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 pre-authorization 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 treatment.
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:
Sr. No. | Type of Claim | Prescribed Time Limit |
1. | Reimbursement of hospitalisation, day care and pre hospitalisation expenses | Within thirty days of date of discharge from hospital |
2. | Reimbursement of post hospitalisation expenses | Within fifteen days from completion of post hospitalisation treatment/td> |
3. Notification of Claim
Notice with full particulars shall be sent to the Company/TPA (if applicable) as under:
4. Documents to be submitted:
The reimbursement claim is to be supported with the following documents and submitted within the prescribed time limit.
[Note: The Company may specify the documents required in original and waive off any of above required as per our claim procedure]
Note:
5. Co-Payment in the event of Claims due to any epidemic/ Pandemic in presence of a pre-existing co-morbid condition:
In the event of each and every Claim for hospitalisation due to any epidemic/ Pandemic in presence of a pre-existing co-morbid condition, a co-payment will be applicable as per the following table:
Co-pay applicable for Pre-Existing Co-morbidities |
Pre-existing Co-morbid Condition | Policy Year |
1st | 2nd | 3rd | 4th | |
Any one disease | 33% | 25% | 17% | 8% |
Any two diseases | 50% | 38% | 25% | 13% |
More than two diseases | 67% | 50% | 33% | 17% |
6. Claim Settlement (provision for Penal Interest)
(Explanation: "Bank rate" shall mean the rate fixed by the Reserve Bank of India (RBl) at the beginning of the financial year in which claim has fallen due).
7.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-authorisation 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
8. Payment of Claim
All claims under the policy shall be payable in Indian currency only.
IRDA Registration no. 545
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