CASHLESS CLAIMS

Step 1. Hospitalization:- Who Will Do it : Policy Holder.

What Should be done? locate nearest network hospital

Step 2. Avail Cashless Hospitalization & Submission of Documents:- Who Will Do it : Policy Holder.

What Should be done? Avail cashless at the network hospital by showing your health card and valid photo ID

Step 3. Preauthorization:- Who Will Do it : Network Hospital.

What Should be done? Hospital will send the cashless request to HDFC ERGO and coordinate with us for the Pre-authorisation form.

Step 4. At the time of Discharge & Settlement of claim:- Who Will Do it : HDFC ERGO.

What Should be done? HDFC ERGO/ TPA will scrutinize all the received documents and convey the final stand on the claim.

Step 5. Status Update:- Who Will Do it : HDFC ERGO.

What Should be done? You will receive an update through SMS/Emails at every stage of the claim on your registered mobile number or email id.

Step 6. Cashless authorisation & Approval of Claim:- Who will do it: HDFC ERGO & Network Hospital.

What should be done? Hospital shall send the final bill to HDFC ERGO for authorisation and HDFC ERGO shall scrutinize the same and give final authorization in case of approved transactions to the hospital. Any inadmissible expenses, copayments, deductions will have to be paid by you.

Document Check List

On receipt of complete documents, the claim would be processed in 1 hour from the time the last document is received.( Please note In case of internal verification the final stand will be confirmed within 24 hours from the time the last document is received by HDFC ERGO/ TPA )

For seamless processing of claims make sure to submit below details

• Provide NEFT details in the claim form along with cancelled cheque
• Provide KYC ( Know your customer ) form along with photocopy of any one of following KYC documents for all claims amounting to Rs 1 lakh and above.

Critical Illness Insurance Policy Claim Process

In case of any event leading to a claim under the policy, please call us at 022-6234 6234 (accessible from India Only). Our Claims service personnel will guide you on the claim procedures and documents required.

Duly filled and signed claim form.

Photocopy of ID card.

A medical certificate confirming the diagnosis of critical illness from a doctor not less qualified than MD/MS.

Investigation reports/ other related documents reflecting the critical illness diagnosis.

Original detailed discharge summary / day care summary from the hospital.

Please retain a copy of all the documents you have sent, for your records

Documents in addition to those mentioned above may be called for depending on the nature of claim lodged.Please retain a copy of the documents sent for your records.

Important Notes

Kindly be informed that delay in intimation of claim may lead to rejection of claim.

Issuance of claim form should not be taken as admission of liability under the policy on the part of the insur

" All claims are subject to approval by Surveyor appointed by HDFC ERGO GIC LTD "

HCS Process Flow (Product-wise)

Critical Illness

Provides a Lump Sum Benefit on first diagnosis after a certain, as per the policy, survival period for any one of the Critical Illnesses covered under the plan. It may have waiting period as per the policy terms and conditions e.g. Heart attack (Myocardial Infarction), Coronary artery bypass surgery, Stroke, Cancer, kidney failure, major organ transplant, multiple sclerosis, paralysis etc.

Claim intimation can happen through:-

• IPO and Mobile app
• Web Portal
• Submission of hard copy
• Phone/ Email

Post the intimation, the claim hits the medico team directly

Otherwise, the claim hits the non medico queue –they capture information like NEFT, KYC and other claim related details etc. The medico team validates the information filled by non medico team as per policy terms and conditions, and exclusions

The claim moves to QC bucket post validation from Medico for final checks.

Introduction:

Claims intimation is through a dedicated email id – papayments@hdfcergo.com

Claim documents are received and then scan and uploaded from OPS team. The claim follows the queue of non medico-medico-QC-Payments(if approved)

For any query/deficiency – the reminder letter goes at a interval of 15th day,30th day and 45th day and closed at 60th day due to non-availability of response

Claim payment is done to corporate unless specified to be given to an individual

The trigger mail will go to HR person, broker and sales person

For seamless processing of claims make sure to submit below details at healthclaims@hdfcergo.com

• Provide NEFT details in the claim form along with cancelled cheque
• Provide KYC ( Know your customer ) form along with photocopy of any one of following KYC documents for all claims amounting to Rs 1 lakh and above. For KYC Form Click Here
• KYC Documents: Aadhaar Card, Passport, Driving Licence Voter ID, etc

Step 1. Claim Registration:- Who Will Do it : Policy Holder

What Should be done?
To register your claim, fill the claim form and send to us with required documents to below address
HDFC ERGO General Insurance Company Ltd
C-25, 5th Floor, Tower 1,
Stellar IT Park,Sector-62,
Noida, Uttar Pradesh
Pin Code : 201301

Step 2. Approval of Claim:- Who Will Do it : HDFC ERGO

What will be done?
HDFC ERGO will scrutinize all documents and approve the claim. In case additional information or documents are required, HDFC ERGO will call for the same and upon satisfactory receipt of all necessary documents the claim will be settled by HDFC ERGO.

Step 3. Status Update:- Who Will Do it : HDFC ERGO

What will be done?
You will get your claim updates through SMS/Emails on every stage.

