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Health Insurance 868 views September 11, 2020
If you are thinking about giving yourself a health insurance cover, consider the Mediclaim Insurance Policy of Oriental Insurance Company Ltd. The Mediclaim Insurance of this company covers medical expenses for Hospitalization, Domiciliary Hospitalization, Illness, Accident and Surgery during the policy period. Oriental Mediclaim Insurance policy will be available to any individual aged between 18 to 65 years. Before you buy this health insurance policy, you should know what it covers and what it does not. So, read this page below to know the same in detail.
Table of Contents
The policy covers medical treatment only for illness or injury during the policy period, up to the limit of your Sum Insured (SI). Check out the table below to know how much the policy covers on various illnesses and injuries.
|Room, Boarding and Nursing Expenses as provided by the Hospital /Nursing Home||Up to 1% of the Sum Insured per day|
|Intensive Care Unit (ICU) expenses as provided by the Hospital/Nursing Home||Up to 2% of the Sum Insured per day|
|Surgeon, Anaesthetist, Medical Practitioner, Consultants, Specialists Fees||Limit of Your Sum Insured|
|Anaesthesia, Blood, Oxygen, Operation, Theatre Charges, Surgical Appliances, Medicines & Drugs, Dialysis, Chemotherapy, Radiotherapy, Artificial Limbs, Cost of prosthetic devices like Pacemaker implanted during surgical procedures, relevant laboratory/diagnostic tests, X-ray, and other similar expenses||Limit of Your Sum Insured|
|Ambulance service charges||INR 2,000 or 1% of the Sum Insured per hospitalization, subject to aggregate expenses up to INR 4,000|
|Daily Hospital Cash Allowance||0.1% of the Sum Insured per day, subject to a maximum of 6 days during the policy period. The company will have a deductible of 2 days for each hospitalization|
|Pre and Post hospitalization expenses||Medical expenses incurred 30 days prior to hospitalization and upto 60 days post-hospitalization|
|Donor Expenses ( Hospitalisation expenses incurred for donating an organ by the donor, except the cost of the organ, to the insured person, during the organ transplant operation||Limited to the Sum Insured|
|Personal accident covering of death and permanent disability (Subject to additional premium)||Sum Insured in multiples of INR 2 lakh upto INR 10 lakh per insured person above the age of 18yrs. For persons below 18 years of age, the maximum cover of INR 4 lakh is allowed.|
Domiciliary Hospitalization Expenses
|Surgeon, Medical Practitioner, Consultants, Specialists Fees, Blood, Oxygen, Surgical Appliances, Medicines & Drugs, Diagnostic Material and Dialysis, Chemotherapy, Nursing expenses||20% of the Sum Insured, subject to a maximum of INR 50,000 per Insured person during the policy period
|Treatment for a Dog bite (or a bite of any other rabid animals like monkeys, cats, etc.)||A maximum of INR 5,000 per incident, actually incurred on immunization injections.|
The Oriental Insurance Company Ltd. is not liable to pay for the treatment of the following injury or illness.
Domiciliary Hospitalization benefits may not cover expenses of the insured if the treatment is of only three days or less and any pre- and post-hospitalization treatment for the illness or injury. The cover won’t be available for expenses incurred on the treatment of the following diseases or conditions.
Add Family Members to Oriental Mediclaim Insurance Policy
You can add your family members to the Oriental Mediclaim Insurance Policy at the time of renewal. However, mid-term inclusion is permitted for newly married spouses or newly born children up to the age of 3 months during the policy period.
Sum Insured for Oriental Mediclaim Insurance Policy
The minimum sum insured under the Oriental Mediclaim Insurance Policy is INR 1,00,000 and in multiples of INR 50,000 thereafter, up to INR 5,00,000. Beyond the Sum Insured of INR. 5,00,000, it will be in multiples of INR 1,00,000 up to INR10,00,000. The sum insured for each of the insured people in a policy may vary. The maximum entry age, which is 65 years under Oriental Mediclaim Insurance Policy, can be extended to 70 years. In such cases, a 10% loading is charged on the premium. This 10% loading will also apply to each subsequent renewal. The maximum sum insured that can be opted under the Oriental Mediclaim Insurance Policy by a person after the age of 65 years is INR 5 lakh. Your policy sum insured can be increased only at the time of renewal and at the discretion of the Company. The maximum increase allowed at each renewal is INR 2 lakh per insured up to the age of 45 years. Beyond 45 years, the maximum increase is INR 1 lakh per insured person.
No increase in the sum insured is allowed for the insured if the person is above 70 years of age.
Note: For the increased sum insured, pre-existing disease and waiting period clauses will remain afresh. A one-time discount of 25% on renewal premium is allowed for if the insured is currently covered with less than INR 1 lakh.
Pre-acceptance Medical Checkup for Oriental Mediclaim Insurance Policy
If your age is 55 years, you need to submit the following medical reports from the company’s Diagnostic Centre. The cost will be borne by the insured for the following pre-medical checkups.
