Health Insurance Over ViewIndividual Health Insurance Overview

USGI Health Insurance

Health Insurance Overview

Health insurance (popularly known as Medical Insurance or Mediclaim) protects you and your dependents against any financial constraints arising on account of a medical emergency.

It includes disability and long term medical needs. In Mediclaim, you pay a premium and in return the insurer commits to pay a predetermined sum of money to meet the claims.

Health insurance is new in Indian context and is slowly catching up with the consumers.

Consumers understand the objective of health insurance and it’s offering to cover the ever rising medical expenses.

Before buying a health insurance policy, plan your requirements carefully. It will save you from buying a policy which might not be appropriate for you and can also be expensive.

What is Health Insurance

A health insurance policy is a contract between an insurance company and an individual. Sometimes it is associated with covering disability and custodial needs.

The contract is renewable annually. Health insurance is affordable and carries the assurance and freedom from insecurities that

threaten normalcy now and then type and amount of health care costs that will be covered by the health plan are specified in

advance

Benefit of Health Insurance Benefit depends on the policy you choose and the coverage it provides It helps securing a better future by paying a fraction as an expense today called the

premium. It reduces saving huge amount of financial losses, risk of financial breakdown in case of

expensive medical and post-illness care. It definitely induces a sense of security to the insured. It provides financial security to the family members. It covers your hospitalization and medical bills. It also covers disability and custodial bills. You can avail tax benefits on the premium paid under section 80D of the Income Tax Act. The best factor, you can also opt for health insurance policies even after the age of 60.

Types of Health Insurance

Health care costs have seen a phenomenal rise in the recent times There are two types of health Insurance Medical Insurance also know as indemnity cover Critical Illness Insurance also know as benefit cover

Medical Insurance This is typically a hospitalization cover and reimbursement of the medical expenses incurred in

respect of covered disease or surgery while the insured was admitted in the hospital as a patient. Different types of medical insurances are available in the market like individual medical

insurance, group medical insurance and overseas medical insurance. There are health policies that reimburse you the actual hospitalization cost for treatment of any

disease and are offered by the non-life insurers only. These policies are popularly called "Mediclaim" policies. Critical Illness Insurance Critical Illness plan insures you against the risk of serious illnesses in return of a premium you are

required to pay.

Cont…

In this type of health insurance plan, the insured receives a lump sum amount within a few days of diagnosing critical illness as per his sum Insured

This gives you the same security of knowing that a guaranteed cash sum will be paid if the unexpected happens and you are diagnosed with any one of the critical illness.

Sometimes a critical illness can change your lifestyle in addition to help within the home or the family. Once this lump sum is paid, the plan ceases to remain in force. Typically, a critical illness plan would provide

cover for the illnesses mentioned below.

Aorta graft surgery Cancer Coronary artery bypass surgery First heart attack Kidney failure Major organ transplant Multiple sclerosis Paralysis Primary pulmonary arterial hypertension Stroke

Glossary DEFINITION: 1. Proposal form: The application form You sign for this insurance and any other information You give to us or

which is given to us on Your behalf. 2. Policy: Policy wording, the Schedule, the Proposal form and any applicable endorsement or memoranda. 3. Schedule: It provides details of the insured person(s), which are in force and the level of cover Insured Person(s)

have. 4. Sum Insured: It means the Monetary Amounts shown against insured person(s) which will be our maximum

liability during the Policy Period. 5. Period of Insurance: The time Period for which the contract of insurance is valid as shown in the schedule

Individual Health V3bd 06-11-08 6. We/Ours/Us It means UNIVERSAL SOMPO GENERAL INSURANCE COMPANY LTD. 7. You/Your: It means the person(s) named as Insured in the Schedule 8. Insured Person: The person named as Insured person(s) in the Schedule which may include You and Your family

inclusive of dependent parents 9. Injury: It shall mean accidental bodily injury solely and directly caused by external, physical and visible cause. 10. Disease: It shall mean a condition affecting the general Wellbeing and health of the body that first manifests

itself in the Period of Insurance and which requires treatment by a Medical Practitioner. Disease does not include any mental disease ( a mental or bodily condition marked by disorganization of

personality, mind, and emotions to impair the normal psychological, social or work performance of the individual) regardless of its cause or origin.

11. Medical Practitioner: Person holding a Medical degree of a recognised institution registered by Medical Council of respective State of India.

