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1.What is Mediclaim?

Mediclaim is a Health Insurance Product. Mediclaim Insurance is a cover, which takes care of the hospitalization expenses subject to maximum sum insured of the Insured in respect of the following situations:

  1. In case of a sudden illness.
  2. In case of an accident.
  3. In case of any surgery, which is required in respect of any disease, which has arisen during the policy period.

2.How different is a TPA from Insurance Company?

Third Party Administrator (TPA) is service provider to all insurance companies servicing health Insurance policies. TPA adds value and facilitates smooth operation of health insurance policies through its value-addition like network of healthcare service providers, medical care standardization, Claims management, Client servicing, expert opinion etc.

3.When I call HealthIndia Insurance TPA's Call Center / Office, how will you identify me?

Please mention your Policy Number or your Health India ID to the Call Center Executive. On establishing your identity, we shall be answering your queries related to Claims/Card status.

4.Will location of dependent family matter in availing services under TPA?

No, Location does not affect the operational activities, main member or the dependant member can avail same and equal benefits irrespective of their location. TPA Network of Healthcare Service Providers is across the country.

5.Will the change in names in between policy period matters?

Yes, According to the Insurance Company the claim will not be settled (unless prior intimation to Insurance company) if there is any alterations in the name, it has to be intimated to your respective Insurance Co. & requisite Endorsement for the change in name needs to be passed by Insurance co. This has to be done first hand and not when any claim arises.

6.Should the claim be submitted with the insurance company or with the TPA?

Preferably to the TPA only.

7.If I have not utilized my permissible eligibility amount in a particular policy period will I get any benefits like carry forward for the next period if I renew the policy?

The amount will not be carry forwarded to subsequent periods.

8.What are the documents required to be submitted to TPA to claim under reimbursement procedure?

Documents that you need to submit, for a hospitalization reimbursement claim in original, are:

  • * Hospital Discharge Card.
  • * In-patient hospital bills signed by Insured to authenticate the amount.
  • * Investigation Reports along with their bills.
  • * Prescription of doctor along with their chemist bills.
  • * Claim Form signed by the insured.
  • * Details of consumables & disposables used for medical & surgical procedures. (With their detailed break up)
  • * Doctor’s consultation bills with consultation notes.
  • * Photocopy of indoor case papers / operative notes.
  • * Copy of the TPA ID card or current policy copy and previous year's policy copies (if any).
  • * Any other document as asked by TPA based on the detailed analysis of the claim.

9.How to send reimbursement claims to TPA?

Reimbursement claims can be submitted to us through registered post / courier or can be handed over at any of our Branch offices.

10.Will medical costs be reimbursed from day one of the cover?

Such condition will be applicable only if your policy states the feature, "30 days waiting period waived." However these conditions depends on the nature of the claim and other terms and conditions of the policy.

11.What are "NON-MEDICAL EXPENSES"?

Your health insurance policy pays for reasonable and necessary medical expenditure. There are several items that do not classify as medical expenses which varies for every insurers. These items will not be payable and expenditure towards such items will have to be borne by you. The list of such expenses are periodically revised by the insurers and we are guided by them in this regard.

12.Can I claim medical expenses incurred before and after a surgery?

You can claim medical expenses incurred 30 days before and 60 days after hospitalization (if specified in your policy), provided they are related to the ailment/accident for which you were hospitalized. Such expenses are termed as pre and post hospitalization.

13.Can I claim my dentist's bills?

No, you cannot. Dental treatments are only payable if they are as a result of some accidental injury. However for further clarifications, please refer to the terms and conditions of your policy.

14.Are there any limits to the number of claims on a Health Insurance Plan?

Number of claims are not limited, however the total amount available for claim is up to the sum insured.

15.If I have a health insurance policy in Mumbai, can I make a claim if I am transferred to Delhi?

Yes, your health insurance policy is valid all over the country.

16.Can I claim expenses incurred for my mother's cataract operation in the first year of buying the policy?