In the case of fresh proposals, a 50% cost of Medical Check-up after acceptance is reimbursed by the company. This benefit is allowed in case continuity benefits are not restored and the policy is treated as fresh after the break-in policy period.
The Oriental Insurance Company Ltd. is not liable to make any payment in respect of any expense incurred by you regarding any pre-existing disease (whether treated, untreated, declared, or not declared in the proposal form). The Pre-existing Disease, which is excluded up to 48 months in the policy, shall be covered only if the policy has been continuously in force for 48 months. Exclusions from Oriental Mediclaim Insurance Policy shall also apply to any complications arising from your pre-existing diseases. To know whether a person is suffering from hypertension or diabetes or both hypertension and diabetes at the time of taking the policy, Oriental Mediclaim Insurance Policy shall have the following exclusions.
Any disease other than those stated above, if contracted to the insured during the first 30 days from the date of inception. The expenses on treatment of the excluded ailments, diseases, surgeries, if manifested after the inception of the first policy, are not payable during the following waiting period as specified below.
|Ailment / Disease / Surgery||Waiting Period|
|Benign ENT disorders and surgeries i.e. Tonsillectomy, Adenoidectomy, Mastoidectomy, Tympanoplasty, etc.||1 year
|Polycystic ovarian diseases||1 year|
|Surgery of hernia||2 years|
|Surgery of hydrocele||2 years|
|Non-infective Arthritis||2 years|
|Undescended Testes||2 years|
|Surgery of benign prostatic hypertrophy||2 years|
|Hysterectomy for menorrhagia or fibromyoma or myomectomy or prolapse of the uterus||2 years|
|Fissure / Fistula in anus||2 years|
|Sinusitis and related disorders||2 years|
|Surgery of gallbladder and bile duct excluding malignancy||2 years|
|Surgery of genitourinary system excluding malignancy||2 years|
|Pilonidal Sinus||2 years|
|Gout and Rheumatism||2 years|
|Calculus diseases||2 years|
|Surgery for the prolapsed intervertebral disk unless it is a cause of an accident||2 years|
|Surgery of varicose veins and varicose ulcers||2 years|
|Congenital internal diseases||2 years|
|Joint Replacement due to Degenerative condition||4 Years|
|Age-related osteoarthritis and Osteoporosis||4 Years|
Note: However, this may not apply in case the insured person is hospitalized for injuries suffered in an accident, which occurred after the inception of the policy.
The premium under the policy can be paid in advance. No receipt for the premium is valid except the official form of the Oriental Insurance Company Ltd. signed by a duly authorized official. No waiver of any terms, provisions, conditions and endorsements of this policy shall be valid unless it is made in writing and signed by an authorized official of the Company.
Oriental Insurance Company Ltd. is not liable or responsible for the non-renewal of a policy due to non-receipt or delayed receipt. The company shall not deny the renewal unless there are cases like fraud, moral hazard, misrepresentation, or non-cooperation by the insured.
The premium rates, which are applied to your Oriental Mediclaim Insurance Policy, are valid only for the period of the policy. Oriental Insurance Company Ltd. can revise the premium rates and the terms & conditions, upon renewal. Any revision or modification in the policy will be notified to the policyholder 3 months in advance.
To claim Oriental Mediclaim Insurance Policy, you need to submit an immediate notice of claim with particulars such as Policy Number, ID Card No, Name of the insured person, Nature of the disease/injury, Name and Address of the attending medical practitioner/Hospital/Nursing Home, etc. This notice should be given to the company or TPA by Fax or Email while taking treatment in the Hospital/Nursing Home. The notice should be given within 48 hours of admission or before discharge from Hospital/Nursing Home unless it is waived in writing.
To make a cashless claim for the Oriental Mediclaim Insurance Policy, you need to get admission to a network Hospital/Nursing Home for pre-admission authorization. The company or TPA reserves the right to approve or deny the pre-authorization in case you and the hospital are unable to provide the relevant information. If any information available to the company or TPA makes the claim inadmissible or doubtful and warrants further investigations, the authorization of the cashless facility may be withdrawn.
The company or TPA needs the claim form and the documents within 15 days of discharge from the Hospital or Nursing Home. All claims are payable in Indian currency only and the medical treatment for this insurance policy should be taken in India only.
You are entitled to a reimbursement of the cost of Health check-up undertaken once at the expiry of a block of every 3 continuous underwriting years if there are no claims made during the block years. The reimbursement amount is equal to or 0.75% of the average sum Insured for Personal Accident or INR 3,000 per insured, whichever is less. This benefit is available to the insured only after 3 claim-free years, till the expiry of the fourth year. If the benefit is not claimed in the fourth year, the last three claim-free years preceding the year shall be taken into consideration when the insured claim.
This clause shall apply separately to each insured person, if there is no claim reported for the preceding 3 years – you are eligible for a benefit even when there is a claim reported for another insured person covered under the Oriental Mediclaim Insurance Policy. This benefit is applicable only in respect of continuous insurance without any break.
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