Insurance Plans September 8, 2020

Oriental HOPE Senior Citizen Health Insurance Plan

Oriental Insurance Company Ltd. offers a special health insurance plan for senior citizens who are aged 60 years and above with Oriental Hope Senior Citizen Health Insurance Plan, This health insurance plan covers the insured with a sum insured of INR 1 lakh, 2 lakh, 3 lakh, 4 lakh and 5 lakh. The health insurance policy is available to any Indian citizen to meet his/her hospitalization expenses in India. Read this page below to know what it covers, exclude, and several other information.

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Oriental Hope Senior Citizen Health Insurance Plan Cover

The company will cover specified Diseases, illness and injury of senior citizens only. Check the pointers below to know about them.

  1. Accidental Injury Up to 100% of the Sum Insured
  2. Knee Replacement up to 70% of the Sum Insured
  3. Cardiovascular Diseases up to 50% of the Sum Insured
  4. Chronic Renal Failure up to 50% of the Sum Insured
  5. Cancer Treatment up 50% of the Sum Insured
  6. Hepato-Biliary Disorders up to 50% of the Sum Insured
  7. Chronic Obstructive Lung Diseases up to 20% of the Sum Insured
  8. Stroke up to 20% of the Sum Insured
  9. Benign Prostatic up to 15% of the Sum Insured
  10. Orthopedic Diseases up to 15% of the Sum Insured
  11. Ophthalmic Diseases up to 10% of the Sum Insured

The following are the expenses which are payable under the specified disease, illness, or injury treatment.

  1. Room Rent up to 1% of the Sum Insured per day
  2. Boarding and Nursing Expenses by the Hospital or Nursing Home up to 1% of the Sum Insured per day
  3. I.C.U expenses up to 2% of the Sum Insured per day
  4. Ambulance Services covered upto INR 1,000 or the actual expenses, whichever is less
  5. Fees of Surgeons, Anaesthetists, Medical Practitioners, Consultants, Specialists
  6. Anesthesia, Blood, Oxygen, Operation Theatre Charges, Surgical Appliances, Medicines & Drugs, Dialysis, Chemotherapy, Radiotherapy, Artificial Limbs, Cost of Prosthetic devices implanted during surgical procedure like a pacemaker, Relevant Laboratory / Diagnostic test, X-Ray, etc.

Hospitalization Expenses

The company will pay the hospitalization expenses of the insured if he/she is hospitalized for a minimum of 24 hours. However, it may not apply to the following:

  1. Hemodialysis
  2. Parenteral Chemotherapy
  3. Radiotherapy
  4. Eye Surgery
  5. Lithotripsy (kidney stone removal)
  6. Dental surgery following an accident
  7. Coronary Angioplasty
  8. Coronary Angiography
  9. Surgery of Gallbladder
  10. Surgery of Pancreas and bile duct
  11. Surgery of Prostate.
  12. Treatment of fractures and dislocation excluding hairline fracture, contracture releases and minor reconstructive procedures of limbs that otherwise require hospitalization.
  13. Arthroscopic Knee surgery
  14. Laparoscopic therapeutic surgeries
  15. Surgery under General Anaesthesia or any such procedure agreed by the TPA or Company before treatment

Exclusions from Oriental Hope Senior Citizen Health Insurance Plan

The company is not liable to make any payment under the policy if the expenses arise from any disease, health condition, illness, or ailment other than the specified covered illness and injury.

  1. Non-infective Arthritis
  2. Cataract
  3. Surgery of benign prostatic hypertrophy
  4. Surgery of gallbladder and bile duct excluding malignancy
  5. Surgery of the genitourinary system excluding malignancy
  6. Gout and Rheumatism
  7. Calculus diseases
  8. joint Replacement due to Degenerative condition
  9. Age-related osteoarthritis and Osteoporosis
  10. Illness or Injury due to War, Invasion, Act of Foreign Enemy, War like operations
  11. Circumcision
  12. Vaccination
  13. Inoculation
  14. Change of life
  15. Cosmetic treatment
  16. Hair transplant
  17. Plastic surgery
  18. Eyesight surgery
  19. Cost of spectacles, contact lenses, hearing aids, etc.
  20. Convalescence
  21. General debility
  22. “Run down” condition
  23. Rest cure
  24. Congenital external diseases
  25. Defects or Anomalies
  26. Sterility
  27. Any fertility, subfertility, or assisted conception procedure
  28. Venereal diseases
  29. Intentional self-injury or suicide
  30. All psychiatric and psychosomatic disorders and diseases
  31. Accident due to misuse or abuse of drugs and alcohol
  32. Expenses arising out of any condition directly or indirectly caused by Human T-cell Lymphotropic Virus Type III (HTLD – III), Lymphadenopathy Associated Virus (LAV), Mutants Derivative, Variations Deficiency Syndrome, or any Syndrome or condition of AIDS, HIV and its complications including the sexually transmitted diseases.
  33. Expenses for evaluation or diagnosis incurred at Hospitals or Nursing Homes, which are not followed by any active treatment for the illness or injury.
  34. Expenses on vitamins, tonics, mineral water and allied items unless it is part of treatment for injuries or diseases
  35. Naturopathy treatment
  36. Unproven procedure or treatment
  37. Experimental treatment
  38. Alternative medicine
  39. Treatment-related to acupressure, acupuncture, magnetic and other therapies, etc.
  40. Expenses incurred for investigation or treatment of irrelevant diseases diagnosed during hospitalization, including Private nursing charges, Referral fee to family doctors, Outstation consultants or Surgeon’s fee, etc.
  41. External and durable Medical or Non-medical equipment such as Ambulatory devices i.e. Walker, Crutches, Belts, Collars, Caps, Splints, Slings, Braces, Stockings, etc.
  42. All non-medical expenses including your comfort and convenience items like telephone, television, Aya, barber, beauty services, diet charges, baby food, cosmetics, napkins, toiletry items, etc, guest services and similar incidental expenses or services, etc.
  43. Change of treatment unless it is agreed by the TPA or Company
  44. Treatment of obesity
  45. The weight control program, services, or supplies, etc.
  46. Any treatment required due to participation in any hazardous activity such as scuba diving, motor racing, parachuting, hang gliding, rock or mountain climbing, other allied similar activities, etc.
  47. Any treatment received in a convalescent home, convalescent hospital, health hydro, nature care clinic, or similar establishments
  48. Stay in the hospital for domestic reasons where no medical treatment is given by the specialist or physician
  49. Outpatient Diagnostics
  50. Medical or Surgical procedures and treatments
  51. Non-prescribed drugs and medical supplies
  52. Massages, Steam bathing, Shirodhara under Ayurvedic treatment
  53. Any kind of Service charges, Surcharges, Admission fees, Registration charges, File Charges, etc, levied by the hospital
  54. Doctor’s home visit charges
  55. Attendant or Nursing charges during pre- and post-hospitalization periods
  56. Treatment continued before hospitalization and continued even after discharge for an ailment/disease/injury other than the one for which the hospitalization claim is made / admissible.

