Insurance

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Contents
Policy Coverage
1
Guidelines Donts
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Policy Terms Conditions
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General Exclusions
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Cashless Process
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Day care Procedures
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Reimbursement Process
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Important Information
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Document Check List
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E-Cards and Claim Intimation
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Guidelines Dos
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Escalation Matrix
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Policy Coverage
The Policy provides financial assistance to you
and your family against the Hospitalization
Expenses towards disease/illness/injury in India
along with host of value additions/options.
The claim will be approved on fulfillment of the
following

• Claims Arising during the policy period
• Treatment taken in a registered HOSPITAL or
  NURSING HOME
• The admission is medically justified
• The amount claimed for the treatment is
  reasonable and customary (which means that the
  treatment amount claimed is as per usual charges
  of the hospitals in a particular place, or set
  of circumstances)
• Duration of hospitalization and justified
  treatment is more than 24 Hrs. (Except for a
  few listed Day Care procedures wherein 24 hr.
  hospitalization is not required)

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Policy Terms Conditions
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Cashless Process
IN CASE OF PLANNED HOSPITALISATION
IN CASE OF EMERGENCY HOSPITALISATION
Intimate TPA prior to Admission and provide
Pre-authorization request form through Hospital
Approach nearest network hospital and submit ID
card and send pre-auth request form within 24
hours of admission
TPA extends cashless if all information provided
else raises relevant document / medical query and
on receipt of relevant query reply extends
cashless subject to TC of policy, after the
receipt of the requisite papers.
Cashless extended in two portions - Initial
Approval at the time of discharge sent in the
range of 50-70 of requested amount. Balance at
the time of discharge
At the time of Discharge from the hospital
Insured/attendant to the patient signs the
Discharge Summary Final Bill and also pays for
the non payable items as per the policy and
leaves the all the originals at the hospital.
TPA shall approve the final discharge/Bill after
the receipt of the final bill and discharge
summary from the hospital.
The hospital may ask for a security deposit at
the time of admission that would be adjusted at
the time of discharge after deducting for the
non-payable items
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Reimbursement Process
Claim intimation to TPA within 24hours of
admission and claim submission within 30 days of
discharge
Claim verified by TPA Doctor within 7 working
days after the receipt of the claim documents.
Query sent to the insured and after the receipt
of the query reply again sent for Doctor
processing
Financial settlement of the Claim within 10
working days after doctors processing
Query
AUDIT Verification
If the query reply is not submitted even after 3
reminders (every reminder sent after 15 days) the
claim shall be closed and shall opened only after
it is condoned by the insurer
NEFT Issuance within 20 days after the receipt of
claim
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Documents Check list
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Guidelines Dos
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Guidelines Donts
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General Exclusions
OPD Expenses
Physiotherapy treatment on OPD basis
Dental expenses
Hospitalization under the influence of drugs/alcohol
Congenital External disorder
Infertility/sterility related treatment
Any hospitalization for observation/investigation
Plastic Surgery or any treatment/surgery related to beautification
HIV/AIDS
Self injury/ Suicide/ Poisoning
Expenses on Vitamins and Tonics
Expenses on correction of eyesight, spectacles, Contact lenses, Hearing Aids
Referral fee to the doctor, outstation expenses
Plastic Surgery owing to any accident
Naturopathy Treatment
Only diagnostic services administered in hospital
Registration charge /Personal Comfort charge
Conditions arising owing to obesity
Massage, Steam Bath, Shirodhara charge
 Medical termination of pregnancy will not be paid unless a case of emergency
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Day Care Procedures
Dialysis
Chemotherapy
Radiotherapy
Eye Surgery
Lithotripsy (Kidney Stone Removal)
Tonsillectomy
Dental Surgery Due To Accident
Hysterectomy
Coronary Angioplasty
Surgery Of Gall Bladder, Pancreas Bile Duct
Surgery Of Prostate
Gastro Intestinal Surgery
Genital Surgery
Surgery Of Nose
Surgery Of Throat
Surgery Of Appendix
Surgery Of Urinary System
Arthroscopic Knee Surgery
Laparoscopic Therapeutic Surgeries
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Important Information

• Intimation is compulsory for all claims.
  Intimation should be received within 24 hours of
  hospitalization as instructed by Royal Sundaram
  Alliance Insurance Company)
• Bills and documents to be submitted within 15
  days from Date of Discharge of the hospital.
• Cashless TAT 4 Hours for Emergency
• Cashless request must be intimated within 24
  hours of hospitalization.
• Planned Surgery 48 hours prior intimation
  Mandatory.

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E-Cards Download Claim Intimation
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Escalation Matrix
VIPUL MEDCORP TPA PVT LTD VIPUL MEDCORP TPA PVT LTD VIPUL MEDCORP TPA PVT LTD VIPUL MEDCORP TPA PVT LTD VIPUL MEDCORP TPA PVT LTD
Location Name Designation Contact No Email ID
Pan India VIKAS CHAUHAN Sr. Executive 91 9599943810 noidaservice_at_vipulmedcorp.com
Pan India PRANEETA MITTAL Senior Manager 91 9999298887 praneeta_at_vipulmedcorp.com
MAHINDRA INSURANCE BROKERS LTD MAHINDRA INSURANCE BROKERS LTD MAHINDRA INSURANCE BROKERS LTD MAHINDRA INSURANCE BROKERS LTD MAHINDRA INSURANCE BROKERS LTD
Location Name Designation Contact No Email ID
Pan India PRATIK JAISWAL Sr. Executive 91 9971115933 Jaiswal.pratik_at_mahindra.com
Pan India Dr. DIPA Area Head 91 9811588531 Rani.dipa_at_mahindra.com
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