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Health Insurance 843 views September 18, 2020
Top-up is an add-on cover to your existing health insurance that provides additional financial support when medical costs rise. The Oriental Insurance Company Ltd. offers you a top-up plan that you can buy on your existing health insurance plan. There is a maximum entry age of 65 years for this policy. Oriental Super Health Top-up Policy provides you with additional coverages on your health insurance policy. As a result, the premium amount increases. To become eligible for the Oriental Super Health Top-up Policy, you do not have to appear for any premedical examination if you are below 55 years. However, persons with adverse medical history may require the pre-insurance medical tests irrespective of age. Read this page below to know what this policy covers and how it will protect you financially against future health risks.
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The insurer compensates the insured for all admissible expenses incurred exceeding the deductible limit but not exceeding the policy Sum Insured. Under Oriental Super Health Top-up Policy, the company will pay for the hospitalization expenses from the date of admission in the hospital falling within the policy period.
The number of days of stay for the above treatment should not exceed the total number of days of stay in the Hospital. Expenses, which are mentioned below, are also payable as per the room rent limit. However, the medicines, pharmaceuticals and body implants would be payable on an actual basis. Any expense over reasonable and customary charges, or above the negotiated prices in case of a network hospital is borne by the insured.
Note: Relaxation of 24 hours is allowed in specified Daycare procedures and surgeries only if the treatment is taken in a Hospital or a Daycare Centre and not in the Out-Patient department of a hospital. For any other Daycare Treatment not mentioned in the policy clause, you need to take prior approval from the company or TPA in writing. In Ayurvedic, Yoga and Naturopathy, Unani, Siddha and Homeopathic treatment, Hospitalization expenses are admissible only in case of in-patient treatment.
Maternity Cover in Oriental Super Health Top-up Policy
The policy provides an automatic maternity cover of 10% of your Sum Insured. The company will pay the medical expenses as an inpatient for delivery, including the cesarean, or lawful medical termination of pregnancy during the policy period. Only 2 deliveries or terminations, or either during a lifetime are covered under the policy. Maternity cover is not available to those who already have two children. This cover is only for the insured or his/her spouse if the policy has been in force for a continuous period of 12 months in respect of both the Insured and his/her spouse.
However, miscarriage due to accident, an abdominal operation for extra uterine pregnancy and certified to be life-threatening by the attending Medical Practitioner, is not covered in the Oriental Super Health Top-up Policy.
Oriental Super Health Top-up Policy Newborn Baby Cover
This is a benefit cover for the insured and couples expecting a baby. An automatic cover up to 5% of the Sum Insured to the newborn baby up to 90 days from the date of birth. To get coverage beyond 90 days for the full Sum Insured, you need to pay an additional premium. In case the Newborn Baby cover is spread over two policy periods, the aggregate liability of the Oriental company, for all claims in respect of the Newborn Baby cover, will be limited to 5% only. A claim under newborn baby cover is independent of the claim status in respect of the maternity expenses, i.e admissibility.
Note: The claim is admissible only if the expenses are incurred in a Hospital as an in-patient. In the case of family floater plan, the policy Sum Insured would be considered for ascertaining the sublimit of 10% & 5%, and in the case of an individual plan, the Sum Insured of the insured mother would be considered. The company’s overall liability in respect of all claims under this clause during the policy period shall not exceed the Sum Insured as mentioned in the policy schedule.
Coverage When Travelling to SAARC Countries
Oriental Super Health Top-up Policy automatically covers the insured visiting the South Asian Association for Regional Cooperation (SAARC) countries such as Afghanistan, Bangladesh, Bhutan, Maldives, Nepal, Pakistan, Sri Lanka. However, there is no cashless service available for treatment in SAARC countries and such claims are reimbursed based on the return of the insured. All other conditions of the policy in respect of the claim shall apply.
The insurer is not liable to make any payment under the Oriental Super Health Top-up policy to the insured for the following expenses:-
Note: If the above diseases are pre-existing at the time of inception, pre-existing disease exclusion is applied, which means the above diseases will be covered only after the policy has completed 48 months. If continuity of renewal is not maintained or the Sum Insured is enhanced, subsequent cover will be treated as afresh policy and exclusion shall apply afresh.
