Medical

In-Patient & Day-Care benefits Hospital Accommodation, Accidents and Emergencies, Intensive Care & Operation Theatre Costs, Surgical Operations & procedures, Surgeons, Anaesthetists & Physicians fees, Prescribed Medicine & drugs, Prostheses and Surgical Appliances, (Artificial body parts surgically implanted to form parts of an insured’s body), Diagnostic tests, Oncology Treatment, Radiotherapy & Chemotherapy, Ophthalmology, Acute (reversible) kidney failure, Physiotherapy.

Out-Patient Benefits Diagnostic tests, Specialists, Consultants, General Medical Practitioner and Family Physician fees, Out-Patient home visits for emergency conditions, Oncology, Prescribed Medicines & Dressings, Emergency Ambulance (to and/or from point of treatment), Outpatient Surgical Procedures, Physiotherapy

Other benefits: Chronic & Pre-existing conditions, Emergency local ambulance, Organ transplant, Nursing at home, Compassionate emergency home visit, Hospital cash benefits, Repatriation, burial or cremation of mortal remains, Emergency medical evacuation.

Optional benefits:

• Routine dental care benefits
• Maternity care benefits
• Optical benefits

Pre-Authorisations

Prior approval may be necessary for certain services/treatments for which your Provider shall contact OQIC either in writing or over the phone.

With this, your Provider as well you may be assured of:

• The eligibility of the stated service under your Policy/Plan.
• The extent/limit of cover of the specific service as per the limits specified in your policy.

Out-Patient Services

Services/treatments rendered by the Medical Practitioner in the Out-Patient clinic or that which do not require a stay in the hospital is termed as Out-Patient Service.

You should note that some non–urgent services require pre-authorization, here are a few examples:

• MRI, CT, PET Scans
• Endoscopic procedures
• Physiotherapy
• Complimentary therapies such as Chiropractic, Acupuncture, Osteopathy
• Dental services
• Maternity related investigations or Out-patient procedures
• Optical related services

In-Patient /Daycare Services

• Services /treatments rendered by the Medical Practitioner that requires a stay at the hospital for one or more night is termed as In–Patient Service.
• Services /treatments rendered by the Medical Practitioner that are eligible under the Policy benefits wherein an admission is necessary but does not require an overnight stay in the hospital is termed Daycare Service.
• Prior to availing any non – urgent or planned in–patient treatments and / or day care treatments the insured should inform the TPA (by email) with a medical report from the attending Medical Practitioner outlining the diagnosis, plan of management and estimated expense and obtain written pre-authorization for your proposed In-patient / Daycare admission or procedure a minimum of 48 hours prior to the planned admission.
• We shall validate, in writing to you, with a specified Pre-approval Code, the extent of the respective procedure’s coverage and further requirements, if any, subject to your policy terms, conditions and exclusions.
• Verbal confirmation does not constitute pre-authorization. If in doubt, please contact the medical helpline, as shown on your membership card.
• Planned Treatment under taken without pre-authorization from OQIC may not be eligible for a full refund in accordance with the policy terms and conditions, unless our Help Line response is delayed beyond a reasonable time. Furthermore, any expenses not related to the treatment shall be borne by the Insured.

The following Elective / Planned services such as but not limited to require pre-authorization:

• All In-Patient treatments specified or limited to under the Policy
• All Daycare admissions

Emergency Services

In the event of Emergency treatment pre-approval is not required but it is the liability of the Network Provider to inform OQIC of the case within 24 hours of admission to the hospital.

• The Table of Benefits (TOB) details the services, treatments, limits, and benefits that you are entitled for.
• Online access is available for each and every member detailing benefits of the Policy/Plan.
• The Providers give specific details in accordance with your network tier. Network Tier is detailed in your plan as well as in your medical card. The Network Providers include Hospitals, Polyclinics, Private Practitioner Clinics, Laboratory and Diagnostic Centers and Pharmacies that you may choose to avail your service / treatment from both within Oman as well as outside of Oman. Treatment outside Oman is on reimbursement basis subject to usual, reasonable customary costs at Designated Service Providers in Oman.
• The Policy Exclusions detail those services that you are not covered for under your Plan/Policy.
• The expenses incurred within the Network Providers shall be on a direct billing basis unless stated otherwise in your TOB/Policy Terms and Conditions.
• The expenses incurred Outside the Network Provider (within and outside Oman) shall be on a Cash Reimbursement basis, the details of which are explained under Reimbursement Claims/Table of Benefits.
• Should there be any queries or further clarifications, you may contact our TPA call center on the contact numbers provided on the back of your Medical card.
• TPA call center is available for your assistance 24/7, throughout the year.

• The plan you are covered under is printed on your card. You may refer to your online Table of Benefit (TOB) to get the detailed services, treatments, limits, and benefits that you are entitled for.
• You may choose the Provider from the list of Network Providers enlisted under your network tier.
• We have an arrangement of Direct Billing with our Network Providers for the eligible expenses. When you visit the Provider, please present your OQIC Medical Card to the receptionist to ensure you avail your benefits efficiently.
• You may be asked to pay before or after meeting with your medical practitioner the Deductible and/or Coinsurance/Copayment specified on your Medical Card at the provider.
• You may also be asked to sign a claim form so that the Medical Practitioner can fill in the details of your visit / illness which are essential for the processing of your claim.
• Please ensure that you have signed the claim form as well all the invoices pertaining to the expenses incurred by you.
• Make sure that the Physician has completed the required data, signed and stamped your claim form, which shall then be forwarded by the Provider to OQIC/TPA.
• You will bear any expenses incurred for treatments or services that are not covered by your policy.
• You may contact the insurance coordinator at your preferred Provider or OQIC Call Center for any queries or immediate assistance.
• Your Physician may require a pre-approval from the OQIC on certain Out Patient / Daycare / In-Patient services which are detailed under the Pre-Authorization section.

Contact:

OQIC Medical Call center no: 8007 0202

Dr. Harshad Veetil

Senior Manager – Medical Claims – Medical
Direct tel: +968 24765331
Mobile no: +968 9805 2774
Email: harshad.veetil@oqic.com

Dr. Shyam Raj Thangappan

Deputy Manager – Medical
Direct tel: +968 2476 5329
Mobile no: +968 9116 9086
Email: shyamraj.thangappan@oqic.com