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Oriental Health of Privileged Elders (HOPE)

Oriental Health of Privileged Elders (HOPE) is exclusively designed for people who are 60 years old and above. Cashless Service is available under this product through TPA only and is limited to Rs. 1 lakh. The policy offers a discount on premiums for opting for Voluntary Co-payment. Apart from the basic benefits, AYUSH treatment and modern treatment are also covered under this policy. To know more about this policy, have a look at the following mentions.

Eligibility Criteria

Age at entry60 years and above
Policy period1 year
Sum insured options

Minimum – Rs. 1 lakh

Maximum – Rs. 5 lakhs

Coverage Details

This table gives a glimpse of the policy and its sub-limits.

Pre-hospitalization expenses30 days
Post-hospitalization60 days
TelemedicineUp to Rs. 2000 per policy per person
Room, Boarding, and Nursing ExpensesUp to 1% of the Sum Insured per day.
I.C unit expensesUp to 2% of the sum insured per day
Domiciliary hospitalizationUp to Rs. 20000 per person
Robotic surgeriesPer policy period 10% of SI, subject to a maximum of INR 1,00,000.
Orthopaedic Diseases15 % of the sum insured

Major Highlights of Oriental Health of Privileged Elders (HOPE)

This policy has come up with a sack full of benefits and facilities. The important mentions are as follows.

Modern Treatment:

All the following procedures will be covered in the policy if treated as in-patient care or as a part of domiciliary hospitalization or as daycare treatment in the hospital, within the sub-limits in the complete policy period – Oral chemotherapy, Immunotherapy- Monoclonal Antibody to be given as an injection, Intravitreal injections, Robotic surgeries, Stereotactic radio surgeries, Vaporization of the prostrate, and IONM – (Intra Operative Neuro Monitoring)

Domiciliary Hospitalization:

It is covered, which means medical treatment for a period exceeding three days for such an illness/disease/injury, which in the normal course would require care and treatment at a hospital but is actually taken while confined at home under any of the following circumstances:

  • the condition of the patient is such that he/she is not in a condition to be removed to a hospital, or
  • the patient takes treatment at home on account of the non-availability of room in a hospital. Subject, however to the condition that Domiciliary Hospitalisation benefit shall not cover

Cost of Health Check-up:

The Insured shall be entitled to reimbursement of the cost of a Health checkup

undertaken once at the expiry of a block of every four continuous claim-free underwriting years provided there are no claims reported during the block. The cost so reimbursable shall not exceed the amount equal to 1% of the average sum Insured during the block of four claim-free underwriting years.

No Claim Discount:

The insured shall be entitled to a No Claim Discount at the rate of 5% of the renewal premium payable after every claim-free policy year, subject to a maximum of 20%, as per the table below, provided the policy is renewed without any break:

Discount available on renewal premium payable after one (or the first) claim-free annual policy5%
Discount available on renewal premium payable on the second continuous claim-free renewal of annual Policy10%
Discount available on renewal premium payable on the third continuous claim-free renewal of annual Policy15%
Discount available on renewal premium payable on the fourth continuous claim-free renewal of annual Policy20%

Voluntary Co-payment:

The insured may opt to bear a part of the claim amount (after application of compulsory co-payment) for which discounts are applicable, subject to a maximum of 50%.

Telemedicine:

Expenses incurred by the insured on telemedicine/Teleconsultation with a registered medical practitioner for Diagnosis & treatment of a disease/illness covered under the Policy.

Ambulance Services Charges per illness by registered ambulance:

Actual Expenses or Rs 1000/- whichever is less shall be reimbursable in case the patient has to be shifted from residence to hospital in case of admission in Emergency Ward, I.C.U. Or from one Hospital, Nursing home to another Hospital or Nursing Home for hospitalization.

General Exclusions of Oriental Health of Privileged Elders (HOPE)

Before buying an insurance plan, it is very important to know and understand the exclusions of the policy for which it does not offer any coverage to avoid any future problems. So, to avoid future complexities and claim denial, here are the general exclusions of Oriental Health of Privileged Elders (HOPE).

