Reliance General Insurance Reliance HealthWise Policy - Step-by-Step Guide for Claims

To provide prompt claims servicing to you we have appointed Third Party Administrator (TPA) duly licensed by IRDA. We also directly serve our customers through Reliance Health Claims Management Team ( HCMT) in certain areas. Contact numbers are available on the HealthWise Card/Policy Schedule.

We will be glad to provide you with services in a hassle free manner within the terms and conditions of your policy. We will provide you the following claims services:

• "Cashless Facility" at all our Network Hospitals.
• Processing and settlement of claims under the Policy with a time bound approach.
• 24 hours Customer Helpline Service.

Claim Procedure:

Claims are broadly of two types: a. Reimbursement Claims b. Cashless Claims

General Claim Procedure

As soon as there is a need for hospitalisation, please intimate the HCMT/TPA on 24x7 Customer Helpline number as mentioned in your Health Card/Policy Schedule.

You are required to furnish the following information while intimating a claim:

• Contact Numbers
• Policy Number (as on the Health Card//Policy Schedule)
• Name of Insured person who is hospitalised
• Nature of sickness/accident
• Date & Time in case of accident, commencement date of
symptom of disease in case of sickness
• Location of accident

As Reliance HealthWise Policy holder you have the option of either choosing our network hospital or a hospital outside the network.

The benefit of choosing our network hospital is that you can avail of "Cashless Facility" while you are hospitalised whereas you will have to settle your hospital bills in the hospital which is outside our network.

You have to follow the procedures listed below to get the services in different situations.

Procedures for "Cashless Facility"

"Cashless Facility" is the service wherein you need not pay your hospitalisation bills to the hospital either at the time of admission or at the time of discharge from the hospital. This facility is available only at our Network Hospitals. To avail the "Cashless Facility" you need to fill "Cashless request form" available in all the network hospitals. The hospitals will co-ordinate to get the authorisation from the HCMT/TPA for such "Cashless Facility". This authorisation along with a copy of the card issued by us needs to be given to the Hospital at the time of admission. You are also required to carry a Photo ID Card. Please Note: HCMT/TPA shall authorise "Cashless Facility" at the Network Hospitals in respect of treatments which are covered under the policy.

"Cashless Facility" may be denied by the HCMT/TPA in some of the situations as listed below.

• In case of any doubt on coverage of the present ailment/ treatment under the policy
• If the information sent by you /hospital is insufficient
• The ailment/condition etc. not being covered under the policy
• If the request for preauthorization is not sent in time

Denial of "Cashless Facility" is not denial of treatment. You may continue with the treatment, pay for the services to the hospital, and later submit the claim for processing and reimbursement.

Emergency hospitalisation

Step 1. Take admission into the hospital.

Step 2. As soon as possible, Intimate the claim at the call centre, obtain the pre-authorisation form from hospital and get the same filled in and signed by the attending doctor.

Step 3. Fax the pre-authorisation form to the HCMT/TPA along with necessary medical details like investigation report etc at the number mentioned in your Health Card/Policy Schedule. The hospital will co-ordinate for the same.

Step 4. (Option I)

A. If an authorisation for "Cashless Facility" from HCMT/TPA has been received

• At the time of discharge
  • You will be required to pay for all such expenses that are not payable as per the terms of the policy.
  • Verify the bills and sign on all the bills
  • Leave the original discharge summary and other investigation reports with the hospital. Retain a Xerox copy for your records

Step 4. (Option II)

B. In case "Cashless Facility" has been denied by HCMT/TPA

• At the time of discharge settle the hospital bills in full and collect all the original bill documents and reports
• Lodge your claim with HCMT/TPA for processing and reimbursement

Planned hospitalisation

Step 1. Please co-ordinate with your doctor and the hospital and send all the details about the planned hospitalisation including the plan of treatment, cost estimates etc. to HCMT/TPA.

This may be sent at least 2 days prior to the planned admission.

Step 2. (Option I)

A. If authorisation for "Cashless Facility" from TPA has been received

• At the time of admission, present the authorisation letter and photo ID card to the hospital
• At the time of discharge
  • Pay for those expenses that are not reimbursable under the policy
  • Verify the bills and sign on all the bills.
  • Leave the original discharge summary and other investigations reports with the hospital. Retain a Xerox copy for your records

Step 2. (Option II)

B. In case "Cashless Facility" has been denied by HCMT/TPA

• Get admitted and take treatment
• At the time of discharge settle the hospital bills in full and collect all the original bill documents and reports
• Lodge your claim with HCMT/TPA for processing and reimbursement

"Please note that failure to intimate HCMT/TPA as soon as the hospitalisation takes place can invalidate your claim."

Procedures for Reimbursement Claims Emergency hospitalisation

Step 1. Take admission into the hospital.

Step 2. As soon as possible, intimate the HCMT/TPA about the hospitalisation.

Step 4. Lodge your claim with HCMT/TPA for processing and reimbursement, by filling in the claim form and attaching required documents as mentioned in the claim form.

Planned hospitalisation

Step 1. Intimate HCMT/TPA of the planned hospitalisation.

Step 2. Get admitted into the hospital.

Step 3. At the time of discharge, settle the hospital bills in full and collect all the original bills, documents and reports.

Step 4. Lodge your claim with HCMT/TPA for processing and reimbursement.

How to lodge your claim with HCMT/TPA for processing and reimbursement

Within 7 days after discharge, please lodge your claim for processing. While submittiing your claim, please make sure that all the documents listed under the document check list are attached.

Document Check list for Hospitalisation, Domiciliary Hospitalisation & Critical illness claims

Hospitalisation / Day Care Treatment

• First prescription of doctor with commencement date of the symptom of disease
• Treatment papers along with doctors prescriptions
• Investigation reports (X-ray/Scan/ECG, Laboratory etc)
• Original medical bills and receipt of hospital, doctors, medical shops, diagnostic centre etc supported by Doctor's advice
• Hospital discharge card, in original
• Copy of FIR (if any in case of accident)

Critical Illness Claims

• Claim form duly completed
• Original Specialist Doctor's certificate confirming the diagnosis and when the symptoms first occurred
• Relevant Investigation reports (Radiology, Pathology etc) confirming the diagnosis
• Hospital admission & discharge card / certificate

Domiciliary Hospitalisation

• First prescription of doctor with commencement date of the symptom of disease
• Treatment papers along with doctors prescriptions
• Investigation reports (X-ray/Scan/ECG, Laboratory etc)
• Original medical bills and receipt of doctors, medical shops, diagnostic centre etc supported by Doctor's advice
• Copy of FIR (if any in case of accident)
• Certificate from attending Doctor/Physician stating the condition of the patient is not permissible for him/her to be removed to Hospital/Nursing Home or documentary proof of lack of accommodation in Hospital/Nursing Home

Please note the above list is only indicative. We may call for additional documents/information if required.