Insurance Plans 104 views September 18, 2020

Oriental Super Health Top-up Policy

Top-up is an add-on cover to your existing health insurance which provides additional financial support when medical costs rise. The Oriental Insurance Company Ltd. offers you a top-up plan which you can buy on your existing health insurance plan. There is a maximum entry age of 65 years for this policy. Oriental Super Health Top-up Policy provides you with additional coverage on your health insurance policy. As a result, the premium amount increases. To become eligible for the Oriental Super Health Top-up Policy, you do not have to appear for any premedical examination if you are below 55 years. However, persons with adverse medical history may require the pre-insurance medical tests irrespective of age. Read this page below to know what this policy covers and how it will protect you financially against future health risks.

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Oriental Super Health Top-up Policy Coverage

The insurer compensates the insured for all admissible expenses incurred exceeding the deductible limit but not exceeding the policy Sum Insured. Under Oriental Super Health Top-up Policy, the company will pay for the hospitalization expenses from the date of admission in the hospital falling within the policy period.

  1. Room, Boarding and Nursing Expenses provided by the Hospital/Nursing Home up to 1 % of the Deductible Amount as per the Policy Schedule per day.
  2. Intensive Care Unit (ICU) expenses provided by the Hospital/Nursing Home up to 2% of the Deductible Amount as per the Policy Schedule, per day.

The number of days of stay for the above treatment should not exceed the total number of days of stay in the Hospital. Expenses, which are mentioned below, are also payable as per the room rent limit. However, the medicines, pharmaceuticals and body implants would be payable on an actual basis. Any expense over reasonable and customary charges, or above the negotiated prices in case of a network hospital is borne by the insured.

  1. Surgeon, Anesthetist, Medical Practitioner, Consultants, Specialists Fees
  2. Anesthesia, Blood, Oxygen, Operation Theatre Charges, Surgical Appliances, Medicines & Drugs, Diagnostic Material and X-Ray, Dialysis, Chemotherapy, Radiotherapy, Pacemaker, Artificial limbs and similar types of expenses.
  3. Organ donor benefit up to 10% of the Sum Insured when the Insured is a donor
  4. Donor expenses limits within the Sum Insured when the Insured is a recipient
  5. Medical expenses incurred 30 days before hospitalization and up to 60 days post hospitalization

Note: Relaxation of 24 hours is allowed in specified Day Care procedures and surgeries only if the treatment is taken in a Hospital or a Day Care Centre and not in the Out-Patient department of a hospital. For any other Day Care Treatment which is not mentioned in the policy clause, you need to take prior approval from the company or TPA in writing. In Ayurvedic, Yoga and Naturopathy, Unani, Siddha and Homeopathic treatment, Hospitalisation expenses are admissible only if the treatment is in-patient.

Maternity Cover in Oriental Super Health Top-up Policy

The policy provides an automatic maternity cover of 10% of your Sum Insured. The company will pay the medical expenses as an inpatient for delivery, including the cesarean, or lawful medical termination of pregnancy during the policy period. The policy is limited to only 2 deliveries or terminations, or either during a lifetime. Maternity cover is not available to those who already have two children. This cover is only for the insured or his/her spouse if the policy has been in force for a continuous period of 12 months in respect of both the Insured and his/her spouse.

However, miscarriage due to accident, an abdominal operation for extra uterine pregnancy and certified to be life-threatening by the attending Medical Practitioner, is not covered in the Oriental Super Health Top-up Policy.

Oriental Super Health Top-up Policy Newborn Baby Cover 

This is a benefit cover for the insured and couples expecting a baby. An automatic cover up to 5% of the Sum Insured to the newborn baby up to 90 days from the date of birth. To get coverage beyond 90 days for the full Sum Insured, you need to submit payment of requisite additional premium. In case the Newborn Baby cover is spread over two policy periods, the aggregate liability of the Oriental company, for all claims in respect of the Newborn Baby cover, will be limited to 5% only. A claim under newborn baby cover is independent of the claim status in respect of the maternity expenses, i.e admissibility.

Note: The claim is admissible only if the expenses are incurred in a Hospital as an in-patient. In the case of family floater plan, the policy Sum Insured would be considered for ascertaining the sublimit of 10% & 5%, and in the case of an individual plan, the Sum Insured of the insured mother would be considered. The company’s overall liability in respect of all claims under this clause during the policy period shall not exceed the Sum Insured as mentioned in the policy schedule.

