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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:

  1. The company shall only accept bills/invoices/medical treatment related documents only in the Insured Person’s name for whom the claim is submitted 
  2. In the event of a claim lodged under the Policy and the original documents having been submitted to any other insurer, the Company shall accept the copy of the documents and claim settlement advice, duly certified by the other insurer subject to satisfaction of the Company 
  3. Any delay in notification or submission may be condoned on merit where delay is proved to be for reasons beyond the control of the Insured Person 

5. Claim Settlement (provision for Penal Interest)

  1. The Company shall settle or reject a claim, as the case may be, within 30 days from the date of receipt of last necessary document.  
  2. In the case of delay in the payment of a claim, the Company shall be liable to pay interest from the date of receipt of last necessary document to the date of payment of claim at a rate 2% above the bank rate.
  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, the Company 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 from the date of receipt of last necessary document to the date of payment of claim. 

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 

  1. Claim settlement and claim rejection;  
  2. Any services directly to any insured person or to any other person unless such service is in accordance with the terms and conditions of the Agreement entered into with the Company. 

7. Payment of Claim

All claims under the policy shall be payable in Indian currency only. 

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