Oriental Senior Citizen Hope Health Insurance

Oriental Senior Citizen Hope Health Insurance covers medical expenditures for adults over the age of 60. The Oriental Insurance Company Limited’s Hope of Privileged Elders (HOPE) plan was created specifically for elderly persons to cover hospitalisation and treatment costs associated with specific ailments.

About Oriental Insurance Company

The Oriental Health Insurance Company Ltd. is a central public sector organization controlled by the Ministry of Finance of the Government of India. The company’s headquarters are in New Delhi. It has approximately 1500 active branches and 29 regional offices spread across the country. It is also present in Nepal, Kuwait, and Dubai. The public sector undertaking earned a gross premium of Rs. 12,747.42 crores in fiscal year 2020-21. The company offers around 170 different types of general insurance, including the Hope Senior Health Insurance package. The IRDA registration number for the firm is “556.”

Benefits of Oriental Senior Health Insurance 

The following are the primary advantages of Oriental Senior Health Insurance:

  • Multiple sums insured options, ranging from Rs. 1 lakh to Rs. 5 lakhs, are available for individual coverage.

  • A voluntary co-payment discount of up to 50% is available

  • A 5% No Claim Bonus is available for every year without a claim

  • A free health check-up facility is available for every four years without a claim.

  • Tax savings on premiums are available under Section 80D of the Income Tax Act.

Inclusions of Oriental Senior Health Insurance

The following are included in Oriental Health Insurance for Senior Citizens:

  • Expenses Associated with Hospitalization

  • Expenses for Domiciliary Hospitalization

  • Ambulance Fees

  • Procedures for Day-care

  • Expenses for Pre-hospitalization

  • Expenses for Post-Hospitalization

  • AYUSH Therapy

The Following Reasonable and Necessary Expenses

The following reasonable and necessary expenses, subject to the limits outlined below, are covered by the policy only if they fall within the overall limit outlined above for the specified diseases, illnesses, or injuries:

  • The hospital or nursing home will cover your room, board, and nursing costs up to 1% of the insured sum per day.

  • I.C. Unit expenses not exceeding daily expenses equal to 2% of the Sum Insured.

  • (Stay in the Room and, if necessary, a stay in the ICU should not exceed the total number of days spent in the hospital)

  • In the event that a patient needs to be transferred from their home to a hospital in the event that they are admitted to an emergency room or intensive care unit, or from one hospital or nursing home to another hospital or nursing home for the purpose of being hospitalized, ambulance services charges per illness by registered ambulance—actual expenses or Rs 1000/- whichever is less—will be reimbursed.

  • Fees for surgeons, anaesthesiologists, medical professionals, consultants, and specialists

  • Anaesthesia, blood, oxygen, charges for the operating room, surgical equipment, medicines, dialysis, chemotherapy, radiotherapy, artificial limbs, and the cost of prosthetic devices like pacemakers that are inserted during surgery, as well as relevant laboratory or diagnostic tests, X-rays, and other similar expenses.
  • Hospitalization expenses are only allowable if the hospitalisation lasts at least 24 (twenty-four) hours. This time restriction does not apply to particular treatments received in a Networked Hospital /Nursing Home when the Insured is released on the same day. Such treatment will be regarded to have been received under the Hospitalisation Benefit.
  • Haemodialysis

  • Parenteral Chemotherapy

  • Radiotherapy

  • Eye Surgery

  • Lithotripsy (kidney stone removal)

  • Accidental Dental Surgery

  • vii. Coronary Artery Angioplasty

  • Coronary Angiography

  • Gallbladder, Pancreas, and Bile Duct Surgery

  • Prostrate Surgery

  • Treatment of fractures and dislocations, avoiding hair line fractures, contracture releases, and modest reconstructive surgeries of limbs that would otherwise necessitate hospitalisation.

