Oriental Health Insurance Review

Established in 1947, Oriental Insurance evolved from a LIC subsidiary into a leading public sector insurer. Headquartered in New Delhi, it operates 1,500+ branches across India and has a presence in Nepal, Kuwait, and Dubai. Known for its broad non-life portfolio—spanning health, motor, and marine—it caters to both individuals and large businesses. With an average health insurance income of ₹7,519 crores (2021–2024) and access to over 4,000 network hospitals, Oriental offers legacy-backed trust and a strong nationwide footprint.

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Overview

Overview of Oriental Health Insurance

Oriental Health Insurance is one of India’s oldest government-owned insurers, with a legacy dating back to 1947. It has a wide presence, particularly in tier-2 and tier-3 cities, and caters primarily to customers looking for basic, affordable health insurance coverage. While it may not be as tech-driven or fast-paced as newer private players, Oriental has maintained trust through its association with the public sector and relatively straightforward policies. That said, it has lagged in digital innovation and product modernization, which makes it less appealing to younger, urban buyers who expect seamless digital experiences and feature-rich plans.

Claim Settlement Ratio of Oriental Health Insurance

One of the most important factors to evaluate when choosing a health insurance provider is the Claim Settlement Ratio (CSR). It reflects the percentage of claims an insurer successfully settles in a year, and is calculated as:

(Total number of claims settled in a year / Total number of claims received) × 100

A high CSR indicates an insurer’s efficiency and reliability in paying out claims — a vital consideration, especially during health emergencies. While a CSR above 90% is considered solid for health insurers, consistency across years matters too.

Here’s how Oriental Health Insurance has performed over the last three years compared to the industry average:

Insight: Oriental Health Insurance has maintained a robust average CSR of 96% between 2021 and 2024 — well above the industry average of 90%. While 2021–22 saw a perfect score, the following years remained consistent and reliable. This strong claim track record makes Oriental dependable, especially when timely claim approvals are non-negotiable.

Incurred Claim Ratio of Oriental Health Insurance

The Incurred Claim Ratio (ICR) is a critical measure of how much an insurer spends on claims compared to the premiums it collects. It’s calculated using the formula:

ICR = (Total amount paid in claims during the year / Total premium collected during the year) × 100

For example, if an insurer collects ₹150 crores in premiums and pays ₹120 crores in claims, the ICR would be 80%.

An ideal ICR typically ranges between 50% and 80%. A higher ICR may suggest generous claim settlements but could also raise questions about long-term sustainability. Conversely, a very low ICR might mean fewer claims are being paid.

Here’s how Oriental Health Insurance has performed on the ICR front in recent years:

Insight: Oriental Health Insurance has recorded a notably high average ICR of 124% over the last three years, far exceeding the industry average of 84%. While this shows the company has been highly generous in settling claims — possibly offering great value to policyholders — it also hints at potential underwriting or pricing concerns. If this trend continues, it may impact the insurer's profitability or lead to premium hikes in the future.

Offered Riders in Oriental Insurance’s Health Insurance Plans

Health Insurance Plans Offered by Oriental Insurance

1) Happy Family Floater Policy

The Happy Family Floater is a family-focused health insurance policy by Oriental Insurance that comes in four variants — Silver, Gold, Diamond, and Platinum. It offers flexible coverage for families. While the basic structure remains the same, each variant adds more features such as maternity or assisted reproduction based on the sum insured and policy type. The policy is well-suited for families looking for traditional coverage with optional add-ons, though it lacks important features like sum insured restoration or bonus, and has significant room rent restrictions.

