Health Insurance

Claims will be administered by the following TPAs as per the occurrence of the claim:

a)Location of Hospital: South & West Zone –Paramount Health Services Pvt Ltd
b)Location of Hospital: North & East Zone – Emeditek Solutions Ltd

How to avail cashless service at Network Hospital – CASHLESS CLAIMS

Step1: For planned hospitalization, forward your request letter 3-4 days prior to hospitalization in the prescribed format (format available from the website of the TPA/Insurance Company, benefit guide, branch offices of TPA/Insurance Company).

Step2: For emergency hospitalization, forward your request letter within 24 hours of hospitalization in the prescribed format (format available from the website of the TPA/Insurance Company, benefit guide, branch offices of TPA/Insurance Company)

Step 3: TPA will issue an authorization letter for the coverage as per the policy to network hospital.

Step 4: Insured approaches the network hospital with ID card and authorization letter.

Step 5: Network Hospital will extend cashless treatment to the insured up to authorized amount.

Step 6: At the time of discharge insured leaves back all the documents and sign the claim form

Step 7: The Insured makes the payment in cash to network hospital for the services that are not covered under the policy

How to avail service at Non Network Hospital – REIMBUSEMENT CLAIMS

Step 1: Incase of hospitalization in non network hospital, the insured is required to intimate the TPA 3-4 days prior to planned hospitalization and within 24 hours of emergency hospitalization

Step 2: Insured avails treatment from hospital and makes payment for the entire amount

Step 3: After discharge, the insured submits the above documents to the TPA within 7 days.

Pre & Post hospitalization expenses can be submitted along with or separately with the Claim to the TPA

The following are the general documents required for processing of the claim. Depending upon complexities of claim any additional document required can be called for.

1. First prescription regarding the current illness for which treatment undergone in hospital/nursing home , in original
2. Medical advice for hospitalization
3.Discharge Summary of Hospital, in original
4. Medical Fitness certificate, in original
5.All test reports supported by medical prescription(pre & post hospitalization), in original
6.All vouchers of the test report mentioned above, in original
7.All medicines purchased from outside the hospital at any point of time to be supported by original prescription, in original
8.Complete and signed claim form with filled in attending doctor’s prescription.
9.Copy of the policy document

PRE AND POST HOSPITALIZATON EXPENSES

Please submit along with or separately with claim the pre and post hospitalization expenses to the concerned TPA

Know your TPA’s: Third Party Administrator

“TPA” means a Third Party Administrator who is licensed by IRDA and has been appointed by us to render the following services:

1 Answer queries relating to the policy taken by you

2 Cashless access to network hospitals in case of hospitalization (subject to terms, conditions, exclusions and limitations of your policy)

3 Reimbursement of hospitalization claims (subject to terms, conditions, exclusions and limitations of your policy)

Claims will be administered by the following TPAs as per the occurrence of the claim:

a)   Location of Hospital: South & West Zone – Paramount Health Services Pvt Ltd

  Location of Hospital: North & East Zone – Emeditek Solutions Ltd

DO'S

Remember a Few Simple but Important Steps incase of Hospitalization.

• In emergency cases you can get admitted in the network hospital by showing the ID card and contact the TPA in the next 24 hours to obtain the pre-authorization
• Always carry your card with you
• Obtain Pre-authorization letter from the TPA 3-4 days prior to admission for planned cases
• Pre-authorization form is to be signed by Treating Doctor/Hospital, Nursing Home
• Ensure that the Pre-authorization is obtained by the hospital within 24 hours
• Avail cashless treatment at the network hospital for the covered ailment within eligible amount under the policy
• Leave back all the original documents and signed claim form with the network hospital at the time of discharge if opted for cashless admission
• Make payment to network hospital for expenditure over and above the sum insured, and for the treatment not covered under the policy
• In case of any query, kindly contact the TPA
• In case of admission to non network hospital, please make the payment on discharge and then lodge a reimbursement claim with us
• In case of Accidental injury, lodge FIR at the earliest, if required
• All documents  to be submitted in original
• Health card have been issued only for identification of the insured and is not a credit card.

We are here to Help You

• Our TPA will contact you within six working hours but not later than 1 working day of Claim intimation.
• Our TPA will brief you on the procedure & documents required & also advise you on the nearest Hospital Location.
• Pre- authorization will be done with in 24 hrs
• You can avail for cashless facility at network hospital only.
• Incase of Cashless, the Company shall make the payment in favor of the Hospital directly subject to deduction of Policy excess, limitation, time deductible, etc, as applicable & any additional work carried out .

DONT'S

• Don’t insist upon admission for investigation or evaluation or Health Check - ups
• Don’t carry back any original document at the time of discharge from the hospital
• Don’t forget to sign on the claim form
• Don’t insist on admission at network hospital without obtaining pre-authorization from the TPA unless it is an emergency admission
• In case of loss  of card, inform immediately to the TPA and us
• Cashless Services can be denied- In case sufficient information in the prescribed format is not given, in case of vague symptoms, where medical team of TPA is not sure of  your eligibility under the coverage due to inadequate medical information , pre-authorization for cashless may be denied. The denial of cashless does not mean the denial of treatment/claim and does not prevent you from seeking necessary medical treatment or hospitalization. You can lodge the claim on reimbursement basis, on completion of treatment.

NON PAYABLE EXPENSES

Insurance company is not liable to pay any expenses incurred on treatment which comes under exclusion clause of the policy as follows:

Expenditure towards registration/admission charges, Ambulance charges, extra bed for attendant, bed retaining charges, expenses on luxury items like radio/TV/air condition/laundry/telephone expenses on vitamins, tonics if not related to treatment, sanitary items, special duty nursing fee, food and beverages for attendant, Xerox/certifying charges, vaccination/nutritional dietetics, expenses on spectacles/hearing aids or any accessories, equipment or any other aid to be used on person or expenses not payable under policy condition etc, is to be paid by the policy holder.

DENIAL OF CASHLESS

In case sufficient information in the prescribed format is not given or in case of indistinct symptoms where medical team of the TPA/Insurance company is not sure of your eligibility, pre authorization for cashless can be denied.

The denial of cashless facility does not mean denial of treatment and does not prevent you from seeking necessary medical attention or hospitalization.