Care Health Insurance Claims Procedure

Care Health Insurance, formerly Religare Health Insurance, provides a seamless claims procedure that ensures settlement of claims without any delay or hassle. Whether it is for reimbursement of treatments or cashless treatment, all that is required is a simple 3-step process that can be completed online on the website of the insurer. Tracking of claims can also be done easily online on the insurer's website.

NCB Super Add-On made Mandatory under certain Sum Insured Options
  • The add-on is mandatory in case the SI is Rs.3 lakh and Rs.4 lakh.
  • The add-on is mandatory in case the SI is Rs.5 lakh and the age of the individual is 45 years and below.
  • Incurred Claim Ratio for Care Health Insurance:

    Though the claim ratio is a highly touted measure of how effective and reliable an insurer is, it is not the only yardstick through which health insurers should be chosen. Irrespective of that, a good incurred claim ratio indicates the speed of the overall process and the efficiency through which an insurer operates. The incurred claim ratio for Care Health Insurance is shown in the table below –

    Incurred Claims Ratio for Care Health Insurance for the Year 2016-17:

    Net Earned Premium (in Crore) Net Claims Paid (in Crore) Incurred Claims Ratio (in %)
    484.00 crore 244.50 crore 50.52%

    Incurred Claims Ration for Care Health Insurance for the Year 2017-18:

    Net Earned Premium (in Crore) Net Claims Paid (in Crore) Incurred Claims Ratio (in %)
    679.67 crore 353.21 crore 51.97%

    Generally a value from 50% to 90% is a good figure concerning ICR (Incurred Claim Ratios). That indicates Care actually has built up a good pool of resources from where it can meet the claims that are being generated. It will not be taxing the financials of Care in any condition.

    Claim Scenarios:

    Claim scenarios normally come up in two forms, either in cashless treatment or in case of reimbursement of expenditure that happens during a treatment. Let’s take a look at how the situations would be in each scenario pertaining to health insurance.

    Cashless Treatment:

    This kind of treatment can be availed across the network of hospitals that have tie-ups with Care Health. In such cases, one doesn’t need to pay for the treatment as the bills generated are sent across to Care Health itself.

    Procedure to File a Claim (Planned/Emergency Hospitalisation):

    1. The provided cashless treatment card should be carried on person, or the policy number and member ID should be provided at the network hospital
    2. One should call and inform Care at the number 1800-200-4488 within 24 hours of admission in case of an emergency hospitalisation
    3. One should either intimate Care on 1800-200-4488 or write to the customer helpdesk on in case of a planned hospitalisation at least 48 hours before
    4. One would need to furnish personal details and policy ID or member ID to the hospital’s insurance desk and fill up the Pre-Authorisation form in the customer’s section
    5. Once the balance details are filled up by the hospital, the Pre-Authorisation form will be faxed to Care at 1800-200-6677
    6. The Care in-house medical team will review the case and documents received and intimate the guardian and hospital in case of approval, pending approval or rejection
    7. In case of pending approval cases, Care will contact the hospital to furnish more details and in cases of rejection, a claim reimbursement process needs to be followed

    Claims Process for Cashless Treatment:

    1. Post the filling up of the pre-authorisation form, the requisite details will be verified by the hospital and the TPA
    2. Upon submission of the pre-authorisation form, all communications will be taken care of by Care pertaining to the settlement of the bill
    3. If in case some expenses are not covered or are beyond the scope of the policy, the same will be intimated to the patient before or post release from hospitalisation

    Reimbursement of Treatment Expenses:

    In case one has to resort to a hospital that is not in the panel of networked hospitals of Care or the pre-authorisation form has been rejected, one could file a claim for reimbursement of expenses. The procedure for the same and important points to consider are mentioned below.

    Procedure to File a Claim:

    1. In case of an emergency admission, Care should be informed of the same within 24 hours of admission on the number 1800-200-4488. If the hospitalisation is planned, the intimation should be done 48 hours in advance on the number 1800-200-4488 or the email address
    2. The details required during this procedure will be the following –
      • Policyholder’s name
      • Claimant’s name and customer ID
      • Details of the hospital
      • Details of diagnosis and treatment
      • An approximation of the claim amount
      • Date of admission

    Documents Required:

    The claim form can be downloaded from Care’s website and along with the filled up form, the following documents need to be provided –

    1. The original copy of the claim form, fully filled and duly signed
    2. Government approved valid photo ID proof
    3. Referral letter from medical practitioner advising hospitalisation
    4. Letter from medical practitioner detailing the list of tests, medications and consultations if any
    5. Original copies of bills, receipts and discharge card from the hospital or the medical practitioner
    6. Original copies of bills or receipts from pharmacies or druggists involved
    7. Original copies of tests and reports done along with payment receipts
    8. Indoor case papers
    9. If applicable, the First Information Report and the Final Police Report
    10. Original copy of the post mortem report, if conducted

    The above list of documents are the bare minimum necessities. Care might require additional documentation as and when needed.

    The above mentioned list of documents and the claim form needs to be sent via post to the address at –

    Care Health Insurance Company Limited,

    Claims Department,

    GYS Global, A-3, 4, 5, Sector-125, Noida,

    Uttar Pradesh - 201 301

    Claims Process for Reimbursement Cases:

    Once the filled claim form along with the relevant documents is received by Care, is initiated and the following happens –

    1. The in-house medical team of Care reviews the case and documents received
    2. The case if approved, will cause the reimbursement of funds to be processed and the procedure will be completed within a week and a fortnight. Intimation of the same will be sent to the claimant
    3. In case the request has incomplete information, the same will be intimated to the claimant and requisite details will be requested to ensure claim resolution at the earliest
    4. In case of request rejection, the reason will be mentioned for the same and an intimation letter will be sent to the claimant. If there are further documents to strengthen the case, the same will be studied and the claim can be reopened for review.

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    GST rate of 18% applicable for all financial services effective July 1, 2017.

    Disclaimer: Premiums may vary depending upon factors like age, location and prevailing taxes/GST.

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