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 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 required or before the Insured Person’s discharge from Hospital, whichever is earlier.
2. At least 48 hours before admission in Hospital in case of a planned Hospitalization.

2. Procedure for Cashless Claims

1. For the first claim under the Policy (i.e., the claim in which cumulative medical expenses exceeds the threshold) cashless facility shall be available provided all evidences and documents are produced prior to cashless authorization, to substantiate that the Cumulative Medical Expenses exceeds the Threshold. For all subsequent claims under the Policy cashless facility shall be available as usual, subject to sl. no ii to ix below.
2. Cashless facility for treatment shall be available to the Insured in network hospitals only.
3. Treatment may be taken in a network provider/PPN hospital and is subject to pre-authorization by the TPA. The 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.
4. 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
5. On admission in the network provider/PPN hospital, please produce the ID card issued by the TPA at the Hospital Helpdesk. Cashless-request-form available with the network provider/PPN and TPA shall be completed and sent to the TPA for authorization.
6. 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.
7. At the time of discharge, the Insured Person shall verify and sign the discharge papers and pay for non-medical and inadmissible expenses.
8. The TPA reserves the right to deny pre-authorization in case the Insured Person is unable to provide the relevant medical details.
9. 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 the treating doctor’s advice and submit the claim documents to the TPA for possible reimbursement.

3. Procedure for Reimbursement of Claims

1. 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 within the prescribed time limit.
2. Claims for Pre and Post-Hospitalization will be settled on reimbursement basis on production of relevant claim papers and cash receipts within the prescribed time limit.

4. Supporting 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 the date of diagnosis, advice for admission, investigation/test-reports etc. supported by the prescription from attending medical practitioner.
4. Medical history of the patient as recorded, Hospital bills (including break up of charges) and payment receipts duly supported by the prescription from attending medical practitioner.
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 Lac as per AML Guidelines
12. Any other document required by company/ TPA

Note

1. The Insured shall preserve and submit all original documents and/ or certified copies of documents related to all hospitalisation(s) during the policy period to enable the Company to calculate the cumulative medical expenses and threshold, for determining admissibility and payment of claims.
2. 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 19.D and claim settlement advice duly certified by the other Insurer subject to satisfaction of the Company. In all such cases, any amount payable under this Policy for any covered expense shall be reduced by any amount paid/ payable by the other insurer for the same expense during the same hospitalisation.

5. Time Limit for Submission of Documents

6. Claim Assessment

We will assess all admissible indemnity claims under the Policy in the following progressive order:

1. Limit/ Sub Limit on Medical Expenses as applicable under the policy
2. Opted Threshold Amount

7. 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 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 Threshold Level opted for the Insured Person/Family as applicable and stated in the schedule,
• after deducting any amount above threshold 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.

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.

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.

Notes on Claim Procedure:

1. Waiver of condition of timelines as mentioned above 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. The Company shall only accept bills/invoices/medical treatment related documents only in the Insured Person’s name for whom the claim is submitted.
3. The Insured Person shall also give the TPA / Company such additional information and assistance as the TPA / Company may require in dealing with the claim including an authorisation to obtain Medical and other records from the hospital, lab, etc.
4. 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.