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| Senior Citizens Health Insurance (Mediclaim Policy) in India |
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| 6- Senior Citizens Mediclaim Policies - The Oriental Insurance Co. Ltd. |
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| SENIOR CITIZEN SPECIFIED DISEASES INSURANCE |
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| 5. CONDITIONS |
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5.1 ENTIRE CONTRACT: The policy, 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.
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.
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 fulfillment 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 authorized official of the Company.
5.4 The policy shall be deemed to be void ab-inito (since its inception) if the payment instrument is dishonoured for any reasons whatsoever and under this circumstance the Company shall not admit any liability whatsoever under this policy.
5.5 NOTICE OF CLAIM: Immediate 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 notice should be given within 48 hours of admission or before discharge from Hospital / Nursing Home, whichever is earlier, unless waived in writing by the Company.
5.6 CLAIM DOCUMENTS: Final claim along with hospital receipted original 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.
a. Original bills, receipts and discharge certificate / card from the hospital.
b. Medical history of the patient recorded by the Hospital.
C. Original Cash-memo from the hospital (s) / chemist (s) supported by proper prescription.
d. 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.
e. Attending Consultants / Anaesthetists / Specialist certificates regarding diagnosis and bill / receipts etc.
f. Surgeon’s original certificate stating diagnosis and nature of operation performed along with bills / receipts etc.
g. Any other information required by TPA / Insurance Company.
All documents must be duly attested by the insured person.
In case of post hospitalisation treatment (limited to 60 days) all supporting claim papers / documents are listed above should also be submitted within 7 (seven) days after completion of such treatment (upto 60 days or actual period which ever is less) to the Company / T.P.A. In addition insured should also provide the Company / TPA such additional information and assistance as the Company / TPA may require in dealing with the claim.
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 on behalf of the insured 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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| 5.7 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 admission is in a listed hospital in the agreed list of the networked Hospitals / 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.
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 and /or deficiency of service. 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 days of the discharge from Hospital / Nursing Home.
iii) In case any information available to the TPA / Company which makes the claim inadmissible or doubtful requiring investigations, the authorisation of cashless facility shall be withdrawn. However this shall be done by the TPA before the patient is discharged from the Hospital. |
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| 5.8 NON ADMISSION OF CLAIM: |
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A (I): Where the policy is being serviced by TPA, it 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. The insured person may approach the policy issuing office of the Company for any grievance relating to the claim. The Company’s decision in this regard shall be final and binding on TPA.
A (II): Where the policy is serviced by the Company and in case of repudiation of the claim, insured may approach the concerned Regional Office of the Company for redressal of any grievance relating to the claim.
B: In case claim is repudiated by the Company as per A (1) & A (II) the insured person may approach the Chief Manager Grievance Cell of the Company’s Regd. Office situated at A-25/27, Asaf Ali Road, New Delhi-110002.
C: The Central Government has established office of the Insurance Ombudsman for redressal of grievances and the insured may approach the Insurance Ombudsman for redressal of his grievance. The insured may visit the site of http://www.ombudsmanindia.org/ for details. |
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