IFFCO Tokio Health Insurance Claim Procedure

Organization : IFFCO-Tokio
Service Name : Health Insurance Claim Procedure

Website : https://www.iffcotokio.co.in/claims/claim-procedure

Health Insurance Claim Procedure

All insurance contracts are based on the information provided by the insured in the proposal form. The proposal form forms the basis of insurance contracts.

Related / Similar Facility : IFFCO Tokio Insurance Two Wheeler Renewal

In view of varied nature of policies, certain points distinct to individual policies, in addition to the above, are listed below: (Please note that the documents mentioned are indicative and based on the circumstances of the claim, insurer may request for additional documents)

Health :
** You can apply for a Health Insurance claim in 2 ways. You can either go for Cashless Claim or get Reimbursement for your claim.

Given below are the procedures to be followed:
** Cashless claims facility is available only with the network hospitals of the TPA we are tied with. You are advised to understand from our TPA before you get admitted, about current status of networking of any particular hospital.
** Under this facility the network hospital shall assist you in completing the formality related to cashless request. You can also contact our Third Party Administrator through their helpline numbers , by quoting your Membership Number given on your health card.

Cashless claims are of two types:

** Cashless Claims procedure for Emergency Admission
** Cashless Claims procedure for Planned Admission

Cashless Claims procedure for Emergency Admission:
Step 1: In case of network hospital, on admission, intimate the Third party administrator (TPA) through their Toll free no. Please quote your health card Membership number
Step 2: Fill in the cashless request form which is available with the Hospital Insurance Help Desk and get it certified by your treating doctor
Step 3: Fax the cashless request form along with supporting medical records to the TPA
Step 4: The TPA will scrutinize the document and convey the decision to the hospital. The TPA could sanction the cashless request or call for additional documents, if required.
Step 5: On approval of cashless claim by TPA, the hospital bills will be settled directly (subject to policy limits). Inadmissible amounts like telephone charges, food, attendant charges etc would have to be settled by you
Step 6: If the cashless claim is not approved by TPA, please settle the bill with the hospital and apply for reimbursement. The claim will be processed as per policy terms and conditions

The Turnaround time for approving Cashless decision by our TPA is 24 HOURS AFTER RECEIPT OF ALL DOCUMENTS.

Cashless Claims procedure for Planned Admission
Step 1: Select a hospital from our list of network hospitals for treatment
Step 2: Intimate our Third party administrator (TPA) through the Helpline Number before 3 days of admission, quoting your Health card Membership number
Step 3: Fill in the cashless request form which is available with the Hospital Insurance Help Desk and get it certified by your treating doctor
Step 4: Fax the cashless request form along with supporting medical records to the TPA
Step 5: The TPA will scrutinize the document and convey the decision to the hospital. The TPA could sanction the cashless request or call for additional documents, if required.
Step 6: On approval of cashless claim by TPA, the hospital bills will be settled directly (subject to policy limits). Inadmissible amounts like telephone charges, food, attendant charges etc would have to be settled by you .
Step 7: If the cashless claim is not approved by TPA, please settle the bill with the hospital and apply for reimbursement. The claim will be processed as per policy terms and conditions.

The Turnaround time for approving Cashless decision by our TPA is 24 HOURS AFTER RECEIPT OF ALL DOCUMENTS.

Procedure for Reimbursement of Claim
If you have not availed cashless facility in network hospital or you have taken treatment in a hospital which is not a part of net work then you may submit your original documents for reimbursement.
Step 1: Intimate IFFCO-Tokio through the toll number – 1800 103 5499 immediately on admission not later than 7 days from the date of discharge. Please quote your Policy Certificate Number while intimating the claim.
Step 2: Avail treatment and settle all the bills with the hospital and then file a claim for reimbursement.
Step 3: Download the relevant claim form from our website (or) request for one through our call centre.

Claim documents may also be submitted to local IFFCO TOKIO Office address which can be obtained by calling our Toll Number 1800 543 5499. If you need a guidance on the claims process, you could also contact us through our Toll Numbers – 1800 543 5499.

Document checklist:
Documents to be submitted in case of Reimbursement of Claim – Duly filled claim form along with Doctor’s certificate
** Discharge summary
** Bills
** Prescriptions
** Advance and final receipts
** Diagnostic Test Reports, X Ray, Scan and ECG and other films

If required claim processing team shall seek further more documents other than the above listed ones.

Please Note:
** Claims would be processed on receipt of all required documents and additional documents/information if any required will be called for after scrutiny of the claim
** Cheque will be dispatched to you if the claim is admissible. If not, a repudiation letter would be sent to you
** The turnaround time for Reimbursement claims is 20 days from the date of receipt of all documents

Payment of Claim
** All claims under this Policy shall be payable in Indian currency. All medical treatments for the purpose of this insurance will have to be taken in India only.
** IFFCO TOKIO shall not be liable to pay any interest/penalty for sums paid or payable under the policy other than as provided by IRDA regulations.
** The claim if admissible shall be paid to the legal heir of the proposer in case the proposer is not surviving at the time of payment of claim.