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  • ICICI Lombard Health Insurance Claims Procedure

    ICICI Lombard Health Insurance

    This insurance company is a result of a joint venture among India’s financial tycoon ICICI Bank and Lombard Canada Ltd. of Canada’s Fairfax Financial Holdings Ltd., who happen to be both very well regarded in the insurance industry. ICICI Bank is considered as one of India’s top private banks, with proofs of their performance in profitability, operational efficiency and customer service. It has established a far-reaching network of branches which services an impressive customer-base, in both the urban and rural sectors. It services corporate and retail clients alike through its many innovative and personalised products, developed to suit diverse banking needs, economically and efficiently.

    Currently ICICI Lombard has 4 plans for health insurance, to meet the various requirements most customers may have. The plans include ICICI Complete Health Insurance, Health Care Plus, Personal Protect and ICICI Lombard Health Advantage Plus. All these health insurance have cashless as well as reimbursement facilities. The major differences in these plans include the number of people they cover as well as the illnesses covered under the product.

    Incurred Claim Ratio for ICICI Lombard 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 ICICI Lombard 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 (%)
    106,110 92,720 87.38%

    We can see here that ICICI Lombard has well established ratio for profit signifying great performance. It also shows that they have had good business in the year in terms of premium earnings and have served their customer claims well in 2014-15.

    How to Claim:

    There are two situations that may occur when claiming health insurance. The cashless treatment is one that allows the policyholder to use the insurance as money to seek their treatment without having to pay any money upfront for treatment. The other scenario that is possible is in the case that the treatment has been already done and paid for but claim settlement requires to be made to allow the individual to be returned the money spent for treatment.

    For Cashless Treatment:

    Cashless treatment generally allows people to get treated for an illness covering all medical expenses for the treatment through the ICICI Lombard health insurance on an individual basis. The person concerned can do so at any of the network hospitals enlisted by ICICI Lombard on their website, or policy brochure, across the country.

    Procedure for filing cashless claims (planned, emergency):

    Here are the simple steps that need to be followed for cashless treatment both planned and emergency:

    1. You would first need to get in touch with the network hospital that provides cashless facility for ICICI Lombard health insurance. You need to ensure that you have your health card with you which would be issued by ICICI Lombard and seek admission for your treatment..
    2. You need to intimate the cashless facility. Simply call the number mentioned on the card or the health insurance helpline number mentioned on the company website. For planned hospitalization make sure you reach out to the company 2 days prior to admission.
    3. Submit the health card along with a proof of ID to the network hospital who in turn will conduct the verification of your credentials.
    4. A pre-authorization form will be required to be filled in, from the hospital, where the attending doctor will have to sign it. This can be downloaded from the ICICI Lombard website but needs to be faxed to the insurance company along with relevant information.
    5. The insurance company will then communicate with the relevant bank to update the status of the claim made, which could be either be acceptance or rejection or possibly the request for additional information or documentation. You can check out the claim status on the website itself.
    6. Once accepted, the medical bills and costs covered under the policy are settled by ICICI Lombard. But the things or expenses not covered under the health insurance have to be paid by you.
    7. As a policy owner you need to verify and sign the original bills and at the same time keep a photocopy of the entire hospitalisation record.

    Claims process:

    Here is how the claim process for ICICI Lombard works:

    1. You need to first register the claim within 7 days of the patient’s or the covered individual’s discharge, inform ICICI Lombard about it immediately.
    2. Fill and submit the Claims Form. Also provide a photocopy of a valid photo ID proof along with it.
    3. You need to send the relevant medical certificates along with diagnosis reports need to be assisted by a doctor.
    4. Reports and discharge summary i.e. original has to be submitted for verification.

    ICICI Lombard will then approve or reject it based on the policy in place.

    For Reimbursement of treatment expenses:

    There are chances when New India Assurance may reject the claim for cashless hospitalisation and treatment. However, the insured individual can claim a reimbursement for the expenses incurred for the treatment with a few simple steps.

    Procedure to file a claim:

    Here is what you need to do to file a claim

    1. Once you are hospitalised inform ICICI Lombard.
    2. Once the treatment is completed, all hospital bills have to be settled by the policyholder, make sure that you keep all the bills and documentation of the treatment with you.
    3. The policy owner then needs to submit the duly filled claims form to ICICI Lombard for processing and reimbursement. The insurer will reimburse all bills if as long as all the information provided is given correctly.

    Documents required:

    The following documents need to be submitted to ICICI Lombard:

    1. Claim Form: The claim form which needs to be filled with relevant details, signatures and finally be submitted.
    2. Hospital Bills and Summary: All the original hospital bills, with stamps and signatures from the hospital has to be submitted.
    3. The original discharge report has to be submitted as well.
    4. All other originals reports related to the treatment (including medicine bills and investigation reports) has to be submitted.
    5. The future line of treatment as well as follow-up check-ups by the relevant doctor should be sent as well.
    6. If seeking treatment in a non-network or unregistered hospital, you need to get the details of the hospital on the official letterhead that includes the number of doctors, nurses and beds available.

    Note: You may be asked for further documentation for the claim approval.

    Claims process:

    1. You need to let the insurer know about hospitalisation within 7 days of his/her discharge.
    2. Pre-authorization might be required from the company for certain situations.
    3. All documents must be submitted within 10 days of the patient’s discharge.

    The claim will be approved or rejected based on the policy as well as documentation provided.

    What Do the Claim Status Mean?

    Here is what needs to be done, based on your claim status:

    • Accepted: You will be sent a cheque for all the expenditures covered under the policy for your treatment.
    • Rejected: You will be a sent a letter stating why the claim was rejected. If you still think that should be accepted you may contact the company in person and if it is distinctly unfair to your belief seek the help of an insurance lawyer.
    • Query: They will request for further documents which you need to submit. If you do not do so in 15 days, they will send you another letter within a span of 15 days. By 45 days, the claim will be closed. This does not mean that your claim has been rejected. You can file an application for the claim again.
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