1. Procedure for Cashless claims:
(i) Treatment may be taken in a network provider and is subject to pre authorization by the Company or its authorized TPA. (ii) Cashless request form available with the network provider and TPA shall be completed and sent to the Company/TPA for authorization. (iii) The Company/ TPA upon getting cashless request form and related medical information from the insured person/ network provider will issue preauthorization letter to the hospital after verification. (iv) At the time of discharge, the insured person has to verify and sign the discharge papers, pay for non-medical and inadmissible expenses. (v) The Company / TPA reserves the right to deny pre-authorization in case the insured person is unable to provide the relevant medical details. (vi)In case of denial of cashless access, the insured person may obtain the treatment as per treating doctor’s advice and submit the claim documents to the Company / TPA for reimbursement.
2. Procedure for reimbursement of claims:
For reimbursement of claims the insured person may submit the necessary documents to TPA (if applicable)/Company within the prescribed time limit as specified hereunder.
Sl.No | Type Of Claim | Prescribed Time limit |
1. | Reimbursement of hospitalization and pre hospitalization expenses | Within thirty days of date of discharge from hospital |
2. | Reimbursement of post hospitalization expenses | Within fifteen days from completion of post hospitalization treatment |
3. | Reimbursement of Home Care expenses | Within thirty days from completion of home care treatment |
3. Notification of Claim
Notice with full particulars shall be sent to the Company/TPA (if applicable) as under:
Within 24 hours from the date of emergency hospitalization/cashless home care treatment.
At least 48 hours prior to admission in Hospital in case of a planned Hospitalization.
4. Documents to be submitted:
The claim is to be supported with the following documents and submitted within the prescribed time limit.
Benefits | Claims Documents Required |
1. Covid Hospitalization Cover |
i. Duly filled and signed Claim Form ii. Copy of Insured Person’s passport, if available (All pages) iiiPhoto Identity proof of the patient (if insured person does not own a passport) iv. Medical practitioner’s prescription advising admission v. Original bills with itemized break-up vi. Payment receipts vii.Discharge summary including complete medical history of the patient along with other details. viii. Investigation reports including Insured Person’s test reports from Authorized diagnostic centre for COVID. ix. OT notes or Surgeon’s certificate giving details of the operation performed, wherever applicable x.Sticker/ Invoice of the Implants, wherever applicable. xi. NEFT Details (to enable direct credit of claim amount in bank account) and cancelled cheque. xii.KYC (Identity proof with Address) of the proposer, where claim liability is above Rs 1 Lakh as per AML Guidelines xiii.Legal heir/succession certificate, wherever applicable xiv. Any other relevant document required by Company/TPA for assessment of the claim. |
2. Home Care treatment expens |
i.Duly filled and signed Claim Form . ii. Copy of Insured Person’s passport, if available (All pages) . iii. Photo Identity proof of the patient (if insured person does not own a passport). iv.Medical practitioners’ prescription advising hospitalization . v. A certificate from medical practitioner advising treatment at home or consent from the insured person on availing home care benefit. vi.Discharge Certificate from medical practitioner specifying date of start and completion of home care treatment. vii. Daily monitoring chart including records of treatment administered duly signed by the treating doctor is maintained. |
Note:
5. Claim Settlement (provision for Penal Interest)
6. Services Offered by TPA (To be stated where TPA is involved)
Servicing of claims, i.e., claim admissions and assessments, under this Policy by way of pre-authorization of cashless treatment or processing of claims other than cashless claims or both, as per the underlying terms and conditions of the policy.
The services offered by a TPA shall not include
7. Payment of Claim
All claims under the policy shall be payable in Indian currency only.
IRDA Registration no. 545
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