iob-policywordings

IOB HEALTH CARE PLUS POLICY
POLICY WORDING
This policy is an evidence of the contract between you and Universal Sompo General Insurance
Company Limited. The information furnished by you in the proposal form and the declaration
signed by you forms the basis of this contract.
The Policy, the Schedule and any Endorsement shall be read together and any word or
expression to which a specific meaning has been attached in any part of this Policy or of
Schedule shall bear such meaning whenever it may appear.
This Policy witnesses that in consideration of Your having paid the premium, We undertake
that if during the period of insurance or during the continuance of this policy by renewal You
contract any disease or suffer from any illness or sustain any bodily injury through accident
and if such disease or injury shall require, upon the advices of a qualified Medical Practitioner,
hospitalization for medical/surgical treatment in any Nursing Home/ Hospital in India as
defined in the policy, We will pay to YOU the amount of such expenses as may be reasonably
and necessarily incurred in respect thereof as stated in the schedule but not exceeding the
sum insured in aggregate in any one period of insurance provided that all the terms,
conditions and exceptions of this Policy in so far as they relate to anything to be done or
complied with by You have been met.
DEFINITION
The terms defined below and at other junctures in the Policy have the meanings ascribed to
them wherever they appear in this Policy and, where, the context so requires, references to
the singular include references to the plural; references to the male includes the female and
references to any statutory enactment includes subsequent changes to the same.
Accident means a sudden unforeseen and involuntary event caused by external, visible and
violent means.
Accidental Bodily Injury means any accidental physical bodily harm solely and directly
caused by external, violent and visible means which is verified and certified by a Medical
Practitioner but does not include any sickness or disease.
Adventure Sports means participation in sports activities such as bungee jumping, sky diving,
white water canoeing/rafting and engaging in racing, hunting, mountaineering, ice hockey,
winter sports and the like.
AYUSH Treatment: refers to the medical and / or hospitalization treatments given under Ayurveda,
Yoga and Naturopathy, Unani, Siddha and Homeopathy systems.
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Policy Wording - IOB Health Care Plus PolicyUIN: UNIHLIP25015V042425
Any one illness means a continuous Period of illness and it includes relapse within 45 days from
the date of last consultation with the Hospital/Nursing Home where treatment was taken
AYUSH Day Care Centre means and includes Community Health Centre (CHC), Primary Health
Centre (PHC), Dispensary, Clinic, Polyclinic or any such health centre 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;
iii. Maintaining daily records of the patients and making them accessible to the
insurance company‘s authorized representatives.
AYUSH Hospital - An 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.
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.
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 approve
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Company means ―Universal Sompo General Insurance Company Limited.
Congenital Anomaly means a condition(s) which is present since birth, and which is abnormal
with reference to form, structure or position.
a) Internal Congenital Anomaly: means which is not in the visible and accessible parts
of the body
b) External Congenital Anomaly: means which is in the visible and accessible parts of
the body
Co-payment means a cost sharing requirement under a health insurance Policy that provides
that the Policy holder/Insured will bear a specified percentage of the admissible claim amount.
A co-payment does not reduce the Sum Insured.
Cumulative Bonus means any increase or addition in the Sum Insured granted by the insurer
without an associated increase in premium.
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 Surgical Procedures are
carried out;
• maintains daily records of patients and will make these accessible to the
insurance Company‘s authorized personnel
Day Care Treatment means medical treatment, and/or surgical procedure which is:
i. undertaken under General or Local Anesthesia in a hospital/day care centre in less

than 24 hrs because of technological advancement, and
ii. which would have otherwise required hospitalization of more than 24 hours.
iii. Treatment normally taken on an out-patient basis is not included in the scope of
this definition.
Dental Treatment means a treatment related to teeth or structures supporting teeth including
examinations, fillings (where appropriate), crowns, extractions and Surgery.
Dependent Child refers to a child (natural or legally adopted), who is financially dependent
on You and does not have his/her independent sources of income and is up to21 years of age
(male child) and 25 years of age or till she marries (female child).
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Condition Precedent means a Policy term or condition upon which the Insurer's liability under
the Policy is conditional upon.
Disclosure to information norm means 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.
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.
Emergency Care 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.
Family Member means person(s) whose names are specifically appearing in the Schedule and
are related to You as spouse, Dependent Children and / or Dependent Parents.
Grace period 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.
Hospitalization 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.
Hospital means any institution established for in-patient care and Day Care Treatment of Illness
and/or Injuries and which has been registered as a Hospital with the local authorities under the
Clinical Establishments (Registration and Regulation) Act, 2010 or under the enactments
specified under the Schedule of Section 56(1) of the said Act OR complies with all minimum
criteria as under:
• has qualified nursing staff under its employment round the clock;
• has at least 10 in-patient beds in towns having a population of less than 10,00,000
and at least 15 in-patient beds in all other places;
• has qualified Medical Practitioner(s) in charge round the clock;
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• 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.
Inpatient Care means treatment for which the Insured Person has to stay in a Hospital for
more than 24 hours for a covered event.
Intensive Care Unit means an identified section, ward or wing of a Hospital which is under
the constant supervision of a dedicated Medical Practitioner(s), and which is specially
equipped for the continuous monitoring 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.
ICU (Intensive Care Unit) Charges 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.
Insured means the individual whose name is specifically appearing in the Schedule herein after
referred as ―You/Your/Yours/Yourself.
Insured Person means person(s) named in the schedule of the Policy.
Injury means accidental physical bodily harm excluding Illness or disease solely and directly
caused by external, violent, visible and evident means which is verified and certified by a
Medical Practitioner.
Illness means a sickness or a disease or pathological condition leading to the impairment of

