| 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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| 3.OTHER DEFINITIONS AND INTERPRETATIONS: |
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| 3.1 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. |
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| 3.2 ENTIRE CONTRACT: This POLICY, SCHEDULE, PROPOSAL / DECLARATION given by the insured constitute a complete contract. Only Insurer may alter the terms and conditions of the policy and such alterations made by the insurer shall only be evidenced by a duly signed endorsement on the policy with the Company stamp. |
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| 3.3 TPA (THIRD PARTY ADMINISTRATOR): means any company / body who has obtained licence from IRDA to practice as a third party administrator and is appointed as TPA by the Company. |
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| 3.4 NETWORK HOSPITAL: means hospital that has agreed with the Company / TPA to participate in providing cashless health services to the insured persons. The list is maintained by and available with the TPA and the same is subject to amendment from time to time without any notice to the insured. |
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| 3.5 HOSPITALISATION PERIOD: The period for which an insured person is admitted in the hospital as 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 |
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| 3.6 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. |
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| 3.7 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. |
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| 3.8 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. |
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| 3.9 QUALIFIED NURSE: means a person who holds a certificate in NURSING from a recognised Nursing Institute. |
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| 3.10 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. |
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| 3.11 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. |
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| 3.12 REASONABLE & NECESSARY EXPENSES: |
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- For a networked hospital means the rate pre-agreed between Network Hospital and the TPA / Company, for surgical / medical treatment that is necessary for treating the insured person who was hospitalized.
- For any other hospital it shall mean the cost of surgical / medical treatment that is necessary and reasonable for treating the condition for which insured person was hospitalized.
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| NOTE: Any expenses other than the above have to be borne by the insured person himself. |
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| 3.13 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. |
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| 3.14 I.D. CARD: means the card issued to the Insured Person by the TPA to avail Cashless facility in the Network Hospital. |
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