Deletion of Room Rent Limit
The coverage limits are not applicable if the insured pays the required additional premium for removal of Room Rent limits. In such a case, room rents and other covered expenses become payable on an actual basis. Additional premium payment is as per the loadings mentioned below.
You need to go through the following tests that are performed at the Oriental list of diagnostic centres if you want to buy Oriental Super Health Top-up Policy.
In case the insured has an adverse medical history, the insurer may ask for some additional tests depending on the medical condition. Medical reports upto 30 days before the date of the proposal are valid. In the case of the fresh proposal, 50% cost of Medical Check-up will be reimbursed by the company if it is accepted.
If there has been a break in the Policy Period and continuity benefits are not restored, you have to undergo a Medical Check up again. In such cases, 50% of the cost of Medical Check-up will be reimbursed.
A period of 15 days is provided to the insured to review the terms and conditions of the policy and return the same if not satisfied. The free look period will be applicable from the date of inception of the fresh policy. When you don’t make any claim during the free look period, you are entitled to the following:-
When the aggregate of actual admissible expenses are incurred in respect of any one or more claim during the policy period and it exceeds the deductible under the policy, you can claim it by submitting a notice to the company or TPA.
If there are other sources from where you can receive an amount greater than the deductible, you have an option either to exhaust other options first and subsequently claim the Policy; or to first claim the Policy. If you choose to claim under the policy first and subsequently receive reimbursement from other sources which have also been paid under this Policy, you should refund to the company such excess payment.
To claim the Oriental Super Health Top-up Policy, you need to submit the original Bills, Cash memos, reports, claim form and documents listed below within 15 days of your discharge from the Hospital or Nursing Home.
Note: If there are previous claims during the policy period, and a subsequent claim has exceeded or likely to exceed the Deductible, above listed documents would also be required for the previous claim in addition to the one under consideration. If the TPA is the same for both the policies and the documents have been submitted to the TPA, irrespective of the insurer of the base policy, the Insured just needs to mention the claim number allotted by the TPA and submit the same along with the duly filled claim form. When the TPA under Oriental Super Health Top-up policy and the Base Policy is different, you must submit the documents in respect of all the treatment taken during the policy period as given in the policy. If original documents are already submitted elsewhere, photocopies can be submitted to the concerned TPA or the Insurer, as the case may be, and countersigned by the Insured person, are required to be submitted.
Submit an immediate notice of claim with particulars like policy number, ID Card No., Name of the Insured Person to whom the claim is made, Nature of disease/injury and Name and Address of the attending Medical Practitioner, Hospital, Nursing Home, etc.
It should be submitted to the company or TPA while taking treatment in the Hospital or Nursing Home, either by fax, e-mail, etc. The claim notice should be given within 48 hours of admission, but before the discharge from Hospital or Nursing Home. The company may consider condonation of delay in cases of hardship where it is proven before it or the TPA that the concerned individual was not in a position to give such notice within the prescribed time limit given the circumstances that were there.
The Company or TPA provides admission to the insured in a network Hospital or Nursing Home which is subject to pre-admission authorization. For the pre-admission authorization, you need to submit the related medical details, relevant information of the treatment from the Network Hospital or Nursing Home. The company or TPA pays the sum for which the insured gets admitted as an in-patient after getting the preauthorization request within 48 hours of its receipt.
Your preauthorization request can be denied by the company or TPA in case you do not provide the relevant details. In such cases, the Insured may obtain the treatment as per his/her treating doctor’s advice and later seek reimbursement.
If any information available to the company or TPA makes the claim inadmissible or doubtful and warrants further investigations, the authorization for the cashless facility is withdrawn.
If you take treatment in a non-network hospital, contact the TPA within 7 days from the date of admission with policy details like ID card number, nature of illness, name and address of the hospital or Nursing home. Submit the duly filled Claim Form along with the required documents.
NOTE: The maximum liability of the company is the sum insured as stated in the schedule of the policy.
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