Universal Sompo Gen - Complete Health Care Insurance

Objectives

The Complete Healthcare Insurance comes with comprehensive plans that reimburse medical expenses incurred in a hospital and also the out-patient charges and various value added services

Benefits

Medical Benefits
If you are admitted in a hospital , for a minimum period of 24 hours, we pay for room charges, nursing expenses and intensive care unit charges to surgeon
s fees, doctor
s fees, anaesthesia, blood, oxygen, operation theatre charges , medicines, drugs, consumables etc.
If hospitalisation is less than 24 hours
We will also pay for your medical expenses if you undergo a day care treatment at a hospital that requires hospitalisation upto 24 hours only.
What
s more!!! We will pay Medical expenses for 141 Day Care Procedures enlisted in the Annexure.
Treatment at Home
Despite suffering from illness/disease/injury ( which would normally require care and treatment at a hospital), hospitalisation may not be possible
perhaps your state of health is such that you are in no condition to be moved to a hospital, or a room may not be available. Don
t worry, we understand that and are happy to let you know that under
Domiciliary hospitalisation
, we will reimburse the medical expenses incurred by you during the treatment at home as long as it involves medical treatment for a period exceeding 3 days and had actually merited hospitalisation.
You will also be happy to know that the cover under this benefit is available to you to the limit of your chosen sum insured.
Before hospitalised
Examination, tests and medicines- we all know that the procedures that finally may lead us to hospitalisation such as investigation tests and medicines can be quite financially draining. We cover the medical expenses incurred by you 30 days prior to your being hospitalised. If you intimate us 5 days in advance of your being hospitalised, then, we will pay such actual incurred medical expenses up to 60 days prior to your being hospitalised.
After hospitalisation

Healing is a matter of time and there are bound to be follow-up visits to your doctor, medication that needs to be followed and sometimes further even confirmatory tests.

We will cover all these costs incurred by you up to 60 days after your hospitalisation.However, if you had intimated us 5 days in advance before you were hospitalised, then, we will pay such medical expenses incurred up to 90 days from day of your being discharged from hospital.

Organ Donation
One
s wounds are not a measure of one individual
s sad fate, but an indication of one
s unity with others. Keeping this in belief, you would want a health insurance plan which would cover not only your medical expenses but also cover costs incurred by a person who is donating organ for your use.
You need not look any further, as we will cover medical expenses for an organ donor
s treatment for harvesting of the donated organ.
What
s more!!! Such expenses shall not be limited and shall be paid by us to the limit of your chosen Sum Insured.
Getting to a Hospital
It is of immediate concern to us to help you get the best of medical services especially in case of emergencies. To ensure the same, we will reimburse the cost of your transportation to the nearest hospital facilitated by an ambulance.
Such expenses towards availing an ambulance shall be payable by us as per your chosen plan.
You are covered for emergency and non-emergency treatment in both Network and Out-of-Network Hospitals.
Dental Treatment (in case of Accidents)
We do not suffer as much in an accident than by not being treated timely for injuries. As a means of extending financial support to you during such an unfortunate eventuality, we will reimburse costs incurred by you for taking dental treatment in a hospital as an in-patient.
What
s more!!! Such medical expenses as actually incurred shall be reimbursed to the limit of your chosen sum insured. In other words, there is no limit for such accidental dental treatment in a hospital.
Avail Treatment of your choice
Ayurveda which literally translates as "Knowledge of Life," dates back 5,000 years to the ancient Sanskrit texts, is being increasingly recognised as an alternate medical science all over the world.
As an endeavour to help you secure best medical care, we will also cover your medical expenses as per plan chosen, incurred as an in-patient under Ayurveda, Unani, Sidha or Homeopathy if you so desire.
child goes to Hospital
You can always help your child during the stay simply by being there. We know that you will make sure your child feels they're not alone when they are being hospitalised.
If your insured child is less than 12 years of age and has been continuously hospitalised for more than 72 hours, we will provide you with a daily allowance as per plan chosen to meet out non-medical expenses incurred by you.
Vaccination
In the unfortunate event of your being bitten, we will pay you the medical expenses subject to limit of chosen sum insured, incurred for vaccination including inoculation and immunizations in case of such post-bite treatment.
Cough, Cold or Mild Fever etc
We know your health insurance is not complete, if it doesn
t ensure your complete wellbeing.
Most of us, at times, feel the need to be seen by a specialist who will listen to our problem and answer any questions we might have.
Medical insurance in general do not cover medical charges incurred by a person as an out-patient.
Our plans have therefore been designed in way to cover most of such incurred costs as per following heads
Diagnostic Tests
Diagnostic tests taken by you from a diagnostic centre (not necessarily to be prescribed by network medical practitioner).
Out-patient Dental Treatment
Any medically necessary dental treatment taken by you from dentist provided that we will not pay for any Dental Treatment that comprises cosmetic treatment.
Spectacles, Contact lenses, Hearing Aid
Either one pair of spectacles or contact lenses, provided that these have been prescribed for you by an Eye specialist Medical Practitioner
Out-patient Consultation
Consultation expenses incurred by you to assess your health condition for any Illness
A waiting period of 3 years shall be applicable before any expenses under any of the above heads become payable.
serious ill
If you are seriously ill and have been hospitalised for a period of more than 10 days, we shall pay you a
Convalescence benefit
of Rs 10,000 once during the policy year.
What
s more!!! The above benefit shall be payable flat on per member basis without accounting for actual medical expenses incurred during those 10 days.
Routine Pregnancy
Medical expenses associated with normal pregnancy and childbirth, including normal deliveries, complicated deliveries, and caesarean costs while hospitalised.
Pre and Post natal expenses:
We shall also pay for pre natal and post natal expenses under this head.
Baby Care
iii. New Born Care
We will cover your new born baby for medical expenses incurred as in
patient up to the basic sum insured till the expiry of your policy with us or the child is 91 days old whichever is earlier at NO additional premium.
When the new born baby is older than 91 days, then you will have a take an individual policy for the new born or wait till your next renewal to cover the baby under a regular family floater plan.

