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

The following reasonable and necessary expenses(subject to limits)are payable under the policy for various benefits:

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 and Drugs,Diagnostic Material and X-Ray,Dialysis,Chemotherapy,Radiotherapy,Cost of Pacemaker,Artificial limbs & similar expenses As per the limits of the sum insured As per the limits of the sum insured
e. Ambulane Services charges as defined hereinafter under Rs.1000/- per illness and limited to maximum 1% of the sum insured or Rs.3000/-whichever is less,for the entire policy period. Rs.2000/- per illness and limited to maximum 1% of the sum insured or Rs.6000/-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 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,Nusing 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 rapid animal like monkey,cat etc.) Reasonable expenses limited upto Rs.5000/- actually incurred for immunisation injections in any one policy Reasonable expenses limited upto Rs.5000/- actually incurred for immunisation injections in any one policy
NOTE:FOR THE PURPOSE OF THIS SECTION THE PRE_REQUISITE CONDITIONS FOR DOMICILIARY HOSPITALISATION CLAIM SHALL NOT APPLY

1.3

Hospitalisation/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 pyable or 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 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 Sum insured in multiples of Rs.100,000/- and upto Rs.500,000/- per person aged 18 years and above.50% of this limit for persons less than 18 years. Sum insured in multiples of Rs.200,000/- 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

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:


BENEFIT COVERED DESCRIPTION AMT.PAYABLE
1. Accidental Death only 100% of CSI
2. Loss of Two entire Limbs, or sight of two eyes or one entire limb and sight of one eye 100% of CSI
3. Loss of one entire Limb or sight of one eye 50% of CSI
4. Permanent Total Disablement resulting in the insured becoming in engaging in any Employment or occupation whatsoever. 100% of CSI

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
Benefits:
PLan Total amount Payable Amount payable on survival for 180 days and above from the date of discharge from the hospital(the first discharge date in case of more than one hospitalisations are involved). Amount payable on survival for 270 days and above from the date of discharge from the hospital(the first discharge date in case of more than one hospitalisations are involved).
A. 15% of Sum Insured under the policy 5% of the sum insured 10% of the sum insured
B. 25% of Sum Insured under the policy 10% of the sum insured 15% of the sum insured

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:


Status of No Claim Discount(NCD)/Loading in the expiring policy In the event of No Claim,the position of No Claim Discount(NCD)/Loading in renewal policy In the event of No Claim,the position of Claim Discount(NCD)/Loading in renewal policy
0% NCD / Loading 5% NCD 5% Loading
5% NCD 10 % NCD 0% NCD / Loading
10% NCD 15% NCD 0% NCD / Loading
15% NCD 20% NCD 0% NCD / Loading
20% NCD 20% NCD 0% NCD / Loading
5% loading 0% NCD / Loading 10% Loading
10% Loading 5% Loading 15% Loading
15% Loading 10% Loading 20% Loading
20% Loading 15% Loading 20% Loading
  • 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:

This policy is subject to regulation 5 of IRDA (Protection of Policy Holder interest)regulation.

4. IT EXEMPTION:

The premium under the policy is eligible for Income Tax exemption under Section 80-D of the IT Act.

5. PREMIUM:


SILVER Plan:
A. PRIMARY MEMBER PREMIUM
Sum Insured AGE IN YEARS
21-35 36-45 46-55 56-60 61-65
100000 1320 1580 2470 3520 5240
150000 1940 2320 3640 5180 7750
200000 2490 2980 4720 6750 10110
250000 2980 3570 5720 8210 12330
300000 3480 4160 6730 9670 14560
350000 3910 4670 7640 11030 16640
400000 4340 5180 8560 12380 18730
450000 4770 5700 9480 13740 20820
500000 5200 6210 10400 15090 22900

The Entry age limit of the proposer is maximum 55years
However, continuous renewals will be accepted till the proposer is 65years old.


B. FAMILY MEMBER PREMIUM(PER PERSON)
Sum Insured Domiciliary Hos limit AGE BAND
3m-20 21-35 36-45 46-55 56-60 61-70 above 70
100000 10000 240 260 320 490 700 1310 1760
150000 15000 350 390 460 730 1040 1940 2630
200000 20000 450 500 600 940 1350 2530 3450
250000 25000 540 600 710 1140 1640 3080 4230
300000 25000 630 700 830 1350 1930 3640 5020
350000 25000 700 780 930 1530 2210 4160 5750
400000 25000 780 870 1040 1710 2480 4680 6490
450000 25000 860 950 1140 1900 2750 5200 7230
500000 25000 940 1040 1240 2080 3020 5730 7970

C. PERSONAL ACCIDENT
Sum Insured
PREMIUM PER PERSON
100000 200000 300000 400000 500000
60 120 180 240 300

Total premium will be the sum of A and B above. If add on cover is taken, premium under C is also to be added.

