Insurance Plans September 7, 2020

Oriental Happy Family Floater Policy covers an individual, his/her family that includes Spouse, Children, Parents, and Parents in-laws. The policy is available to you in three plans Silver, Gold, and Diamond. Today, health issues are arising more often, and the expenses are quite high, a family health insurance policy assures you and your family to be protected during unfortunate medical situations. Because protecting and caring is what a family man does. Oriental Happy Family Floater Policy is dedicated to those who always put their family first. Read this page to know more about Oriental Happy Family Floater Policy coverage and exclusion.

What Does the Oriental Happy Family Floater Policy Cover?

The table below shows the expenses this Happy Family Floater Policy cover, the extent of coverage across several variants.

Expenses CoveredSilver Plan CoverageGold Plan CoverageDiamond Plan Coverage
Room, Boarding and Nursing 1% of the Sum Insured1% of the Sum InsuredINR 10,000 + 0.50% of the Sum Insured above INR 10 lakh per day
Intensive Care Unit (ICU)2% of the Sum Insured2% of the Sum InsuredINR 20,000 + 1% of the Sum Insured above INR 10 lakh per day
Surgeon, Anaesthetist, Medical Practitioner, Consultants, Specialists Fees As per the limits of Sum InsuredAs per the limits of Sum InsuredAs per the limits of Sum Insured
Anaesthesia, Blood, Oxygen, Operation Theatre Charges, Surgical Appliances, Medicines & Drugs, Diagnostic Material and X-Ray, Dialysis, Chemotherapy, Radiotherapy, Cost of Pacemaker, Artificial Limbs and similar expensesAs per the limits of Sum Insured
As per the limits of Sum InsuredAs per the limits of Sum Insured
Daily Hospital Cash Allowance
Daily Hospital Cash Allowance Not Available0.1% of the Sum Insured (INR 600 to INR1,000 per day of Hospitalization), subject to maximum compensation for 10days per Illness.
Overall liability of the Company during the Policy Period will be limited to 1.5% of the Sum Insured
0.1% of the Sum Insured (INR 1,200 to INR 2,000 per day of Hospitalization), subject to maximum compensation for 10 days per Illness.
Overall liability of the Company during the Policy Period will be limited to 1.5% of the Sum Insured
Attendant allowance Not AvailableINR 500 per day of Hospitalization, subject to maximum compensation for 10 days per Illness.
Overall liability of the Company during the Policy Period will be limited to compensation for 15 days of Hospitalization
INR 1,000 per day of Hospitalization, subject to maximum compensation for 10 days per Illness.
Overall liability of the Company during the Policy Period will be limited to compensation for 15 days of Hospitalization
Maternity expensesNot AvailableNot Available2.5% of the Sum Insured
New Born BabyNot AvailableNot Available2.5% up to 90 days from the date of birth. After that, the baby will be covered in the policy on payment of the requisite premium
Medical Second Opinion on specified major IllnessesUpto INR 5,000 in the policy periodUpto INR 10,000 in the policy periodUpto INR 15,000 in the policy period
Organ Donor Benefit when Insured Person is Donor10% of the Sum Insured in a lump sum10% of the Sum Insured in a lump sum10% of the Sum Insured in a lump sum
Donor Expenses when the Insured Person is Recipient

As per the limits of Sum InsuredAs per the limits of Sum InsuredAs per the limits of Sum Insured

Additional Coverage on Oriental Happy Family Floater Policy

Restoration of the Sum Insured: When the policy sum insured is reduced or exhausted if you have made a claim, this additional coverage will restore the sum insured to the extent of the claim amount not exceeding the restoration limit. For this feature, you need to pay an additional premium in addition to your sum insured.

The restoration limit is 50-100% of your sum insured that ranges from INR 3 to 10 lakh. You need to make sure that the maximum amount for any one claim payable shall not exceed the Sum Insured and Restored Sum Insured.

