CLAIMS

1. What is an Authorization Letter?

Authorization Letter is the communication authorizing extension of cashless hospitalization to the Insured.
The same is issued by The TPA subject to admissibility of the claim and availability of balance sum
insured for the member.

2. How do I know whether my Claim has been admitted for Cashless or not?
Authorization Letter or Denial Letter shall be faxed directly to the Hospital and the Hospital will intimate
you about the same.

3. Is it possible to have cashless approval for Pre and Post Hospitalization?

Cashless Facility will not be given for Pre & Post Hospitalization Expenses. Reimbursement of these
expenses is possible on submitting of complete, detailed bills and documents relating to the same.

4. Will I get my claim papers back if I need it for my future reference?

No, you will not get the original claim papers back even after settlement of the claim as the same will be
retained by the hospital for further settlement with the TPA. You are requested to arrange for a photocopy
of the same for your future reference, before submitting the papers to the hospital. However, films (X-ray,
CT Scan, MRI, etc.) can be obtained from the TPA once the cashless is settled by the TPA as the same
cannot be photocopied for future reference. Do remember to put the request for the same to your JLT
representative or TPA in advance.

5. I have been advised for physiotherapy post my discharge from hospital. If the doctor visits my
home for the treatment, will it be payable under the policy?
Doctor visits at residence are considered as part of domiciliary charges. Since your policy does not
provide domiciliary cover, these charges under pre and post hospitalization will also not be covered.
Similarly expenses incurred for nurse who is nursing patient at home is not payable.
The patient's visit to the hospital or doctor's clinic for physiotherapy as a part of post hospitalization
expenses can be paid.

6. Recently when my colleague was admitted, the hospital had sent an initial estimated bill of Rs.
35,000 to the TPA; however, the TPA only approved Rs. 12,000. Does the TPA always approve
lesser amount than the total estimated amount?
Please note that in most cases pre-approved amount will be lesser than the final amount and this fact is
known to Hospitals. The initial approval is sent so that the Hospital can continue the treatment of the
patient.
At the time of discharge, the final bill amount is faxed to the TPA and the TPA approves the rest of the
amount based on the policy terms and condition of the policy.

7. Some hospitals tend to ask for certain advance payment when patient get admitted for
cashless. Why should a patient pay when cashless facility is available?
Most hospitals today require patient to make certain deposit to the hospital at the time of admission as a
security amount.
You are requested to ask the hospital to return the deposit made by you at the time of discharge if your
claim is being settled through cashless.
In case of re-imbursement, the deposit amount made by you can be adjusted with the final bill amount
and can be claimed later by submitting the bills to the TPA.

8. Can I leave once the doctor has given a go ahead to me for discharge? Do I need to contact the
TPA desk again for formalities?
On doctor's approval for discharge, the billing desk at the hospital first prepares the final bill and
discharge summary which is faxed to the TPA for further approval. The TPA then based on the
documents received, approves the rest of the bill and faxes back to the hospital TPA desk.

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You are supposed to clear the unpaid amount (for example, the deductions based on the policy terms, the
cost of non-payable items etc.) to the hospital. The entire process usually takes around couple of hours
and please do not forget to follow up with the TPA desk in the hospital on the status once the final bill is
faxed to the TPA. Patient has to sign certain documents to validate the bill amount & cashless amount
approved.

9. If I go to higher category of room than what is allowed in the policy, do I just need to pay the
differential room rent amount?
Along with the differential room rental amount, you will also need to pay the associated incremental
charges that increase with the increase in room category. For example, for hospitals certain charges like
surgeon charges, doctor visits etc. differs according to room categories and the same needs to be borne
by the insured.

10. Do I need to show anything to the hospital while going for a cashless treatment?
You must carry the patient's cashless card (copy of the e card will also work fine) provided by the TPA
along with a valid photo id of the patient.

11. The TPA had sent the initial pre-authorization amount when my colleague's father was
admitted. However, when the final bill was sent for approval, the TPA denied the cashless. On
what grounds can cashless be denied after providing initial pre-authorization?

Cashless in such cases is denied by the TPA usually on the following grounds:
If the patient is hospitalized only for investigation/ observation or monitoring purpose and ultimately no
active line of treatment takes place.

The proposed line of treatment provided in the pre-authorization form by the doctor deviates from the
actual treatment process and the TPA doctor does not find it relevant enough.

