Oriental HOPE policy

Features of HOPE policy

The features of this plan include:

• Exclusively designed for Citizens aged 60 years and above and forhospitalisation in India only.
• Policy is available for Sum Insured ₹1 lac, 2 lac, 3 lac, 4 lac and 5 lacs.
• Covers specified diseases only.
• Compulsory co-payment of 20% on admissible claim amount.
• Discount in premium for opting Voluntary Co-payment.
• No claim discount in premium.
• Loading for new entrants.
• Benefit of continuity extended if already insured with any mediclaim policy ofthe Company.
• TPA service available.
• Cashless Service through TPA only and limited to Rs. 1 lakh.

The proposer has to submit any of the following documents as age proof:

• Birth Certificate
• Matriculation Certificate
• School Leaving Certificate
• Photo Voter Identity Card
• Driving Licence
• PAN Card
• Passport

The Policy reimburses the payment of hospitalisation and / or domiciliaryhospitalisation expenses for the specified diseases contracted or injury sustained bythe insured persons. The settlement of the claim will be done by the Company/TPAeither to the network hospital or to the insured.
Only the following Specified Diseases / illness/ injury are covered underthe policy and the maximum liability of the Company in respect thereofshall be as follows:

Sr No	Name of Disease	Maximum Limit of Liability per illness (including domiciliary hospitalisation benefit, if any)
1	Accidental Injury	100% of Sum Insured
2	Knee Replacement	70% of Sum Insured
3	Cardio Vascular Diseases	50% of Sum Insured
4	Chronic Renal Failure	50% of Sum Insured
5	Cancer	50% of Sum Insured
6	Hepato-BilliaryDisorders	50% of Sum Insured
7	Chronic Obstructive Lung Diseases	50% of Sum Insured
8	Stroke	20% of Sum Insured
9	Benign Prostrate	15% of Sum Insured
10	Orthopaedic Diseases	15% of Sum Insured
11	Ophthalmic Diseases	10% of Sum Insured

Note: Company’s Liability in respect of all claims admitted during the Period ofinsurance shall not exceed the Sum Insured per Person mentioned in the Policy /Schedule. Reasonable & necessary expenses upto the following limits are payable / reimbursable under the policy, for the specifieddiseases / illness/ injury only, within the overall limit asspecified above:

1. Room, Boarding and Nursing Expenses as provided by the Hospital /NursingHome not exceeding 1% of the Sum Insured per day.
2. I.C. Unit expenses not exceeding 2% of the Sum Insured per day.(Stay in the Room and the stay in I.C.U., if required, should not exceed totalnumber of days of admission in the hospital).
3. Ambulance Services Charges per illness by registered ambulance – ActualExpenses or Rs 1000/- whichever is less shall be reimbursable in case patienthas to be shifted from residence to hospital in case of admission in EmergencyWard / I.C.U. Or from one Hospital / Nursing home to another Hospital / NursingHome for hospitalisation.
4. Surgeon, Anaesthetist, Medical Practitioner, Consultants, Specialists Fees
5. Anaesthesia, Blood, Oxygen, Operation Theatre Charges, Surgical Appliances,Medicines & Drugs, Dialysis, Chemotherapy, Radiotherapy, Artificial Limbs, Costof Prosthetic devices implanted during surgical procedure like pacemaker,Relevant Laboratory / Diagnostic test, X-Ray etc.

Note: Only reasonable and necessary expenses based on the severity (minor /medium / major) of the Specified Diseases / illness/ injury will be payable under the policy but not exceeding the maximum limit irrespective of the expenses incurred by the insured.