normal physiological function which manifests itself during the Policy Period and requires
medical treatment.
a) Acute Condition is a disease, Illness or Injury that is likely to respond quickly to treatment
which aims to return the person to his or her state of health immediately beforesuffering
the disease/Illness/Injury which leads to full recovery.
b) Chronic condition is defined as a disease, Illness, or Injury that has one or more of the
following characteristics
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• it needs on-going or long-term monitoring through consultations, examinations,
check-ups, and/or tests
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• Medical treatment expenses traceable to childbirth (including complicated
deliveries and caesarean sections incurred during Hospitalization).
• it needs on-going 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.
Maternity Expenses means:
Expenses towards lawful medical termination of pregnancy during the Policy Period.
Medical Advice means any consultation or advice from a Medical Practitioner including the
issuance of any prescription or follow-up prescription
Medical Expenses means those expenses that an Insured Person has necessarily and actually
incurred for medical treatment on account of Illness or Accident on the advice of a Medical
Practitioner, as long as these are no more than would have been payable if the Insured Person
had not been insured and no more than other Hospitals or doctors in the same locality would
have charged for the same medical treatment.
Medical Practitioner is a person who holds a valid registration from the Medical Council of
any State or Medical Council of India or Council for Indian Medicine or for Homeopathy set up
by the Government of India or a State Government and is thereby entitled to practice medicine
within its jurisdiction; and is acting within the scope and jurisdiction of licence.
Medically Necessary Treatment means any treatment, tests, medication, or stay in Hospital
or part of a stay in Hospital which
• is required for the medical management of the Illness or Injury suffered by the insured;
• must not exceed the level of care necessary to provide safe, adequate and appropriate
medical care in scope, duration, or intensity
• must have been prescribed by a Medical Practitioner, must conform to the professional
standards widely accepted in international medical practice or by the medical
community in India
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.
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Network Provider means Hospitals or health care providers enlisted by an insurer, TPA or
jointly by an insurer and TPA to provide medical services to an insured on payment by a
cashless facility.
New Born Baby means baby born during the Policy Period and is aged upto 90 days.
Nominee means the person(s) nominated by the Insured Person to receive the insurance
benefits under this Policy payable on his/her death.
Non-Network means any Hospital, day care centre or other provider that is not part of the
network.
Notification of Claim is the process of notifying a claim to the insurer or TPA through any of
the recognized modes of communication.
OPD Treatment is one in which the Insured 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.
Policy means Our contract of insurance with the Insured providing cover as detailed in this
document.
Policy Period means the Policy Period as set out in the Schedule for which the insurance cover
will remain valid.
Pre-Hospitalization Medical Expenses means the Medical Expenses incurred during predefined
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 Hospitalisation was required, and
• The In-patient Hospitalization claim for such Hospitalization is admissible by the
Insurance Company.
Pre-Existing Disease (PED): 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
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.
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.
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Post-Hospitalization Medical Expenses means the 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
insurance Company.
Premium means an agreed amount to be paid by the Policyholder to Us in full and in
advance for the purpose of coverage under the Policy. The due payment of Premium and
observance of all terms and conditions shall be a condition precedent for acceptance of
liability by Us under the Policy.
Qualified Nurse means a person who holds a valid registration from the Nursing Council of
India or the Nursing Council of any state in India
Reasonable and Customary Charges means the charges for services or supplies, which are
the standard charges for the specific provider and consistent with the prevailing charges in
the geographical area for identical or similar services, taking into account the nature of the
Illness / Injury involved .
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 all waiting periods.
Room Rent means the amount charged by a Hospital towards Room and Boarding
expenses and shall include associated Medical Expenses.
Service Providers means any person, institution or organization that has been empaneled
by the Company to provide services to the Insured Person specified in the Policy.
Schedule means Schedule attached to and forming part of this Policy mentioning the
details of the Insured/Insured Persons, the Sum Insured, the period and the limits to which
benefits under the Policy would be payable.
Surgery or Surgical Procedure means manual and / or operative procedure (s) required for
treatment of an Illness or Injury, correction of deformities and defects, diagnosis and cure
of diseases, relief of suffering or prolongation of life, performed in a Hospital or day care
centre by a Medical Practitioner.
TPA means the third party administrator that the Company appoints from time to time as
specified in the Schedule.
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Unproven/Experimental Treatment means the treatment including drug experimental
therapy, which is not based on established medical practice in India, is treatment
experimental or unproven.
You/Your/Yours/Yourself means the person(s) that We insure and is/are specifically

named as Insured in the Schedule.
We/Our/Ours/Us mean Universal Sompo General Insurance Company Limited.
War means War, whether declared or not, or any warlike activities, including use of military
force by any sovereign nation to achieve economic, geographic, nationalistic, political,
racial, religious or other ends.
SECTION A - SCOPE UNDER THE POLICY
WHAT WE COVER
The Hospitalization expenses of the insured when he/she sustains any injury or contracts
any disease and is advised hospitalization by a Medical Practitioner
We will pay Reasonable and Customary charges of the following Hospitalization expenses:
1. The Medical Expenses incurred on Room, Boarding and Nursing Expense as provided
in the Hospital/ Nursing Home
2. The Medical Expenses incurred on Medical Practitioner/ Anesthetist, Consultant
fees, Surgeons fees and similar expenses
3. The Medical Expenses incurred on Anesthesia, Blood, Oxygen, Operation Theatre,
Surgical Appliances, Medicines and Drugs, Diagnostic Materials and X-ray, Dialysis,
Chemotherapy, Radiotherapy, Cost of Pacemaker, Artificial Limbs, Cost of Organ
harvesting and similar expenses.
4. The medical expenses on treatment arising from or traceable to pregnancy,
childbirth and expenses on the treatment of the newly born child up to 5% of the
sum insured, subject to such treatment not being carried out before the completion
of 9 months from the commencement of the policy.
5. The Medical Expenses incurred in the 30 days immediately prior before the date You
were Hospitalized, provided that any Nursing expenses during Pre Hospitalization
will be considered only if Qualified Nurse is employed on the advice of the attending
Medical Practitioner for the duration specified
6. The Medical Expenses incurred in the 60 days immediately after Your date of
discharge from Hospital provided that any Nursing expenses during Pre
Hospitalization will be considered only if Qualified Nurse is employed on the advice
of the attending Medical Practitioner for the duration specified
7. Cost of Health Checkup: Insured Person shall be entitled for reimbursement of cost
of medical checkup once at the end of a block of every three claim free Policies. The
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reimbursement shall not exceed the amount equal to 1% of the average Basic Sum
Insured during the block of four claim free Policies.
Additional benefits
8. In case of hospitalization of children below 12 years, a lump sum amount of Rs.1000/-
as Out of Expenses to any of the parents during the policy period.
9. Ambulance charges in connection with any admissible claim limited to Rupees1000/-

per policy period.
10. In case of death in hospital, funeral expenses are reimbursed up to Rs. 1000/ over and
above the sum insured subject to the original illness/accident claim admitted under the
policy.
NB:
a) Expenses on Vitamins and Tonics only if forming part of treatment as certified by the
attending Medical Practitioner.
b) The Hospitalization expenses incurred for treatment of any one illness under agreed
package charges of the Hospital/Nursing Home will be restricted to 75% of the Sum
Insured.
c) Cashless facility for the medical treatment carried out in Network Hospital/ Nursing
home is available through our nominated Third-Party Administrator (TPA)
d) A co-payment of 20% shall be applicable on each and every claim of Insured Person who
is above 55 years of age under the Policy
e) If medical expenses are incurred under two Policy Periods, the total liability shall not
exceed the Sum Insured of the Policy during which the Insured Person‘s medical
treatment commenced and the entire claim will be considered under that Policy only
f) Expenses on hospitalization for a minimum period of 24 hours are admissible. However,
this time limit is not applied to specific treatments, i.e. Dialysis,
Chemotherapy, Radiotherapy, Eye Surgery, Lithotripsy (Kidney stone removal), D&C,
Tonsillectomy taken in the Hospital / Nursing Home and where in the insured is
discharged on the same day, such treatment will be considered to have been taken
under hospitalization benefit. This condition will also not apply in case of stay in Hospital
for less than 24 hours provided
(a) the treatment is such that it necessitates hospitalization, and the procedure involves
specialized infrastructural facilities available in hospitals
(b) due to technological advances hospitalization is required for less than 24 hours only.
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SECTION B – WAITING PERIOD
The Company shall not be liable to make any payment under the policy in connection with
or in respect of following expenses till the expiry of waiting period mentioned below:
1. 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 us.
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 us.
2. Specific Waiting Period: (Code- Excl02)
a) Expenses related to the treatment of the following listed conditions,

