A. Claims Administration & Process

It shall be the condition precedent to admission of Our liability under this Policy that the terms and conditions of making the payment of premium in full and on time, insofar as they relate to anything to be done or complied with by You or any Insured Person, are fulfilled including complying with the following in relation to claims:

1.On the occurrence or discovery of any Illness or Injury that may give rise to a Claim under this Policy, the Claims Procedure set out below shall be followed.

2.The treatment should be taken as per the directions, advice and guidance of the treating Medical Practitioner. Any failure to follow such directions, Medical advice or guidance will prejudice the claim.

3.The Insured Person must submit to medical examination by Our Medical Practitioner or our authorized representative in case requested by Us and at Our cost, as often as We consider reasonable and necessary and We/Our representatives must be permitted to inspect the medical and Hospitalisation records pertaining to the Insured Person’s treatment and to investigate the circumstances pertaining to the claim.

4.We and Our representatives must be given all reasonable co-operation in investigating the claim in order to assess Our liability and quantum in respect of the claim.

B. Notification of claim

Upon the happening of any event which may give rise to a claim under this Policy, the insured person/insured person’s representative shall notify the TPA (if claim is processed by TPA)/company (if claim is processed by the company) in writing providing all relevant information relating to claim including plan of treatment, policy number etc. within the prescribed time limit as under:

i.Within 24 hours from the date of emergency hospitalization required or before the Insured Person’s discharge from Hospital, whichever is earlier

ii.At least 48 hours prior to admission in Hospital in case of a planned Hospitalization.

C. Procedure for Cashless claims

1.Cashless facility for treatment in network hospitals only shall be available to insured if opted for claim processing by TPA.

2.Treatment may be taken in a network provider/PPN hospital and is subject to pre- authorization by the TPA. Booklet containing list of network provider/PPN hospitals shall be provided by the TPA. Updated list of network provider/PPN is available on website of the company (https://uiic.co.in/en/tpa-ppn- network-hospitals) and the TPA mentioned in the schedule.

3.Call the TPA’s toll free phone number provided on the health ID card for intimation of claim and related assistance. Inform the ID number for easy reference.

4.On admission in the network provider/PPN hospital, produce the ID card issued by the TPA at the Hospital Insurance-desk. Cashless request form available with the network provider/PPN and TPA shall be completed and sent to the TPA for pre- authorization.

5.The TPA upon getting cashless request form and related medical information from the insured person/ network provider/PPN shall issue pre-authorisation letter to the hospital after verification.

6.Once the request for pre-authorisation has been granted, the treatment must take place within 15 days of the pre-authorisation date at a Network Provider and pre- authorisation shall be valid only if all the details of the authorized treatment, including dates, Hospital and locations, match with the details of the actual treatment received. For Hospitalization where Cashless Facility is pre-authorised by Us or the associated TPA, We will make the payment of the amounts assessed directly to the Network Provider.

7.In the event of any change in the diagnosis, plan of Treatment, cost of Treatment during Hospitalization to the Insured Person, the Network Provider shall obtain a fresh authorization letter from Us in accordance with the process described under V.4 above.

8.At the time of discharge, the insured person shall verify and sign the discharge papers and final bill and pay for non-medical and inadmissible expenses.

Note: (Applicable to V C): Cashless facility for Hospitalization expenses shall be limited exclusively to Medical Expenses incurred for Treatment undertaken in a Network Provider/ PPN hospital for Illness or Injury / Accident/ Critical Illness as the case may be which are covered under the Policy. For all cashless authorisations, the Insured Person will, in any event, be required to settle all non-admissible expenses, expenses above specified Sub Limits (if applicable), Co-Payments and / or opted Deductible (Per claim/ Aggregate/ Corporate) (if applicable), directly with the Hospital.

 9.The TPA reserves the right to deny pre-authorisation in case the insured person is unable to provide the relevant medical details. Denial of a Pre-authorisation request is in no way to be construed as denial of treatment or denial of coverage. The Insured Person may get the treatment as per treating doctor’s advice and submit the claim documents to the TPA for possible reimbursement.

