Insurance Plans September 11, 2020

Oriental Mediclaim Insurance Policy

If you are thinking about giving you 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 Hospitalisation, 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.

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Oriental Mediclaim Insurance Policy Coverage

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.

Hospitalization Expenses

ExpensesLimit
Room, Boarding and Nursing Expenses as provided by the Hospital /Nursing HomeUp to 1% of the Sum Insured per day
Intensive Care Unit (ICU) expenses as provided by the Hospital/Nursing HomeUp 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 expensesLimit 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 Allowance0.1% 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 expensesMedical 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

ExpensesLimit
Surgeon, Medical Practitioner, Consultants, Specialists Fees, Blood, Oxygen, Surgical Appliances, Medicines & Drugs, Diagnostic Material and Dialysis, Chemotherapy, Nursing expenses20% 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.

Exclusions from the Oriental Mediclaim Insurance Policy

The Oriental Insurance Company Ltd. is not liable to pay for the following injury or illness treatment.

  1. Intentional self-injury, suicide or attempted suicide
  2. Influence of intoxicating liquor or drugs
  3. Engagement in hazardous activity including ballooning, speed contests, racing of any kind (other than on foot), bungee jumping, parasailing, parachuting, ski-diving, paragliding, hang gliding, mountain or rock climbing necessitating the use of guides or ropes, potholing, abseiling, deep-sea diving using hard helmet and breathing apparatus, polo, snow and ice sports or involving a military, air force or naval operations, but it is not limited to aviation mounting or dismounting from traveling in any aircraft other than as a passenger (fare-paying or otherwise), in any duly licensed standard type of aircraft, anywhere in the world.
  4. Symptoms caused directly or indirectly by venereal diseases or insanity
  5. Injury or illness arising or resulting from the insured committing a breach of law with a criminal intent
  6. War, invasion, an act of a foreign enemy, hostilities (whether war be declared or not), civil war, rebellion, revolution, insurrection, mutiny, military or usurped power, seizure, capture, arrest, restraints and detainments of people
  7. Direct or indirect causes of ionizing radiations, contamination by radioactivity from any nuclear fuel, nuclear weapon material, or from any nuclear waste from the combustion of nuclear fuel
  8. Direct or indirect causes aggravated or prolonged by childbirth or from pregnancy or in consequence thereof.

Domiciliary Hospitalisation

Domiciliary Hospitalisation 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 following diseases or conditions.

  1. Asthma
  2. Bronchitis,
  3. Chronic Nephritis and Nephritic Syndrome,
  4. Diarrhea and all types of Dysenteries including Gastro-enteritis,
  5. Diabetes Mellitus and Insipidus,
  6. Epilepsy
  7. Hypertension
  8. Influenza, Cough and Cold
  9. All Psychiatric or Psychosomatic Disorders
  10. Pyrexia of unknown origin for less than 10 days
  11. Tonsillitis and Upper Respiratory Tract infection including Laryngitis and Pharyngitis
  12. Arthritis, Gout and Rheumatism
  13. Circumcision (unless necessary for the treatment of a disease or accident)
  14. Vaccination
  15. Inoculation
  16. Change of life
  17. Cosmetic or of aesthetic treatment of any description
  18. Plastic surgery unless necessitated due to an accident or as a part of any illness
  19. Surgery for correction of eyesight
  20. Any dental treatment or surgery unless arising from disease or injury
  21. Convalescence
  22. General debility
  23. “run down” condition or rest cure
  24. Congenital external diseases or defects or anomalies
  25. Sterility
  26. Any fertility, subfertility, or assisted conception procedure
  27. Venereal diseases
  28. All expenses arising out of any condition directly or indirectly caused by, or related to Human T-cell Lymphotropic Virus Type III (HTLD – III) or Lymphadenopathy Associated Virus (LAV) or the Mutants Derivative or Variations Deficiency Syndrome or any Syndrome or condition of a similar kind commonly referred to as AIDS, HIV and its complications including sexually transmitted diseases.
  29. Expenses incurred at Hospitals or Nursing Homes primarily for evaluation or diagnostic purposes which are not followed by active treatment for the ailment during the hospitalized period
  30. Expenses on vitamins and tonics unless they are a part of treatment for injury or disease as certified by the attending physician
  31. Any treatment arising from or traceable to pregnancy, childbirth, miscarriage, cesarean section, abortion, or complications of any of these including changes in chronic condition as a result of pregnancy, except in the case of abdominal operation for extra uterine pregnancy (ectopic pregnancy) which is proved by diagnostic means and certified to be life-threatening by the attending Medical Practitioner, if left untreated.
  32. Naturopathy treatment, unproven procedure or treatment, experimental or alternative medicine (other than Ayurveda, Unani & Homeopathy), and related treatment including acupressure, acupuncture, magnetic and such other therapies.
  33. Expenses incurred for investigation or treatment irrelevant to the diseases diagnosed during hospitalization or primary reasons for admission. Private nursing charges, Referral fee to family doctors, Outstation consultants/Surgeons fees, etc.
  34. Genetic disorders and stem cell implantation/surgery
  35. Cost of external and or durable Medical and Nonmedical equipment of any kind used for diagnosis and treatment including CPAP, CAPD, Infusion pump, etc., Ambulatory devices i.e. walker, Crutches, Belts, cost of spectacles, contact lenses, hearing aids, Collars, Cap, splints, slings, braces, Stockings, etc. of any kind, Diabetic footwear, Glucometer/Thermometer, Blood Pressure monitoring machine and similar related items and also any medical equipment which is subsequently used at home.
  36. All non-medical expenses including comfort and convenience items or services such as wi-fi/internet charges, telephone, television, Aya, barber or beauty services, diet charges, baby food, cosmetics, napkins, toiletry items, etc, guest services and similar incidental expenses or services, etc.
  37. Change of treatment from one Medical Practitioner/Consultant to another
  38. Treatment of obesity or condition arising therefrom (including morbid obesity) as well as any other weight control programme
  39. Treatment underwent in an establishment, a place for drug addicts or a place for alcoholics, a hotel, convalescent home, convalescent hospital, health hydro, nature care clinic, or similar establishments
  40. Expenses of stay in the hospital for any domestic reason if no active regular treatment is given by the specialist
  41. Outpatient Diagnostic, Medical/Surgical procedures or treatments
  42. Non-prescribed drugs and medical supplies
  43. Hormone replacement therapy
  44. Massages, Steam bathing, Shirodhara, and like treatment under Ayurvedic treatment
  45. Any kind of Service charges, Surcharges, Admission fees and Registration charges, etc. levied by the hospital
  46. Doctor’s home visit charges, Attendant, Nursing charges during pre and post-hospitalization period
  47. Pre and post hospitalization expenses unrelated to the disease or injury for which hospitalization claim is admitted under the policy.

