Post on 14-Apr-2018
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TheOrientalInsuranceCompanyLimited
1
THEORIENTALINSURANCECOMPANYLIMITED,
Regd.Office:OrientalHouse,P.B.No.7037, A25/27,AsafAliRoad,NewDelhi 110002
MEDICLAIMINSURANCEPOLICY(INDIVIDUALS)
1 WHEREAStheinsurednamedintheScheduleheretohasbyaproposalanddeclarationdatedstatedintheSchedule(whichshallbethebasisofthisContractandisdeemedtobeincorporatedherein)hasappliedto
THE ORIENTAL INSURANCE COMPANY LIMITED (hereinafter called the Company) for the insurance
hereinaftersetforthinrespectofpersons(s)namedintheSchedulehereto(hereinaftercalledtheINSURED
PERSON(S))andhaspaidpremiumtotheCompanyasconsiderationforsuch insurancetobeservicedby
ThirdPartyAdministrator(hereinaftercalledtheTPA)ortheCompanyasthecasemaybe.
1.1 NOWTHISPOLICYWITNESSESthatsubjecttotheterms,conditions,exclusions and definitionscontainedherein or endorsed or otherwise expressed hereon, the Company undertakes that, if during the period
stated intheSchedule any insuredPersonshallcontractanydiseaseorsufferfromany illness/ailment/
disease (hereinafter called DISEASE) or sustain any bodily injury through accident (hereinafter called
INJURY)and ifsuchdiseaseor injuryshallrequireupontheadviceofadulyqualifiedPhysician/Medical
Specialist/MedicalPractitioner
(hereinafter
called
MEDICAL
PRACTITIONER)
or
of
aduly
qualified
Surgeon
(hereinafter called SURGEON) to incur (a)hospitalisation expenses for medical/surgicaltreatmentat any
NursingHome/Hospital inIndiaashereindefined(hereinaftercalledHOSPITAL)asan inpatientOR(b)on
domiciliarytreatmentinIndiaunderDomiciliaryHospitalisationBenefitsashereinafterdefined,theTPAwill
paytotheHospitals(onlyiftreatment istakenatNetworkHospital(s)withpriorconsentofTPA)ortothe
insuredperson ifpolicy isservicedbytheTPA.OtherwisetheCompanywillpaytotheInsuredPersonthe
amountofsuchexpenses.Itisapreconditionthattheseexpensesarereasonablyandnecessarilyincurredin
respectthereofbyoronbehalfofsuch insuredpersonbutnotexceedingthesum insured inaggregate in
anyoneperiodofinsurancestatedintheschedulehereto.
1.2 ThepolicyreimbursesthepaymentofHospitalisationand/orDomiciliaryHospitalisationexpensesonlyforillness/diseasescontractedorinjurysustainedbytheInsuredPersons.Intheeventofanyclaimbecoming
admissibleunder
this
policy,
the
TPA
will
pay
to
the
hospital
(only
iftreatment
is
taken
at
network
Hospitals
/ Nursing Homes with prior consent of TPA) or to the insured, if policy is serviced by the TPA or the
Company will reimburse to the Insured person, if the policy is not serviced by the TPA, the amount of
expenses reasonably and necessarily incurred under different heads mentioned below by or on behalf of
suchInsuredPersonnotexceedingtheSum Insured inaggregate inrespectof InsuredPersonasstated in
thescheduleforallclaimsadmittedduringtheperiodofinsurancementionedintheschedule.
FOLLOWINGREASONABLE&CUSTOMARYEXPENSESAREREIMBURSABLEUNDERTHEPOLICY
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a. Room,BoardingandNursingExpensesasprovidedbytheHospital/NursingHomenotexceeding1%oftheSumInsuredorRs.5000/ perdaywhicheverisless.
b. I.C.Unitexpensesnotexceeding2%oftheSumInsuredorRs.10,000/ perdaywhicheverisless.(RoomincludingI.C.U.stayshouldnotexceedtotalnumberofadmissiondays).
c. Surgeon,Anaesthetist,MedicalPractitioner,Consultants,SpecialistsFees.d.
Anaesthesia,
Blood,
Oxygen,
Operation
Theatre
Charges,
Surgical
Appliances,
Medicines
&
Drugs,
Dialysis,
Chemotherapy, Radiotherapy, Artificial Limbs, Cost of Prosthetic devices implanted during surgical
procedurelikepacemaker,RelevantLaboratory/Diagnostictest,XRayetc..
e. Ambulanceservices 1%ofthesum insuredorRs2000/ whichever is lessshallbe reimbursable incasepatienthastobeshiftedfromresidencetohospitalincaseofadmissioninEmergencyWard/I.C.U. orfrom
oneHospital/NursinghometoanotherHospital/NursingHomebyregisteredambulanceonlyforbetter
medicalfacilities.
Note:
1.CompanysLiabilityinrespectofallclaimsadmittedduringthePeriodofinsuranceshallnotexceedtheSum
InsuredperPersonmentionedintheSchedule.
2.Hospitalizationexpensesincurredfordonatinganorganbythedonor(excludingcostof organifany)tothe
insuredpersonduringthecourseoforgantransplantwillalsobepayable.Howeverinanycasetheliabilityof
theCompanywillbelimitedtooverallSumInsuredoftheInsuredPerson.
2 DEFINITIONS:2.1 HOSPITAL/NURSINGHOME:meansany institutioninIndiaestablishedfor indoorcareandtreatment
ofsicknessandinjuriesandwhicheither
a) Isduly licensed andregisteredas a Hospital or Nursing Home with the appropriate authorities and isunderthesupervisionofaregisteredandqualifiedMedicalPractitioner.