Entry Age Details

Minimum
18 for adults and policyholder
91 days for dependent children
1 day for children under floater plan
Maximum
70 years

Policy Term

1 to 3 years

Free Look Period

If you find that the coverage under the policy is unsuitable for your family, you may return the policy to us within 15 days of your receiving the policy to review terms and condition and if you have not made any claim during such free look period, you shall be entitled to
a) A refund of the premium paid less any expenses incurred by us on your medical examination and the stamp duty charges or;
b) Where the risk has already commenced and the option of return of the policy is exercised by you, a deduction towards the proportionate risk premium for period on cover or;
c) Where only a part of the risk has commenced, such proportionate risk premium commensurate with the risk covered during such period.

Grace Period

we shall provide with a window to renew your policy within 30 days from renewal due date without loss of your continuity benefits.

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Frequently Asked Questions About Insurance

Health

Life

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What is health insurance? +

Health insurance is a type of coverage that pays for medical and surgical expenses incurred by the insured. It may also provide coverage for other types of health-related costs, such as prescription drugs, mental health services, and preventive care.

Why do I need health insurance? +

Health insurance helps protect you from high medical costs. It provides access to medical care when you need it, helping to pay for doctor visits, hospital stays, surgeries, prescription medications, and other health-related services.

What is a premium? +

A premium is the amount you pay for your health insurance every month. Depending on your plan, the premium may vary based on factors like age, location, and level of coverage.

What is a deductible? +

A deductible is the amount of money you must pay out-of-pocket before your health insurance starts covering your medical expenses. For example, if you have a deductible of $1,000, you must pay $1,000 out-of-pocket before your insurance starts covering your medical bills.

What are copayments and coinsurance? +

Copayment (copay): A fixed amount you pay for a covered health care service, typically when you get the service. Coinsurance: The percentage of the cost you pay for covered health services after you've paid your deductible. For example, if your coinsurance is 20%, you pay 20% of the bill, and the insurance company pays the remaining 80%.

What is an out-of-pocket maximum? +

The out-of-pocket maximum is the maximum amount you can spend on your health insurance. If you exceed this amount, your insurance company will pay 100% of your medical expenses.

What is the difference between in-network and out-of-network providers? +

In-network providers: Health care providers that have a contract with your health insurance plan to provide services at negotiated rates. Out-of-network providers: Providers that don't have a contract with your insurance plan. Services from these providers may cost more or not be covered at all.

What is a Special Enrollment Period (SEP)? +

The Special Enrollment Period (SEP) is a special time during the year when you can sign up for or make changes to your health insurance plan. If you miss this period, you may have to wait until the next one unless you qualify for a Special Enrollment Period (e.g., due to a life event like marriage or having a baby).

Can I keep my doctor with health insurance? +

If you have a preferred doctor, it’s important to check if they are in-network with your insurance plan. If they are not in-network, you may need to pay more out-of-pocket, or you may have to switch to another doctor who is in-network.

What is a Health Savings Account (HSA)? +

A tax-advantaged account for people with high-deductible health plans (HDHPs). The funds roll over from year to year and can be used for qualifying medical expenses.

What is a Flexible Spending Account (FSA)? +

A tax-advantaged account for people with low-deductible health plans (LDHPs). The funds roll over from year to year and can be used for qualifying medical expenses.