surgeries/treatments shall be excluded until the expiry of 12 months of continuous
coverage, as may be the case after the date of inception of the first policy with us.
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
preexisting 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 under the policy,
then waiting period for the same would be reduced to the extent of prior coverage.
f) List of specific diseases/procedures: • Cataract

• Benign Prostatic Hypertrophy
• Myomectomy, Hysterectomy
• Hernia, Hydrocele
• Fistula in anus, Piles
• Arthritis, Gout, Rheumatism
• Joint replacement unless due to accident
• Sinusitis and related disorders
• Stone in the urinary and biliary systems
• Dilatation and Curettage
• Skin and all internal tumors/cysts/nodules/polyps of any kind, including breast
• lumps unless malignant, adenoids and hemorrhoids
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• Dialysis required for rental failure
• Surgery on tonsils and sinuses Gastric and duodenal ulcers
3. First Thirty Days Waiting Period (Code- Excl03)
i 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.
ii This exclusion shall not, however, apply if the Insured Person has Continuous Coverage for
more than twelve months.
iii The within referred waiting period is made applicable to the enhanced sum insured in the
event of granting higher sum insured subsequently.
4. Maternity Expenses (Code – Excl 18):

(Excluded until the expiry of 9 months after the date of inception of the first policy with us)
i Medical treatment expenses traceable to childbirth (including complicated deliveries and
caesarean sections incurred during hospitalization) except ectopic pregnancy;
ii Expenses towards miscarriage (unless due to an accident) and lawful medical
termination of pregnancy during the policy period.
SECTION C- EXCLUSIONS:
The Company shall not be liable to make any payment under the policy, in respect of any expenses
incurred in connection with or in respect of:
A. Investigation & Evaluation(Code- Excl04)
a) Expenses related to any admission primarily for diagnostics and evaluation purposes.
b) Any diagnostic expenses which are not related or not incidental to the current diagnosis
and treatment
B. Rest Cure, Rehabilitation and Respite Care (Code- Excl05)
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.
ii. ii Any services for people who are terminally ill to address physical, social,
emotional and spiritual needs.
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C. Obesity/ Weight Control (Code- Excl06)
Expenses related to the surgical treatment of obesity that does not fulfil 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 (BMl);
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
D. 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.
E. 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.
F. 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.
G. 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.
H. Excluded Providers: (Code-Excl11)
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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.
I. Treatment for, Alcoholism, drug or substance abuse or any addictive condition and
consequences thereof.(Code- Excl12)
J. 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)
K. 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)
L. 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.
Refractive Error:(Code- Excl15)
Expenses related to the treatment for correction of eyesight due to refractive error
less than 7.5 dioptres.
M. 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.
N. 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
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O. 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.
P. 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:
i. 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.Chemical attack or weapons means the
emission, discharge, dispersal, release orescape of any solid, liquid or gaseous
chemical compound which, when suitably distributed, is capable of causing any
Illness, incapacitating disablement or death.
ii. 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.
Q. Treatment taken outside the geographical limits of India
R. In respect of the existing diseases, disclosed by the insured and mentioned in the
policy schedule (based on insured‘s consent), policyholder is not entitled to get the
coverage for specified ICD codes.
SECTION D- CLAIMS PROCEDURE
Claim Intimation
Claim intimation can be done online on our Health Serve Web Portal or by calling at our
toll free number 1800 200 4030 or by emailing us at healthserve@universalsompo.com.
i Within 24 hours from the date of emergency hospitalization required

ii At least 48 hours prior to admission in Hospital in case of a planned Hospitalization.
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Cashless Process
Follow below steps to avail Cashless facility through our In house Health Claims
Management:
Step I: Locate nearest Hospital by visiting our website or web portal or call our Health
Helpline 1800 200 4030.
Step II: Visit Network hospital and show your Health Serve Card issued by the company
along with Valid Photo ID proof and get 'Cashless Request Form' from Insurance helpdesk
of the hospital.
Step III: Fill your details in the 'Cashless Request Form' & submit it to the Hospital Insurance
helpdesk.
Step IV: Hospital verifies the patient details and sends duly filled Cashless Request Form to
Universal Sompo
Step V: Universal Sompo Health team will review and judge the admissibility of the
Cashless Request as per Policy Terms &Conditions and the same will be communicated to
Insured and Hospital with in 60 mins for Initial Cashless request & 3 hrs for discharge
request on their registered mobile number & Email ID respectively.
Cashless Anywhere
You can now avail cashless facility from non-network hospitals.
To avail the treatment under cashless from non-network hospitals, please find the below
steps.
Prior Intimation is required for processing cashless from non-network hospitals:
➢ Inform us (Toll Free Helpline – 1800 200 4030) minimum 48 hours before admission for
planned hospitalization and with 24 hours of admission for emergency hospitalization
across India.
➢ Mail us at healthserve@universalsompo.com
Reimbursement Process
Follow below steps to avail reimbursement facility through our In house Health Claims
Management:
Step I: Visit our Web Portal to register claim or Call our Health Helpline 1800 200 4030 or
email us at healthserve@universalsompo.com and inform about your claim.
Step II: Visit hospital and undergo your treatment. Settle your hospitalization bill and collect
all the documents after discharge from the hospital.
15
Step III: Fill in Reimbursement Claim Form and submit all original documents to our below
mention office for reimbursement.
Universal Sompo General Insurance Company Limited,

Health Claims Management Office,
1st FloorC-56- A/13,
Block- C Sector- 62,
Noida,
Uttar Pradesh, Pincode: 201309
Step IV: On receipt of document your claim will processed as per Terms & Conditions
of policy and the same will be communicated over SMS & Email.
Step V: Outcome of the claim will be communicated within 15 days from date of
Submission of claim
Claim Documents submission checklist:
I. Claim form duly filled and signed by the Insured

