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Formalities for a health insurance claim

You can make a claim under a Health insurance policy in two ways:
1.On a Cashless basis and
2.A Reimbursement Claim

On a Cashless basis : For a claim on cashless basis, your treatment must be only at a network hospital of the Third Party Administrator (TPA) who is servicing your policy.

You have to seek authorization for availing the treatment on a cashless basis as per procedures laid down and in the prescribed form.

Please read the policy document as soon as you receive it to familiarize yourself with the process rather than wait for a claim to arise.

Claims on reimbursement basis : Read the clause relating to claims in your policy document as soon as you receive it to ensure that you understand the procedure and the documents required for making a claim on reimbursement basis.

When a claim arises you should inform the insurance company as per procedures required.

After hospitalisation, you have to ensure that you obtain and keep ready documents such as claim form, discharge summary, prescriptions and bills that you should submit for a claim.

What happens to the policy coverage after a claim is filed : After a claim is filed and settled, the policy coverage is reduced by the amount that has been paid out on settlement.

For Example:

In January you start a policy with a coverage of Rs 5 Lakh for the year. In April, you make a claim of Rs 2 lakh. The coverage available to you for the May to December will be the balance of Rs.3 lakh.

What is the maximum number of claims allowed over a year : Any number of claims is allowed during the policy period unless there is a specific cap prescribed in any policy.

However the sum insured is the maximum limit under the policy.
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