Coverage When Travelling to SAARC Countries

Oriental Super Health Top-up Policy automatically covers the insured visiting the South Asian Association for Regional Cooperation (SAARC) countries such as Afghanistan, Bangladesh, Bhutan, Maldives, Nepal, Pakistan, Sri Lanka. However, there is no cashless service available for treatment in SAARC countries and such claims are reimbursed based on the return of the insured. All other conditions of the policy in respect of the claim shall apply.

Exclusions

The insurer is not liable to make any payment under the Oriental Super Health Top-up policy to the insured for the following expenses:-

  1. All Pre-existing Diseases whether treated or untreated, declared or not declared in the Proposal Form, are excluded up to 48 months. It also applies to any complications that arise from your pre-existing diseases.
  2. Expenses in connection with voluntary medical termination of pregnancy in the first 12 weeks from the date of conception
  3. Prenatal and postnatal expenses are excluded unless admitted in Hospital and taken a treatment there
  4. Pre Hospitalisation and Post Hospitalisation benefits are not available under Maternity and Newborn Baby cover.
  5. Any treatment that is traceable to pregnancy, childbirth, miscarriage, caesarean section, abortion, or complications of any of these including changes in chronic condition as a result of pregnancy.  Expenses incurred on the treatment of the below-mentioned ailment, diseases, surgeries, if contracted after the inception of the first policy, are not payable during the waiting period as specified below.
  6. Benign ENT disorders and surgeries, Tonsillectomy, Adenoidectomy, Mastoidectomy, Tympanoplasty and Polycystic ovarian diseases with a waiting period of 12 months
  7. Surgery of hernia, hydrocele, Noninfective Arthritis, Undescended Testes, Cataract, Surgery of benign prostatic hypertrophy, Hysterectomy for menorrhagia, fibromyoma, myomectomy, or prolapse of the uterus, Fissure and Fistula in the anus, Piles, Sinusitis and related disorders, gallbladder and bile duct excluding malignancy, genitourinary system excluding malignancy, Pilonidal Sinus, Gout and Rheumatism, Hypertension,  Diabetes, Calculus diseases, prolapsed intervertebral disk unless arising from an accident, varicose veins and varicose ulcers, Congenital internal diseases with a waiting period of 24 months.
  8. Joint Replacement due to Degenerative condition and age-related osteoarthritis and Osteoporosis with a waiting period of 48 months.
  9. Any disease other than above-stated pointers, if contracted to the Insured Person during the first 30 days from the inception date of the fresh policy. However, it may not apply in case of injuries suffered in an accident, which occurred after the inception of the policy.

Note: If the above diseases are pre-existing at the time of inception, pre-existing disease exclusion is applied, which means the above diseases will be covered only after the policy has completed 48 months. If continuity of renewal is not maintained or the Sum Insured is enhanced subsequent cover will be treated as afresh policy and exclusion shall apply afresh.