What is a Health Maintenance Organization (HMO)? +

An HMO is a type of health insurance plan that requires you to choose a primary care physician (PCP) and get referrals from them to see specialists. HMOs often have lower premiums and out-of-pocket costs but offer less flexibility in choosing providers.

What is a Preferred Provider Organization (PPO)? +

A PPO is a health insurance plan that offers more flexibility in choosing healthcare providers and doesn’t require referrals to see specialists. You can see any doctor, but you’ll pay less if you use in-network providers.

What is the difference between a Health Savings Account (HSA) and a Flexible Spending Account (FSA)? +

HSA: A tax-advantaged account for people with high-deductible health plans (HDHPs) The funds roll over from year to year and can be used for qualifying medical expenses. FSA: A tax-advantaged account for people with low-deductible health plans (LDHPs) The funds roll over from year to year and can be used for qualifying medical expenses.

What does the term "pre-existing condition" mean? +

A pre-existing condition is a medical condition that you had before you got your health insurance. It could include things like diabetes, high blood pressure, or heart disease.

Can I cancel my health insurance at any time? +

Yes, you can cancel your health insurance plan at any time. However, if you cancel outside the open enrollment period, you may not be able to get another plan until the next enrollment period unless you qualify for a Special Enrollment Period.

Are prescription drugs covered by health insurance? +

Many health insurance plans cover prescription medications, but the coverage may vary. Plans typically have a formulary, or list of covered drugs, and different drugs may have different levels of coverage, depending on whether they are generic, brand-name, or specialty drugs.

What is preventive care? +

Preventive care includes health services that help prevent illnesses, such as vaccinations, screenings, and annual checkups. Under the Affordable Care Act, most preventive services are covered by health insurance plans at no additional cost to the policyholder.

What should I do if my health insurance claim is denied? +

If your claim is denied, you can appeal the decision. Review the denial letter for reasons, contact your insurer for assistance, and file a written request for a hearing. If you win the appeal, you may be able to get a refund or other compensation.

How can I choose the best health insurance plan for me? +

When selecting a plan, consider factors like: Your health care needs (e.g., frequent visits, prescriptions) The plan’s network of doctors and hospitals The cost of premiums, deductibles, copays, and out-of-pocket maximums Coverage for specialized care or treatments Compare the different plans and benefits to find one that meets your needs.

What happens if I don't have health insurance? +

If you don’t have health insurance, you can still access some health care services, such as emergency care, in-network doctors, and in-network hospitals. You may be eligible for Medicaid, which provides some health care services at no cost to you.

What is life insurance? +

Life insurance is a contract between you and an insurance company, where you pay regular premiums in exchange for a lump sum payment (death benefit) to your beneficiaries upon your death.

What are the different types of life insurance? +

Term Life Insurance: Provides coverage for a specific period (e.g., 10, 20, or 30 years). If you pass away during this term, your beneficiaries receive the death benefit. It does not build cash value. Whole Life Insurance: Offers lifetime coverage with a death benefit and also builds cash value over time, which you can borrow against or use. Universal Life Insurance: A flexible policy that allows you to adjust the premiums and death benefit while also building cash value.

How much life insurance coverage do I need? +

The amount of coverage you need depends on factors like your income, debts, family needs, and long-term financial goals. A common rule is to have coverage worth 10 to 15 times your annual income, but this can vary based on your individual situation.

What is the difference between beneficiaries and policyholders? +

The policyholder is the person who owns the life insurance policy and pays the premiums, while the beneficiary is the person or group that receives the death benefit when the policyholder passes away.

Can I change my beneficiaries? +

Yes, you can change your beneficiaries at any time during the life of the policy, as long as the policy is in force and you follow the correct procedure with the insurance company.

What is the contestability period? +

The contestability period is the time during which you have the right to contest the decision of the insurer to pay the death benefit. This period varies depending on the type of life insurance policy and the insurer.

Does life insurance cover accidental death? +

Some life insurance policies include accidental death coverage, while others may require a separate rider for this benefit. Be sure to review your policy to understand what’s covered.

Can I cancel my life insurance policy at any time? +

Yes, you can cancel your life insurance policy at any time, provided you follow the correct procedure with the insurance company.

What is cash value? +

Cash value is the accumulated value of the life insurance policy that can be used to pay for expenses, such as medical bills or funeral expenses.

How do I borrow against cash value? +

You can borrow against the cash value of your life insurance policy, but it will need to be repaid, and any unpaid loan will reduce the death benefit.

What is the difference between whole life and universal life insurance? +

Whole life insurance provides coverage for a specific period (e.g., 10, 20, or 30 years) and builds cash value over time. Universal life insurance offers lifetime coverage with a death benefit and also builds cash value over time.

