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Comprehensive Claim Management


Reimbursement of the hospitalization expenses can be claimed where Cashless Hospitalisation facility is not availed or treatment is availed in a Non-network Hospital. You will have to settle the hospital bill, collect all original hospitalisation documents and submit the documents to our office for their scrutinizing the same in terms of the policy and check the admissibility or otherwise of the claim/ expenses.

 

  • Reimbursement claims may be filed in the following circumstances:

         a.    Hospitalization at a non-network hospital

         b.    Post-hospitalization and pre-hospitalization expenses

         c.    Denial of preauthorization on application for cashless facility at a network hospital

  • Reimbursement claims can be submitted to us through registered post / courier or can be handed over at any of our Branches.
  • One of the very basic requirements of insurance is ‘Claim Intimation’.  It simply means intimating us or the Insurance Company about the hospitalisation.  Some of the policies indicate a time frame of 24 hours or 7 days from the date of admission, most of the policies require that intimation has to be lodged immediately on admission. Non-compliance to this may make your claim inadmissible.
  • The documents that you need to submit for a hospitalization reimbursement claim are:

         a.    Original hospital final bill

         b.    Pre-Numbered / Printed Receipts for payments made to the hospital

         c.     Complete break-up of the hospital bill

         d.    Original Detailed Discharge Summary

         e.    All Investigation reports

         f.     All medicine bills with relevant prescriptions

         g.    Operation Theatre Notes in the event of a surgery performed

         h.    Sticker for the Implant, if any, used during surgery

         i.      A copy of the Invoice for the implant, if any, used during surgery performed

         j.     Original duly completed and signed claim form

         k.    Duly completed and signed Medical Practitioner’s Form

         l.      Copy of our ID card or current policy copy and previous years’ policy copies if any 

         m.   Company Employee ID card if you and your family are insured through your employer

         n.    Documents for National Electronic Fund Transfer (NEFT)

                  i.   NEFT Format giving details of the Bank Account where you need the claim amount to be transferred

                 ii.    A copy of the page of the Bank Pass Book containing the Account Number & the Name/ Address of the Account Holder.

                 iii.   A cancelled Cheque for the above Account in to which the claim amount has to be transferred

         o.  Covering letter stating your complete current address, contact address if available and the list of documents attached.

  • The documents that you need to submit for a Post-hospitalization or a Pre-hospitalization claim are:

        a.     Copy of the discharge summary of the corresponding hospitalization

        b.    All relevant doctors’ prescriptions for investigations and medication

        c.    All bills for investigations done with the respective reports

        d.    All bills for medicines supported by relevant prescriptions

        e.   NEFT Documents as above. (If you have furnished the NEFT Documents for the main hospitalisation claim earlier, you want the            amount be transferred to the same Bank Account, Please furnish the Claim Particulars for us to pick up NEFT Details there from.)

  • Once the reimbursement claim is received, it is processed.  Our medical team will determine whether the condition requiring admission and the treatment are covered by your health insurance policy. They will also check with all the other terms and conditions of your insurance policy.  All Non-admissible Expenses will be disallowed.
  • The policies stipulate a period from the Date of Discharge within which the claim documents have to be submitted. Submission of claim papers after the stipulated period could lead to denial of the claim. Normally it is 7 days from the date of discharge for hospitalisation claim and for Post-hospitalisation it is 7 days from the date of completion of the post-hospitalisation treatment. Please check for the time frame for submission of the claim papers. In case the claim papers are submitted beyond 7 days from the date of discharge the claim is liable to be denied as per the policy terms. Hence, ensure compliance to the time frame without fail.
  • Based on the processing of the claim, a denial or approval is executed. In case of approval, settlement is made by transferring the approved amount to your Bank Account. We will also send you the settlement particulars along with the computation sheet to the address mentioned in your health insurance policy.  In case you have been insured through your Company, the cheque will be dispatched to the address based on instructions received from your company.
  • In case we require additional documents we may send you a Shortfall Letter. Kindly comply with the requirements within the stipulated time. In case you do not submit the required documents within the stipulated time, after 2 reminders we will reject the claim and send the Denial Letter. Once the claim is denied as above, you will forfeit your right to the claim.
  • In case your claim is denied, the denial letter is sent to you by courier / post quoting the reason for denial of your claim. In case you have been insured through your Company, the denial letter will be dispatched based on instructions received from your company.
  • In the event you are aggrieved with the settlement or the denial of the claim, you may kindly represent your case to our Grievance Cell. You may also refer the matter to your Insurer’s Grievance Cell.
  • If you are not satisfied with the redressal of your grievance either through our Grievance Cell or that of the Insurer, you may present your case before the Insurance Ombudsman.