  1. Injury or disease directly or indirectly caused by War, Invasion, an Act of a Foreign Enemy, War like operations (whether the war is declared or not), nuclear weapons, nuclear materials.
  2. Circumcision (unless treatment is necessitated due to an accident)
  3. Vaccination (including the animal bite unless it results in hospitalization)
  4. Inoculation
  5. Cosmetic or aesthetic treatment of any description
  6. Plastic surgery (unless the treatment is necessitated due to an accident or if it is a part of illness)
  7. Surgery for correction of eyesight or hearing which includes the cost of spectacles, contact lenses, cochlear implant, hearing aids and other external aids or implants used in the surgery.
  8. Any dental treatment or surgery which involves corrective, cosmetic, or aesthetic procedures like filling of cavities, crowns, root canal treatment including treatment for wear and tear (unless the treatment is necessitated due to an accident or if it is a part of illness).
  9. Convalescence, general debility, “run-down” condition, rest cure, congenital external diseases, defects, or anomalies, sterility, any fertility, subfertility, or assisted conception procedure, venereal diseases.
  10. Intentional self-injury/suicide
  11. All psychiatric and psychosomatic disorders, diseases, or accidents due to abuse of drugs, alcohol, or any intoxicating substances or not.
  12. All expenses arising out of any condition whose direct or indirect cause is associated with 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.
  13. Expenses incurred primarily for evaluation or diagnostic purposes and not related to the active treatment for the ailment during the hospitalized period.
  14. Expenses on vitamins and tonics for injury or disease if not certified by the attending physician.
  15. Unproven or experimental procedure and treatment like acupressure, acupuncture, magnetic therapies.
  16. Expenses for investigation or treatment which is irrelevant to the disease
  17. Stem cell implantation or surgery
  18. Cost of external and or durable Medical and Non-medical equipment used in diagnosis or treatment including CPAP, CAPD, APDS, Infusion pump, Ambulatory devices i.e walker, Crutches, Belts, Collars, Caps, splints, slings, braces, Stockings, of any kind, Diabetic foot wear, Glucometer Thermometer, Blood Pressure monitoring machine and also any medical equipment used at home. All non-medical expenses like, wi-fi/internet charges telephone, television, Ayah, barber or beauty services, diet charges, baby food, cosmetics, napkins, toiletry items, guest services.
  19. Change of treatment from one system of medicine to another unless allowed or recommended by the Medical Practitioner or Consultant under whom the treatment is currently taken.
  20. Treatment for Age-related Macular Degeneration (ARMD)
  21. Treatments such as Rotational Field
  22. Quantum Magnetic Resonance (RFQMR)
  23. External Counterpulsation (ECP)
  24. Enhanced External
  25. Counter Pulsation (EECP)
  26. Hyperbaric Oxygen Therapy
  27. Treatment of obesity
  28. Any condition arising from the treatment of obesity (including morbid obesity) and any other weight control programme.
  29. Treatment for sleep apnoea and immuno-modulator drugs for cancer treatment
  30. Injury or Illness due to participation in any hazardous activity including but not limited to aviation or ballooning, speed contests or racing on any kind(other than on foot), 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 and other hazardous activities or involving military, air force or naval operations, or whilst mounting into, dismounting from or travelling in any aircraft other than as a passenger (fare-paying or otherwise), in any duly licensed standard type of aircraft, anywhere in the world.
  31. Treatment in an establishment, where aged, drug addicts or alcoholics stay, a hotel, convalescent home, hospital, health hydro, nature care clinic.
  32. Any stay in the hospital expenses if no active treatment is given by the Medical Practitioner to the insured.
  33. All Out-patient treatments which include diagnostic, Medical/Surgical procedures, non-prescribe drugs or medical supplies, Hormone replacement therapy, Sex change treatment.
  34. Ayurvedic treatment like Massages, Steam bathing, Shirodhara and all other external therapies, which are not essential for the treatment of diseases.
  35. Service charges, Surcharges, Admission fees, Registration charges, RMO charges, levied by the hospital.
  36. Doctor’s home visit, attendant, nursing charges during pre and post hospitalization
  37. Pre and post hospitalization expenses unrelated to the disease or injury
  38. Any illness or injury arising from breach of Law with criminal intent

Deletion of Room Rent Limit

The coverage limits are not applicable if the insured pays the required additional premium for removal of Room Rent limits. In such a case, room rents and other covered expenses become payable on an actual basis. Additional premium payment is as per the loadings mentioned below.

  1. 20% additional premium if the deductible is up to INR 5 lakh
  2. 10% additional premium if the Deductible is from INR 6-10 lakh
  3. 5% additional premium if the Deductible is up to INR 15 lakh or above

Pre-medical Check-up

You need to go through the following tests which are performed at the Oriental list of diagnostic centres if you want to buy Oriental Super Health Top-up Policy.

  1. General Physical Examination
  2. CBC with ESR
  3. Lipid Profile
  4. HbA1c
  5. S.Creatinine
  6. Urine routine and molecular
  7. ECG
  8. TSH
  9. X-ray chest
  10. USG
  11. EYE examination fundus and glaucoma

In case the insured has an adverse medical history, the insurer may ask for some additional tests depending on the medical condition. Medical reports upto 30 days before the date of the proposal are valid. In the case of the fresh proposal, 50% cost of Medical Check-up will be reimbursed by the company if it is accepted.

If there has been a break in the Policy Period and continuity benefits are not restored, you have to undergo a Medical Check up again. In such cases, 50% of the cost of Medical Check-up will be reimbursed.

