Oriental Happy Family Floater Policy Wording


                                HAPPY FAMILY FLOATER POLICY

1.1 WHEREAS the insured named in the Schedule hereto has by a proposal and declaration dated stated in the Schedule (which shall be the basis of this Contract and is deemed to be incorporated herein) has applied to THE ORIENTAL INSURANCE COMPANY LIMITED (hereinafter called the Company) for the insurance hereinafter set forth in respect of persons(s) named in the Schedule hereto (hereinafter called the INSURED PERSON(S) and has paid premium to the Company as consideration for such insurance to be serviced by Third Party Administrator (hereinafter called the TPA) or the Company as the case may be.

NOW THIS POLICY WITNESSES that subject to the terms, conditions, exclusions and definitions contained herein or endorsed or otherwise expressed hereon, the Company undertakes that, if during the period stated in the Schedule any insured Person shall contract any disease or suffer from any illness / ailment / disease (hereinafter called ‘DISEASE’) or sustain any bodily injury through accident (hereinafter called ‘INJURY’)

                                                         AND

 if such disease or injury shall require, upon the advice of a duly qualified Physician / Medical Specialist/Medical Practitioner (hereinafter called MEDICAL RACTITIONER) or of a duly qualified Surgeon (hereinafter called ‘SURGEON’) to incur (a) hospitalisation expenses for medical/surgical treatment at any Nursing Home/Hospital in India as herein defined (hereinafter called ‘HOSPITAL’) as an inpatient OR (b) on domiciliary treatment in India under Domiciliary Hospitalisation Benefits as hereinafter defined, the TPA will pay to the Hospitals (only if treatment is taken at Network Hospital(s) with prior written approval of TPA) or to the insured person (s) if the payment to the hospital is not agreed or the insured person(s) opts for re-imbursement of the claim) the amount of such expenses are reasonably and necessarily incurred in respect thereof by or on behalf of such insured person(s) up to the limit of liability specified in the policy and or schedule of the policy but not exceeding the sum insured in any one period of insurance for one or all the family member(s) stated in the schedule hereto. In the event the policy is not serviced by the TPA such expenses shall be reimbursed to the insured person(s) by the Company.

The benefits under this policy are available under either of the two plans, viz Silver or Gold as opted by the proposer in the proposer form.

1.2 COVERAGE UNDER THE POLICY

A                                       HOSPITALISATION BENEFITS
  BENEFIT SILVER PLAN
(Limit of Reimbursement )

GOLD PLAN (Limit of Reimbursement)

a. Room, Boarding and Nursing
Expenses as provided by the
Hospital /Nursing Home.
Not exceeding 1 % of the Sum
Insured per day
Not exceeding 1 % of the Sum
Insured per day.

b.

Intensive Care(IC) Unit
Expenses as provided by the
Hospital /Nursing Home.
Not exceeding 2% of the Sum
Insured per day.
Not exceeding 2% of the Sum
Insured per day.
    No of days of stay under a and b above should not exceed total number of days of admission in the hospital.
c. Surgeon, Anaesthetist, Medical
Practitioner, Consultants,
Specialists Fees
As per the limits of the sum
insured.
As per the limits of the sum
insured.
d. 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 expenses.
As per the limits of the sum
insured.
As per the limits of the sum
insured.
e. Ambulance services charges
as defined hereinafter under
Rs.1,000/- per illness and
limited to maximum 1% of the
sum insured or Rs. 3,000/-
whichever is less, for the entire
policy period.
Rs.2,000/- per illness and limited
to maximum 1% of the sum
insured or Rs. 6,000/- whichever
is less, for the entire policy
period.
f. DAILY HOSPITAL CASH
ALLOWANCE, AS DEFINED
HEREINAFTER under
NIL. 0.1% of sum insured per day per
illness subject to a maximum
compensation for 10 days per
illness. The overall liability of the
Company during the policy period
will be limited to 1.5% of the sum
insured.
g. Attendant allowance as
hereinafter defined under
NIL Rs.500/- per day of
hospitalisation per illness and
upto 10 days per illness. The
overall liability of the Company
during the policy period will be
limited to compensation for 15
days of hospitalisation.
       
