FAQs

Health Insurance is protection against medical costs. A health insurance policy is a contract between an insurer and an individual/group in which the insurer agrees to provide specified health insurance cover at a particular premium. The health insurer usually provides either direct payment or reimburses the expenses associated with illnesses and injuries

Ericson Insurance TPA Pvt. Ltd as a TPA has entered into agreements with a set of hospitals (called Network Service Providers) where the member can avail hospitalization services on the basis of an authorization provided by Ericson TPA. The member does not pay for his treatment up to the limit authorized provided it is covered by the policy and only pays the non covered expenses and any excess over the authorized limit. This saves the need for the member to arrange for cash to pay to the hospital.

Cashless Hospitalization fall under two circumstances Planned and Emergency. Pre authorization of the estimated hospital expense is a must to avail this facility. In the case of planned hospitalization or admission, you would have first consulted a doctor who in turn would have advised you on the probable date or time of hospitalization. In such a case, you are required to apply for a pre authorization to Ericson Insurance TPA Pvt. Ltd at least 3 - 4 days prior to the date of hospitalization. We suggest you to call Ericson Insurance TPA Pvt. Ltd immediately to intimate and take advice on the cashless process.

  • Your Consultant doctor Advices you for admission or hospitalization.
  • You can choose a network hospital or a nursing home from Ericson Insurance TPA Pvt. Ltd website, Member Manual or you can also call the call centre and ask for the names of NSP.
  • Get the pre authorization form filled by the NSP at least 3 to 4 days in advance and insure that it is faxed or emailed to Ericson Insurance TPA Pvt. Ltd.
  • Once Ericson Insurance TPA Pvt. Ltd receives the pre auth request from the NSP it will process the request and either approve or deny the pre auth request depending on the policy term and condition of the insurer.
  • The authorization letter which can be a approval or a denial will be sent to the NSP via fax or email and a SMS or email will be sent to the Insured informing him the status of the pre auth request. In case of emergency hospitalization or admission, the member covered needs to approach any of our NSP (hospital or nursing home) of your choice and present your Ericson Insurance TPA Pvt. Ltd ID card to the help desk at the NSP. The help desk at the NSP will get the pre auth form filled and faxed or emailed to Ericson Insurance TPA Pvt. Ltd on a fast track basis. For a cashless treatment it is mandatory for the NSP to have an approval from Ericson Insurance TPA Pvt. Ltd. In case you cannot wait for receiving the approval owing to medical urgency you can undertake the treatment by paying the necessary cash deposit. Once the approval is received by the NSP from Ericson Insurance TPA Pvt. Ltd the NSP will return the cash deposit made by you. Note: Denial of cashless treatment does not in any way mean denial of treatment. You can apply for reimbursement of your claim once you get discharged from the hospital /nursing home. The claim shall be dealt with as per the policy term and condition of the insurer.

Reimbursement Claim is the process of a member applying for financial reimbursement in line with the terms of the policy, having paid his hospitalization expenses out of his own resources.

Yes. Under the Health Policy, you can opt for cashless as well as Reimbursement. We would advise that in case you are taking treatment from a network hospital, then you should avail of the cashless facility. This will give you the financial advantage of not paying for your hospital treatment and also gives you more cushions to meet your post hospitalization expenses.

Pre Authorization is the prior approval that is required to be taken from Ericson Insurance TPA Pvt. Ltd to grant cashless treatment in a network hospital.

It is a letter issued by Ericson Insurance TPA Pvt. Ltd to the hospital directly authorizing the hospital to treat the patient and incur expenditure up to the amount mentioned in the letter. Letter of Assurance will be issued only after all relevant information is provided to Ericson Insurance TPA Pvt. Ltd by the policyholder/hospital. The preauthorization certificate will be limited to the maximum of the sum assured or such lower amount that may be decided by the company based on the facts of the individual cases or medical opinion or both. Non issue of letter of Assurance for want of specific information, does not mean, denial of treatment or denial of settlement of claims. The claim can be duly filed with the Ericson Insurance TPA Pvt. Ltd office at the end of the treatment for reimbursement.