OR
b) In areas where licensing and registration facilities with appropriate authorities are not available, theinstitution must be one recognised in locality as Hospital / Nursing Home and should comply with
minimumcriteria
as
under
i. Itshouldhaveatleast15inpatientmedicalbedsincaseofMetrocities,AClasscities&Bclasscitiesor10in patientmedicalbedsincaseofCclasscities.ClassificationofcitiesshallbeasperGovtofIndia
Notificationsissuedinthisrespectfromtimetotime.
ii. Fullyequippedand engaged in providingMedical andSurgical facilitiesalongwithDiagnostic facilitiesi.e.PathologicaltestandXray,E.C.G.etc forthecareandtreatmentof injuredorsickpersonsas in
patient.
iii. Fullyequippedoperationtheatreofitsown,whereversurgicaloperationsarecarriedout.iv. Fullyqualifiednursingstaffunderitsemploymentroundtheclock.v. FullyqualifiedDoctor(s)shouldbephysicallyinchargeroundtheclock.ThetermHospital/NursingHomeshallnotincludeanestablishmentwhichisaplaceofrest,aplaceforthe
aged,aplace
for
drug
addicts
or
aplace
for
alcoholics,
ahotel
or
asimilar
place.
Note:IncaseofAyurvedic/Homeopathic/Unanitreatment,Hospitalisationexpensesareadmissibleonlywhen
thetreatmentistakenasinpatient,inaGovernmentHospital/MedicalCollegeHospital.
2.2SurgicalOperationmeansmanualand/oroperativeproceduresforcorrectionofdeformities/defectsandinjuries,cureofdiseases,reliefofsufferingandprolongationoflife.
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2.3HOSPITALISATIONPERIOD: ExpensesonHospitalisationareadmissibleonlyifhospitalisationisforaminimumperiodof24hours. However,
(A) This time limit will not apply to following specific treatments taken in the Networked Hospital /
NursingHomewheretheInsuredisdischargedonthesameday.Suchtreatmentwillbeconsideredto
betakenunderHospitalisationBenefit.
i. HaemoDialysis,ii.
Parentral
Chemotherapy,
iii. Radiotherapy,iv. EyeSurgery,v. Lithotripsy(kidneystoneremoval),
vi. Tonsillectomy,vii. D&Cviii. Dentalsurgeryfollowinganaccident
ix. Hysterectomyx. CoronaryAngioplasty
xi. CoronaryAngiographyxii. Surgeryof Gallbladder,Pancreasandbileduct
xiii. SurgeryofHerniaxiv. SurgeryofHydrocele.xv. SurgeryofProstrate.
xvi. GastrointestinalSurgery.xvii. GenitalSurgery.
xviii. SurgeryofNose.xix. Surgeryofthroat.xx. SurgeryofAppendix.
xxi. SurgeryofUrinarySystem.xxii. Treatmentoffractures/dislocationexcludinghair linefracture,Contracturereleasesandminor
reconstructiveproceduresoflimbswhichotherwiserequirehospitalisation.
xxiii. ArthroscopicKneesurgery.xxiv. Laproscopictherapeuticsurgeries.xxv. AnysurgeryunderGeneralAnaesthesia.
xxvi. Oranysuchdisease/procedureagreedbyTPA/Companybeforetreatment.(B) Further if the treatment / procedure / surgeries of above diseases are carried out, in Networked
specialised Day Care Centre which is fully equipped with advanced technology and specialised
infrastructurewheretheinsuredisdischargedonthesameday,therequirementofminimumbedswill
beoverlookedprovidedfollowingconditionsaremet.
i. The operation theatre is fully equipped for the surgical operation required in respect of sickness /ailment/injurycoveredunderthepolicy.
ii. DayCarenursingstaffisfullyqualified.iii. The doctor performing the surgery or procedure as well as post operative attending doctors are also
fullyqualifiedforthespecificsurgery/procedure.
(C)Thisconditionofminimum24hoursHospitalisationwillalsonotapplyprovided
I)The treatment is such that it necessitates hospitalisation and the procedure involves specialisedinfrastructuralfacilitiesavailableonlyinhospitals,
BUT
II) Duetotechnologicaladvanceshospitalisationisrequiredforlessthan24hours.AND/OR
iii) SurgicalprocedureinvolvedhastobedoneunderGeneralAnaesthesia.
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ABOVEAREADMISSIBLESUBJECTTOTERMS&CONDITIONSOFTHEPOLICY.
NOTE:PROCEDURES/TREATMENTSUSUALLYDONEINOUTPATIENTDEPARTMENTARENOTPAYABLEUNDER
THEPOLICYEVENIFCONVERTEDTODAYCARESURGERY/PROCEDUREORASINPATIENTINTHEHOSPITAL
FORMORETHAN24HOURS.
2.4
DOMICILIARY
HOSPITALISATION
BENEFIT:
means
Medical
treatment
for
a
period
exceeding
three
days
for
suchillness/disease/injurywhichinthenormalcoursewouldrequirecareandtreatmentatahospital/nursing
homeasinpatientbutactuallytakenwhilstconfinedathomeinIndiaunderanyofthefollowingcircumstances
namely:
i. Theconditionofthepatientissuchthathe/shecannotberemovedtotheHospital/NursingHomeOR
ii. ThepatientcannotberemovedtoHospital/Nursinghomeduetolackofaccommodation inanyhospitalinthatcity/town/village.