B. DOMICILIARY HOSPITALISATION (AS DEFINED HEREINAFTER)
a. Surgeon, Medical Practitioner,
Consultants, Specialists Fees,
Blood, Oxygen, Surgical
Appliances, Medicines &
Drugs, Diagnostic Material and
Dialysis, Chaemotherapy,
Nursing expenses.
10% of Sum Insured, Maximum
Rs.25000/- during policy period.
Rs.50000/- during policy period.
b. Treatment for Dog bite (or bite
of any other rabid animal like
monkey, cat etc.)
Reasonable expenses limited
upto Rs.5,000/- actually incurred
for immunisation injections in any
one policy period.
Reasonable expenses limited
upto Rs.5,000/- actually incurred
for immunisation injections in any
one policy period.
  NOTE: FOR THE PURPOSE OF THIS SECTION THE PRE-REQUISITE CONDITIONS FOR
DOMICILIARY HOSPITALISATION CLAIM SHALL NOT APPLY.
   

 

1.3 Hospitalization / nursing home charges, surgery, medicines, drugs, pathological tests etc. incurred for donating an organ by the donor to the insured person during the course of organ transplant shall also be payable under this policy. However, cost of organ is not payable / reimbursable under the policy.

1.4 Company’s overall Liability in respect of all claims admitted under sections 1.2 and 1.3 during the Period of insurance shall not exceed the Sum Insured per Family mentioned in the Schedule.

1.5 REGISTRATION CHARGES: are not payable under either SILVER or GOLD plans.

1.6 ADD ON COVERS (OPTIONAL, SUBJECT TO EXTRA PREMIUM)

  ITEM SILVER PLAN GOLD PLAN
a. PERSONAL ACCIDENT as
defined hereinafter 3.22
Sum insured in multiples of
Rs.1,00,000/- and upto
Rs.5,00,000/- per person aged 18
years and above . 50% of this
limit for persons less than 18
years.
Sum Insured in multiples of
Rs.2,00,000/-, and upto
Rs.10,00,000/- per person aged 18
years and above. 50% of this limit
for persons less than 18 years.
b. LIFE HARDSHIP SURVIVAL
BENEFIT AS DEFINED
HEREINAFTER
Nil Plans of benefit AS DEFINED
HEREINAFTER

2. DEFINITIONS

2.1. ‘‘HOSPITAL/NURSING HOME’ means any institution in India established for indoor care and treatment of sickness and injuries and which either

a) Is duly licensed and registered as a Hospital or Nursing Home with the appropriate authorities and is under the supervision of a registered and qualified Medical Practitioner.

OR

b) In areas where licensing and registration facilities with appropriate authorities are not available, the institution must be one recognised in locality as Hospital / Nursing Home and should comply with minimum criteria as under;

i. It should have at least 15 in-patient medical beds in case of Metro cities, A Class cities & B class cities or 10 in- patient medical beds in case of “C class” cities. Classification of cities shall be as per Govt of India Notifications issued in this respect from time to time.

ii. Should have fully equipped and engaged in providing Medical and Surgical facilities along with Diagnostic facilities i.e. Pathological test and X-ray, E.C.G. etc for the care and treatment of injured or sick persons as in-patient.

iii. Should have fully equipped operation theatre of its own, wherever surgical operations are carried out.

iv. Should have fully qualified nursing staff under its employment for 24 hours.

v. Fully qualified Doctor(s) should be physical in- charge for 24 hours.

The term ‘Hospital/Nursing Home’ shall not include an establishment which is a place of rest, a place for the aged, a place for drug addicts or a place for alcoholics, a hotel or a similar place.

Note: In case of Ayurvedic / Homeopathic / Unani treatment, Hospitalisation expenses are admissible only when the treatment is taken as in-patient, in a Government Hospital / Medical College Hospital.

2.2 Surgical Operation means manual and/or operative procedures for correction of deformities/defects and injuries, cure of diseases, relief of suffering and prolongation of life.