Waiting period	Initial waiting period: 30 daysfor all illnesses (not applicableon renewal or for accidents) Specific waiting periods:24 months for nameddiseases Pre-existing diseases: Coveredafter 24 months
Payout Basis	Cashless services of covered expenses upto Rs. 1 lakh only Reimbursement of covered expenses upto Sum Insured
Cost sharing (Co–Pay)	20% of each claim as Co-payment Option of Voluntary Co-payment
Renewal Benefits	5% discount on renewal premium for every claim free year, subject to a maximum of 20%
Free Health Check-up	For every block of 4 claim free policy years, free health check up for the insured persons subject to maximum 1%of average sum insured.
Pre Hospitalisation Expenses	Related Medical Expenses incurred during the period upto 30 days prior to the date of admission to hospital
Post Hospitalisation Expenses	Related Medical Expenses incurred for a period upto 60 days post discharge from the hospital

Exclusions for HOPE policy

• The expenses on treatment of following ailments / diseases / surgeriesfor first two policy years are not payable.
  • Non infective Arthritis.
  • Cataract.
  • Surgery of benign prostatic hypertrophy.
  • Surgery of gallbladder and bile duct excluding malignancy.
  • Surgery of genito urinary system excluding malignancy.
  • Gout and Rheumatism.
  • Calculus diseases.
  • Joint Replacement due to Degenerative condition.
  • Age related osteoarthritis and Osteoporosis.
• Injury or disease directly or indirectly caused by or arising from orattributable to War, Invasion, Act of Foreign Enemy, War like operations(whether war be declared or not) or by nuclear weapons / materials.
• Circumcision (unless necessary for treatment of a disease includedhereunder or as may be necessitated due to any accident), vaccination,inoculation or change of life or cosmetic or of aesthetic treatment of anydescription, hair transplant, plastic surgery other than as may benecessitated due to an accident or as a part of any illness / disease.
• Surgery for correction of eye sight, cost of spectacles, contact lenses,hearing aids etc.
• Convalescence, general debility, “run down” condition or rest cure,congenital external diseases or defects or anomalies, sterility, anyfertility, sub-fertility or assisted conception procedure, venereal diseases,intentional self-injury/suicide, all psychiatric and psychosomatic disordersand 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 Lymphadinopathy Associated Virus (LAV) or the Mutants Derivative orVariations Deficiency Syndrome or any Syndrome or condition of similarkind commonly referred to as AIDS, HIV and its complications includingsexually transmitted diseases..
• Expenses incurred at Hospital or Nursing Home primarily forevaluation / diagnostic purposes which is not followed by activetreatment for the ailment during the hospitalised period.
• Expenses on vitamins, tonics, mineral water and allied items unlessforming part of treatment for injury or disease as certified by theattending physician.
• Naturopathy treatment, unproven procedure or treatment,experimental or alternative medicine and related treatment includingacupressure, acupuncture, magnetic and such other therapies etc.
• Expenses incurred for investigation or treatment irrelevant to thediseases diagnosed during hospitalisation or primary reasons foradmission. Private nursing charges, Referral fee to family doctors, Outstation consultants / Surgeons fees etc.
• External and / or durable Medical / Non medical equipment likeAmbulatory devices i.e. Walker , Crutches, Belts ,Collars ,Caps , Splints,Slings, Braces ,Stockings etc of any kind, CPAP, CAPD, Infusion pump,Diabetic foot wear, Glucometer / Thermometer, nebuliser and similarrelated items etc and also any medical equipment which is subsequentlyused at home etc.
• Treatment of obesity or condition arising there from (including morbidobesity) and any other weight control programme, services or suppliesetc.
• Any treatment required arising from Insured’s participation in anyhazardous activity such as scuba diving, motor racing, parachuting, hanggliding, rock or mountain climbing, other allied similar activities etc.
• Any treatment received in convalescent home, convalescent hospital,health hydro, nature care clinic or similar establishments.
• Out Patient Diagnostic, Medical or Surgical procedures or treatments,non-prescribed drugs and medical supplies.
• Any kind of Service charges, Surcharges, Admission fees /Registration charges, File Charges etc levied by the hospital.
• Doctor’s home visit charges, Attendant / Nursing charges during preand post hospitalisation period.
• Treatment which is continued before hospitalization and continuedeven after discharge for an ailment / disease / injury other than the onefor which hospitalisation claim is made / admissible.

Disclaimer: “For the detailed list of exclusions under the policy, kindly refer to the same provided in your policy kit”