* CLAIMS PROCEDURE AND MANAGEMENT Of Care Health Insurance
This section explains about procedures involved to file a valid Claim by you and related processes involved to manage the Claim by us.
1. Pre-requisite for admissibility of a Claim:
Any claim being made by You or attendant of Yours during Hospitalization on behalf of You should comply with the following conditions:
(i) The Condition Precedent Clause has to be fulfilled.
(ii) The health damage caused, Medical Expenses incurred, subsequently the Claim being made, should be with respect to the Insured Person
only. We will not be liable to indemnify you for any loss other than the covered benefits and any other person who is not accepted by the Us as
an Insured Person.
(iii) The holding Insurance Policy should be in force at the event of the Claim. All the Policy Terms and Conditions, wait periods and
exclusions are to be fulfilled including the realization of Premium by their respective due dates.
(iv) All the required and supportive Claim related documents are to be furnished within the stipulated timelines. We may call for
additional documents wherever required.
2. Claim settlement - Facilities
(a) Cashless Facility
We extend Cashless Facility as a mode to indemnify the medical expenses incurred by the Insured Person at a Network Provider. For this
purpose, the Insured Person will be issued a “Health card” at the time of Policy purchase, which has to be preserved and produced at any of
the Network Providers in the event of Claim being made, to avail Cashless Facility. The following is the process for availing Cashless Facility:-
(i) Submission of Pre-authorization Form: A Pre-authorization form which is available on Our Website or with the Network
Provider, has to be duly filled and signed by the Insured Person and the treating Medical Practitioner, as applicable, which has to
be submitted Electronically by the Network Provider to us for approval. Only upon due approval from us, Cashless Facility can
be availed at any Network Hospital.
(ii) Identification Documents: The “Health card” provided by us under this Policy, along with one Valid Photo Identification Proof of
the Insured Person are to be produced at the Network Provider, photocopies of which shall be forwarded to us for authentication
purposes. Valid Photo Identification Proof documents which will be accepted by us are Voter ID card, Driving License, Passport,
PAN Card, Aadhar Card or any other identification proof as stated by us.
(iii) Approval: We will confirm in writing, authorization or rejection of the request to avail Cashless Facility for the Insured
Person's Hospitalization.
(iv) Authorization:
a) If the request for availing Cashless Facility is authorized by us, then payment for the Medical Expenses incurred in respect of
the Insured Person shall not have to be made to the extent that such Medical Expenses are covered under this Policy and fall
within the amount authorized in writing by us for availing Cashless Facility.
b) An Authorization letter will include details of Sanctioned Amount, any specific limitation on the Claim, and any other
details specific to the Insured Person, if any, as applicable.
c) In the event that the cost of Hospitalization exceeds the authorized limit, the Network Provider shall request us for an
enhancement of Authorization Limit stating details of specific circumstances which have led to the need for increase in
the previously authorized limit. We will verify the eligibility and evaluate the request for enhancement on the availability of
further limits.
(v) Event of Discharge from Hospital: All original bills and evidence of treatment for the Medical Expenses incurred in respect of
the Hospitalization of the Insured Person and all other information and documentation specified under Clauses 4.4 and 4.5
shall be submitted by the Network Provider immediately and in any event before the Insured Person's discharge from Hospital.
(vi) Rejection: If We do not authorize the Cashless Facility due to insufficient Sum Insured or insufficient information provided to us
to determine the admissibility of the Claim, then payment for such treatment will have to be made by the Policyholder / Insured
Person to the Network Provider, following which a Claim for reimbursement may be made to us which shall be considered subject
to the Insured Person's Policy limits and relevant conditions. Please note that rejection of a Pre-authorization request is in no
way construed as rejection of coverage or treatment. The Insured Person can proceed with the treatment, settle the hospital bills
and submit the claim for a possible reimbursement.
(vii) Network Provider related: We may modify the list of Network Providers or modify or restrict the extent of Cashless Facilities
that may be availed at any particular Network Provider. For an updated list of Network Providers and the extent of Cashless
Facilities available at each Network Provider, the Insured Person may refer to the list of Network Providers available on Our website
or at the call center.
