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  • Oriental Health Insurance Claims Procedure

    Oriental Health Insurance

    To make health insurance claims with Oriental Insurance, the customer will be required to visit the insurance provider’s website and login using the unique user ID and password provided by the company. Then enter the “Claim” tab and you will gain access to the claim forms where you will have to enter the policy number against which the claim is intimated. The form must then be submitted online following which the company will receive your intimation. The intimated claim forms can be viewed via “My Intimated Claims”, but individuals will have to personally pay a visit to an office of the Oriental Insurance Company for the submission of the detailed claim form along with other necessary documents as it serves as an evidence for the registration of claims with the company. The claim will appear on the user’s homepage only after registration with the company is complete.

    Claims must be sent to the company in writing, be it in the form of e-mails or letters. Letters can be sent to the registered office at Oriental House, A-25/27, Asaf Ali Road, New Delhi – 110002. In case a customer wishes to contact the company for information related to claims, calls can be made to 011-43659595.

    Incurred Claim Ratio for Oriental Health Insurance:

    The Incurred Claim Ratio of an insurance company is one of the main indicators of its performance and it helps prospective customers to get a better sense of the company’s reliability. The Incurred Claim Ratio for Oriental Health Insurance is as follows:

    Net Earned Premium Net Claims Paid Incurred Claims Ratio
    Rs.200,410 lacs Rs.234,517 lacs

    117.02%

    It is crucial to note that the Incurred Claim Ratio of a company is not the only parameter against which it must be judged as there could be factors that may not be taken into consideration when computing the same. A comprehensive comparison of insurance policies and the record of the companies that provide these policies must be checked before choosing one.

    How to Make Claims?

    1. In Case of Cashless Treatment:
      • Procedure to File a Claim (Planned / Emergency Hospitalisation):

        Claim forms in case of cashless treatment must be pre-authorised by the network hospital / day care centre / nursing home. Insured individuals can claim Third party Accident once the TPA receives the relevant medical details from the network provider / insured individual. The insurance company will look at the medical information and determine whether or not that particular individual is eligible for claims.

        Should the company find the information satisfactory, a guarantee of payment or pre-authorisation letter will be sent to the day care centre / nursing home / hospital. This letter will contain details regarding the guaranteed sum that the customer will receive. If the insured individual cannot for whatever reason furnish the requisite medical information as requested by the TPA, the TPA will determine whether or not pre-authorisation can be provided to the customer. The TPA will notify the customer in writing if it does not accept pre-authorisation and the insured individual will have to undergo treatment based on the advice of his / her treating doctor / medical practitioner. After treatment, the claim papers can be submitted in full to the TPA to facilitate the reimbursement of claims. The claim documents must be sent to Oriental House, A-25/27, Asaf Ali Road, New Delhi – 110002.

    2. In Case of Reimbursement of Treatment Expenses:
      • Procedure to File a Claim:

        The customer must provide the insurance company with details regarding the particulars of the policy number, the insured individual’s name in whose name the claim is going to be made, nature of injury / illness, and the name and contact details of the nursing home / hospital / medical practitioner.

      • Documents Required:

        The customer will have to submit certain documents for the claims process to be initiated by the Oriental Insurance Company. These documents include a copy of the claim form along with a Xerox of premium and policy receipt, medical treatment report / hospital discharge report, original test reports (EGG / Sonography / X-Rays, etc.), medical recovery report, employer’s leave certificate, information regarding medical expenses such as cash memos / original bills / prescriptions, registration number of the nursing home / hospital (in case the nursing home / hospital is not registered, a certificate from the treating doctor must be provided and said certificate must contain details regarding the number of beds in the treatment facility, availability of qualified 24/7 staff / nurses and doctors and fully equipped operation theatre in the nursing home / hospital), and first information report from the police containing all details about the accident.

      • Claims Process:

        The TPA must be intimated about the claim within seven days after the date on which the insured individual was hospitalised. The final claim documents must be sent along with cash memos / original bills from the hospital and other documents that are mentioned in the claim form before the completion of 30 days from the date on which the insured individual was discharged from the hospital. Any other information or documents requested by the TPA / company must also be provided to the TPA / company to ensure easy facilitation of claims. The documents can be sent to the registered office at:

        Oriental House, A-25/27, Asaf Ali Road, New Delhi – 110002.

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