2.3 HOSPITALISATION PERIOD: Expenses on Hospitalisation are admissible only if hospitalisation is for a minimum period of 24 hours. However,

(A) This time limit will not apply to following specific treatments taken in the Network Hospital/Nursing Home where the Insured is discharged on the same day. Such treatment will be considered to be taken under Hospitalisation Benefit.

i. Haemo Dialysis,

ii. Parentral Chemotherapy,

iii. Radiotherapy,

iv. Eye Surgery,

v. Lithotripsy (kidney stone removal),

vi. Tonsillectomy,

vii. D & C,

viii. Dental surgery following an accident

ix. Hysterectomy

x. Coronary Angioplasty

xi. Coronary Angiography

xii. Surgery of Gall bladder, Pancreas and bile duct

xiii. Surgery of Hernia

xiv. Surgery of Hydrocele.

xv. Surgery of Prostrate.

xvi. Gastrointestinal Surgery.

xvii. Genital Surgery.

xviii. Surgery of Nose.

xix. Surgery of throat.

xx. Surgery of Appendix.

xxi. Surgery of Urinary System.

xxii. Treatment of fractures / dislocation excluding hair line fracture, Contracture releases and minor reconstructive procedures of limbs which otherwise require hospitalisation.

xxiii. Arthroscopic Knee surgery.

xxiv. Laproscopic therapeutic surgeries.

xxv. Any surgery under General Anaesthesia.

xxvi. Or any such disease / procedure agreed by TPA/Company before treatment.

(B) Further if the treatment / procedure / surgeries of above diseases are carried out, in Networked specialised Day Care Centre which is fully equipped with advanced technology and specialised infrastructure where the insured is discharged on the same day, the requirement of minimum beds will be overlooked provided following conditions are met.

i. The operation theatre is fully equipped for the surgical operation required in respect of sickness / ailment / injury covered under the policy.

ii. Day Care nursing staff is fully qualified.

iii. The doctor performing the surgery or procedure as well as post operative attending doctors are also fully qualified for the specific surgery / procedure.

(C) Other than the treatments mentioned under 2.3 (A), the condition of minimum 24 hours Hospitalisation shall also not apply provided

i. The treatment is such that it necessitates hospitalisation and the procedure involves specialised infrastructural facilities available only in hospitals,

                                                           BUT

ii. Surgical procedure involved has to be done under General Anaesthesia.

                                                          AND / OR

iii. Due to technological advances hospitalisation is required for less than 24 hours.

2.4 DOMICILIARY HOSPITALISATION BENEFIT means:

Medical treatment for a period exceeding three days for such illness/disease/injury which in the normal course would require care and treatment at a hospital/nursing as in-patient home but actually taken whilst confined at home in India under any of the following circumstances namely:

i. The condition of the patient is such that he/she cannot be removed to the Hospital/Nursing Home

                                                           OR

ii. The patient cannot be removed to Hospital/Nursing home due to lack of accommodation in any hospital in that city / town / village.

Subject however to the condition that Domiciliary Hospitalisation benefit shall not cover

a) Expenses incurred for pre and post hospital treatment and

b) Expenses incurred for treatment for any of the following diseases :

i. Asthma

ii. Bronchitis,

iii. Chronic Nephritis and Nephritic Syndrome,

iv. Diarrhoea and all types of Dysenteries including Gastro-enteritis,

v. Diabetes Mellitus and Insipidus,

vi. Epilepsy,

vii. Hypertension,

viii. Influenza, Cough and Cold,

ix. All Psychiatric or Psychosomatic Disorders,

x. Pyrexia of unknown origin for less than 10 days,

xi. Tonsillitis and Upper Respiratory Tract infection including Laryngitis and Pharingitis,

xii. Arthritis, Gout and Rheumatism.

Note: Liability of the Company under this clause is restricted as stated in the schedule attached hereto.

3 OTHER DEFINITIONS AND INTERPRETATIONS:

3.1 INSURED PERSON: Means Person(s) named on the schedule of the policy.

3.2 ENTIRE CONTRACT: This policy / proposal and declaration given by the insured constitute the complete contract of this policy. Only Insurer may alter the terms and conditions of this policy. Any alteration that may be made by the insurer shall only be evidenced by a duly signed and sealed endorsement on the policy with the Company Stamp.

3.3 THIRD PARTY ADMINISTRATOR (TPA): means any Company who has obtained licence from IRDA to practice as third party administrator and is appointed by the Company.