II. Certificate from attending medical practitioner mentioning the first symptoms
and date of occurrence of ailment.
III. All treatment papers of current ailment including previous treatment papers if
any.
IV. Original Discharge Card from the hospital, Indoor Case Papers.
V. All original medical Investigation reports (viz. X-ray, ECG, Blood test etc).
VI. Original hospital bill and receipts.
VII. Original bills of chemist, medical practitioner, medical investigation, etc.
supported by the doctor’s prescription.
VIII. NEFT details and Personalized cancelled cheque/ Passbook copy in the name of
proposer for electronic fund transfer.
IX. Valid Photo ID Proof of the patient.
X. For accident Cases: MLC (Medico Legal Certificate) / FIR (First Information
report).
XI. Copy of latest valid address proof of proposer like electricity bill, water bill or
telephone bill or updated bank statement along with copy of PAN card &
Aadhaar Card as per AML/KYC Norms.
The above list of documents is indicative. In case of any further document
requirement, our team shall contact you on receipt of your claim documents
by us.
16
SECTION E- GENERAL CONDITIONS:
i.Disclosure of Information
The policy shall be void and all premium paid thereon shall be forfeited to the Company in
the event of misrepresentation, misdescription or non-disclosure of any material fact by the
policyholder.
ii.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.
iii. Claim Settlement (provision for Penal Interest)

i) The Company shall settle or reject a claim, as the case may be, within 30 days from the
date of 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 to the policyholder from the date of receipt of last necessary document 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 30 days from the date of receipt of last necessary document. In
such cases, the Company shall settle or reject the claim within 45 days from the date
of receipt of last necessary document.
iv) In case of delay beyond stipulated 45 days, the Company shall be liable to pay interest
to the policyholder at a rate 2% above the bank rate from the date of receipt of last
necessary document to the date of payment of claim.
iv. 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 a valid discharge towards payment of claim by the Company to the extent of
that amount for the particular claim.
v.Multiple Policies
i. In case of multiple policies taken by an insured person during a period from 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.
ii. 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 claimsubject
to the terms and conditions of this policy.
17
iii. If the amount to be claimed exceeds the sum insured under a single policy, the insured
person shall have the right to choose insurer from whom he/she wants to claim the
balance amount.
iv. Where an insured person has policies from more than one insurer to cover the same risk
on indemnity basis, the insured person shall only be indemnified the treatment costs in
accordance with the terms and conditions of the chosen policy.
vi. 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 and the premium paid shall be
forfeited.
Any amount already paid against claims made under this policy but which are found
fraudulent later shall be repaid by all recipient(s)/policyholder(s), who has made that
particular claim, who shall be jointly and severally liable for such repayment to the insurer.
For the purpose of this clause, the expression "fraud" means any of the following acts
committed by the insured person or by his agent or the hospital/doctor/any other 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 factor that such
misstatement of or suppression of material fact are within the knowledge of the insurer.
vii.Cancellation
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
18
viii.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.
ix. 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 lndian
General/Health insurer, the proposed insured person will get the accrued continuity
benefits in waiting periods as per IRDAI guidelines on portability.
x. 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. The Company will endeavour to give notice for renewal.

ii. Renewal shall not be denied on the ground that the insured person had made a claim
or claims in the preceding policy years.
iii. Request for renewal along with requisite premium shall be received by the Company
before the end of the policy period.
iv. At the end of the policy period, the policy shall terminate and can be renewed within
the Grace Period to maintain continuity of benefits without break in policy. Coverage
is not available during the grace period.
v. No loading shall apply on renewals based on individual claims experience.
xi. 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. as per IRDAI guidelines,
provided the policy has been maintained without a break.
19
xii. Moratorium Period
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.
xiii. Possibility of Revision of Terms of the Policy Including the Premium Rates
The Company, with prior approval of IRDAI, 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 effected.
xiv. Free look period

The Free Look Period shall be applicable on new individual health insurance policies and
not on renewals or at the time of porting/migrating the policy.
The insured person shall be allowed free look period of 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;
xv. Redressal of Grievance

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 us at:
Customer Service Universal Sompo E- mail Address
General Insurance Co. Ltd. contactus@universalsompo.com
Unit No. 601 & 602, 6th Floor, Reliable For more details:
Tech Park, Thane- Belapur Road, Airoli, www.universalsompo.com
Navi Mumbai, Maharashtra – 400708 Toll Free Numbers: 1800-22-4030 or
1800-200-4030
Senior Citizen toll free number: 1 8 0 0 -
2674030
20
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
th
Unit No. 601 & 602, 6 Floor, Reliable
Tech Park, Thane- Belapur Road, Airoli, For more details:
Navi Mumbai, Maharashtra – 400708 www.universalsompo.com
Visit Branch Grievance Redressal Officer (GRO) - Walk into any of our nearest branches and
request to meet the GRO.
• We will acknowledge receipt of your concern Immediately
• Seek and obtain further details, if any, from the complainant (permitted only once) Within
one week
• Within 2 weeks of receiving your grievance, we will respond to you with the best solution.
• We shall regard the complaint as closed incase on non-receipt of reply from the complainant
Within 8 weeks from the date of registration of the grievance
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, For more details:
Navi Mumbai, 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
21
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 mentioned in Annexure
B.
xv. 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. 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/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.
ANNEXURE A:
List I — Items for which coverage is not available in the policy
List of Expenses Generally Excluded ("Non-Medical") in Hospital Indemnity Policy -

Serial no Toiletries/ cosmetics/ personal comfort or convenience items
1. HAIR REMOVAL CREAM Not Payable
BABY CHARGES (UNLESS SPECIFIED/INDICATED) Not Payable
2.
3. BABY FOOD Not Payable
4. BABY UTILITES CHARGES Not Payable
5. BABY SET Not Payable
6. BABY BOTTLES Not Payable
7. BRUSH Not Payable
8. COSY TOWEL Not Payable
9. HAND WASH Not Payable
10. MOISTURISER PASTE BRUSH Not Payable
11. POWDER Not Payable
22
12. RAZOR Payable
13. SHOE COVER Not Payable
14. BEAUTY SERVICES Not Payable
15. BELTS/ BRACES Essential and should be paid at least
specifically for cases who have
undergone surgery of thoracic or
lumbar spine
16. BUDS Not Payable
17. BARBER CHARGES Not Payable
18. CAPS Not Payable
19. COLD PACK/HOT PACK Not Payable
20. CARRY BAGS Not Payable
21. CRADLE CHARGES Not Payable
22. COMB Not Payable
DISPOSABLES RAZORS CHARGES ( for site Payable
23.
preparations)
24. EAU-DE-COLOGNE / ROOM FRESHNERS Not Payable
25. EYE PAD Not Payable
26. EYE SHEILD Not Payable
27. EMAIL / INTERNET CHARGES Not Payable
FOOD CHARGES (OTHER THAN PATIENT's DIET Not Payable
28.
PROVIDED BY HOSPITAL)
29. FOOT COVER Not Payable
30. GOWN Not Payable
31. LEGGINGS Essential in bariatric and varicose vein
surgery and may be
considered for at least these
conditions where surgery itself is
payable.
32. LAUNDRY CHARGES Not Payable
33. MINERAL WATER Not Payable
34. OIL CHARGES Not Payable
35. SANITARY PAD Not Payable
36. SLIPPERS Not Payable
37. TELEPHONE CHARGES Not Payable
38. TISSUE PAPER Not Payable
39. TOOTH PASTE Not Payable
40. TOOTH BRUSH Not Payable
41. GUEST SERVICES Not Payable
42. BED PAN Not Payable
43. BED UNDER PAD CHARGES Not Payable
44. CAMERA COVER Not Payable
45. CLINIPLAST Not Payable
CREPE BANDAGE Not Payable/ Payable by the patient
46.
47. CURAPORE Not Payable
23
48. DIAPER OF ANY TYPE Not Payable
49. DVD, CD CHARGES Not Payable ( However if CD is
specifically sought by Insurer/TPA then
payable)
50. EYELET COLLAR Not Payable
51. FACE MASK Not Payable
52. FLEXI MASK Not Payable

