Oriental Insurance Company Comprehensive Health Cover for Family -
   Policy Wording
COVERAGE UNDER THE POLICY
The following reasonable and necessary expenses (subject to limits) are payable under the policy for various benefits:
Hospitalisation Benefits
A 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 th e Sum Insured per day. b
(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 2.5 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 3.19 NIL. 0.1% of sum insured per day per illnes s 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 3.20 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.
*.This time limit SHALL not apply to following specific treatments taken in the Network Hospital / Nursing Home where the Insured is discharged on the same day. Such treatment SHALL be


Considered to be taken under Hospitalisation Benefit.
Dialysis (haemo dialysis, Peritoneal dialysis)
Parental Chemotherapy (injectible);
Radiotherapy,
Eye Surgery,
Lithotripsy (kidney stone removal),
Tonsillectomy,
Dilation and Curettage (D&C)
Dental surgery following an accident
Hysterectomy
Coronary Angioplasty
Coronary Angiography
Surgery of Gall bladder, Pancreas and bile duct
Surgery of Hernia
Surgery of Hydrocele.
Surgery of Prostrate.
Gastrointestinal Surgery.
Genital Surgery.
Surgery of Nose.
Surgery of throat and ear.
Surgery of Appendix.
Surgery of Urinary System.
Treatment of fractures / dislocation excluding hair line fracture, Contracture releases and minor reconstructive procedures of limbs which otherwise require hospitalisation.
Arthroscopic Knee surgery.
Laproscopic therapeutic surgeries.
Any surgery under General Anaesthesia.
Any such disease / procedure agreed by TPA/Company before treatment.

HOSPITALISATION PERIOD:
The period for which an insured person is admitted in the hospital 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 policy. The minimum period of stay shall be 24 (twenty four) hours
PRE-HOSPITALISATION:
Reasonable and necessary medical expenses incurred for the treatment of disease/ injury during the period upto 30 (thirty) days prior to date of admission in hospital sustained SHALL be considered as part of claim mentioned under item 1.2 above.
POST-HOSPITALISATION:
Reasonable and necessary medical expenses incurred for the treatment of disease/ injury for a period upto 60 (sixty) days from discharge from the date of discharge from hospital SHALL be considered as part of claim mentioned under item 1.2 above.
MEDICAL PRACTITIONER:
means a person who holds a effective degree/diploma from a recognised institution and is registered by Medical Council of any State of India. The term Medical Practitioner shall include Physician, Specialist and Surgeon.
PRE EXISTING HEALTH
CONDITION OR DISEASE: means any condition, ailment or injury or related condition(s) for which the insured person/s had signs or symptoms, and / or were diagnosed, and / or received medical advice/ treatment, within 48 months prior to his / her first hospitalization benefit policy with the Company.
IN-PATIENT:
An Insured person who is admitted to hospital and stays for at least 24 hours for the sole purpose of receiving the treatment for suffered ailment / illness / disease / injury / accident during the currency of the policy.
CASHLESS FACILITY:
The TPA may authorise upon the request of the insured for direct settlement of admissible claim as per agreed charges between Network Hospitals and the TPA./ Company In such cases, the TPA SHALL directly settle all bills of admissible amounts with the Network Hospitals and the Insured Person may not have to pay such admissible amounts to the Hospital to the extent the claim is covered under the policy.
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 network specialised Day Care Centre which is fully equipped with advanced technology and specialised infrastructure and where the insured is discharged on the same day after treatment.


EXCLUSIONS
Benign ENT disorders and surgeries i.e. Tonsillectomy, Adenoidectomy, Mastoidectomy, Tympanoplasty etc.
Polycystic ovarian diseases .
Surgery of hernia.
Surgery of hydrocele.
Non infective Arthritis.
Undescendent Testes.
Cataract.
Surgery of benign prostatic hypertrophy.
Hysterectomy for menorrhagia or fibromyoma or myomectomy or prolapse of uterus.
Fissure / Fistula in anus.
Piles.
Sinusitis and related disorders.
Surgery of gallbladder and bile duct excluding malignancy.
Surgery of genito- urinary system excluding malignancy.
Pilonidal Sinus.
Gout and Rheumatism.
Hypertension.
Diabetes.
Calculus diseases.
Surgery for prolapsed inter vertebral disk unless arising from accident.
Surgery of varicose veins and varicose ulcers.
Joint Replacement due to Degenerative condition.
Age related osteoarthritis and Osteoporosis.

