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    Ericson Insurance Tpa Pvt. LTD.: Checklist For Reimbursement Claims

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    akvgaurav
    This document provides a checklist of documents required for reimbursement of medical insurance claims. It lists 17 items that may need to be submitted including the original claim form, hospital bills, discharge summary, death summary if applicable, payment receipts, consultation letters, hospital registration, doctor's registration details, pharmacy bills, investigation reports, police reports for certain injuries, invoices for medical devices, and identification documents. It notes that copies should be kept, claims must be submitted within 15 days, and that this is an indicative list as document requirements may vary by insurer.

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    Ericson Insurance Tpa Pvt. LTD.: Checklist For Reimbursement Claims

    Uploaded by

    akvgaurav
    867 views1 page
    This document provides a checklist of documents required for reimbursement of medical insurance claims. It lists 17 items that may need to be submitted including the original claim form, hospital bills, discharge summary, death summary if applicable, payment receipts, consultation letters, hospital registration, doctor's registration details, pharmacy bills, investigation reports, police reports for certain injuries, invoices for medical devices, and identification documents. It notes that copies should be kept, claims must be submitted within 15 days, and that this is an indicative list as document requirements may vary by insurer.

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    This document provides a checklist of documents required for reimbursement of medical insurance claims. It lists 17 items that may need to be submitted including the original claim form, hospital bills, discharge summary, death summary if applicable, payment receipts, consultation letters, hospital registration, doctor's registration details, pharmacy bills, investigation reports, police reports for certain injuries, invoices for medical devices, and identification documents. It notes that copies should be kept, claims must be submitted within 15 days, and that this is an indicative list as document requirements may vary by insurer.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    867 views1 page

    Ericson Insurance Tpa Pvt. LTD.: Checklist For Reimbursement Claims

    Uploaded by

    akvgaurav
    This document provides a checklist of documents required for reimbursement of medical insurance claims. It lists 17 items that may need to be submitted including the original claim form, hospital bills, discharge summary, death summary if applicable, payment receipts, consultation letters, hospital registration, doctor's registration details, pharmacy bills, investigation reports, police reports for certain injuries, invoices for medical devices, and identification documents. It notes that copies should be kept, claims must be submitted within 15 days, and that this is an indicative list as document requirements may vary by insurer.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 1

    ERICSON INSURANCE TPA PVT. LTD.

    11-C, Corporate Park, S.T. Road, Chembur, Mumbai-71


    Website: www.ericsontpa.com E mail: [email protected]
    Tel. No: 022-25280280 Fax No: 022-25270200

    Checklist for Reimbursement Claims


    Name of the Insured - Gaurav Sharan______ (Date of Birth30/06/1986) Patient Name – Gaurav Sharan
    Name of the company – Indian Overseas Bank Employee ID - 59773
    Policy No -_____________________________ UHID - _________________ Contact Number- 9108264435 E- Mail ID [email protected]

    Please put tick mark against the submitted documents:

    1. Completely filled Original Claim Form with claimed amount, duly signed by you.
    (In case of cashless claim, hospital need to get the same filled & signed from insured)
    2. Original Main Hospital bill with Bill Number & break up of all the charges mentioned in the bill.
    (Break up of Room rent, Nursing, Pharmacy/Medicines, Investigation charges etc. )
    3. Original Discharge summary with Hospital seal & signature of the authorized person.
    (Provides details of complaints & treatment given to patient during hospitalisation)
    4. Original Death summary.
    (In case of death of Patient during Hospital stay).
    5. Original Hospital Payment Receipt with receipt number.
    (With seal & signature of hospital)
    6. Original consultation letters with numbered Payment Receipt.
    (For consultation/surgeon charges, follow up charges charged outside the main hospital bill).
    7. Hospital registration certificate copy.
    (Mentioning hospital Registration No. , Number of beds & validity).
    8. Doctor’s registration number with specialisation details.
    (On doctor’s letterhead with signature).

    9. Original Pharmacy and Investigation bills


    (Along with prescriptions & Lab reports).

    10. Original prescriptions


    (On doctor’s letterhead mentioning duration and dosage for medicines and advice for diagnostic tests).
    11. Investigation reports in original/attested from hospital
    (Reports for all tests done along with images)
    12. Police FIR / Medico Legal Certificate (MLC)
    (Mandatory for All Road traffic accidents/poisoning & burns cases-Duly attested by Police with seal)

    13. Invoices of the implants or Lenses used for the surgery.


    (Surgeries like cataract, angioplasty, knee replacement etc)
    14. Cancelled Cheque

    15. Implants Stickers in case of Cataract/Joint Replacement, Total Knee/Joint


    Replacement.
    16. Claims Intimation – Cashless – care @ericsontpa.com

    17. Claims Intimation – Reimbursement – [email protected]


    NOTE:-

    1. Kindly keep a copy of the submitted documents with you for future references.
    2. As per Policy Condition, each and every Claim is required to intimated immediately to Insurer/TPA. In case of delayed
    intimation, necessary approval from Insurer will be required for processing of the claims. Claim papers are required to be
    submitted within 15 days from the date of discharge. For late submission, necessary approval from Insurer will be
    required for processing of the claims.
    3. Do not forget to collect the acknowledgement copy from our executives for the submitted documents.
    4. Claim form, Discharge summary/death summary, final bill with receipt, Hospital registration copy, MLC/FIR, Implant
    invoices, supportive investigation reports are the mandatory documents which needs to be submitted in the relevant
    claims for faster settlement of claim.
    5. Cancelled Cheque to be attached with every claim form. If there are more than 1 claim, then if the Bankers are changed,
    the necessary intimation/cancelled cheque should be attached. For Claim above Rs.1,00,000, Electricity Bill/ Telephone
    Bill copy is to attached along with Adhar card copy and Pan Card copy.
    6. Please note that this is just an indicative checklist & not an exhaustive one, the documents requirement may vary as per
    the insurer’s guidelines which will be intimated accordingly.
    7. For any assistance please feel free to call our customer care executives on Tel.no. 022-25280280
    Toll Free Number 1800 22 2034 Whats App Intimation No. 9167251896

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