53. GAUSE SOFT Not Payable
54. GAUZE Not Payable
55. HAND HOLDER Not Payable
56. HANSAPLAST/ ADHESIVE BANDAGES Not Payable
57. INFANT FOOD Not Payable
58. SLINGS Reasonable costs for one sling in
case of upper arm fractures may
be considered
Items specifically excluded in the policies
WEIGHT CONTROL PROGRAMS/ SUPPLIES/ SERVICES Exclusion in unless
59. policy otherwise
specified
COST OF SPECTACLES/ CONTACT LENSES/ HEARING Exclusion in unless
60. AIDS ETC., policy otherwise
specified
DENTAL TREATMENT EXPENSES THAT DO NOT Exclusion in unless
61. REQUIRE HOSPITALISATION policy otherwise
specified
HORMONE REPLACEMENT THERAPY Exclusion in unless
specified
HOME VISIT CHARGES Exclusion in unless
specified
INFERTILITY/ SUBFERTILITY/ ASSISTED Exclusion in unless
64. CONCEPTION PROCEDURE policy otherwise
specified
OBESITY (INCLUDING MORBID OBESITY) TREATMENT Exclusion in unless
65. IF EXCLUDED IN POLICY policy otherwise
specified
CORRECTIVE SURGERY FOR REFRACTIVE ERROR Exclusion in unless
specified
DONOR SCREENING CHARGES Exclusion in unless
specified
24
ADMISSION/REGISTRATION CHARGES Exclusion in unless
specified
HOSPITALISATION FOR Exclusion in unless
69. EVALUATION/ DIAGNOSTIC PURPOSE policy otherwise
specified
70. EXPENSES FOR INVESTIGATION/ Not Payable - Exclusion in policy
TREATMENT IRRELEVANT TO THE DISEASE FOR unless otherwise specified
WHICH ADMITTED OR DIAGNOSED
Items which form part of hospital services where separate consumables are not payable but the
service is
WARD AND THEATRE BOOKING CHARGES Payable under OT Charges, not
71.
payable separately
72. ARTHROSCOPY & ENDOSCOPY Rental charged by the hospital
INSTRUMENTS payable. Purchase of
Instruments not payable.
MICROSCOPE COVER Payable under OT Charges, not
73.
payable separately
74. SURGICAL BLADES,HARMONIC Payable under OT Charges, not
SCALPEL,SHAVER payable separately

SURGICAL DRILL Payable under OT Charges, not
75.
payable separately
EYE KIT Payable under OT Charges, not
76.
payable separately
EYE DRAPE Payable under OT Charges, not
0.
payable separately
X-RAY FILM Payable under Radiology
1.
Charges, not as consumable
SPUTUM CUP Payable under Investigation
2.
Charges, not as consumable
BOYLES APPARATUS CHARGES Part of OT Charges, not
3.
Separately
BLOOD GROUPING AND CROSS MATCHING OF Part of Cost of
4.
DONORS SAMPLES Blood, not payable
ANTISEPTIC OR DISINFECTANT LOTIONS Not Payable-Part of Dressing
5.
Charges
25
BAND AIDS, BANDAGES, STERLILE Not Payable - Part of Dressing
6.
INJECTIONS, NEEDLES, SYRINGES charges
COTTON Not Payable-Part of Dressing
7.
Charges
26
COTTON BANDAGE Not Payable- Part of Dressing
85. Charges
86. MICROPORE/ SURGICAL TAPE Not Payable-Payable by the
patient when prescribed,
otherwise included as Dressing
Charges
87. BLADE Not Payable
88. APRON Not Payable -Part of Hospital
Services/ Disposable linen to be
part of OT/ICU chatges
89. TORNIQUET Not Payable (service is charged by
hospitals, consumables
cannot be separately charged)
90. ORTHOBUNDLE, GYNAEC BUNDLE Part of Dressing Charges
91. URINE CONTAINER Not Payable
ELEMENTS OF ROOM CHARGE
92. LUXURY TAX Actual tax levied by government is
payable. Part of room chargefor
sub limits
HVAC Part of room charge not payable
93.
separately
HOUSE KEEPING CHARGES Part of room charge not payable
94.
separately
SERVICE CHARGES WHERE NURSING Part of room charge not payable
95.
CHARGE ALSO CHARGED separately
96. TELEVISION & AIR CONDITIONER Payable under room charges not if
CHARGES separately levied

SURCHARGES Part of Room Charge, Not
97.
payable separately
ATTENDANT CHARGES Not Payable - Part of Room Charges
98.
IM IV INJECTION CHARGES Part of nursing charges, not

99.
payable
CLEAN SHEET Part of Laundry/Housekeeping not
0.
payable separately
27
1. EXTRA DIET OF PATIENT(OTHER THAN THAT WHICH Patient Diet provided by hospital is
FORMS PART OF BED CHARGE) payable
2. BLANKET/WARMER BLANKET Not Payable- part of room charges

