As soon as a claim occurs, please intimate the TPA Help line/Toll free number as mentioned in your Health Card.
Cashless Service is the service wherein you need not pay any amounts either as a deposit at the time of admission or for the hospital bills at the time of discharge. This facility is available only at the Network Hospitals. To avail the "Cashless Service" you need to fill "Cashless request form" available in the network hospital to get an authorization from TPA. This authorization along with a copy of the card issued by TPA has to be given to the Network Provider at the time of admission. Please Note: TPA will authorize "Cashless Service" at the Network Providers in all cases eligible under the insurance policy.
"Cashless Service" may be denied in some of the situations as listed below.
- In case of any doubt in the policy terms with respect to the present ailment.
- If the information sent to TPA is insufficient to confirm coverage
- The ailment/condition etc. not being covered under the policy
- If the request for preauthorization is not received by TPA in time.
Denial of "Cashless Service" is not denial of treatment. You can continue with the treatment, pay for the services to the hospital, and later send the claim to TPA for processing and reimbursement.
A) Emergency hospitalization
- Take admission into the hospital.
- As soon as possible, please obtain the pre-authorization form from hospital and get the same filled in and signed by the attending doctor.
- Fax the pre-authorization form by you/hospital along with necessary medical details like investigation report etc to TPA at the number mentioned in your health card.
- A) If authorization for "Cashless Service" from TPA has been received by hospital
- i. At the time of discharge settle the hospital bills in full and collect all the bills documents and reports
- Pay for those items that are not reimbursable under the MEDICLAIM policy.
- Verify the bills and sign on all the bills.
- Leave the original discharge summary and other investigations reports with the hospital. Retain a Xerox copy for your records.
OR
- B) In case "Cashless Service" was denied by TPA
- At the time of discharge
- Lodge your claim with TPA for processing and reimbursement
B) Planned hospitalization
- Please co ordinate with your doctor and the hospital and send in all the details of your planned hospitalization including the plan of treatment, cost estimates etc. to TPA. This should be sent to TPA at least 2 days prior to the admission.
- A) If authorization for "Cashless Service" from TPA has been received.
- At the time of admission, hand in the authorization letter and a photocopy of your ID card to the hospital.
- Pay for those items that are not reimbursable under the MEDICLAIM policy
- Verify the bills and sign on all the bills.
- Leave the original discharge summary and other investigations reports with the hospital. Retain a Xerox copy for your records.
OR
- B) In case "Cashless Service" was denied by TPA
- At the time of discharge settle the hospital bills in full and collect all the bills documents and reports.
- Lodge your claim with TPA for processing and reimbursement.
"Please note: failure to intimate TPA as soon as the claims occur may invalidate your claim."
Procedure for Reimbursement Claims:
To avail inpatient hospitalization services, you can go to any hospital of your choice, either a hospital on the company�s network or a hospital outside the network. The difference between the two being that TPA can authorize for "Cashless Service" in the network hospital whereas you will have to settle all the bills in the hospital which is outside network.
However you have to follow the procedures listed below to get the services in different situations.
A) Emergency hospitalization
- Take admission into the hospital.
- As soon as possible, inform TPA about the hospitalization.
- At the time of discharge, settle the hospital bills in full and collect all the bills, documents and reports.
- Lodge your claim with TPA for processing and reimbursement.
B) Planned hospitalization
- Inform TPA about the planned hospitalization.
- Get admitted into the hospital.
- At the time of discharge, settle the hospital bills in full and collect all the bills, documents and reports.
- Lodge your claim with TPA for processing and reimbursement.
"Please note: failure to intimate TPA as soon as the claims occur may invalidate your claim."
How to submit your claim with TPA for processing and reimbursement:
Step 1. Please collect all documents
Step 2. Please fill up the claim form provided to you fully.
Step 3. Within 7 days after discharge, please lodge your claim with TPA local branch for processing.
Please note, when lodging your claim with TPA, please make sure that the documents are sent as per the check list mentioned below:
Document Check list for Health & Critical illness:
Document Check list for Health & Critical illness:
- First prescription of doctor with commencement date of the symptom of disease.
- Treatment papers along with doctors prescriptions
- Investigation reports (X-ray/Scan/ECG, Laboratory etc)
- Original medical bills and receipt of Hospital, doctors, medical shops, Diagnostic centre etc supported by Doctor's advice.
- Hospital discharge card.
- Copy of FIR (if any in case of accident).
Domiciliary Hospitalization
- First prescription of doctor with commencement date of the symptom of disease.
- Treatment papers along with doctors prescriptions
- Investigation reports (X-ray/Scan/ECG, Laboratory etc)
- Original medical bills and receipt of doctors, medical shops, Diagnostic centre etc supported by Doctor's advice.
- Copy of FIR (if any in case of accident).
- Certificate from attending Doctor / Physician stating the condition of the patient is not permissible for him / her to be removed to Hospital/Nursing Home or documentary proof of lack of accommodation in hospital/nursing home
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