Universal Sompo A Plus Health Insurance (Diamond)

Universal Sompo A Plus Health Insurance (Diamond) is a health insurance product provided by Universal Sompo General Insurance Company Limited. It assists you in safeguarding yourself against surprise medical bills, which tend to be a huge expense at times. It is available with various benefits, features, wellness programs, and add-ons, all of which are designed to cover various expenses effectively. It is created to alleviate financial pressures in case of medical emergencies and provide for your and your family's medical requirements.

The policy is affordable and provides extensive coverage with a number of robust features, like the ability to lower waiting periods for pre-existing conditions, an organ donor premium discount, and so on. It also covers maternity costs, non-medical expenses, and even OPD treatments for diabetes and hypertension from Day 1 at an extra cost. Global coverage is also included under this policy.

One of the cons of the plan is that this plan does not provide for a monthly premium payment. However, according to our research, it received a higher number of complaints related to policy purchase compared to several other insurers.

Now, let’s dive deeper into what the Universal Sompo A Plus Health Insurance (Diamond) Plan has to offer.

What are the benefits offered by the Universal Sompo A Plus Health Insurance (Diamond) Plan?

Here are the key product benefits that define what the Universal Sompo A Plus Health Insurance (Diamond) Plan offers:

• Inpatient hospitalisation coverage: This policy pays for the majority of the cost when you're hospitalized for over 24 hours. It provides coverage for the room rent, nursing care, medicines prescribed by doctors, doctor's consultation charges, ICU, and other expenses incurred during your stay in the hospital. The policy shields you from the expense of these costs.
• Pre-hospitalisation coverage: Prior to hospitalisation, you may have to go through medical examinations, tests, X-rays, CT scans, and others. These are referred to as pre-hospitalisation charges. Under this plan, such expenses are covered for 90 days, up to the sum insured. However, they are only covered if they are directly related to the illness that led to your hospitalisation and if the claim is approved under inpatient treatment.
• Post-hospitalisation coverage: After being discharged, you may still have follow-up visits, medical tests, or check-ups. These are called post-hospitalisation expenses. The plan covers them for 180 days, up to the sum insured. Like with pre-hospitalisation, these costs are covered only if they are linked to the illness you were admitted for and your inpatient claim is approved.
• Daycare treatment coverage: Daycare treatments are medical procedures or surgeries that previously required long hospital stays but can now be completed in less than 24 hours due to advancements in medical technology. The Universal Sompo A Plus Health Insurance (Diamond) plan covers 547 daycare treatments up to the sum insured, so you don’t have to worry about the cost involved.
• Domiciliary treatment coverage: Domiciliary treatment refers to getting medical attention at home for a serious condition or injury when hospitalisation is not feasible. This may be because of the patient's health or lack of bed space in hospitals. In the case of the Universal Sompo A Plus Health Insurance (Diamond) plan, all domiciliary treatment costs are covered up to the sum insured. But the treatment has to be substantiated with a certificate issued by the doctor in charge and should fulfill all necessary conditions. Domiciliary treatment is covered only if it is undertaken for the management of a sickness, not for enteral nutrition or terminal care.
• Organ donor coverage: This plan also includes coverage for organ donor expenses where the insured is the recipient, which means it takes care of the cost of harvesting the donor’s organ, up to the sum insured.
• Modern Treatment coverage: Treatments that are advanced and technologically complex medical procedures are covered without any financial limit as long as they are medically necessary and fall under the scope of inpatient care or listed procedures.
• Non-medical expenses coverage: The Universal Sompo A Plus Health Insurance (Diamond) plan also covers non-medical expenses, with no monetary limit, up to the sum insured. It is a paid add-on feature, available at an extra cost. This includes consumables used during treatment, such as nebulisation kits, gloves, oxygen masks, and other essential medical supplies, which are typically listed as non-payable items under Annexure I.
• No Claim Bonus: If you do not make any claims throughout the policy term, the insurer gives you a No Claim Bonus (NCB). With the Universal Sompo A Plus Health Insurance (Diamond) plan, you can earn up to a 200% bonus. For each year that you drive claim-free, you receive a 50% yearly bonus, which ensures that you build your overall cover over time. If you make a claim during the policy period, the bonus you’ve built up will be reduced in the same proportion as it was earned. 
• Super No Claim Bonus: The Super No Claim Bonus is a more enhanced version of the standard NCB and works similarly. That being said, the Universal Sompo A Plus Health Insurance (Diamond) plan does not have this benefit.
• Restoration benefit: The restoration benefit helps restore your sum insured once it has been used up during a policy year. Under this plan, the benefit allows for one refill in a policy year. It is triggered by subsequent claims that result in partial exhaustion of the sum insured. This applies to both related and unrelated illnesses, ensuring you continue to have coverage even after the original sum insured has been used.

