Permanent Exclusions^

Hearing Aids, Spectacles or contact lenses including optometric therapy

Treatment for baldness, alopecia, wigs, toupees, and similar treatment

Cosmetic, Aesthetic & reshaping treatments and surgeries

Any illness/ injury/ accident due to abuse of intoxicants

Breach of law with Criminal intent, intentional self-injury

War, Act of foreign enemy, uprising, revolution, insurrection, military or usurped acts 

Cashless Process:

1. Customer to visit the TPA/ admin desk at hospital and fill the preauthorization form which has been sent to Aditya Birla Health Insurance for approval.

2.Documents gets verified at Aditya Birla Health Insurance

a. In case of deficiency, additional documents are requested from the hospital. Communication letters gets triggered on registered Email ID.

b. If documents are not submitted after request for additional documents, repudiation call is made to the customer and rejection letter gets triggered on hospital’s registered Email ID.

c. If claim is not admissible then the claim gets rejected and the rejection letter gets triggered on hospital’s registered Email ID.

d. If documents are complete, then claim admissibility is checked. If payable, the claim gets approved and Aditya Birla Health Insurance issues the approval letter to the hospital.

3.Hospital provides the treatment to the patient. Member(s) completes the treatment and get discharged.

4.Proactive discharge call is made to the customer.

Reimbursement process

1. Documents to be sent to Aditya Birla Health Insurance by Courier/branch/customer portal/ Customer Care center.

2. Documents get verified and scanning and registration of the claim gets done in inward department and forwarded to non-medico team for billing process.

3. Claim gets processed by non-medico team and forwarded to medico team to check admissibility.

4. Medico team will process the claim and will give their decision based on the available documents (deficiency, approved or repudiate). In case of deficiency, additional documents are requested from the customer. Communication letters gets triggered on the registered Email ID.

a. Three reminder mails would be triggered for the pending documents at the interval of 10 days, if the documents are not submitted, the claim will be closed on Non-submission of mandatory documents.

5. If approved, then payment amount gets computed, and the payment is processed.

6. If repudiated, then the same is conveyed to the customer on his registered contact number and the rejection letter gets triggered on registered Email ID.

Claims Documents

Aditya Birla Health Insurance shall be provided the following necessary information and documentation in respect of all Claims at Your/Insured Person’s expense within 30 days of the Insured Person’s discharge from Hospital:

(i) Claims for Pre-Hospitalization Medical Expenses and Post-Hospitalization Medical Expenses to be submitted to Aditya Birla Health Insurance within 30 days of the completion of the post Hospitalization treatment.

(ii) For those claims for which the use of Cashless Facility has been authorized, Aditya Birla Health Insurance will be provided these documents by the Network Provider immediately following the Insured Person’s discharge from Hospital:

a.       Duly signed, stamped and completed Claim Form;

b.       Photo ID & Age Proof;

c.       Copy of claim intimation letter / reference of Claim Intimation Number in the absence of main claim documents);

d.       Copy of the Network Provider’s Registration Certificate / Copy of Form C in case of Hospitalization;

e.       Original Discharge Card / Day Care Summary / Transfer Summary;

f.        Original final Hospital Bill with all original deposit and final payment receipt;

g.       Original invoice with payment receipt and implant stickers for all implants used during surgeries i.e. lens sticker and invoice in cataract Surgery, stent invoice and sticker in Angioplasty Surgery;

h.       All previous consultation papers indicating history and treatment details for current ailment;

i.         All original diagnostic reports (including imaging and laboratory) along with Medical Practitioner’s prescription and invoice / bill receipt from diagnostic center;

j.         All original medicine / pharmacy bills along with Medical Practitioner’s prescription;

k.       MLC / FIR Copy – in Accidental cases only;

l.         Copy of Death Summary and copy of Death Certificate (in death claims only);

m.     Pre and Post-Operative Imaging reports – in Accidental cases only;

n.       Copy of indoor case papers with nursing sheet detailing medical history of the patient, treatment details, and patient’s progress (if available);

o.       Original invoice for Vaccination and payment receipt;

p.       KYC documents.

q.       Additional documents in case of below covers in case of Multiple Policy claims:

·       Photocopy of entire claim document duly attested by previous Insurer or TPA

·       Original payment receipts for expenses not claimed/settled by previous insurer

·       Discharge voucher/settlement letter by previous insurer. Road Ambulance Cover Photocopy of discharge card.

·       Original Ambulance invoice & paid receipt

(iii) For acceptance of claims in electronic mode, the documents shall be submitted in such form and manner as may be specified by Aditya Birla Health Insurance.

(iv) For the following Claims, please notify the same at Aditya Birla Health Insurance call center/website/e-mail. TM • Health Assessment TM • HealthReturns • Health Check-up Program • Health Coach • Domestic Emergency Assistance Services (including Air Ambulance) • International Emergency Assistance Service

Waiting Period

A. Initial Waiting Period - 30 Days (not applicable in case of accident and subsequent renewal)

B. Specific illness waiting period - 24 months.

C. For Pre-Existing Disease- 48 months