BUDS
6 COLD PACK/HOT PACK
7 CARRY BAGS
8 EMAIL / INTERNET CHARGES
9 FOOD CHARGES (OTHER THAN PATIENT's DIET PROVIDED BY
HOSPITAL)
10 LEGGINGS
11 LAUNDRY CHARGES
12 MINERAL WATER
13 SANITARY PAD
14 TELEPHONE CHARGES
15 GUEST SERVICES
16 CREPE BANDAGE
17 DIAPER OF ANY TYPE
18 EYELET COLLAR
19 SLINGS
20 BLOOD GROUPING AND CROSS MATCHING OF DONORS SAMPLES
21 SERVICE CHARGES WHERE NURSING CHARGE ALSO CHARGED
22 Television Charges
23 SURCHARGES
24 ATTENDANT CHARGES
25 EXTRA DIET OF PATIENT (OTHER THAN THAT WHICH FORMS PART OF
BED CHARGE)
26 BIRTH CERTIFICATE
27 CERTIFICATE CHARGES
28 COURIER CHARGES
29 CONVEYANCE CHARGES
30 MEDICAL CERTIFICATE
31 MEDICAL RECORDS
32 PHOTOCOPIES CHARGES
33 MORTUARY CHARGES
34 WALKING AIDS CHARGES
35 OXYGEN CYLINDER (FOR USAGE OUTSIDE THE HOSPITAL)
36 SPACER
37 SPIROMETRE
38 NEBULIZER KIT
52
39 STEAM INHALER
40 ARMSLING
41 THERMOMETER
42 CERVICAL COLLAR
43 SPLINT
44 DIABETIC FOOT WEAR
45 KNEE BRACES (LONG/ SHORT/ HINGED)
46 KNEE IMMOBILIZER/SHOULDER IMMOBILIZER
47 LUMBO SACRAL BELT
48 NIMBUS BED OR WATER OR AIR BED CHARGES
49 AMBULANCE COLLAR
50 AMBULANCE EQUIPMENT
51 ABDOMINAL BINDER
52 PRIVATE NURSES CHARGES- SPECIAL NURSING CHARGES
53 SUGAR FREE Tablets
54 CREAMS POWDERS LOTIONS (Toiletries are not payable, only prescribed
medical pharmaceuticals payable)
55 ECG ELECTRODES
56 GLOVES
57 NEBULISATION KIT
58 ANY KIT WITH NO DETAILS MENTIONED [DELIVERY KIT, ORTHOKIT,
RECOVERY KIT, ETC]
59 KIDNEY TRAY
60 MASK
61 OUNCE GLASS
62 OXYGEN MASK
63 PELVIC TRACTION BELT
64 PAN CAN
65 TROLLY COVER
66 UROMETER, URINE JUG
67 AMBULANCE
68 VASOFIX SAFETY
Sr. List of Expenses Generally Excluded ("Non-medical")in Hospital Indemnity

No. Policy
List II – Items that are to be subsumed into Room Charges
1 BABY CHARGES (UNLESS SPECIFIED/INDICATED)
2 HAND WASH
3 SHOE COVER
4 CAPS
5 CRADLE CHARGES
6 COMB
7 EAU-DE-COLOGNE / ROOM FRESHNERS
53
8 FOOT COVER
9 GOWN
10 SLIPPERS
11 TISSUE PAPER
12 TOOTH PASTE
13 TOOTH BRUSH
14 BED PAN
15 FACE MASK
16 FLEXI MASK
17 HAND HOLDER
18 SPUTUM CUP
19 DISINFECTANT LOTIONS
20 LUXURY TAX
21 HVAC
22 HOUSE KEEPING CHARGES
23 AIR CONDITIONER CHARGES
24 IM IV INJECTION CHARGES
25 CLEAN SHEET
26 BLANKET/WARMER BLANKET
27 ADMISSION KIT
28 DIABETIC CHART CHARGES
29 DOCUMENTATION CHARGES / ADMINISTRATIVE EXPENSES
30 DISCHARGE PROCEDURE CHARGES
31 DAILY CHART CHARGES
32 ENTRANCE PASS / VISITORS PASS CHARGES
33 EXPENSES RELATED TO PRESCRIPTION ON DISCHARGE
34 FILE OPENING CHARGES
35 INCIDENTAL EXPENSES / MISC. CHARGES (NOT EXPLAINED)
36 PATIENT IDENTIFICATION BAND / NAME TAG
37 PULSEOXYMETER CHARGES