SubjecthowevertotheconditionthatDomiciliaryHospitalisationbenefitshallnotcover
a) Expensesincurredforpreandposthospitaltreatmentandb) Expensesincurredfortreatmentforanyofthefollowingdiseases:
i. Asthmaii. Bronchitis,iii. ChronicNephritisandNephriticSyndrome,iv. Diarrhoeaandalltypesof Dysenteriesincluding Gastroenteritis,v. DiabetesMellitusandInsipidus,vi. Epilepsy,vii. Hypertension,viii.Influenza,CoughandCold,ix. AllPsychiatricorPsychosomatic Disorders,x. Pyrexiaofunknownoriginforlessthan10days,xi. TonsillitisandUpperRespiratoryTractinfectionincluding LaryngitisandPharingitis,xii. Arthritis,GoutandRheumatism.
Note:Liability
of
the
Company
under
this
clause
is
restricted
as
stated
in
the
schedule
attached
hereto.
3 OTHERDEFINITIONSANDINTERPRETATIONS:3.1 INSUREDPERSON: MeansPerson(s)namedonthescheduleofthepolicy.3.2 ENTIRE CONTRACT: This policy / proposal and declaration given by the insured constitute the
completecontractofthispolicy.Only Insurermayalterthe termsandconditionsofthispolicy.Any
alteration that may be made by the insurer shall only be evidenced by a duly signed and sealed
endorsementonthepolicy.
3.3 THIRDPARTYADMINISTRATOR (TPA): meansanyCompanywhohasobtained licencefrom IRDAtopractice
as
athird
party
administrator
and
is
appointed
by
the
Company.
3.4 NETWORK HOSPITAL: means hospital that has agreed with the TPA to participate for providingcashlesshealthservicestothe insuredpersons. The list ismaintainedbyandavailablewiththeTPA
andthesameissubjecttoamendmentfromtimetotime.
3.5 HOSPITALISATION PERIOD: The period for which an insured person is admitted in the hospital asinpatientandstaysthereforthesolepurposeofreceivingthenecessaryandreasonabletreatmentfor
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thedisease/ailmentcontracted/injuriessustainedduringtheperiodofpolicy.The minimumperiod
ofstayshallbe24hours
3.6 PREHOSPITALISATION:Relevantmedicalexpenses incurredduringthe periodupto30dayspriortohospitalisation on disease/ illness/ injury sustained will be considered as part of claim mentioned
underitem1.2above.
3.7 POSTHOSPITALISATION: Relevant medical expenses incurred for the period of 60 days afterhospitalisationondisease/illness/injurysustainedwillbeconsideredaspartofclaimmentionedunder
item1.2above.
3.8 MEDICALPRACTITIONER:meansapersonwhoholdsadegree/diplomaofarecognisedinstitutionandisregisteredbyMedical Councilof any Stateof India. The term MedicalPractitioner would include
Physician,SpecialistandSurgeon.
3.9 QUALIFIEDNURSE:meansapersonwhoholdsacertificateofarecognisedNursingCouncil.3.10PREEXISTINGHEALTHCONDITIONORDISEASE:meansanyailment/disease/injuriesthattheperson
issufferingfrom,(treated/untreated,declaredornotdeclared intheproposalform)whiletakinga
policyforthefirsttime.
Furtheranycomplicationsarisingfrompreexistingailment/disease/injurieswillbeconsideredasa
partofthatpreexistinghealthcondition.
3.11INPATIENT:AnInsuredpersonwhoisadmittedtohospitalandstaysforatleast 24hoursforthesolepurposeofreceivingthetreatmentforsufferedailment/illness/disease/injury/accidentduringthe
currencyofthepolicy.
3.12REASONABLE&CUSTOMARYEXPENSES:meansreasonableandcustomarysurgicalmedicaltreatmentexpenseswithinthescopetotreattheconditionforwhichtheinsuredpersonwashospitalized.
3.13CASHLESSFACILITY: meanstheTPAmayauthoriseupontheInsuredsrequestfordirectsettlementofadmissibleclaimasperagreedchargesbetweenNetworkHospitals&theTPA. InsuchcasestheTPA
will directly settleall eligible amounts withthe Network Hospitals andthe Insured Person may not
have to pay any bills after the end of the treatment at Hospital to the extent the claim is covered
underthepolicy.
3.14I .D.CARD: means thecard issued tothe Insured Person by the TPA toavail Cashless facility intheNetworkHospital.
3.15DAYCAREPROCEDURE:meansthecourseofMedicaltreatment/surgicalprocedurelistedat 2.3(A)carried out, in Networked specialised Day Care Centre which is fully equipped with advanced
technology and specialised infrastructure where the insured is discharged on the same day, the
requirementof
minimum
beds
will
be
over
looked
provided
other
conditions
are
met.
3.16LIMITOF INDEMNITY: means theamountstated in the schedule against thenameof each insuredperson which represents maximum liability for any and all claims made during the policy period in
respect of that insured person in respect of that insured person in respect of hospitalization taking
placeduringcurrencyofthepolicy.
3.17ANYONEILLNESS:Anyoneillnesswillbedeemedtomeancontinuousperiodofillnessanditincludesrelapsewithin105daysfromthedateofdischargefromtheHospital/nursinghomefromwherethe
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treatmentwastaken.Occurrenceofthesameillnessafteralapseof105daysasstatedabovewillbe
consideredasfreshillnessforthepurposeofthispolicy.
