Oriental Health Insurance Health of Privileged Elders : Coverage, claim & Renewal

Updated: 07-02-2019 07:53:36 AM

Retirement is usually considered as a happy second innings. However, for senior citizens, it is also the time when their health starts to degrade. In times like today where the cost of medicines and hospitalization treatment are increasing at an exponential rate, senior citizen health insurance policy has become important. Health of Privileged Elders plan from Oriental Health Insurance is one such policy which is designed for people 60 and above and covers medical costs which is usually not covered by other insurance providers. 

What is Health of Privileged Elders plan? 

Health of Privileged Elders policy is exclusively designed for senior citizens to cover their hospitalization and domiciliary expenses due to accidental bodily injury or from the specified diseases.

Eligibility Criteria 

Health of Privileged Elders plan by Oriental Health Insurance is designed for citizens aged 60 years and above. 

Health of Privileged Elders Plan Features

• This health policy is issued for one year and available for minimum sum insured of Rs 1 lakh which can go up to Rs 5 lakh
• Premium will be loaded by 10% for new entrants
• Policy seeker needs to undergo pre-acceptance health check-up
• Health of Privileged Elders policy is portable provided the previous policy has been maintained without any break
• The insured is entitled to have a free look period of 15 days where S/he can review the terms and conditions of the respective policy
• Policyholder will be entitled for No Claim Discount at the time of renewal of the policy after every claim free policy year

What this policy covers?

• Room, boarding and nursing expenses
• ICU expenses not exceeding 2% of the sum insured per day
• Ambulance service charges
• Surgeon, consultant’s fees
• Cost of prosthetic devices implanted during the surgery
• Ayurvedic, homeopathic and unani hospitalization expenses are covered if it is taken as in-patient in a government hospital

Below are the following specified illness/disease/ injury which are covered under this policy along with the maximum liability of the company

S.No	Name of the disease	Maximum limit of liability
1	Accidental injury	100% of sum Insured
2	Knee Replacement	70% of sum Insured
3	Cardio Vascular disease	50% of sum Insured
4	Chronic Renal Failure	50% of sum Insured
5	Cancer	50% of sum Insured
6	Hepato-Billiary Disorders	50% of sum Insured
7	Chronic Obstructive Lung Disease	20% of sum Insured
8	Stroke	20% of sum Insured
9	Benign Prostrate	15% of sum Insured
10	Orthopaedic Disease	15% of sum Insured
11	Ophthalmic Disease	10% of Sum Insured

Documents required for claim process

To claim, following are the documents which should be submitted to the company/TPA within 7 days of discharge from the hospital/nursing home:

• Original test reports, bills, cash memos of medical expenses
• Medical history of the patient
• Medical treatment and recovery report
• Duly filed claim form
• Hospital discharge report

Claim Settlement

As soon as the insured is admitted in the hospital, details like Policy Number, ID Card No., Name of insured person in respect of whom claim is made, Nature of disease / injury, name of the hospital, etc. should be given to the insurance company /TPA within 48 hours of admission but before discharge unless waived in writing. In case of post hospitalization, supporting claim papers and documents given above should also be submitted within 7 days.

Cases where you can’t claim Health of Privileged Elders policy

The insurance company is not liable to make any payment in respect of any following expenses incurred by the insured person:

• Any disease, health condition, illness and ailment which was not mentioned in the policy
• Injury or disease directly or indirectly caused by war, invasion, act of foreign enemy
• Expenses incurred at hospital for diagnostic purpose but not followed by treatment for the ailment during the hospitalized period
• Non-medical expenses including personal comfort such as television, aya
• Massages, steam bathing, shirodhara under Ayurveda treatment
• Doctor’s home visit charges during Pre and post hospitalization period

How long does it take to pay out a claim? 

Health of Privileged Elders policy by Oriental health Insurance provides cashless service which can cover up to Rs 1 lakh of hospitalization expenses and above that reimburses the amount.

If the insured wants to opt for the cashless access service, S/he needs to take a pre admission authorization either from the insurance company or from the TPA. Upon getting the required documents, medical details from the insured and network hospital, it will issue a pre-authorization letter / guarantee of payment letter to the Hospital mentioning the sum guaranteed as payable.

If in case, the insurance company deny the claim, the insured may gets the treatment as per the doctor’s advice and later on submit the claim papers to the company for reimbursement within 7 days from the discharge.

Renewal Process of Health of Privileged Elders

The renewal of Health of Privileged Elders policy is not automatic; thus, premium should be paid to the company before the due date. The policyholder will be entitled to get 5% discount if no claim were made in the policy year.

Advantages of buying Health of Privileged Elders Policy

• The insured will get discount in premium if they opt for the voluntary co-payment
• Cashless service is available in Health of Privileged Elders plan through TPA which is only limited to Rs 1 lakh
• The insured is entitled to have a free look period of 15 days where S/he can review the terms and conditions of the respective policy

Important Aspects (Critical things) 

• Claims made during the policy term should not exceed the sum insured opted by the insured person at the time of inception of the policy
• In case of fresh proposals, insured needs to submit certain medical reports to the insurance company which in turn will reimburse 50% cost per person
• Insurance company is not liable to pay for the hospitalization expenses if the policy is in the break period
• Cost of health check-up will be reimbursed after four continues claim free years provided there were no claims reported during the period. The amount so reimbursable shall not exceed 1% of the average sum insured 

Features
Claim Type (In-House or TPA)	Both
Pre-Hospitalization	30 days prior to hospitalization
Network Hospital Count	1800+
Post-Hospitalization	60 days from the date of discharge
Room Eligibility	Up to 1% of the sum insured per day
Share Claim Payments	20% as compulsory co-payment, 10-50% as voluntary co payment
Restoration of Cover	NA
No Claim Bonus	5%-20%
Ambulance Charges	Up to Rs 1000
Worldwide Coverage	No
Maternity Cover	NA
Hospitalization at Home	Shall not exceed Rs 20,000
Day Care Treatment	Covered
Non-Allopathic Treatment Coverage	Covered
Emergency Ambulance	NA
Health Check-up	Covered

FAQ’S 

Q1. Is this policy portable?

Yes, the policyholder anytime may switch from one insurer to another insurer. In case, the insured desires to port their policy, request for the same has to be made 45 days before the renewal date.

Q2. Is there any no claim bonus with this policy?

The insured will get No Claim Discount after every claim free year at the time of the renewal of the policy provided it is renewed without any break as per the table:

Discount available after one claim free year	5%
Discount available on second continuous claim free year	10%
Discount available on third continuous claim free year	15%
Discount available on fourth continuous claim free year	20%

Q3. What is the process of cancellation of this policy?

The insured may at any time cancel this policy by giving 30 days’ notice period to the insurance company. In such event, the company will process refund of premium at short period rate only provided no claim has occurred during the policy period.

Period on Risk	Rate of premium to be charged
Upto 1 month	¼ of the annual rate
Upto 3 months	½ of the annual rate
Upto 6 months	¾  of the annual rate
Exceeding 6 months	Full annual rate

 

Q4. Is there any waiting period in this policy?

There is an initial waiting period of 30 days which is applicable for all illness but specific disease and pre-existing disease can only be covered after two years of waiting period.