·       Investigation & Evaluation

·       Rest Cure, rehabilitation and respite care

·       Obesity/ Weight Control

·       Change-of-Gender treatments

·       Cosmetic or plastic Surgery

·       Hazardous or Adventure sports

·       Breach of law

·       Excluded Providers

·       Treatment for, alcoholism, drug or substance abuse or any addictive condition and consequences thereof.

·       Treatments received in heath hydros, nature cure clinics, spas or similar establishments or private beds registered as a nursing home attached to such establishments or where admission is arranged wholly or partly for domestic reasons.

·       Dietary supplements and substances that can be purchased without prescription, including but not limited to vitamins, minerals and organic substances unless prescribed by a Medical Practitioner as part of Hospitalization claim or Day Care procedure.

·       Refractive Error

·       Unproven Treatments

·       Birth control, Sterility and Infertility

·       Maternity Expenses

·       Charges related to a Hospital stay not expressly mentioned as being covered.

·       Circumcision

·       Conflict & Disaster

·       External Congenital Anomaly

·       Dental/oral treatment

·       Hormone Replacement Therapy

·       Multifocal Lens and ambulatory devices such as walkers, crutches, splints, stockings of any kind and also any medical equipment which is subsequently used at home.

·       Sexually transmitted Infections & diseases (other than HIV / AIDS)

·       Sleep disorders

·       Any treatment or medical services received outside the geographical limits of India.

·       Any expenses incurred on OPD treatment

·       Unrecognized Physician or Hospital

Refer to the policy document for detailed list of exclusions, exclusion for personal accident cover and critical illness cover.

WAITING PERIOD

• Pre-existing disease waiting period of 36 months since inception of the policy and continuous renewal
• Initial waiting period of 30 days unless the treatment needed is the result of an accident.
• Specific waiting period of 24 months for some listed illnesses, unless the condition is directly caused by cancer (covered after initial waiting period of 30 days) or an accident (covered from day 1)
• Please note that Waiting Periods shall not apply to e-consultation, Personal Accident Cover and Critical Illness Cover.
• Please do read more about the common exclusions in the policy terms & conditions.

Cashless facility

Wherever Cashless facility would apply, Niva Bupa should ensure that all the Insured Persons are provided with adequate facilities so that they do not have to pay any deposit at the commencement of the treatment or bills after the end of treatment to the extent as the Services are covered under the policy and up to the limits specified in the policy and to the extent that a prior authorization for cashless settlement has been made by the Niva Bupa to the network provider.

In order to avail the cashless claim facility, the insured has to be treated in an empaneled hospital. By providing the details of the health insurance policy and presenting the e-card or other physical proof of the health insurance taken in the name of the policyholder, he or she can avail cashless hospitalization and treatment, if the illness/ injury is covered under the policy. Once the patient is discharged from the hospital, all the medical bills are sent to the insurance provider by the hospital. The insurance provider then evaluates the expenses and settles the payment.

Cashless claims process for planned treatment

·       The insured has to inform Niva Bupa of the hospitalization or treatment requirement ahead of time in order to avail cashless treatment. For the same, the Insured has to visit any of  Niva Bupa’s network hospitals. For a list of Niva Bupa’s network hospitals pls. visit https://transaction.Nivabupa.com/Pages/hospitalnetwork.aspx

·       Niva Bupa should be informed at least 48 hours before the treatment date. A cashless claim request form should be submitted at the relevant address of the insurance provider – mostly via post, e-mail, or fax. For more information pls. contact Customercare@Nivabupa.com

·       Once these steps are completed, Niva Bupa will notify the insured as well as the concerned hospital regarding the policy cover and eligibility. Niva Bupa will review and provide confirmation to the Network Hospital by fax and E-mail and also send a text message and an E-mail confirming the same to Insured. Niva Bupawill respond to Hospital / Insured request for availing cashless within 30 Minutes

·       On the day of admission in the hospital, the policyholder has to display his/her health insurance card and the confirmation letter. Niva Bupa will settle the claim (as per policy terms & conditions) with the hospital after completion of all formalities. The medical bills will be paid by Niva Bupa, directly to the hospital.

Cashless claims process for emergency treatment

·       The policyholder can contact the customer care help desk of Niva Bupa in order to get information about the nearest network hospital. For a list of Niva Bupa’s network hospitals Insured may also visit https://transaction.Nivabupa.com/Pages/hospitalnetwork.aspx

·       The hospital has to fill in the cashless claim request form and submit it at the relevant address of the insurance provider – mostly via post, e-mail, fax or through customer care.

·       An Authorization Letter will then be issued by the insurance provider to the hospital, indicating the policy coverage. The medical bills will be paid by the insurance provider, directly to the hospital (as per policy terms & conditions). In case of rejection of the claim, a letter will be sent to the insured, stating the reasons for rejection.

