Health Insurance 205 views February 12, 2021

Oriental Insurance Health of Privileged Elders (HOPE) Policy provides coverage for hospitalization expenses when an illness or injury requires medical or surgical treatment as advised by the qualified medical practitioner. The Oriental Insurance Health of Privileged Elders (HOPE) Policy is exclusively designed for senior citizens whose age is 60 or above. This policy covers all their hospitalization needs, so they don’t have to worry about the finances when a medical risk arises during the policy term. Read this page further and know more about the Oriental Insurance Health of Privileged Elders (HOPE) Policy coverages and exclusions.

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Specified Diseases Covered Under Oriental Insurance Health of Privileged Elders (HOPE) Policy

The following diseases, illness or injuries are covered under the Accidental Injury

  1. Knee Replacement
  2. Cardiovascular Diseases
  3. Chronic Renal Failure
  4. Cancer
  5. Hepato-BilliaryDisorders
  6. Chronic Obstructive Lung Diseases
  7. Stroke
  8. Benign Prostate
  9. Orthopedic Diseases
  10. Ophthalmic Diseases

Your accidental injury is capped at 100% of the sum assured, while the knee replacement surgery claim amount is up to 70% of the sum insured only. The rest of the illness, disease or injury is capped at 50% of the sum insured.

List of Reasonable and Necessary Expenses Covered Under Oriental Insurance Health of Privileged Elders (HOPE) Policy

Oriental Insurance will pay directly or reimburse the following fees if you are hospitalized during the policy term.

  1. Room, Boarding and Nursing charges up to 1% of the sum insured
  2. ICU charges not more than 2% of the sum insured
  3. Pre-hospitalization expenses up to 30 days
  4. Post-hospitalization expenses up to 60 days
  5. Ambulance fees up to actual expenses or INR 1,000, whichever is less
  6. Surgeon, anesthetist, medical practitioner, consultants, specialists fees
  7. Cost of anesthesia, blood, oxygen, Operation Theatre (OT) charges, surgical appliances, medicines & drugs, dialysis, chemotherapy, radiotherapy, artificial limbs, prosthetic devices such as a pacemaker, relevant laboratory or diagnostic test, X-Ray, etc.

Note – The company will pay only reasonable and necessary expenses as per the severity of your specified diseases, illness or injury. And the maximum shouldn’t exceed the limit irrespective of the expenses incurred by the insured.

Hospitalization Period Limit for Oriental Insurance Health of Privileged Elders (HOPE) Policy

The company will pay for the hospitalization only if it is for a minimum period of 24 hours. However, this hospitalization time limit won’t apply to the following –

  1. Hemodialysis
  2. Parenteral Chemotherapy
  3. Radiotherapy
  4. Eye Surgery
  5. Lithotripsy (kidney stone removal)
  6. Dental surgery (if part of the accident injury treatment)
  7. Coronary Angioplasty
  8. Coronary Angiography
  9. Surgery of Gallbladder, Pancreas and bile duct
  10. Surgery of Prostate
  11. Treatment of fractures or dislocation except for hairline fracture
  12. Arthroscopic knee surgery
  13. Laparoscopic therapeutic surgeries
  14. Surgery under general anesthesia or any such procedure which is agreed by TPA or the company before treatment.

If the above-mentioned illness or injury treated at a daycare center, the medical facility should meet the following –

  1. Qualified nursing staff
  2. Qualified medical practitioner
  3. Fully equipped operation theatre
  4. Daily record maintenance of patients
  5. Minimum number of beds

Also in case of domiciliary hospitalization, the period of hospitalization should not exceed 3 days for an illness, disease or injury.

Oriental Insurance Health of Privileged Elders (HOPE) Policy Co-Payment Clause

As stated in the policy bond, the insured has to bear 20% of every claim. The copayment means you need to pay a part of your medical expenses while the rest will be payable by the company.

No Claim Discount on Oriental Insurance Health of Privileged Elders (HOPE) Policy

If you haven’t claimed in a policy year, you will be entitled to a No Claim Discount (NCB) at a rate of 5% of the renewal premium. The NCB subject to a maximum of 20%, provided the policy is renewed without any break. Check out the table below and know how these NCB will apply to your Oriental Insurance Health of Privileged Elders (HOPE) Policy –

Claim Free Policy YearDiscount Rate
After 1st year5%
on 2nd year10%
On 3rd year15%
On 4th year20%

Note  – NCB shall become ‘NILl’ if a claim has been made under the policy, irrespective of the claim amount. You can get the NCB on renewal of this policy only. At the company discretion where a policy is renewed within 7 days from the date of expiry, the renewal is permissible with the applicable NCB.