Step 4. Settlement of claim:- Who Will Do it : HDFC ERGO

What will be done?
On receipt of complete documents, the claim would be processed and payment will be made through NEFT.

DOCUMENT CHECKLIST

Accidental Death Home Suraksha Policy

• Duly filled and signed Claim Form
• Death Certificate from Municipal Corporation
• FIR or MLC Copy
• Post Mortem Report or Cause of death certificate from treating doctor
• NEFT details for payment: Cancelled cheque in the name of nominee or bank statement/1st page of passbook copy attested by bank
• Outstanding Loan Statement from financer
• For all claims amounting 1 lakh and above: KYC form along with photocopy of any one KYC document of nominee - Aadhar card, Passport, Driving license, Voter ID, etc
• Blood analysis report or Histopathology or Chemical viscera (If done)

Accidental Death Individual Personal Accident

• Duly filled and signed Claim Form
• Death Certificate from Municipal Corporation
• FIR or MLC Copy
• Post Mortem Report or Cause of death certificate from treating doctor
• NEFT details for payment: Cancelled cheque in the name of nominee or bank statement/1st page of passbook copy attested by bank
• Last Income tax return (ITR)
• For all claims amounting 1 lakh and above: KYC form along with photocopy of any one KYC document of nominee - Aadhar card, Passport, Driving license, Voter ID, etc
• Blood analysis report or Histopathology or Chemical viscera (If done)

Critical Illness Home Suraksha Policy

• Duly filled and signed Claim Form
• Copy of discharge card /death summary
• Investigation Reports and other related documents reflecting Critical Illness diagnosis
• NEFT details for payment: Cancelled cheque in the name of Payee (proposer) or bank statement/1st page of passbook copy attested by bank
• For all claims amounting 1 lakh and above: KYC form along with photocopy of any one KYC document of Payee (proposer) - Aadhar card, Passport, Driving license, Voter ID, etc

Loss of Job

• Duly filled and signed claim form
• Termination letter issued from the employer with the reason for termination
• Form 26 AS
• EMI confirmation statement from financer (HDFC Bank LTD) from where the loan is granted
• NEFT details for payment: Cancelled cheque in the name of Payee (proposer) or bank statement/1st page of passbook copy attested by bank
• For all claims amounting 1 lakh and above: KYC form along with photocopy of any one KYC document of Payee (proposer) - Aadhar card, Passport, Driving license, Voter ID, etc

Permanent Total Disablement/Permanent Partial Disablement

• Duly filled and signed Claim Form
• Disability Certificate from Government Hospital
• All treatment papers and Investigation report
• FIR / MLC Copy
• NEFT details for payment: Cancelled cheque in the name of Payee (proposer) or bank statement/1st page of passbook copy attested by bank
• For all claims amounting 1 lakh and above: KYC form along with photocopy of any one KYC document of Payee (proposer) - Aadhar card, Passport, Driving license, Voter ID, etc
• Outstanding loan statement from financer in case of 100% disability*
• *Required for SS and HSP

Child Education (add-on with death)

• Birth Certificate of the child/ Aadhar Card of the child/ Ration Card
• School ID card
• Copy of Fee receipt of school/college

Claim documents to be send to below address
HDFC ERGO General Insurance Co. Ltd. 5th floor, Tower 1, Steller IT Park, C-25, Sector-62, Noida - 201301

Section 1 loss: Notice of loss is required as soon as practicable but no later than 14 days after discovery.

Section 2 loss: Notice of loss is required as soon as practicable but no later than 48 hours after the loss event is triggered.

For burglary, theft, arson, riot and strike, malicious damage, immediate notice of the crime should be given to the Police/ Fire Brigade, as applicable.

In the event of a fire, immediate notice shall be given to the Fire Brigade/ Police, as applicable.

On the happening of any loss event resulting in a claim under the Policy, the Insured shall take all possible steps to minimize the loss.

The Insured must provide proof of loss with full particulars within 14 days after the date of the initial discovery.

Proof of loss must include all relevant documents together with internal and external records of any kind, correspondence with carriers, other parties, legal documents, bills, cash memos, receipts or such other documents as HDFC ERGO General Insurance Company Limited deems necessary for handling the claim.

Notice of claim shall be provided in writing to HDFC ERGO General Insurance Company Limited at its address as set forth in the policy or by email to the email address mentioned on the policy or by calling our call centre (Please consider if you would like to insert a clause stating that “All information recorded by the call centre shall be binding on the Insured”). Subsequently a claim form needs to be submitted by the Insured.

Methodology for the valuation of property is provided for in the policy.

For property losses under Sec.1 of the policy, a surveyor may be appointed to assess the loss.

For claims under Medical Illness, death and PTD, the loan amount excluding the premium financed would be paid. While for Loss of Job claim 3 EMI's at actuals would be payable.

In case of change in Rate of interest the actual EMI being charged by Bank / Financial Institution at the time of loss would be payable.

In case of fixed plans where the loans are prepaid before the end of the policy period, the 3 EMIs in case of Loss of Job claims would be paid as per the original EMI schedule.