1. 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:

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

2. 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 Helpdesk. Cashless request form available with the network provider/PPN/TPA shall be completed and sent to the TPA for authorization.
5. The TPA upon getting cashless request form and related medical information from the insured person/ network provider/PPN shall issue pre-authorization letter to the hospital after verification.
6. At the time of discharge, the insured person shall verify and sign the discharge papers and pay for non-medical and inadmissible expenses.
7. The TPA reserves the right to deny pre-authorization in case the insured person is unable to provide the relevant medical details.
8. Denial of a Pre-authorization 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.

3. 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.

4. Documents

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

1. Duly completed claim form
2. Photo Identity proof of the patient
3. Attending medical practitioner’s / surgeon’s certificate regarding diagnosis/ nature of operation performed or Operation Theatre (OT) Notes, along with date of diagnosis, advise for admission, investigation test reports etc. supported by the prescription from attending medical practitioner.
4. Medical history of the patient recorded, bills (including break up of charges) and payment receipts duly supported by the prescription from attending medical practitioner/ hospital.
5. Discharge certificate/ summary from the hospital.
6. Cash-memo/ bills/ invoices from the Diagnostic Centre(s)/ hospital(s)/ chemist(s) supported by proper prescription.
7. Payment receipts from doctors, surgeons and anaesthetist. 
8. Bills, receipt, Sticker of the Implants.
9. MLR (Medico Legal Report copy if carried out and FIR (First Information Report) if registered, wherever applicable)
10. NEFT Details (to enable direct credit of claim amount in bank account) and cancelled Cheque
11. KYC (Identity proof with Address) of the proposer, where claim liability is above Rs. 1 Lakh as per AML Guidelines
12. Any other document required by company/ TPA

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 7.7.d and claim settlement advice duly certified by the other insurer subject to satisfaction of the company.

5.    Time Limits for Submission of Documents:

Note:

1. 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.
2. Any medical practitioner or Authorised Person authorised by the TPA / Company shall be allowed to examine the Insured Person in case of any alleged injury or disease leading to Hospitalisation if so required.

6. Basis of Payment

1. Any claim under this policy shall be payable by the Company only if

1. it is in respect of Covered Expenses specified in this Policy and
2. the aggregate of Covered Expenses in respect of hospitalisation/s of Insured Person in case of Individual Policy or all Insured Persons in case of Family Floater Policy exceeds the Threshold Level

2. The claim payable under this Policy will be the amount by which the aggregate of such Covered Expenses in respect of hospitalisations with dates of admission falling within the policy period exceeds the higher of the following:

1. the Threshold Level opted for the insured person/family as applicable and stated in the schedule or
2. the amount received/receivable under any/all Health Insurance Policies (whether or not issued by the Company)/ Reimbursement Scheme and including any amount paid earlier under this policy covering the Insured person/family as applicable for such Covered Expenses, subject to multiple policy clause.

3. Each claim, if more than one, during the period of this policy shall be separately subject to the above Basis of Payment.
4. In no case shall the Company be liable to pay any sum in excess of the Sum Insured in aggregate of all claims during the period of this Policy.

7. 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 Policyholder 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 Policyholder 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).

8. Services Offered by TPA

Servicing of claims i.e. claim admissions and assessments, under this Policy by way of pre-authorization of cashless treatment or processing of claims, as per the 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.