Personal Accident Cover: If during the policy period you get any bodily Injury from sudden, unforeseen and involuntary events caused by external, visible and violent means anywhere in the world, the company undertakes to pay the Capital Sum Insured  (CSI) to the insured, nominee, or the legal heir if the nominee isn’t present. Let’s check out how CSI will be given

  1. 100% of CSI in case of accidental death
  2. 100% of CSI in case of loss of 1 or 2 limbs and loss of sight of 1 or 2 eyes
  3. 50% of CSI in case of loss of one entire limb and loss of one eye
  4. 100 % of CSI for Permanent Total Disablement

Life Hardship Benefit Plan: If you are diagnosed with any 11 critical illness which is covered in this policy, the company will provide you with survival benefits as mentioned in the table below.

Plan Total Amount PayableSurvival for 180 days and above post-discharge from the hospitalSurvival for 270 days and above post-discharge from the hospital
A15% of the sum insured under the policy5% of the sum insured10% of the sum insured
B25% of the sum insured under the policy10% of the sum insured15% of the sum insured

However, the benefits will not apply to pre-existing critical illnesses. And the benefit is paid under the policy once during the lifetime of the insured.

What is Excluded from the Oriental Happy Family Floater Policy?

  1. Intentional self-injury and attempted suicide
  2. Illness due to the intoxicating influence of liquor or drugs
  3. Engagement in a hazardous sport like bungee jumping, parasailing, parachuting, ski-diving, BASE jumping, paragliding, hang gliding, mountain or rock climbing necessitating the use of guides or ropes, solo climbing, ice climbing, ice canoeing, scuba diving, Caving, cave diving, potholing, abseiling, snowboarding, wave ski surfing, deep-sea diving using hard helmet and breathing apparatus, polo, snow and ice sports.
  4. Hazardous activities such as military, air force or naval operations
  5. The direct or indirect cause of venereal disease or insanity
  6. Illness or Injury arising due to a criminal act or breach of law
  7. When the insured’s illness or injury is a direct or indirect result of war, invasion, an act of a foreign enemy, hostilities, civil war, rebellion, revolution, insurrection, mutiny, military or usurped power, seizure, capture, arrest, restraints, and detainments of people
  8. The direct or indirect cause of injury or illness arising from ionizing radiation or contamination by radioactivity from any nuclear fuel, nuclear weapon material, or from any nuclear waste from the combustion of nuclear fuel
  9. Health risks due to childbirth or pregnancy
  10. Tumors showing the malignant changes of carcinoma in situ
  11. Tumors which are histologically
  12. Carcinoma in situ of breasts
  13. Cervical dysplasia CIN-1, CIN -2 & CIN-3
  14. Any skin cancer other than invasive malignant melanoma
  15. All tumors of the prostate unless histologically classified as having a Gleason score > 6
  16. Papillary microcarcinoma of the thyroid < 1 cm in diameter
  17. Chronic lymphocytic leukemia < RAI stage 3
  18. Micro carcinoma of the bladder
  19. All tumors in the presence of HIV infection
  20. Non-ST-segment Elevation Myocardial Infarction (NSTEMI) with an elevation of troponin I or T
  21. Acute Coronary Syndromes
  22. Any type of angina pectoris.
  23. Angioplasty and any other intra-arterial procedures
  24. Any keyhole or laser Surgery
  25. Catheter-based technique including but not limited to, balloon valvotomy or valvuloplasty are excluded
  26. Coma resulting from alcohol or drug abuse
  27. Transient ischemic attack (TIA)
  28. Traumatic Injury of Brain
  29. The vascular disease affecting only one eye, optic nerve, or vestibular functions
  30. Stem cell transplants where only islets of Langerhans are transplanted
  31. Neurological damage cause such as SLE and HIV
  32. Any form of cosmetic surgery or implants.
  33. Illness or disease is caused by external, violent, and visible and evident means which is verified and certified by a Medical Practitioner.
  34. Surgery of gallbladder and bile duct excluding malignancy
  35. Surgery of the genito-urinary system excluding malignancy

Critical Illness Covered Under Oriental Happy Family Floater Policy

The health insurance plan secures you and your family from these below mentioned 11 major illnesses like –

Cancer of Specified Severity: A malignant tumor is identified by the uncontrolled growth and spread of malignant cells with invasion and destruction of normal tissues.

The diagnosis is supported by histological evidence of malignancy and confirmed by a pathologist. The term cancer includes leukemia, lymphoma, and sarcoma as well.

