National Insurance – Health insurance Policy for Senior Citizens - Claims Procedure

Claims Procedure

11. Claims Procedure

11.1 Section I:-

Upon the happening of any event, which may give rise to a claim under this section notice with full particulars shall be sent to the Company within 7 days from the date of Injury/ Hospitalization/Domiciliary Hospitalization.

5.1 Claim must be filed within 30 days from date of discharge from the Hospital and where post-hospitalization treatment is not completed, it shall be within 30 days from the date of completion of Post-hospitalization treatment.

NOTE: Waiver of this condition may be considered in extreme cases of hardship where it is proved to the satisfaction of the Company that under the circumstances in which the Insured was placed it was not possible for him or any other person to give such notice or file claim within the prescribed time limit.

Claims will be settled by the Third Party Administrators (TPA). They will send details of the claims procedure for emergency/planned hospitals.

Documents to be submitted:-

1. Claim form
2. First consultation document
3. Copy of admission advice
4. Discharge Summary
5. Prescription with bills & receipts
6. Test Reports
7. Any other document required by TPA pertaining to this insurance contract/policy.

Advertisement

Procedure for availing Cashless Access Services in Network Hospital/Nursing Home:

Claims in respect of Cashless Access Services will be through the list of network Hospitals/Nursing Homes and is subject to pre-admission authorization. The TPA shall, upon getting the related medical information from the insured persons/network provider, verify that the person is eligible to claim under the policy and after satisfying itself will issue a pre-authorization letter/ guarantee of payment letter to the Hospital/Nursing Home mentioning the sum guaranteed as payable, also the ailment for which the person is seeking to be admitted as a patient.

Advertisement

The TPA reserves the right to deny pre-authorization in case the insured person is unable to provide the relevant medical details as required by the TPA. The TPA will make it clear to the insured person that denial of Cashless Access is in no way construed to be denial of treatment. The insured person may obtain the treatment as per his/her treating doctor’s advice and later on submit the full claim papers to the TPA for reimbursement subject to admissibility of claim under the terms and conditions of the policy.

The TPA may repudiate the claim, giving reasons, if not covered under the terms of the policy. The insured person shall have right of appeal to the insurance company if he/she feels that the claim is payable. The insurance company’s decision in this regard will be final and binding on TPA.