12. What is the procedure to file a re-imbursement claim?

After discharge from hospital, you need to submit the following documents to your JLT representative
strictly within 15 days from the date of discharge:
Following documents in ORIGINAL must be submitted at the time of claims submission,
- Dully filled and signed claim form.
- Discharge card/Death Summary (Death Summary in case patient expired during hospitalization)
- Final hospital bill with proper payment receipt
- All Original Reports
- Prescriptions and medicine bills
- Consultation Bill along with supporting Consultation letters
- A letter from the doctor mentioning the obstetric history in GPLA format. (In case of maternity
claim)
- FIR/MLC copy in case of accidental claim.
- Indoor Case Papers if required.
-Cancel Cheque (Name should be printed on cheque)
- Any other document as may be requested by the TPA for further processing of claim.
The above list includes the general documents and is not comprehensive. The requirement for
documents may differ specific to treatment. Please ensure you collect all documents from the hospital
related to the hospitalization.

13. I had to travel to US immediately after my spouse's discharge from hospital. I have returned
almost after a month now. Is there any time line for submitting a re-imbursement claim?
Yes. All bills must necessarily be submitted within 15 working days from the date of discharge of the
patient from the hospital,
If the claim is not submitted within the specified timelines, Insurance company has right to reject the
claim.

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14. Will the claim submitted by me under re-imbursement be fully paid to me up to the sum
insured or sublimit in the policy?
If the claim is admissible in the policy, it will be paid to you as per the policy terms (after making
deductions on account of room rent restriction, copay etc. if applicable in the policy) and also after
deducting the non-payable charges like registration fee, expenses by patient's attendant, telephone
charges, disposable items like syringes, cotton etc.
The maximum amount paid to you will be restricted to the sublimit if applicable for any benefits/ailments in
the policy and to the total unused sum insured in case there is no sublimit.

15. What all do I need to take from the hospital at the time of discharge for submitting my claim for
re-imbursement?
All the bills, reports, films, prescription and any other documents related to hospitalization in original.
All original payment receipts must be taken from the hospital including invoices for implants and
stickers in case of lenses.
Further, you must ensure that the date and time of admission and discharge is correctly mentioned in
the discharge summary and final bill.

16. My company provides insurance for self, spouse and 2 children. I have joined the company
couple of weeks ago and I am yet to receive my health insurance card. Can I still file the claim for
re-imbursement under the policy if my spouse is hospitalized this week?
Since your company covers the employees and their declared dependents from date of joining, you need
to ensure that you have declared the details of your spouse to your company. In that case, you may file
the claim for re-imbursement although your card is not available as yet. Please ensure that you submit
the claim within the 15 days from the date of discharge. The claim will otherwise not be entertained for
processing.

17. I am covered under 2 corporate policies, one provided by my company and the other one
under the policy provided by my spouse's company. Can I avail cashless facility under both the
policies?
You can avail cashless under only one policy. You will have to file for re-imbursement under the second
policy for the remaining amount not paid under the first policy. But it is important to provide written
intimation to the TPA servicing the second policy so that the claim does not get rejected under the second
policy due to delay in submission.
You will need to additionally obtain a letter of partial payment settled by the TPA who have processed the
cashless and provide the same along with the medical papers to the TPA who would be processing your
re-imbursement claim. Kindly note that claim under both the policies will settled as per the guidelines laid
under the contribution clause.

18. Doctor has recommended dialysis to be done at home for my mother. Would this be payable?
Dialysis done at home is normally referred to as Peritoneal dialysis and is not payable. Haemodialysis
which is done at a medical facility is payable.

19. There is an accidental claim for my colleague and he has submitted the hospitalisation papers
for re-imbursement claim. The TPA has raised deficiency for FIR/MLC, however, FIR was not done.
Please suggest what can be done in such case?
Please obtain a letter from the treating doctor stating that FIR/MLC has not been done and description of
the cause of the accident. The letter must mention if the patient was under the influence of alcohol or drug
when the accident took place.

20. There was a deficiency raised in the claim for which I submitted the deficient documents.
There has been another deficiency raised now. Are TPAs just trying to harass employees by
raising deficiencies one after another?

The first deficiency raised for you was maybe because of some basic document missing like discharge
summary or some report. However, based on the documents received from you, the TPA has raised the

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second deficiency for documents related to the specific diagnosis or if the TPA doctors feel that the
treatment is not adequately justified.

21. My hospitalization claim had got rejected on the basis of admission being done for
investigation/evaluation purpose. However, I got re-admitted after 20 days of discharge for the
same ailment and this time, the cashless was granted. Can I now claim the rejected amount
(during the first hospitalization) as a part of pre-hospitalization expenses?

Yes. Charges (investigation, OPD, medicines, etc.) related to the treatment would be payable as pre hospitalization
expenses, however, room rent / ICU and doctor visit charges related to hospitalization will not be payable as these
do not form a part of pre and post hospitalization coverage.

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