No. Policy
List III – Items that are to be subsumed into Procedure Charges
1 HAIR REMOVAL CREAM
2 DISPOSABLES RAZORS CHARGES (for site preparations)
3 EYE PAD
4 EYE SHEILD
5 CAMERA COVER
6 DVD, CD CHARGES
7 GAUSE SOFT
8 GAUZE
54
9 WARD AND THEATRE BOOKING CHARGES
10 ARTHROSCOPY AND ENDOSCOPY INSTRUMENTS
11 MICROSCOPE COVER
12 SURGICAL BLADES, HARMONICSCALPEL,SHAVER
13 SURGICAL DRILL
14 EYE KIT
15 EYE DRAPE
16 X-RAY FILM
17 BOYLES APPARATUS CHARGES
18 COTTON
19 COTTON BANDAGE
20 SURGICAL TAPE
21 APRON
22 TORNIQUET
23 ORTHOBUNDLE, GYNAEC BUNDLE

No. Policy
List IV – Items that are to be subsumed into costs of treatment
1 ADMISSION/REGISTRATION CHARGES
2 HOSPITALISATION FOR EVALUATION/ DIAGNOSTIC PURPOSE
3 URINE CONTAINER
4 BLOOD RESERVATION CHARGES AND ANTE NATAL BOOKING
CHARGES
5 BIPAP MACHINE
6 CPAP/ CAPD EQUIPMENTS
7 INFUSION PUMP– COST
8 HYDROGEN PEROXIDE\SPIRIT\ DISINFECTANTS ETC
9 NUTRITION PLANNING CHARGES - DIETICIAN CHARGES- DIET
CHARGES
10 HIV KIT
11 ANTISEPTIC MOUTHWASH
12 LOZENGES
13 MOUTH PAINT
14 VACCINATION CHARGES
15 ALCOHOL SWABES
16 SCRUB SOLUTION/STERILLIUM
17 Glucometer & Strips
18 URINE BAG
ANNEXURE 2 - List of Hospitals where Claim will not be admitted
55
Hospital Name Address
Nulife Hospital And 1616 Outram Lines,Kingsway Camp,Guru Teg Bahadur
Maternity Centre Nagar , New Delhi , Delhi
Taneja Hospital F-15,Vikas Marg, Preet Vihar , New Delhi , Delhi
Shri Komal Hospital &
Dr.Saxena's Nursing
Home Opp. Radhika Cinema,Circular Road , Rewari , Haryana
Sona Devi Memorial
Hospital & Trauma
Centre Sohna Road, Badshahpur , Gurgaon , Haryana
Sector-70,S.A.S.Nagar, Mohali, Sector 70 , Mohali ,
Amar Hospital Punjab
Brij Medical Centre K K 54, Kavi Nagar , Ghaziabad , Uttar Pradesh
A-55,Sector 61, Rajat Vihar Sector 62 , Noida , Uttar
Famliy Medicare Pradesh
162,Lowther Road, Bai Ka Bagh , Allahabad , Uttar
Jeevan Jyoti Hospital Pradesh
City Hospital & Trauma C-1,Cinder Dump Complex,Opposite Krishna Cinema
Centre Hall,Kanpur Road, Alambagh , Lucknow , Uttar Pradesh
Dayal Maternity &
Nursing Home No.953/23,D.C.F.Chowk, DLF Colony , Rohtak , Haryana
Metas Adventist Hospital No.24,Ring-Road,Athwalines, Surat , Surat , Gujarat
Sai Dwar Oberoi Complex,S.A.B.T.V.Lane
Road,Lokhandwala,Near Laxmi Industrial Estate, Andheri
Surgicare Medical Centre , Mumbai , Maharashtra
Paramount General Laxmi Commercial Premises,Andheri Kurla Road ,
Hospital & I.C.C.U. Andheri , Mumbai , Maharashtra
Gokul Hospital Thakur Complex , Kandivali East , Mumbai , Maharashtra
Gokul Nagri I,Thankur Complex,Western Express
Shree Sai Hospital Highway, Kandivali East , Mumbai , Maharashtra
Akash Arcade,Bhanu Nagar,Near Bhanu Sagar
Theatre,Dr.Deepak Shetty Road, Kalyan D.C. , Thane ,