10.In case of admission in PPN hospitals, duly filled and signed PPN declaration format available with the hospital must be submitted.

11.Claims for Pre and Post-Hospitalisation will be settled on a reimbursement basis on production of cash receipts alongwith supporting documents.

D. Procedure for reimbursement of claims

In non-network hospitals payment must be made up-front and for reimbursement of claims the insured person may submit the necessary documents to TPA (if claim is processed by TPA)/company (if claim is processed by the company) within the prescribed time limit.

E. Documents

1.The claim is to be supported with the following original documents and submitted within the prescribed time limit.

i.Duly completed claim form;

ii.Photo ID and Age proof;

iii.Health Card, policy copy, photo ID, KYC documents;

iv.Attending medical practitioner’s / surgeon’s certificate regarding diagnosis/ nature of operation performed, along with date of diagnosis, investigation test reports etc. supported by the prescription from attending medical practitioner.

v.Original discharge card / day care summary / transfer summary;

vi.Original final Hospital bill with detailed break-up with all original deposit and final payment receipt;

vii.Original invoice with payment receipt and implant stickers for all implants used during Surgeries i.e. lens sticker and Invoice in cataract Surgery, stent invoice and sticker in Angioplasty Surgery;

viii.All previous consultation papers indicating history and treatment details for current ailment;

ix.All original diagnostic reports (including imaging and laboratory) along with Medical Practitioner’s prescription and invoice / bill with receipt from diagnostic center;

x.All original medicine / pharmacy bills along with the Medical Practitioner’s prescription;

xi.MLC / FIR copy – in Accidental cases only;

xii.Copy of death summary and copy of death certificate (in death claims only);

xiii.Pre and post-operative imaging reports;

xiv.Copy of indoor case papers with nursing sheet detailing medical history of the Insured Person, treatment details and the Insured Person’s progress;

xv.KYC documents

xvi.Cheque copy with name of proposer printed on the cheque leaf or copy of the first page of the bank passbook or the bank statement not later than 3 months.

Note

In the event of a claim lodged as per Settlement under multiple policies clause and the original documents having been submitted to the other insurer, the company may accept the duly certified documents listed under condition 5.6.4 and claim settlement advice duly certified by the other insurer subject to satisfaction of the company.

2.Time limit for submission of documents

Note: Waiver of this Condition may be considered in extreme cases of hardship where it is proved to the satisfaction of the Company that under the circumstances in which the insured was placed it was not possible for him or any other person to give such notice or file claim within the prescribed time-limit.

3.The Insured Person shall also give the TPA / Company such additional information and assistance as the TPA / Company may require in dealing with the claim including an authorisation to obtain Medical and other records from the hospital, lab, etc.

4.All the documents submitted to TPA shall be electronically collected by Us for settlement and denial of the claims by the appropriate authority.

F. Scrutiny of Claim Documents

a.TPA/ We shall scrutinize the claim form and the accompanying documents. Any deficiency in the documents shall be intimated to the Insured Person/ Network Provider as the case may be.

If the deficiency in the necessary claim documents is not met or is partially met in 10 working days of the first intimation. We will send a maximum of 3 (three) reminders. We may, at Our sole discretion, decide to deduct the amount of claim for which deficiency is intimated to the Insured Person and settle the claim if we observe that such a claim is otherwise valid under the Policy.

b.In case a reimbursement claim is received when a pre-authorisation letter has been issued, before approving such a claim, a check will be made with the Network Provider whether the pre-authorisation has been utilized as well as whether the Insured Person has settled all the dues with the Network Provider. Once such check and declaration is received from the Network Provider, the case will be processed.

c.The Pre-Hospitalisation Medical Expenses Cover claim and Post- Hospitalization Medical Expenses Cover claim shall be processed only after decision of the main Hospitalization claim.\

G. Claim Assessment

We will pay the fixed or indemnity amount as specified in the applicable Base or Optional cover in accordance with the terms of this Policy.

We will assess all admissible claims under the Policy in the following progressive order:

1.Application Proportionate clause as per Note 1.clause II.1.