Note: Cashless Facility is only available at hospitals in the cashless network. In case of Planned Hospitalization contact your service provider two days prior to admission. In case of Emergency Hospitalization contact your service provider within 24 hours of hospitalization. In the event of a claim, please call Niva Bupa 24x7 Customer helpline number: 1860-500-8888 or email Niva Bupa at customercare@Nivabupa.com. Please send the relevant documents to :

“Claims Department, Niva Bupa Health Insurance Company Limited, 2nd Floor, Plot No D-5, Sector 59, Noida, Gautam Budhnagar – 201301 Fax No.  011-3090-2010 Or reach Niva Bupa on customercare @nivabupa.com

International treatment assistance:
Customer helpline number: 1860-500-8888
Email ID:Customercare@Nivabupa.com

Emergency Medical Evacuation : +45 7923 2403
Email id: emergency@ihi.com

Reimbursement Claim Process

The reimbursement claim for Niva Bupa can be made if the policyholder opts to go to a hospital of his/ her choice, which is a non-empaneled hospital. In this case, the cashless claim facility cannot be used, therefore, the insured has to pay all his/ her medical bills and other costs involved in hospitalization and treatment and then claim for reimbursement.  In order to avail reimbursement claim, Insured has to provide the necessary documents including original bills to Niva Bupa either physically or digitally.

Niva Bupa will then evaluate the claim to see its scope under the policy cover and then makes a payment to the insured. In case the treatment is not covered under the policy, the claim will be rejected. Niva Bupa will be communicating the reason for the rejection with the Insured via e-mail.

Important Note:

1.     Claim documents notified at IDFC FIRST Bank branch should be scanned and shared on email ID - customercare@nivabupa.com and subsequently physical copies to be dispatched to Niva Bupa Health Insurance Company Limited, 2nd Floor, D-5, Logix Infotech park Sector 59 Noida U.P. 201301.

2.     For Digital claim submission, pls. refer the detailed process as mentioned below

Mandatory Documentation required for filing a reimbursement claim:

·       Duly filled claim form

·       Medical Certificate/ Form which is signed by the treating doctor.

·       Discharge summary or card (original), availed from the hospital.

·       All bills and receipts (original)

·       Prescription and cash memos from pharmacies/ the hospital.

·       Investigation report

·       If it is an accident case, then the FIR or Medico Legal Certificate (MLC) is required.

Important points for consideration while availing Reimbursement claim facility

·       In case of non-network hospitalization notify Niva Bupa within 48 hours of admission in Niva Bupa’s network or non-network hospital. After getting admitted pay directly to the hospital.

·       On discharge, please ensure you collect all relevant documents, invoices, medical reports and discharge certificate from the Hospital in originals.

·       Send these documents and the completely filled and signed claim form to Niva Bupa along with your valid ID proof and age proof. The claim form is available on Niva Bupa’s website https://transaction.Nivabupa.com/customer-care/health-services/download-forms.aspx  

Claim processing basis scanned documents

Niva Bupa Health Insurance (Niva Bupa)being a customer centric organization and in order to serve the customers better in the current Covid-19 pandemic situation, Niva Bupa will now accept scanned copy of the original claim documents from customers in order to ensure that:

·       They stay inside their homes and are safe.

·       They comply with the lockdown guidelines issued by Government of India. 

·       They can submit their claim documents despite the fact courier service vendors are not working.

In order to enable customers at this hour of need, Niva Bupa will accept the documents not only if they are mailed by the customer himself, but also if his agent/ advisor, broker, bank partner and Corporate HR mails them on his / her behalf.

Customer/s or their representatives can send the documents through claimbcp@Nivabupa.com email id.

Customer/s need to submit following documents for expeditious processing of their claims:

o   Duly filled and signed Reimbursement claim form

o   Declaration on a letter and/or email: "I hereby declare that the benefits paid under this claim shall not be claimed from anywhere else in any form. Further, Niva Bupa Health Insurance Company reserves the right to ask for original claim documents for processing of claims wherever necessary."

o   Customer should write “Submitted to Niva Bupa Health Insurance Co. Ltd.” on each page of the “Discharge summary, Hospital Bill and Payment receipt” along with the claim intimation number (as provided by Niva Bupa)

o   Complete Discharge Summary with investigation reports

o   Bill with detailed breakup

o   Payment Receipt 

o   Cancelled Cheque Copy / NEFT details (Personalized Cancelled cheque or Front page of passbook with account holder and account details)

o   KYC documents for claim amount 1 lakh and above

-          PAN card

-          Aadhaar card or Voter ID Or Driving Licence or Passport

-          Latest photo for passport photo

In order to help Niva Bupa customers during these testing times, Niva Bupa would like to assure that no reimbursement claim will be denied on grounds of delay in submission of reimbursement claim documents or the additional documents that are triggered by the claim function.

On a similar note, in order to help the network providers tide over this crisis, Niva Bupa will process Provider claims basis the scanned documents. The providers will have to send claim documents to Niva Bupa through Dsscanned@Nivabupa.com email id along with Pre-authorization id in the subject line. Niva Bupa Health Insurance Company reserves the right to ask for original claim documents for processing of claims wherever deemed necessary.