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FAQ on Claim Process Under Health Insurance

   
  1. Should the claim be submitted to the Insurance Company or TPA?
  2. Will the medical costs be reimbursed from day one of the cover?
  3. Will I get the entire amount of the claimed expenses?
  4. Can any claim be rejected or refused?
  5. In case of part settlement can an insured claim for the balance amount?
  6. How can I check the status of my claim?
  7. How will the insured arrange for 64 VB?
  8. How does one get Reimbursement for pre and post hospitalization expenses?  
  9. What is the procedure to get Reimbursement in case of emergency hospitalization?
  10. What is the procedure to get Reimbursement in case of planned hospitalization?
  11. How does one get Reimbursements in case of treatment in non- network hospitals?
  12. How does one avail of Cashless Facility?
  13. What are the situations under which one may be denied cashless hospitalization?
  14. What is the information one needs to furnish while intimating a claim?
  15. What if I donít remember my Card Number and Policy Number and I am in an emergency situation?
   
  1. Should the claim be submitted to the Insurance Company or TPA?
  The claim has to be submitted directly to the TPA for timely settlement.  
     
  2. Will the medical costs be reimbursed from day one of the cover?  
  No, there is a general waiting period of 30 days except in case of due to accident.  
     
  3. Will I get the entire amount of the claimed expenses?  
  The entire amount of the claim is payable, if it is within the Sum Insured and is related with the in-house treatment as per policy conditions and is supported by proper documents, except the expenses which are excluded.  
     
  4. Can any claim be rejected or refused?  
  Yes, the claim, which is not covered under the policy conditions, can be rejected. In case you are not satisfied by the reasons for rejection, you can represent to the insurer within 15 days of such denial.  
     
  5. In case of part settlement can an insured claim for the balance amount?  
  Normally, part payments are made due to deficiency of documents or for expenses which are not covered under the policy. In case of the former if the requisite documents are made available, the claim may be considered.  
     
  6. How can I check the status of my claim?  
  You can call the helpline number of your TPA or check on their site using your Policy number or member id.  
     
  7. How will the insured arrange for 64 VB?  
  Contact your insurance agent or insurer.  
     
  8. How does one get Reimbursement for pre and post hospitalization expenses?  
  The Mediclaim Policy allows reimbursement of medical expenses incurred towards the ailment/ disease for which hospitalization was necessitated prior to hospitalization and up to a certain number of days after discharge as per the limit specified in the policy.

For reimbursement, send all bills in original with supporting documents along with a copy of the discharge summary and a copy of the authorization letter to your TPA. The bills must be sent to the TPA within 7 days from the date of completion of treatment. The insured must also provide the company/TPA with additional information and assistance as may be required by the company/TPA in dealing with the claim.
 
     
  9. What is the procedure to get Reimbursement in case of emergency hospitalization?  
  1 Take admission into the hospital.

2 As soon as possible, inform TPA about the hospitalization

3 At the time of discharge, settle the hospital bills in full and collect all the original bills, documents and reports.

4 Lodge the claim with TPA for processing and reimbursement by duly filling in the claim form & enclosing all original bills/vouchers/receipts.
 
     
  10. What is the procedure to get Reimbursement in case of planned hospitalization?  
  1 Inform TPA about the planned hospitalization.

2 Get admitted into the hospital as planned.

3 At the time of discharge, settle the hospital bills in full and collect all the bills, documents and reports.

4 Lodge the claim with TPA for processing and reimbursement by duly filling in the claim form & enclosing all original bills/vouchers/receipts.
 
     
  11. How does one get Reimbursements in case of treatment in non- network hospitals?  
  In case of treatment in a non-network hospital, TPA will reimburse you the amount of bills subject to the conditions of the policy taken by the insured.

The insured must ensure that the hospital where treatment is taken fulfils the conditions of definition of Hospital in the Mediclaim policy. TPA should be contacted within 7 days from the time of admission with the following documents in original:

1 Claim Form duly filled and signed by the claimant

2 Discharge Certificate from the hospital

3 All documents pertaining to the illness starting from the date it was first detected i.e. Doctor's consultation reports/history

4 Bills, Receipts, Cash Memos from hospital supported by proper prescription

5 Receipt and diagnostic test report supported by a note from the attending medical practitioner/surgeon justifying such diagnostics.

6 Surgeon's certificate stating the nature of the operation performed and surgeon's bill and receipt

7 Attending doctor's / consultant's / specialist's / anesthetist's bill and receipt, and certificate regarding diagnosis

8 Certificate from the attending medical practitioner / surgeon that the patient is fully cured

9 Details of previous policies if the details are not already with TPA except in the case of accidents
 
     
  12. How does one avail of Cashless Facility?  
  Cash Less facility is available only in network hospitals. In case the patient wants to be referred to a network hospital the TPA needs to obtain the following documents from the patient before issuing a preadmission authorization for cash less facility:

1 Original first prescription of the doctor referring the hospitalization, complete with details of symptoms and diagnosis on his/her prescription letter head.

2 Hospitalization Form in the given format

3 Details of previous policies: if the details are not already available with TPA except in case of accidents.

In case information is not complete in the hospitalization form or if the history of the disease is not confirmed, a preadmission authorization cannot be issued for cash less facility. In such a case, if the patient is admitted in a network hospital, treatment will be same as in the case of a non-network hospital.

The doctor must mention in the history sheet - the record of history of the disease, relation to preexisting diseases like hypertension, diabetes etc if any and history of the same.
 
     
  13. What are the situations under which one may be denied cashless hospitalization?  
  1 If there is any doubt in the coverage of treatment of present ailment under the Policy

2 If the information sent to TPA is insufficient to confirm coverage

3 If the ailment/condition is not being covered under the policy

4 If the request for pre-authorization is not received by TPA in time

In such a situation, the Insured can take the treatment, pay for the treatment to the hospital and after discharge, send the claim to TPA for processing.
 
     
  14. What is the information one needs to furnish while intimating a claim?  
  The following information needs to be furnished while intimating a claim:

1 Name of Insured person who is sick or injured

2 Nature of Sickness/Accident

3 Contact Numbers

4 Policy Number (as reflecting on the Health Card)

5 Date & Time in case of accident, commencement date of symptom of disease in case of sickness

6 Location of accident
 
     
  15. What if I donít remember my Card Number and Policy Number and I am in an emergency situation?  
  In case you are in an emergency situation, TPA can search your details based on the following:

Name, Address, Date of Birth

Insurer

Underwriting Office Code
 
       

FAQ Disclaimer

Health Insurance Claim Process FAQ are provided for informational purposes only. We don't guarantee on the accuracy of these answers as answers for some of the questions may change from time to time as and when insurance companies or industry change their policies/rules. Please refer to the policy wording for more detail. Please read our Legal Disclaimer in this regard.