Claims Procedure of IFFCO Tokio Individual Health Protector Policy

You must follow the right course of action that needs to be followed to make you should keep in mind the dos and don’ts of Mediclaim. Here, we have discussed in detail the complete guidelines that policyholders should know, to have a clear idea. It covers cashless Mediclaim as well as post-hospitalization reimbursement claim procedures.

General Guidelines

The following are the guidelines that are common to all the categories irrespective of the time of the claim settlement. These points need to be followed to word to avoid rejection of claim afterward: -

  • Excluded/Blacklisted Hospitals and Doctors: - We do not take any responsibility of claims if the medical procedure on the insured, is performed in any blacklisted/excluded hospital or doctor. We constantly keep the list of such doctors and hospitals updated so that our clients can check it before getting admission. You can also contact our customer care executives for the same information. Neither cashless nor reimbursement will be done in such cases.

  • Timely Information: - It is requested that clients intimate us about the proposed hospitalization and the nature of treatment at least 48 hours before the scheduled time. In case of emergencies, the same should be done within 24 hours of admission. This is to help us serve you better and let you have a hassle-free treatment at the hospital while we take care of the cashless facilities or reimbursement.

Check your Documents: - Keep all your necessary documents organized in a separate folder so that you do not forget at the last minute and need to go back to it again. The documents you will need are Membership ID card; a government-approved ID (AADHAR or Voter’s ID or driver’s license) and a copy of the Mediclaim policy. Keep the original documents of the first two documents as well as a photocopy, as the hospital might want them to keep a record.

In case you do not have or have not received your Member ID cards yet, kindly choose any of the following procedures for the same: -

  • You can make a call to our customer care number and mention your policy number ID along with your details. Your card will be mailed to your registered address as soon as possible.

  • If it is an emergency scenario, you can get a print out of your E-card from our customer portal. All you need to do is log in with your credentials to the portal.

  • Always submit complete documents: - Keep your contact details updated on your Mediclaim account and in case of any change, intimate us as soon as possible. Also, keep all your medical records regarding hospitalization compiled together so that when you submit them for claims, there is no discrepancy or lack of sufficient proof.

  • Choose the Hospital Judiciously: - To file a claim under your Mediclaim Policy including Mediclaim for senior citizens, you have to get admitted into a hospital which is on our list of network hospitals. If you have any questions regarding this or want to know which hospitals nearby, falls under that category, simply give our customer care department a call. Also, as general advice, choose the venue of medical treatment carefully. Just because a hospital is very expensive and looks state-of-the-art, does not mean it offers quality healthcare.

  • Negotiate Hard: - To grab the most reasonable health package fora specific treatment under your cheapest Mediclaim policy including Mediclaim for senior citizens, negotiate hard with the hospital authority. Leave no stone unturned to manage the best possible deal. Even though you will be covered by cashless facility or reimbursement, a less expensive bill will save valuable sum insured which you can utilize at a later period under your Mediclaim policy including Mediclaim for senior citizens.

  • Choose the Room Carefully: - Even the best Mediclaim policy has a certain upper limit to the hospital room rent. If the room you settle for crosses that limit, the extra amount of money will have to be borne by you. An upgrade in the room of choice means the charges of nursing, doctor fees, and all other services will also go up at the same time. In case you are unaware of the room rent ceiling, you can always call up our customer care executives to be sure.

  • Do not try to be a doctor yourself: - Thanks to the internet, we have the world’s information at our fingertips, and that often makes us think we have detailed knowledge about every discipline – we do not. It is best to leave things like health and medicine to the professionals, who have the qualifications and experience to offer the right treatment. Making things worse with your trialing might turn against you, make your health deteriorate and cost more money.

  • Common Ailments not covered: - When you buy the Mediclaim policy, learn about all the diseases and disorders that the policy will cover, or will not cover. There are certain common ailments the treatments for which are not covered by our policies. It is best that you, as our client be aware of that beforehand, to avoid any displeasure afterward. Refer to our website or contact the customer service helpline for detailed information.

Here are some specific guidelines to make the procedure of claim settlement smooth for you, in both cashless claim facility as well as reimbursement policy.

