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  • IFFCO Tokio Health Insurance Claims Procedure

    IFFCO Tokio Health insurance claims can be applied in 2 ways. You can either opt for cashless claim or get a reimbursement for your claim. Cashless claims facility is made available with network hospitals of the Third Party Administrator that IFFCO Tokio is tied with. You must understand the current status of networking through the TPA before you are getting admitted. The network hospital will assist you in completing the formality regarding the cashless request. The Third Party Administrator can be contacted through the helpline number and you will have to quote your membership number provided to you and the TPA will guide you through the process. There are over 3,000 network hospitals that provide cashless hospitalisation benefits.

    Incurred Claim ratio of IFFCO Tokio Health Insurance:

    IRDA publishes ICR or Incurred Claims Ratio for Health Insurance companies in India. ICR is the overall value of the claims that the company has paid divided by the total sum of premiums collected during that period. The following is the incurred claim ratio for IFFCO Tokio for the year 2014-15 and 2015-16:

    For 2015-16

    Net Earned Premium (in lakhs INR) Net Claims Paid (in lakhs INR) Incurred Claims Ratio (Percentage)
    41531 43296 104.25

    For 2014-15

    Net earned premium (in lakhs) Net claims paid (in lakhs) Incurred claims ratio
    29,989 27,714 92.41%

    IFFCO Tokio has a good incurred claims ratio and thus proving that the company is making profit and is in a position to settle claims.

    Claim procedure:

    You can make either cashless claims or you can get a reimbursement for the claims. The following is the claim procedure for the both:

    1. Cashless claim:

      In cashless claim, you do not have to settle the bill if you are hospitalised in a network hospital. IFFCO Tokio will be represented by the TPA and the TPA will coordinate with the hospital and settle the bill. The process for cashless claim for emergency and planned admissions are different.

      • Cashless claims procedure for emergency admission:

        You may be admitted in a hospital due to emergency and you worry about paying the hospital bill. If you have been admitted in a network hospital then you can contact the TPA of IFFCO Tokio and check if cashless claim can be made. If you are allowed to make the cashless claim, then you will have to follow the following procedure to claim for emergency admission:

        • Intimate the Third Party Administrator and quote your health card membership number if you are getting admitted in a network hospital.
        • You must then fill in the cashless request form which will be available at the Hospital Insurance Help Desk. Get the form certified by your attending doctor.
        • Fax the request form along with supporting medical documents to the TPA. You can avail the Fax number by calling the toll free number - 1800-103-5499.

        Claims process:

        • The TPA will check the document that you have faxed and convey their decision to the hospital. If needed, TPA may call for additional documents.
        • On approval of the claim from TPA, the hospital bills will be settled. The other bills like telephone charges, food, attendant charges will have to be covered by you.
        • If the cashless claim is not approved, then you must settle the bill and then apply for reimbursement.
        • The TPA will take 24 hours after receiving the documents to decide if the claim is approved or not.
      • Cashless claims procedure for planned admission:

        If you are getting any treatment or operation then you can decide on which network hospital you wish to be admitted in and then you must follow the following procedure to claim for planned admission:

        • Select the hospital from the network hospital list.
        • Then you must intimate the Third Party Administrator before 3 days of admission and quote your health card membership number. You can intimate the TPA through the toll free number – 1800-103-5499.
        • You must then fill in the cashless request form that you can find at the Hospital Insurance Help Desk. You must get it certified from the attending doctor.
        • You must then fax the request form to the TPA along with the supporting medical records.

        Claims process:

        • The Third Party Administrator will then check the documents and convey the decision to the hospital. TPA can also ask for additional documents if needed or can sanction the request.
        • After the claim has been approved, the hospital bill will be settled directly. Telephone charges, food, attendant charges, etc. will have to be settled by you.
        • If the claim is not approved, then you must settle the bill and then apply for reimbursement.
        • TPA takes 24 hours after receiving the documents to take a call on the claim.
    2. Reimbursement of treatment expenses:

      You can reimburse your treatment expenses if your cashless claim does not get approved or if you got the treatment at a non-network hospital. You will however have to clear the hospital bill first. The following is the procedure to file a claim:

      • You will have to intimate IFFCO Tokio on admission or not later than 7 days from the date of discharge. The number to intimate the TPA is 1800-103-5499.
      • You must quote the policy number while intimating.
      • You must then avail the treatment and settle the bill and then claim for reimbursement.
      • The claim form can be downloaded from the website and it can be requested through the call centre. The claim document must be submitted to the IFFCO Tokio office address.

      Documents required:

      While reimbursing your healthcare insurance claim, you must submit the following documents:

      • The claim form must be filled and a doctor’s certificate must be attached.
      • Discharge summary
      • Treatment bills
      • Prescription notes
      • Advance and final receipts
      • Diagnostic test reports, scan, X-ray, ECG or other relevant films.
      • The documents must be mailed to the IFFCO Tokio office address which you can avail by calling the toll free number - 1800-103-5499.

      Claims process:

      • The claim processing team will check the above documents and ask for additional documents if required.
      • If the claim is admissible, the cheque will be dispatched.
      • If the claim is not admissible you will get a repudiation letter.
      • The reimbursement claim process will take 20 days turnaround time from the day the documents are received.

    Claim payment:

    The claims under the IFFCO Tokio Health insurance are payable in Indian currency. The treatment will have to be taken in India only. The company is not liable to pay any interest or penalty for sum paid under the policy other than as provided under the IRDA regulations. If the insured is not surviving at the time of paying the claim, then it will be paid to the legal heir.

    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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