Sl No | Features | Silver | Gold | Diamond |
---|---|---|---|---|
1. | Sum Insured (in ₹ INR) | 1, 2, 3, 4, 5 lacs | 6, 7, 8, 9, 10 lacs | 12, 15, 18, 20 lacs |
2. | Daily Hospital Cash Allowance | 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 the 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 the Sum Insured. |
3. | 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. |
4. | Organ Donor Benefit- when Insured Person is the donor-waiting period 12 months. | Lumpsum payment of 10% of the Sum Insured | Lumpsum payment of 10% of the Sum Insured | Lumpsum payment of 10% of the Sum Insured. |
5. | Medical Second Opinion for 11 specified major illnesses - taken from anywhere in the world | Maximum ₹5000 in a Policy period. | Maximum ₹10000 in a Policy period. | Maximum ₹15000 in a Policy period. |
6. | Maternity Expenses (available only for the Proposer or his spouse). Both proposer & his/her spouse should be covered under the policy for atleast 24 months. | Not Available | Not Available | Medical Expenses for a delivery (including caesarean section) or lawful medical termination of pregnancy limited to two deliveries or terminations or either during the lifetime of the Insured Person, after the policy (Diamond Plan) has been continuously in force for 24 (twenty four) months Liability of the Company limited to 2.5% of the Sum Insured. |
7. | New Born Baby cover. This is subject to claim being admitted under Maternity Expenses cover | Not Available | Not Available | Medical expenses incurred on treatment taken in Hospital as an In-patient in respect of the new born baby from day one upto the age of 90days. Liability of the Company limited to 2.5% of the Sum Insured. Coverage beyond 90days only on payment of requisite premium. |
8. | Restoration of Sum Insured for Sum Insured between ₹3 to 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 |
9. | Compulsory Co-payment | 10% of each & every claim | Nil | Nil |
10. | Maximum Entry | Age 65 years for all members | 65 years for all members | 65 years for all members |
11. | Extension of Maximum Entry Age | Upto 70 years, with compulsory Copayment of 20% of each & every claim (in addition to the 10% compulsory Co-payment under the Plan). Copayment to apply on all subsequent renewals also. | Upto 70 years, with compulsory Co-payment of 20% of each & every claim. Co-payment to apply on all subsequent renewals also. | Not Available |
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 |
|
|
|
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 |
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 |
The entire process followed in current TPA allocation exercise was duly uploaded on company’s portal and was kept in public domain for any representation, observation, grievance and objection for redressal by specially constituted Appellate Committee. You can access the notice on the noted url: url
A claim is registered, processed and finally paid within 30 days of the receipt of the last necessary document by the TPA/Insurer, as per terms and conditions of the policy. Exception is made for settlement and final payment for 45 days in case a claim warrants an investigation.
Insurance companies have tie-up arrangements with several hospitals which are called network hospitals. Under a health insurance policy, a policyholder can take treatment in any of the network hospitals without having to pay the hospital bills as the payment is made to the hospital directly by the insurance company. TPA helps in organizing cashless treatment to the member. However, expenses beyond the limits or sub-limits as per terms and conditions of the insurance policy or expenses not covered under the policy have to be paid by customer directly to the hospital. Preauthorization, however, is not available if treatment is taken in a nonnetwork hospital.
Review Oriental Happy Family Floater insurance brochure to understand coverage details.
Review Oriental Happy Family Floater insurance policy wordings which explains the terms and conditions.
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