Kotak General India health insurance

Network hospital refers to all such hospitals/nursing homes in which the cashless facility may be availed by the insured for treatment as provided herein. The list of network hospitals is subject to amendment from time to time and shall be available with the Company.

Yes, you are eligible to lodge he claim with us. Please note, the hospital/nursing home should meet the criteria as defined in the Policy. Your claims will be assessed on reimbursement basis subject to other terms and conditions of the Policy.

The health policy covers medical expenses incurred towards the ailment, subject to the condition that the ailment is admissible under the Policy. Following are the broad heads of expense:

• Hospital (room & boarding and operation theatre) charges
• Fees of surgeon, anaesthetist, nurse, specialists
• Cost of diagnostic tests, medicines, blood, and oxygen; as long as these are medically necessary

Cashless/Reimbursement requests can be turned down under the following circumstances:

• If the information provided at the time of cashless request is insufficient to judge the admissibility of the possible claim
• If the hospitalisation is in a non-network hospital,
• If the claim attracts any of the standard exclusions of the policy including the pre-existing and waiting period clauses
• If there is a violation of terms and conditions of the Policy
• Policy invalid at the time of claim or sum insured exhausted due to previous claims under the Policy.

In such a case, the hospital will request the Insurance Company to increase the amount approved if needed during the treatment. The request will be assessed by the Insurance Company and additional approval will be given subject to terms and conditions of the Policy and availability of the sum insured.

The following information should be provided while intimating a reimbursement claim:

• The policy number
• Name of the policyholder
• Name and address of the insured person in respect of whom the request is being made
• Nature of illness or injury, and the treatment / surgery taken
• Name and address of the attending medical practitioner
• Hospital where treatment/surgery was taken
• Date of admission and date of discharge
• Any other information that may be relevant to the illness / injury / hospitalisation

The claim documents, duly completed, should be submitted at the following address as early as possible, but no later than 30 days from the date of discharge. Health claims department address:
Family Health Plan Insurance TPA Limited,
Srinilaya – Cyber Spazio, Suite # 101,102,109&110,
Ground Floor,Road No. 2, Banjara Hills,
Hyderabad : 500034, Telangana , India.

The pre-hospitalisation claim documents duly completed should be submitted at the following address within 15 days from the date of discharge. All post-hospitalisation claim documents should be submitted within 30 days from the date of completion of treatment, or expiry of the post-hospitalisation period as per the Policy, whichever is earlier.

The following documents are required for the processing of reimbursement claims:

• Claim form duly filled and signed by the insured and attending doctor
• All treatment papers of current ailment mentioning first symptoms and date of occurrence of the ailment, previous treatment papers (if any)
• Discharge card from the hospital
• All original medical investigation reports (viz. X-ray, ECG, blood test, etc.)
• Original hospital bills and receipts
• Original bills of chemist, medical practitioner, medical investigation, etc. supported by prescriptions
• NEFT details: Cancelled cheque of policy holder, copy of blank passbook/statement of policy holder if cancelled cheque does not contain name of the policy holder, and copy of the PAN card of the policy holder
• Know Your Customer (KYC) details viz. address proof, photo ID, and 2 recent passport size photographs (applicable for claim amounts overRs.1 lakh)

You need to submit the original documents to one of the insurance companies. After settlement of the claim, you need to obtain certified true copies of the documents along with a settlement letter and submit the same to the other insurer for the claim.

• Reimbursement Claim: These claims shall be processed within 15 working days from the receipt of complete documents. Complete documents means submission of all medical documents as mentioned in the claim procedure along with all previous treatment papers (if any).
• Cashless Claims: We shall convey our decision on the cashless mode within 6 business hours from the receipt of complete details. Complete details means submission of pre-authorisation form with information viz. provisional / final diagnosis, estimated treatment expense, length of stay & past medical history (if any) and duly signed by the treating doctor.

It refers to payment of the Medical Expenses incurred by the insured while undergoing Specified Day Care Procedures/ Treatment (as mentioned in the Day Care Surgeries list), which require less than 24 hours Hospitalization.

Co-payment is a cost-sharing requirement under a health insurance policy, where the Policy Holder / insured will bear a specified percentage of the admissible costs

A ‘Free Look Period’ is a period of 15 days from the date of receipt of the policy that a policyholder, in this case you, have to review the entire health insurance plan. If you disagree with any of the terms or conditions mentioned in the policy, you have the option of returning the policy by stating the reasons for the objection. Following this, you are entitled to a refund of the premium paid, provided no claim has been made under this mediclaim insurance policy (subject only to a deduction of the expenses incurred by the company on medical examination and the stamp duty charges). Please note that this facility is not applicable on renewal and portability cases.

Sub limit defines the capping of insurance amount, for specific surgeries and medical procedures, which reduces the premium of the plan. You can also opt for an add on cover by paying extra premium to remove the sub- limits under the policy.