Download his claims guidelines

HIS CLAIMS GUIDELINES
This document is intended to assist an associate in understanding the HIS claim process. In case wherein any
litigation arises in the comprehension of this document, the Policy document issued by New India Assurance
will be used as the sole basis of settlement.
All reimbursement claims should be raised against the appropriate heads of Domiciliary or Hospitalisation in
the portal within 90 days from the date of expense (in case of domiciliary claims) or within 90 days from the
date of discharge (in case of hospitalisation claims), in the same financial year. If a window of 90 days is not
available during the end of financial year, all claims must be submitted by the last day of the financial year i.e.
31st March.
Claiming Process:
Remember - The basis of quick settlement of claims is correct documentation!
A separate claim should be raised for every illness. For example, if you are treated for Fever this week and
Bronchitis in the next month, you should raise two separate claims (with attached documents supporting the
same) for each of the illnesses. Single claims for multiple illnesses will be denied as “Date Range Claims”.
Associates can raise multiple claims for the same (continuous) treatment. For example, Heart patients who
take medicines every day can raise multiple claims for the same treatment to ensure that the claims are raised
within 90 days from the expense date. (In such case photo copy of prescription can be attached where it
should be mentioned that medicines need to be consumed over the period of time)
Note: The prescription will be considered as valid for the particular financial year only.
Domiciliary:
Domiciliary treatment will cover all illnesses (subject to policy conditions) that do not require hospitalisation
including treatments taken either from a Physician or at the OPD in a hospital.
To raise a domiciliary claim, you need to submit these documents in the mentioned order:
1.
2.
3.
4.
5.
6.
Duly signed Claim form
Doctor’s prescription: This must contain the Nature of ailment, Line of treatment and period of
treatment with details of medicines dispensed or prescribed to the Patient. A prescription should not
contain payment details
Pre numbered doctor’s bill from doctor’s official bill book (original)
Chemist bills/ Cash memos for medicines purchased from a Chemist (original)
Copies of all LAB and other test reports if applicable
Day to Day case summary as additional document in case of Dental treatments
Doctor’s Prescription: This must contain the Line of treatment with details of medicines dispensed or
prescribed to the Patient. Cost of medicines prescribed and/or dispensed must be in line with the cost of
medicines available in the market. Also, the quantum of medicines dispensed must be in line with medicines
normally consumed for the illness. For example : If an Antibiotic is dispensed for a Chest Infection for 5 days,
the medicine dispensed should be for 5 days and not for an extended period of days/time. Any inflated
medicine would automatically be curtailed to a “Reasonable and Customary” amount. Please note that a
prescription should not contain payment details.
Chemist Bills: Please attach Chemist bills for the medicines which have been prescribed. Chemist bills for
medicines not prescribed will be denied. Please note that the date on Chemist bills should fall within the
Policy Period and during the course of the treatment. Any bills before and after the Policy Period will be
denied.
1
Chemist bills should also have Valid VAT/ Drug Licence No. Unlicensed bills will not be acceptable to the
Insurance Company. Please note: All bills must be numbered and preformatted. “Rubber Stamp” bills will be
denied.
Doctor’s Bills and Receipts: This document should be from the Doctors Official Receipt Book, which contains
pre-printed doctor’s information and pre-printed receipt number. Blank document with Doctors Signature
and Stamp will not be admissible as receipt proof.
Kindly note that “Letter Head Bills” of Doctors will not be acceptable to the Insurance Company
Referral for Tests: Every test carried out should be referred by a Doctor. Broad Spectrum Tests generally
carried out as Master Health check up and Executive check up will not be entertained by the Insurance
Company. It is mandatory to submit photo copies of all LAB and other test reports (if applicable), specially if
the total claim amount includes the expenses towards the same.
Dental coverage under domiciliary:
1.
2.
Expenses for extraction, fillings, medicines, consultants’ fees, and x-rays only can be reimbursed
under Domiciliary.
It is mandatory to submit the x-ray film (if any) and Day to Day case summary (day wise treatment
undergone during the entire cycle of the treatment) in case Root canal or other dental treatment
where multiple visits/sittings are being carried out.
Hospitalisation:
Hospitalisation benefits are applicable only if the insured person is admitted to a hospital continuously for a
minimum of 24 hours. (Exception is Day Care Procedures mentioned in the policy)
To raise a Hospitalisation claim, you need to submit these documents in the mentioned order:
1.
2.
3.
4.
5.
6.
7.
Duly signed Claim form
Printed and detailed admission/ discharge card issued by the hospital (original)
Detailed Hospital bill showing all break ups
Printed and numbered bill receipt issued by the hospital (original)
Copies of all LAB and other test reports if applicable
Cash memos for medicines properly arranged if purchased from chemist with prescriptions (original)
Indoor case papers
Please number all the documents /pages so that no page is lost.
Also, please note:


