Medical Insurance : Overview
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:
- In case of a sudden illness.
- In case of an accident.
- In case of any surgery, which is required in respect of any disease,
which has arisen during the policy period.
How different is a TPA from Insurance Company?
Third party administrator (TPA) is service provider to different 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.
Please mention your policy number whenever connecting with TPA / Insurance company Call center executive. On establishing your identity, they shall be answering your queries related to claims.
For Cashless Claims :-
1st Check if the Hospital falls under the Networked Hospitals or not, as Cashless is available only for Networked hospitals.
For planned Hospitalizations, intimations to be sent to the TPA in advance with details of name and Address of the Hospital while emergency Hospitalization, intimation to be sent to the TPA within 24hrs of admission with details of Name and Address of the Hospital
On admission, Ensure that a Pre-authorization request for cashless has been sent to the TPA by the Hospital – duly signed by the insured and hospital authorities giving the details of admission, illness, proposed line of treatment and the estimated expenses and after acceptance , then treatment is started. Please Furnish Clarifications If Any Required By TPA.
On Discharge from Hospital, Please pay the Difference of Amount disallowed under The Policy or limited by the Sum Insured.
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.
All documents in original to be submitted within 7 days to TPA, after completion of Post hospitalization treatment.
For Reimbursement Claims: -
Yes, claims will be reimbursed even if insured is not treated in network hospital this is non cashless facility and later you can apply for reimbursement claim. Typically, the insured can make a claim if her/his hospitalization is for over 24 hours.
Written Intimation About Hospitalization To Be Sent To Insurance Company Office / TPA Immediately, and Within 24 Hours Of Hospitalization In The Case Of Emergency Hospitalization.
Before Leaving The Hospital, Discharge Summary, Copy Of Investigation Report And Other Relevant Documents May Be Obtained From The Hospital Authorities.
Documents That You Need To Submit In Original Generally Within 7 Days From Date Of Discharge. to Insurance Company / TPA .
- Original Hospital Final Bill
- Original Numbered Receipts For Payments Made To The Hospital
- Complete Breakup Of The Hospital Bill
- Original Discharge Summary
- All Original Investigation Reports Along With Prescriptions
- All Original Medicine Bills With Relevant Prescriptions
- Photocopy Of Indoor Case Papers With Operative Notes.
- Original Signed Claim Form
- Copy Of The TPA ID Card Or Current Policy Copy And Previous Years' Policy Copies (If Any)
- Covering Letter Stating Your Complete Address, Contact Numbers, And Email Address (If Available).
- Any Other Document As Asked By Tpa Based On The Detailed Analysis Of The Claim.
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.
All documents in original to be submitted within 7 days to TPA, after completion of Post hospitalization treatment.
Save Tax with Health Insurance
It's common knowledge that buying health insurance helps you to save tax. Under Section 80D of the Income Tax Act 1961, you can get a maximum tax benefit of Rs.15000 on health insurance premium paid. The exemption limits are as follows:
An individual can avail an annual deduction of Rs.15000 from taxable income for health insurance premium paid for self and dependents.
In the case of senior citizens (aged 60 years and above), the annual deduction from taxable income goes up to Rs.20000.
If you are paying the premium for your parents' health insurance, you can claim an additional tax benefit up to Rs.15000 under the provisions of Section 80D.
If your parents are senior citizens (aged 60 years and above), the benefit goes up to Rs.20000.
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