First Heart Attack of Specified Severity: The first occurrence of myocardial infarction, which signifies the death of a portion of the heart muscle due to inadequate blood supply to the relevant area. The diagnosis for a heart attack will be identified by all of the following:

  1. Chest Pain
  2. Electrocardiogram Changes
  3. Elevation of infarction specific enzymes like Troponins or other specific biochemical markers

Open Chest Coronary Artery Bypass Grafting (CABG): The actual undergoing of open chest surgery for the correction of one or more coronary arteries, which is/are narrowed or blocked, by CABG. The diagnosis should be supported by a coronary angiography, and the realization of the surgery must get confirmed by a specialist medical practitioner.

Open Heart Replacement or Repair of Valves: The actual undergoing of open-heart valve Surgery is to replace or repair one or more heart valves, as a consequence of defects in, abnormalities of, or disease-affected cardiac valve(s). The diagnosis of a valve abnormality must be supported by echocardiography and the realization of the surgery later confirmed by a specialist medical practitioner.

Coma of Specified Severity: An unconscious state with no reaction or response to external stimuli or internal needs. This diagnosis must be supported by the following evidence:

  1. No response to any external stimuli for a minimum of 96 hours
  2. Life support measures are necessary to sustain life; and
  3. The permanent neurological deficit which must be assessed at least 30 days after the onset of the coma.

Kidney Failure Requiring Regular Dialysis: End-stage renal disease presenting as a chronic irreversible failure of both kidneys to function, as a result of which either regular renal dialysis (hemodialysis or peritoneal dialysis) is instituted or renal transplantation is carried out. The diagnosis of this ailment should be confirmed by a specialist medical practitioner.

Stroke Resulting in Permanent Symptoms: These symptoms occur when a cerebrovascular incident produces permanent neurological sequelae. This also includes infarction of brain tissue, thrombosis in an intracranial vessel, hemorrhage, and embolization from an extracranial source. The diagnosis needs to be confirmed by a specialist Medical Practitioner and evidenced by clinical symptoms and typical findings in CT Scan or MRI of the brain.

Major Organ or Bone Marrow Transplant: The actual undergoing of a transplant of one of the following human organs: heart, lung, liver, kidney, pancreas, resulting from an irreversible end-stage failure of the relevant organ, or Human bone marrow using hematopoietic stem cells. The transplant must get confirmed by a specialist medical practitioner.

Permanent Paralysis of Limbs: Total and irreversible loss of use of two or more limbs due to an injury or cause of a disease of the brain or spinal cord. A specialist Medical Practitioner must think that the paralysis will be permanent with no hope of recovery and must be present for more than 3 months.

Motor Neuron Disease with Permanent Symptoms: Motor neuron disease diagnosed by a specialist Medical Practitioner as spinal muscular atrophy, progressive bulbar palsy, amyotrophic lateral sclerosis, or primary lateral sclerosis. There should be progressive degeneration of corticospinal tracts, anterior horn cells, or bulbar efferent neurons. It should be current significant and permanent functional neurological impairment with objective evidence of motor dysfunction that has persisted for a continuous period of at least 3 months.

Multiple Sclerosis with Persisting Symptoms: The definite occurrence of multiple sclerosis needs to be diagnosed with the support of the following investigations-

  1. Typical MRI and CSF findings
  2. Current clinical impairment of motor or sensory function persisted for a continuous period of at least 6 months
  3. Clinical history of exacerbations and remissions of said symptoms or neurological deficits with at least two clinically documented episodes at least one month apart.

Free Look Period of Oriental Happy Family Floater Policy

When you buy Oriental Happy Family Floater Policy, the company provides you a free look period which is applicable from the date of inception. During this period, the insured is allowed to review the terms and conditions of the policy and can return the same within 15 days if you don’t find it appealing. If you don’t make any claim during the free look period and return the policy, you are entitled for –

  1. Refund of the paid premium less any expenses incurred due to the medical examination and the stamp duty charges.
  2. A deduction towards the proportionate risk premium for the period on the cover if the risk is commenced and you have returned the policy.
  3. A risk premium corresponding to the risk covered during the period when only a part of the risk is commenced.

