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Insurance Coverage

नेपाली भाषाको लागि यहाँ थिच्नुहोस्|

Benefits Table (Service Provider-Oriental Insurance Co. Ltd.)
 
  • Group Personal Accident Insurance for Account Holders
Specific account holders shall be insured under this policy for the benefits against any bodily injury as per Table of Benefit mentioned below resulting solely and directly from accident caused by external violent and visible means.
  • Sum Insured: NPR 1,000,000.00
  • Sum Insured: NPR    500,000.00
  • Age Limit: Account holders of all age group shall be eligible for this Insurance Coverage and Benefits.
  • Waiting Period: Not Applicable
 
Table of Benefits:
 
Accidental Death 100% of the Sum Insured
Permanent Total Disablement
Loss of Sight of Both Eyes or Hands or Legs 100% of the Sum Insured
Loss of Sight of One Eye or One Hand or One leg 50% of the Sum Insured
Loss of Speech 50% of the Sum Insured
Loss of Hearing Power of Both Ears 50% of the Sum Insured
Loss of Hearing Power of One Ear 20% of the Sum Insured
Loss of Thumb of Hand 20% of the Sum Insured
Others As specified in the policy.

Note: The Cover is Worldwide

Exclusions:

The policy does not cover death, injury or disablement resulting from:

  • i) Intentional self-injury
  • ii) Suicide or attempted suicide
  • iii) Insanity, venerals disease or the influence of intoxicant drink or drugs.
  • iv) Medical or surgical treatment ( except where such treatment is rendered necessary within the scope of the policy)
  • v) Aviation other than as a passenger (fare-paying or otherwise) in any duly licensed standard type of aircraft anywhere in the World.
  • vi) Persons engaged in activities like racing on wheels or horseback, Bungee Jumping, Paragliding, motorcycle racing and persons engaged/occupations/activities of similar hazard except helping to save human life
  • vii) Persons engaged in polo, hunting, Scuba Diving, Mountaineering, ice hokey, ballooning, skiing etc.
  • viii) Whilst committing any breach of law with criminal intent.
  • ix) Any consequence of war, invasion, act of foreign enemy, Hostiles ( whether war be declared or not) war, rebellion, revolution insurrection, mutiny or usurpted power, seizure, capture, arrest restraint and detainments of all kings, princes and people of whatsoever nation condition or quality.
  • x) Nuclear radiation of nuclear weapons materials.
  • xi) Consequential loss
  • xii) Nervous related injury if not an accident.
 
  • 1. Required Documents for Group Personal Accident Claim
  • • Documents required in case of a death claim
  • Death Certificate
  • Relationship Certificate
  • Citizenship of Deceased
  • Citizenship of Beneficiary
  • Autopsy Report/ Post Mortem Report
  • Police Report
  • Ghatanasthal Muchulka
  • Claim Form
  • • Documents required in case of an injury claim
  • Notify the policy issuing office immediately
  • Original Medical Bills
  • Discharge Bills
  • Prescription, Emergency Ticket, Medical report
  • Discharge Summary
  • Police report, if any
  • Account detail comprising account opening date
  • Claim form

Note: Additional documents can be asked as per the nature of accident.

  • Group Medical / Hospitalization Insurance for Account Holders
This insurance covers the medical expenses of the insured person arising out of accidental injury and illness, where treatment is taken at hospitals /polyclinics only. The insured must be hospitalized for at least 24 hours to lodge any claim. The maximum liability in respect of one sickness for one-year period shall be as per Table of Benefits mentioned below:
 