Cashless Claims

At IFFCO-Tokio, we try our best to serve our clients and help them with cashless hospitalization at all times. But there certainly are certain situations in which your cashless claim can get rejected or delayed. Here are some of them: -

  • Delay in the Intimation of hospitalization or claim submission from your side.

  • Lack of insurance details for the previous years.

  • Inadequate details about the medical condition.

  • Hospital or doctor is not on our list or is blacklisted/unauthorized.

  • Cases where admission is only for observation and no actual treatment.

  • The medical condition is excluded from our policy.

  • When the hospitalization is for less than 24 hours other than mentioned day care procedures.

  • If our records do not match with the documents and details, you have submitted.

  • If you misrepresent or do not disclose some significant piece of information regarding the treatment.

There can be many other reasons as to why your cashless claim might get delayed or denied. We, at IFFCO-Tokio, give authenticity the topmost priority.

If your cashless claim has got delayed, we can still help you by reimbursing the amount if your claim is legitimate. The only drawback is that you have to settle the hospital bills out of your pocket. But once you have submitted all the necessary documents and fulfilled the conditions, and our officials at IFFCO-Tokio find your claim to be valid, you will be reimbursed fully up to the permissible amount as per the terms of your policy.

  • We only settle cashless claims for treatments carried out in hospitals which are on our list, at the time of admission. We repeatedly advise our clients to keep themselves updated about the eligible hospitals where they can get cashless medical treatment. If this is not taken care of, right at the admission, you might lose your claim later on, because we do not entertain bills from any hospital other than those mentioned.

  • If there is any delay in settlement of your cashless hospital treatment, get in touch with our customer care team and make sure that no documents are still pending for the completion of the application process. If there is, submit the necessary papers immediately to begin the process.

  • It might take up to 4 hours to get an application for cashless Mediclaim approved. It is preferred that clients intimate us about the date and time of discharge beforehand, right after consulting with the doctor or hospital authorities. This is to help you get a seamless discharge procedure and hassle-free settlement of bills.

  • Even if you are not paying the bill out of your pocket, or maybe only a portion of it that exceeds the limit of the sum insured, always check the bill thoroughly during discharge. Clarify with the hospital staff if you find any discrepancies. Saving sum insured means keeping them for a future emergency.

  • Collect the copies of the invoice, payment receipt, discharge papers and everything else and keep them secured in your medical file at home.

Reimbursement Claims

As mentioned before, you can claim for reimbursement if for some reason your cashless Mediclaim was not settled. If your claim is valid and all the documents are in order and conditions fulfilled, then we will reimburse your hospital bill, up to the right amount. Here are the guidelines you need to follow, to apply for reimbursement: -

  • File your reimbursement claim within 30 days of completion of a procedure or 90 days of discharge from the hospital.

  • While your discharge summary is being processed by the hospital authorities, make sure that you have all the necessary documents that will be needed while filing for the claim such as Discharge Summary, Pharmacy Bills, Test reports, Prescriptions, Bills, etc. in the original. Please make sure that the discharge summary and Invoice are as per guidelines specified by IRDA. You can download the format from our site.

  • During the discharge, make sure you collect all the necessary documents from the hospital because you will need them when filing the reimbursement claim. Pharmacy bills, test reports, doctor’s prescriptions, discharge summary, hospital bills – all these should be available with you in the original. Also, the discharge summary and invoices should be as per the IRDA specified guidelines, which you can download from our website.

  • Make sure that there are no discrepancies in the doctor’s prescriptions and the diagnostic bills, pharmacy bills or lab reports. If there are any, it might become difficult for you to claim reimbursement.

  • Download the sample claim filing form from our website and get the same filled by the hospital authorities.

  • Following are the documents that you should have for smooth claim settlement: -

  • If we need more information or need to clarify something, our executives will reach you via telephone or mail or both. You will be expected to revert within 15 days along with the necessary supporting documents.

  • Your policy ID and phone number should be constant in every communication you make. That is our main system of client identification. In case you have changed your phone number or email address, convey the same to us as early as possible.