Key Benefits:

• There is no mandatory co-payment in all variants except Silver, where 10% is compulsory per claim.
• Pre-hospitalization (30 days) and post-hospitalization (60 days) expenses are covered, including diagnostics, medication, and consultation costs.
• Daycare treatments are fully covered, including chemotherapy, dialysis, and minor surgeries that don’t require 24-hour admission.
• AYUSH treatments are covered across all variants, up to the full sum insured, for alternative systems like Ayurveda, Unani, Siddha, and Homeopathy.
• Room rent is capped at 1% of the sum insured for regular rooms and 2% for ICU across all variants. If limits are breached, a proportionate deduction applies.
• Maternity and newborn coverage is available under the Diamond and Platinum variants. Newborns are covered from day 1 if maternity is claimed.
• Assisted Reproduction Treatment (ART) is offered under the Platinum variant with a 3-year waiting period, covering up to ₹2L if both partners are insured.
• Domiciliary hospitalization is available in all variants. Applicable if hospital admission isn’t possible.
• Optional covers include restoration (only for Silver & Gold variants), accidental death benefit & personal accident cover, geographical extension (SAARC), waiver of proportionate deduction, and hardship cover.
• Mental illness and HIV/AIDS are covered under IRDAI regulations across all variants.

Drawbacks:

• Room rent capping at 1% of the sum insured can lead to significant out-of-pocket expenses if the patient is admitted to a room beyond the allowed category.
• No inbuilt restoration benefit is available in any variant — once the sum insured is exhausted, coverage ends for the policy year.
• No cumulative bonus (NCB) is offered, making it less attractive for claim-free/loyal policyholders.
• Waiting period for pre-existing diseases is 3 years across all variants, with no add-ons to reduce it. 
• No wellness rewards, fitness-linked discounts, or inbuilt health check-up benefits — features that are increasingly standard in modern health plans.

The Happy Family Floater policy may be ideal for families seeking traditional coverage with maternity support. The Silver and Gold variants are suited for those on a budget, while the Diamond and Platinum variants cater to growing families looking for maternity and ART benefits. However, it may fall short for those seeking consumable coverage, restoration, comprehensive plans with no limits, or no-claim rewards.

2) Youth Eco Care Policy

Youth Eco Care is a budget-friendly health insurance plan designed for young individuals and families. It comes in two different coverage levels, Basic and Premium, and offers flexible coverage options for individuals and families. The plan covers key benefits like pre- and post-hospitalization, AYUSH treatments, and daycare procedures, while the Premium variant adds features like maternity cover, daily hospital cash, and second medical opinion. However, it lacks advanced features like sum insured restoration and annual health check-ups.

Key Benefits:

• There is no mandatory co-payment.
• Pre-hospitalization expenses are covered for 45 days, and post-hospitalization for 90 days, including follow-ups and diagnostics.
• AYUSH treatments, including Ayurveda, homeopathy, and other alternative systems, are covered up to the full sum insured.
• Domiciliary hospitalization is included if home treatment is advised due to medical necessity or lack of hospital beds.
• The Premium plan includes daily hospital cash and a medical second opinion benefit for added support during treatment.
• Maternity and ART treatments are covered under the Premium variant, with applicable waiting periods and sub-limits.
• Mental illness and HIV/AIDS are covered, in line with current regulatory norms.
• Both road and air ambulance services are covered.

Drawbacks:

• Room rent is capped at 1% of the sum insured for non-ICU rooms and 2% for ICU rooms for a sum insured up to 10 lakhs. Exceeding these limits may lead to proportionate deductions. Beyond 10L sum insured, the restrictions go away.
• The plan does not offer restoration of the sum insured once it is exhausted during a policy year.
• The plan is restricted to people between 18-45 years only (youth) and does not include options to reduce waiting periods.
• Consumables coverage, Wellness rewards & Free Annual health check-ups are not included.

Youth Eco Care is an okay pick for young, healthy individuals or families looking for a cost-effective plan with core benefits.. It provides good coverage for hospitalization, maternity, and alternative treatments, but may not suit those needing comprehensive features.

3) Oriental Mediclaim Insurance Policy

This is a basic and budget-friendly health insurance plan from Oriental Insurance. It provides essential hospitalization benefits without any co-payment requirement, making it appealing for those who want a straightforward policy that doesn’t strain their wallet. While it covers key aspects like AYUSH treatments, day care procedures, and pre- and post-hospitalization expenses, it lacks important features like restoration benefits or shorter waiting periods. It's best suited for individuals seeking a low-cost plan with standard coverage, rather than comprehensive protection.