How are life insurance premiums determined? +

Life insurance premiums are based on factors like age, health, lifestyle (e.g., smoking), coverage amount, and type of policy. Generally, younger, healthier individuals pay lower premiums.

Can I borrow money from my life insurance policy? +

If you have a whole life or universal life policy, it may build cash value over time. You can borrow against this cash value, but it will need to be repaid, and any unpaid loan will reduce the death benefit.

What happens if I stop paying my life insurance premiums? +

If you stop paying premiums, your policy may lapse. For permanent policies like whole or universal life, the cash value may cover the premiums for a time, but eventually, if premiums are not paid, the policy will end.

What is auto insurance? +

Auto insurance is a contract between you and an insurance company that provides financial protection against damage or injury caused by accidents, theft, or other incidents involving your vehicle. It covers both liability and your vehicle's repair costs depending on the type of policy.

What types of auto insurance coverage are available? +

There are several types of auto insurance coverage, including liability, collision, comprehensive, uninsured/underinsured motorist, and additional coverage like roadside assistance and collision damage waiver.

How much auto insurance do I need? +

The amount of coverage you need depends on factors such as the value of your car, your driving habits, your state's legal requirements, and whether you own or lease your vehicle. A good starting point is to meet your state's minimum required coverage, but you may want additional coverage for added protection.

Can I cancel my auto insurance policy at any time? +

Yes, you can cancel your auto insurance policy at any time, provided you follow the correct procedure with the insurance company.

What is the difference between liability and comprehensive coverage? +

Liability coverage covers the damages and injuries caused by accidents, while comprehensive coverage also covers non-accident damages, such as theft or vandalism.

How do I choose the right auto insurance policy? +

When selecting an auto insurance policy, consider factors such as the type of coverage you need, your driving habits, the value of your vehicle, and your state's legal requirements.

What factors affect my auto insurance premium? +

Several factors impact your insurance premium, including: Your driving history (accidents, tickets), The make, model, and age of your car, Your location (accident rates in your area), Your age, gender, and marital status, The level of coverage you choose, Your credit score (in some states).

What is a deductible? +

A deductible is the amount you must pay out of pocket before your insurance policy starts to cover the remaining cost of repairs or claims. For example, if you have a $500 deductible and incur $2,000 in damages, you will pay $500, and your insurer will pay the remaining $1,500.

What is the difference between comprehensive and collision coverage? +

Collision coverage pays for repairs to your vehicle after a collision with another vehicle or object, regardless of who is at fault. Comprehensive coverage covers non-collision incidents, such as theft, vandalism, or damage from natural disasters.

Can I get uninsured/underinsured motorist coverage? +

Yes, uninsured/underinsured motorist coverage is available in some states. This coverage provides financial protection for you if another driver is uninsured or underinsured.

Is auto insurance required by law? +

Yes, in most states, you are required to have a minimum level of liability insurance. Some states also require additional coverage like Personal Injury Protection (PIP) or uninsured motorist coverage. The requirements vary by state, so it’s important to check your local laws.

What happens if I don’t have auto insurance? +

If you drive without insurance, you risk facing legal penalties, fines, and the possibility of your driver's license being suspended. If you're involved in an accident, you could be held responsible for the damages.

Can I add other drivers to my auto insurance policy? +

Yes, you can add other drivers, such as family members or friends, to your policy. However, their driving record and age may affect your premium. It's important to inform your insurer about all the drivers in your household.

What should I do if I get into an accident? +

If you're in an accident, follow these steps: Ensure safety by moving to a safe location if possible. Call the police and file a report. Exchange contact and insurance information with the other driver(s). Take photos of the accident scene, vehicle damage, and injuries. Notify your insurance company about the accident as soon as possible.

What is home insurance? +

Home insurance is a contract between you and an insurance company that provides financial protection against damage or loss caused by natural disasters, theft, or other incidents.

What types of home insurance coverage are available? +

There are several types of home insurance coverage, including flood, fire, burglary, and liability. You may also have coverage for water damage, mold, and other property damage.

How much home insurance do I need? +

The amount of home insurance coverage you need depends on the value of your property, the type of coverage you want, and your insurance provider. You may also need additional coverage for water damage, mold, and other property damage.

Can I cancel my home insurance policy at any time? +

Yes, you can cancel your home insurance policy at any time, provided you follow the correct procedure with the insurance company.

What is the difference between flood and fire coverage? +

Flood coverage covers damage caused by floods, while fire coverage covers damage caused by fires.

How do I choose the right home insurance policy? +

When selecting home insurance, consider factors such as the type of coverage you need, the value of your property, and your insurance provider.

What factors affect my home insurance premium? +

Factors such as the type of coverage you need, the value of your property, and your insurance provider can significantly impact your premium.