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  • HDFC ERGO Health Insurance Claims Procedure

    HDFC Ergo Health Insurance

    One of the most awarded insurance companies in the country, HDFC ERGO is known for its quality service and world class products. A key reason for the company winning so many awards is its simple and transparent claims settlement process which minimise customer effort, eliminating red-tape and making it people friendly. With over 5,000 plus hospitals in its network across the country, insured members can be rest assured that a hospital isn’t far away during emergencies, regardless of the town or city they are in.

    HDFC ERGO has a dedicated claims settlement team in place, ensuring that policyholders or their loved ones have easy access to members during an eventuality. The company puts their customer ahead of other needs, providing assistance at all stages during hospitalisation or while applying for a claim.

    Incurred Claim Ratio for HDFC ERGO Health Insurance:

    The Incurred Claim Ratio (ICR) of an organisation is a strong indicator of their performance, helping people get a broad understanding about what they can expect. The Incurred Claim Ratio for HDFC ERGO Health Insurance for the period 2014-2015 is mentioned in the table below.

    Net Premium Earned (Rs Lakhs) Net Claims Paid (Rs Lakhs) Incurred Claims Ratio (%)
    58,145 32,843 56.48

    The ICR indicates the ability of HDFC ERGO to make profits, showcasing that they are in a position to clear claims without having to overburden their finances.

    Claim scenarios:

    There are two different scenarios one can experience with regards to using a health policy, with the first one being cashless treatment and the second one related to reimbursement of expenses incurred after a treatment.

    In case of cashless treatment:

    Cashless treatment involves getting treated for a particular illness with all medical expenses taken care off by HDFC ERGO, subject to the cover availed by an individual. One can avail cashless treatment at any of the network hospitals across the country.

    • Procedure to file a claim (Planned/emergency hospitalisation):

      Listed below are the simple steps which an insured individual should follow in order to file a medical insurance claim.

      • Approach a network hospital with the health card issued by HDFC ERGO and get admitted.
      • Intimating HDFC ERGO about such admission is critical, with intimation expected to be provided 2 days before planned hospitalisation. Intimation can be done by calling the TPA on 1800-2-700-700 or 1800-200-1999.
      • Submit the health card and a photo ID proof to the hospital to verify your credentials. Once this is done you will have to fill a pre-authorization form from the hospital, with the attending doctor expected to sign it. In case of planned hospitalisation, the letter of authorisation needs to be provided.
      • The completed pre-authorization form will be sent by the hospital to the insurance company with other relevant information.
      • The insurance company will communicate with the bank to update the status of your claim, either accepting it, denying it or requesting for additional information.
      • On acceptance, all medical bills covered under the policy will be settled by HDFC ERGO, while those which aren’t covered under the policy need to be paid by the patient/card holder.
      • The policyholder will need to verify and sign the original bills while keeping a photocopy of the entire hospitalisation record.
    • Claims process:

      HDFC ERGO has a simple and efficient claims process in place, with individuals expected to follow the following points.

      • A claim should be registered within 7 days of discharge, with the policyholder expected to notify the company about the same.
      • The policyholder should fill and submit the Claims Form, providing a photocopy of a valid ID proof along with it.
      • Relevant medical certificates and diagnosis report should be sent, with the signature of a doctor.
      • All reports and discharge summary (original) should be submitted for verification.

      HDFC ERGO will look into the claims request and either approve or reject it based on the policy in place.

    In case of Reimbursement of treatment expenses:

    There are cases when HDFC ERGO could reject the claim for cashless hospitalisation and treatment, but the insured individual can claim a reimbursement for the expenses incurred by him/her by keeping a few simple points in mind.

    1. Procedure to file a claim:

      Listed below are the steps one needs to follow in order to file a claim

      • The insured individual needs to inform the company immediately after being hospitalised. This can be done by calling the TPA on 1800-2-700-700 or 1800-200-1999.
      • Post treatment, all hospital bills need to be settled by the policyholder, with all original bills and reports to be kept by him/her.
      • Submit the duly filled claims form to the company for processing and reimbursement. The company will reimburse all bills if the information provided is in concurrence with the plan opted for.
    2. Documents required:

      The following documents need to be submitted to HDFC ERGO.

      • Claim form – The claim form should be duly filled, signed and submitted.
      • Hospital bills – An individual should submit all the original hospital bills, duly stamped and signed by the hospital.
      • Discharge report – The original discharge report should be submitted.
      • Other reports – All other reports pertaining to the treatment (including medicine bills and investigation reports) should be submitted in original.
      • Follow-up details – The future line of treatment and follow-up advice by the doctor should be sent.
      • Hospital details – In the event of an insured undergoing treatment in a non-network or unregistered hospital, he/she should get the details of the hospital on the official letterhead, indicating the number of doctors, nurses and beds available.

      These documents need to be sent to the health insurance claim office of HDFC ERGO. These offices are located in Noida and Chennai and one can mail the documents to either of the following addresses:

      HDFC ERGO General Insurance Company Limited,

      5th floor, Tower 1,

      Stellar IT Park,

      C-25, Sector 62,

      Noida - 201301


      HDFC ERGO General Insurance Company Limited,

      6th floor, MBC Tower,

      #199, Luz Church Road,


      Chennai - 600004

      One can also call them on their toll free number, 1800-2-700-700 or fax them on 1860-2000-600.

      Note: HDFC ERGO might ask for additional supporting documents in certain cases, as per the requirement.

    3. Claims process:
      • The policyholder should intimate HDFC ERGO about hospitalisation within 7 days of his/her discharge.
      • Pre-authorization from the company should be availed in relevant situations.
      • All documents requested by the company should be submitted within 10 days of discharge.
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