3.4 NETWORK HOSPITAL: means hospital that has agreed with the TPA to participate for providing cashless health services to the insured persons. The list is maintained by and available with the TPA and the same is subject to amendment from time to time.

3.5 HOSPITALISATION PERIOD: The period for which an insured person is admitted in the hospital as inpatient and stays there for the sole purpose of receiving the necessary and reasonable treatment for the disease / ailment contracted / injuries sustained during the period of the policy. The minimum period of stay shall be 24 hours.

3.6 PRE-HOSPITALISATION: Relevant medical expenses incurred during the period upto 30 days prior to hospitalisation on disease/ illness/ injury sustained will be considered as part of claim mentioned under item 1.2 above.

3.7 POST-HOSPITALISATION: Relevant medical expenses incurred for the period of 60 days after hospitalisation on disease/illness/injury sustained will be considered as part of claim mentioned under item 1.2 above.

3.8 MEDICAL PRACTITIONER: means a person who holds a degree/diploma of a recognised institution and is registered by Medical Council of any State of India. The term Medical Practitioner would include Physician, Specialist and Surgeon.

3.9 QUALIFIED NURSE: means a person who holds a certificate in NURSING from a recognised Nursing Institute.

3.10 PRE EXISTING HEALTH CONDITION / DISEASES: means any condition, ailment / disease / injury or related condition(s) for which the insured person/s had signs or symptoms, and were diagnosed, and / or received medical advice / treatment, with in 48 months prior to his /her first hospitalization benefit policy with the Company.

3.11 IN-PATIENT: An Insured person who is admitted to hospital and stays for at least 24hours for the sole purpose of receiving the treatment for suffered ailment /illness /disease / injury / accident during the currency of the policy.

3.12 REASONABLE & CUSTOMARY EXPENSES:

a) For a networked hospital means the rate pre-agreed between the networked Hospital and the TPA for surgical / medical treatment that is necessary, customary and reasonable for treating the condition for which insured person was hospitalized.

b) For any other hospital it shall mean the cost of surgical / medical treatment that is necessary customary and reasonable for treating the condition for which insured person was hospitalized to the extent that such cost does not exceed the reasonable and customary charges for which insured was hospitalized.

NOTE: Any expenses other than the above have to be borne by the insured person himself.

3.13 CASHLESS FACILITY: means the TPA may authorise upon the Insureds’ request for direct settlement of admissible claim as per agreed charges between Net work Hospitals & the TPA. In such cases the TPA will directly settle all eligible amounts with the Net work Hospitals and the Insured Person may not have to pay any bills after the end of the treatment at Hospital to the extent the claim is covered under the policy.

3.14 I.D. CARD: means the card issued to the Insured Person by the TPA to avail Cashless facility in the Network Hospital.

3.15 DAY CARE PROCEDURE: means the course of Medical Treatment / Surgical procedure listed at

2.3 (A) and 2.3 (C) carried out, in Network Hospitals or Networked specialised Day Care Centre which is fully equipped with advanced technology and specialised infrastructure where the insured is discharged on the same day after the treatment.

3.16 LIMIT OF INDEMNITY: means the amount stated in the schedule which represents maximum liability for any and all claims made during the policy period in respect of that insured family.

3.17 ANY ONE ILLNESS: Any one illness will be deemed to mean continuous period of illness and it includes relapse within 105 days from the date of discharge from the Hospital / nursing home from where the treatment was taken. Occurrence of the same illness after a lapse of 105 days as stated above will be considered as fresh illness for the purpose of this policy.

3.18 PERIOD OF POLICY: This insurance policy is issued for a period of one year shown in the schedule.

3.19 DAILY HOSPITAL CASH ALLOWANCE: When an insured member of the family is hospitalized and a claim is admitted under the GOLD plan of the policy, then the insured person SHALL be paid a daily cash allowance as specified in section 1.2 A f of the policy.

3.20 ATTENDANT ALLOWANCE: When an insured member of the family aged between three months to 10 years is hospitalized and a claim is admitted under the GOLD plan of the policy, a sum as mentioned in the table of benefit under 1.2 A g will become payable under the policy.

