Royal Sundaram Advanced Top-Up Health Insurance Plan

Cashless Claim:

The following are the steps to be followed for the cashless claim.

• The insured party must contact the TPA helpline within 72 hours of admission for scheduled hospitalisation and 48 hours of access for emergency hospitalisation and provide the membership number, policy number, and patient’s name.

• The insured must also submit the required form, which is accessible at the insurance help desk at the hospital, along with information on the hospitalisation, including diagnosis, name of the hospital, length of stay, expected hospitalisation costs, etc., to the TPA via email or through the TPA’s web site.

• The insured must also give the TPA’s medical panel any further information or medical records that they may want.

• Following the determination of the claim’s eligibility under the policy, the TPA must give the hospital a pre-authorization guaranteeing payment of the hospitalisation costs, subject to the insured sum, terms, conditions, and policy limitations. The insured is responsible for paying any difference between the pre-authorization amount that was granted and the final hospital bill as a result of deductions such as non-payable items, excluded items, policy sub-limits, co-pay amounts, deductible amounts, etc.

Reimbursement Claim:

• Notice of claim

In the event of planned hospitalisation, the insurer should be notified at least 72 hours before admission; in the event of emergency hospitalisation, the insurer should be notified no later than 48 hours before discharge. The preliminary information of the claim should include details relating to the policy number, name of the insured person in respect of whom the claim is made, nature of illness or injury, and name and address of the attending hospital.

• Submission of Claim

Not later than 30 days following discharge, the insured must submit the claim form, the attending physician’s certificate, and the remaining claim documentation.

Documents Required:

Listed below are the documents required to file a claim for the policy.

• The hospital will provide a complete discharge statement that includes information about the complaints’ type, length, treatments, recommendations for discharge, etc.

• Letter of original settlement from the main insurer.

• If the covered individual passes away at a hospital, a death summary will be provided. Initial consultation documents.

• prescriptions from doctors recommending or confirming admission.

• All test reports such as X-rays, ECG, Scan, MRI, Pathology, etc., including doctor’s prescription advising such tests/investigations (CDs of the angiogram, surgery, etc., need not be sent unless specifically sought).

• Original hospital final bills, and receipts for initial and final payments.

• Prescriptions from doctors accompanied by cash payments for drugs acquired outside of the hospital.

• F.I.R / MLC. In the case of accidental injury and English translation of the same, if in vernacular language.

• In the event of claims deriving from injuries (in the absence of an FIR), a detailed self-description indicating the date, time, circumstances, and nature of the accident is required.

• Certificate of legal heirship in the absence of a nomination under the policy in the event of the proposer’s death. Evidence proving legal heirship may be offered in the absence of a legal heir certificate.

• For b) Cataract claims – IOL sticker c) PTCA claims – Stent sticker. d) Implant sticker for surgeries involving implants.

• A confirmation from the other insurer confirming the final claim amount decided by them and that original claim documents are kept at their end is required if any other insurer only partially resolves a claim.

• Comprehensive medical records of any prior hospitalisations or treatments.

• A certificate from the attending physician stating that the patient’s condition is such that they do not need to be transported to a hospital or that there are no beds available in the hospital close to the insured’s place of residence is required for claims involving domiciliary hospitalisation.

• A cancelled check leaf bearing the proposer’s name, the IFSC number, and the account holder’s name.

• CKYC number of the proposer. Assuming the insured does not already have a CKYC number, the proposer must properly complete the CKYC format and provide photo identification and address verification following the AML criteria set forth by the Government of India.