Health & Cancer Protection Plus Claims

• Policy Number
• Insured/Claimant contact details (phone no., email id, address etc.)
• Bank details for Primary Insured
• Name of Insured/ claimant, who is hospitalized
• Relationship of Insured with the person who is hospitalized
• Name of the Hospital
• Nature of Ailment
• Commencement date of the symptom of ailment

• Nature of Accident
• Date & Time of Accident
• Location of Accident
• FIR/MLC (Medico Legal Case) Certificate in case of Road Traffic Accident
• Self-Declaration explaining / providing details of circumstances of accident with a copy of Doctor’s certificate in case of other than Road Traffic Accident

In the event that the policyholder is hospitalized /planning a hospitalization in a network hospital / nursing home, he / she need not pay the medical expenses (as per coverage) up to the sum insured specified under the policy. This is subject to claim intimation to the TPAs appointed by Reliance Nippon Life Insurance Company Limited (RNLIC) and approval of the request as per terms of the policy.

The insured has to approach the TPA desk of the hospital along with the RNLIC Health Card, KYC (a Photo ID card such as Pan Card, Voter ID card, Driving Licence etc.) and all the medical reports including diagnosis report. The hospital will then send the request for authorization of treatment to RNLIC through TPA. TPAs appointed by RNLIC will coordinate with the hospital/nursing home directly for approval and/ or pre-authorization, if required and also for settlement of the bills to the extent of authorization only to the hospital directly by the insurance company after the insured patient is discharged. If the request is denied as per the policy’s terms and conditions, the insured himself/ herself has to pay the bills and submit the claim documents for a reimbursement to the insurance company through the TPA.

1. Planned Hospitalization: Since the hospitalization/treatment is planned (in advance), the policyholder should inform the TPA at least 48 hours prior to hospitalization with necessary documents such as Cashless claim form duly filled and signed by treating Doctor and Hospital, treatment records advising Hospitalization etc. The TPA will then evaluate the case and will “pre-authorize” the claim subject to terms and conditions of the policy.
2. Emergency Hospitalization: In case of a medical emergency, the policyholder should provide the Health card along with KYC docs (Pan Card, Voter ID card and Driving License etc) at the Network Hospital to get admission without paying the initial deposit. The Hospital will then intimate the TPA to formalize the Pre-authorization process, which will then process Cashless treatment subject to the terms and condition of the policy, plan of medical management, and completeness of documentation.

Note: In cashless hospitalization, RNLIC will pay 95% of total admissible expenses while the balance 5% and inadmissible expenses (if any) will be borne by the Policyholder at the time of discharge from the hospital.

In the event that an insured is hospitalized in any hospital / nursing home (within India) and pays the treatment expenses at the time of discharge, he / she needs to file a claim with RNLIC for the amount due under the policy. RNLIC will process the claim as per the terms of the policy and reimburse the medical expenses covered to the insured if the claim is admissible.

Ideally within 15 days from the date of discharge from the hospital, the insured has to ship / courier mandatory documents to the TPAs addresses mentioned below:

1. Cashless Claim: As the name suggests, the claim is settled to the tune of an approved amount at the time of discharge from the hospital. The hospital bill, to the tune of amount approved by the TPA is settled by RNLIC directly and the policyholder needs to settle the remaining amount directly with the hospital.
2. Reimbursement Claim: Once the claim documents are received at TPA’s Office, the same are reviewed. Additional requirements, if any, are informed to policyholders through letters / SMS. Once all requisite documents are received, the claim is decisioned within 14 working days.

This happens due to various reasons. The most common are:

1. Capping of expenses under specified Expense Heads as per policy’s terms and conditions.
2. Exclusions as per policy’s terms and conditions.
3. Co-Payment: In co-pay policies, policyholders and insurance providers share the hospital expenses. A certain percentage of the medical bills are paid by the policyholder while the remainder, the lion’s share, is paid by the insurance company.
4. Any other policy terms and conditions which are part of policy documents sent to policyholders.

Yes, the claim would be payable subject to the payment of renewal premium before date of discharge from the Hospital or within the grace period, whichever is earlier.

There is no limit on the number of claims during the policy period; however the settlement amount of all claims should not exceed the Sum Insured under the policy.

When members of the same family are covered under a single plan and the Sum Insured is utilized by any one member or all the members collectively during the policy year, the plan is called Family floater.