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Insurance - Frequently Asked Questions
Can the Applicant get claim on the pre-hospitalization treatment?
Many a times it has been observed that the patient undergoes various tests (blood, urine, X-ray, etc.) as advised by the local doctor for diagnosis of the disease. After examination and if it is beyond his scope he advises him to get admitted to the local hospital. At the Hospital, the patient has to once again undergo all the tests. The patient can claim the expenses incurred during hospitalization and also pre-hospitalization subject to certificate from the local doctor justifying the advice for tests being done pre-hospitalization.
If the Applicant dies during hospitalization, will his / her family get the benefit of mediclaim?
The Applicant’s nominee can get the benefit of mediclaim, if the patient dies during Hospitalization.
If the Applicant dies during hospitalization, will his / her family get dual benefit of mediclaim and accidental death claim?
If the Applicant is hospitalized due to accident and dies during hospitalization, his / her nominee can get dual benefit of mediclaim as well as accidental death claim.
How can the claimant claim mediclaim, if both, the Applicant and his / her declared nominee dies?
In case of death of the Applicant as well as his / her declared nominee, the claimant should approach the Court for Succession Certificate and submit the same along with the claim case file for settlement of claim. It is also essential to submit NOC (No Objection Certificate) from other members of the family, forfeiting their claim in favor of the person appointed by the Court to accept the claim.
Is the Applicant eligible for all the expenses incurred by him / her for the treatment?
The patient is eligible for all the expenses incurred for the treatment. The claim amount however should not exceed the policy coverage amount.
Can the Applicant get back the papers submitted along with claim case file?
The papers submitted by the Applicant along with claim case file are not returned to him / her, even incase of acceptance or rejection. Hence it is advisable that the Applicant keeps a copy of the papers, before submitting the original papers.
How many times in a calendar year can the Applicant submit his claim?
In a calendar year, the Applicant can submit the claim, equivalent to the policy coverage amount.
Can the Applicant submit the claim even after the termination of his membership?
Any claim submitted by the Applicant after the termination of the membership will lead to non settlement of claim.
While handing over the accidental death claim cheque to the nominee why does the nominee have to provide his identity proof?
It is essential to confirm the relation between the dead Applicant and the nominee to avoid mishandling of the claim cheque; hence nominee’s identity proof is required to be provided at the time of collecting the cheque. The nominee must get along with him / her original ration card, election card, bank passbook along with Xerox copy of the same.
Why are the mediclaim and accidental death claim cheques handed over only to the Applicant / nominee and the nominee respectively?
If the claim cheque is lost, it takes 7 to 8 months to issue a duplicate cheque. Hence the claim cheques are handed over to the Applicant and / or nominee only to avoid any delay.
Why should the claimant submit all original documents in the claim case file?
The original papers are required to be submitted in the claim case file, so as to avoid any misuse of the papers with regards to duplicate claim submission, etc. Only PANCARD membership certificate can be submitted in Xerox.
Is it mandatory to submit the Annexure form with the doctor’s signature from the hospital where the Applicant has undergone treatment?
It is very essential to submit the duly filled in Annexure form, signed and stamped by the doctor as a proof of treatment undertaken by the Applicant. This provides the registration number of the doctor and confirms that the hospital too is registered.
Why should the mediclaim form be filled in completely?
In order to make available all details of illness, treatment taken at the hospital and the expenses incurred, the Insurance company insists on completely filled in mediclaim form by the Applicant.
What are Indoor Case papers?
"When any patient gets admitted in the hospital, doctors give instructions for treating the patient. Various tests are conducted; different types of medicines are administered to the patient. From time to time, all this is recorded on paper till the patient is discharged. These papers are called as Indoor Case papers."
Why is it necessary to submit doctor’s prescription along with doctor’s name and patient’s name on the medicine bills?
When the patient is admitted to the hospital, treating doctor prescribes medicines required for the patient’s treatment. These medicines are bought from the chemist. In some cases, the claimants try to attach bills having no relevance with the illness for which the patient is getting treated or attach fraud bills with the intension of getting more money from the Insurance Company. Hence submission of doctor’s prescription along with doctor’s name and patient’s name on the medical bill is mandatory for smooth claim settlement.
Why is it necessary to submit discharge card along with claim case file?
The discharge card is the most important document in the claim case file. It gives details of the proof patients date of admission and date of discharge from the hospital.
What is final bill?
At the time of getting discharge from the hospital, the patient is provided with the final bill for the expenses incurred during hospitalization. This bill should be submitted in original having hospital rubber stamp and revenue stamp affixed. Any advances paid at the time of hospitalization, same should be mentioned in the final bill and receipt against the advance payment also should be submitted along with claim case file.
What are the additional documents required incase of hospitalization due to accident?
Apart from the other basic documents for claim settlement, Police FIR and Medico-Legal Certificate is extremely essential incase of hospitalization due to accident.
Which documents are required if the patient is transferred from one hospital to another during the course of the treatment?
Transfer Certificate is required if the patient is transferred from one hospital to another during the course of the treatment.
Within how many days does the Applicant need to submit the mediclaim case file?
The Applicant must submit the mediclaim case file within 30 days from the date of discharge at any of the PANCARD offices.
Who can sanction the claims?
The onus of acceptance or rejection of the claim lies with the management of the Insurance Company.
Can the bills be submitted subsequently after submitting the claim case file?
The Applicant must ensure that all the bills related to the claim are submitted along with the claim case file. Incomplete papers shall not be entertained.
Can the Applicant submit all documents in claim case file in any language apart from English?
All documents in claim case file must be in English only, except for the State of Maharashtra. If the documents are in any other language like Bengali, Gujarati, Hindi, etc, then the Applicant must submit the translations of these documents along with the original papers.