3.18PERIODOFPOLICY:Thisinsurancepolicyisissuedforaperiodofoneyearasshowninthe schedule.4 EXCLUSIONS:
The
Company
shall
not
be
liable
to
make
any
payment
under
this
policy
in
respect
of
any
expenses
whatsoeverincurredbyanyInsuredPersoninconnectionwithorinrespectof:
4.1 Preexisting health condition or disease or ailment / injuries: Any ailment / disease / injuries / healthconditionwhicharepreexisting(treated/untreated,declared/notdeclaredintheproposalform),when
thecoverinceptsforthefirsttimeareexcludedupto4yearsofthispolicybeinginforcecontinuously.
For the purpose of applying this condition, the date of inception of this Mediclaim policy taken from
Oriental Insurance Company shall be considered, provided the renewals have been continuous and
withoutanybreakinperiod.
Thisexclusionwillalsoapplytoanycomplicationsarisingfrompreexistingailments/diseases/injuries.
Such complications will be considered as a part of the pre existing health condition or disease. To
illustrateifaperson issufferingfromhypertensionordiabetesorbothhypertensionanddiabetesatthe
timeoftakingthepolicy,thenpolicyshallbesubjecttofollowingexclusions.
Diabetes Hypertension Diabetes&Hypertension
DiabeticRetinopathy CerebroVascularaccident DiabeticRetinopathy
DiabeticNephropathy HypertensiveNephropathy DiabeticNephropathy
DiabeticFoot/wound InternalBleed/Haemorrhages DiabeticFoot
DiabeticAngiopathy CoronaryArteryDisease DiabeticAngiopathy
DiabeticNeuropathy DiabeticNeuropathy
Hyper/Hypoglycaemicshocks Hyper/Hypoglycaemicshocks
CoronaryArteryDisease
CerebroVascularaccident
HypertensionNephropathy
InternalBleeds/Haemorrhages
4.2 Any disease other thanthose stated in clause 4.3, contracted by the Insured person during the first30daysfromthecommencementdateofthepolicyexcepttreatmentforaccidentalexternalinjuries.
4.3 During the period of insurance cover, the expenses on treatment of following ailment / diseases /surgeriesforspecifiedperiodsarenotpayableifcontractedand/ormanifestedduringthecurrencyof
thepolicy.
i Benign ENT disorders and surgeries i.e. Tonsillectomy, Adenoidectomy, Mastoidectomy,
Tympanoplastyetc.
1 year
ii Polycysticovariandiseases. 1 year
iii Surgeryofhernia. 2 years
iv Surgeryofhydrocele. 2 years
v NoninfectiveArthritis. 2 years
vi UndescendentTestes. 2 Years
vii Cataract. 2 Years
viii Surgeryofbenignprostatichypertrophy. 2 Years
ix Hysterectomyformenorrhagiaorfibromyomaormyomectomyorprolapseofuterus. 2 Years
x Fissure/Fistulainanus. 2 Years
xi Piles. 2 Years
xii Sinusitisandrelateddisorders. 2 Years
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xiii Surgeryofgallbladderandbileductexcludingmalignancy. 2 Years
xiv Surgeryofgenitourinarysystem excludingmalignancy. 2 Years
xv PilonidalSinus. 2 Years
xvi GoutandRheumatism. 2 Years
xvii Hypertension. 2 Years
xviii Diabetes. 2 Years
xix Calculusdiseases. 2 Years
xx Surgeryforprolapsedintervertebraldiskunlessarisingfromaccident. 2 Years
xxi Surgeryofvaricoseveinsandvaricoseulcers. 2 Years
xxii Congenitalinternaldiseases. 2 Years
xxiii JointReplacementduetoDegenerativecondition. 4 Years
xxiv AgerelatedosteoarthritisandOsteoporosis. 4Years
IfthecontinuityoftherenewalisnotmaintainedwithOrientalInsuranceCompanythensubsequent
coverwillbetreatedasfreshpolicyandclauses4.1.,4.2,4.3willapplyunlessagreedbytheCompany
andsuitableendorsementpassedonthepolicy.
4.4 Injuryor disease directlyor indirectly causedbyorarising from or attributableto War, Invasion, ActofForeignEnemy,Warlikeoperations(whetherwarbedeclaredornot)orbynuclearweapons/materials.
4.5 Circumcision (unless necessary for treatment of a disease not excluded hereunder or as may benecessitated due to any accident), vaccination, inoculationorchange of life or cosmeticorof aesthetic
treatmentofanydescription,plasticsurgeryotherthanasmaybenecessitatedduetoanaccidentorasa
partofanyillness.
4.6 Surgeryforcorrectionofeyesight,costofspectacles,contactlenses,hearingaidsetc.4.7 Anydentaltreatmentorsurgerywhich iscorrective,cosmeticorofaestheticprocedure,fillingofcavity,
root canal including wear and tear etc unless arising from disease or injury and which requires
hospitalisationfortreatment.
4.8 Convalescence,generaldebility,rundownconditionorrestcure,congenitalexternaldiseasesordefectsor anomalies, sterility, any fertility, subfertility or assisted conception procedure, venereal diseases,
intentionalselfinjury/suicide,allpsychiatricandpsychosomaticdisordersanddiseases/accidentdueto
and or use, misuse or abuse of drugs / alcohol or use of intoxicating substances or such abuse or
addictionetc.
