Health Insurance Claim Services

Basically there are two types of process in Health Claims – Cashless claims & Reimbursement claims.

Cashless Claims

• For claim on cashless basis, the insured should get admitted to network hospitals of Third Party Administrator (TPA)/Insurance Company.
• The pre-authorisation form along with necessary documents like investigation report, previous consultation paper (if any),Cashless ID, Photo ID proof, residence proof etc. will be mailed by the hospital to the TPA/Insurance Company.
• The TPA will review the claim request and accordingly approve, query or reject the same as per the policy terms and conditions.
• TPA will settle the claim as per policy terms and conditions with the hospital after completion of necessary formalities.

Reimbursement claims

• For claim on reimbursement basis, the insured should get admitted to any Network/Non Network hospital. The claim should be intimated to the TPA/Insurance Company to get the claim number within stipulated time as per the policy terms and conditions.
• After getting discharged from the hospital, the insured should collect all the original documents from the hospital and submit the same to the TPA/Insurance Company along with the claim form and policy copy within stipulated time as per the policy terms and conditions.
• The TPA/ Insurance Company will review the claim request and accordingly approve, query or reject the same as per the policy terms and conditions.
• For approved cases, Settlement letter is mailed/couriered to the insured/proposer and Payment is released through NEFT/RTGS by the insurance company.
• For queried cases, query letter is sent to the client requesting for additional documents/information. Reminders are sent to the client and if the requested documents are not received after reminders, the claim closure letter is sent to the insured.
• For rejected cases, rejection letter is sent to the insured mentioning sufficient reasons as per the terms and conditions of the policy.

Documents for Claim

• Copy of the policy
• Copy of the Intimation Letter / Mail / Intimation No
• Duly filled & signed claim form
• Original discharge card / Discharge Summary duly signed by treating doctor and with hospital stamp.
• Original hospital bill with break-up details with serial no. duly sealed & signed.
• Original pre-numbered hospital payment receipt duly sealed & signed,
• Original prescriptions,
• Original pharmacy bills (please make sure patient name is mentioned on the bill)
• Original advance paid receipt if any
• Original investigation reports along with original bills & payment receipts for the investigations done within & outside hospitals.
• Original consultation papers, if any
• All Imaging Films, ECG Strips, Doppler / Angiogram CD etc.
• Hospital Registration Certificate (in case of a unknown small hospital)
• Any other original documents related to the claim.
• MLC/FIR in case of Accident cases.
• The copy of the cancelled cheque of the policy holder / Employee in case of corporate client where in claim is payable to employee
• If employee has availed a cashless but if the same is not utilized letter from the hospital mentioning the same.
• Copy of Valid Photo Id Proof of the patient & Policy holder / Employee in case of corporate client.
• Address Proof of Policy holder / Employee in case of corporate client if the claim is more than 1 lakh.