  • Any self-inflicted injury, suicide, or suicide attempt falls under the category of exclusions.
  • Diagnosis expenses not related to the current diagnosis and treatment are not covered by the plan.
  • If you are having bed rest and do not have any medical treatment for the disease, is not covered by the policy.
  • Any treatment cost related to obesity control will not be compensated by the policy.
  • Any unrecognized or unauthorized medical procedure is to be excluded and the doctor, surgeon, or medical practitioner has to be licensed and registered.
  • Coronary heart disease, severe sleep apnoea, baldness, alopecia, wigs, and toupees are excluded from the policy.
  • Any treatment or surgery related to gender treatment will not be reimbursed by the company.
  • Cosmetic surgery and plastic surgery are not covered by the plan.
  • If you take part in any kind of hazardous activities or adventurous sports like sky diving, para-gliding, scuba diving, etc., and gain injury from that, that is not covered by the plan.
  • Injury incurred due to the participation in any unlawful act or due to war, war-like situation, riots, public unrest, etc, will not be covered by the policy.
  • Treatments for the consumption of alcohol, drug, or any intoxicating substance are excluded.
  • If you receive treatment for the correction of eyesight due to refractive error less than 7.5 dioptres, it will be under the exclusions.
  • Gestational Surrogacy and reversal of sterilization are excluded.

How Can You Buy Oriental Health of Privileged Elders (HOPE)?

One can easily buy this policy by following the below easy steps carefully.

  • Scroll up to find the ‘Products’ tab. Hover over it and click on ‘Health Insurance’.
  • Select your gender and input your “pin code” in the section on the right-hand side of the page. Click “Continue” from the menu.
  • Choose the individual you wish to insure next. You must then choose your “deductible amount” and enter your age before continuing. (Select whether you have experienced ailments by selecting yes or no). Click “Get Plan” after that.
  • Go through the list of plans and find Oriental Health of Privileged Elders. Enter the required details and pay the premium to buy the plan.

Know The Claim Process of Oriental Health of Privileged Elders (HOPE)

The company offers both cashless and reimbursement facilities. Both procedures are discussed below.

Cashless Claim Procedure:

  • Intimate the insurer and TPA as soon as the incident happens.
  • The Company/TPA reserves the right to deny pre-authorization in case the hospital / insured person is unable to provide the relevant information or medical details as required by the Company/TPA.
  • Submit all the required documents. Do not produce any false information.
  • 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 Company/TPA for reimbursement within 7 days of the discharge from the Hospital/Nursing Home.
  • A surveyor might be appointed to assess and evaluate the claim.
  • If no discrepancy is found, the claim amount will be settled directly to the hospital.

Reimbursement Claim Procedure:

  • Once the treatment is received after the discharge, submit all the documents to the company.
  • The company will evaluate the claim.
  • If no discrepancy is found, the claim amount will be settled within the stipulated time.

Claim Documents:

  • Original bills, receipts, and discharge certificate/card from the hospital.
  • Medical history of the patient recorded by the Hospital.
  • Original Cash-memo from the hospital (s) / chemist (s) supported by proper prescription.
  • The original receipt, pathological and other test reports from a pathologist/radiologist, including film, etc., supported by the note from the attending medical practitioner/surgeon demanding such tests.
  • Attending Consultants, Anaesthetists, Specialist certificates regarding diagnosis and bill, receipts, etc.
  • Surgeon’s original certificate stating diagnosis and nature of operation performed along with bills, receipts, etc.
  • Any other information required by TPA or Insurance Company. All documents must be duly attested by the insured person.

Frequently Asked Questions

Insured has to bear 20% of the admissible claim amount in each and every claim.

The Insured Person will have the option to port the Policy to other insurers by applying to such insurer to port the entire policy along with all the members of the family, if any, at least 45 days before, but not earlier than 60 days from the policy renewal date as per IRDAI guidelines related to portability.

Any person desiring to take fresh insurance coverage has to submit the following medical reports (and any other medical reports) required by the company from the authorized network Diagnostic Centre.

This provision shall also be applicable for renewal where there is a break in the policy period. The cost of such a checkup shall be borne by the insured. However, in case of fresh proposals, the Company shall

reimburse per person 50% cost of the Medical Checkup. A list of the diagnostic centers will be provided.

Medical list – Physical examination, urine, glycosylated haemoglobin, ultrasonography, x-ray of both knees, completed eye test, and stress test.

After the completion of eight continuous years under this policy, no look back is to be applied. This period of eight years is called a moratorium period. The moratorium would be applicable for the sums insured of the first policy and subsequently, completion of eight continuous years would be applicable from the date of enhancement of sums insured only on the enhanced limits.

The insured person will have the option to migrate the policy to other health insurance

products/plans offered by the Company by applying for migration of the policy at least 30 days before the policy renewal date as per IRDAI guidelines on Migration.

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