Health Claims: the reason for taking a Health Policy!

We hope you use cashless services at any of our network hospitals or the common network hospitals, details of which are on our website. If you use services at other hospitals, you will need to submit a reimbursement claim. For cashless services at a common network hospital, you can write to support@hizuno.com, call us at 1800 12000, or connect with your TPA as mentioned on your card.

When you’re covered by a health insurance policy and need to be hospitalized, you have to claim to get the money back from the insurance company. The insurer will check the details, and make sure that the treatment you are claiming for is covered by your policy, before approving your claim. We assure you that all claims will be processed within the standard timelines specified below-

Cashless initial approvals: within 1 hour
Final approvals: within 3 hours
Reimbursement claims: within 15 days

Claims are of two types. We make both easy.

Cashless Mediclaim

If you get treated at a hospital that is part of our network, you don’t need to pay out of your pocket at all. If your treatment or procedure is covered by the policy, we pay the hospital directly, taking a big stress off your mind.

Cashless treatment for Planned Hospitalization:Submit a Pre-authorization Request to our TPA 72 hours before you plan to get admitted.

Cashless treatment for Emergency Hospitalization: The hospital will submit the pre-authorization to our TPA within 24 hours of admission.

Cashless Claim Process:

Check the list of network hospitals on our website or TPA webpage and choose one for hospitalization.
Inform us and get pre-approval.
Present your health card/policy at the hospital’s insurance desk, fill out a pre-authorization form, and get admitted.
Our TPA will send an approval letter to the hospital.
Contact our TPA at the time of discharge. Their hospital representative will complete the billing formalities and help you get the final authorization.
Pay the non-medical expenses or any other charges as per policy terms to the hospital.
Get discharged from the hospital.

Cashless at Common Network Hospital:

For cashless services at a common network hospita l, write to support@hizuno.com, call us at 1800 12000, or connect with your TPA as mentioned on your card.
We will contact the hospital and request cashless approval.
Once the hospital agrees, fill out the pre-authorization form and get admitted.
Our TPA will send an approval letter to the hospital.
Contact our TPA at the time of discharge. Their hospital representative will complete the billing formalities and help you get the final authorization.
Pay the non-medical expenses or any other charges as per policy terms to the hospital.
Get discharged from the hospital.

Reimbursement Claim

Here, you pay the hospital directly, and then claim the amount you spent from us. You’ll have to collect all the bills and documents, submit your claim and let us work on it. If your claim is approved, we’ll reimburse the amount that your claim is eligible for. (Yes, even we think Cashless is much easier!)

Reimbursement Claim Process:

Inform us or our TPA within 24 hours of hospitalization that you intend to raise a claim.
Complete your treatment, pay the medical bills, and get discharged from the hospital.
Begin the claim filing process by obtaining/downloading the claim form from our website and fill out all the requested details.
Gather all treatment-specific documents – diagnosis reports, original hospital bills, discharge card, etc., and submit them to the TPA or our office with the duly-filled claim form.
We will verify your claim, request additional documentation if needed, and reimburse your medical expenses within 30 days.

Alternatively, you may call us to inform us about your reimbursement claim. We will arrange to collect the documents from the hospital, subject to your authentication and the readiness of the respective hospital

What are the documents needed to claim reimbursement?

We’ve kept the documents to a minimum!

Original filled-out Claim Form

A covering letter with your complete address, contact numbers and email address (if available), along with the Schedule of Expenses

Copy of the TPA ID card or your current policy copy, and previous years' policy copies (if you have these)

Original Discharge Card/Summary

Original of the hospital’s final bill

Original numbered receipts for payments you made to the hospital

Complete break-up of the hospital bill

All bills for tests done, with their reports

All bills for medicines, with their prescriptions

A cancelled cheque of the account where you want us to transfer your payment

FAQs:

What is a TPA?

‘TPA’ means a Third Party Administrator who is licensed by the IRDAI, and serves you on our behalf, especially during a claim.

What is a Network Hospital?

A hospital which has an agreement with a TPA to provide Cashless treatment is called a 'Network Hospital'. Cashless treatment is given only at network hospitals.

What are the different ways to claim your hospitalization expenses?

You can claim either on a Cashless or Reimbursement basis.
Cashless: Get treated at one of our network hospitals without paying anything from your pocket.
Reimbursement: Here, you pay the hospital bills, and once you get discharged, claim from us for reimbursement of expenses.

What are ‘Non Admissible/Non Payable Expenses’?

Your health insurance policy pays for reasonable and necessary medical expenses, and many items do not qualify as necessary. These items will not be paid for by your insurer.

If I take a health insurance policy in Mumbai, can I make a claim after being transferred to Delhi?

Yes, your health insurance policy is valid all over the country. (However, some policies have zone-wise limitations. Make sure you check!)

Are all diagnostic tests prescribed by a doctor at a hospital reimbursed?

Expenses such as X-rays, blood analysis, ECG, etc. will be reimbursed if they are related to the condition for which the hospitalization was needed.

If I do not get admitted in a network hospital, am I still eligible to claim the expenses?

Yes, of course! Claims will be reimbursed even if you don’t get treated in a network hospital.

Is there a minimum time for which I have to be in hospital, in order to make a claim?

Typically, you have to be admitted for more than 24 hours. But there are exceptions. For certain treatments, such as dialysis, chemotherapy, eye surgery etc., you can stay for less than 24 hours, and this is treated as day care. Check your policy document for the complete list of day care procedures.

What is Co-pay?

Co-pay is the percentage of the claim amount that a policyholder has to pay from their own pocket, as per the policy terms and conditions.

When can a claim be rejected?

Claims are checked against the Policy Terms, Conditions & Exclusions. A claim can be rejected if it falls under the exclusions mentioned in the policy, or if the policy conditions have not been met, or there is an issue in the documents you submit.

What is a Deficiency Letter?

This is a letter we send if we need more documents for your claim, or if you haven’t submitted all the ones we asked for. These documents should be sent within 7 days from the time you get the Deficiency Letter.

What does ‘incremental/proportionate charge’ mean?

Quite simply, if there is a sub-limit on room rent, and you get admitted into a room with a higher tariff, the proportional deduction on ‘associated medical expenses’ is the extra charge which you have to pay.