GOLD PLAN(without add on covers):

I. PRIMARY MEMBER PREMIUM
Sum Insured AGE IN YEARS
21-35 36-45 46-55 56-60 61-65
600000 7140 8520 14210 20600 31220
700000 8320 9930 16570 24020 36410
800000 9500 11340 18920 27440 41600
900000 10670 12750 21280 30860 46790
1000000 11850 14150 23640 34280 51980

II. FAMILY MEMBER PREMIUM(PER PERSON)
Sum Insured Domiciliary Hos limit AGE BAND
3m-20 21-35 36-45 46-55 56-60 61-70 above 70
600000 50000 1290 1430 1700 2840 4120 7800 10860
700000 50000 1500 1660 1990 3310 4800 9100 12660
800000 50000 1710 1900 2270 3780
900000 50000 1920 2130 2550 4260 6170 11700 16280


III. PERSONAL ACCIDENT
Sum Insured 200000 400000 600000 800000 1000000
PREMIUM PER PERSON 120 240 360 480 600

Total premium will be the sum of (I) and (II).
If Personal Accident to be opted the relevant premium from table (III) to be added.

GOLD PLAN(with add on covers):

IV. GOLD WITH ADD-ON HARDSHIP PLAN 'A'
PREMIUM FOR PRIMARY MEMBER
Sum Insured AGE IN YEARS
21-35 36-45 46-55 56-60 61-65
600000 7350 8780 14640 21220 32160
700000 8570 10230 17070 24740 37500
800000 9790 11680 19490 28260 42850
900000 10990 13130 21920 31790 48190
1000000 12210 14570 24350 35310 53540


V. GOLD WITH ADD-ON HARDSHIP PLAN 'A'
FAMILY MEMBER PREMIUM (PER PERSON)
Sum Insured Domiciliary Hos Limit AGE BAND
3m-20 21-35 36-45 46-55 56-60 61-70 above 70
600000 50000 1330 1470 1750 2930 4240 8030 11190
700000 50000 1550 1710 2050 3410 4940 9370 13040
800000 50000 1760 1960 2340 3890 5650 10710 14900
900000 50000 1980 2190 2630 4390 6360 12050 16770
1000000 50000 2190 2440 2910 4870 7070 13390 18620


Total premium will be the sum of (IV) and (V).
If Personal Accident to be opted the relevant premium from table (III) to be added.


VI. GOLD WITH ADD-ON HARDSHIP PLAN 'B'
PREMIUM FOR PRIMARY MEMBER
Sum Insured AGE IN YEARS
21-35 36-45 46-55 56-60 61-65
600000 7500 8950 14920 21630 32780
700000 8740 10430 17400 25220 38230
800000 9980 11910 19870 28810 43680
900000 11200 13390 22340 32400 49130
1000000 12440 14860 24820 35990 54580


VII. GOLD WITH ADD-ON HARDSHIP PLAN 'B'
FAMILY MEMBER PREMIUM (PER PERSON)
Sum Insured Domiciliary Hos limit AGE BOND
3m-20 21-35 36-45 46-55 56-60 61-70 above 70
600000 50000 1350 1500 1790 2980 4330 8190 11400
700000 50000 1580 1740 2090 3480 5040 9560 13290
800000 50000 1800 2000 2380 3970 5760 10920 15190
900000 50000 2020 2240 2680 4470 6480 12290 17090
1000000 50000 2240 2490 2970 4970 7200 13650 18980


Total premium will be the sum of (VI) and (VII).
If Personal Accident to be opted the relevant premium from table (III) to be added.
For full terms and conditions exclusions etc. please visit our site www.orientalinsurance.org.in


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.

Illustration:



Individual mediclaim policy period / Family floater policy period Beneficiaries Under the individual mediclaim policy / Family Floater policy. Sum insured Date of migration to family floater policy applicable Limit of pre existing condition under the family floater.
01/05/2005
-06
A 75000 01/05/2009 NA
01/05/2006
-07
A
B
100000
100000
-do- NA
NA
01/05/2007-
08
A
B
C
100000
100000
50000
-do-
-do-
-do-
NA
NA
NA
01/05/2008-
09
A
B
C
100000
50000
100000
-do-
-do-
-do-
NA
NA
NA
01/05/2009-
10 (fly Flr)
A (Fly Flr)
B (Fly Flr)
C (Fly Flr)
200000
200000
200000
01/05/2009 75000
Not eligible
Not eligible
01/05/2010
s
A (Fly Flr)
B (Fly Flr)
C (Fly Flr)
200000
200000
200000
01/05/2010 100000
100000
Not eligible
01/05/2011
s
A (Fly Flr)
B (Fly Flr)
C (Fly Flr
200000
200000
200000
01/05/2010 100000
100000
50000




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