| 8- Family Floater Coverage -Oriental Insurance Company Limited - Policy Wording |
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THE ORIENTAL INSURANCE COMPANY LIMITED,
Regd. Office: Oriental House, P.B. No. 7037, A-25/27, Asaf Ali Road, New Delhi- 110 002 |
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| 5 CONDITIONS |
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| 5.1 ENTIRE CONTRACT: the policy, SCHEDULE, proposal form, prospectus and declaration given by the insured shall constitute the complete contract of insurance. Only insurer may alter the terms and conditions of this policy/ contract. Any alteration that may be made by the insurer shall only be evidenced by a duly signed and sealed endorsement on the policy. |
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| 5.2 COMMUNICATION: Every notice or communication to be given or made under this policy shall be delivered in writing at the address of the policy issuing office / Third Party Administrator as shown in the Schedule. |
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| 5.3 PAYMENT OF PREMIUM: The premium payable under this policy shall be paid in advance. No receipt for premium shall be valid except on the official form of the Company signed by a duly authorized official of the company. The due payment of premium and the observance and fulfilment of the terms, provisions, conditions and endorsements of this policy by the Insured Person in so far as they relate to anything to be done or complied with by the Insured Person shall be condition precedent to any liability of the Company to make any payment under this policy. No waiver of any terms, provisions, conditions and endorsements of this policy shall be valid, unless made in writing and signed by an authorised official of the Company. |
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| 5.4 NOTICE OF CLAIM: Immediate written notice of claim with particulars relating to Policy Number, ID Card No., Name of insured person in respect of whom claim is made, Nature of disease / illness / injury and Name and Address of the attending medical practitioner / Hospital/Nursing Home etc. should be given to the Company / TPA while taking treatment in the Hospital / Nursing Home by Fax, Email. Such written notice should be given within 48 (forty eight) hours of admission or before discharge from Hospital / Nursing Home, whichever is earlier unless waived in writing. |
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| 5.5 CLAIM DOCUMENTS: Final claim along with originals of hospital Bills/Cash memos/reports, claim form and list of documents as listed below should be submitted to the Company / TPA within 7 (seven) days of discharge from the Hospital / Nursing Home. |
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Original bills, receipts and discharge certificate / card from the hospital.
Medical history of the patient recorded by the Hospital.
Original Cash-memo from the hospital (s) / chemist (s) supported by proper prescription.
Original receipt, pathological and other test reports from a pathologist / radiologist including film etc supported by the note from attending medical practitioner / surgeon demanding such tests.
Attending Consultants’ / Anaesthetists’ / Specialists’ certificates regarding diagnosis and bill / receipts etc. in original.
Surgeons’ original certificate stating diagnosis and nature of operation performed along with bills / receipts etc.
Any other information required by TPA / the Company.
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| All documents must be duly Attested by the insured person. |
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| In case of post hospitalisation treatment all supporting claim papers / documents as listed above should also be submitted within 7 (seven) days after completion of such treatment to the Company / T.P.A. In addition, insured should also provide to the Company / TPA such additional information and assistance as the Company / TPA may require in dealing with the claim. |
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| NOTE: Waiver of the condition may be considered in extreme cases of hardship where it is proved to the satisfaction of the Company that under the circumstances in which the insured was placed it was not possible for him or any other person to give such notice or file claim within the prescribed time limit. Otherwise Company / TPA has a right to reject the claim. |
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| 5.6 PROCEDURE FOR AVAILING CASHLESS ACCESS SERVICES IN NETWORK HOSPITAL/NURSING HOME : |
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| (i) Claim in respect of Cashless Access Services SHALL be through the TPA provided treatment is undertaken in a network hospital / Nursing Homes and is subject to pre admission authorization. The TPA shall, upon getting the related medical details / relevant information from the insured person / network Hospital / Nursing Home, verify that the person is eligible to claim under the policy and after satisfying itself SHALL issue a pre-authorisation letter / guarantee of payment letter to the Hospital / Nursing Home mentioning the sum guaranteed as payable, also the ailment for which the person is seeking to be admitted as in-patient. |
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| (ii) The TPA reserves the right to deny pre-authorisation in case the hospital / insured person is unable to provide the relevant information / medical details as required by the TPA. In such circumstances denial of Cashless Access should in no way be construed as denial of claim. The insured person may obtain the treatment as per his/her treating doctor’s advice and later on submit the full claim papers to the TPA for reimbursement within 7 (seven) days of the discharge from Hospital / Nursing Home. |
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| (iii)Should any information be available to the TPA which makes the claim inadmissible or doubtful requiring investigations, the authorisation of cashless facility may be withdrawn. However this shall be done by the TPA before the patient is discharged from the Hospital and notice to the effect given to the treating hospital / the insured. |
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