Universal Sompo Health Insurance Claims Procedure

Universal Sompo General Insurance (USGI) is one of the first Private Partnership in the Indian General Insurance Industry, This joint venture is being capitalized with shareholders’ funds of over Rs. 230 crore including the share premium. Sompo Japan Insurance Inc. is headquartered in Tokyo, and is a Fortune 500 Company with the capital of around 70 billion yen. Universal Sompo General Insurance offers Health & Critical Illness, Personal Accident & Disability, Home, Motor and Property insurance. The Company received the Licence and Certificate of Registration from IRDA as recently as November, 2007.

The company has a whopping and impressive set of 12 health insurance policies, of course catering to various requirements of individuals in the Indian household and beyond. USGI has an impressive product portfolio catering to individuals, SMEs and large corporates. Their numerous health insurance policies are customised to suit the requirements of both individuals and their families. These basic plans can be topped-up to make coverage more comprehensive with add-on covers.

Incurred Claim Ratio for Universal Sompo Health Insurance:

The Incurred Claim Ratio (ICR) of a particular is highly indicative of the company's performance, allowing prospective customers get a better understanding about what to expect in terms of health insurance. The Incurred Claim Ratio for USGI Health Insurance products for the time 2016-17 and 2017-18 has been mentioned in the table:

Incurred Claims Ratio of Universal Sompo Health Insurance for the Year 2016-17:

Net Earned Premium (in Crore) Net Claims Paid (in Crore) Incurred Claims Ratio (in %)
98.07 crore 84.47 crore 86.14%

Incurred Claims Ratio of Universal Sompo Health Insurance for the Year 2017-18:

Net Earned Premium (in Crore) Net Claims Paid (in Crore) Incurred Claims Ratio (in %)
133.06 crore 138.60 crore 104.17%

The number surely do not give any room for profits, however one needs to keep it in mind that this is a new contender in the game of health insurance in India. In fact the numbers indicate that they may be soon picking up profit soon. This also means that they have very positive number when it comes to claim settlements.

How to Claim?

There are two situations that may occur when claiming health insurance. The cashless treatment is one that allows the policyholder to use the insurance as money to seek their treatment without having to pay any money upfront for treatment. The other scenario that is possible is in the case that the treatment has been already done and paid for but claim settlement requires to be made to allow the individual to be returned the money spent for treatment.

To Claim for Cashless Treatment:

Cashless treatment is basically treatment for a disease or illness, which is covered by the insurer including medical expenses for the treatment but on an individual basis, regardless whether the patient is a part of a group health insurance or a family insurance plan. The patient requiring the treatment claim for a cashless facility at any of the network hospitals enlisted by USGI on their website, or policy brochure, across the country.

  • Procedure to File a Claim (Planned/Emergency Hospitalisation):

    Here is all that you have to file a cashless claim.

    1. You first need to contact the network hospital and ensure that you have the health card issued by USGI and seek admission.
    2. Intimating, which is an important part of the filing process for the cashless facility can be done easily by contacting the number mentioned on the card or the health insurance helpline number mentioned on the company website.
    3. For planned hospitalization circumstances you need to reach out to the company 2 days prior to admission.
    4. You need to then provide the hospital with the health card as well as an ID proof with photo who will then start the verification of your credentials.
    5. Once this process is over, a pre-authorization form needs to filled with appropriate details by the hospital. This form will require the signature from the attending doctor. In cases of planned hospitalisation, an authorisation letter is required to be submitted.
    6. The pre-authorization form, once is filled, signed and overall completed needs to be sent to the the insurance provider with relevant information by the hospital.
    7. The insurance providing company will then contact the relevant bank to update the status of the claim made, which will be either accepted or rejected or possibly a request for additional information or documentation.
    8. On acceptance, the medical bills covered under the policy is settled by USGI, while things that are not covered will have to be taken care of, by the patient/card holder.
    9. The policy holder needs to then take a thorough look verify and sign the original bills and at the same time keep a photocopy of the entire hospitalisation record.
  • Claims Process:

    Here is how the claim process for USGI health insurance works:

    1. It is required to register the claim within 7 days of the patient’s or the covered individual’s discharge, and immediately let New India Assurance know about it.
    2. You need to fill and submit the Claims Form, providing a photocopy of a valid ID proof along with it.
    3. Then you must send the required medical certificates along with diagnosis reports which has been signed by a doctor.
    4. All the reports as well as the discharge summary i.e. original copy has to be submitted for verification.

USGI will then approve or reject it based on the policy in place.

For Reimbursement of Treatment Expenses:

The insured individual can claim a reimbursement for the expenses incurred for the treatment with a few simple steps, after receiving the treatment and paying for the treatment.

  • Procedure to File a Claim:

    Here is what you need to do to file a claim for reimbursement of medical bills through your mediclaim:

    • USGI has to be informed immediately once the person covered under the mediclaim is being hospitalised.
    • After the treatment is completed, all hospital bills have to be settled by the policyholder, along with keeping all the bills and reports.
    • Submit the duly filled claims form to USGI for processing and reimbursement. The insurer will reimburse all bills if as long as all the information provided is given correctly.
  • Documents Required:

    The following documents need to be submitted to USGI:

    • Bills: All the original hospital bills, with stamps and signatures from the hospital has to be submitted.
    • Claim form: The claim form which needs to be filled with relevant details, signatures and finally be submitted.
    • Discharge Report: The original discharge report has to be submitted as well.
    • All other originals reports related to the treatment (including medicine bills and investigation reports) has to be submitted.
    • The future line of treatment as well as follow-up check-ups by the relevant doctor should be sent as well.
    • If seeking treatment in a non-network or unregistered hospital, you need to get the details of the hospital on the official letterhead, which includes the number of doctors, nurses and beds available.

    Note: You may be asked for further documentation for the claim approval.

  • Claims Process:

    • The policyholder must let the insurer know about hospitalisation within 7 days of his/her discharge.
    • Pre-authorization might be required from the company for certain situations.
    • All documents must be submitted within 10 days of the patient’s discharge.

    The claim will be approved or rejected based on the policy as well as documentation provided.

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