ADMINISTRATIVE OR NON-MEDICAL CHARGES
28
103. ADMISSION KIT Not Payable
104. BIRTH CERTIFICATE Not Payable
BLOOD RESERVATION CHARGES AND ANTE NATAL Not Payable
105.
BOOKING CHARGES
106. CERTIFICATE CHARGES Not Payable
107. COURIER CHARGES Not Payable
108. CONVENYANCE CHARGES Not Payable
109. DIABETIC CHART CHARGES Not Payable
DOCUMENTATION CHARGES / Not Payable
110.
ADMINISTRATIVE EXPENSES
111. DISCHARGE PROCEDURE CHARGES Not Payable
112. DAILY CHART CHARGES Not Payable
ENTRANCE PASS / VISITORS PASS Not Payable
113.
CHARGES
EXPENSES RELATED TO PRESCRIPTION ON To be claimed by patient under
114.
DISCHARGE Post Hosp where admissible
115. FILE OPENING CHARGES Not Payable
INCIDENTAL EXPENSES / MISC. CHARGES (NOT Not Payable
116.
EXPLAINED)
117. MEDICAL CERTIFICATE Not Payable
118. MAINTAINANCE CHARGES Not Payable
119. MEDICAL RECORDS Not Payable
120. PREPARATION CHARGES Not Payable
121. PHOTOCOPIES CHARGES Not Payable
PATIENT IDENTIFICATION BAND / NAME TAG Not Payable
122.
1. WASHING CHARGES Not Payable

2. MEDICINE BOX Not Payable
MORTUARY CHARGES Payable upto 24 hrs, shifting
3.
charges not payable
MEDICO LEGAL CASE CHARGES (MLC Not Payable
4.
CHARGES)
EXTERNAL DURABLE DEVICES

123. WALKING AIDS CHARGES Not Payable
124. BIPAP MACHINE Not Payable
125. COMMODE Not Payable
126. CPAP/ CAPD EQUIPMENTS Device not payable
29
127. INFUSION PUMP - COST Device not payable
OXYGEN CYLINDER (FOR USAGE OUTSIDE THE Not Payable
128. HOSPITAL)
133. PULSEOXYMETER CHARGES Device not payable

134. SPACER Not Payable
135. SPIROMETRE Device not payable
136. SPO2 PROBE Not Payable
137. NEBULIZER KIT Not Payable
138. STEAM INHALER Not Payable
139. ARMSLING Not Payable
140. THERMOMETER Not Payable (paid by patient)
141. CERVICAL COLLAR Not Payable
142. SPLINT Not Payable
143. DIABETIC FOOT WEAR Not Payable
144. KNEE BRACES ( LONG/ SHORT/ HINGED) Not Payable
KNEE IMMOBILIZER/SHOULDER Not Payable
145. IMMOBILIZER
146. LUMBO SACRAL BELT Essential and should be paid atleast
undergone surgery of lumbar
spine.
147. NIMBUS BED OR WATER OR AIR BED CHARGES Payable for any ICU patient
requiring more than 3 days in ICU,
all patients with
paraplegia/quadriplegia for any
reason and at reasonable cost of
approximately Rs 200/ day
148. AMBULANCE COLLAR Not Payable
149. AMBULANCE EQUIPMENT Not Payable
150. MICROSHEILD Not Payable
151. ABDOMINAL BINDER Essential and should be paid atleast
undergone surgery of lumbar
spine.
ITEMS PAYABLE IF SUPPORTED BY A PRESCRIPTION
152. BETADINE \ HYDROGEN Payable when prescribed for
PEROXIDE\SPIRIT\\DETTOL\SAVLON\ patient, not payable for hospital
DISINFECTANTS ETC use in OT or ward or for dressings in
hospital
PRIVATE NURSES CHARGES- SPECIAL Post hospitalization nursing charges
153.
NURSING CHARGES not Payable
154. NUTRITION PLANNING CHARGES - Patient Diet provided by hospital
30
DIETICIAN CHARGES- DIET CHARGES is payable
31
155. SUGAR FREE TABLETS Payable -Sugar free variants of
admissible medicines are not
excluded
156. CREAMS POWDERS LOTIONS (Toiletries are not Payable when prescribed
payable, only prescribed medical
pharmaceuticals payable)
157. DIGESTION GELS Payable when prescribed
158. ECG ELECTRODES Upto 5 electrodes are required for
every case visiting OT or ICU.For
longer stay in ICU, may require a
change and at least one set every
second day must be payable.
GLOVES Sterilized Gloves payable /

5.
unsterilized gloves not payable
HIV KIT Payable - payable Pre-operative
6.
screening
7. LISTERINE/ ANTISEPTIC MOUTHWASH Payable when prescribed
8. LOZENGES Payable when prescribed
9. MOUTH PAINT Payable when prescribed
NEBULISATION KIT If used during hospitalization is
10.
payable reasonably
11. NOVARAPID Payable when prescribed
12. VOLINI GEL/ ANALGESIC GEL Payable when prescribed
13. ZYTEE GEL Payable when prescribed
VACCINATION CHARGES Routine Vaccination not Payable /
14.
Post Bite Vaccination Payable
PART OF HOSPITAL'S OWN COSTS AND NOT PAYABLE
AHD Not Payable - Part of Hospital's
15.
internal Cost
ALCOHOL SWABES Not Payable - Part of Hospital's
16.
internal Cost
SCRUB SOLUTION/STERILLIUM Not Payable - Part of Hospital's
17.
internal Cost
OTHERS
18. VACCINE CHARGES FOR BABY Not Payable
19. AESTHETIC TREATMENT / SURGERY Not Payable
20. TPA CHARGES Not Payable
21. VISCO BELT CHARGES Not Payable
22. ANY KIT WITH NO DETAILS MENTIONED Not Payable
[DELIVERY KIT, ORTHOKIT, RECOVERY KIT, ETC]
32
23. EXAMINATION GLOVES Not payable
24. KIDNEY TRAY Not Payable
33
179. MASK Not Payable
180. OUNCE GLASS Not Payable
OUTSTATION CONSULTANT'S/ SURGEON'S FEES Not payable, except for

181. telemedicine consultations where
covered by policy
182. OXYGEN MASK Not Payable
183. PAPER GLOVES Not Payable
184. PELVIC TRACTION BELT Should be payable in case of
PIVD requiring traction as this is
generally not reused
185. REFERAL DOCTOR'S FEES Not Payable
186. ACCU CHECK ( Glucometery/ Strips) Not payable pre hospitilasation or
post hospitalisation / Reports and
Charts required/ Device not
payable
187. PAN CAN Not Payable
188. SOFNET Not Payable
189. TROLLY COVER Not Payable
190. UROMETER, URINE JUG Not Payable
191. AMBULANCE Payable-Ambulance from home to
hospital or inter hospital shifts is
payable/ RTA as specific
requirement is payable
TEGADERM / VASOFIX SAFETY Payable - maximum of 3 in 48 hrs
192.
and then 1 in 24 hrs
193. URINE BAG Payable where medically
necessary till a reasonable cost -
maximum 1 per 24 hrs
194. SOFTOVAC Not Payable
STOCKINGS Essential for case like CABG etc.
195.
Where it should be paid.
34
List II — Items that are to be subsumed into Room Charges
SI
N Item
1o BABY CHARGES (UNLESS SPECIFIED/INDICATED)
2 HAND WASH
3 SHOE COVER
4 CAPS
5 CRADLE CHARGES
6 COMB
7 EAU-DE-COLOGNE / ROOM FRESHNERS
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
35
List III — Items that are to be subsumed into Procedure Charges
SI No. Item
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
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
List IV — Items that are to be subsumed into costs of treatment
SI No. Item
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
36
7 INFUSION PUMP— COST
8 HYDROGEN PEROXIDE\SPIRIT\ DISINFECTANTS ETC