Shreedevi Hospital Maharashtra
Saykhedkar Hospital And
Research Centre Pvt. Trimurthy Chowk,Kamatwada Road,Cidco Colony ,
Ltd. Nashik , Maharashtra
Arpan Hospital And No.151/2,Imli Bazar,Near Rajwada, Imli Bazar , Indore ,
Research Centre Madhya Pradesh
Ramkrishna Care Aurobindo Enclave,Pachpedhi Naka,Dhamtri
Hospital Road,National Highway No 43, Raipur , Chhattisgarh
Gupta Multispeciality
Hospital B-20, Vivek Vihar , New Delhi , Delhi
3C/59,BP,Near Metro Cinema, New Industrial Township 1
R.K.Hospital , Faridabad , Haryana
Prakash Hospital D -12,12A,12B,Noida, Sector 33 , Noida , Uttar Pradesh
56
Old Railway Road,Near New Colony, New Colony ,
Aryan Hospital Pvt. Ltd. Gurgaon , Haryana
Medilink Hospital
Research Centre Pvt. Near Shyamal Char Rasta,132,Ring Road, Satellite ,
Ltd. Ahmedabad , Gujarat
Khoya B-Wing,Near National Park,Borivali(E), Kandivali
Mohit Hospital West , Mumbai , Maharashtra
628,Niti Khand-I, Indirapuram , Ghaziabad , Uttar
Scope Hospital Pradesh
Agarwal Medical Centre E-234,- , Greater Kailash 1 , New Delhi , Delhi
Oxygen Hospital Bhiwani Stand, Durga Bhawan , Rohtak , Haryana
Prayag Hospital &
Research Centre Pvt.
Ltd. J-206 A/1, Sector 41 , Noida , Uttar Pradesh
Palwal Hospital Old G.T. Road,Near New Sohna Mod, Palwal , Haryana
No.18,1st Cross,Gandhi Nagar, Adyar , Bellary ,
B.K.S. Hospital Karnataka
East West Medical
Centre No.711,Sector 14, Sector 14 , Gurgaon , Haryana
Anand Nagar,Sinhgood Road , Anandnagar , Pune ,
Jagtap Hospital Maharashtra
Dr. Malwankar's Romeen Ganesh Marg,Tagore Nagar , Vikhroli East , Mumbai ,
Nursing Home Maharashtra
Noble Medical Centre SVP Road, Borivali West , Mumbai , Maharashtra
Rama Hospital Sonepat Road,Bahalgarh, Sonipat , Haryana
Lake Bloom 16,17,18 Opposite Solaris Estate, L.T.Gate
No.6,Tunga Gaon, Saki-Vihar Road, Powai , Mumbai ,
S.B.Nursing Home & ICU Maharashtra
Divya Smruti Building, 1st Floor, Opp Toyota Showroom,
Saraswati Hospital Malad Link Road, Malad West , Mumbai , Maharashtra
3-B Tashkant Marg,Near St. Joseph Collage, Allahabad ,
Shakuntla Hospital Uttar Pradesh
Mahaveer Hospital &
Trauma Centre 76-E,Station Road, Panki , Kanpur , Uttar Pradesh
Eashwar Lakshmi Plot No. 9,Near Sub Registrar Office, Gandhi Nagar ,
Hospital Hyderabad , Andhra Pradesh
Plot No. NH-34,P-2,Omega -1, Greater Noida , Noida ,
Amrapali Hospital Uttar Pradesh
Hardik Hospital 29c,Budh Bazar, Vikas Nagar , New Delhi , Delhi
Jabalpur Hospital & Russel Crossing,Naptier Town, Jabalpur , Madhya
Research Centre Pvt Ltd Pradesh
Plot No. 260A,Uran Naka, Old Panvel , Navi Mumbai ,
Panvel Hospital Maharashtra
L-629/631,Hapur Road, Shastri Nagar , Meerut , Uttar
Santosh Hospital Pradesh
57
5/58,Near Police Station, Vikas Nagar , Lucknow , Uttar
