Health Ensure Policy

Health Insurance Claim Process

Claim by Direct Click (CDC)

Bajaj Allianz General Insurance has introduced an app based claim submission process known as “Health Claim by Direct Click” (CDC)

This facility allows you to register and submit claim documents through the app itself for claims up to Rs 20,000.

What You Need to Do:

● Register your policy and card number in the Insurance Wallet App.

● Register your policy and health card number in the app.

● Register the claim.

● Fill the claim form and arrange hospital-related documents.

● Upload the documents using the app menu.

● Submit the claims for further processing.

● Get confirmation within a few hours.

Cashless Claim Process (Only applicable for treatment at a network hospital):

Cashless facility at network hospitals is available 24x7 throughout the year without any interruption in service. The list of hospitals where cashless settlement can be availed is a dynamic list and is liable to change without notice. You must check the hospital list before getting admitted to the hospital. The updated list is available on our website and with our call center. Bajaj Allianz Health Card along with a government ID proof is mandatory at the time of availing cashless facility.

When you are opting for cashless claims, the process can be summarised as follows:

● Get the pre authorisation request form filled and signed by the treating doctor/hospital and signed by you, at the hospital’s insurance desk.

● The network hospital will fax the request to the Health Administration Team (HAT).

● HAT doctors will examine the pre authorisation request form and decide on cashless availability, as per the policy guidelines.

● Authorisation letter (AL)/denial letter/additional requirement letter is issued within 3 hrs depending on the plan and its benefits.

● At the time of discharge, the hospital will share the final bill and discharge details with HAT and based on their assessment, final settlement will be processed.

Important Points to Note

● In case of planned hospitalisation, register/reserve your admission as per the network hospital’s procedure for admission in advance.

● Admission at network hospital is subject to availability of a bed.

● Cashless facility is always subject to your policy terms and conditions.

● The policy does not cover the following :

● Telephone

● Food and beverages for relatives

● Toiletries

● The cost of the above services have to be borne by you and paid directly to the hospital before discharge.

● In-room rent nursing charges are included. However, if a higher room is used then the incremental charges will be borne by you.

● In case the treatment is not covered as per the policy terms and conditions, your claim- cashless or reimbursement, will be denied.

● In case of inadequate medical information, pre authorisation for cashless claim can be denied.

● The denial of cashless facility does not mean denial of treatment and does not in any way prevent you from seeking necessary medical attention or hospitalisation.

Reimbursement of Pre/post Hospitalisation Expenses:

Relevant medical expenses incurred before admission and after discharge from the hospital will be reimbursed as per the policy. Prescriptions and bills/receipts of such services should be submitted to Bajaj Allianz along with the duty signed claim form.

Reimbursement Claim Process

● Inform the BAGIC HAT team about the hospitalization.

● To register your claim online click here

● To register your claim offline, please call us on our toll-free number: 1800-209-5858.

● After discharge, you must submit the following documents to the HAT team (within 30 days of discharge):

● Duly filled and signed claim form with mobile number and email ID

● Original hospital bill and payment receipt

● Investigation report

● Discharge card

● Prescriptions

● Bills of medicines and surgical items

● Details of pre-hospitalization expenses (if any)

● In-patient department (IPD) papers, if required.

● All documents to be sent to the HAT for further processing and based on the assessment, the final settlement will be done within 10 working days.

● Post hospitalisation claim documents must be sent within 90 days from the date of discharge.

Documents Required for Reimbursement Claim

● Original pre-numbered hospital payment receipt duly sealed and signed.

● Original prescriptions and pharmacy bills.

● Original consultation papers (if any).

● Original investigation and diagnostic reports along with original bills and payment receipt for the investigation done within and outside the hospital.

● If you availed a cashless claim but did not utilise it, a letter from the hospital stating the same.

● A letter from the treating doctor mentioning incident details (in case of an accident).

● Hospital registration certificate and hospital infrastructure on the letterhead.

● A cancelled cheque bearing IFSC code and name of the insured.

● Indoor case paper copy attested from the hospital from date of admission to date of discharge with detailed medical history and doctor’s notes with TPR (temperature, pulse and respiration) charts.

● X-ray films (in case of a fracture).

● Obstetric history from treating doctor (in maternity cases).

● FIR copy (in accident case).

