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  • L&T Health Insurance Claims Procedure

    L & T Health Insurance

    L&T allows you claim the health insurance 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 L&T is tied with. The network hospital will assist you in finishing the formality regarding the cashless request. You must contact the Third Party Administrator through the helpline number and you will have to quote your membership number provided to you and the TPA will guide you through the entire process. There are over 2,800+ network hospitals that provide cashless hospitalisation benefits.

    Incurred Claim ratio of L&T Health Insurance:

    Incurred Claim Ratio is published by IRDA for all Health Insurance companies in India. Incurred Claim Ratio or 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 L&T for the year 2014-15:

    Net earned premium (in lakhs) Net claims paid (in lakhs) Incurred claims ratio
    3,502 1,819 51.93

    L&T has a low incurred claims ratio and it is making profit and is in a position to settle claims comfortably.

    Claim procedure:

    L&T allows you to claim in the following ways:

    1. Cashless claim:

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

      • Cashless claims procedure for emergency admission:

        If you have been admitted in a network hospital on an emergency, then you can contact the TPA of L&T within 24 hours of admission and check if cashless claim is applicable. If you are allowed to make the cashless claim, then you will have to follow the following procedure to claim for emergency admission:

        • File the cashless pre-authorisation form that is available at the Cashless counter of the hospital.
        • Intimate the TPA. You can notify your claims by calling the TPA at 1800-209-5846 for intimation.
        • You will have to submit the pre-admission prescription and medical reports along with copy of the photo-ID and health card.

        Claims process:

        • The claim reference number will be sent to you after the TPA decides to approve the claim or reject you.
        • The claim approval or rejection decision will be taken within 6 hours after receiving the documents.
        • If the cashless claims are approved, you will have to clear out the uncovered expenses before you leave the hospital.
        • If the claim is not approved, you will have to pay the bill and then file for a reimbursement for which you will get a response within 6 working days on receipt of the document.
      • Cashless claims procedure for planned admission:

        If you are getting any treatment in a network hospital, you must follow the following procedure to claim for planned admission:

        • Select the hospital from the network hospital list.
        • Intimate the TPA at least 72 hours before admitting. You can notify your claims by calling the TPA at 1800-209-5846 for intimation.
        • Fill up the cashless pre-authorisation form that is available at the cashless counter at the hospital.
        • You will have to submit the pre-admission prescription and medical reports, if any along with the copy of your photo- ID and health card.

        Claims process:

        • Once you have faxed the form, you will receive a claim reference number along with the approval or rejection intimation.
        • You will receive the intimation within 6 hours from receiving the documents.
        • If the claim is approved, you will have to only pay for the uncovered expenses before leaving the hospital.
        • If the claim is not approved, then you must pay the entire bill and then claim for reimbursement. You get a response for the reimbursement claim within 6 days from receipt of the documents.
    2. Reimbursement of treatment expenses:

      Reimbursement of claim is done if you cashless claim is rejected or if you are getting treated at a non-network hospital. Reimbursement can be availed for planned hospitalisation as well as emergency hospitalisation. The reimbursement for planned hospitalisation must be intimated to L&T at least 72 hours before hospitalisation and the emergency hospitalisation reimbursement is to be intimated within 24 hours of hospitalisation.

      The procedure for claiming for reimbursement is as follows:

      • Submit the claim intimation. Intimate the TPA. You can notify your claims by calling the TPA at 1800-209-5846 for intimation.
      • Get your claim reference number.
      • Submit the claim form along with Policy number, name of the person who is availing the treatment, nature of the illness or disease or injury, address and name of the hospital or medical practitioner, date of admission and discharge, approximate of the claim expenses and relevant information, if any.
      • You will have to complete the treatment procedure and settle the bill and then collect the medical bills.

      Documents required:

      If your claim is rejected and you want to claim for reimbursement, then you will have to submit the following documents:

      • Duly filled claim form
      • Copy of claim intimation.
      • Original hospital bill payment receipt and hospital discharge card or summary must be submitted.
      • Submit the basic hospital main bill and original hospital bill break up
      • You must also submit the original pharmacy bill with supporting prescription and the original bills and receipt if you are claiming for ambulance charges.
      • Submit the medical investigation report as well as the doctor’s consultation note.
      • If you are claiming for pre and post hospitalisation, then you must submit the claim form, if you are claiming it separately along with the pharmacy bills backed with prescription and medical investigation reports and doctor’s consultation reports.
      • The documents have to be mailed to Claim Servicing Office, L&T General Insurance Company Limited, 6th Floor, City 2, Plot number-177, CST Road, Near Bandra Kurla Telephone Exchange, Kalina, Santacruz East, Mumbai – 400 098.

      Claims process:

      Once you have cleared out all the bill and have all the relevant documents, which you have submitted, the L&T TPA will intimate you the decision on if the reimbursement is approved or not within 6 days after receiving the documents.

    Do’s and Don’ts:

    While you are applying for a claim on your health insurance plan, do the following:

    • Obtain all necessary documents.
    • Forward the relevant reports for the claim.
    • Retain a copy of the hospital related documents for your record.

    Don’t do the following while you are applying for a claim:

    • Misrepresent or hide any information.
    • Providing incomplete information.
    • Hesitating to seek clarification on the deduction details.
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