Sona Medical Centre Pradesh
City Super Speciality Near Mohan Petrol Pump,Gohana Road, Rohtak ,
Hospital Haryana
Navjeevan Hospital & 753/21,Madanpuri Road, Near Pataudi Chowk , Gurgaon ,
Maternity Centre Haryana
Abhishek Hospital C-12,New Azad Nagar, Kanpur , Kanpur , Uttar Pradesh
Raj Nursing Home 23-A, Park Road , Allahabad , Uttar Pradesh
Saras Healthcare Pvt Ltd. K-112, SEC-12 ,Pratap Vihar , Ghaziabad , Uttar Pradesh
Getwell Soon
Multispeciality Institute S-19, Shalimar Garden Extn. , Near Dayanand Park,
Pvt Ltd Sahibabad , Ghaziabad , Uttar Pradesh
Shivalik Medical Centre
Pvt Ltd A-93, Sector 34 , Noida , Uttar Pradesh
126, Aaradhnanagar Soc,B/H. Bhulkabhavan School,
Aakanksha Hospital Aanand-Mahal Rd. , Adajan , Surat , Gujarat
Harsh Apartment,Nr Jamna Nagar Bus Stop, Goddod
Abhinav Hospital Road , Surat , Gujarat
Dawer Chambers,Nr. Sub Jail, Ring Road , Surat ,
Adhar Ortho Hospital Gujarat
A 223-224, Mansarovar Soc,60 Feet, Godadara Road ,
Aris Care Hospital Surat , Gujarat
Arzoo Hospital Opp. L.B. Cinema, Bhatar Rd. , Surat , Gujarat
B-44, Gujarat Housing Board, Pandeshara , Surat ,
Auc Hospital Gujarat
Dharamjivan General
Hospital & Trauma Karmayogi - 1, Plot No. 20/21, Near Piyush Point,
Centre Pandesara , Surat , Gujarat
Dr. Santosh Basotia
Hospital Bhatar Road , Bhatar Road , Surat , Gujarat
344, Nandvan Soc., B/H. Matrushakti Soc. , Puna Gam ,
God Father Hosp. Surat , Gujarat
Govind-Prabha Arogya Opp. Ratna-Sagar Vidhyalaya,Kaji Medan, Gopipura ,
Sankool Surat , Gujarat
Hari Milan Hospital L H Road , Surat , Gujarat
Jaldhi Ano-Rectal 103, Payal Apt., Nxt To Rander Zone Office, Tadwadi ,
Hospital Surat , Gujarat
Jeevan Path Gen. 2Nd. Fl., Dwarkesh Nagri, Nr. Laxmi Farsan, Sayan ,
Hospital Surat , Gujarat
Yashkamal Complex, Nr. Jivan Jyot, Udhna , Surat ,
Kalrav Children Hospital Gujarat
Kanchan General Plot No. 380, Ishwarnagar Soc, Bhamroli-Bhatar,
Surgical Hospital Pandesara , Surat , Gujarat
Krishnavati General
Hospital Bamroli Road , Surat , Gujarat
Niramayam Hosptial & Shraddha Raw House, Near Natures Park , Surat ,
Prasutigruah Gujarat
58
Patna Hospital 25, Ashapuri Soc - 2, Bamroli Road, Surat , Gujarat
Harekrishan Shoping Complex 1St Floor, Varachha Road
Poshia Children Hospital , Surat , Gujarat
R.D Janseva Hospital 120 Feet Bamroli Road, Pandesara , Surat , Gujarat
Radha Hospital & 239/240 Bhagunagar Society, Opp Hans Society, L H
Maternity Home Road, Varachha Road, Surat , Gujarat
Santosh Hospital L H Road , Varachha , Surat , Gujarat
Sparsh Multy Specality
Hospital & Trauma Care G.I.D.C Road, Nr Udhana Citizan Co-Op.Bank , Surat ,
Center Gujarat
Annexure III –List of Hospitals where Co-Payment of 20% is not applicable under
Optional Benefit “Smart Select”