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 is 65 years under Oriental Mediclaim Insurance Policy which 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 Diagnostic Centre. The cost will be borne by the insured for the following pre-medical checkup.

  • Physical Examination
  • Urine (Microalbuminuria)
  • Glycosylated Haemoglobin
  • Ultrasonography (Whole Abdomen and Pelvis)
  • X-ray for both knees (Anteroposterior and lateral)
  • Complete eye tests including fundus, etc.
  • Stress Test (TMT)

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.

General Exclusions From Oriental Mediclaim Insurance Policy

The Oriental Insurance Company Ltd. is not liable to make any payment in respect of any expense that is incurred by you in connection to 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. Exclusion 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.

  1. Diabetic Retinopathy
  2. CerebroVascular accident
  3. Diabetic Nephropathy
  4. Hypertensive Nephropathy
  5. Diabetic Foot /wound
  6. Internal Bleed/Haemorrhages
  7. Diabetic Foot
  8. Diabetic Angiopathy
  9. Coronary Artery Disease
  10. Diabetic Angiopathy
  11. Hyper or Hypoglycemia shocks
  12. Hypertension Nephropathy

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 / SurgeryWaiting Period
Benign ENT disorders and surgeries i.e. Tonsillectomy, Adenoidectomy, Mastoidectomy, Tympanoplasty, etc.1 year
Polycystic ovarian diseases1 year
Surgery of hernia2 years
Surgery of hydrocele2 years
Non-infective Arthritis2 years
Undescended Testes2 years
Cataract2 years
Surgery of benign prostatic hypertrophy 2 years
Hysterectomy for menorrhagia or fibromyoma or myomectomy or prolapse of the uterus2 years
Fissure / Fistula in anus2 years
Piles 2 years
Sinusitis and related disorders 2 years
Surgery of gallbladder and bile duct excluding malignancy2 years
Surgery of genitourinary system excluding malignancy2 years
Pilonidal Sinus2 years
Gout and Rheumatism2 years
Hypertension2 years
Diabetes2 years
Calculus diseases2 years
Surgery for the prolapsed intervertebral disk unless it is a cause of an accident2 years
Surgery of varicose veins and varicose ulcers2 years
Congenital internal diseases2 years
Joint Replacement due to Degenerative condition4 Years
Age-related osteoarthritis and Osteoporosis4 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.

Oriental Mediclaim Insurance Policy Premium Payment

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 Mediclaim Insurance Policy Renewal

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.

Oriental Mediclaim Insurance Policy Revision

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 policyholders 3 months in advance.

Oriental Mediclaim Insurance Policy Claim

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.

Cashless Claims

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 which is available to the Company or TPA that 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.

Oriental Mediclaim Insurance Policy Health Check-up Cost

You are entitled to a reimbursement of the cost of Health checkup 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, then in the future at the time insured claiming this benefit, the last three claim-free years preceding the year shall be taken into consideration.

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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