4.9 Allexpensesarisingoutofanyconditiondirectlyorindirectlycausedby,orassociatedwithHumanTcellLymphotropic Virus Type III (HTLD III) or Lymohadinopathy Associated Virus (LAV) or the Mutants
Derivative or Variations Deficiency Syndrome or any Syndrome or condition of similar kind commonly
referredtoasAIDS,HIVanditscomplicationsincludingsexuallytransmitteddiseases..
4.10 ExpensesincurredatHospitalorNursingHomeprimarilyforevaluation/diagnosticpurposeswhichisnotfollowed
by
active
treatment
for
the
ailment
during
the
hospitalised
period.
4.11 Expensesonvitaminsandtonicsetcunlessformingpartoftreatmentforinjuryordiseaseascertifiedbytheattendingphysician.
4.12 AnyTreatmentarisingfromortraceabletopregnancy,childbirth,miscarriage,caesareansection,abortionorcomplicationsofanyoftheseincludingchangesinchronicconditionasaresultofpregnancy.
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4.13 Naturopathy treatment, unproven procedure or treatment, experimental or alternative medicine andrelatedtreatmentincludingacupressure,acupuncture,magneticandsuchothertherapiesetc.
4.14 Expenses incurred for investigation or treatment irrelevant to the diseases diagnosed duringhospitalisationorprimaryreasons foradmission.Privatenursingcharges,Referralfeetofamilydoctors,
Outstationconsultants/Surgeonsfeesetc,.
4.15 Geneticaldisordersandstemcellimplantation/surgery.4.16 ExternalandordurableMedical/Nonmedicalequipmentofanykindusedfordiagnosisandortreatment
includingCPAP,CAPD,Infusionpumpetc.,Ambulatorydevicesi.e.walker,Crutches,Belts,Collars,Caps,
splints, slings, braces ,Stockings etc of any kind, Diabetic foot wear, Glucometer / Thermometer and
similarrelateditemsetcandalsoanymedicalequipmentwhichissubsequentlyusedathomeetc..
4.17 All non medical expenses including Personal comfort and convenience items or services such astelephone, television, Aya / barber or beauty services, diet charges, baby food, cosmetics, napkins ,
toiletryitemsetc,guestservicesandsimilarincidentalexpenses orservicesetc..
4.18 Changeoftreatmentfromonepathytootherpathyunlessbeingagreed/allowedand recommendedbytheconsultantunderwhomthetreatmentistaken.
4.19 Treatment of obesity or condition arising therefrom (including morbid obesity) and any other weightcontrolprogramme,servicesorsuppliesetc...
4.20 Any treatment required arising from Insureds participation in any hazardous activity including but notlimited to scuba diving, motor racing, parachuting, hang gliding, rock or mountain climbing etc unless
specificallyagreedbytheInsuranceCompany.
4.21 Anytreatmentreceived inconvalescenthome,convalescenthospital,healthhydro,naturecareclinicorsimilarestablishments.
4.22 Any stay in the hospital for any domestic reason or where no active regular treatment is given by thespecialist.
4.23 OutpatientDiagnostic,MedicalorSurgicalproceduresortreatments,nonprescribeddrugsandmedicalsupplies, Hormone replacement therapy, Sex change or treatment which results from or is in any way
relatedtosexchange.
4.24 Massages,Steambathing,Shirodharaandaliketreatmentunder Ayurvedictreatment.4.25 AnykindofServicecharges,Surcharges,Admissionfees/Registrationchargesetcleviedbythehospital.4.26 Doctorshomevisitcharges,Attendant/Nursingchargesduringpreandposthospitalisationperiod.4.27 Treatmentwhichiscontinuedbeforehospitalizationandcontinuedevenafterdischargeforanailment/
disease/injurydifferentfromtheoneforwhichhospitalizationwasnecessary.
5 CONDITIONS
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5.1 ENTIRE CONTRACT: the policy, proposal form, prospectus and declaration given by the insured shallconstitute thecomplete contractof insurance. Only insurer may alter the terms and conditions ofthis
policy/contract. Anyalterationthatmaybemadebytheinsurershallonlybeevidencedbyadulysigned
andsealedendorsementonthepolicy.
5.2 COMMUNICATION : Every notice or communication to be given or made under this policy shall bedelivered
in
writing
at
the
address
of
the
policy
issuing
office
/
Third
Party
Administrator
as
shown
in
the
Schedule.
5.3 PAYMENTOFPREMIUM:Thepremiumpayableunderthispolicyshallbepaidinadvance.NoreceiptforpremiumshallbevalidexceptontheofficialformoftheCompanysignedbyadulyauthorizedofficialof
thecompany. Theduepaymentofpremiumandtheobservanceandfulfilmentoftheterms,provisions,
conditionsandendorsementsofthispolicybytheInsuredPersoninsofarastheyrelatetoanythingtobe
doneorcompliedwithbytheInsuredPersonshallbeconditionprecedenttoanyliabilityoftheCompany
tomakeanypaymentunderthispolicy.Nowaiverofanyterms,provisions,conditionsandendorsements
ofthispolicyshallbevalid,unlessmadeinwritingandsignedbyanauthorisedofficialoftheCompany.
5.4 NOTICE OF CLAIM: Immediate notice of claim with particulars relating to Policy Number, ID Card No.,Nameofinsuredpersoninrespectofwhomclaim ismade,Natureofdisease/ illness/injuryandName
and Address ofthe attending medical practitioner / Hospital/Nursing Home etc.shouldbegiven to the
Company/TPAwhiletakingtreatmentintheHospital/NursingHomebyFax,Email.Suchnoticeshould
begivenwithin48hoursofadmissionorbeforedischargefromHospital/NursingHome,unlesswaivedin
writing.
