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  • Chola MS Health Insurance Claims Procedure

    Chola Ms Health Insurance

    Chola MS (Cholamandalam MS) General Insurance Company is a joint venture between Murugappa Group and Mitsui Sumitomo Insurance Group. Being one of the prominent assurance companies, Chola MS provides a range of insurance schemes. The health insurance scheme, with different options of sum assured, covers all expenses that include hospitalization and domiciliary. This scheme offers a lump sum amount, to cover financial burdens that can occur during a medical emergency, for critical illnesses or accidents.

    Having tie ups with 4300+ hospitals, insurance policyholders can avail cashless and domiciliary treatment to cover pre and post hospitalization expenses. Cholamandalam MS Health Insurance has a team of Third Party Administrators (TPA), licensed by IRDA, at every tie-up hospital. This team helps the policyholder through the claims and reimbursement process in a hassle-free manner.

    Incurred Claim Ratio for Chola MS Health Insurance:

    The performance of an organization in the market is marked with the Incurred Claim Ratio (ICR). This parameter helps prospective policyholders understand the working and performance of the insurance scheme, thereby helping them choose a suitable plan for investment. Chola MS’ incurred claim ratio for the financial year 2014-2015 has been provided in the table mentioned below:

    Net Earned Premium (in Lakhs) Net Claims Paid (in Lakhs) Incurred Claims Ratio (%)
    Rs 19,635 Rs 10,295 52.43

    Incurred Claim Ratio is a clear indication of the company’s business status. Chola MS has cleared all claims and reimbursements they received, without overburdening their capital.

    Claim Scenarios:

    Claims for health insurance are of two kinds - cashless treatment and expense reimbursement after treatment. Cashless claims can be made at the tie-up hospitals. The TPA desk at the hospital will guide the policyholder through the process.

    In Case of Cashless Treatment:

    The insurance company takes care of all treatment and hospitalization of the policyholder, under cashless treatment scheme. Chola MS provides cashless treatment, depending on the cover opted by the policyholder. The life insured can avail this facility at any empanelled hospital, anywhere in the country.

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

    • In case of planned hospitalization, the insured should inform Chola MS insurance company or the TPA three days prior to admission, through the helpline number 1800-200-5544 (Toll free). The individual should also provide the membership or health card number as reference.
    • Health card and a photo ID (for verification) are mandatory and have to be submitted at the TPA desk.
    • The “Cashless Request Form” that is available at the insurance company’s TPA at the hospital, should be filled with correct and exact details. Supporting medical records and the form should be faxed to the TPA, after getting it stamped and signed by the treating doctor.
    • The documents will be verified by the TPA and the decision taken will be conveyed to the hospital. Cashless requests or calls for additional documents can be sanctioned by the TPA. Twenty-four hours after the receipt of all duly signed and stamped documents, the cashless decision will be approved by the third party administrators (TPA).
    • Subject to policy limits, Chola MS or the TPA, post approval, will directly settle the hospital bills. The life insured will have to take care of other inadmissible expenses such as attendant charges, food, and telephone charges etc.
    • The original bills and reports will have to be signed by the claimant. Photocopies of the same should be retained in case of future verification.

    Claims Process:

    Depending on the policy, Chola MS will first scrutinize the request for claims and then approve or reject the same. The following process should be followed for reimbursement claims:

    • The claim should be requested and the TPA should be intimated once the policyholder has been discharged from the hospital.
    • The claim forms and a valid photo ID’s photo, along with a photocopy of a valid photo ID proof should be submitted.
    • Relevant medical certificates and other reports, that are signed and stamped by the doctor in attendance, should be mailed to the TPA. The company may also require the original discharge summary and reports in order to scrutinize the case.

    In Case of Reimbursement of Treatment Expenses:

    In some instances, the insurance company may reject the policyholder’s claims for reimbursement in case of cashless hospital and treatment. Reimbursements can still be claimed by following the mentioned process:

    Procedure to File a Claim:

    Sometimes insurance companies may not accept settlement claims, in case the policyholder is availing treatment or admitted in a hospital that is not tied up with Chola MS’s TPA. In such a scenario, the person concerned can file for a reimbursement claim for the expenses incurred while at the hospital. Here’s is the process to file a claim:

    • Chola MS should be notified immediately, and not a week after discharge, via the toll free, landline number or email about the admission. The numbers are - Toll free: 1860 425 0000; Landline: 91-44-7117 7117.
    • Post the treatment, all dues should be taken care of at the hospital. A claim for reimbursement can be filed along with all the original bills.
    • The relevant claim form, downloaded from the company’s website, should be duly filled with correct details and submitted to the TPA desk for processing the reimbursement. If the claim complies with the regulations set by the insurance company, there will be no issues in getting the reimbursement.

    Documents Required:

    The following documents, along with duly filled claims form and doctor’s certificate, have to be submitted in case of reimbursement of the expenses incurred at the hospital. The claim processing team will get in touch with the policyholder in case more documents are required.

    • Diagnostic test reports
    • Reports of X Ray, Scan and ECG and other investigation reports
    • Discharge summary
    • Treatment and investigation bills.
    • Prescriptions.
    • Advance and final receipts

    Claims Process:

    • The insurance company or TPA should be notified about the policyholder’s hospitalization and discharge, within a week.
    • In some cases, it is necessary to avail a pre-authorization from the company.
    • Original copies of bills, reports, and other relevant documents, should be submitted within 10 days post discharge, based on the company’s request. The documents should be sent to the following address:

      Cholamandalam MS General Insurance Company Ltd,

      2nd Floor, "Dare House",

      No.2, NSC Bose Road,

      Chennai - 600001, India.

    Follow the above mentioned process in order to file a claim with Chola MS Health Insurance. Claim requests are processed only after the receipt and verification of all documents, which can take up to two weeks.

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