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  • Tata AIG Health Insurance Claims Procedure

    Tata Aig Health Insurance

    Tata AIG allows cashless claims and reimbursement claims on their health insurance plans. Cashless claims facility is available with the network hospitals. The Third Party Administrator has to be informed about the claim and the TPA will assist you in completing the formality regarding the claim request. If you are getting treated in a non-network hospital, then you must clear all the bills at the hospital and then claim for reimbursement. There are over 3,000+ network hospitals covered with Tata AIG.

    Incurred Claim ratio of Tata AIG Health Insurance:

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

    Net earned premium (in lakhs) Net claims paid (in lakhs) Incurred claims ratio
    35,591 24,892 69.94%

    Tata AIG has a low incurred claims ratio and thus proving that the company is making a good profit and is in a position to settle claims. Hence, the company will not load your premium as they are not incurring loss.

    Claim procedure:

    You can make either cashless claims or you can get reimbursement.

    Cashless claim:

    In cashless claim, you do not have to settle the bill if you are hospitalised in a network hospital on an emergency or if it is planned. Tata AIG will be represented by the Third Party Administrator and the TPA will coordinate with the hospital and settle the bill. The process for cashless claim is as follows:

    Cashless claims procedure:

    You may be admitted in a hospital due to emergency or it could be planned, you need not worry about paying the hospital bill. If you are planning the hospitalisation, you must contact the service provider 48 hours before the admission. Emergency admission has to be notified within 24 hours of hospitalisation. If you have been admitted in a network hospital then you can contact the TPA of Tata AIG and check if cashless claim can be made. You will then have to follow the following procedure to claim:

    Cashless claims process:

    • TPA will then review the documents.
    • The confirmation will be communicated to the hospital by fax or e-mail.
    • The claim request will be communicated to you.
    • After completing the formalities, the claim will be settled as per the policy terms and conditions.

    Reimbursement of treatment expenses:

    You can reimburse your treatment expenses if your cashless claim does not get approved or if you are getting treated at a non-network hospital. You will however have to clear the hospital bill first. You will then have to notify the TPA within 48 hours of the admission if it is planned or within 24 hours if it is an emergency hospitalisation. The following is the procedure to file for reimbursement:

    Documents required:

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

    • If you want reimbursement for hospital cash or medical benefits:
      • Duly filled claim form
      • Report from the attending doctor
      • Discharge card or proof of hospitalisation that includes the treatment details
      • Prescription bills
      • X-ray reports or pathological reports, if any
    • If you want to claim for weekly benefits:
      • Duly filled claim form
      • Report from the attending doctor
      • Disability certificate, if any
      • Investigation or lab reports
      • If hospitalised, then original discharge or admission card
      • If you are employed, then employer’s leave certificate that includes your grade or designation information
      • You will have to submit your latest salary certificate
    • If you are claiming for death benefit:
      • Duly filled claim form
      • Original death certificate
      • Attending doctor’s report
      • Original or attested coroner’s report
      • Attested copy of FIR
      • Police inquest report, if applicable

    Claims process:

    • The claim processing team will check the documents and if required ask for additional documents.
    • The claim request will be reviewed and the approval or rejection of the claim will be communicated to you.
    • The claim will be settled as per the terms and conditions of the policy
    • The approved amount will be then reimbursed to you.
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