Under normal retail policy, this treatment in first year of coverage falls under exclusion. Still one must verify in Terms and Conditions of their policy.

17.If an individual is already suffering from a disease, will the health insurance plan still reimburse his or her expenses related to the disease?

Such condition will be applicable only if your policy states the feature, "Pre-existing diseases covered". However, various options in terms and conditions are available. Hence one must carefully read the Terms and conditions of the policy for further clarity.

18.Are all the tests prescribed by the doctor at a hospital reimbursed under the Health Insurance Plan?

Expenses incurred at a hospital or a nursing home for diagnostic purposes such as X-rays, blood analysis, ECG, etc. will be reimbursed if they are consistent with or incidental to the diagnosis and treatment of the ailment for which the policy holder has been hospitalized.

19.Will my claims be reimbursed even if I do not get myself treated at a network hospital?

Yes, claims will be reimbursed even if insured is not treated in network hospital.

20.Is there a minimum time limit for stay within the hospital under the health insurance plan?

Typically, the insured can make a claim if her/his hospitalization is for over 24 hours. However, for certain treatments, such as dialysis, chemotherapy, eye surgery, Fractures etc, the stay could be less than 24 hours.

21.What happens when the limit of insurance is exhausted under a Health Insurance Policy?

If the insurance limit i.e. the sum insured is exhausted in a particular year due to large medical expenses, the insurer is not liable to bear/reimburse the insured for any further expenses within the said policy period.

22.What is the procedure for availing cashless facility?

  1. Insured / Patient approaches the hospital which is in the network of TPA with the ID card issued. This can be enquired • By accessing website of the TPA • OR by calling the Concerned TPA call centre.
  2. Hospital authority fills & Fax the TPA’s Cashless request form i.e. Authorization Letter (A/L) along with Xerox of the TPA. ID card at the TPA fax & they should confirm it by calling at the TPA.
  3. At TPA dept the details of A/L are verified with respect to • Policy coverage, its terms & conditions. • Medical details. • Hospital details.
  4. After verification of all the complete documents required, an Authorization Letter is issued by sending the fax from the TPA to the hospital authority sanctioning a calculated amount.
  5. If the provided medical details from hospital are incomplete, then hospital authority is asked to fulfill it and then an A\L is issued from TPA.
  6. On discharge from the hospital, Insured signs all bills to authenticate the amount and also pays non-medical expenses to the hospital.
  7. After the treatment the patient is discharged. Hospital sends the mediclaim file (i.e. with discharge card, hospital bills, investigation reports & other relevant papers in originals) to the TPA to settle the mediclaim directly with the Hospital.

23.If I avail of the cashless facility, will the insurance company pay the entire bill at the hospital?

No, a part of the bill will have to be borne by the insured if it consists of the inadmissible/non-payable items & amounts that are listed by the insurer.

24.What happens in case of an Emergency hospitalization where Cashless facility is not authorized to me?

The liability for paying the hospital will be on the Insured. However, the insurance company will reimburse the admissible amount.

25.Is maternity benefit available under an individual Health Insurance Plan?

Such condition will be applicable only if your policy states the feature, "Maternity covered."

26.What will be the Maximum Room rent charges, I am entitled for?

There is a room rent cap of 1% of SI per day for Normal room & 2% of SI per day for ICU. In case the Insured opts for a room, with rent higher than the entitled category, then the charges payable for Investigations, Doctor Visit, Operation Theatre, Surgery, Anaesthetist, etc. shall be limited to the charges applicable to the entitled category only.

27.In case I require my original medical papers back for future reference, what should I do?

Please carry a complete set of photocopied documents when you lodge your claim. The relevant original documents will be returned to you after verification. We will however stamp the original. Please note that normally, the original doctor prescription, medicine bills and discharge summary along with the hospital bills will be retained by us. Only X-ray films, ECG, other medical records will be returned to you as a special case after verification / approval of our medical team.