5.5 CLAIM DOCUMENTS: Final claim along with hospital receipted original Bills/Cash memos/reports, claimformand listofdocumentsas listedbelowshouldbesubmittedtotheCompany/TPAwithin7daysof
dischargefromtheHospital/NursingHome.
a. Originalbills,receiptsanddischargecertificate/cardfromthehospital.b. MedicalhistoryofthepatientrecordedbytheHospital.c. OriginalCashmemofromthehospital(s)/chemist(s)supportedbyproperprescription.d. Original receipt, pathological and other test reports from a pathologist / radiologist including film etc
supportedbythenotefromattendingmedicalpractitioner/surgeondemandingsuchtests.
e. AttendingConsultants/Anaesthetists/Specialistcertificatesregardingdiagnosisandbill/receiptsetc.f. Surgeons original certificate stating diagnosis and nature of operation performed along with bills /
receiptsetc.
g. AnyotherinformationrequiredbyTPA/InsuranceCompany.Alldocumentsmustbedulyattestedbytheinsuredperson.
Incaseofposthospitalisationtreatment(limitedto60days)allsupportingclaimpapers/documentsas
listedaboveshouldalsobesubmittedwithin7daysaftercompletionofsuchtreatment(upto60daysor
actual period which ever is less ) to the Company / T.P.A. In addition insured should also provide the
Company/TPA
such
additional
information
and
assistance
as
the
Company
/TPA
may
require
in
dealing
withtheclaim.
NOTE:Waiveroftheconditionmaybeconsideredinextremecasesofhardshipwhereitisprovedtothe
satisfaction of the Company that under the circumstances in which the insured was placed it was not
possible for him or any other person to give such notice or file claim within the prescribed time limit.
OtherwiseCompany/TPAhasarighttorejecttheclaim.
5.6 PROCEDUREFORAVAILINGCASHLESSACCESSSERVICESINNETWORKHOSPITAL/NURSINGHOME:
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i) ClaiminrespectofCashlessAccessServiceswillbethroughtheTPAprovidedadmissionisinalistedhospital in the agreed list of the networked Hospitals / Nursing Homes and is subject to pre
admission authorization. The TPA shall, upon getting the related medical details / relevant
informationfromthe insuredperson/networkHospital/NursingHome,verifythattheperson is
eligible to claim under the policy and after satisfying itself will issue a preauthorisation letter /
guarantee
of
payment
letter
to
the
Hospital
/
Nursing
Home
mentioning
the
sum
guaranteed
as
payable,alsotheailmentforwhichthepersonisseekingtobeadmittedasinpatient.
ii) TheTPAreservestherighttodenypreauthorisationincasethehospital/insuredpersonisunabletoprovidetherelevantinformation/medicaldetailsasrequiredbytheTPA. Insuchcircumstances
denialofCashlessAccessshouldinnowaybeconstruedasdenialofclaim. Theinsuredpersonmay
obtain the treatment as per his/her treating doctors advice and later on submit the full claim
paperstotheTPAforreimbursementwithin7daysofthedischargefromHospital/NursingHome.
iii) Should any information be available to the TPA which makes the claim inadmissible or doubtfulrequiringinvestigations,theauthorisationofcashlessfacilitymaybewithdrawn.Howeverthisshall
bedonebytheTPAbeforethepatientisdischargedfromtheHospital.
5.7REPUDIATION:
A (I): The TPA, if policy is being serviced by them, shall repudiate the claim if not covered / not payable
underthepolicy.TheTPAshallmentionthereasonsforrepudiation inwritingtothe insuredperson. The
insuredpersonshallhavetherighttoappeal/approachthepolicyissuingofficeoftheinsurancecompanyif
he/she feelsthattheclaim ispayable. The insurancecompanysdecision inthisregardwillbe finaland
bindingonTPA.
A( II): Ifpolicy isservicedby InsuranceCompany, in caseofrepudiationofclaim, insuredshallhavethe
righttoappealtotheconcernedRegionalOfficeoftheInsuranceCompany,ifhe/shefeelsthattheclaimis
payable.
B : Ifclaim isrepudiatedbythecompany asperA (1)&A (II)butthe insured feelsthathis/herclaim is
payabletheninsuredpersonshallhavearighttoappeal/approachtheChiefManagerGrievanceCellofthe
Companysituated
at
A
25/27,Asaf
Ali
Road,
New
Delhi
110002.
C: The Central Government has established an office of the Insurance Ombudsman for redressal of
grievancesofuptoRs20lacsrelatedtopersonallinesofinsurances.
5.8 AnymedicalpractitionerauthorisedbytheTPA/CompanyshallbeallowedtoexaminetheInsuredPersonincase of any alleged injury or Disease requiring Hospitalisation when and so often as the same may
reasonablyberequiredonbehalfoftheTPA/Company.
5.9 FRAUD/MISREPRESENTATION/CONCEALMENT: TheCompanyshallnotbe liabletomakeanypaymentunder this policy in respect of any claim if such claim be in any manner intentionally or recklessly or
otherwise misrepresented or concealedornondisclosure of material facts ormaking false statements or
submittingfalls
bills
whether
by
the
Insured
Person
or
Institution
/Organization
on
his
behalf
.Such
action
shallrenderthispolicynullandvoidandallclaimshereundershallbeforfeited. Companymaytakesuitable
legalactionagainsttheInsuredPerson/Institution/OrganizationasperLaw.
