Oriental Happy Family Floater Insurance

Coverages Happy Family Floater Insurance

Sl No	Expenses Covered Silver	Limits of covered Expenses Gold	Limits of covered Expenses Diamond	Limits of covered Expenses
A. Hospitalisation Expenses
1.	Room, Boarding and Nursing Expenses as provided by the Hospital /Nursing Home	1 % of the Sum Insured per day	1 % of the Sum Insured per day	₹10,000 + 0.5% of the Sum Insured above ₹10 lacs, per day
2.	Intensive Care Unit (ICU) Expenses as provided by the Hospital /Nursing Home	2% of the Sum Insured per day	2% of the Sum Insured per day	₹20,000 + 1% of the Sum Insured above Rs.10lacs, per day
	Number of days of stay under ‘i’ and ‘ii’ above should not exceed total number of days of admission in the Hospital. All related expenses (including iii and iv below) shall also be payable as per the entitled room category based on the Room Rent limit as mentioned above. This will not apply on medicines / pharmaceuticals and body implants.
3.	Surgeon, Anaesthetist, Medical Practitioner, Consultants, Specialists Fees	As per the limits of Sum Insured	As per the limits of Sum Insured	As per the limits of Sum Insured
4.	Anaesthesia, 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	As per the limits of Sum Insured	As per the limits of Sum Insured	As per the limits of Sum Insured
5.	Ambulance service charges	Per Illness -₹1000 maximum Per Policy Period - 1% of Sum Insured, subject to maximum ₹3000	Per Illness- ₹2000 maximum Per Policy Period - 1% of Sum Insured, subject to maximum ₹6000	Per Illness- ₹3000 maximum Per Policy Period- 1% of Sum Insured, subject to maximum ₹8000
6.	Daily Hospital Cash Allowance as Hereinafter defined	Not Available	0.1% of Sum Insured (₹600 to ₹1000) per day of Hospitalisation, subject to a maximum compensation for 10 days per Illness. Overall liability of the Company during the Policy Period will be limited to 1.5% of Sum Insured	0.1% of Sum Insured (₹1200 to ₹2000) per day of Hospitalisation, subject to a maximum compensation for 10 days per Illness. Overall liability of the Company during the Policy Period will be limited to 1.5% of Sum Insured
7.	Attendant Allowance	Not Available	₹500/- per day of Hospitalisation, subject to maximum compensation for 10 days per Illness. Overall liability of the Company during the Policy Period will be limited to compensation for 15 days of Hospitalisation.	₹1000/- per day of Hospitalisation, subject to maximum compensation for 10 days per Illness. Overall liability of the Company during the Policy Period will be limited to compensation for 15 days of Hospitalisation.
8.	Maternity Expenses #	Not Available	Not Available	Automatic cover upto 2.5% of the Sum Insured
9.	New Born Baby Cover #	Not Available	Not Available	Automatic cover upto 2.5% of the Sum Insured upto 90 days from the date of birth. Cover beyond 90 days, available for full Sum Insured only on payment of requisite premium.
10.	Medical Second Opinion on Specified major Illnesses ##	Maximum ₹5000 in a Policy Period	Maximum ₹10000 in a Policy Period	Maximum ₹15000 in a Policy Period
11.	Organ Donor Benefit when Insured Person is Donor	Lumpsum payment of 10% of the Sum Insured.	Lumpsum payment of 10% of the Sum Insured.	Lumpsum payment of 10% of the Sum Insured.
12.	Donor Expenses when Insured Person is Recipient	As per the limits of Sum Insured	As per the limits of Sum Insured	As per the limits of Sum Insured
13.	Pre and Post Hospitalisation Expenses	Medical expenses incurred 30days prior to Hospitalisation and upto 60 days post Hospitalisation
14.	Compulsory Co-payment	10% of each & every claim	Not Applicable	Not Applicable