● A requirement for some special cases. “In case of a cataract operation-lens sticker with a bill copy”. “In case of a surgery-implant sticker with a bill copy”. “In case of a heart-related treatment-stent sticker with a bill copy”.

Additional Benefits with Your Health Ensure Policy

This health insurance plan provides relief from medical expenses with various other benefits listed below:

Preventive Health Check-up

You can avail a free preventive health check-up at the end of a continuous period of 3 years during which your Health Ensure policy is active.

Tax Saving

Tax saving up to Rs 1 lakh under Section 80D of the Income Tax Act.*

*On opting for Health Ensure policy for yourself, your spouse, children and parents, you can avail Rs 25,000 per annum as a deduction against your taxes (provided you are not over 60 years). If you pay a premium for your parents who are senior citizens (age 60 or above), the maximum health insurance benefit for tax purposes is capped at Rs 50,000. As a taxpayer, you may, therefore, maximise tax benefit under Section 80D up to a total of Rs 75,000, if you are below 60 years of age and your parents are senior citizens. If you are above the age of 60 years and are paying a medical insurance premium for your parents, the maximum tax benefit under Section 80D is, then, Rs 1 lakh.

Cumulative Bonus

At the time of renewal if there is no claim in the previous year policy the insured would be eligible for a 5% cumulative bonus.

Hassle-free Claim Settlement

Our in-house claim settlement team ensures a convenient, quick, smooth and easy claim settlement process. Also, we offer cashless claim settlement at more than 18,400+ network hospitals* across India. This comes in handy in case of hospitalisation or treatment wherein we take care of paying the bills directly to the network hospital and you can focus on recovering and getting back on your feet.

Long-term Discount

Avail a long-term policy discount as mentioned below: 4% discount is applicable if the policy term is 2 years. An 8% discount is applicable if the policy term is 3 years.

Inclusions

Ayurvedic/homoeopathic Cover

Covers ayurvedic and homoeopathic hospitalisation if the admission period is not less than 24 hours.

Ambulance Cover

Covers ambulance charges in case of an emergency.

Pre and Post Hospitalisation Expenses

Covers pre and post hospitalisation expenses up to 30 days and 60 days respectively.

Daycare Procedures

Covers medical expenses incurred during the treatment of listed daycare procedures or surgeries.

Organ Donor Expenses

Covers expenses towards organ donor’s treatment for harvesting of the donated organ.

Exclusions

Waiting Period

A waiting period is the duration as determined by your policy conditions, during which your healthcare coverage is not admissible under the policy. This period must pass for you to enjoy the benefits of your insurance. We’ve listed the waiting periods for some of the more common conditions below:

Note: Please refer the policy wordings for detailed policy terms and conditions.

General Exclusions

● Any treatment arising from or traceable to pregnancy or childbirth, including caesarean section and/or any treatment related to pre and postnatal care and complications arising out of pregnancy and childbirth. However, this exclusion will not apply to ectopic pregnancy proved by diagnostic means and certified to be life-threatening by the attending doctor.

● Any dental treatment that comprises of cosmetic surgery, dentures, dental prosthesis, dental implants, orthodontics, orthognathic surgery, jaw alignment or treatment for the temporomandibular joint, or upper and lower jaw bone surgery and surgery related to the temporomandibular unless necessitated by an acute traumatic injury requiring hospitalisation.

● Medical expenses where in-patient care is not warranted and does not require supervision of qualified nursing staff and qualified medical practitioner round-the-clock. This exclusion is, however, not applicable for any daycare treatment taken for an accidental bodily injury in a daycare centre/hospital.

● War, invasion, acts of foreign enemies, hostilities (whether war be declared or not), civil war, commotion, unrest, rebellion, revolution, insurrection, military or usurped power or confiscation or nationalisation or requisition of or damage by or under the order of any government or public, local authority.

● Circumcision unless required for the treatment of an illness or accidental bodily injury.

● Cosmetic or aesthetic treatments of any description, treatment or surgery for change of life/gender.

● Any form of plastic surgery unless necessary for the treatment of cancer, burns or accidental bodily injury.

● The cost of spectacles, contact lenses, hearing aids, crutches, dentures, artificial teeth and all other external appliances and/or devices whether for diagnosis or treatment, except for intrinsic fixtures used for orthopaedic treatments such as plates and K-wires.

