THE ORIENTAL INSURANCE COMPANY LIMITED

Regd.Office:Oriental House,P.B.No.7037,A-25/27,Asaf Ali Road,New Delhi-110 002

HAPPY FAMILY FLOATER POLICY-PROSPECTUS

1.1 SALIENT FEATURES OF THE POLICY:

• A floater covering the proposer and his/her family under one sum insured under one policy.
• The Sum insured floats over all the beneficiaries under the policy.
• No medical examination for persons upto the age of 60 years.
• Pre-existing conditions cover after four consecutive renewals with the Company.
• Coverage under two options-SILVER and GOLD Covers.
• SILVER offers sum insured slabs of 1 to 5 lacs.
• SILVER is subject to 10% Co-pay.
• GOLD offers sum insured slabs of 6 to 10 lacs.
• Policy covers the hospitalisation expenses for the covered diseases/accident upto specific limits
• GOLD plan offers as an inbuilt cover daily cash allowance and attendant allowance upto limits specified.
• Personal Accident cover is offered as add on cover under both the covers.In addition GOLD cover offers add on cover of life hardship survival benefit.
• Discount in OMP premium when family floater policy is taken.
• Option of TPA and non TPA services.
• Discount in premium if TPA services not opted.

1.2 COVERAGE UNDER THE POLICY

1.3

1.4

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

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

PERSONAL ACCIDENT COVER:(WORLD_WIDE)

SCOPE OF COVER:

If at any time during the currency of the policy the insured sustains any bodily injury resulting solely and directly from accident caused anywhere in the world by external, violent, and visible means,then the Company undertakes to pay the insured or his/her legal personal representative,as the case may be,the following sums:

The overall liability in the event of one or more of the eventualities occuring SHALL be restricted to the CSI

CSI means capital sum insured opted for the personal accident section.

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

The limit of liability SHALL be applicable for all the insured persons severally or jointly.The benefit under this section shall be paid only once under this policy or subsequent renewals for the same diseases for the same person

2. DEFINITIONS/OTHER MAJOR FEATURES:

• AMBULANCE SERVICES: Means ambulance servicec charges reasonably and necessarily incurred in case the insured person is to be shifted from residence to hospital or from one hospital to another hospital.The ambulance service charges are payable only if the hospitalisation expenses are admissible.Further the ambulance service charges are admissible only if such expenses are paid to registered ambulance services providers.


• INSURED PERSON: Means Person(s) named on the schedule of the policy which includes family comprising of the proposer,his/her legally wedded spouse,dependent unemployed children between 3(three months) to the age of 25 years,unmarried daughters including divorcee,and widowed daughters and dependent Parents or parents-in-law(either of them only).The minimum number of persons to be covered under the policy shall be the proposer plus one family member.


• ANY ONE ILLNESS: Any one illness shall be deemed to mean continuous period of illness and it includes relapse within 105(one hundred and five)days from the date of discharge from the Hospital / Nursing Home / Day Care Center from where the treatment was taken.Occurance of the same illness after a lapse of 105(one hundred and five)days as stated above shall be considered as fresh illness for the purpose of this policy.


• 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.


• 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.


• MIDTERM INCLUSION: Midterm inclusion of members is permitted for newly wed spouse only.Spouse can be included within three months of marriage or at the time of renewal of the policy.


• NO CLAIM DISCOUNT / LOADING: A discount of 5% on the premium,in respect of each claim free year,subject to a maximum of 20% shall be allowed provided the policy is renewed with the company witout any break.In case any claim is admitted under the policy, the entire No Claim Discount shall be forfeited in the next renewal of the renewal of the policy.However,the No Claim Discount shall continue to accrue afresh from the next claim free year.

In case of any claim is admitted under the policy,where No Claim Discount has not accrued or the earned No Claim Discount has been forfeited, a loading shall be levied on the renewal premium @5% for each claim occured year subject to a maximum of 20%.

The position of No Claim Discount (NCD)/Loading on premium shall be as per illustration below:

• FRAUD/MISREPRESENTATION/CONCEALMENT:Non-Disclosure,concealment or mis-representation of material facts in the Proposal Form and/or in the Claim Form or any other documents,shall render the Policy null and void ab-initio and the company shall not be liable under the policy.The company shall not be liable under this policy in respect of any claim if such calim in any manner intentionally or fraudulently or otherwise misrepresented or concealed or on making false statement or submitting false bills whether by the Insured person or Institution / Organisation on his behalf.Company shall be at liberty to take suitable legal action against the Insured Person / Institution / Organisation as per Law.
• MEDICLAIM WITH OMP: In case where the whole Family covered under THE FAMILY FLOATER Policy goes abroad by taking Oriental's Overseas Mediclaim Policy his / her FAMILY FLOATER Policy become suspended for the period he/she is abraod.And may be extended by number of days,the insured Family was subject to written request being made by the insured before leaving India.The EXTENSION WONT BE APPLICABLE UNLESS THE ENTIRE FAMILY TAKES THE OPMP POLICY FROM THE COMPANY.
• DISCOUNT ON OMP PREMIUM: A DISCOUNT OF 15% ON Overseas Mediclaim Policy PREMIUM WOULB BE ALLOWED WHEN EVEN A SINGLE FAMILY Member COVERED under the Happy Family Floater Policy, TAKES THE Overseas Medicliam Policy FROM the Company, provided the happy family flaoter policy is valid as on the date of taking Overseas Mediclaim policy of the company.

3. IRDA REGULATION NO 5:

4. IT EXEMPTION:

5. PREMIUM:

6. Migration:

The following guidelines have to be observed in case of migration:

• Migration is permitted only if the current policy is an individual mediclaim policy or the Insured is covered under a Group Mediclaim Policy issued by the Company and is valid as on the date of migration.



• The migration is permitted only at the time of renewal of the existing individual mediclaim policy/Group Mediclaim Policywith the Company. However in the case of Group Mediclaim Policy such migration to this policy will be allowed even in case the insured withdraws from the Group Mediclaim policy due to retirement / resignation or change of employment.
  The pre existing cover in case of such migration will be granted after the completion of four years of consecutive (without break) individual mediclaim policies with the Company including the Family floater policy. The benefit of the pre-existing will be restricted to those insureds who have completed four consecutive (without break) individual mediclaim policies with the Company including the family floater policy. The limit of liability for the pre existing cover will be the least of the sum insured of all the five policies considered for the pre existing cover (subject to the per illness cap of the family floater policy). In the case of migration from group Mediclaim policy, in spite of the status of the pre-existing clause in the Group Mediclaim Policy, the terms and conditions of this policy will be prevailing.

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