Free Look Period Available on Oriental Super Health Top-up Policy

A period of 15 days is provided to the insured to review the terms and conditions of the policy and return the same if not satisfied. The free look period will be applicable from the date of inception of the fresh policy. When you don’t make any claim during the free look period, you are entitled to the following:-

  1. A refund of the paid premium less the expenses incurred by the company on medical examination and the stamp duty charges.
  2. A deduction towards the proportionate risk premium for the period on cover, if the risk has already commenced and the insured has exercised the policy return.
  3. A proportionate premium commensurate with the insurance coverage, if only a part of the insurance coverage has commenced during the free look period.

Oriental Super Health Top-up Policy Trigger

When the aggregate of actual admissible expenses are incurred in respect of any one or more claim during the policy period and it exceeds the deductible under the policy, you can claim it by submitting a notice to the company or TPA.

If there are other sources from where you can receive an amount greater than the deductible, you have an option either to exhaust other options first and subsequently claim the Policy; or to first claim the Policy. If you choose to claim under the policy first and subsequently receive reimbursement from other sources which have also been paid under this Policy, you should refund to the company such excess payment.

List of Documents

To claim the Oriental Super Health Top-up Policy, you need to submit the original Bills, Cash memos, reports, claim form and documents listed below within 15 days of your discharge from the Hospital or Nursing Home.

  1. Original bills
  2. All receipts and discharge certificate or card from the hospital
  3. All documents about the illness, from the date it was first detected
  4. Doctor’s consultations reports or history
  5. Medical history of the patient as recorded by the Hospital or Nursing Home
  6. Original Cash-memo from the hospital or chemist with a prescription
  7. Original receipt
  8. Pathological and other test reports from a pathologist, radiologist including film, etc. with a note from attending medical practitioners, surgeons who demand such tests.
  9. Original attending Consultant, Anaesthetists, Specialist certificates regarding diagnosis and bills or receipts, etc.
  10. Surgeon’s original certificate stating the diagnosis and nature of operation along with bills or receipts, etc.
  11. MLC, FIR, Post Mortem Report,( if applicable)
  12. Document in respect of organ donation – a certificate from the concerned hospital
  13. Original bills with supporting documents to the TPA for the reimbursement of expenses incurred during pre and post-hospitalization.
  14. Any other information required by the company/TPA

Note: If there are previous claims during the policy period, and a subsequent claim has exceeded or likely to exceed the Deductible, above listed documents would also be required for the previous claim in addition to the one under consideration. If the TPA is the same for both the policies and the documents have been submitted to the TPA, irrespective of the insurer of the base policy, the Insured just needs to mention the claim number allotted by the TPA and submit the same along with the duly filled claim form. When the TPA under Oriental Super Health Top-up policy and the Base Policy is different, you must submit the documents in respect of all the treatment taken during the policy period as given in the policy. If original documents are already submitted elsewhere, photocopies can be submitted to the concerned TPA or the Insurer, as the case may be, and countersigned by the Insured person, are required to be submitted.

How to Claim Oriental Super Health Top-up Policy?

Submit an immediate notice of claim with particulars like policy number, ID Card No., Name of the Insured Person to whom the claim is made, Nature of disease/injury and Name and Address of the attending Medical Practitioner, Hospital, Nursing Home, etc.

It should be submitted to the company or TPA while taking treatment in the Hospital or Nursing Home, either by fax, e-mail, etc. The claim notice should be given within 48 hours of admission, but before the discharge from Hospital or Nursing Home. The company may consider condonation of delay in cases of hardship where it is proven before it or the TPA that the concerned individual was not in a position to give such notice within the prescribed time limit given the circumstances that were there.

Cashless Claim:-

The Company or TPA provides admission to the insured in a network Hospital or Nursing Home which is subject to pre-admission authorization. For the pre-admission authorization, you need to submit the related medical details, relevant information of the treatment from the Network Hospital or Nursing Home. The company or TPA pays the sum for which the insured gets admitted as an in-patient after getting the preauthorization request within 48 hours of its receipt.

Your preauthorization request can be denied by the company or TPA in case you do not provide the relevant details. In such cases, the Insured may obtain the treatment as per his/her treating doctor’s advice and later seek reimbursement.

If any information available to the company or TPA makes the claim inadmissible or doubtful and warrants further investigations, the authorization for the cashless facility is withdrawn.

Reimbursement:-

If you take treatment in a non-network hospital, contact the TPA within 7 days from the date of admission with policy details like ID card number, nature of illness, name and address of the hospital or Nursing home. Submit the duly filled Claim Form along with the required documents.

NOTE: The maximum liability of the company is the sum insured as stated in the schedule of the policy.

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