5.10 CONTRIBUTION : If at the time when any claim arises under this policy, there is in existence any otherinsurance (other than Cancer Insurance Policy in collaboration with Indian Cancer Society) whether it be
effectedbyoronbehalfofanyInsuredPersoninrespectofwhomtheclaimmayhavearisencoveringthe
same loss, liability,compensation,costsorexpenses,thecompanyshallnotbe liabletopayorcontribute
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TheOrientalInsuranceCompanyLimited
11
morethanitsrateableproportionofanyloss,liability,compensation,costsorexpenses. Thebenefitsunder
thispolicyshallhoweverbeinexcessofthebenefitsavailableunderCancerInsurancePolicy.
5.11 CANCELLATION CLAUSE: Company may at any time without assigning any reason cancel this Policy bysendingtheInsured30daysnoticebyregistered letterattheInsureds lastknownaddressand insuchan
eventtheCompanyshallrefundtotheInsuredaproratapremiumforunexpiredPeriodofInsurance. The
Company
shall,
however,
remain
liable
for
any
claim
which
arose
prior
to
the
date
of
cancellation.
The
InsuredmayatanytimecancelthispolicyandinsucheventtheCompanyshallallowrefundofpremiumat
Companysshortperiodrateonly(tablegivenherebelow)providednoclaimhasoccurredduringthepolicy
perioduptodateofcancellation.
PeriodonRisk Rateofpremiumtobecharged
Upto1Month 1/4thoftheannualrate
Upto3Months 1/2oftheannualrate
Upto6Months 3/4thoftheannualrate
Exceeding6months Fullannualrate
5.12 ARBITRATIONCLAUSE:Ifanydisputeordifferenceshallariseastothequantumtobepaidunderthepolicy(liabilitybeingotherwiseadmitted)suchdifferenceshall independentlyofallotherquestionsbe
referredtothedecisionofasolearbitratortobeappointed inwritingbythepartiesor iftheycannot
agree upon a single arbitrator within 30 days of any party invoking arbitration, the same shall be
referredtoapanelofthreearbitrators,comprisingoftwoarbitrators, onetobeappointedbyeachof
the partiestothedispute/differenceandthethird arbitratortobe appointedbysuchtwoarbitrators
andarbitrationshallbeconductedunderand inaccordancewiththeprovisionsoftheArbitrationand
ConciliationAct,1996.
Itisclearlyagreedandunderstoodthatnodifferenceordisputeshallbereferabletoarbitrationasherein
beforeprovided,iftheCompanyhasdisputedornotacceptedliabilityunderorinrespectofthispolicy.
Itisherebyexpresslystipulatedanddeclaredthatitshallbeaconditionprecedenttoanyrightofaction
or suitupon this policy thataward by such arbitrator/ arbitratorsoftheamountofthe lossor damage
shallbe
first
obtained.
5.13 DISCLAIMEROFCLAIM:ItisalsoherebyfurtherexpresslyagreedanddeclaredthatiftheTPA/CompanyshalldisclaimliabilityinwritingtotheInsuredforanyclaimhereunderand suchclaimshallnotwithin
12calendarmonthsfromthedateofsuchdisclaimerhavebeenmadethesubjectmatterofasuitina
court of law, thenthe claimshall for all purposes bedeemed to have been abandoned and shall not
thereafterberecoverablehereunder.
5.14 PAYMENTOFCLAIM:Thepolicycoversillness,diseaseoraccidentalbodilyinjurysustainedbytheinsuredpersonduringthepolicyperiodanywhereinIndiaandallmedical/surgicaltreatmentunderthispolicy
shallhavetobetakeninIndiaandadmissibleclaimsthereofshallbepayableinIndiancurrency.
a) Payment of claim shall be made through TPA to the Hospital / Nursing Home or to the InsuredPersonincasepolicyisservicedthroughTPA.
b) InnonTPAcasetheclaimwillbepaidtotheinsuredpersonbytheInsuranceCompany.6 COST OF HEALTH CHECK : The Insured shall be entitled for reimbursement of cost of Health check up
undertakenonceattheexpiryofablockofevery fourcontinuousclaimfreeunderwritingyearsprovided
therearenoclaimsreportedduringtheblock.Thecostsoreimbursableshallnotexceedtheamountequal
to1%oftheaveragebasicsumInsuredduringtheblockoffourclaimfreeunderwritingyears.
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IMPORTANT
HealthCheckupprovisionisapplicableonlyinrespectofcontinuousinsurancewithoutbreak.
7 PERIODOFPOLICY:Thisinsurancepolicyisissuedforaperiodofoneyear.8 RENEWALOFPOLICY:
a) TheCompanyshallnotberesponsibleorliablefornonrenewalofpolicyduetononreceiptordelayed receipt (i.e. After the due date) of the proposal form or of the medical practitioners
reportwhereverrequiredorduetoanyotherreasonwhatsoever.
b) Notwithstandingthis,however,thedecisiontoacceptorreject forcoverageanypersonuponrenewalofthisinsuranceshallrestsolelywiththeCompany. Thecompanymayatitsdiscretion
revisethepremiumratesand/ortheterms&conditionofthepolicyeveryyearuponrenewal
thereof. Renewalofthispolicyisnotautomatic;premiumduemustbepaidbytheproposerto
thecompanybeforetheduedate.
c) The Company normally sends renewal notice but not sending it will not tantamount todeficiencyinservices.