How to Make a Claim for Oriental Happy Family Floater Policy?

You can claim by sending the following details about the policy.

  1. Policy Number
  2. ID Card No
  3. Name of the Insured Person
  4. Nature of the disease or injury
  5. Name and Address of the attending Medical Practitioner, Hospital or Nursing Home, etc.

This notice is to be submitted to the Company or Third Party Administrator (TPA) while the insured is treated in the Hospital or Nursing Home by fax or email, whichever is suitable to you. Such notice should be given within 48 hours of hospitalization.

Along with original Bills, Cash memos, Medical reports and claim form, you need to send other documents to Oriental Insurance Company or TPA within 15 days of discharge.

  1. Original bills
  2. All receipts and Discharge certificate and card from the Hospital or Nursing Home
  3. Documents about Illness, such as the starting date of the disease detection
  4. Medical history of the patient recorded by the Hospital
  5. Original Cash-memo from the Hospital (s) or chemist (s) with a proper prescription.
  6. Test reports from a pathologist or radiologist including film etc. supported by a note from the attending Medical Practitioner or Surgeon who prescribed tests.
  7. Attending Consultants, Anaesthetists, Specialist certificates regarding diagnosis with bills, receipts, etc.
  8. Surgeon’s original certificate stating the diagnosis and nature of operation along with bills, receipts, etc.
  9. MLC/FIR/Post Mortem Report,( if needed in the case)
  10. Disability certificate
  11. Death certificate ( if applicable)

Documents for Organ Donation

  1. Details of previous policies if you have not submitted them to the TPA.
  2. Any other additional information which is required by the TPA or Company
  3. All documents should be duly attested by the Insured Person or the Claimant

Cashless Facility in Network Hospitals/Nursing Homes

A pre-admission authorization is necessary for a cashless facility from TPA or Company. The Company or TPA requires the related medical details or relevant information from the Insured Person, Network Hospital, or Nursing Home, to verify whether the person is eligible to claim or not. If any of the two finds you eligible, you will be issued a pre-authorization letter, which is a guarantee of payment letter to the Hospital or Nursing Home.

The Company or TPA reserves the right to deny a pre-authorization in case the Hospital or the Insured Person is unable to provide information and medical details. In such cases, the denial of cashless facilities happens. You must get the treatment as per your treating doctor’s advice and later on submit the documents along with claim papers to the Company or TPA within 15 days of discharge.

The cashless facility may be withdrawn if any information which makes the claim inadmissible or doubtful, and warrants further investigations. However, this is done by the Company or TPA before you are discharged from the Hospital and notice to this effect is given to the treating Hospital or insured. The list of network hospitals is available on the official website of the Oriental Insurance Company Ltd. which is www.orientalinsurance.org.in and will also be provided by the concerned TPA.

Premium Payment and Sum Insured

You need to pay the Oriental Happy Family Floater Policy premium in advance. No receipt from the insured is acceptable for premium, except on the official form of the insurance company, which is signed by the company authorized official. The due payment of premium by the insured person is to be done or complied with the condition precedent to any liability of the company. No waiver of any terms, provisions, conditions and endorsements of Oriental Happy Family Floater Policy is valid unless it is made in writing and signed by an authorized official of the Company.

The insured can get covered with a sum of INR 2 lakh to INR 20 lakh under Oriental Happy Family Floater Policy. An existing insured person with a sum insured of INR 1 lakh can continue with the same. Whereas those who have an existing policy of INR 1.5 lakh can also opt for Oriental Happy Family Floater Policy at INR 1 lakh sum insured,

When you cancel this policy, the company shall allow you to get a refund of the paid premium at its short period rate only if no claims occur during the period. Look at the table below to know the short period rate of Oriental Insurance Company Ltd.

Plan Total Amount PayableSurvival for 180 days and above post-discharge from the hospitalSurvival for 270 days and above post-discharge from the hospital
A15% of the sum insured under the policy5% of the sum insured10% of the sum insured
B25% of the sum insured under the policy10% of the sum insured15% of the sum insured

However, no refund is made on the policy if cancellation is due to fraud or moral hazard

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