Mediclaim Insurance Claim Procedure: Detailed Guide

The mediclaim insurance claim is a request raised by the policyholder to compensate for the incurred medical expenses for treatment. The insurer verifies the claims and settles the bills either directly with the hospital or reimburses the amount. It depends on the type of claim procedure one has selected. At Bajaj Allianz General Insurance Company, the claims are directly settled by the in-house claim settlement team of the company. No third-party administrator is engaged. At the sole discretion of the company, it reserves the right to engage a third-party administrator (TPA). The key objective of a best mediclaim insurance policy is to provide financial assistance at the time of need. Anyone who meets with any accidental bodily injury or might suffer an illness resulting in a claim must comply with the following:

Cashless Claims Procedure

The cashless treatment is available at network hospitals only. To avail of the cashless treatment, the following process needs to be followed:

• The treatment might be taken by the network provider. It is subject to pre-authorization either by the company or the authorized third-party administrator.
• The form of cashless request is available with the network provider and TPA. It is to be completed and sent to the company or TPA for authorization.
• The company or TPA once receives the cashless request form and other related medical information from the insured person or network provider issues a pre-authorized letter post verification to the hospital.
• During discharge, the insured person needs to verify and sign the discharge papers. Pay for the non-medical and inadmissible expenses.
• In case the insured person is not able to provide substantial medical bills, the company or TPA has the right to deny any pre-authorization.
• In case the cashless access is denied, the insured person can get the treatment as per the medical advice and later submit the documents for reimbursement to the company or TPA.

*Standard T&C Apply

Reimbursement Claims Procedure

When it comes to the reimbursement claim, one has to initially pay for the treatment and file for reimbursement later. When filing for a claim, produce all the medical bills and various other records that show the money has been spent on treatment and hospitalization. If the pre-authorization as per the cashless claims procedure is denied or the treatment is taken in a non-network hospital. If one does not wish to avail of the cashless health insurance facility, then follow the steps below for the reimbursement claims procedure:

• The insured person or anyone claiming on behalf needs to inform in writing. This should be done immediately within 48 hours of emergency hospitalization. In the case of planned hospitalization, it needs to be 48 hours before hospitalization.
• Immediately consult a medical practitioner and follow the advice and treatment recommended.
• Take reasonable measures or steps to minimize the quantum of any claim made under the mediclaim policy.
• The insured person or anyone claiming on their behalf should claim promptly within 30 days of discharge from the hospital.
• In case the insured person passes away, the company needs to be informed in writing. A copy of the postmortem report needs to be sent within 30 days.
• In case the original documents are submitted with the co-insurer, the attested xerox copies by the co-insurer also need to be submitted.

Claim Type	Time Limit Prescribed
Reimbursement of daycare, hospitalization, and pre-hospitalization	Within 30 days of discharge date from the hospital
Reimbursement of post-hospitalization expenses	Within 15 days from post-hospitalization treatment completion

*Standard T&C Apply Follow the steps carefully and get the mediclaim insurance policy claim approved.  Please note to keep the documents safe. The insurer might ask for any documents during the insurance claim process of the mediclaim health insurance policy. Insurance is the subject matter of solicitation. For more details on benefits, exclusions, limitations, terms and conditions, please read the sales brochure/policy wording carefully before concluding a sale.