  • Arthroscopic Knee Surgery

  • Laparoscopic therapeutic procedures

Exclusions of Oriental Senior Health Insurance

The following are the treatments are all excluded from Oriental Insurance’s coverage. HOPE—Health of Privileged Elders:

  • Any health condition that is not listed in the policy.

  • Any condition that was already present during the first two policy years.

  • Any illness that is mentioned in the policy but that is contracted within the first thirty days of the policy’s term.

  • Treatment of a few specific diseases that the policy mentions.

  • Injuries caused by nuclear materials, invasion, or war.

  • Vaccination, lifestyle alteration, circumcision, treatment for cosmetic or aesthetic reasons, or hair transplant.

  • Unless an accident requires it, plastic surgery.

  • improvement of vision; expenses for spectacles and contact lenses

  • Rest cure, convalescence.

  • Sterility, fertility or sub-fertility procedures, assisted conception procedures, and external congenital diseases or defects

  • Mental health issues, suicide, and intentional self-injury.

  • Treatments for substance use disorders.

  • Costs associated with HIV/AIDS and other sexually transmitted diseases, as well as their complications.

  • Procedures for evaluation or diagnosis without hospitalization

  • Mineral water, vitamins, supplements, and tonics, unless they are being used to treat a disease or injury.

  • alternative treatments like acupressure, experimental therapies, and naturopathy.

  • Expenses for treatment that have nothing to do with the illness for which you were hospitalized.

  • Equipment that is outside and lasts and is not medical, like ambulatory devices. Walkers, belts, crutches, slings, braces, and others are among these. Additionally, glucometer, nebulizer, etc.

  • Costs for convenience and comfort that are not related to medicine.

  • Change the treatment plan unless the TPA or the company agrees.

  • Any treatments for obesity or weight loss.

  • Treatment as a result of engaging in risky activities.

  • Surcharges, file fees, service fees, registration fees, etc. Paid for by the hospital.

  • Specialist’s conference charges while guaranteed is treated at home. Charges for nursing care incurred prior to and after hospitalization.

Procedure for Accessing Cashless Services Available in Network Hospitals and Nursing Homes

  1. Any claim for Cashless Access Services must be made through the Company or TPA, as long as the patient is admitted to a hospital that is on the agreed-upon list of networked hospitals or nursing homes and has received pre-admission authorization. After receiving relevant medical information from the insured person or a network hospital or nursing home, the company or TPA must confirm that the person is eligible to make a claim under the policy and issue a pre-authorization or guarantee of payment letter to the hospital or nursing home detailing the amount guaranteed as payable and the condition for which the person wants to be admitted as an inpatient.

  2. In the event that the hospital or insured person is unable to provide the pertinent information or medical details that the Company or TPA requires, the Company or TPA reserves the right to deny pre-authorization. Denial of Cashless Access in such circumstances should never be interpreted as denial of claim or service. Within seven (seven) days of being discharged from a hospital or nursing home, the insured person may receive treatment according to the advice of their treating physician and then submit the complete claim paperwork to the Company or TPA for reimbursement.

  3. The authorization for the cashless facility will be revoked in the event that the TPA or Company has access to information that renders the claim invalid or raises questions that call for further investigation. Anyway, this will be finished by the Organization/TPA before the patient is released from the Emergency clinic.

Cancellation Clause

The Company may cancel this Policy at any time by providing the Insured 30 (Thirty) days’ notice by registered mail to the Insured’s last known address, and in such a case, the Company shall return to the Insured a pro-rata premium for the remaining Period of Insurance.

(Such cancellation by the Company shall be limited to moral hazards such as intentional misrepresentation / malicious suppression of facts intended to mislead the Company about the acceptability of the proposal, filing a fraudulent claim, and other such intentional acts by the insured / beneficiaries under the policy.) However, the Company will be responsible for any claims that originated prior to the date of cancellation. The Insured may terminate this policy at any time, and the Company will return the premium at the Company’s short period rate only (see table below), provided no claims have occurred during the policy period up to the date of cancellation.