Fortis Flt.Lt.Rajan Dhall Sector B,Pocket 1, Aruna Asif Ali Marg, Vasant Kunj,
Hospital New Delhi – 110070
Majtha-Verka Bypass Road, Khanna Nagar, Amritsar –
Fortis Escorts Ltd. 143004
Jawahar Lal Nehru Marg, Opposite Hotel Clarks Amer,
Fortis Escorts Hospital Malviya Nagar, Jaipur – 302017
Raheja Raghunalaya Marg, Near New Police Quarters
Fortis Sl Raheja Hospital Colony, Mahim, Mumbai – 400016
Hiranandani Fortis Mini Sea Shore Road, Sector 10A, Vashi, Maharashtra –
Hospital 400703
52,First Main Road, Gandhi Nagar, Adyar, Chennai –
Fortis Malar Hospital 600020
Fortis Hospital Sector 62,Phase VIII, Sector 62, Mohali – 160062
Maxcure Mediciti
Hospitals 5-9-22,Secretariat Road, Hill Fort, Hyderabad – 500063
Maxivision Laser Centre 40-1-48,Krishna Sai Bhavan, Opposite D.V.Manor Hotel,
Pvt. Ltd. Labbipeta, Vijayawada – 520010
Maxivision Laser Centre 1-11-252/1A To 1D,Alladin Mansion, Street No 3,
Pvt. Ltd. Begumpet, Hyderabad – 500016
Maxivision Laser Centre No.16-11-741/D/66, Dilsukhnagar, Moosa Ram Bagh,
Pvt. Ltd. Hyderabad – 500036
Maxivision Laser Centre
Pvt. Ltd. 6-9-903/A/1/1, Somajiguda, Hyderabad – 500082
Fortis Hospitals Ltd No.730, EM Bypass Road, Anandpur, Kolkata – 700107
Fortis Hospital Ltd Mulund Goregaon Link Road, Mulund, Mumbai – 400078
Fortis Health No.23 80 Feet Road,Guru Krupa Layout, 2nd Stage,
Management Ltd Nagarbhavi, Bangalore – 560072
Fortis Hospital A Block, Shalimar Bagh, New Delhi – 110088
59
111A, Rash Behari Avenue, Rashbehari Avenue, Kolkata
Fortis Hospitals Ltd. – 700029
Fortis Hospital Ltd.- 154,9, Opposite IIM-B, Bannerghatta Road, Bangalore –
Wockhardt 560076
Fortis Hospital Ltd.- No 14,Cunningham Road, Sheriffs Chamber,
Wockhardt Cunnigham, Bangalore – 560052
Opposite APMC Market,Bail Bazaar, Shill Road, Kalyan
Fortis Hospital Ltd City, Kalyan - 421301
International Hospital
Limited - Fortis Hospital No.111,West of Chord Road, 1st Block Junction,
Ltd Rajajinagar, Bangalore – 560086
Fortis Hospital Ltd.- No.65,1St Main Road, Seshadripuram, Bangalore –
Wockhardt 560020
Fortis Memorial Research Sector 44, Opposite HUDA Center Metro Station, HUDA
Institute Metro Station, Gurgaon – 122002
Fortis C-Doc Healthcare B-16, Chirag Enclave, Opp Nehru Place, New Delhi –
Limited 110041
Max Smart Super Press Enclave Marg, Mandir Marg, Saket, New Delhi –
Specialty Hospital 110017
2nd Floor,Pt Deen Dayal, Coronation Hospital, Curzon
Fortis Escorts Hospital Road, Dehradun – 248001
Kangra-Dharamshala Road, Near Main Bus Stand,
Fortis Healthcare Limited Kangra – 176001
Maxivision Eye Care
Medfort Hospitals No. 78/6, 3rd Avenue, Anna Nagar, Chennai – 600102
Max Vision Eye Care 95,Neel Padam Sarovar Marg, Nursery Circle,Gandhi
Centre Path,Nemi Nagar, Vaishali, Jaipur – 302021
Fortis O.P. Jindal Hospital Patrapali, Kharsia Road, Raigarh – 496001
Radha Swami Satsang, Chandigarh Road,Village -
Fortis Hospital Mundian, Radha Swami Satsang, Ludhiana – 141001
Fortis Medical Centre 2/7, Sarat Bose Road, Kolkata – 700020
Maxcare Hospital And
Laparoscopic Surgery 1st Floor,Hyatt Medicare, Plot No.12,Khare Marg,
Institute Dhantoli, Nagpur – 440012
Near Ashoka Hotel, Opp.Kuda Office, Hanamkonda,
Max Care Hospital Warangal – 506001
S.No.29/8,9,10,11 Javali Garden, Off Gokul Road,Opp.
To Reg. KSRTC Bus Depot,Off NH4 Highway, Hubli -
Fortis Suchirayu Hospital 580030
Max Vision Advanced 216-A,Soham Plaza, Soham Gardens,Opp. Manpada
Eye Care Centre Bus Stop,Chitalsar, Chitalsar G.B Road, Thane - 400607
Note: The below is a Non-exhaustive list of Network Hospitals under Smart Select
optional cover. Please check the latest & complete list of Network Hospitals on Website:
www.universalsompo.com
60
Registered & Corp Office: Universal Sompo General Insurance Company Ltd. 8th
Floor & 9th Floor (South Side), Commerz International Business Park, Oberoi
Garden City, Off Western Express Highway, Goregaon East, Mumbai 400063, Toll
free no: 1800-22-4030/1800-200-4030, IRDAI Reg no: 134, CIN#
U66010MH2007PLC166770 E-mail: contactus@universalsompo.com, website link
www.universalsompo.com
61