Ifthepolicyistoberenewedforenhancedsuminsuredthentherestrictionsasapplicabletoafreshpolicy
(condition4.1,4.2&4.3willapplytoadditionalsuminsured)asifaseparatepolicyhasbeenissuedforthe
difference,subjecttomedicalcheckupaspernormsoftheCompany.ThecostofMedicalcheckupshallbe
bornebytheinsured.
9 PREACCEPTANCEHEALTHCHECKUP:Anypersonbeyond45yearsofagedesiringtotakeinsurancecoverhastosubmit followingmedicalreports fromauthorisedNetworkDiagnosticCentreoranyothermedical
reports required bythe company in case of fresh proposal and renewalwherethere is a break in policy
period.Thecostshallbebornebytheinsured.
Incaseoffreshproposals,50%costofMedicalCheckupnotexceeding20%ofpremiumchargeableshallbe
reimbursedbytheCompanyafteracceptance.
Age 4555 ABOVE55Years
MEDICAL
TEST
PHYSICALEXAMINATION PHYSICALEXAMINATION
URINE(MICROALBUMIN UREA) URINE(MICROALBUMIN UREA)
GLYCOCYLATED,HAEMOGLOBIN GLYCOCYLATEDHAEMOGLOBIN
ULTRASONOGRAPHY(WHOLEABDOMEN
ANDPELVIS)
ULTRASONOGRAPHY (WHOLE ABDOMEN AND
PELVIS)
ELECTROCARDIOGRAM XRAYBOTHKNEES(ANTEPOSTERIORAND LATREL)
COMPLETEEYETESTINCLUDINDFUNDUS
ETC
COMPLETEEYETESTINCLUDINDFUNDUSETC
STRESSTEST(TMT)
10
SUM
INSURED:
The
Companys
liability
in
respect
of
all
claims
admitted
during
the
period
of
Insurance
shallnotexceedthesuminsuredoptedbytheInsuredperson.MinimumsuminsuredisRs50,000/ andin
multiplesofRs25,000/ uptoRs2,00,000/.BeyondtheSumInsuredofRs.200000/ inmultiplesofRs.
50000/ uptoRs500000/.
11 AUTHORITYTOOBTAINRECORDS:a) The insured person hereby agrees to and authorises the disclosure to the insurer or the TPA or any
other person nominated by the insurer of any and all Medical records and information held by any
Institution / Hospital or Person from which the insured person has obtained any medical or other
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treatment to the extent reasonably required by either the insurer or the TPA in connection with any
claimmadeunderthispolicyortheinsurersliabilitythereunder.
b) The insurer and the TPA agree that they will preserve the confidentiality of any documentation andinformationthatcomes into their possessionpursuant to (a) above andwillonlyuse it inconnection
withanyclaimmadeunderthispolicyortheinsurersliabilitythereunder
12
CHANGE
OF
ADDRESS:
Insured
must
inform
the
company
immediately
in
writing
of
any
change
in
the
address.
13 REASONABLE,CUSTOMARYANDNECESSARYEXPENSES:13.1 ForanetworkedhospitalmeanstheratepreagreedbetweenNetworkedHospitalandtheTPA
forsurgical/medicaltreatmentthatisnecessary,customaryandreasonablefortreatingthecondition
forwhichinsuredpersonwashospitalized.
13.2 Foranyotherhospital itshallmeanthecostofsurgical/medicaltreatmentthatisnecessary,customaryandreasonablefortreatingtheconditionforwhich insuredpersonwashospitalizedtothe
extent that such cost does not exceed the reasonable and customary charges for which insured was
hospitalized.
NOTE: Any expenses as mentioned above which are not covered under the policy and / or which are not
reasonable,customaryandnecessary,thesamehavetobebornebytheinsuredpersonhimself.
14 QUALITYOFTREATMENT:The insuredherebyacknowledgesandagreesthatpaymentofanyclaimbyoronbehalfoftheinsurershallnotconstituteonpartoftheinsurancecompanyaguaranteeorassuranceas
tothequalityoreffectivenessofanymedicaltreatmentobtainedbytheinsuredperson,itbeingagreedand
recognized by the policy holder that insurer is not in any way responsible or liable for the availability or
quality of any services (Medical or otherwise) rendered by any institution (including a network hospital)
whetherpreauthorizedornot.
15 IDCARD:ThecardissuedtotheinsuredpersonbytheTPAtoavailcashlessfacilityintheNetworkHospitalonly. Uponthecancellationornonrenewalofthispolicy,allIDcardsshallimmediatelybereturnedtothe
TPAatthepolicyholdersexpenseandthepolicyholderandeach insuredpersonagreestoholdandkeep
harmless,theinsurerandtheTPAagainstanyorallcosts,expenses,liabilitiesandclaims(whetherjustified
ornot)arisinginrespectoftheactualorallegeduse,misuseofsuchIDcardspriortotheirreturn.
16 ADDONBENEFIT:MEDICLAIMWITHOMP:
In case where a person covered under Mediclaim Policy (Individual) goes abroad by taking Orientals
OverseasMediclaimPolicyhis/herMediclaimPolicybecomesinoperativefortheperiodhe/sheisabroad.
Since there is no provision for adjustment/ refund of premium, Mediclaim Policy may be extended by
number of days, the insured person was abroad subject to written request being made by the insured
beforeleavingIndia.
17 IRDAREGULATIONNO.5.:Thispolicyissubjecttoregulation5ofIRDA(ProtectionofPolicyHolderinterest)regulation.