| 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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| 5.7Any medical practitioner authorised by the TPA/Company shall have deemed permission to examine the Insured Person in case of any alleged injury or Disease requiring Hospitalisation when and so often as the same may reasonably be required on behalf of the TPA/Company. |
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| 5.8 CONTRIBUTION : If at the time when any claim arises under this policy, there is in existence of any other insurance including medical benefits from the employer, (other than Cancer Insurance Policy in collaboration with Indian Cancer Society) whether it be effected by or on behalf of any Insured Person in respect of whom the claim may have arisen covering the same loss, liability, compensation, costs or expenses, the company shall not be liable to pay or contribute more than its rateable proportion of any loss, liability, compensation, costs or expenses. The benefits under this policy shall however be in excess of the benefits available under Cancer Insurance Policy. |
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| 5.9 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 also not be liable under this policy in respect of any claim if such claim be in any manner intentionally or fraudulently or otherwise misrepresented or concealed or on making false statements or submitting false bills whether by the Insured Person or Institution / Organization on his behalf. Company shall be at liberty to take suitable legal action against the Insured Person / Institution / Organization as per Law. |
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| 5.10 REPUDIATION: |
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| (a)(I): The TPA, if policy is being serviced by them, shall repudiate the claim if not covered / not payable under the policy. The TPA shall mention the reasons for repudiation in writing to the insured person. Wherever the claim is being serviced by the Company (in cases where services of the TPA are not opted) such repudiation of the claim SHALL be done by the Company. In either of the cases the insured person shall have the right to appeal / approach the Grievance Redressal Cell of the company at its policy issuing office, concerned Divisional Office, concerned Regional Office or the Grievance Cell of the Head Office of the Company, situated at A-25/27, Asaf Ali Road, New Delhi-110002. against the repudiation. |
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| (b)If the insured is not satisfied with the decision / of the reply of the Grievance Cell under 5.7 (A), he / she may approach the Ombudsman of Insurance, established by the Central Government for redressal of grievances. The Ombudsman of Insurance is empowered to adjudicate on personal lines of insurance claims upto Rs.20 lacs. |
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| 5.11 CANCELLATION CLAUSE: Company may at any time, cancel this Policy by sending the Insured 30 (Thirty) days notice by registered letter at the Insured’s last known address and in such an event the Company shall refund to the Insured a pro-rata premium for un-expired Period of Insurance. (such cancellation by the Company may be for reasons such as intentional misrepresentation / malicious suppression of facts intended to misleading the insurance company about the acceptability of the proposal, lodging a fraudulent claim and such other intentional acts of the insured / beneficiaries under the policy). The Company shall, however, remain liable for any claim which arose prior to the date of cancellation. The Insured may at any time cancel this policy and in such event the Company shall allow refund of premium at Company’s short period rate only (table given here below) provided no claim has occurred during the policy period up to date of cancellation. |
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| Period on Risk |
Rate of premium to be charged |
| Upto 1 Month |
1/4th of the annual rate |
| Upto 3 Months |
1/2 of the annual rate |
| Upto 6 Months |
3/4th of the annual rate |
| Exceeding 6 months |
Full annual rate |
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| 5.12 ARBITRATION CLAUSE: If any dispute or difference shall arise as to the quantum to be paid under the policy (liability being otherwise admitted) such difference shall independently of all other questions be referred to the decision of a sole arbitrator to be appointed in writing by the parties or if they cannot agree upon a single arbitrator within 30 days of any party invoking arbitration, the same shall be referred to a panel of three arbitrators, comprising of two arbitrators, one to be appointed by each of the parties to the dispute/difference and the third arbitrator to be appointed by such two arbitrators and arbitration shall be conducted under and in accordance with the provisions of the Arbitration and Conciliation Act, 1996. |
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| It is clearly agreed and understood that no difference or dispute shall be referable to arbitration as herein before provided, if the Company has disputed or not accepted liability under or in respect of this policy. |
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| It is hereby expressly stipulated and declared that it shall be a condition precedent to any right of action or suit upon this policy that award by such arbitrator/ arbitrators of the amount of the loss or damage shall be first obtained. |
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