Whom do I have to contact for claim intimation and settlement?

You must notify Us either at the call center or in writing, in the event of planned or emergency hospitalisation.

Who is a Third Party Administrator?

A Third Party Administrator (commonly referred to as TPA) is an IRDA (Insurance Regulatory and Development Authority) approved specialized health care service provider.

How is the claim settled?

You can avail of our cashless facility arrangement with over 4000 network hospitals across India. Decision of the cashless claim will be given to you/hospital within 90 mins of receipt of last necessary document( i.e last document necessary for us to decide admissibility of cashless). At the time of discharge, we will confirm the final approved amount. The deductions on account of non payable expenses if any will have to paid by you at the time of discharge. Post discharge of patient from hospital, hospital sends us the original claim documents for us to reimburse the expenses to the extent of the approved amount.

Alternatively, you can pay all hospitalization bills directly and submit the original claims documents post discharge for reimbursement to nearest CIGNA TTK branch. Once we approve the claim, a cheque will be sent to you for the benefit amount payable under your policy.

What are the details to be provided at the time of intimation of Claim ?

The following details are to be provided to the Company at the time of intimation of Claim:

  1. Policy Number
  2. Name of the Policyholder
  3. Name of the Insured Person in whose relation the Claim is being lodged
  4. Nature of Illness / Injury
  5. Name and address of the attending Medical Practitioner and Hospital
  6. Date of Admission
  7. Any other information as requested by Us

What is planned hospitalization?

In planned hospitalization the treatment is planned well in advance. The intimation of such hospitalization and authorization from us has to be taken minimum 3 days prior to the date of hospitalization. E.g. Cataract, Pace Maker Implantation, Total Knee Replacement etc.

What is the process of Planned Hospitalisation ?

  1. The Insured Person should at least 3 days prior to admission to the Hospital approach the Network Provider for Hospitalization for medical treatment.
  2. The Network Provider will send the request for authorization in the pre-authorization form prescribed by the IRDA.
  3. The Network Provider shall electronically send the pre-authorization form along with all the relevant details to the 24 (twenty four) hour authorization/cashless department along with contact details of the treating Medical Practitioner and the Insured Person.
  4. Upon receiving the pre-authorization form and all related medical information from the Network Provider, we will verify the eligibility of cover under the Policy.
  5. Wherever the information provided in the request is sufficient to ascertain the authorisation We shall issue the authorisation Letter to the Network Provider. Wherever additional information or documents are required we will call for the same from the Network provider and upon satisfactory receipt of last necessary documents the authorisation will be issued. All authorisations will be issued with a period of 90 minutes from the receipt of last complete documents.
  6. The Authorisation letter will include details of Amount Sanctions, any specific limitation on the claim, any co-pays or deductibles and non-payable items if applicable.
  7. The authorisation letter shall be valid only for 15 days from the date of sending the authorization.

What is Emergency Hospitalization?

In Emergency Hospitalization the patient is admitted to the hospital in an emergency situation, for e.g. severe abdominal pain, accident, heart attack etc. In such event, we should be intimated within 48 hours of admission to the hospital.

What is the process of Emergency Hospitalisation ?

In the event of an Emergency:

  1. The Insured Person may approach the Network Provider for Hospitalization for medical treatment.
  2. The Network Provider shall forward the request for authorization within 48 hrs of admission to the Hospital.
  3. It is agreed and understood that we may continue to discuss the Insured Person’s condition with treating Medical Practitioner till it receives Our recommendations on eligibility of coverage for the Insured Person.
  4. In the interim, the Network Provider may either consider treating the Insured Person by taking a token deposit or treating him as per their norms in the event of any lifesaving, limb saving, sight saving, Emergency medical attention requiring situation.
  5. The Network Provider shall refund the deposit amount to You barring a token amount to take care of non-covered expenses once the pre-authorization is issued.

What is the time limit to submit the claim in case I do not use cashless facility?

You should submit your claim within 15 days from date of discharge from the hospital.

Is my claim payable in grace period?

We will not be liable to pay for any claim arising out of an Injury/ Accident/ Condition that occurred during the Grace Period.

Can claim be submitted even if covered by any other plan?

If two of more policies are taken by You during the same period from one or more Insurers to indemnify treatment costs and the amount of claim is within the Sum Insured limit of any of the policies, You will have the right to opt for a full settlement of Your claim in terms of any of Your policies.

Where the amount to be claimed exceeds the Sum Insured under a single policy after considering Deductibles, Co-pays (if applicable), You can choose the insurer with which You would like to settle the claim. Wherever We receive such claims We have the right to apply the Contribution clause while settling the claim.

What is the maximum number of claims allowed over a year?

Any number of claims is allowed during the policy period. However the sum insured is the maximum limit under the policy.

Who will receive the claim amount if the principle insured/policy owner dies during the time of treatment?