  • Sum Insured : NPR 1,000,000.00
  • Age Limit: Account holders of age group from 6 months to 65 years
  • Waiting Period: 30 Days
  • Table of Benefits: Rs.100,000.00
Benefits Hospitalization Rs.100,000/-
Room / Bed etc. Nursing expenses including Nursing Exp. Aggregate limit during the policy period (Rs. 1500 per day & for ICU Rs. 2500/- per day ) 25,000.00
Doctors / Anaesthesia / Surgeon / Specialist fee Aggregate Limit during the policy period (Rs. 500 per visit) 15,000.00
Surgical Operation including Anesthesia charge, operation theatre charge and Surgeon's Charge for operation, Blood, Oxygen and other related materials and equipment charges including cost of Dialysis / Chemotherapy / Radio Therapy / Ventilator and similar expenses. Aggregate Limit 25,000.00
Pathology charge, X-Ray, MRI, CT Scan, Angiography and other investigative tests or charges. Aggregate Limit 12,500.00
Medicines / Drugs, injections, Artificial Limbs and Surgical appliances. Aggregate Limit 12,500.00
Cost of Physiotherapy during Hospitalization. Aggregate Limit 10,000.00
Total Rs. 100,000.00
  • Group Medical / Hospitalization Insurance for Account Holders
This insurance covers the medical expenses of the insured person arising out of accidental injury and illness, where treatment is taken at hospitals /polyclinics only. The insured must be hospitalized for at least 24 hours to lodge any claim. The maximum liability in respect of one sickness for one-year period shall be as per Table of Benefits mentioned below:
 