	Note: 1. In case of Ayurvedic /Siddha/ Homeopathic / Unani treatment, Hospitalisation expenses are admissible only when the treatment is taken as an in-patient, in a Government Hospital or in any Institute recognised by Govt. and/or accredited by Quality Council of India / National Accreditation Board on Health. 2. Relaxation to 24 hours minimum duration for Hospitalization is allowed in a Day care procedures / surgeries ^^ 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 b Any other day care treatment as mentioned in clause 3.11 and for which prior approval from Company / TPA is obtained in writing.
B. Domiciliary Hospitalisation Benefits ###
1.	Surgeon, Medical Practitioner, Consultants, Specialists Fees, Blood, Oxygen, Surgical Appliances, Medicines & Drugs, Diagnostic Material and Dialysis, Chemotherapy, Nursing expenses	10% of Sum Insured, Maximum ₹25000/- during the Policy Period	Maximum ₹50000/- during the Policy Period.	Maximum 50₹000/- during the Policy Period.
2.	Treatment for Dog bite (or bite of any other rabid animal like monkey, cat etc.)	Maximum Rs.5,000/- actually incurred on immunisation injections in any one Policy Period. This will be part of Domiciliary Hospitalisation limits as specified. For the purpose of this clause the conditions for Domiciliary Hospitalisation benefit shall not apply.
C. Optional Covers (Can be availed by paying Additional Premium)
1.	Geographical Extension To SAARC Countries (Expenses will be reimbursed, no Cashless Treatment)	The Policy can be extended to cover Insured Persons visiting other SAARC (South Asian Association for Regional Co-operation) countries -Afghanistan, Bangladesh, Bhutan, Maldives, Nepal, Pakistan, Sri Lanka. No additional premium will be charged for this extension. However, the Insured Person has to make a request for such extension, in writing, before leaving the country, duly informing the duration, purpose and country(ies) of visit. Endorsement for such extension will be issued by the Company
2.	Restoration Of Sum Insured for Sum Insured Between ₹3lacs & ₹10 lacs, both slabs inclusive ####	2 options - (i) 50% of the Sum Insured (ii) 100% of the Sum Insured	2 options - (i) 50% of the Sum Insured (ii) 100% of the Sum Insured	Not Available
3.	Personal Accident	CSI in multiples of ₹1,00,000/- upto ₹5,00,000/-per Insured Person aged 18 years and above. However, for Insured Person below 18 years of age maximum CSI of ₹3lacs is allowed subject to this being lower than the CSI of the Insured	CSI in multiples of ₹1,00,000/- upto ₹10,00,000/-per Insured Person aged 18 years and above. However, for Insured Person below 18 years of age maximum CSI of ₹5lacs is allowed subject to this being lower than the CSI of the Insured	CSI in multiples of ₹1,00,000/- upto ₹20,00,000/-per Insured Person aged 18 years and above. However, for Insured Person below 18 years of age maximum CSI of ₹10lacs is allowed subject to this being lower than the CSI of the Insured
		Coverage	Sum Insured Payable
		Accidental Death only	100 % of CSI
		Loss of two entire limbs, or sight of two eyes or one entire limb and sight of one eye	100 % of CSI
		Loss of one entire limb or Sight of one eye	50 % of CSI
		Permanent Total Disablement resulting in totally and absolutely disabling the person insured from engaging in any employment or occupation whatsoever.	100 % of CSI
4. Life Hardship Survival Benefit #####	Plan	Total amount payable	Amount payable on survival for 180 days and above from the date of discharge from the Hospital (the first discharge date when more than one Hospitalisation is involved).	Amount payable on survival for 270 days and above from the date of discharge from the Hospital (the first discharge date when more than one Hospitalisation is involved).
	A	15 % of Sum Insured under the Policy	5% of the Sum Insured	10% of the Sum Insured
	B	25 % of Sum Insured under the Policy	10% of the Sum Insured	15% of the Sum Insured