Exclusions from Oriental Insurance Health of Privileged Elders (HOPE) Policy

The following won’t be admissible for claim under Oriental Insurance Health of Privileged Elders (HOPE) Policy –

  1. Any disease or health condition not specified in the policy
  2. Pre-existing health conditions, disease or ailment will be excluded for up to 2 years, provided renewals are continuous for the policy. Also, the complications shall be excluded as they are a part of the pre-existing health condition or disease.
  3. Diabetic Retinopathy
  4. Diabetic Nephropathy
  5. Diabetic Foot /wound
  6. Diabetic Angiopathy
  7. Diabetic Neuropathy
  8. Hyper/Hypoglycemia shocks
  9. CerebroVascular accident
  10. Hypertensive Nephropathy
  11. Internal Bleed/ Haemorrhages
  12. Coronary Artery Disease
  13. Any disease during the first 30 days from the commencement date. This exclusion shall not apply to accidental injuries.
  14. Expenses for Non-infective Arthritis, Cataract, Surgery of benign prostatic hypertrophy, surgery of gallbladder and bile duct excluding malignancy, surgery of genitourinary system excluding malignancy, gout and rheumatism, calculus diseases, joint replacement due to degenerative condition, and age-related osteoarthritis and osteoporosis shall be excluded under this policy for the first 2 policy years only.
  15. If an illness or injury is caused due to war, invasion, an act of foreign enemy or warlike operations
  16. Circumcision (unless required for treatment of a disease)
  17. Vaccination
  18. Inoculation
  19. Change of life
  20. Cosmetic or aesthetic treatment
  21. Hair transplant
  22. Plastic surgery (unless necessitated due to an accident or if a part of illness/disease treatment)
  23. Surgery for correction of eyesight
  24. Cost of spectacles, contact lenses, hearing aids, etc.
  25. Convalescence, general debility, “run-down” condition or rest cure
  26. Congenital external diseases/defects/anomalies
  27. Sterility, any fertility, sub-fertility or assisted conception process
  28. Venereal diseases
  29. Intentional self-injury/suicide,
  30. Psychiatric and psychosomatic disorders and diseases
  31. Drugs/alcohol abuse
  32. Illness associated with Human T-cell Lymphotropic Virus Type III (HTLD – III), Lymphadenopathy Associated Virus (LAV), mutant derivative or variations deficiency syndrome, or any syndrome referred to as AIDS.
  33. HIV and its complications
  34. Sexually transmitted diseases
  35. Expenses incurred at Hospital/Nursing Home for evaluation/diagnostic purposes only
  36. Expenses on vitamins, tonics, mineral water and allied items unless they are part of treatment for injury or disease
  37. Naturopathy treatment
  38. Unproven procedure or treatment
  39. Experimental or alternative medicine and related treatment
  40. Acupressure, acupuncture, magnetic and other therapies
  41. Private nursing charges, referral fee to family doctors, fees of outstation consultants/surgeons, etc.
  42. Non-medical equipment such as walkers, crutches, belts, collars, diabetic footwear, etc.
  43. Change of treatment from one system of medicine to another (unless necessitated and agreed/allowed by the TPA/Company.
  44. Treatment of obesity or any condition arising such as morbid obesity
  45. The weight control program, services or supplies, etc.
  46. Participation in scuba diving, motor racing, parachuting, hang gliding, rock or mountain climbing, etc.
  47. Treatment in a convalescent home, convalescent hospital, health hydro, nature care clinic or similar establishments.
  48. Stay in hospital expenses if there is no domestic reason or no active regular medical treatment is provided.
  49. Outpatient diagnostic, medical or surgical procedures/treatments
  50. Non-prescribed drugs and medical supplies
  51. Massages, steam bathing, shirodhara and such other treatment under Ayurvedic treatment.
  52. Doctor’s home visit fees, attendant or nursing charges in pre and post-hospitalization period.
  53. Continued treatment before hospitalization and after discharge

Free Look Period for Oriental Insurance Health of Privileged Elders (HOPE) Policy

You will have a free look period of 15 days starting from the date of receipt of the policy. During the free look period, you can read the policy terms and conditions and return the same if not agreeable. If you do so, you will be entitled to a refund of the paid premiums less the stamp duty and medical examination charges.

Claim Process of Oriental Insurance Health of Privileged Elders (HOPE) Policy

First send immediate notice of claim to the company/TPA if you are taking treatment in the hospital/nursing home with particulars such as policy number, ID card number, name of the insured person (in respect of whom claim is made), nature of disease, illness or injury, address of the attending medical practitioner, hospital/nursing home, etc. This notice should be given within 48 hours of admission or before discharge, whichever is earlier, by fax or email.

Once you send the notice, submit the hospital original bills/cash memos/reports, along with the following documents within 7 days of discharge

  1. Original bills, receipts and discharge certificate/card
  2. Medical history
  3. Original cash memos
  4. Original receipt, pathological and other test reports
  5. Attending consultants, anesthetists, specialist certificates related to the diagnosis and bill or receipts
  6. Surgeon’s original certificate stating the reason of diagnosis and operation

Note – The insured should submit any other information if required by the TPA/company.

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