  • Sum Insured: NPR 50,000.00
  • Age Limit: Account holders of age group from 6 months to 65 years
  • Waiting Period: 30 Days
  • Table of Benefits: Rs.50,000.00
Benefits Hospitalization Rs.100,000/-
Room / Bed etc. Nursing expenses including Nursing Exp. Aggregate limit during the policy period ( Rs.750 per day & for ICU Rs. 1000/- per day) 12,500.00
Doctors / Anaesthesia / Surgeon / Specialist fee Aggregate Limit during the policy period (Rs. 500 per visit) 7,500.00
Surgical Operation including Anesthesia charge, operation theatre charge and Surgeon's Charge for operation, Blood, Oxygen and other related materials and equipment charges including cost of Dialysis / Chemotherapy / Radio Therapy / Ventilator and similar expenses. Aggregate Limit 10,000.00
Pathology charge, X-Ray, MRI, CT Scan, Angiography and other investigative tests or charges. Aggregate Limit 7,500.00
Medicines / Drugs, injections, Artificial Limbs and Surgical appliances. Aggregate Limit 7,500.00
Cost of Physiotherapy during Hospitalization. Aggregate Limit 5,000.00
Total Rs. 50,000.00
  • Pre-Hospitalization
Relevant medical expenses incurred during period up to 15 days prior to hospitalization / domiciliary hospitalization on disease/illness/injury sustained will be considered as part of claim under hospitalization.
  • Post- Hospitalization
Relevant medical expenses incurred during period up to 15 days prior after hospitalization on disease/illness/injury sustained will be considered as part of claim under hospitalization.
  • 2. Required Documents for Group Medical Insurance
  • • Original Medical Bills
  • • Copy of Emergency ticket or OPD card ( to be attested by bank)
  • • Original Discharge summary
  • • Prescription slips of medicine
  • • Lab/x-ray/pathology reports and other related documents, if any
  • • Duly filled Claim form
  • 3. Exclusions
OICL shall not be liable for any claim or claims under this Policy arising from:
  • a. All diseases/injuries, which are pre-existing when the cover incepts for the first time. For the purpose of applying this condition, the date of inception of the initial med claim policy taken from any of the Indian/Nepalese insurance companies shall be taken, provided the renewals have been continuous and without any break.
  • b. Any diseases other than those stated in clause (C), contracted by the insured person during the first 30 days from the commencement date of the policy. This condition (b) shall not however, apply in case of the insured person having been covered under this policy or group insurance policy with any of the Indian/Nepalese insurance companies for a continuous period of preceding 12 months without any break.
    • • In the opinion of a panel of medical practitioners constituted by the Company for the purpose, the insured person could not have known of the existence of the disease or any symptoms or complaints thereof at the time of making the proposal for insurance to the company, and
    • • The insured had not taken any consultation. Treatment or medication, in respect of the hospitalization for which claim has been lodged under the policy, prior to taking the insurance.
  • c. During the period of insurance cover, the expenses on treatment of following ailment/diseases/surgeries for specified period of 2 years are not payable if contracted and /or manifested during the currency of the policy. Benign ENT disorders and surgeries i.e Tonsillectomy, Adenoidectomy, Mastoidectomy, Tymponoplasty etc., Polycystic ovarian disease, Surgery of Hernia, Hydrocele , Cataract, Surgery of benign prostatic hypertrophy, Hysterectomy for menorrhagia or fibromyoma or myomectomy or prolapsed of uterus. Fissure/ Fistula in Anus, Piles, Sinusitis and related disorders, surgery of gall bladder and bile duct excluding malignancy , surgery of genitor urinary system excluding malignancy, Pilonidal Sinus, Gout and Rheumatism, Hypertension, Diabetes , Surgery of prolapsed inter vertebral disk unless arising from accident. Surgery of varicose veins and varicose ulcers, Congenital internal diseases, Joint replacement due to Degenerative condition ( 4 years) , Aged related osteoarthritis and Osteoporosis. (4 years). If the continuity of the renewal is not maintained then subsequent cover will be treated as fresh policy.
  • d. Any disease during the first 30 days from the commencement date of the policy is excluded from the policy except treatment for accidental external injuries. Injury or disease directly or indirectly caused by or arising from or attributable to WAR, Invasion, Act of Foreign Enemy, War like operations(whether war be declared or not)
  • e. Circumcision unless necessary for treatment of a disease not excluded hereunder or as may be necessitated due to any accident, vaccination inoculation or change of life or cosmetic or of aesthetic treatment of any description, plastic surgery other than as nay be necessitated due to any accident or as a part of any illness.
  • f. Cost of spectacles and contact lenses, hearing aids. Surgery of correction of eye sight.
  • g. Any dental treatment or surgery which is corrective, cosmetic or of aesthetic procedure, filling of cavity, root canal including wear and tear etc unless arising from disease or injury and which requires hospitalization for treatment.
  • h. Convalescence, general debility "run down” condition or test cure, congenital external disease or defects or anomalies, sterility, any fertility ,sub fertility or assisted conception procedure, venereal disease, international self-injury/suicide, all psychiatric and psychosomatic disorders and diseases/accident due to and or use, misuse or abuse of drug/alcohol or use of intoxicating substances or such abuse or addiction etc
  • i. Charges incurred at Hospital or Nursing Home primarily for diagnostic, X-rays or laboratory examinations not consistent with or incidental to the diagnosis and treatment of the positive existence or presence of any ailment, sickness or injury, for which confinement is required at a hospital/nursing home
  • j. Expenses on vitamins and tonics unless forming part of treatment for injury or disease as certified by the attending physician.
  • k. Injury or disease directly or indirectly caused by or contributed to by nuclear weapons/materials
  • l. Treatment arising from or traceable to pregnancy (including voluntary termination of pregnancy) and childbirth, miscarriage, caesarean section, abortion or complications of any of these including changes in chronic condition as a result of pregnancy.
  • m. Naturopathy treatment, unproven procedure or treatment, experimental or alternative medicine and related treatment including acupressure, acupuncture, magnetic and such other therapies etc.
  • n. Genetical disorders and stem cell implantation / surgery.
  • o. Massage, steam bathing, Shirodhara and alike treatment under ayurvedic treatment
  • p. Outpatient diagnostic, medical or surgical procedures or treatments, non-prescribed drugs and medical supplies, hormone replacement therapy , sex change or treatment which results from or is in any way related to sex change.
  • q. Any stay in the hospital for any domestic reason or where no active regular treatment is given by the specialist.
  • r. Expenses of ambulances
  • s. 10% of claim amount subject to minimum of NPR 1,000.00 on each & every hospitalization claim.
  • t. Hospitalization expenses can be claimed for treatment in Nepal & India only. In case of reimbursement of hospitalization bill of India, patient should have been referred from Nepal’s National Level Hospital.

Note: All above mentioned statements are subject to otherwise terms, conditions, limitations and exclusions in accordance with issued insurance policy.

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