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Home / Health Insurance / Terms & Conditions of Authorization

Terms & Conditions of Authorization
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Terms & Conditions of Authorization

Cashless Authorization letter is issued on the basis of information provided in Pre- Authorization form. In case misrepresentation/concealment of the facts or any material difference/ deviation/ discrepancy in information is observed in discharge summary/ IPD records, then cashless authorization shall stand null & void. At any point of claim processing, Insurer or TPA reserves the right to raise queries for any other document to ascertain admissibility of claim.

KYC (Know your customer) details of proposer/employee/beneficiary are mandatory for claim payout above Rs 1 lakh.

Network providers shall not collect any additional amount from the individual in excess of Agreed Package Rates except costs towards non-admissible amounts (including additional charges due to opting higher room rent than eligibility/choosing separate line of treatment which is not envisaged/considered in package).

Network providers shall not make any recovery from the deposit amount collected from the Insured except for costs towards non-admissible amounts (including additional charges due to opting higher room rent than eligibility/ choosing separate line of treatment which is not envisaged/considered in package).

In the event of unauthorized recovery of any additional amount from the Insured in excess of Agreed Package Rates, the authorized TPA / Insurance Company reserves the right to recover the same or get the same refunded to the policy holder from the Network Provider and/or take necessary action as provided under the MOU.

Where a treatment/procedure is to be carried out by a doctor/surgeon of insured's choice (not empanelled with the hospital),Network Provider may give treatment after obtaining specific consent of policy holder.

Differential Costs borne by policy holder may be reimbursed by insurer subject to the terms and conditions of the policy.

Terms & Conditions of Authorization

Documents to be provided by the hospital in support of the claim
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Detailed Discharge Summary and all Bills from the hospital

Cash Memos from the Hospitals / Chemists supported by proper prescription.

Diagnostic Test Reports and Receipts supported by note from the attending Medical Practitioner / Surgeon recommending such diagnostic tests.

Surgeon's Certificate stating nature of operation performed and Surgeon's Bill and Receipt

Certificates from attending Medical Practitioner / Surgeon giving patient's condition and advice on discharge.

Roocha Kanade profile avatar

Written by

Roocha Kanade

Content Architect

Dr Nitin Kumar Gupta profile avatar

Reviewed by

Dr Nitin Kumar Gupta

SVP – Health Underwriting & Claims at Acko General Insurance