The document provides a comprehensive overview of health insurance in India, highlighting its purpose to protect individuals and families against financial burdens from medical emergencies. It explains different types of health insurance policies, such as medical insurance and critical illness insurance, along with their benefits, coverage options, and exclusions. Additionally, it outlines the claims process and required documentation for reimbursement or cashless claims.

1. Health Insurance Over View
Individual Health Insurance Overview
USGI Health Insurance

2. 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.

3. 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

4. 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.

5. 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.

6. 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

7. 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.

9. 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

10. 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

11. Coverage and Addons
Sr.No Coverage INDIVIDUAL HEALTH
1 SI/Person/Policy/Year(in lakhs) 1 LAC TO 5 LACS, multiples of 50000
2 Pre-hospitalization 30 days
3 Post-hospitalisation 60 days
4 Day Care Procedures Covered both on Cashless and Reimbursement basis
5 Domiciliary Treatment Up to 20% of Basic Sum Insured
6 Pre Existing Cover After (yrs) Covered after 3 Claim free Policy Years with Us
7 Pre Hospitalisation For upto 30 days prior to Hospitalization
8 Post Hospitalisation For upto 60 days post hospitalization
9 Daily Cash Allowance
0.1% 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 INDIA
12 Medical Practitioner/ Consultant fees Upto 25% of Basic Sum Insured
13 Policy Taken With out Medical Examine (Yrs) Upto 45 years
14 PRE POLICY MEDICAL TEST EXPENCES BORNE BY INSURED
15 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)

12. 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

13. 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.

14. 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.

15. 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

16. 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.

17. 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

18. Contact us
 USGI
Product Related
080-41538832
Email ID – insure@kanoeindia.com
 Third Party Administrator(TPA) –Ericson TPA
Toll free no 1800 22 2034
Email 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