Why to buy your Group Health product with Takaful Oman

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Empowering Teams, Nurturing Health Together

We at takaful Oman prioritize the well-being of your team. Our Group Medical Coverage is designed to provide comprehensive healthcare solutions for your employees, promoting a healthy and productive workforce.

With tailored plans and extensive coverage, we aim to safeguard the health and happiness of your team members, offering peace of mind and support for both employers and employees.

Explore our offerings to discover how we can contribute to the overall well-being of your organization.

What to consider while buying a GMC policy

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Assess the needs of the group

Consider the health insurance needs of the group by considering their age, existing health conditions and any other special requirements. All of these factors can help the insurer to create a custom GMC policy for the group.

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Coverages offered by the insurer

Assess the coverages [scope and limits] provided by the insurer and if it meets the requirements of the group. Consider the range of medical services covered, including hospitalization, outpatient care, prescription drugs, and preventive services.

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Network hospital coverage of the insurer

Check the network hospital coverage of the insurer as wider network will ensure that group can access a variety of facilities and secure a comprehensive medical care.

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Group participation

Ensure that the coverages specified by the insurer caters to the requirements of everyone in the group. This will ensure maximum participation in the group. Some insurers also have a minimum participation requirement for the policy to be effective.

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Comprehensive Group Medical Insurance cover

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Benefits

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

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 TAOI 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

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

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

How to utilize my Medical Card?

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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.

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You may choose the Provider from the list of Network Providers enlisted under your network tier.

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We have an arrangement of Direct Billing with our Network Providers for the eligible expenses. When you visit the Provider, please present your TAOI Medical Card to the receptionist to ensure you avail your benefits efficiently.

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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.

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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.

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Please ensure that you have signed the claim form as well all the invoices pertaining to the expenses incurred by you.

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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 TAOI/TPA.

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You will bear any expenses incurred for treatments or services that are not covered by your policy.

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You may contact the insurance coordinator at your preferred Provider or TAOI Call Center for any queries or immediate assistance.

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Your Physician may require a pre-approval from the TAOI on certain Out Patient/Daycare/In-Patient services which are detailed under the Pre-Authorization section.

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Optional benefits offered by Takaful Oman

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Routine dental care <br /> benefits

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Maternity care <br /> benefits

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Optical <br /> benefits

What is Covered and not Covered

Inclusions
Exclusions
  • 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.
  • Self-inflicted injury while sane or insane; treatment of chronic alcoholism, drug addiction, desensitization.
  • Injury or illness resulting from insurrection or declared war, or as a result of a riot, strike or civil commotion.
  • Rest cures sanitaria or custodial care or periods of quarantine or isolation.
  • Cosmetic or plastic surgery including related medicines and products unless medical treatment necessitated by an accidental injury, burn or Cancer occurring while the Insured is covered.
  • Services, accommodation, or treatment charges incurred in health hydrous, spas, nature cure clinics, rest homes or any similar place etc not covered.
  • Any pharmaceutical products which are not on the approved list of drugs and not medically necessary are not covered.
  • Tests or treatment related to contraception, or sterilization, infertility, impotent, sexual dysfunction or any similar condition.
  • Any treatment or test for acquired immune deficiency syndrome (AIDS) and AIDS/HIV related conditions, or sexually transmitted diseases, self-inflicted injury, suicide alcohol or drug addiction/abuse.
  • Sex change operations and related treatments.
  • Treatments resulting from racing of any form and professional participation in hazardous sports.
  • Treatment received outside the territorial limits described in the table of benefits and/or expenses incurred where the insured has traveled against medical advice.
  • All substances which are not considered as medicines such as but not limited to toothpaste, antiseptic solutions, milk formulas, skincare products …etc.
  • Hormone replacement therapy (HRT) unless carried out as part of or immediately after a surgical procedure which is covered under the table of benefits to this plan.
  • Loss of hearing unless caused by a medical condition covered under the policy, hearing aids, ear and body piercing unless and until cover in the policy.
  • Any medical prescription relative to a special diet, weight control, children’s food baby supplies.
  • Experimental unproven treatment or drug therapy.
  • Medical practitioner fees for the completion of a claim from or other administration charges.

Steps to raise a claim

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    Pre-Authorizations

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

    With this, both you and your provider can be rest 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
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    2 Emergency Services

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

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