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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 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:

  1. Within 24 hours from the date of emergency hospitalisation required or before the Insured Person’s discharge from the Hospital, whichever is earlier.
  2. At least 48 hours prior to admission in Hospital in case of a planned Hospitalisation

4. Documents to be submitted:
The reimbursement claim is to be supported with the following documents and submitted within the prescribed time limit.

  1. Duly completed claim form
  2. Photo Identity proof of the patient
  3. Medical practitioner’s prescription advising admission
  4. Original bills with itemized break up
  5. Payment receipts
  6. Discharge summary including complete medical history of the patient along with other details.
  7. Investigation/Diagnostic test reports etc. supported by the prescription from attending medical practitioner
  8. OT notes or Surgeon’s certificate giving details of the operation performed (for surgical cases).
  9. Sticker/Invoice of the Implants, wherever applicable.
  10. MLR (Medico Legal Report copy if carried out and FIR (First Information Report) if registered, wherever applicable)
  11. NEFT Details (to enable direct credit of claim amount in bank account) and cancelled Cheque
  12. KYC (Identity proof with Address) of the proposer, where claim liability is above Rs. 1 Lakh as per AML Guidelines
  13. Legal heir/succession certificate, wherever applicable. 
  14. Any other relevant document required by Company/TPA for assessment of the claim

[Note: The Company may specify the documents required in original and waive off any of above required as per our claim procedure]

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. 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)

  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 to the Insured Person 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 or reject 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 to the Insured Person at a rate 2% above the bank rate from the date of receipt of last necessary document to the date of payment of claim.

(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

  1. Claim settlement and 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.

8. Payment of Claim
All claims under the policy shall be payable in Indian currency only.

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