Oriental Super Health Top Up Insurance

Oriental Super Health Top Up plan insurance benefits

• Features Happy Family Floater Insurance

  I	Insured Expenses	Limits of Insured Expenses
  A.	Hospitalisation Expenses
  a.	Room, Boarding and Nursing Expenses as provided by the Hospital /Nursing Home.	1 % of the Deductible Amount (mentioned in the Policy Schedule) per day *
  b.	Intensive Care Unit (ICU) expenses as provided by the Hospital /Nursing Home.	2 % of the Deductible Amount (mentioned in the Policy Schedule) per day *
  	Number of days of stay under ‘i’ and ‘ii’ above should not exceed total number of days of stay in the Hospital. Expenses as specified in iii and iv below shall also be payable as per the entitled room rent limit as mentioned above. However, medicines / pharmaceuticals and body implants would be payable on actual basis. Any expense in excess of reasonable and customary charges as defined under 3.40, or in excess of negotiated prices (in case of network hospitals) shall be borne by the insured.
  c.	Surgeon, Anesthetist, Medical Practitioner,Consultants,Specialists Fees	Within the limits of Sum Insured, subject to 'a'& 'b' above
  d.	Expenses in respect of Anesthesia, Blood, Oxygen, Operation Theatre Charges, Surgical Appliances, Medicines & Drugs, Diagnostic Material and X-Ray, Dialysis, Chemotherapy, Radiotherapy, Cost of Pacemaker, Artificial limbs and similar expenses.	Within the limits of Sum Insured, subject to 'a' & 'b'above
  e.	Organ Donor Benefit when Insured Person is Donor.	Lumpsum payment of 10% of the Sum Insured.
  f.	Donor Expenses when Insured Person is Recipient	within the limits of Sum Insured
  B.	Relaxation to 24 hours minimum duration of hospitalisation is allowed in specific cases as detailed alongside.	Specified Day Care procedures / Surgeries (as per appendix-I) where such treatment is taken by an Insured Person in a Hospital / Day Care Centre (but not the Out-Patient department of a hospital) (Or) Any other Day Care Treatment as mentioned in clause 3.11 and for which prior approval from Company / TPA is obtained in writing.
  C.	In case of Ayurvedic, Yoga and Naturopathy, Unani, Siddha and Homeopathic treatment, Hospitalisation expenses are admissible only when the treatment is taken as an in-patient.	Maximum liability of the Company under the policy is the Sum Insured stated in the schedule.
  D.	Other Coverages
  a.	Maternity Expenses** :	The Company shall pay the Medical Expenses incurred as an inpatient for a delivery (including caesarean section) or lawful medical termination of pregnancy during the policy period limited to two deliveries or terminations or either, during the lifetime of the Insured Person. Coverage upto 10% of the Sum Insured.
  b.	New Born Baby Cover ** : This benefit is available only if both the insured and his/her spouse are covered under the family floater plan / Individual plan of the Policy, as the case may be. The policy provides automatic cover to the new born baby upto 90days from the date of birth. Cover beyond 90 days is available for full Sum Insured only on payment of requisite additional premium.	Coverage upto 5% of the Sum Insured.
  c.	Coverage Extension to SAARC Countries	The policy automatically covers Insured Persons visiting other SAARC (South Asian Association for Regional Co-operation) countries viz- Afghanistan, Bangladesh, Bhutan, Maldives, Nepal, Pakistan, Sri Lanka. However Cashless service will not be available for treatment taken in countries outside India and such claims shall be considered only on re-imbursement basis on the return of the insured person to India. All other conditions in respect of claim shall apply as such.
  E.	Eligibility Terms
  a.	Sum Insured Options / Deductibles – the following are the options under the Individual and Family Floater Plan available for the Super Top Up Health Plan	Sum Insured	Deductible
  		3,00,000	300,000
  		5,00,000	300,000
  		5,00,000	500,000
  		7,00,000	500,000
  		6,00,000	600,000
  		8,00,000	600,000
  		8,00,000	800,000
  		10,00,000	800,000
  		10,00,000	10,00,000
  		15,00,000	10,00,000
  		10,00,000	15,00,000
  		15,00,000	15,00,000
  		10,00,000	,00,000
  		12,00,000	18,00,000
  		10,00,000	20,00,000
  		20,00,000	20,00,000
  		30,00,000	20,00,000
  b.	Family Discount	10% is available if more than one is person is covered under the policy with individual Sums Insured per person (i.e in respect of an Individual plan).
  c.	Loyalty Discount	10% in premium is available for the persons who at the inception of this policy are also covered under a base health insurance policy from Oriental (retail or bancassurance only). To be eligible for this discount at renewals, such base health policy from Oriental has to be in force at the time of such renewal also. Even in case of Family Floater Plan, Loyalty discount would only be in respect of the person(s) who already has such a policy from Oriental and not on the whole policy premium.
  d.	Maximum Entry Age	Maximum entry age under the policy is 65years. However, persons above the age of 65 years and upto the age of 70 years can also take this policy, subject to a premium loading of 10%. So, in all such cases, a 10% loading will be charged on the premium applicable to the age of such proposed insured. This 10% loading will also apply on every subsequent renewal of the policy. No such loadings on renewal shall however, apply in respect of insured persons who had entered the policy at the age of 65years or earlier.
  e.	Deletion Of Room Rent Limit	Room Rent limits are linked to the Deductible under the policy. However, on payment of an additional premium these limits can be removed. Additional premium shall be as per the loadings below: Deductible (INR) Additional Premium to be charged Upto 5,00,000 20% of applicable premium 6,00,000- 10,00,000 10% of applicable premium 15,00,000 and above 5% of applicable premium
  f.	Pre-Insurance Medical Check-Up ***	In following cases, pre-insurance Medical Check-up is required: Age Pre-insurance Medical Tests Persons with adverse Medical History Required irrespective of age Persons above 55years Required in all cases
  g.	Free Look Period	A period of 15 days from the date of receipt of the policy to review the terms and conditions of the policy and return the same, if not acceptable.
  h.	Grace Period	30 days is allowed for payment of renewal premium

  *Deletion of Room Rent Limit: These limits are not applicable if the insured has paid the requisite additional premium for removal of Room Rent limits. In such a case, room rents and expenses in respect of iii & iv above, become payable on actuals basis, subject to other terms & conditions of the policy.

