| 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 * | |||||||||
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| 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. |
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| 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. |
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| 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:
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| f. | Pre-Insurance Medical Check-Up *** | In following cases, pre-insurance Medical Check-up is required:
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| 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 | |||||||||
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.
Cashless facility can be availed at any of the network hospitals listed with the servicing TPA (List available on website) or insurance company website. The insured has a choice to go to any of the hospitals/nursing homes which are part of the Insurer/TPA network; it can also be confirmed through call center toll free numbers. It is useful and requested to confirm before seeking admission because network of hospitals is continuously updated with new additions and deletions. In the absence of network hospital of choice or due to any other reason, insured can get treated at the hospital of choice which means the entire bill is paid by the policy holder and claim for reimbursement of expenses. The claim shall then be processed as per policy terms and conditions.
You may write / email to us giving details of your grievance at csd@orientalinsurance.co.in or TPAs call centre or grievance department. We assure you that our grievance department will address the issue within 72 hours
Review Oriental Super Health Top Up insurance brochure to understand coverage details.
Review Oriental Super Health Top Up insurance policy wordings which explains the terms and conditions.
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