# Special conditions applicable to Maternity Expenses and New Born Baby Cover are:
- These benefits are admissible only if the expenses are incurred in Hospital/Nursing Home as inpatients in India.
- 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/Nursing Home and treatment is taken there.
- 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.

##Major Illnesses covered - If the Insured Person is diagnosed with one of the specified major Illnesses listed below, and takes Medical Second Opinion (including opinion obtained from overseas) whether before starting the treatment or during the course of treatment, the Policy covers Medical Expert’s fees to the respective limits. The illnesses include:
- Cancer
- Renal Disease
- Stroke resulting in Permanent Symptoms
- Coma
- All Cardiac conditions /surgeries
- Major Organ / Bone Marrow transplantation
- Paralysis of Limbs
- Motor Neurone disease
- All Brain related conditions /surgeries
- Multiple Sclerosis
- Liver failure

### Domiciliary Hospitalisation benefit shall, however, not cover expenses in any of the following cases
- if the treatment lasts for a period of three days or less
- incurred on Pre and Post Hospitalisation treatment and
- incurred on treatment of any of the following diseases:
o Asthma
o Bronchitis
o Chronic Nephritis and Nephritic Syndrome
o Diarrhoea and all types of Dysenteries including Gastro-enteritis
o Diabetes Mellitus and Insipidus
o Epilepsy vii. Hypertension
o Influenza, Cough and Cold
o All Psychiatric or Psychosomatic Disorders
o Pyrexia of unknown origin for less than 10 days
o Tonsillitis and Upper Respiratory Tract infection including Laryngitis and Pharyngitis
o Arthritis, Gout and Rheumatism.

- Note: Liability of the Company under Domiciliary Hospitalisation Benefit is restricted as per policy terms and conditions

#### Restoration Of Sum Insured - If during the Policy Period the Sum Insured gets reduced or exhausted on account of a claim under the Policy, the Sum Insured is automatically restored to the extent of the claim amount but not exceeding the Restoration limit opted (50% / 100% of Sum Insured) at the inception of the Policy. The above is subject to the following:
- Aggregate of all the restored amounts during the Policy Period shall not exceed 50% / 100% of the Sum Insured, as opted by the Insured.
- At no point of time during the Policy Period, will the available coverage be more than the Sum Insured mentioned in the Schedule.
- Aggregate of all the claims payable for any one Insured Person under the Policy shall not be more than the Sum Insured.
- During a Policy Period, the maximum amount for any one claim payable shall be the Sum Insured and the aggregate of all claims payable shall not exceed the sum of the Sum Insured and Restored Sum Insured.

##### Life Hardship Survival Benefit Plan - If during the Policy Period, any Insured Person is diagnosed with any of the 11 critical Illnesses defined hereunder and which results in admissibility of a claim, then a survival benefit as mentioned below, shall become payable to the Insured Person. However, this benefit shall not be available for the Illness which the Insured Person is already suffering from (irrespective of the stage of the disease) at the time of opting for this cover for the first time. The 11 Critical Illnesses are:
- Cancer Of Specified Severity
- First Heart Attack - Of Specified Severity
- Open Chest CABG
- Open Heart Replacement Or Repair Of Heart Valves
- Coma Of Specified Severity
- Kidney Failure Requiring Regular Dialysis
- Stroke Resulting In Permanent Symptoms
- Major Organ/Bone Marrow Transplant
- Permanent Paralysis Of Limbs
- Motor Neuron Disease With Permanent Symptoms
- Multiple Sclerosis With Persistent Symptoms

^^ Day Care Treatment - refers to medical treatment, and/or surgical procedure which is:
• undertaken under General or Local Anaesthesia in a Hospital/day care centre in less than 24 hrs because of technological advancement, and
• which would have otherwise required a Hospitalisation of more than 24 hours.
• 116 Day care procedures are covered – please refer to the policy wordings for the entire list of 116 procedures
• Treatment normally taken on an out-patient basis is not included in the scope of this definition.

Premium for Optional Covers

Basic Premium (without GST) in ₹ INR	Sum Insured	Premium Payable
Restoration Of Sum Insured- Only For Si Of ₹3lacs to ₹10 lacs	50% of SI	15% of Total Basic Premium
	100% of SI	25% of Total Basic Premium
Personal Accident	From ₹1 lac to ₹20 lacs per Insured person	60 per lac per person Family Discount of 10% if more than one member is covered under this section
Life Hardship Survival Benefit	Plan A	3% of Total Basic Premium
	Plan B	5% of Total Basic Premium