There are two ways to make claim under a Health Insurance Policy: on cashless basis and on reimbursement basis. In simple terms, for making a claim on cashless basis, the treatment must be done only at a network hospital of the insurance company servicing your policy. For availing the treatment, you would have to first seek an authorization as per the procedures laid down and in the prescribed form.
In case of claims on reimbursement basis, the insurance company has to be informed as per their prescribed procedures. The policyholder has to ensure that documents such as claim form, discharge summary, prescriptions and bills to be submitted for the claim on reimbursement are obtained after hospitalization.
Oriental Health Insurance has a well-defined claim processing system.
Cashless Service: seeking Pre-Authorization
- Complete the pre-authorization form available at the hospital’s insurance/TPA Desk.
- Send the completed form via email or fax.
- Approved letter will be sent by the claim management team. Remember that the claim management team could send an inquiry to the hospital or you before authorization.
- In case the authorization is rejected, initiate the treatment and file for reimbursement claim.
Reimbursement Claim: Claim Submission
- Complete the necessary form and submit along with required documents, as per the policy terms and conditions.
- Necessary documents include discharge summary, prescriptions, bills etc.
- Approved letter will be sent by the claim management team. Remember that you will be answerable to any queries raised by the claim management team before the letter is issued.
- In case the claim is rejected, the reasons will be communicated by the team.
In case of any emergencies, you need to inform Oriental Insurance within 24 hours of the admission. In case of planned emergencies, the notification has to reach the company 48 hours prior to the hospitalization. The claim intimation can be done via Oriental Insurance's toll free number 1800-118-485. The same could also be emailed to firstname.lastname@example.org
Note: If you are a Coverfox customer, you can directly reach out to us for all your claim-related issues and queries.
Frequently Asked Questions
- I am looking to buy Oriental Insurance Company’s Family Floater plan. What are the key points I should be considering?
Happy Family Floater Health Insurance Policy is available in two plans- Silver and Gold Plan. Silver plan offers coverage between Rs. 1 – 5 lakhs and Gold Plan offers cover between Rs.6-10 lakhs. Also, 10% co-payment applies in Silver Plan which is not the case in Gold Plan. For details on terms and coverage, please refer to the Policy Wordings.
- Is Personal Accident covered in Family Floater Plans?
Personal Accident - Available in Silver and Gold plans
- In Silver up to Rs.5 lakhs.
- In Gold up to Rs.10 lakhs.
- Do I have to undergo a pre-policy medical check-up?
Pre acceptance medical examination is not required if the beneficiaries are below 45 years of age.
- What are the major exclusions in Oriental Health policy?
Any pre-existing disease, any expense incurred during first 30 days of cover except injury due to accident, all expenses incurred in respect of any treatment relating to pregnancy and child birth. Treatment for Cataracts, Benign prostatic hypertrophy,Hysterectomy, Menorrhagia or Fibromyoma, Hernia,Fitula of anus,Piles, Sinusitis, Asthma,Bronchitis, All Psychiatric or Psychosomatic disorders are excluded from the scope of the cover. For detailed list, please refer the Policy Wordings.
- Which all hospitals are covered under Oriental Insurance's cashless network?
Cashless services are available at a network hospital. To locate a Oriental Insurance network hospital near you, click here.
Review of Oriental Insurance Company Limited
- Competitive pricing
- Exceptional claim settlement record and ratio
Could be better…
- Absence of No Claim Bonus for claim-free years
- 4 years of waiting period for pre-existing conditions
- Network of affiliated hospitals for cashless settlement could be stronger