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SUPREME HEALTHCARE POLICY

2.1.1. Accidental / Accident is a sudden, unforeseen and involuntary event caused

2.1.2. AYUSH Hospital is a healthcare facility wherein medical/surgical/para-

(a) Central or State Government AYUSH Hospital or

i. Having qualified registered AYUSH Medical Practitioner(s) in charge;

Internal Congenital Anomaly –

2.1.7. Co-payment is a cost-sharing requirement under a health insurance policy

• has qualified nursing staff under its employment;

2.1.11. Deductible is a cost-sharing requirement under a health insurance policy that

2.1.12. Dental Treatment means a treatment related to teeth or structures

2.1.14. Domiciliary Hospitalization means medical treatment for an

• The condition of the patient is such that he/she is not in a condition to be

2.1.15. Emergency Care (Emergency) means management for an illness or injury

2.1.18. Hospitalization (not applicable for Overseas Travel Insurance) means

2.1.19. Illness means a sickness or a disease or a pathological condition leading to

(a) Acute condition - Acute condition is a disease, illness or injury that is

• It needs ongoing or long-term monitoring through consultations,

2.1.24. Maternity expenses shall include—

• Medical treatment expenses traceable to childbirth (including complicated

2.1.25. Medical Advice means any consultation or advice from a Medical

2.1.27. Medical Practitioner (not applicable for Overseas Travel Insurance) is a

2.1.29. Migration means a facility provided to policyholders (including all members

2.1.35. Portability means a facility provided to the health insurance policyholders

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

2.1.37. Pre-hospitalization Medical Expenses means Medical Expenses incurred

2.1.38. Post-hospitalization Medical Expenses means Medical Expenses incurred

2.1.44. Surgery/Surgical Procedure: means manual and/or operative procedure(s)

2.1.45. Unproven/Experimental Treatment means a treatment including drug

2.2. Specific Definitions:

2.2.2. AYUSH Treatment refers to the medical and / or hospitalization treatments

2.2.4. Ambulance means a vehicle (Road/Air) operated by a licensed/ authorized

2.2.9. Company (also referred as Insurer/We/Us) means Universal Sompo General

2.2.10. Diagnosis means pathological conclusion drawn by a registered medical

2.2.11. Excluded Providers means hospital or any other provider specifically

2.2.13. Indemnity/Indemnify means compensating the Insured Person up to the

2.2.15. Insured Person (Insured) means a self, legally married spouse,

2.2.16. Mental Illness means a substantial disorder of thinking, mood, perception,

2.2.27. Rehabilitation means assisting an Insured Person who, following a

2.2.29. Single Private AC Room means an air conditioned room in a Hospital

2.2.31. Therapy - A therapy is the attempted remediation of a health problem,

3.1.1 Hospitalization Expenses

(iii) Advance Technology Methods:

(iv) Pre-Hospitalization Medical Expenses

(v) Post-Hospitalization Medical Expenses

(vi) Benefit: AYUSH Treatment

(vii) Benefit : Domiciliary Hospitalization

(i) The Domiciliary Hospitalization continues for a period exceeding 3

(viii) Benefit: Organ Donor Cover

The Company will indemnify the Insured Person, through Cashless or

(ix) Conditions applicable for Benefit “Hospitalization Expenses”:

3.1.2 Road Ambulance Cover

The Company will indemnify the Insured Person, through Cashless or

(i) Such road ambulance transportation is offered by a Hospital or by an

3.1.3 Cumulative Bonus:

3.1.4 Unlimited Automatic Recharge

3.1.5 Unlimited E-Consultation

The Company shall offer unlimited e-consultations with qualified General

The Company shall provide the following Services:

3.2. OPTIONAL BENEFITS

3.2.1. Smart Select