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  • Royal Sundaram Health Insurance Claims Procedure

    Royal Sundaram Health Insurance

    One of the leading general insurance firms, Royal Sundaram offers a comprehensive range of health insurance plans with a number of benefits. Affordable and flexible, these schemes come with different sum insured options that come with a lump sum amount, to take care of large expenses incurred during hospitalization, be it for accidents or health ailments.

    With 1000+ hospital tie ups, health and medical insurance policyholders can enjoy cashless treatment benefits and reimbursements. The organization has registered quite a significant growth in the health insurance arena. With Third Party Administrators (TPA), licensed by IRDA, available at every tie-up hospital for a hassle-free claims process, Royal Sundaram has been servicing policyholders from rural and urban areas, since its inception.

    Incurred Claim Ratio for Royal Sundaram Health Insurance:

    The Incurred Claim Ratio (ICR) is a parameter where the performance of an organization can be monitored. By observing the ICR, prospective policyholders can have a clear understanding of the insurance company and the policies it offers. They can also chalk out a plan of their investments and what they can expect from the company. The incurred claim ratio of Royal Sundaram Health Insurance’s for the financial year 2014-2015 can be viewed in the table mentioned below:

    Net Earned Premium (in Lakhs) Net Claims Paid (in Lakhs) Incurred Claims Ratio (%)
    Rs 22,577 Rs 11,942 52.89

    By observing the ICR of Royal Sundaram Health Insurance it is clearly indicated that the company is able to clear all the claims that they received, without it being a burden on their finances.

    Claim Scenarios:

    A policyholder can avail a health policy and claim reimbursements under two scenarios - cashless treatment and expense reimbursement after treatment.

    In Case of Cashless Treatment:

    Cashless treatment under the insurance policy, is a scheme where the insurance company pays all the expenses incurred during the treatment of a life insured. Royal Sundaram offers cashless treatment claims, depending on the insurance cover. An individual can avail cashless claim facility at network hospitals the insurance company is tied with.

    1. Procedure to File a Claim (Planned/Emergency Hospitalization):
      • Royal Sundaram or TPA should be notified of the life insured’s planned hospital, before three days of admission, through the helpline number 1860 425 0000 (Toll free). The individual should also quote the Health Card membership number.
      • It is mandatory to carry the health card, which has to be submitted along with a photo ID as a part of the verification process.
      • Duly fill the “Cashless Request Form”, that can be availed from the hospital’s insurance help desk. Supporting medical records and the form should be faxed to the TPA, after getting it stamped and signed by the treating doctor.
      • The documents will be verified by the TPA and the decision taken will be conveyed to the hospital. Cashless requests or calls for additional documents can be sanctioned by the TPA. Twenty-four hours after the receipt of all duly signed and stamped documents, the cashless decision will be approved by the third party administrators (TPA).
      • Subject to policy limits, Royal Sundaram or the TPA, post approval, will directly settle the hospital bills. The life insured will have to take care of other inadmissible expenses such as attendant charges, food, and telephone charges etc.
      • The original bills and reports will have to be signed by the claimant. Photocopies of the same should be retained in case of future verification.
    2. Claims Process:

      Depending on the policy, Royal Sundaram will first scrutinize the request for claims and then approve or reject the same.The following process should be followed for reimbursement claims:

      • The claim should be requested and the TPA should be intimated once the policyholder has been discharged from the hospital.
      • The claim forms and a valid photo ID’s photo, along with a photocopy of a valid photo ID proof should be submitted.
      • Relevant medical certificates and other reports, that are signed and stamped by the doctor in attendance, should be mailed to the TPA. The company may also require the original discharge summary and reports in order to scrutinize the case.

    In Case of Reimbursement of Treatment Expenses:

    In some instances, the insurance company may reject the policyholder’s claims for reimbursement in case of cashless hospital and treatment. Reimbursements can still be claimed by following the mentioned process:

    1. Procedure to File a Claim:

      Sometimes insurance companies may not accept settlement claims, in case the policyholder is availing treatment or admitted in a hospital that is not tied up with Royal Sundaram’s TPA. In such a scenario, the person concerned can file for a reimbursement claim for the expenses incurred while at the hospital. Here’s is the process to file a claim:

      • Royal Sundaram should be notified immediately, and not a week after discharge, via the toll free, landline number or email about the admission. The numbers are - Toll free: 1860 425 0000; Landline: 91-44-7117 7117.
      • Post the treatment, all dues should be taken care of at the hospital. A claim for reimbursement can be filed along with all the original bills.
      • The relevant claim form, downloaded from the company’s website, should be duly filled with correct details and submitted to RCare for processing the reimbursement. If the claim complies with the regulations set by the insurance company, there will be no issues in getting the reimbursement.
    2. Documents Required:

      The following documents, along with duly filled claims form and doctor’s certificate, have to be submitted in case of reimbursement of the expenses incurred at the hospital. The claim processing team will get in touch with the policyholder in case more documents are required.

      • Discharge summary
      • Treatment and investigation bills.
      • Prescriptions.
      • Advance and final receipts
      • Diagnostic Test Reports, X Ray, Scan and ECG and other investigation reports.
    3. Claims Process:
      • Royal Sundaram insurance company or TPA has to be informed about the hospitalization within a week of the policyholder’s discharge.
      • In relevant scenarios, pre-authorization from the company should be availed.
      • Original bills, documents and any other relevant reports, should be submitted within 10 days post discharge, based on the company’s request. The documents should be sent to the following address:

        Royal Sundaram General Insurance Co. Ltd

        Vishranthi Melaram Towers

        No.2/319 , Rajiv Gandhi Salai (OMR)

        Karapakkam, Chennai - 600097

      In order to file a claim with Royal Sundaram insurance company, the above mentioned process should be followed. Claims will only be processed on the receipt of all necessary documents. The person insured may receive a cheque or repudiation letter, within 20 days of receiving and processing the documents.

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