  ** Special conditions applicable to Maternity Expenses and New Born Baby Cover
  • These benefits are admissible only if the expenses are incurred in a Hospital as an in-patient.
  • Expenses incurred in connection with voluntary medical termination of pregnancy during the first twelve weeks from the date of conception are not covered.
  • Pre-natal and post-natal expenses are not covered unless admitted in Hospital and treatment is taken there. Prenatal is the medical care given to a pregnant woman and for the purpose of this policy it starts from the date of conception upto the childbirth. Post natal is the medical care given to a woman after her baby is born and coverage is for a period of six weeks from the date of childbirth.
  • Pre Hospitalisation and Post Hospitalisation benefits are not available under these two clauses.
  • Subject to the terms & conditions, the policy covers New Born Baby beyond 90 days only on payment of requisite premium.

  *** Following tests are required. The list of Diagnostic centres is available and can be made available:

  • General Physical Examination
  • CBC With ESR
  • Lipid Profile
  • HbA1C
  • S.Creatinine
  • Urine-Routine & Molecular
  • ECG
  • TSH
  • X-Ray Chest
  • & Glaucoma

  In case of adverse medical history, the Company may ask for additional tests depending on the medical condition. Medical reports upto 30 days prior to the date of proposal, are only valid.

• General exclusions for all Oriental insurance plans

  Some of the general exclusions under this policy where Oriental Insurance Company shall not be liable to make any payment in respect of any expense whatsoever incurred by any Insured Person are:

  • All Pre-existing Disease (whether treated / untreated, declared or not declared in the proposal form), which are excluded upto 48 months of the policy being in force. Pre-existing diseases shall be covered only after the policy has been continuously in force for 48 months.
  • Illnesses Contracted by the Insured person during the first 30 days from the inception date of fresh policy. This shall, however, not apply in case the insured person is hospitalised for injuries suffered in an accident, which occurred after inception of the policy.
  • The expenses on treatment of following ailments / diseases / surgeries, if contracted and / or manifested after inception of first policy ( subject to continuity being maintained), are not payable during the respective waiting periods – kindly refer detailed policy wordings /terms and conditions.
  • Circumcision (unless necessary for treatment of a disease not excluded hereunder or as may be necessitated due to any accident), vaccination, inoculation or change of life or cosmetic or of aesthetic treatment of any description, plastic surgery other than as may be necessitated due to an accident or as a part of any illness.
  • Surgery for correction of eye sight, cost of spectacles, contact lenses, hearing aids etc.
  • Any dental treatment or surgery which is corrective, cosmetic or of aesthetic procedure, filling of cavity, crowns, root canal treatment including treatment for wear and tear etc unless arising from disease or injury and which requires hospitalisation for treatment.
  • Convalescence, general debility, “run down” condition or rest cure, congenital external diseases or defects or anomalies, sterility, any fertility, sub-fertility or assisted conception procedure, venereal diseases, intentional self-injury/suicide, all psychiatric and psychosomatic disorders and diseases / accident due to and or use, misuse or abuse of drugs / alcohol or use of intoxicating substances or such abuse or addiction etc.
  • All expenses arising out of any condition directly or indirectly caused by, or associated with Human T-cell Lymphotropic Virus Type III (HTLD - III) or Lymphadenopathy Associated Virus (LAV) or the Mutants Derivative or Variations Deficiency Syndrome or any Syndrome or condition of similar kind commonly referred to as AIDS, HIV and its complications including sexually transmitted diseases.
  • Expenses incurred at Hospital or Nursing Home primarily for evaluation / diagnostic purposes which is not followed by active treatment for the ailment during the hospitalised period.
  • Any treatment arising from or traceable to pregnancy, childbirth, miscarriage, caesarean section, abortion or complications of any of these including changes in chronic condition as a result of pregnancy except in the case of abdominal operation for extra uterine pregnancy (ectopic pregnancy) which is proved by diagnostic means and certified to be life threatening by the attending Medical Practitioner, if left untreated.
  • Naturopathy treatment, unproven procedure or treatment, experimental or alternative medicine (other than Ayurveda, Unani & Homeopathy as expressed in clause 2.4 A) and related treatment including acupressure, acupuncture, magnetic and such other therapies.
  • Genetic disorders and stem cell implantation / surgery.
  • Cost of external and or durable Medical / Non medical equipment of any kind used for diagnosis and or treatment including CPAP, CAPD, Infusion pump etc., Ambulatory devices i.e. walker , Crutches, Belts ,Collars ,Caps , splints, slings, braces ,Stockings etc of any kind, Diabetic foot wear, Glucometer / Thermometer, Blood Pressure monitoring machine and similar related items and also any medical equipment which is subsequently used at home. Exhaustive list available on our website (www. orientalinsurance.org.in).
  • Treatment of obesity or condition arising therefrom (including morbid obesity) and any other weight control programme, and similar services or supplies.
  • Out patient Diagnostic, Medical or Surgical procedures or treatments, non-prescribed drugs and medical supplies, Hormone replacement therapy, Sex change or treatment which results from or is in any way related to sex change.