Claim Process
Claim Process
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Health Insurance

Claim Procedure:

Health Claims can be broadly categorized in to two types:

1. Cashless Claim
2. Reimbursement Claim

Procedures for Cashless Claim

Cashless claim process – Network Hospitals

Cashless claim is the service wherein you need not pay your hospitalization bills to the hospital either at the time of admission or at the time of discharge from the hospital. Cashless claim for medical treatment is available only in network hospitals.

To avail the cashless facility you need to fill "Cashless request form" available in all the network hospitals. The hospitals will co-ordinate to get the authorization from the HCS/TPA for such cashless facility. This authorization along with a copy of the card issued by us needs to be given to the hospital at the time of admission. You are also required to carry a Photo Id Card.

Cashless facility may be denied by the HCS/TPA in some of the situations as listed below.

  • If the information sent by you /hospital is insufficient
  • The ailment/condition is not covered under the policy
  • If the request for preauthorization is not sent in time

Denial of cashless facility is not denial of treatment. You may continue with the treatment by paying the hospital for the services, and later submit the claim for processing and reimbursement.

 

" All claims are subject to approval by Surveyor appointed by HDFC ERGO GIC LTD "

 

Cashless claim process – Network Hospitals

Health Insurance- Cashless claim process – Network Hospitals

Emergency hospitalization



Step 1

Get admission in network hospital.

Step2

Intimate the call center about the hospitalization as soon as possible.

Step 3

Provide the health card of the patient along with the photo Id proof to the hospital. Obtain the pre-authorization form from hospital and get the same filled in and signed by the attending doctor.

Step 4

The hospital will fax/mail the pre-authorization form to the HCS/TPA along with necessary medical details like investigation report etc at the number mentioned in your Health Card/Policy Schedule.

Step 5

1. You will need to pay for all expenses that are not payable under the policy

2. Verify the bills and sign on all the bills

3. Get the photocopy of all the investigation reports & discharge summary for your records as the original will
be retained by hospital

In case cashless facility is denied by HCS/TPA

A) You need to settle the hospital bills in full and collect all the original bill documents & reports at the time of
discharge

d) Register your claim with HCS/TPA for processing and reimbursement

 

" All claims are subject to approval by Surveyor appointed by HDFC ERGO GIC LTD "

 

Planned hospitalization



Step 1

Approach any of the network hospital and finalize the hospitalization date & tentative expense. Intimate the HCS / TPA about the hospitalization with all the details at least 48-72 hrs prior to the planned admission.

Step2

If cashless facility is approved by HCS/TPA

1) At the time of admission, present the authorization letter and photo Id card to the hospital

2) At the time of discharge:

a. Pay for expenses that are not reimburseble under the policy
d. Verify the bills and sign on all the bills
c. Get the Xerox copy of all the investigation reports & discharge summary for your records as the original
will be retained by hospital
 

Step3

In case cashless facility is denied by HCS/TPA

1) Get admitted and take treatment

2) You need to settle the hospital bills in full and collect all the original bill documents & reports at the time of
discharge

3) Register your claim with HCS/TPA for processing and reimbursement

Health Insurance- reimbursement Claim process / Non-network hospitalisation

 

" All claims are subject to approval by Surveyor appointed by HDFC ERGO GIC LTD "

 

Health Insurance- Reimbursement Claim process / Non-network hospitalisation

2. Procedures for Claim Reimbursement -

Step 1

Get admission in hospital.

Step2

Intimate the HCS/TPA about the hospitalization as soon as possible.

Step3

Settle hospital bills in full and collect all the original bill documents & reports at the time of discharge

Step4

Register your claim with HCS/TPA for processing and reimbursement by submitting duly filled claim form along with required documents as mentioned in the claim form.

Documents require for claim process

  • Duly filled & signed claim form
  • All hospital bills in original including final hospital bill (with bill number signed & stamped by the hospital) with itemized bill & original receipts
  • Discharge card or discharge summary (original) or death certificate in case of death (in hospital)
  • All original investigation reports & medicine bills with doctor’s prescription.
  • Follow-up advice or letter for line of treatment after discharge from hospital from doctor.
  • In case the hospital is not registered, please get letters on the hospital letterhead mentioning the number of beds and availability of doctors and nurses round the clock.
  • In case of non-network hospital, you may have to get the hospital and doctor’s registration number in hospital letterhead and get the same signed and stamped by the hospital, if required.

 

Important information
As soon as there is a need for hospitalization, please intimate the HCS/TPA on 24x7 customer helpline number 1800 2 700 700 / 1800 200 1 999 as mentioned in your Health Card/Policy Schedule.
List of network hospital is available on our website.
You are required to furnish the following information while intimating a claim:

  • Contact Numbers
  • Policy Number (as on the Health Card//Policy Schedule)
  • Name of insured person who is hospitalized
  • Nature of disease / illness / injury
  • Date & time in case of accident/ Injury, commencement date of symptom of disease in case of illness

Note - Please note failure to intimate HCS/TPA as soon as the hospitalization takes place can invalidate your claim

" All claims are subject to approval by Surveyor appointed by HDFC ERGO GIC LTD "

 


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