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  • SBI Health Insurance Claims Procedure

    SBI Health Insurance

    SBI General Insurance Company Limited is a joint venture between the State Bank of India and Insurance Australia Group (IAG). This insurance service provider offers a range of health insurance schemes that come with a lump sum amount, to take care of large expenses incurred during hospitalization, be it for accidents or health ailments.

    There are around 3000+ hospitals, tied up with SBI insurance for hassle-free services on health policies. To ensure a fast and smooth claims process, SBI Insurance has set up in-house health claim unit desks at every tie up hospital. Third Party Administrators (TPA), who are licensed by IRDA, have also been set up at hospitals.

    Incurred Claim Ratio for SBI Health Insurance:

    One of the parameters of measuring an organization’s performance is Incurred Claim Ratio (ICR). The ICR helps prospective customers to get a better sense of the company’s reliability. SBI’s Health Insurance’s incurred claim ratio for the financial year 2014-2015 is as follows:

    Net Earned Premium (in Lakhs) Net Claims Paid (in Lakhs) Incurred Claims Ratio (%)
    Rs 24,252 Rs 19,492 80.37

    SBI Health Insurance’s ICR indicates the company’s profits, where they are able to clear claims without overburdening their finances.

    Claim Scenarios:

    There are two types of scenarios, where a health policy can be used and reimbursements claimed - cashless treatment and expense reimbursement incurred post treatment.

    In Case of Cashless Treatment:

    When a person insured undergoes medical treatment for a particular illness, with all expenses taken care of by a health insurance company, then it is termed as cashless treatment. Depending on the insurance cover opted by the individual, SBI Health Insurance also offers cashless treatment. In order to avail this policy, the person will have to avail treatment at any of the hospitals in the country, where the health insurance provider has registered.

    1. Procedure to File a Claim (Planned/Emergency Hospitalization):
      • For the planned hospitalization SBI Health Insurance or TPA should be intimated at least two days in advance. Call the helpline number 1800 3009 (Toll Free) This will be provided in the card for intimating the TPA desk at the tie up hospital.
      • Carry the health card when getting admitted in any of the network hospitals. Submit the card, along with a photo ID proof for verification. Fill the “Cashless Request Form”, which is available at the TPA desk in all hospitals.
      • Once the hospital has verified the credentials, a pre-authorization form, duly signed by the doctor in attendance, has to be filled. In case of planned hospitalization, submit the authorization letter along with a photo ID at the time of admission.
      • The pre-authorization form along with other necessary medical details will be sent to the TPA by the hospital. The insurance provider will then coordinate with the bank to check and update the claim status. Depending on the relevance of the claim, the company may either accept or reject it. The person insured may also have to provide additional information, if requested by the provider.
      • 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.
      • The medical bills, if covered in the policy taken by claimant, will be settled by SBI Health Insurance. The uncovered expenses will have to be taken care of by the policyholder.
    2. Claims Process:

      The health insurance company will verify the claims request and then approve or reject the same, depending on the policy. In order to claim a reimbursement for the expenses incurred during medical treatment, the following procedure should be followed:

      • Post discharge, the policyholder should file for a claim and notify the insurance provider regarding the same.
      • The claim forms, along with a photocopy of a valid photo ID proof should be submitted.
      • Reports of investigation and relevant medical certificates, signed by the treating doctor, should be sent to the company. Original reports and discharge summary will have to be submitted for verification.

    In Case of Reimbursement of Treatment Expenses:

    In some instances, SBI Health Insurance can reject the person insured’s reimbursement claims for cashless hospital and treatment. In such a case, the concerned person can still claim reimbursements by following the process mentioned below:

    1. Procedure to File a Claim:

      Not every time does an insurance company accept claims for settlement from the life insured admitted or getting treated at a non-registered hospital. However, if this is the case, here’s what the person can do:

      • At the time of emergency hospitalization, the next of kin of the life insured should intimate the insurance provider or TPA through a phone call or email. The number is - Toll-Free: 1800 22 9090.
      • The hospital dues should be promptly settled in full, retaining all the original bills and reports to be submitted while claiming.
      • The claim form 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:

      In order to claim the money spent in hospital bills and treatment, the person insured will have to submit original copies of the following documents:

      • Hospital details – When the person insured is undergoing treatment in an unregistered or non-network hospital, the details of the hospital should be provided. Details may include duration of treatment, number of doctors, nurses, and available beds.
      • Hospital bills – All the original bills, duly stamped and signed by a person of authority in the hospital should be submitted.
      • Discharge report – The person will also have to submit the original discharge report.
      • Other reports – Original reports regarding treatment, such as lab reports, other investigation reports, and medicine bills have to be submitted.
      • Follow-up details – The life insured will also have to send details regarding follow-up and future line of treatment, along with bills, if any, in original.
      • Claim form The claim form, correctly filled and signed should be submitted along with the other original documents mentioned above.
    3. Claims Process:
      • The insurer or TPA should be notified about the policyholder’s hospitalization within a week of 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:

        SBI Life Insurance Co. Ltd.,


        M.V. Road & Western Express Highway Junction,

        Andheri (East), Mumbai - 400 069

      This was the SBI Health Insurance claims process. In order to avail complete benefit of the policy, make sure you follow the procedure correctly.


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