Claim settlement Procedure in Insurance Health Policy

If any claim arises in health insurance policy, the same can be settled in any of the
following ways:

1. Reimbursement of expenses: If a policyholder falls sicand hospitalized in non-empanelled hospital then hshould follow the following procedure:

• Intimation to the insurer/ Third Party Administrator

(TPA) along with the name of the person who hasfallen sick

• Policy number
• Name of the hospital
• Name of the doctor

The above information should be sent within 7 days of the hospitalization. Within 30 days final claim form should be furnished along with the following documents:

• Hospital receipts/ original bills.
• Cash memos.
• Various reports and tests.
• Hospital admission and discharge slip.
• Case history.
• Any other documents desired by TPA or hospital.

Note: Kindly ensure that insured person has been
admitted to a hospital/nursing home as defined in the
policy.

2. Cashless facility for planned hospitalization:

• The expected expenses to be incurred should be sent to TPA through the agreed list of network hospital
• Policy no. & card number should be shown to the hospital
• On confirmation from the TPA the treatment can be taken in that hospital.
• If expenses increase during the treatment then the hospital will sent revised estimate to the TPA for their approval.
• For any post hospitalization treatment the original bills/cash memos can be sent to the TPA after completing the treatment for the reimbursement.

3. Cashless facility for emergent hospitalization

• A card issued by the insurer should be shown to the hospital.
• The expected expenses may sent to the TPA for their approval.
• For any post hospitalization treatment the original bills/cash memo can be sent to the TPA after completing the treatment for the reimbursement.

Important: Kindly ensure that the Identity-Card is easily available with the policyholder.

Procedur To Be Followed For Buying Health Insurance Policy

1.  Filling of proposal form: The proposal form will contain the personal information of the person like name, address, age, occupation, sum insured etc. and two photographs of an individual is to be enclosed.
2. Declaration of good health/medical questionnaire: A person should give a declaration of his good health. In case of adverse health then he should submit the certificate from the doctor.
3. Medical examination report: It is required from the doctor, who is having the qualification of MD, if the age of person is more than 45 years. It is must even if the person is possessing good health.
4. Payment: The premium is paid through cheque to get the tax benefit under Income Tax Act, 1961.
5. Issue of Policy documents : The policy document is issued once above mentioned information/documents submitted.
6. Issue of Photo Card by Third Party Administrator (TPA): After issuing the policy documents, the TPA will issue the photo identity card for each person which will help to get the treatment in the hospital on cashless basis. TPA are licensed by the IRDA who will settle the health insurance claims on behalf of the insurance companies. TPA have empanelled various hospitals on all India basis who will provide the health treatment on cashless basis meaning thereby, that the policyholder will not pay any amount to the hospital and the hospital will get the payment directly from the TPA up to the sum insured of a person. If some insured is not sufficient to meet the bill of the hospital then the excess amount will be paid by the policyholder.

Exclusions That the Health Insurance Policy Does not Cover

1. All diseases / injuries which are pre-existing when the cover incepts for the first time.
2. Any disease other than those stated in clause (c) below, contracted by the insured person during the first 30 days from the commencement date of the policy. This exclusion shall not, however, apply if in the opinion of Panel of Medical Practitioners constituted by the company for the purpose, the insured person could not have known of the existence of the disease or any symptoms or complaints thereof at the time of making the proposal for insurance to the company. This condition shall not however apply in case of the insured person have been covered under this scheme or group insurance scheme with any of the Indian Insurance Companies for a continuous period of preceding 12 months without any break.
3. During the first or more years of the operation of the policy the expenses on treatment of diseases such as Cataract, Benign Prostates Hypertrophy, Hysterectomy for Menorrhagia or Fibromyoma, Hernia, Hydrocele,Congenital Internal Disease, Fistula in anus. Piles, Sinusitis and related disorders. If these diseases are preexisting at the time of proposal they will not be covered even during subsequent period of renewal.
4. Circumcision unless necessary for treatment of a disease not excluded hereunder or as may be necessitated due to an accident, vaccination or inoculation or change of life or cosmetic or aesthetic treatment of any description, plastic surgery other than as may be necessitated due to an accident or as a part of any illness.
5. Cost of spectacles and contact lenses, hearing aids. (These may be termed as normal maintenance expenses.)
6. Dental treatment or surgery of any kind unless requiring
7. hospitalisation.
8. Convalescence, general debility, run down condition or rest cure, congenital external disease, or defects or anomalies, sterility, venereal disease, intentional self injury and use of intoxicating drugs / alcohol.
9. Various conditions commonly referred to as AIDS.
10. Charges incurred at hospital or nursing home primarily for diagnostic. X-Ray or laboratory examinations or other diagnostic studies not consistent with the positive existence or presence of any ailment, sickness or injury for which confinement is required at a Hospital / Nursing Home or at Home under Domiciliary Hospitalisation as defined.
11. Expenses on vitamins and tonics unless forming part of treatment.
12. Treatment arising from childbirth including Caesarean section (can be deleted, if maternity benefit is covered).
13. Voluntary medical termination of pregnancy (abortion) during the first 12 weeks from the date of conception.
14. Naturopathy treatment.