Claims Process

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Health Claim Process

You can make a claim under a Health insurance policy in two ways:
1. Cashless
2. Reimbursement

You are advised to familiarize yourself with the policy document to acquaint yourself with the process rather than wait for a claim to arise.

Cashless

For a cashless claim, you need to avail the medical services of the network hospital provided by the servicing Third Party Administrator (TPA). You are required to procure an authorisation from the TPA for availing the treatment on a cashless basis as per prescribed procedures.

You need to first check whether the said hospital is on the panel of TPA, list of TPA network hospital can be accessed on TPA website. Approach the TPA desk at the hospital and tell them the name of TPA, show your TPA card, valid photo ID proof issued by government of India. In the cashless request note initial details like, patient name, insurer name, TPA card No. etc. needs to be filled by you, and the rest of the details like, line of treatment, estimated cost and stay in hospital is filled by the hospital and treating doctor. Once all details are filled hospital will send the cashless request note to the respective TPA.

TPA on receipt of the request will validate the same as per policy terms and conditions and will revert to the hospital, revert can be categorized as:

  • Further documents required from hospital/member to evaluate the case
  • Initial approval to the hospital
  • Rejection letter to the hospital in case the treatment is not falling under the policy terms and conditions
  • Rejection of cashless doesn’t mean denial of the claim, member can submit the same as reimbursement for further evaluation and consideration

Cashless Hospitalization can be categorized as:

Planned Hospitalization:

In case of a planned treatment, the insured is required to get the cashless initiated with the hospital and TPA 48 hrs prior to the date of admission.

Emergency Cashless Hospitalization:

In case of emergency hospitalization regularization should be done within 24Hrs of hospitalization.

Reimbursement

You are required to intimate the claim to the Insurance Company or the TPA within 30 days of discharge and provide documents such as claim form, discharge summary, prescriptions and bills that you should submit for a claim. Our Customer Support is available for claim intimation services. Please call us on 1800 2666 748 or write to us on lifekaplan@tmibasl.com.

Documents Checklist

  • Claim form
  • E-Card or Medical card issued by Insurer/TPA
  • KYC document – Photo identity and address proof
  • PAN Card
  • Doctor’s advice for admission to the hospital
  • Hospital discharge certificate
  • Final hospital bill in original
  • Payment receipt with pre-printed receipt no. for the payments done to hospital
  • Doctor's prescriptions
  • Investigation reports in original
  • Medicine bills
  • Insured’s Bank details including a cancelled cheque
  • Police FIR for road accidents and other mishaps (if applicable)

Please Note: Above is a tentative list of documents which are mandatorily required to lodge and process a claim, TPA/Insurer might ask for any other additional documents if required to ascertain the admissibility of claim.

Rejection of Claims

A claim can be repudiated if the treatment is not falling under the policy terms and condition or the documents or information furnished are tampered with, in that case insurance company may repudiate the claim under intimation to insured along with a written confirmation on repudiation of claim and under which clause/reason the same is repudiated.

One of the most common reasons for claim rejection is when a claim has been lodged during the waiting period or lodged for a treatment which is not covered under the policy terms and conditions. Indicative examples could include Cosmetic Surgeries, Out Patient Department (OPD) claims if not covered under the policy and permanent exclusions.

A detailed process workflow for both Cashless and Reimbursement Claims is available for your reference.