The UNIVERSAL HEALTH INSURANCE policy is provided to both individuals and groups. An insured person must include all eligible members under a single group policy. The Individual Policy is issued to the earning head of a family along with the details of his or her family members. The Group Policy is issued in the name of the Group or Institution (referred to as insured) with a schedule of names of the members including their eligible family members to form a part of the policy.
HOSPITALISATION EXPENSES
- In the instance of illness or injury, the insured or the family members are eligible for reimbursement for hospitalisation expenses. If the claim becomes admissible under the policy, then the company would pay the hospital / nursing Home or the insured individual, the reimbursement amount for hospitalisation which is limited under different heads mentioned below that lies within the sum insured amount (all claims in aggregate) for the particular insured.
- The hospitalisation benefits are limited to a room and boarding expenses. If the insured is admitted in an ICU facility then he or she is eligible for a sum of up to 0.5% to 1.0% of Sum Insured on a daily basis.
- There is an additional provision of payment to Surgeon, Anesthetist, Medical Practitioner, Consultants, Specialists Fees, and Nursing Expenses for an amount up to 15% of Sum Insured for different medical expenses.
- The coverage has an added provision of up to 15% of Sum Insured per illness or Injury.
- The coverage has a provision for maternity benefit for just one child, where an amount of Rs.2,500 will be delivered in the instance of normal delivery and Rs.5,000 in the instance of cesarean delivery. This amount is inclusive of medical expenses faced with regards to an infant up to 12 weeks. The company’s liability is limited to a sum of Rs. 30 thousand per family or person.
- The total expense incurred for any one ailment is limited to Rs.15000 (not including the Maternity Benefit).
PERSONAL ACCIDENT COVER TO EARNING HEAD
If the insured person suffers a physical injury due to an accident caused by outward, violent, and visible means, that causes the death of the person within six-month period, then the Company shall pay to the Insured the sum as specified below:
- Death of Insured Person (earning head of the family) solely due to accident Rs.25,000.
- DISABILITY COMPENSATION FOR EARNING HEAD AND/ OR SPOUSE in the instance of hospitalisation due to accident or disease would be given within a period of three days. In every policy period, the hospitalisation charges would be given at a rate of Rs50 per day from the fourth day onward for a maximum period of 15 days.
Note: The maximum liability of the Company is limited to Rs.750/- during the entire policy period.
AGE LIMIT
Any person between 5 years to 70 years is eligible for this scheme. Children in the age group of 3 months to 5 years could also be covered if one of both parents is covered concurrently.
NOTICE OF CLAIM:
- An early claim notice containing policy numbers, insured individual’s name, nature of illness, and name and address of the attending medical practitioner must be provided to the TPA immediately and in the instance of emergency hospitalisation within 24 hours from the date of hospitalisation.
- Final claim along with cash memos, claim form, and the necessary list of documents must be provided to the TPA within a 3-day-period from the last treatment date.
Note: A waiver condition could be considered in extreme instances of hardship after the Company feels satisfied in its enquiry that the situation of the insurer made it impossible to submit the notice or file claim within the stipulated time frame.
PAYMENT OF CLAIM
- The payment shall be made in Indian currency only.
- All medical treatments would only have to take place in India.
- The TPA shall make the payment on behalf of the Company either to the medical institute or the Insured Person.
DETAILS OF INSURED PERSON
The insured is required to compile a complete list of insured people in the subsequent manner. Any additions and removals in the course of the policy term must be immediately informed to the Company in the same format. These types of additions and removals would be included in the policy from the first day of the following months on the condition of pro-rata premium adjustment.
| Sr. No. | Names of Injured Persons | Relation with Insured | Age | Gender |
| 1 | ||||
| 2 | ||||
| 3 |
NOTE: There will be no refund of premium for a member whose name has been deleted in the UHIS scheme.
- Hospitalisation Benefit : Rs.30,000/- per family – per policy period (Rs.30,000/- is inclusive of Maternity benefit of Rs. 2500/- for normal and Rs.5000/- for cesarean delivery)
- Total expenses incurred for any one illness is limited to Rs.15,000/- (other than Maternity Benefit)
- Accidental death of earning head of the family Rs.25,000/- Section II: (B) Disability compensation payable due to hospitalisation of earning head and or spouse at the rate of Rs.50/- per day upto maximum of period of 15 days in a policy tear with a time excess of 3 days . Maximum compensation is restricted to Rs.750/- in one policy year.
PAYMENT OF PREMIUM
| COVERAGE | PREMIUM | INSURED’S SHARE | GOI SUBSIDY |
| Individual | Rs. 300 | Rs. 100 | Rs. 200 |
| Family Having 5 Members | Rs. 450 | Rs. 150 | Rs. 300 |
| Family Having 7 Members | Rs. 600 | Rs. 200 | Rs. 400 |
BPL FAMILY
To avail the UHIS policy the applicant must show a BPL certificate as proof of his or her eligibility. The certificate must be issued by an official equal to or greater the rank of a B.D.O. or a Tehsildar of the Revenue Department of the concerned State Government.
