| 8- Oriental Insurance Company Limited - Family Floater Policy Wording |
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| Source: Website of The Oriental Insurance Company Limited |
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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which makes the claim inadmissible or doubtful requiring investigations, the authorisation of cashless facility may be withdrawn.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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| 5.7 Any 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) 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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