If the mediclaim and / or death claim cheque is not collected or not deposited in the bank by the Applicant or nominee, can he / she get another cheque against the earlier cheque, even if it is stale?
The Applicant and nominee can request to revalidate the cheque by submitting an application giving justification as to why the cheque was not collected or deposited in the bank for encashing it.
Is the Applicant informed about rejection of claim? If yes, how?
The Applicant is informed about the rejection of claim through a letter mentioning the reason for rejection as well.
What does, "In Process", "Under Investigation" and "LC" mean?
"In Process" means all papers submitted for the claim are correct and are being checked by the Insurance Company’s Doctor. "Under Investigation" means that the Insurance Company’s Doctor has some doubts and he has sent the papers to their Investigation Department before concluding the claim settlement. If the Applicant has submitted any papers after requirement given by the Insurance Company, this status of claim case file is called "LC", i.e. "Liability Claim".
How many claim case files are received on monthly basis?
On an average 600 claim case files are received in a month. Out of which 97% to 98% claims are settled. Balance 3% to 2% are rejected due to incomplete and incorrect (bogus) papers. The total claim amount generally ranges between 2 to 3 crores.
Why can’t the Applicant submit his/ her claim case file at other branch offices of the Insurance Company at various cities?
PANCARD Clubs Limited has tied-up with the Insurance Company at one of their branches. Hence all claim case files are submitted at this branch only.
Does any claim file get re-opened after it is rejected (bogus)?
No, the Insurance Company does not re-open the rejected (bogus) claim case file once it is closed.
Can the Applicant directly enquire with the Insurance Company regarding the claim status?
No, the Applicant cannot directly enquire regarding claim status with the Insurance Company.
Why is it so that, sometimes the claim is settled against Life Insurance but are rejected against Accidental Death Claim?
While sanctioning the Life Insurance claims, the Insurance Company validates the death of the Applicant. Whereas in accidental death claim, the reason for death is also checked by the Insurance Company. If the Applicant has not died due to accident, then the claim against accidental death claim is not settled.
From when does the Insurance coverage start for the Applicant?
The Insurance coverage starts from the Insurance commencement date as mentioned on the Membership certificate issued to the Applicant. The same is within 90 days from the date of membership date, only once he / she is registered with the Insurance Company.
Can the Applicant claim immediately upon obtaining Room Nights?
No, the Applicant cannot claim immediately upon obtaining Room Nights. The Applicant is eligible for any claims only after he / she is registered with the Insurance Company.
Can the claimant submit copy if the original case papers incase of murder is not made available by the Police?
Incase of murder, if the original papers are not made available by the Police, then Xerox papers attested by the Police can be submitted along with the claim case file.
Is it mandatory to submit postmortem report along with the claim case file?
Yes, it is mandatory to submit postmortem report along with the claim case file. However, in remote areas where this facility is not available, a certificate stating that last rites have been done without postmortem is a must. This can be issued by Police Patil / Sarpanch / Government Hospital / nearest Police Station. In absence of such a certificate, claims shall be rejected.
Does the claimant get any acknowledgement against the submission of claim case file?
An acknowledgement slip bearing the claim serial number is issued to the claimant on submission of claim case file.
Can the Applicant submit partial claim documents?
Partial claim documents are not accepted by the Insurance Company, hence the Applicant is not allowed to submit incomplete claim case file.
If the parent / guardian has signed on the Holiday Option form on behalf of the minor Applicant at the time of obtaining Room Nights and if the Applicant (now a major) submits the claim, who has to sign on the claim form?
The claim form must be signed by the Applicant (now a major) and the same needs to be attested by the parent / guardian The son/daughter will sign and the same has to be attested by the parent confirming that his son/daughter have become major. The Applicant (now a major) must get his / her signature attested by the bank so as to enable the Company to issue the claim settlement cheque in his / her favor.
If the Applicant is a minor and dies when he / she become a major, does the death claim benefit increase?
The claimant can get the death claim amount as per the Insurance eligibility mentioned on the Membership certificate issued to the Applicant. The claim benefits do not increase if the Applicant dies upon becoming a major.
Can any other person collect the claim cheque if a disabled or old parent (claimant) of the deceased is unable to visit PANCARD office?
If a disabled or old parent (claimant) is unable to visit PANCARD office, he / she can authorize close relative to collect the claim cheque on his / hr behalf through an authorization letter. The Company cannot be held responsible for any loss of cheque in such a case.
Is the Applicant eligible to claim the Insurance benefits immediately after the Insurance commencement date?
The Applicant is eligible to the claim the Insurance benefits only after 90 days from the Insurance commencement date and not from the Policy commencement date.
Can the Applicant submit the claim for undergoing treatment at any hospital?
Yes, the Applicant can submit the claim for undergoing treatment at any doctor or hospital. However, if the number of beds in the hospital is below 10 the claim is rejected. No claims are entertained if the treatment is taken from an Ayurvedic or Unani doctor. Also if the Applicant has undergone treatment at any of the Hospitals listed in Annexure "A", claim is rejected.
Can the claimant avail the benefit of claim incase of death / hospitalization due to any reason?
No, the claimant cannot avail death claim / mediclaim benefit if the death / hospitalization is due to any reason. Death claim benefit cannot be availed if the Applicant has committed suicide (suicide due to depression, jumping in the well, setting self on fire, jumping before a moving train, poisoning, etc). Mediclaim cannot be availed if the Applicant has fallen while performing Dahihandi, travelling triple seat on motor cycle, driving in drunken state, street fighting under the influence of alcohol, driving without a valid license, traveling under the influence of alcohol, etc.