Pre-acceptance Medical Check-up

If you are buying the Oriental Hope Senior Citizen Health Insurance Plan, you need to submit the following medical reports.

  1. Physical Examination
  2. Urine (Microalbuminuria)
  3. Glycosylated Haemoglobin
  4. Ultrasonography (whole abdomen and pelvis)
  5. X-ray of both knees (Anteroposterior and Lateral)
  6. Complete eye test including fundus etc
  7. Stress test (TMT)

This medical test will be applicable for renewal if there is a break in your policy period. The cost of such a pre-medical check-up is borne by the insured. However, in a fresh proposal, the company shall reimburse per person 50% of the cost of the pre-medical check-up. The test will proceed in the list of diagnostic centers approved by the company.

Free Look Period

With your Oriental Hope Senior Citizen Health Insurance Plan, you shall have a free look period that is applicable at the inception of the fresh policy. In this period, the insured is allowed 15 days from the date of receipt of the policy to review the policy and return the same if it is not acceptable.

If you don’t make any claim during this free look period, you can get the following benefits –

  1. A refund of the premium minus the stamp duty charge and pre-medical check-up
  2. A deduction towards the proportionate risk premium if the risk is commenced during the free look period and the policy is returned by the insured.
  3. A risk premium commensurate with the risk covered during the free look period if only a part of the risk is commenced.

Claim Procedure for Oriental Hope Senior Citizen Health Insurance Plan

Reimbursement: You should make claims by submitting particulars such as Policy Number, ID Card No, Name of the insured, Nature of the disease, illness or injury, name, and address of the attending doctor, hospital, nursing home, etc.

You should submit these details to the Company or TPA while taking treatment in the Hospital or a Nursing Home by Fax or Email. The notice should be submitted within 48 hours of admission or before discharge from the Hospital or a Nursing Home, whichever is earlier, unless it is waived in writing by the Company.

For the final claim, you need to submit hospital receipts, original Bills, Cash memos, reports, claim form, and list of documents as listed below, within 7 days of discharge.

  1. Original bills
  2. Receipts
  3. Discharge certificate or card from the hospital
  4. Medical history of the patient
  5. Original Cash-memo from the hospital or chemist with a prescription
  6. Original receipt
  7. Pathological and other test reports from a pathologist or radiologist including the film, etc, with a note from attending medical practitioners or surgeons demanding such tests
  8. Attending Consultants, Anaesthetists, a Specialist certificate regarding diagnosis and bill receipts, etc.
  9. Surgeon’s original certificate stating the diagnosis and nature of the operation
  10. Any other additional information which is required by the TPA or Insurance Company

All the documents must be duly attested with the claim form and submitted before the due date by the insured person. In the case of post-hospitalization treatment, all the documents should be submitted to the Insurance Company or TPA within 7 days after completion of the treatment.

Note: Waiver of the condition is considered in extreme cases where it is impossible for the insured or any other person on behalf of the insured to submit the notice within the prescribed time limit. Otherwise, the Company or TPA has the right to reject your claim.

Cashless Claim: Insured can use the cashless claim by submitting a pre-authorization letter to the TPA or Company. You should get this facility only if you are admitted to the network hospital. The TPA or Company will check the nature of your treatment to provide you with a list of network hospitals suitable for it.

The Company or TPA reserves the right to deny the insured a pre-authorization letter if the hospital or insured person is unable to provide the relevant information or medical details. In the case of denial of a cashless facility, you should obtain the treatment as per your treating doctor’s advice and later submit the claim paper to the Company or TPA for reimbursement.

In case of any information available to the TPA or Company which makes the claim inadmissible or doubtful, the authorization of a cashless facility shall be withdrawn.

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