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HDFC ERGO Health Insurance Claim

Today, claim ratio and procedure are perhaps the most important aspects a person has to scan through while finalizing a health insurance policy. With 20+ health insurance providers in the market, a few are able to satisfy the potential policyholders and their customers with their hassle-free health claim settlement process. HDFC ERGO is one of them. One of the most significant benefits of HDFC ERGO is that the company offers a very quick, resilient, and hassle-free health claim service, which can also be attested by its incurred claim ratio (79.3%). To dig deeper into the company’s claim procedure, check out the article given below.

Types of Health Insurance Claims Offered By HDFC ERGO

The claim settlement process of HDFC ERGO company is divided into two categories:

  • Cashless claim process, and 
  • Reimbursement claim process

The policyholders of HDFC ERGO health insurance plans can settle their claim using either of these methods, as per their requirements. Given below is a detailed, step-by-step explanation of both these procedures. Let’s take a look.

Cashless Claim Procedure

As the name suggests, the cashless claims process allows customers to avail the medical service at any network hospital without paying for the expenses from their pocket. The insurance company would directly interact with the hospital and take care of the expense. However, to claim this insurance, customers need to fulfill the below two prerequisites:

  • The plan opted by the customer must cover the ailment that policyholder or their family member is diagnosed with.
  • The hospital that policyholders want to visit should be in the list of network hospitals of your insurer.

If the above two conditions are fulfilled and it is a planned hospitalization, the customer can opt for a cashless claim. Now, let’s discuss the procedure of availing this insurance claim.

  1. Locate your nearest network hospital and get admitted there.
  1. Submit your health card and valid photo ID to avail cashless treatment at the network hospital.
  1. Fill the pre-authorization form. Hospital will send the cashless request to HDFC ERGO.
  1. Submit the other documents, as specified by the company or hospital.
  1. The TPA of the HDFC ERGO will scrutinize all the received documents and convey the final stand on the claim.
  1. The customer will receive an update through SMS/Emails at every stage of the claim on the registered mobile number or email id.
  1. The hospital will send the final bill to HDFC ERGO for authorisation and HDFC ERGO will scrutinize the same and give final authorization in case of approved transactions to the hospital.

Please note that any inadmissible expenses such as copayments, deductions will have to be paid by the policyholder. Such expenses will not be borne by the insurance company.

Reimbursement Claim Process

Reimbursement claims are the complete opposite of cashless claims. This claim facility is designed for customers who fail to opt for the cashless facility or have to be hospitalized in a non-network hospital. With this type of claim, the policyholder can go through the normal hospitalization process and complete the payment. Once they’re discharged, they need to reach out to the insurer at the earliest and submit the claim request along with all the relevant hospital documents. The insurance company will submit the approved amount to the policyholder’s bank account.

Let’s take a look at HDFC ERGO’s reimbursement claim procedure.

  1. Complete the necessary form and submit along with required documents, including the discharge summary, prescriptions, bills, etc as per the policy terms and conditions.
  1. The HDFC ERGO doctors team will review all the documents.
  1. The company will intimate you about any additional information or documents that may be required. This intimation will be done either by SMS & Email.
  1. Upon satisfactory receipt and verification of all the documents, the claim will be settled by HDFC ERGO within 7 days from the time of the last document is received and approved claim payment would be processed. The approved claim amount will be transferred to your bank account through NEFT.
  1. In case the claim is rejected, the reasons will be communicated by the team.

The customer shall receive complete updates about their claim status through SMS / emails at every stage of the claim. They can also track your claim status instantly by visiting the official claim tracking page of the company at- claim status and authentication.

Documents Checklist

There are a variety of documents that are required to be submitted along with the application form while applying for a claim at the HDFC ERGO insurance company. Given below is a general list of all those documents. Let’s take a look at them.

  • Duly filled and signed claim form along with HDFC Ergo policy number
  • Original document of the discharge summary
  • Original final bill with detailed breakup, payment receipt and original pharmacy invoices supported by prescriptions
  • Original investigation reports including blood reports, X-Ray, etc.
  • Implant sticker or invoice, if used (eg. for stent in angioplasty, lens cataract, etc).
  • Past treatment documents, if any.
  • Medico Legal Certificate (MLC) or FIR (in cases of accident)
  • Incase of Proposer expired Nominee details to be provided. Legal heir certificate is required if the nominee is minor.
  • NEFT details for payment – Canceled cheque in the name of the proposer or passbook copy attested by bank
  • All other relevant documents, as requested by the company
  • For all claims amounting to Rs. 1 lakh and above, the KYC (Know your customer) form must be submitted along with the photocopy of any one of the following KYC documents-
    • Passport,
    • Driving License,
    • Voter ID

How To Locate Nearest HDFC ERGO Network Hospital?

From the above discussions, it is clear that if any policyholder wants to avail cashless medical treatment, he/she first needs to locate the nearest network hospitals of their selected insurance company. It is the customer’s responsibility to find a cashless hospital or healthcare center nearby their area and seek admission into that hospital for their future medical treatment. The same rule applies for HDFC ERGO cashless claim process as well. For your convenience, we’ve stated below the detailed process of how you can find the nearest network hospital of HDFC ERGO insurance company.

  1. Visit the official website of HDFC ERGO Insurance and click on the ‘Menu’ tab available at the top left corner of the homepage.
  1. Select the ‘Hospital Network’ option from the options available in the menu bar.
  1. Enter your pin code and choose the state and city name according to your preference.
  1. All the network hospitals or healthcare centers will appear on the screen within your vicinity.

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