2.Co-pay as applicable.

3.Limit/ Sub Limit on Medical Expenses are applicable as specified in the Policy Schedule/ Certificate of Insurance

4.Opted Deductible (Per claim/ Aggregate) Claim Assessment for Benefit Plans:

We will pay fixed benefit amounts as specified in the Policy Schedule/ Certificate of Insurance in accordance with the terms of this Policy. We are not liable to make any reimbursements of Medical Expenses or pay any other amounts not specified in the Policy.

H. Claim Settlement

1.On receipt of the final document(s), the company shall within a period of 30 (thirty) days offer a settlement of the claim to the insured person.

2.In the cases of delay in the payment, the company shall pay interest from the date of receipt of last necessary document to the date of payment of claim at a rate that is 2% (two percent) above the bank rate prevalent at the beginning of the financial year in which the claim is paid.

3.However, where the circumstances of a claim warrant an investigation in the opinion of the company, it shall initiate and complete such investigation at the earliest, in any case not later than 30 days from the date of receipt of last necessary document. In such cases, Insurer shall settle the claim within 45 days from the date of receipt of last necessary document. 

4.In case of delay beyond stipulated 45 days the company shall be liable to pay interest at a rate 2% above the bank rate prevalent at the beginning of the financial year in which the claim is paid, from the date of receipt of last necessary document to the date of payment of claim.

5.The payment of the amount due shall be made by the company, upon acceptance of an offer of settlement by the insured person as stated above.

6.A claim, which is not covered under the policy cover and conditions, can be rejected.

I. Claim Rejection/ Repudiation

If the company, for any reasons, decides to reject a claim under the policy, we shall communicate to the insured person in writing explicitly mentioning the grounds for rejection/repudiation and within a period of 30 (thirty) days from the receipt of the final document(s) or investigation report (if any), as the case may be. Where a rejection is communicated by Us, the Insured Person may, if so desired, within 15 days from the date of receipt of the claims decision represent to Us for reconsideration of the decision.

 J. Claim Payment Terms

i.We shall have no liability to make payment of a claim under the Policy in respect of an Insured Person once the Sum Insured for that Insured Person is exhausted. All claims will be payable in India and in Indian rupees.

ii.We are not obliged to make payment for any claim or that part of any claim that could have been avoided or reduced if the Insured Person could have reasonably minimized the costs incurred, or that is brought about or contributed to by the Insured Person by failing to follow the directions, Medical Advice or guidance provided by a Medical Practitioner.

iii.The Sum Insured opted under the Policy shall be reduced by the amount payable / paid under the Policy terms and conditions and any optional covers applicable under the Policy and only the balance shall be available as the Sum Insured for the unexpired Policy Period.

iv.If the Insured Person suffers a relapse within 45 days from the date of discharge from the Hospital for which a claim has been made, then such relapse shall be deemed to be part of the same claim and all the limits for “Any one illness” under this Policy shall be applied as if they were under a single claim.

v.For Cashless claims, the payment shall be made to the Network Provider whose discharge would be complete and final.

vi.For Reimbursement claims, the payment shall be made to the Insured Person. In the unfortunate event of the Insured Person’s death, we will pay the Nominee (as named in the Policy Schedule/ Certificate of Insurance) and in case of no Nominee, to the legal heir who holds a succession certificate or indemnity bond to that effect, whichever is available and whose discharge shall be treated as full and final discharge of Our liability under the Policy.

Claim Process for Optional Covers

•In the case of Accidental Death Benefit/ PTD/ PPD/ Critical Illness (if applicable) -The Insured Person or the Nominee, as the case may be, shall notify Us either at the call centre or in writing, within 10 days from the date of occurrence of such Accident/diagnosis of a Critical Illness.

2.Reimbursement Process : In addition to the documents mentioned in the Base Cover claim reimbursement process, the following additional documents will be required for reimbursement claim for the respective Options.