In case of Road Traffic Accident (RTA) copy of FIR and/ or MLC is a must.
In claims towards expenses incurred outside India, EOB issued by CIGNA/ overseas insurance policy is
a must in addition to all above documents (claim documents should be sent directly to Mumbai
address).
Ideally Hospitalisation claims should be submitted immediately after discharge and pre/post claims if any can
be claimed subsequently.
-
The documents arranged serially as mentioned above while submitting the claim will help in easy and
smooth processing of claims and will prevent documents from getting misplaced. It is suggested that you
mention your employee number and claim number on each document or on the envelope containing the
documents.
-
Documents along with dully filled claim form can be dropped in the drop box in your / nearest TCS office
locations. Alternatively, documents can be sent to any one of the (nearest) addresses mentioned in the
claim form.
Associate should retain scanned or photo copies of all the documents, so that the same can be produced if/
when required.
2
Exclusions:
The following Illnesses /medical conditions are not payable under the HIS Policy:
1.
Vaccination and Inoculation: MMR/BCG/Polio/Anti Typhoid and any other vaccination
2.
Circumcision: This excludes Phimosis or any Circumcision due to Medical reasons
3.
Change Of Life: Any treatment for Menopause/General debility
4.
Beauty Treatment:

Plastic Surgery unless necessitated by an accident

Hair Loss/Alopecia and its treatment

Weight Loss/ Height Gain treatment

Acne/ Pimples Treatment

Congenital birth defects like Cleft Lips

Nervous Breakdown/ Instability /Self Injury
5.
Run Down/ General Weakness/ Convalescence: Anemia and supplementary tonics for the abovementioned Beauty treatments are not payable. If the above condition exists due to an illness, it is
payable.
6.
Active Line of Treatment: Treatment that is directed immediately to the cure of the disease or injury is
called ‘Active Line of Treatment’. If admission to a hospital is mainly for diagnosis of an ailment which
can be carried out as outpatient or for a routine evaluation of the patient and the treatment involves
few oral medications only, it will not be covered under Hospitalisation benefits.
7.
Expenses incurred at Hospital or Nursing Home primarily for evaluation / diagnostic purposes which is
not followed by ’Active line of treatment’ for the ailment during the hospitalised period
8.
Congenital Illness: Illnesses that a patient was born with
9.
Alcohol/ Drug Abuse: Cirrhosis due to Alcohol abuse/ Addiction /De Toxification is not payable. Also,
any illness or death caused due to Alcohol or drug abuse is not payable.
10. AIDS/HIV: AIDS/HIV or any of its derivatives are not payable. Sexually Transmitted Decease (STD)
illnesses like Syphilis/Veneral Decease are not payable.
11. Spectacles/Eye Glass/Frame/Contact Lens
12. Insanity/ anxiety / Mental Illness or its treatment
13. Health routine check-up examination / Master Check-up
14. General Check Up / General Diagnostic Check Up /Pregnancy Check Up
15. Robotic Surgery, Cyberknife surgeries are not allowed unless justified
16. Diagnostics are not payable if not necessitated by an illness/death.
Diagnostic reports in all cases is mandatory.
Submission of a copy of
17. Dental Expenses for Scaling, polishing, tooth implants and bleaching of teeth are not covered
3