Please note that the limitations and conditions mentioned above apply to a sum insured of Rs. 10 lakhs.

Universal Sompo A Plus Health Insurance (Diamond): Financial Limits

• Room rent limit: The room rent limit is the maximum amount your insurance will cover for your hospital room charges. As long as you stay within this limit, you won’t have to pay anything extra. However, if you choose a room that costs more than your eligible limit, a proportionate deduction will apply. Under the Universal Sompo A Plus Health Insurance (Diamond) plan, there is no room rent limit.
• ICU rent limit: The ICU rent limit refers to the maximum your insurer will pay for your stay in the Intensive Care Unit. With the Universal Sompo A Plus Health Insurance (Diamond) plan, there is no limit on ICU rent. The plan covers ICU charges in full, up to the total sum insured.
• Copayment: You pay a fixed portion of the claim from your pocket, and the insurer covers the balance. In the Universal Sompo A Plus Health Insurance (Diamond) plan, there is no copayment.
• Deductible: A deductible is how much you pay out of pocket before the insurance company starts paying for your medical bills. The Universal Sompo A Plus Health Insurance plan (Diamond) does not have any deductible options.
• Limits on surgeries/treatments: This refers to the maximum coverage for specific medical procedures or treatments. Some health plans impose caps here. Under the Universal Sompo A Plus Health Insurance (Diamond) plan, cataract treatments and joint replacement surgeries are covered up to the full sum insured.

Please note that the above financial limits apply to a 30-year-old individual who has chosen a sum insured of Rs. 10 lakhs.

Universal Sompo A Plus Health Insurance (Diamond): Waiting Periods & Exclusions

👉 Waiting period

The waiting period is the initial span of time after you buy a health insurance policy during which specific illnesses or treatments won’t be covered. You can only make claims for these conditions after the waiting period has elapsed.

Here are the key types of waiting periods:

• Initial waiting period: For all diseases, other than those resulting from accidents, there is a 30-day initial waiting period. You cannot claim hospitalisation for any reason during this period, except if caused by an accident.
• Waiting period for pre-existing illnesses: Pre-existing illness is any sickness or health problem you suffered from during the 36 months prior to purchasing the policy. In the case of the Universal Sompo A Plus Health Insurance (Diamond) plan, a 12-month waiting period, as an add-on, exists for pre-existing illnesses. For this duration, you are not allowed to claim any amount towards expenses on account of these conditions.
• Waiting period for specific diseases: In addition to pre-existing conditions, insurers maintain a list of specific illnesses that come with a waiting period, regardless of your past health history. The length of these waiting periods is set by the insurer. For the Universal Sompo A Plus Health Insurance (Diamond) plan, there is a 24-month or 36-month waiting period for various specific diseases.