NUTRITION PLANNING CHARGES – DIETICIAN CHARGES- DIET
9
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 B
37
The contact details of the Insurance Ombudsman offices are as below-
Areas of Jurisdiction Office of the Insurance Ombudsman
Gujarat, Dadra & Nagar Haveli, AHMEDABAD

Daman and Diu Shri Collu Vikas Rao
Insurance Ombudsman
Office of the Insurance Ombudsman,
Jeevan Prakash Building, 6th floor,
Tilak Marg, Relief Road,
AHMEDABAD – 380 001.
Tel.: 079 - 25501201/02
Email: bimalokpal.ahmedabad@cioins.co.in
Karnataka. BENGALURU
Mr Vipin Anand
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
Madhya Pradesh BHOPAL

Chattisgarh. Shri R. M. Singh
Insurance Ombudsman
1st floor,"Jeevan Shikha",
60-B,Hoshangabad Road, Opp. Gayatri Mandir,Arera Hills
Bhopal – 462 011.
Tel.: 0755 - 2769201 / 2769202 / 2769203
Email: bimalokpal.bhopal@cioins.co.in
Odisha BHUBANESHWAR
Shri Manoj Kumar Parida
Insurance Ombudsman
62, Forest park,
Bhubaneswar – 751 009.
Tel.: 0674 - 2596461 /2596455/2596429/2596003
Email: bimalokpal.bhubaneswar@cioins.co.in
38
Punjab, Haryana (excluding CHANDIGARH
Gurugram, Faridabad, Sonepat Mr Atul Jerath
and Bahadurgarh), Himachal Insurance Ombudsman
Pradesh, Union Territories of Office Of The Insurance Ombudsman,
Jammu & Kashmir,Ladakh & Jeevan Deep Building SCO 20-27,
Chandigarh. Ground Floor Sector- 17 A,
Chandigarh – 160 017.
Tel.: 0172-2706468
Email: bimalokpal.chandigarh@cioins.co.in
Tamil Nadu, PuducherryTown CHENNAI

and Karaikal (which are part of Insurance Ombudsman
Puducherry). Office of the Insurance Ombudsman,
Fatima Akhtar Court, 4th Floor, 453,
Anna Salai, Teynampet,
CHENNAI – 600 018.
Tel.: 044 - 24333668 / 24333678
Email: bimalokpal.chennai@cioins.co.in
Delhi & following Districts of DELHI

Haryana - Gurugram, Faridabad, Insurance Ombudsman
Sonepat & Bahadurgarh. Office of the Insurance Ombudsman,
2/2 A, Universal Insurance Building,
Asaf Ali Road,
New Delhi – 110 002.
Tel.: 011 - 46013992/23213504/23232481
Email: bimalokpal.delhi@cioins.co.in
Assam, Meghalaya, Manipur, GUWAHATI

Mizoram, Arunachal Pradesh, Insurance Ombudsman
Nagaland and Tripura Office of the Insurance Ombudsman,
Jeevan Nivesh, 5th Floor,
Near Pan Bazar , S.S. Road,
Guwahati – 781001(ASSAM).
Tel.: 0361 - 2632204 / 2602205 / 2631307
Email: bimalokpal.guwahati@cioins.co.in
Andhra Pradesh, HYDERABAD

Telangana, Insurance Ombudsman
Yanam and Office of the Insurance Ombudsman,
part of Territory of Pondicherry. 6-2-46, 1st floor, "Moin Court",
Lane Opp.Hyundai Showroom ,
A. C. Guards, Lakdi-Ka-Pool, Hyderabad - 500 004.
Tel.: 040 - 23312122 / 23376991 / 23376599 / 23328709 / 23325325
Email: bimalokpal.hyderabad@cioins.co.in
39
Rajasthan. JAIPUR
Insurance Ombudsman
Jeevan Nidhi – II Bldg., Gr. Floor,
Bhawani Singh Marg,
Jaipur - 302 005.
Tel.: 0141- 2740363
Email: bimalokpal.jaipur@cioins.co.in
Kerala, Lakshadweep, Mahe-a KOCHI

part of Union Territory of Insurance Ombudsman
Puducherry Office of the Insurance Ombudsman,
10th Floor, Jeevan Prakash,LIC Building,
Opp to Maharaja's College Ground,M.G.Road,
Kochi - 682 011.
Tel.: 0484 - 2358759
Email: bimalokpal.ernakulam@cioins.co.in
West Bengal, Sikkim, Andaman & KOLKATA

Nicobar Islands. Insurance Ombudsman
Hindustan Bldg. Annexe, 7th Floor,
4, C.R. Avenue,
KOLKATA - 700 072.
Tel.: 033 - 22124339 / 22124341
Email: bimalokpal.kolkata@cioins.co.in
Districts of Uttar Pradesh : LUCKNOW

Lalitpur, Jhansi, Mahoba, Insurance Ombudsman
Hamirpur, Banda, Chitrakoot, Office of the Insurance Ombudsman,
Allahabad, Mirzapur, 6th Floor, Jeevan Bhawan, Phase-II,
Sonbhabdra, Fatehpur, Nawal Kishore Road, Hazratganj,
Pratapgarh, Jaunpur,Varanasi, Lucknow - 226 001.
Gazipur, Jalaun, Kanpur, Tel.: 0522 - 4002082 / 3500613
Lucknow, Unnao, Sitapur, Email: bimalokpal.lucknow@cioins.co.in
Lakhimpur, Bahraich, Barabanki,
Raebareli, Sravasti, Gonda,
Faizabad, Amethi, Kaushambi,
Balrampur, Basti,
Ambedkarnagar, Sultanpur,
Maharajgang, Santkabirnagar,
Azamgarh, Kushinagar, Gorkhpur,
Deoria, Mau, Ghazipur,
Chandauli, Ballia,
Sidharathnagar.
40
Goa, Mumbai Metropolitan MUMBAI
Region (excluding Navi Mumbai Insurance Ombudsman
& Thane) Office of the Insurance Ombudsman,
3rd Floor, Jeevan Seva Annexe,
S. V. Road, Santacruz (W),
Mumbai - 400 054.
Tel.: 022 - 69038800/27/29/31/32/33
Email: bimalokpal.mumbai@cioins.co.in
State of Uttaranchal and the NOIDA