Optional CoverAdditional Documents Required

Critical Illness – Benefit Cover - The Insured Person may submit the following documents for reimbursement of the claim to our policy issuing office at his/her own expense ninety (90) days from the date of first diagnosis of the Illness/ date of Surgical Procedure or date of occurrence of the medical event, as the case may be

•Medical certificate confirming the diagnosis of Critical Illness.

•Discharge certificate/ card from the Hospital, if any.

•Investigation test reports confirming the diagnosis.

•First consultation letter and subsequent prescriptions.

•Indoor case papers, if applicable.

•Specific documents listed under the respective Critical Illness.

•Any other documents as may be required by Us.

•In those cases, where Critical Illness arises due to an Accident, a copy of the FIR or medico legal certificate will be required, wherever conducted.

Out- Patient Cover -The Insured Person shall avail these benefits as defined in Policy T&C if opted for.

(a)Submission of claim

Invoices, treating Medical Practitioner’s prescription, reports, duly signed by Insured Person as the case may be, to the TPA Head Office

(b)Assessment of claim documents

We shall assess the claim documents and ascertain the admissibility of claim.

(c)Settlement & Repudiation of a claim

We shall settle claims, including its rejection, within 30 days of the receipt of the last ‘necessary’ document.

Dental Expenses Cover & Vision Expenses Cover - The Insured Person shall avail these Benefits as defined below, if opted for.

(a)Submission of claim

Insured Person can send the claim form provided along with the invoices, treating Medical Practitioner’s prescription, reports, duly signed by the Insured Person as the case may be, to Our branch office or head office.

(b)Assessment of claim documents

We shall assess the claim documents and ascertain the admissibility of claim.

(c)Settlement & Repudiation of a claim

We shall settle claims, including its rejection, within 30 days of the receipt of the last ‘necessary’ document.

(d)In respect of Orthodontic Treatment claims for Dependent Children below 18 years, pre-authorisation is a must.

For claims in respect of Orthodontic Treatment towards Dependent Children below 18 years, the Employee/ Member or Dependent must send the following information prepared by the Dentist who is to carry out the proposed Treatment to Us before Treatment starts, so that We can confirm the Benefit that will be payable:

•Full description of the proposed Treatment;

•X-rays and study models;

•An estimate of the cost of the Treatment.

Any Benefit will be payable only if We have authorised the cover before Treatment starts.

Refractive Error Correction Expenses Cover - Prescription from Specialist Medical Practitioner specifying the refractive error and medical necessity of the Treatment.

Home Nursing Charges CoverBills from registered nursing service provider.

Air Ambulance Cover - Air ambulance ticket for registered service provider.

Emergency Evacuation Cover

a)In the event of an Insured Person requiring Emergency evacuation and repatriation, the Insured Person must notify Us immediately either at Our call centre or in writing.

b)Emergency medical evacuations shall be pre-authorised by Us.

c)Our team of Specialists in association with the Emergency assistance service provider shall determine the medical necessity of such Emergency evacuation or repatriation post which the same will be approved.

Medical Equipment CoverPrescriptions of treating Specialist for support items and original invoice of actual Medical Expenses incurred.

Ultra-modern Treatment Cover - Certificate by qualified medical surgeons indicating the medical necessity of the procedure.

Birth Control Procedure Cover - All medical records and treating Medical Practitioner’s certificate on the indication.

InfertilityTreatment Cover - Certificate from Specialist Medical Practitioner detailing the cause of infertility, Treatment, procedure.

Deductible (Aggregate/ Per-Claim)

a) Any claim towards Hospitalisation during the Policy period must be submitted to Us for assessment in accordance with the claim process laid down under Section V of the Policy towards Cashless facility or reimbursement respectively in order to assess and determine the applicability of the Deductible on such claim. Once the claim has been assessed, if any amount becomes payable after applying the Deductible, We will assess and pay such claim in accordance with Section V.F and G of the Policy.

b) Wherever such Hospitalisation claims as stated under Section V above is being covered under another policy held by the Insured Person, We will assess the claim on available photocopies duly attested by the Insured Person’s insurer / TPA as the case may be.

We may call for any additional document/information as required based on the circumstances of the claim wherever the claim is under further investigation or available documents do not provide clarity.