Claims Assessment & Repudiation. (i) At Our discretion, We may investigate claims to determine the validity of a claim. This investigation will be conducted within 15 days of the date of assigning the claim for investigation and not later than 6 months from the date of receipt of claim intimation. All costs of investigation will be borne by Us and all investigations will be carried out by those individuals/entities that are authorised by Us in writing. If there are any deficiencies in the necessary claim documents which are not met or are partially met. We will send a maximum of 3 (three) reminders following which We will send a rejection letter or make a part-payment if we have not received the deficiency documents after 45 days from the date of the initial request for such documents.
(ii) We may decide to deduct the amount of claim for which deficiency is intimated to the Insured Person and settle the claim if We observe that such a claim is otherwise valid under the Policy. However documents/ details received beyond such period shall be considered if there are valid reasons for any delay.
(iii) We shall settle or repudiate a claim within 30 days of the receipt of the last necessary information and documentation set out above. In case of any suspected fraud, the last “necessary” document swill include the receipt of the investigation report from Our investigator/representatives.
(iv) Payment for reimbursement claims will be made to the Insured Person. In the unfortunate event of the Insured Person’s death, We will pay the nominee named in the Policy Schedule or Certificate of Insurance, or to the Insured Person’s legal heirs or legal representatives holding a valid succession certificate.
(v) In case of delay in payment, We shall be liable to pay interest at a rate which is 2% above the bank rate prevalent at the beginning of the financial year in which the claim is reviewed by Us. For details on the claims process or assistance during the process, the claimant may contact Us at Our call centre on the toll free number specified in the Policy Schedule or Certificate of Insurance or through Our website. In addition, We will keep the claimant informed of the claim status and explain requirement of documents. Such means of communication shall include but not be limited to mediums such as letters, email, SMS messages, and information on Our Website.
Claims Assessment & Repudiation a. At the Company discretion, the Company may investigate claims to determine the validity of a claim. All costs of investigation will be borne by the Company and all investigations will be carried out by those individuals/entities that are authorized by the Company in writing.
b. The Company shall settle or repudiate a claim within 30 days of the receipt of the last necessary information and documentation set out above. In case of any suspected fraud, the last “necessary” document shall include the receipt of the investigation report from the Company investigator/representatives. In case of delay in payment, the Company shall be liable to pay interest at a rate which is 2% above the bank rate prevalent at the beginning of the financial year in which the claim is reviewed by the Company.
c. Payment for Reimbursement claims will be made to the Insured Person. In the unfortunate event of Insured Person’s death, the Company will pay the Nominee named in the Certificate of Insurance or his legal heirs or legal representatives holding a valid succession certificate.
d. All admissible claims under this Policy shall be assessed by the Company in the following progressive order:-
i. If a room has been opted in a Hospital for which the room category is higher than the eligible limit as applicable for that Insured Person as specified in the Policy Schedule/ Certificate of Insurance, then the Associated Medical Expenses payable shall be pro-rated as per the applicable limits in accordance with Section 2.1c.
ii. Co-payment (if applicable) shall be applicable on the amount payable by the Company as specified in the Policy Schedule/ Certificate of Insurance The claim amount assessed in Section 6.4 d above would be deducted from the amount mentioned against each benefit and Sum Insured as specified in the Policy Schedule/ Certificate of Insurance.
