National Health Insurance Claim Procedure
National Health Insurance Claim Procedure gives you information about how to claim National Health Insurance Policies. You can know about Intimation of claim to the National Insurance Company/TPA (Third Party Administrator), National Health Insurance Claim Procedure to avail Cashless facility, National Health Insurance Claim Procedure for Reimbursement of claims and Documents required during claim settlement.
Notification of National Health Insurance Claim
The Insured person or Insured person’s representative shall intimate the National Insurance Company, if claim is processed by the company or TPA, if the claim is processed by TPA. Insured should intimate them in writing by E-Mail, Fax, Letter with all accurate and relevent information related to the claim including policy number, nature of treatment etc. within the time limit as prescribed.
| Notification of Claim to avail Cashless facility | Information to TPA |
| Planned hospitalisation | At least 72 hours before the insured person’s admission to network hospital/PPN |
| Emergency hospitalisation | Within 24 hours of the insured person’s admission to network hospital/PPN |
| Notification of Claim for Reimbursement | Information to Company/TPA |
| Planned hospitalisation | At least 72 hours before the insured person’s admission to hospital |
| Emergency hospitalisation | Within 72 hours of the insured person’s admission to hospital |
National Health Insurance Claim Procedure for Cashless Claims
- Cashless facility in network hospitals shall be available if you have chosen ‘claim processing by TPA’.
- Insured person can take treatment in a network provider/PPN, subject to pre-authorization by TPA.
- For list of network hospitals please visit www.nationalinsuranceindia.nic.co.in
- Cashless request form will be available with the network provider/PPN and also with TPA. You should fill this form with complete information and submit to the TPA for pre-authorization.
- Upon getting cashless request form and other related medical information from the insured or network provider TPA shall issue pre-authorization letter to the network hospital after verification.
- At the discharge time, the insured has to sign the discharge papers after verifying.
- Insured has to pay for non-medical and inadmissible costs or expenses to the hospital at the discharge time.
- In case Insured is unable to provide the relevant medical details, TPA reserves the right to deny pre-authorization.
- In case of denial, insured may get the treatment as per treating doctor’s advice and submit the required claim documents to the TPA (Third Party administrator) for reimbursement of claims.
National Health Insurance Claim Procedure for Reimbursement of claims
- For reimbursement of claim, the Insured has to submit the required claim documents to the TPA (Third Party administrator) within the time limit as prescribed.
- Insured can obtain treatment as per treating doctor’s advice. During or before the treatment Company will not pay the expenses incurred in treatment to the insured.
- Insured has to pay the expenses incurred in treatment and he should submit the bills and some other required documents to the TPA/Company to get reimbursement of claims.
Documents Required during National Health Insurance Claim Settlement
- Claim form with complete information.
- Original bills, medical history of the patient, payment receipts, discharge certificate from the hospital etc.
- Original cash-memo from the hospital or chemist supported by the prescription.
- Original payment receipt and investigation test reports supported by proper prescription from attending medical practitioner.
- Attending medical practitioner’s certificate regarding bill receipts and diagnosis etc.
- Surgeon’s certificate stating nature or plan of operation performed and diagnosis along with bills etc.
- Any other documents required by National Insurance company/TPA (Third Party Administrator).
National Health Insurance Claim Settlement
- If your offer of settlement is accepted by the company, the payment shall be made within 7 days from the date of acceptance of your offer.
- If, there is a delay in the payment, the National Insurance Company shall pay interest at a rate which is 2 percent above the bank rate.
- If your claim is rejected by the company for any cases, company shall communicate to you in writing & within a period of 30 days from the final document receipt.
Services Offered by TPA:
TPA (Third Party Administrator) handles, claim admission and recommend the National Insurance company for the payment of the claim settlement.
Payment of claim:
All medical treatments for the purpose of National Health insurance will have to be taken in India only. All claims under the National Health policy shall be payable in Indian currency i.e in Rupees only.
National Health Insurance Claim Forms
National Insurance Mediclaim Claim Form