For Cashless Claims, the payment shall be made to the Network Hospital whose discharge would be complete and final. For Reimbursement Claims, the payment will be made to you. In the unfortunate event of death of policy holder, We will pay the nominee (as named in the Policy Schedule) and in case of no nominee to the Legal Heir who holds a succession certificate or Indemnity Bond to that effect, whichever is available and whose discharge shall be treated as full and final discharge of its liability under the Policy.

In case of planned hospitalization, is there any timeline for getting admitted in a hospital after informing you?

In case of planned admissions, you are required to inform us 3 days prior to the date of hospitalisation. We would assess the cashless request basis the proposed date of admission mentioned on the preauthorisation form. If cashless is approved, we will issue authorisation letter which is valid for a period of 15 days from date of issuance of the authorization. Any change in the date of admission needs to be informed to us.

Where can I get the claim form for reimbursement?

You can download a copy of the claim from our website www.cignattkinsurance.in

Where do I submit my duly filled claim form?

You may submit the Claim Form along with the documents for reimbursement of the claim to the nearest CIGNA TTK branch or head office at your own expense not later than 15 days from the date of discharge from the Hospital.

Which are the documents needed for reimbursement of claim ?

List of necessary claim documents to be submitted for reimbursement are as following:

  1. Claim form duly signed
  2. Copy of photo ID of patient
  3. Hospital Discharge summary
  4. Operation Theatre notes
  5. Hospital Main Bill
  6. Hospital Break up bill
  7. Investigation reports
  8. Original investigation reports, X Ray, MRI, CT films, HPE, ECG
  9. Doctors reference slip for investigation
  10. Pharmacy Bills
  11. MLC/ FIR report, Post Mortem Report if applicable and conducted

How will I come to know if you have authorized my claim?

You will receive an update on status of your claim through SMS and emails on the registered contact details with us. Hence, it is important that your contact details are updated with us at all times.

You can also reach out to your health advisor or connect with our health relationship managers to get an update or clarification on the claim.

In case of cashless claims, we will issue the authorisation letter to the hospital through fax or email.

What Identification proof do I have to carry for Hospitalisation?

You should carry thelHealth card provided by the company with this Policy, along with a valid photo identification proof (Voter ID card / Driving License / Passport / PAN Card / any other identity proof as approved by the Company).

What is the process of Scrutiny - Claim Documents ?

  1. We shall scrutinize the claim and accompanying documents. Any deficiency of documents, shall be intimated to You and the Network Provider, as the case may be within 5 days of their receipt.
  2. If the deficiency in the necessary claim documents is not met or are partially met in 10 working days of the first intimation, we shall remind You of the same and every 10 (ten) days thereafter.
  3. We will send a maximum of 3 (three) reminders following which we will send a closure letter.

Are there any investigations that happen after the receipt of claim ?

We may investigate claims at our own discretion to examine validity of claim. Such investigation shall be concluded within 15 days from the date of assigning the claim for investigation and not later than 6 months from the date of receipt of claim intimation. Verification carried out, if any, will be done by individuals or entities authorised by Us to carry out such verification / investigation(s) and the costs for such verification / investigation shall be borne by the Us.

What is the time line where the claim would be settled?

We shall settle claims, including its rejection, within 5 (five) working days of the receipt of the last ‘necessary’ document but not later than 30 days.

What about the Pre and Post-hospitalization claims ?

  1. You should submit the Post-hospitalization claim documents at Your own expense within 15 days of completion of Post-hospitalization treatment or period, whichever is earlier.
  2. We shall receive Pre and Post- hospitalization claim documents either along with the inpatient Hospitalization papers or separately and process the same based on merit of the claim derived on the basis of documents received.

Are there any Payment Terms/Conditions ?

The Sum Insured opted under the Plan shall be reduced by the amount payable / paid under the Benefit(s) and the balance shall be available as the Sum Insured for the unexpired Policy Period.

We are not obliged to make payment for any Claim or that part of any Claim that could have been avoided or reduced You/ Insured Person could reasonably have minimized the costs incurred, or that is brought about or contributed to by You/Insured Person failing to follow the directions, advice or guidance provided by a Medical Practitioner.

If You/ Insured Person suffers a relapse within 45 days of the date of discharge from the Hospital for which a Claim has been made, then such relapse shall be deemed to be part of the same Claim and all the limits for “Instance of same Illness” under this Policy shall be applied as if they were under a single Claim.

What is the settlement period for our claims ?

We shall settle claims, including its rejection, within 5 (five) working days of the receipt of the last ‘necessary’ document but not later than 30 days.

If the company rejects the claim can there be a reconsideration ?

Where a rejection is communicated by Us, You may if so desired within 15 days represent to Us for reconsideration of the decision.

What if there's a delay in submission of claim ?

Completed claim forms and documents must be furnished to Us within the stipulated timelines. Failure to furnish such evidence within the time required shall not invalidate nor reduce any claim if You can satisfy Us that it was not reasonably possible for You to submit / give proof within such time.