following Districts of Uttar Insurance Ombudsman
Pradesh: Office of the Insurance Ombudsman,
Agra, Aligarh, Bagpat, Bareilly, Bhagwan Sahai Palace
Bijnor, Budaun, Bulandshehar, 4th Floor, Main Road, Naya Bans, Sector 15,
Etah, Kanooj, Mainpuri, Mathura, Distt: Gautam Buddh Nagar, U.P-201301.
Meerut, Moradabad, Tel.: 0120-2514252 / 2514253
Muzaffarnagar, Oraiyya, Pilibhit, Email: bimalokpal.noida@cioins.co.in
Etawah, Farrukhabad, Firozbad,
Gautambodhanagar, Ghaziabad,
Hardoi, Shahjahanpur, Hapur,
Shamli, Rampur, Kashganj,
Sambhal, Amroha, Hathras,
Kanshiramnagar, Saharanpur.
Bihar, PATNA
Jharkhand. Insurance Ombudsman
2nd Floor, Lalit Bhawan,
Bailey Road,
Patna 800 001.
Tel.: 0612-2547068
Email: bimalokpal.patna@cioins.co.in
Maharashtra, Areas of Navi PUNE

Mumbai and Thane (excluding Insurance Ombudsman
Mumbai Metropolitan Region) Office of the Insurance Ombudsman,
Jeevan Darshan Bldg., 3rd Floor,
C.T.S. No.s. 195 to 198, N.C. Kelkar Road,
Narayan Peth, Pune – 411 030.
Tel.: 020-24471175
Email: bimalokpal.pune@cioins.co.in
41
42
43
ADDITIONAL EXTENSION
Personal Accident Death Cover:

In case you have opted for additional cover against Personal Accident- Death only benefit
and have paid additional premium, We will pay a lump sum amount as mentioned in the
table below in the event of Accidental Death of the Insured whose name is appearing in the
Schedule forming part of this Policy
The Sum Insured as under shall be applicable as below.
Insured Person % of Sum Insured

In case of Death of Account Holder 100% of the Sum Insured
In case of Death of Spouse 50% of the Sum Insured
44
Policy Wording - IOB Health
Care Plus Policy UIN:
UNIHLIP25015V042425
In case of Death of Children above 12 years of 20% of the Sum Insured
age
In case of Death of Children upto 12 years of 10% of the Sum Insured

age
45
WHAT WE EXCLUDE
1. Natural Death
2. Payment of compensation in respect of death as a consequence of/resulting from
A. Committing or attempting suicide, intentional self-injury.
B. Whilst under influence of intoxicating liquor or drugs.
C. Due to Drug addiction or Alcoholism.
D. Whilst engaged in any adventurous sports like hand gliding, mountaineering, rock
climbing, sky diving, professional or amateur racing, parachuting, skiing, ice skating,
ballooning, river rafting, polo playing, horse racing or sports of similar nature and/or
hazardous activities like persons working in underground mines, explosives, workers
involved in electrical installations with High–tension supply, jockeys, circus personnel
or activities of similar nature
E. Committing any breach of law with criminal intent.
F. War, Civil War, invasion, act of foreign enemies, revolution, insurrection, mutiny,
military or usurped power, seizure, capture, arrest, restraint, or detainment,
confiscation, or nationalization or requisition by or under the order of any
government or public authority.
3. Consequential loss of any kind and/or any legal liability
4. Pregnancy including child birth, miscarriage, abortion or complication arising there from.
5. Participation in any naval, military or air force operations.
46
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
47

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IOB HEALTH CARE PLUS POLICY

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

c) AYUSH Hospital, standalone or co-located with in-patient healthcare facility of any

i. Having at least 5 in-patient beds;

i. undertaken under General or Local Anesthesia in a hospital/day care centre in less

Domiciliary Hospitalization means medical treatment for an Illness/disease/Injury which in the

Hospitalization means admission in a Hospital for a minimum period of 24 consecutive ‗In-

Insured Person means person(s) named in the schedule of the Policy.

Illness means a sickness or a disease or pathological condition leading to the impairment of

• it needs on-going or long-term control or relief of symptoms

Maternity Expenses means:

You/Your/Yours/Yourself means the person(s) that We insure and is/are specifically

We/Our/Ours/Us mean Universal Sompo General Insurance Company Limited.

SECTION A - SCOPE UNDER THE POLICY

9. Ambulance charges in connection with any admissible claim limited to Rupees1000/-

1. Pre-Existing Diseases (Code- Excl01)

2. Specific Waiting Period: (Code- Excl02)

a) Expenses related to the treatment of the following listed conditions,

f) List of specific diseases/procedures: • Cataract

3. First Thirty Days Waiting Period (Code- Excl03)

4. Maternity Expenses (Code – Excl 18):

A. Investigation & Evaluation(Code- Excl04)

B. Rest Cure, Rehabilitation and Respite Care (Code- Excl05)

1) Surgery to be conducted is upon the advice of the Doctor

D. Change-of-Gender Treatments: (Code- Excl07)

Expenses related to any treatment, including surgical management, to change

E. Cosmetic or plastic Surgery: (Code- Excl08)

F. Hazardous or Adventure sports: (Code- Excl09)

Expenses related to any treatment necessitated due to participation as a professional

G. Breach of law: (Code- Excl10)

H. Excluded Providers: (Code-Excl11)

K. Dietary supplements and substances that can be purchased without prescription,

Refractive Error:(Code- Excl15)

M. Unproven Treatments:(Code- Excl16)

Expenses related to any unproven treatment, services and supplies for or in

N. Sterility and Infertility: (Code- Excl17)

Expenses related to sterility and infertility. This includes:

(ii) Assisted Reproduction services including artificial insemination and

Q. Treatment taken outside the geographical limits of India

SECTION D- CLAIMS PROCEDURE

i Within 24 hours from the date of emergency hospitalization required

Universal Sompo General Insurance Company Limited,

Claim Documents submission checklist:

I. Claim form duly filled and signed by the Insured

ii.Condition Precedent to Admission of Liability

iii. Claim Settlement (provision for Penal Interest)

iv. Complete Discharge

i. The Company will endeavour to give notice for renewal.

xi. Withdrawal of Policy

xiv. Free look period

xv. Redressal of Grievance

Step 3: Chief Grievance Redressal Officer

Customer Service Universal Sompo General E- mail Address:

Step 4: Insurance Ombudsman

List I — Items for which coverage is not available in the policy

List of Expenses Generally Excluded ("Non-Medical") in Hospital Indemnity Policy -

52. FLEXI MASK Not Payable

SCALPEL,SHAVER payable separately

CHARGES separately levied

IM IV INJECTION CHARGES Part of nursing charges, not