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Claim settlement Procedure in Insurance Health Policy


 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.

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