The due intimation, submission of documents and compliance with requirements by You as mentioned above shall be essential failing which We shall not be bound to entertain a claim.

What is Health Maintenance benefit ?

This benefit covers reimbursement of outpatient expenses incurred by Insured person upto the limits specified under the plan. It can be used to cover diagnostic tests, medical aids, drugs, prosthetics, dental treatments and alternative forms of medicines.

What is the process to claim Health Maintenance Benefit?

  1. Submission of claim
    You can send the Health Maintenance Benefit claim form along with the invoices, treating Medical Practitioner's prescription, reports, duly signed by You / Insured Person as the case may be, to Our branch office or Head Office. 
  2. Assessment of Claim Documents
    We shall assess the claim documents and assess the admissibility of claim.
  3. Settlement & Repudiation of a claim
    We shall settle claims, including its rejection, within 5 (five) working days of the receipt of the last 'necessary' document but not later than 30 days"

How can the Second Opinion on Critical Illness be claimed ?

You can submit Your request for a expert opinion by calling Our call centre or register request through email. We will schedule an appointment or facilitate delivery of Medical Records of the Insured Person to a Medical Practitioner. The expert opinion is available only in the event of the Insured Person being diagnosed with Covered Critical Illness.

What is the Annual Check up mentioned ?

If the Insured Person has completed 18 years of Age, the Insured Person may avail a comprehensive health check-up with Our Network Provider as per the eligibility details mentioned in the plan opted. Health Check Ups will be and arranged by Us and conducted at Our Network Providers.

 

For Protect plan – Available once every 3rd Policy year

For Plus, Preferred and Premier Plan – Available at each renewal

What is the process of claiming the Annual Health Check up ?

  1. You/Insured Person will be eligible for an annual health check-up during the Policy Year. The list of medical tests which You are eligible for will be available along with the Policy document.
  2. The Insured Person shall seek appointment by calling Our call centre.
  3. The Insured Person will be guided to the nearest medical centre for conducting the medical examination. Reports of the Medical Tests can be collected directly from the centre. A copy of the medical reports will be retained by the medical centre which will be forwarded to Us along with the invoice for reimbursement.

What is Worldwide Emergency Cover ?

We will cover Medical Expenses of the Insured Person incurred outside India, up to limits specified in the Schedule, provided that:

  1. The treatment is Medically Necessary and has been certified as an Emergency by a Medical Practitioner, where such treatment cannot be postponed until the Insured Person has returned to India and is payable under Section II.1 of the Policy.
  2. The Medical Expenses payable shall be limited to Inpatient Hospitalization only.
  3. Any payment under this Benefit will only be made in India, in Indian rupees on a re-imbursement basis and subject to Sum Insured.
  4. The payment of any claim under this Benefit will be based on the rate of exchange as on the date of payment to the Hospital published by Reserve Bank of India (RBI) and shall be used for conversion of foreign currency into Indian rupees for payment of claim. You further understand and agree that where on the date of discharge, if RBI rates are not published, the exchange rate next published by RBI shall be considered for conversion.

What is the process to claim expenses under worldwide emergency cover ?

In an unlikely event of You/Insured Person requiring Emergency medical treatment outside India, the same shall be availed at his/her own cost. You/Insured Person, must notify Us either at the call center or in writing within 48 hours of such admission. You shall file a claim for reimbursement in accordance with Claim Process of the Policy.

What happens if the hospitalisation expenses exceed the cashless authorised limit?

In the event that the cost of Hospitalization exceeds the authorized limit as mentioned in the authorization letter:

  1. The Network Provider shall request Us for an enhancement of authorisation limit including details of the specific circumstances which have led to the need for increase in the previously authorized limit. We will verify the eligibility and in our sole discretion evaluate the request for enhancement on the availability of further limits.

What if there' is a change in the treatment during the hospitalisation ?

In the event of a change in the treatment during Hospitalization to the Insured Person, the Network Provider shall obtain a fresh authorization letter from Us in accordance with the process

Would there be any process to be followed at discharge ?

At the time of discharge:

  1. the Network Provider may forward a final request for authorization for any residual amount to us along with the discharge summary and the billing format.
  2. Upon receipt of the final authorisation letter from us, You may be discharged by the Network Provider.

Are co pays and deductibles paid to you?

You will, in any event, be required to settle all non admissible expenses, co-payment and / or deductibles (if applicable), directly with the Hospital.

Do you always accept the cashless facility for hospitalisation ?

There can be instances where We may deny Cashless facility for Hospitalization due to insufficient Sum Insured or insufficient information to determine admissibility in which case You may be required to pay for the treatment and submit the Claim for reimbursement to Us which will be considered subject to the Policy Terms & Conditions.

The list of hospitals change or remain the same ?

The Company, at its sole discretion, reserves the right to modify, add or restrict any Network Hospital for Cashless services available under the Policy. Before availing the Cashless service, the Policyholder / Insured Person is required to check the applicable list of Network Hospital on the Company’s website.