● External medical equipment of any kind used at home as post hospitalisation care, including the cost of instruments used in the treatment of Sleep Apnoea Syndrome, Continuous Peritoneal Ambulatory Dialysis and oxygen concentrator for a bronchial asthmatic condition.

● Convalescence, general debility, rest cure, congenital external diseases or defects or anomalies, stem cell implantation or surgery, or growth hormone therapy.

● Intentional self-injury, including but not limited to the use or misuse of any intoxicating drugs or alcohol.

● Ailments requiring treatment due to use or abuse of any substance, drugs or alcohol and treatment for de-addiction.

● Any condition directly or indirectly caused by or associated with HIV or variant/mutant viruses and or AIDS.

● Medical expenses related to any hospitalisation primarily and specifically for diagnostic, X-ray or laboratory examinations and investigations, vaccination or inoculation unless forming a part of post-bite treatment or if medically necessary and forming a part of treatment recommended by the treating doctor.

● Any fertility, sub-fertility, infertility, sterility, erectile dysfunction, impotence, assisted conception operation or sterilisation procedure.

● Vitamins, tonics, nutritional supplements unless forming part of the treatment for injury or disease as certified by the attending doctor.

● Experimental or unproven treatment.

● Weight management services and treatment related to weight reduction programmes including treatment of obesity and treatment for direct or indirect complications of obesity.

● Treatment for any mental illness or psychiatric illness.

● All non-medical items as per Annexure-II provided in the policy wordings.

● Any treatment received outside India is not covered under this policy.

Other Exclusion

● Any dental treatment that comprises cosmetic surgery, dentures, dental prosthesis, dental implants, orthodontics, orthognathic surgery, jaw alignment or treatment for the temporomandibular joint, or upper and lower jaw bone surgery and surgery related to the temporomandibular unless necessitated by an acute traumatic injury requiring hospitalisation.

● Medical expenses where in-patient care is not warranted and does not require supervision of qualified nursing staff and qualified medical practitioner round the clock. This exclusion is, however, not applicable for any daycare treatment taken for the accidental bodily injury in a daycare centre/ hospital.

● Medical expenses due to war, invasion, acts of foreign enemies, hostilities (whether war be declared or not), civil war, commotion, unrest, rebellion, revolution, insurrection, military or usurped power or confiscation or nationalisation or requisition of or damage by or under the order of any government or public, local authority.

● Circumcision unless required for the treatment of an illness or accidental bodily injury.

● Cosmetic or aesthetic treatments of any description, treatment or surgery for change of life/gender.

● Any form of plastic surgery unless necessary for the treatment of cancer, burns or accidental bodily injury.

● The cost of spectacles, contact lenses, hearing aids, crutches, dentures, artificial teeth and all other external appliances and/or devices whether for diagnosis or treatment, except for intrinsic fixtures used for orthopaedic treatments such as plates and K-wires.

● External medical equipment of any kind used at home as post hospitalisation care, including the cost of instruments used in the treatment of Sleep Apnoea Syndrome, Continuous Peritoneal Ambulatory Dialysis and oxygen concentrator for a bronchial asthmatic condition.

● Convalescence, general debility, rest cure, congenital external diseases or defects or anomalies, stem cell implantation or surgery, or growth hormone therapy.

● Intentional self-injury (including but not limited to the use or misuse of any intoxicating drugs or alcohol.

● Ailments requiring treatment due to use or abuse of any substance, drugs or alcohol and treatment for de-addiction.

● Any condition directly or indirectly caused by or associated with HIV or variant/mutant viruses and or any syndrome or condition of a similar kind commonly referred to as AIDS.

● Medical expenses related to any hospitalisation primarily and specifically for diagnostic, X-ray or laboratory examinations and investigations, vaccination or inoculation unless forming a part of post-bite treatment or if medically necessary and forming a part of treatment recommended by the treating doctor.

● Any fertility, sub-fertility, infertility, sterility, erectile dysfunction, impotence, assisted conception operation or sterilisation procedure.

● Expenses of vitamins, tonics, nutritional supplements unless forming part of the treatment for injury or disease as certified by the attending doctor.

● Experimental or unproven treatment.

● Weight management services and treatment related to weight reduction programmes including treatment of obesity and treatment for direct or indirect complications of obesity.

● Treatment for any mental illness or psychiatric illness.

● All non-medical items as per Annexure-II provided in the policy wordings.

● Any treatment received outside India is not covered under this policy.