Key Benefits:

• The policy comes with zero co-payment, meaning the insurer bears the entire cost of treatment up to the sum insured.
• Pre- and post-hospitalization expenses are covered for 30 days before admission and 60 days after discharge, including medication and diagnostic tests.
• AYUSH treatments—such as Ayurveda, Homeopathy, and other alternative therapies—are covered up to the full sum insured.
• Daycare treatments are covered, allowing claims for procedures like dialysis, chemotherapy, and minor surgeries that don’t require 24-hour hospitalization.
• Domiciliary hospitalization is covered up to ₹50,000 if treatment at home becomes necessary due to medical reasons or lack of hospital beds.

Drawbacks:

• The policy imposes room rent restrictions, capping non-ICU rooms at 1% of the sum insured and ICU rooms at 2%. Exceeding these limits can lead to proportionate deductions in the claim amount.
• There is no restoration benefit, meaning once the sum insured is exhausted in a policy year, it won’t be replenished for future claims.
• The policy does not offer a no-claim bonus. You won’t receive any additional coverage for remaining claim-free during the policy year.
• There are disease-specific sub-limits, which restrict the amount payable for certain modern treatments and listed conditions.
• A waiting period of three years applies to all pre-existing diseases before related claims are admissible, and no add-on is available to reduce them.

In summary, Oriental’s Mediclaim Insurance Policy is a reliable option for those seeking a low-cost plan with fundamental coverage, but it may not meet the expectations of those looking for extensive features and shorter waiting periods.

Pros and Cons of the Insurer

Pros of the Insurer

• Public Sector Undertaking (PSU): Oriental Insurance is a government-backed insurer, offering reliability, nationwide presence, and decades of trust — especially appealing to risk-averse buyers.
• High Claim Settlement Ratio (CSR): Maintains a robust 96% average CSR (2021–2024), indicating strong claim-paying ability and a dependable claims experience.

Cons of the Insurer

• High Incurred Claim Ratio (ICR): With an ICR of 124%, the insurer is paying more in claims than it earns in premiums, which may raise concerns about future premium hikes or financial sustainability.
• Non-Comprehensive Plans: Many policies (like Happy Family Floater) lack modern features such as sum insured restoration, consumables coverage, cumulative bonus, wellness benefits, or annual health check-ups, making them less competitive in today’s market.
• Sub-Limits and Cappings: Strict room rent limits, maternity sub-limits, and limited OPD benefits restrict flexibility during high-value claims, especially in metro hospitals.
• Limited Network Hospitals: Fewer network hospitals can limit the access to cashless treatment options, making it harder to get timely care and potentially leading to higher out-of-pocket expenses. Ideally, insurers should offer access to 7500+ network hospitals for better cashless treatment options. However, PSU insurers maintain significantly lower numbers, limiting convenience and accessibility.
• TPA Involvement: Public sector insurers often depend on third-party administrators (TPAs) for managing health insurance claims. While this outsourcing model is becoming increasingly common, it can sometimes result in delays, miscommunication, and reduced efficiency during the claims process. As a result, we generally prefer insurers with in-house claims settlement teams, as they offer more streamlined, accountable, and customer-friendly service experiences.

Lack of Seamless Digital Support: Public insurers often offer a not-so-smooth digital experience. Their self-service portals and online platforms can be outdated, making it difficult for users to navigate, manage policies, file claims, or get timely support.

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Conclusion

Oriental Insurance stands as a legacy player with the backing of the government and a strong claim settlement track record. However, its offerings often fall short in terms of digital convenience, product features, and service experience—especially when compared to newer, private insurers. For those who value traditional trust and basic coverage, it’s a dependable choice. But for customers seeking modern features, faster claims, and greater flexibility, exploring private insurers may be more rewarding.