Health Claims
Scope of Cover
Health Insurance Claims arise due to Sickness/illness/Accidents. It covers Expenses that require hospitalization for Illness/Diseases/Injury. The basis of any health Insurance should be Identification of a disease, Cost of treatment ,which includes room rent, nursing expenses, medical practitioner’s charges, medicines, blood, oxygen, anesthesia, diagnostic and pathological tests, operation theater charges, chemotherapy, dialysis, pacemaker, artificial limits etc, fix amount of ambulance charges to cure from the disease. 30 days Pre Hospitalization & 60 days Post Hospitalization expenses are also covered under the policy. Over all expense limits are capped as per policy conditions.
Claims Steps – Cashless Claim
1 :
Select a hospital from our list of network hospitals for treatment
2 :
Intimate our Third party administrator (TPA) through the Helpline Number before 3 days of admission, quoting your Health card Membership number
3 :
Fill in the cashless request form which is available with the Hospital Insurance Help Desk and get it certified by your treating doctor
4 :
Email the cashless request form along with supporting medical records to the TPA
5 :
The TPA will scrutinize the document and convey the decision to the hospital. The TPA could sanction the cashless request or call for additional documents, if required.
6 :
On approval of cashless claim by TPA, the hospital bills will be settled directly (subject to policy limits). Inadmissible amounts like telephone charges, food, attendant charges etc would have to be settled by you.
7 :
If the cashless claim is not approved by TPA, please settle the bill with the hospital and apply for reimbursement. The claim will be processed as per policy terms and conditions.
8 :
If there is any query related to diagnosis or procedure than kindly contact claim settlement department. The Turnaround time for approving Cashless decision by our TPA is 24 hours after receipt of all documents. In case your cashless authorization is delayed, please check with TPA desk of hospital whether any queries raised by the Insurance Company are pending for reply.
Claims Steps – Reimbursement Claim
There may be some hospitals that may not have the cashless facility. In such cases the Insured/claimant has to make a reimbursement claim. The following procedure is to be followed:
1 :
Inform the Insurance company/TPA immediately on admission to the hospital to their Toll free number and obtain a claim number. Period of Intimation differs from Insurer to Insurer therefore immediate intimation is recommended to avoid unwanted issues at later stage.
2 :
Check Policy conditions for claim approval. Take Discharge with complete required documents & Claim form with stamp & signed by medical practitioner.
3 :
Submit Cancelled Cheque & KYC documents.
4 :
Submit Claim file (within 7days) to TPA/Insurance Company. Some Insurers do penalize you for late submission of documents.
5 :
Check approval status & requirement
6 :
Submit further documents required documents & check final approval status
7 :
Check Payment Status.
Documents required for Cashless Claim :
1 :
Health card/Policy Copy
2 :
Duly filled claim form
3 :
Doctor’s consultation papers
4 :
Investigation reports (e.g. X-ray, scans, blood report, etc.)
5 :
Pharmacy invoices supported by respective prescriptions
6 :
In cases of accidents, Medico Legal Certificate (MLC) and / or FIR
7 :
Discharge summary
8 :
Other relevant documents
9 :
Additional Documents if required
10 :
IPD Records/OPD records, admission Reports case to case
11 :
Kindly provide influence of alcohol at the time of incidence certified by treating doctor.
12 :
Kindly provide photograph of injured site in case of Accident.
13 :
Documents other than the Health Card should be submitted in original
Documents required for Reimbursement Claims :
1 :
Claim Form duly filled in and signed – As per prescribed format (Form B to be filled in and signed by the Hospital authorities under seal)
2 :
Copy of Photo ID / Proof
3 :
Copy of Policy
4 :
Discharge Summary (Photo Copy in case of claim for Pre/Post Hospitalization only)
5 :
Hospital Bill (Original Only)
6 :
Hospital Receipt (Original Only)
7 :
Investigation Reports with supporting prescriptions
8 :
Investigation Bills (Original Only)
9 :
Pharmacy Bills (Original Only)with supporting prescriptions
10 :
Any other Bills with supporting documents (Pl specify) (Original Only)
11 :
Summary of claim made providing details of Bill No, Date, Name of the Biller and Amount
12 :
All previous treatment papers related to Ailment.
13 :
Registration Certificate of the Hospital under Clinical Establishment Act or similar state act for medical establishments. Please note registration under Shops and Establishment Act, Registration with CMO etc. are not sufficient to meet the requirements of policy.
14 :
Attached cancel cheque copy
15 :
KYC (know your customer) form, if claim is more than Rs. 1 lac. o. Any other documents specify
16 :
MLC Report and police FIR, etc)
17 :
Kindly provide influence of alcohol at the time of incidence certified by treating doctor
18 :
Pre –hospital bills—- no.
19 :
Post-hospital bills—-no.
Second file for reimbursement file of pre and post hospitalization.
1 :
Old file no. or claim settlement voucher,
2 :
Pre-hospital cash memo with all prescriptions and all reports and payment receipt.
3 :
Post-hospital cash memo with all prescriptions and all reports and payment receipt.
4 :
Attached cancel cheque copy and required KYC form and document.
General intimation form
At the time of an unforeseen event when you need immediate assistance and support you can contact your insurer/TPA through below mentioned modes.
Call Center
Claims Service Representative of Insurer (CSR) shall help you to intimate claim fast and smooth for you. Please feel free to call them on stated phone number mentioned Here round the 365 days.
Walk In
If you wish to intimate your claim in person, Please feel free to visit your policy issuing Insurer Branch Mon- Fri 10:00 AM to 05:00 PM (Except for National Holidays). Please refer Here for more information.
SMS
If you wish to Intimate your claim through SMS, Please SMS “CLAIM” to your insurer. SMS numbers are listed Here.
One of Claims representatives of insurer will get in touch with you in short time.
Please Intimate Motor/Health claim via E-Mail. Insurer are now using Quick & Easy eclaim process and can be done round the clock anywhere, anytime at your convenience.
* Note: Please have all the details pertaining to Loss description, Cause, Workshop/Hospital details etc. at the time of the call