3.21 LIFE HARDSHIP SURVIVAL BENEFIT: If this benefit is opted for (under the GOLD plan only), and if a claim for the specified diseases listed hereunder is admitted under section 1.2 A of the policy, then a survival benefit as mentioned hereunder, SHALL be paid the insured.

Diseases covered:
Cancer - metastasis (stage IV)
End Stage Renal Disease (ESRD)
Stroke leading to paralysis or paraplegia


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By VINAY MAITHANI on Jul 4, 2014 12:16 PM

Is Annual Medical check up covered in this policy ?
By Tarwinder Kaur on Jan 30, 2014 12:14 PM

Please let me know if three familly members are covered in this policy, suppose one member is admitted in the hospital, policy amount exceeds, can the amount is adjusted for the another two members policy.
By asad on Jan 18, 2014 9:50 AM

i have taken oriental floater health policy at last september 2013. now my spouse is pregnant she could be delivered at november 2014. can i claim at nov 14
By anil on Jan 13, 2014 12:38 PM

my query is that, i have taken the mediclaim but within one year( after 3 mnths)of policy some unforeseen event occure like heart attack.so in that case can i claim my expense ..what are chances of its approval..
By Hemant Agarwal on Sep 19, 2013 1:48 PM

Is vaccination is covered under this policy? and in case of maternity any amount cap or time cap is there or not???
By Team Medimanage on Sep 14, 2013 10:34 AM

Hello Nitin, If you are getting operated for eye correction then it will not be covered under Oriental Happy Family Floater. Thank you.
By Nitin Goel on Sep 2, 2013 7:09 PM

In my case I went through a scleral buckling in left eye, my no is -24 both eyes as a post lasik complication. at moment i cant wear soft lences in my buckled eye and was advicd to use scleral or kerasoft special lenses as i also have kretakonus. I cant undergo any sought of cornial surgery as my strength oof cornia is only 250 at moment. In my case is these lenses covered as they are necessary. i hold oriental mediclaim family floater policy nearly 5 yr back.
By Medimanage.com on Aug 6, 2013 10:58 AM

Hello Sanjay, This means that your policy should be continuously renewed for 2 years without any break, then from 3rd year onwards you can claim for hernia. Thank you.
By sanjay kumar sharma on Jun 28, 2013 4:06 AM

I can't understand the term. For example:iii Surgery of hernia. 2 years . The 2 years means (i) after the continous running of policy for 2 years OR (ii) inthe 2nd year? Please explain.
By hemant on Jun 8, 2013 6:24 PM

does oriental insurance happy family floater gives bonus on claim free year?
By s c arora on Nov 28, 2012 10:41 AM

My age is 61 years+(DOB is 1/8/1951) how much will be the premium for Oriental Happy Family Floater Policy silver scheme for Rs 200000/-(2 Lakh).Pl Inform. Thanks & Regards
By koushik jana on Sep 28, 2012 4:45 PM

I WANT TO TAKE THE FAMILY MEDICLAIM POLICY . i HAVE SPOUSE AND ONE GIRL CHILD. PLEASE CONTACT ME. 8641056175
By neeraj on Jul 21, 2012 3:50 PM

hi, does oriental insurance company covers baractric sugery kindly reply on my mail id thanking you neeraj hahl
By shiv miglani on Mar 31, 2012 3:23 PM

I want to know the detail of strictly not covered disease in this policy.
By BONEY JOSEPH VELIATH on Feb 17, 2012 1:04 PM

I WOULD LIKE TO TAKE A HEALTH(SILVER PLAN) POLICY FOR OUR FAMILY. WE ARE FROM KERALA, TRICHUR DISTRICT AND PLACE IS AT KORATTY. KINDLY PROVIDE ME THE EMAIL ADDRESS AND CONTACT PHONE NUMBER OF YOUR AGENT FROM TRICHUR ARA. THANKS. BONEY.
By jai prakash on Dec 24, 2011 12:28 PM

i wnt all details on my id
By S.RAMU on Apr 25, 2011 5:04 PM

Is it there any provision for "heart beat abnormal"Problem for mediclaim CLS Service please send your valuable suggetion to me Iam a Mediclaim holder in Oriental Insurance Co Ltd Since 2009. Thanking You.
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