Guidelines for Health Claim settlement
Protocols for Cashless
(Approach network hospital and show your Cashless Card to the front/help desk)
In case of Emergency Admission:
Obtain a pre-authorisation form from the Hosptial and get it filled and signed by the treating doctor and submit it to the Hospital which will fax the Pre Authorization Form to the TPA along with the necessary investigation reports. After investigation the TPA will fax the approved cashless authorization letter to the hospital.
In case of Planned Hospitalisation:
In this case the insured must go to the hospital at least 72 hours before admission to hospital and provide them the following details:
Diagnosis letter from the treating doctor
Date of Admission
Inform TPA at least 2 days before admission about the hospitalisation, plan of treatment, cost estimates etc. At the time of admission present the authorization letter and photo Health card to the hospital.
In case Cashless gets rejected:
The cashless may get rejected if the current ailment is not covered under the purview of the policy or if the information sent to you by the TPA, is insufficient and if the request for pre authorization is not sent in time.
Then at the time of discharge – pay for all those expenses that are not reimbursable under the policy, verify the bills and sign on all bills and keep a photocopy of all bills and reports in your record. In case cashless is not authorized then pay all the bills which will be reimbursed.
Claims Reimbursement Process
Whether hospitalisation is an emergency or planned, intimate the TPA immediately on the help line and submit the following details:
Name of the insured
Nature of sickness
Date and time of accident or onset of disease
At the time of discharge settle the hospital bills in full and collect all the original bills, documents, reports and discharge summary. Then lodge your claim with TPA for processing and reimbursement by filling in the claim form and attaching required documents.
Documents to be submitted
Must be sent to the TPA within 7 days from date of admission. Can be sent via letter, fax or e-mail. This is essential for processing your claim
The Claim form duly completed should be sent within 7 days from the date of discharge along with the following documents:
Name & Age of patient
Date of admission
Symptoms/appearance of the patient at the time of admission
Tests for analysis
Course of treatment in the hospital
The bill should contain the break-up of all the items/medicines/tests. Consolidated bills without item wise billing are not acceptable. In case of surgeons/consultants bills, kindly insist on a stamped, preferably numbered receipt with doctor’s registration number
Prescriptions for all tests/medicines:
If the same appears in the discharge summary, it will do. However, item wise the prescriptions should match.
Reports for all tests are essential however there is no need for the x-ray/CT scan/MRI films.
Must necessarily be a proper receipt with the revenue stamp affixed and signed by the hospital authorities. This cannot be combined with any other documents like the discharge summary/bills etc.
No non-medical expenses like admission/registration charges, attendant charges, diet charges, toiletries/cosmetics, telephone/television charges etc. are not reimbursed
Any miscellaneous/services/administrative charges that do not pertain to the actual medical treatment will also not be reimbursed
The TPA can still ask for further details depending on the complications of this case but this list if complied will solve 90% of the claimant’s problem
Please inform us if there is going to be any delay in submission of the same
Claims have to be filed within 30 days of the Date of Discharge