12. Qualified Nurse: Person holding certificate of recognized Nursing Council 13. Hospital/Nursing Home : It means an institution registered as a Hospital or Nursing Home within India,

established for indoor care and treatment of disease/injuries.

Individual Health Insurance

USGI IHI overview It is comprehensive Health Insurance Policy Policy designed in a way to suit your need and fit your pocket while providing a wide

Coverage The Policy is your protection against spiraling medical costs The Policy is available for Individuals and Families. It covers pre and post hospitalization Claim includes cashless and reimbursement options Include day care hospitalization and Domiciliary Hospitalization It does have an option of critical illness and daily cash

Key Benefit and Eligibility Key Benefit Covers Day care hospitalization and Domiciliary Hospitalization Add on includes critical illness Cashless Facility provided in over 5000 network hospitals across India Having wide range of sum insured option from 1 to 5 lacs depending on which premium varies No co payment No medical charges for age above 45yrs No Loading – In case of claim in previous year there ill be no loading on premium at times of renewal 1year Exclusion – there are few ailments which are covered after 1yrears where as in most of the

companies it is covered after 2 years

Eligibility The enrollment age is between 3month to 65 yrs Policy is renewable up to 70yrs Maximum 2 Adult and 2 kids can be covered under one policy No health Check up is required up to 45 years of age

Coverage and AddonsSr.No Coverage INDIVIDUAL HEALTH

1 SI/Person/Policy/Year(in lakhs) 1 LAC TO 5 LACS, multiples of 500002 Pre-hospitalization 30 days3 Post-hospitalisation 60 days

4 Day Care Procedures Covered both on Cashless and Reimbursement basis

5 Domiciliary Treatment Up to 20% of Basic Sum Insured6 Pre Existing Cover After (yrs) Covered after 3 Claim free Policy Years with Us7 Pre Hospitalisation For upto 30 days prior to Hospitalization8 Post Hospitalisation For upto 60 days post hospitalization

9 Daily Cash Allowance0.1% of the Basic Sum Insured or Rs. 250/- per day for the duration of hospitalization whichever is less subject to maximum of Rs. 2500/-

10 Critical illness cover upto the SI/ additional 50% of the Basic Premium shall be applicable

11 Network Hospitals 5000 ALL OVER INDIA12 Medical Practitioner/ Consultant fees Upto 25% of Basic Sum Insured13 Policy Taken With out Medical Examine (Yrs) Upto 45 years14 PRE POLICY MEDICAL TEST EXPENCES BORNE BY INSURED15 Major Organ Transplant a) Kidney b) Lung c) Pancreas d) Bone Marrow

16 Emergency Ambulance Limit of 1% of Basic Sum Insured subject to maximum of Rs. 1000/- each Claim

17 TAX BENEFIT tax under Section 80 D up to Rs. 15,000/-, for Senior Citizens the limit is Rs. 20,000/-.

Add on: Critical Illness Rider (On Cashless basis) Available at inception, facility to double the Basic Sum Insured for the following 5 Critical Additional Premium

• Paralytic Stroke• Cancer• Chronic End Stage Renal failure • Coronary Artery Bypass• Major Organ Transplant(Kidney, Lungs, Pancreas, Bone Illness on Payment of Marrow)

Exclusions 30 days exclusions Any Illness contracted within 30 days of Period of Insurance Start Date,

except those incurred as a result of Injury. 1year exclusion Any Medical Expenses incurred by You on treatment of following Illnesses

within the first two (1) consecutive years of Period of Insurance Start Date: Cataract Benign Prostatic Hypertrophy Myomectomy, Hysterectomy Hernia, Hydrocele Fistula in anus, Piles Arthritis, Gout, Rheumatism Joint replacement unless warranted due to an accident Sinusitis and related disorders Medical Management of tonsillitis. Stone in the urinary and biliary systems Dilatation and Curettage

Cont…. Skin and all internal tumors/cysts/nodules/polyps of any kind, including breast lumps unless malignant, adenoids and

hemorrhoids Dialysis required for renal failure Surgery on tonsils and sinuses Gastric and duodenal ulcers 4years Exclusions-In case the Illnesses mention in 1st year exclusions or any other illness mention by insured are Pre-existing

condition(s) at the commencement of this Policy, then those Illnesses shall be covered after 48 months of continuous claim free coverage has elapsed, since Period of Insurance Start Date

Permanent Exclusions Injury or Diseases directly or indirectly caused by or arising from or attributable to war, invasion, act

of foreign enemy, war like operation (whether war be declared or not). Circumcision unless necessary for the treatment of a Disease not otherwise excluded or required as

a result of accidental bodily injury; vaccination, inoculation, cosmetic or aesthetic treatment of any description(including any complications arising thereof),plastic surgery except

those relating to treatment of Injury or Disease . Cost of spectacles and contact lens or hearing aids. Dental treatment or surgery of any kind Convalescence, general debility, run down condition or rest cure, congenital disease or defects or

anomalies, sterility, venereal disease, intentional self injury and use of intoxicating drugs/alcohols.