If the continuity of the renewal is not maintained with the Company then subsequent cover SHALL be treated as fresh policy and clauses 4.1., 4.2, 4.3 SHALL apply unless agreed by the Company and suitable endorsement passed on the policy. Similarly if the sum insured is enhanced subsequent to the inception of the policy, the exclusions 4.1, 4.2 and 4.3 will apply afresh for the enhanced portion of the sum insured for the purpose of this section.

Injury or disease directly or indirectly caused by or arising from or attributable to War, Invasion, Act of Foreign Enemy, War like operations (whether war be declared or not) or by nuclear weapons / materials.
5Circumcision (unless necessary for treatment of a disease not excluded under the policy or as may be necessitated due to any accident), vaccination, inoculation, cosmetic or aesthetic treatment of any description, plastic surgery other than as may be necessitated due to an accident or as a part of any illness.
Surgery for correction of eye sight, cost of spectacles, contact lenses, hearing aids etc.
Surgery for correction of eye sight, cost of spectacles, contact lenses, hearing aids etc.
7Any dental treatment or surgery, unless arising from injury and which requires hospitalisation, which is corrective, cosmetic or of aesthetic in nature, filling of cavity, root canal treatment including treatment for wear and tear etc
Convalescence, general debility, “run down” condition or rest cure, congenital external and internal diseases or defects or anomalies, sterility, any fertility, sub-fertility or assisted conception procedure, venereal diseases, intentional self-injury/suicide, all psychiatric and psychosomatic disorders and diseases / accident due to and / or use, misuse or abuse of drugs / alcohol or use of intoxicating substances or such abuse or addiction etc.
Any treatment received in convalescent home, convalescent hospital, health hydro, nature care clinic or similar establishments.
All expenses arising out of any condition directly or indirectly caused by, or associated with Human T-cell Lymphotropic Virus Type III (HTLD - III) or Lymohadinopathy Associated Virus (LAV) or the Mutants Derivative or Variations Deficiency Syndrome or any Syndrome or condition of similar kind commonly referred to as AIDS, HIV and its complications including sexually transmitted diseases.
Expenses incurred at Hospital or Nursing Home primarily for evaluation / diagnostic purposes which is not followed by active treatment for the ailment during the hospitalised period OR expenses incurred for investigation or treatment irrelevant to the diseases diagnosed during hospitalisation or primary reasons for admission, referral fee to family doctors, out station consultants / Surgeons fees, Doctor’s home visit charges/ Attendant / Nursing charges during pre and post hospitalisation period. etc.
Expenses incurred on vitamins and tonics etc unless forming part of treatment for injury or disease as certified by the attending physician and / or all non medical expenses including personal comfort and convenience items or services.
Any Treatment arising from or traceable to pregnancy, childbirth, miscarriage, caesarean section, abortion or complications of any of these including changes in chronic condition as a result of pregnancy.
Naturopathy treatment, unproven procedure or treatment, experimental or alternative medicine and related treatment including acupressure, acupuncture, magnetic and such other therapies etc.
Genetic disorders and stem cell implantation / surgery.
Cost of external and or durable Medical / Non medical equipment of any kind used for diagnosis and or treatment including CPAP, CAPD, Infusion pump etc., Ambulatory devices i.e. walker , Crutches, Belts ,Collars ,Caps , splints, slings, braces ,Stockings etc. of any kind, Diabetic foot wear, Glucometer / Thermometer and similar related items etc. and also any medical / non medical equipment which is subsequently used at home.
Cost of external and or durable Medical / Non medical equipment of any kind used for diagnosis and or treatment including CPAP, CAPD, Infusion pump etc., Ambulatory devices i.e. walker , Crutches, Belts ,Collars ,Caps , splints, slings, braces ,Stockings etc. of any kind, Diabetic foot wear, Glucometer / Thermometer and similar related items etc. and also any medical / non medical equipment which is subsequently used at home.
Treatment of obesity or condition arising therefrom (including morbid obesity) and any other weight control programme, services or supplies etc...
Change of treatment from one system to another system of medicine unless being agreed / allowed and recommended by the consultant under whom the treatment is taken.
Any treatment arising from Insured’s participation in any hazardous activity including but not limited to scuba diving, motor racing, parachuting, hang gliding, rock or mountain climbing etc unless specifically agreed by the Insurance Company.
Out patient Diagnostic, Medical or Surgical procedures or treatments, non-prescribed drugs and medical supplies, Hormone replacement therapy, Sex change or treatment which results from or is in any way related to sex change.
Massages, Steam bathing, Shirodhara and like treatment under Ayurvedic treatment.
Any kind of Service charges/Surcharges, unless payable to the Govt. Authority, levied by the hospital.
Compulsory Co-Payment: Under the SILVER plan the insured has to bear 10% of admissible claim amount in each and every claim.