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  • National Health Insurance Claims Procedure

    National Health Insurance

    In case the processing of claims will be carried out by the company, the insured individual or his / her representative must inform the National Insurance Company when claims are filed. The TPA (Third Party Administrator) must be intimated in case the processing of claims is done by the TPA. The intimation should be provided in writing, either through a letter, fax or e-mail that contains all the relevant details related to the claim, including information such as nature of treatment, policy number, etc.

    To avail the cashless facility, details related to planned hospitalisation must be intimated to the concerned officials within 72 hours prior to the insured individual’s admission to PPN / network hospital. In case of emergency hospitalisation, the concerned officials of National Insurance must be notified within 24 hours after the insured individual was admitted to PPN / network hospital.

    With regards to notification of claims for reimbursement, planned hospitalisation details must be submitted to the TPA / company within 72 hours prior to the insured individual’s admission to hospital. In case of emergency hospitalisation, the company / TPA must be notified within 72 hours after the insured individual was admitted to hospital. Notifications can be sent by fax to 22831740, or via telephone on 22831705.

    Incurred Claim Ratio for National Insurance Health Insurance:

    The Incurred Claim Ratio of an insurance provider is a prominent indicator of its performance. It enables potential customers to better understand where the company stands in terms of reliability and efficiency. The Incurred Claim Ratio of the National Insurance Company is as follows:

    Net Earned Premium Net Claims Paid Incurred Claim Ratio
    Rs.332,965 lacs Rs.366,344 lacs 110.2%

    It is important to note that Incurred Claim Ratio is not the only parameter against which the credentials of a company can be judged as there can be discrepancies that do not disclose every detail that can help customers figure out whether or not they must choose a particular insurance provider.

    How to Make Claims?

    1. In case of Cashless Treatment:
      • Procedure to File a Claim (Planned / Emergency Hospitalisation):

        Network hospitals will provide the cashless facility to individuals who have selected ‘claim processing by TPA’. The insured individual can undergo treatment in PPNs or network hospitals provided that the TPA (Third Party Administrator) has given the authorisation in advance.

        The list of network hospitals can be accessed at the official website. The same website can be accessed to download the request from which should be filled in with the requisite details and submitted to the TPA so that it can approve and authorise the same.

      • Claims Process:

        When the TPA receives the request form along with other related medical details from the network provider or the insured individual, it will provide the network hospital with the pre-authorisation letter once it has verified the information received. At the time of discharge from the hospital, the insured individual will have to sign the discharge documents following verification and he / she will also have to bear inadmissible and non-medical expenses. If the insured individual cannot provide the necessary medical information, the TPA holds the right to decline pre-authorisation. If the medical insurance claim is declined, the insured individual can undergo treatment based on the advice of the treating doctor after which he / she will have to furnish the relevant claim documents to the TPA so that claims can be reimbursed.

    2. In case of Reimbursement of Treatment Expenses:
      • Procedure to File a Claim:

        To have claims reimbursed, the insured individual will have to furnish the relevant claim documents to the TPA prior to the due date prescribed in the policy. The insured individual can undergo treatment based on the advice of the treating doctor. The company will not cover costs related to the treatment of the insured individual neither before nor during the treatment. The insured individual will have to bear all costs incurred for the treatment. The insured individual will also have to furnish the bills along with the other relevant documents to the company / TPA for the reimbursement of claims.

      • Documents Required:

        The documents that must be furnished when claiming reimbursement from the company / TPA include the original claim form disclosing all the necessary details, payment receipts, original bills, hospital discharge certificate, original hospital cash memo, prescription from the chemist, investigation test reports along with the attending doctor / medical practitioner’s prescription, original payment receipt, certificate related to diagnosis and bill receipts from the attending doctor / medical practitioner, certificate from surgeon disclosing the plan or nature of operation underwent by the individual along with the diagnosis certificate supported by bills, and any other document as required by the TPA or the company.

        The documents can be sent to 3, Middleton Street, Prafulla Chandra Sen Sarani, Kolkata, West Bengal, 700071. They can also be faxed to 22831740.

      • Claims Process:

        Should the company accept the insured individual’s settlement offer, the customer will receive the payment within seven days after the offer has been accepted. In case there’s a delay in making the payment to the customer, the company will pay 2% interest above and beyond the bank rate.

        In case the company rejects the claim of an insured individual for any reason whatsoever, it will communicate the same to the individual in writing within 30 days after it has received the final document.

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