Cont……. Any expense on treatment related to HIV, AIDS and all related medical conditions. Expenses on Diagnostic, X-Ray, or Laboratory examinations unless related to the

treatment of Disease or Injury falling within ambit of Hospitalization or Domiciliary Hospitalization claim.

Expenses on treatment arising from or traceable to pregnancy, childbirth, miscarriage, abortion or complications of any of these, including caesarean section and any infertility, sub fertility or assisted conception treatment.

Injury or Diseases directly or indirectly caused by or contributed to by nuclear weapons/material.

Any expense on treatment of Insured Person as an outpatient in a Hospital. Any expense on Naturopathy, non allopathic treatment and/or any treatments not

approved by Indian Medical council Any expense related to Disease/Injury suffered whilst engaged in adventurous sports.

Any Expense of any treatment related to Human T-Cell Lymphotropic Viruses types III (III-LB-III) or Lymphadinopathy Associated viruses (LAV) or the Mutant derivatives or Variations Deficiency Syndrome.

External medical equipment of any kind used at home as post hospitalization care like wheelchairs, crutches, instruments used in treatment of sleep apnea syndrome (C.P.A.P) or continuous peritoneal ambulatory dialysis (C.P.A.D) and oxygen concentrator for bronchial asthamatic condition, etc.

Cont…. Any expense under Domiciliary Hospitalisation for Pre and Post Hospitalisation treatment� Treatment of following diseases:� I. Asthma II. Bronchitis III. Chronic Nephritis and Nephritic Syndrome IV. Diarrhoea and all type of Dysenteries including Gastroenteritis V. Diabetes Mellitus VI. Epilepsy VII. Hypertension VIII. Influenza, Cough and Cold IX. All types of Psychiatric or Psychosomatic Disorders X. Pyrexia of unknown origin for less than 15 days XI. Tonsillitis and Upper Respiratory Tract infection including Laryngitis and Pharingitis XII. Arthritis, Gout and Rheumatism XIII. Dental Treatment or Surgery Any treatment not exceeding three days.� 17. War, riots, strike, terrorism acts, nuclear weapon induced treatment

Claim Process Cashless Overview

Get admitted in any one of the TPA’s networked hospital Fax the pre-authorisation form along with relevant documents (Investigation reports, Previous consultation papers,

Cashless ID, Photo ID) Your service provider reviews your claim request and accordingly will approve, query or reject the same Your service provider settles the claim

(as per policy terms & conditions) with the hospital after completion of all formalities.

Reimbursement Overview

Upon discharge, pay all hospital bills and collect all original documents of treatments and expenses undergone. Mail the duly filled (and signed by insured and treating doctor) claim form and required documents to your service

provider (TPA). Your service provider reviews your claim request and accordingly will approve, query or reject the same Your service provider settles the claim

(as per policy terms & conditions) and reimburses the approved amount.

Claim documents Required Documents Duly filled Claim form (signed by the Insured and the treating doctor) Discharge summary (with details of complaints & the treatment availed Final Hospital Bill (detail breakup) along with interim bills Payment Receipts Doctor's consultation papers All investigation reports (e.g. Blood report, X-ray, Sonography, MRI, etc.) All pharmacy bills supporting with doctor prescriptions Implant sticker / invoice, if used (e.g. lens details in cataract case, stent details in

angioplasty) Medico Legal Certificate (MLC) and / or FIR for all accident cases For miscellaneous charges - detail bills with supporting prescription of the Treating

doctor Copy of Health card Any other related documents Note: All documents should be Original

Contact us USGI

Product Related

080-41538832

Email ID – insure@kanoeindia.com

Third Party Administrator(TPA) –Ericson TPA

Toll free no 1800 22 2034Email ID – satyadeep@ericsontpa.com

Contact Address ERICSON TPA Healthcare Pvt. Ltd. 4th Floor, New Vijay Cinema Building, S. T. Road, Chembur, Mumbai-400071, Maharashtra. Tel: 022-25280280

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