Oriental Health insurance

There is no upper limit on the number of claims during the policy period. However, the total cumulative claim amount cannot exceed the Policy Sum Insured, unless the chosen plan has a Sum Insured Refill benefit, which provides additional coverage even after filing a claim.

Till the age of 55 years, Medical checkup is not required for buying Individual Health Insurance. Above 55 years a medical checkup is required at the time of first purchase of the policy. Medical checkups are usually not needed for renewal of policies.

When you get a new Oriental Health Insurance Policy, there will be a 30 day waiting period starting from the policy start date, during which period any hospitalization charges will not be payable. However, this is not applicable to any emergency hospitalization occurring due to an accident. This 30 day waiting period is not applicable when the policy is renewed. Some specific ailments have a specific waiting period of one or two years. Some of the covers have specific waiting periods.

A pre-existing disease is any condition, ailment or injury or related condition(s), for which the insured person had signs or symptoms, and /or were diagnosed, and / or received medical advice / treatment within 36/48 months prior to 1st health insurance policy issued by Us under which the insured person was covered.

Under Individual Healthline Insurance, the age, the amount of cover (Sum Insured) and the plan of benefits that you choose are the factors that decide the premium. Usually, younger people are considered healthier and thus pay lower annual premium. Older, people pay a higher Health Insurance premium as their risk of health problems or illness is higher.

The premium paid on a health insurance policy is eligible for deduction under Section 80D of the Income Tax Act. So save with your policy now!

A deductible is a cost-sharing requirement. It states that the insurer will not be liable for a specified amount in case of indemnity policies. This is applicable for a specified number of days/hours in case of hospital cash policies which apply before any benefits are payable by the insurer. Remember that a deductible does not reduce your sum insured.

In planned hospitalization the treatment is planned well in advance. The intimation of such hospitalization and authorization from us has to be taken minimum 3 days prior to the date of hospitalization. E.g. Cataract, pace maker implantation, total knee replacement etc are examples for which the hospitalisation can be planned.The insured person should at least 3 days prior to admission to the hospital approach the network provider for hospitalization for medical treatment.

In emergency hospitalization the patient is admitted to the hospital in an emergency situation, for e.g. Severe abdominal pain, accident, heart attack etc. In such event, we should be intimated within 48 hours of admission to the hospital.

You should carry the health card provided by the company with this policy, along with a valid photo identification proof (voter id card / driving license / passport / pan card / any other identity proof as approved by the company).

It refers to payment of the Medical Expenses incurred by the insured while undergoing Specified Day Care Procedures/ Treatment (as mentioned in the Day Care Surgeries list), which require less than 24 hours Hospitalization.

Co-payment is a cost-sharing requirement under a health insurance policy, where the Policy Holder / insured will bear a specified percentage of the admissible costs

A 'Free Look Period' is a period of 15 days from the date of receipt of the policy that a policyholder, in this case you, have to review the entire health insurance plan. If you disagree with any of the terms or conditions mentioned in the policy, you have the option of returning the policy by stating the reasons for the objection. Following this, you are entitled to a refund of the premium paid, provided no claim has been made under this mediclaim insurance policy (subject only to a deduction of the expenses incurred by the company on medical examination and the stamp duty charges). Please note that this facility is not applicable on renewal and portability cases.

Sub limit defines the capping of insurance amount, for specific surgeries and medical procedures, which reduces the premium of the plan. You can also opt for an add on cover by paying extra premium to remove the sub- limits under the policy.

• Member enrolment and issuance of health card
• Hospitalisation Service and Pre-authorization for cashless treatment
• Reimbursement Claim Processing
• Call center service and SMS Services
• Investigation Service and Fraud and Abuse Management Service
• Customer Relation and Contact Management Service and Grievance Management Service
• Health Check up services and Services in Wellness & Health promotion
• management service Legal Assistance and other specified services buy the insurer

The role of TPA begins after policy issuance by insurance company.

The entire process followed in current TPA allocation exercise was duly uploaded on company’s portal and was kept in public domain for any representation, observation, grievance and objection for redressal by specially constituted Appellate Committee. You can access the notice on the noted url: url

A claim is registered, processed and finally paid within 30 days of the receipt of the last necessary document by the TPA/Insurer, as per terms and conditions of the policy. Exception is made for settlement and final payment for 45 days in case a claim warrants an investigation.

Insurance companies have tie-up arrangements with several hospitals which are called network hospitals. Under a health insurance policy, a policyholder can take treatment in any of the network hospitals without having to pay the hospital bills as the payment is made to the hospital directly by the insurance company. TPA helps in organizing cashless treatment to the member. However, expenses beyond the limits or sub-limits as per terms and conditions of the insurance policy or expenses not covered under the policy have to be paid by customer directly to the hospital. Preauthorization, however, is not available if treatment is taken in a nonnetwork hospital.

Preauthorization is facilitated by TPA at network Hospitals.

• Patient should contact an Empanelled Hospital for treatment.
• Hospital would then send the duly filled preauthorization request to the servicing TPA prior to planned hospitalizations.
• For emergency cases preauthorization process can be initiated within 24 hours of hospitalization.
• Servicing TPA would then process the pre-authorization based on policy terms and convey its decision on admissibility to the Hospital. If the cashless is extended, patient is required to pay only for the Non Payable Expenses.
• If the Preauthorization is denied, patient pays the hospital bill, collects original receipts and other documents at the time of discharge from the Hospital and files for reimbursement claim later on and the same is scrutinized as per terms and conditions of the policy for finalization of claim.

Cashless facility can be availed at any of the network hospitals listed with the servicing TPA (List available on website) or insurance company website. The insured has a choice to go to any of the hospitals/nursing homes which are part of the Insurer/TPA network; it can also be confirmed through call center toll free numbers. It is useful and requested to confirm before seeking admission because network of hospitals is continuously updated with new additions and deletions. In the absence of network hospital of choice or due to any other reason, insured can get treated at the hospital of choice which means the entire bill is paid by the policy holder and claim for reimbursement of expenses. The claim shall then be processed as per policy terms and conditions.

You may write / email to us giving details of your grievance at csd@orientalinsurance.co.in or TPAs call centre or grievance department. We assure you that our grievance department will address the issue within 72 hours