👉 Exclusions

Exclusions are particular situations or conditions that an insurance policy does not cover. Described below are some of the common exclusions:

• Standard Permanent Exclusions: According to the directives of the Insurance Regulatory and Development Authority of India (IRDAI), each health insurance provider must adhere to a specified list of standard permanent exclusions. Some examples include:
  • Investigation and evaluation: Hospital stays are done only for observation or monitoring.
  • Rest, rehabilitation, and respite care: Admission to a facility purely for rest or recovery, without any active medical treatment.
  • Obesity/weight control: Surgeries, treatments, or procedures aimed at weight loss.
  • Gender reassignment: Medical procedures intended to change physical characteristics to match a different gender identity.
  • Plastic/Cosmetic surgery: Treatments or surgeries done to change or enhance physical appearance.
  • Profession in adventure sports: Injuries that occur during professional participation in activities like river rafting, mountaineering, scuba diving, etc.
  • Breach of law: Treatment for injuries sustained while attempting to commit a criminal offence.
  • Excluded providers: Care obtained from hospitals or medical practitioners not included in your policy.
  • Narcotics: Rehabilitation for alcohol, drug, or other allied substance addiction.
  • Treatments in establishments arranged for domestic purposes: Health care administered in facilities such as nursing homes, spas, or any such arrangements intended for domestic or non-health purposes.
  • Dietary supplements purchased without prescription: Vitamins, minerals, or other supplements that are not prescribed by a registered medical professional.
  • Refractive error: Expenditures for the correction of refractive errors up to 7.5 diopters for improving vision.
  • Unproven treatments: Any surgery, treatment, or procedure not proven to be effective.
  • Sterilisation, conception, and infertility costs: Expenditures on sterilisation, contraceptives, artificial insemination, or high-tech fertility treatments like IVF, GIFT, ZIFT, ICSI, and gestational surrogacy, among others.
  • Maternity costs: Fees charged for maternity care, both prenatal and postnatal, childbirth, etc.
• Additional Permanent Exclusions: In addition to the standard list, insurers can also opt for other permanent exclusions for specific diseases or conditions they find too risky to insure. The exclusions should be from the approved list provided by IRDAI. Insurers cannot exclude any illness or condition from coverage unless it is on this approved list.

What can you expect in terms of Claims Experience if you buy from Universal Sompo General Insurance Company Limited?

• Speed of claims: Universal Sompo General Insurance Company Limited's claim settlement ratio stands at 77.18% within 30 days, which reflects a speedy and trouble-free claims experience for insureds.
• Claim-related complaints: Nevertheless, according to our research, the company's claim complaint ratio is 0.04% higher than other insurers. This reflects that there can be lacunas in the claim settlement experience.
• Claims repudiation ratio: Claims repudiation ratio is defined as the portion of claims that an insurer denies or repudiates out of the total number of received claims. It is 0.74% for Universal Sompo General Insurance Company Limited.
• Claim settlement ratio: The claim settlement ratio indicates the percentage of claims paid by the insurer for a financial year out of the total number of claims received. Universal Sompo General Insurance Company Limited reported a claim settlement ratio of 93.27%.

How is the Customer Service of Universal Sompo General Insurance Company Limited?

• Policy purchase complaints: Our research shows that Universal Sompo General Insurance Company Limited has a complaint ratio of 0.01% for its after-sales service, which is significantly higher than that of other insurance companies.
• Response on Toll-Free: According to our research, the response time on the toll-free number for Universal Sompo General Insurance Company Limited is quicker compared to other insurers.
• Twitter response time: Based on our studies, the Twitter response time for Universal Sompo General Insurance Company Limited is slower when compared to other insurance providers.

About Universal Sompo General Insurance Company Limited

Universal Sompo General is a joint venture between banks such as Indian Bank, Indian Overseas Bank, Karnataka Bank Ltd., as well as Dabur Investment Corporation and Sompo Japan Insurance Inc., from Japan, a leading general insurer. The company deals in a wide range of products and targets different customer segments, such as Retail and Rural, SME, and Corporate.

It was established in the year 2007, and the headquarters are in Mumbai. The Managing Director and CEO of the company is Mr. Sharad Mathur.