You can file a claim for reimbursement of your Pre and Post hospitalization expenses (30 days before date of admission and 60 days after the date of discharge) with Ericson Insurance TPA Pvt. Ltd

Please download checklist of pre-authorization & submit all documents mentioned in it.

In case of planned hospitalization:

  • Intimate Ericson Insurance TPA Pvt. Ltd about your hospitalization through fax or email well in advance.
  • Get admitted in the hospital please make sure that the hospital or the nursing home where you are getting yourself or your family member treated meets the insurers criteria.
  • At the time of discharge please collect all the documents in original e.g. discharge summary, final bill, prescription, medicine bills, all the test reports and films.
  • Lodge your claim with Ericson Insurance TPA Pvt. Ltd within 7 days of your discharge.

In case of emergency hospitalization:

  • Get yourself admitted in the nearest hospital/nursing home of your choice.
  • Intimate Ericson Insurance TPA Pvt. Ltd about your hospitalization as soon as possible.
  • At the time of discharge please collect all the documents in original e.g. discharge summary, final bill, prescription, medicine bills, all the test reports and films.
  • Lodge your claim with Ericson Insurance TPA Pvt. Ltd within 7 days of your discharge.

You can submit the claim at any of the Ericson Insurance TPA Pvt. Ltd offices, in person or by courier. Please insist on an acknowledgement when you deliver the documents in person. When you courier, we will send you an email or SMS as an acknowledgement.

A member can start availing the cashless treatment if the member is already enrolled with Ericson Insurance TPA Pvt. Ltd ID No, but it is mandatory to prove the identity at the time of discharge hence the member is advised to provide a photograph along with the proof of identity before discharge.

Ericson Insurance TPA Pvt. Ltd ID card is intended to identify the member insured. The NSP has to verify the coverage under the policy for the member before being assured that insurance will pay him. So the process of prior authorization becomes imminent.

All bills in original, investigation records and discharge summary are to be left with the hospital providing cashless treatment. The patient has to countersign all bills and fill the claim form and also leave the same with the hospital at the time of discharge. A copy of the bills and Discharge Summary can be carried by the patient for his records.

Your medical records will be useful to you in any future time. In addition, there may be a requirement to submit some of these prescriptions, discharge summary, etc along with your post hospitalization claim.

Once the claim is admissible, the health insurance policy will pay for Room and related charges, Nursing, Consultant expenses, Investigations and medicines all related to the treatment of the illness. There could be limits for each of these. Please verify all available facility of your policy.

When you take out the insurance your insurer will ask you (in the proposal) if you are suffering from any condition. You may have listed the conditions that you have suffered, sometimes it is also possible that the condition has been there but you were not aware of it or you forgot to disclose. Your insurer views the contract from the point of whether he knew the state of health of the person insured. When a condition presents itself and is inferred by an expert medical opinion that it was present at the time you took out the insurance, it becomes a preexisting condition. Most insurance policies exclude this as it is not a fortuity.

An illness (and so the treatment) will be deemed to be continuous if the concerned illness relapses within 45 days from the date of last consultation with the doctor/hospital/nursing home. Any occurrence after a lapse of 45 days will be considered as new illness.

PRE-HOSPITALISATION: Relevant medical expenses incurred during the period up to (normally) 30 days prior to hospitalization on disease/illness/injury sustained will be payable.

POST-HOSPITALISATION: Relevant medical expenses incurred for the period of (normally) 60 days after hospitalization on disease/illness/injury sustained will be payable. Please check your policy for the coverage and the number of days.

The policy covers reasonable and necessary expenses for treatment of illness/disease /injury contracted during the coverage of the policy like room rent, nursing care, Doctors fee, investigation charges, medicine charges, operation theatre and like expenses, which fall within the available limit up to the maximum of Sum Insured in any one period of insurance stated in your policy schedule.

Normally YES. However, an extraordinary circumstance such as a patient not being able to be taken to hospital is covered in some policies through Domiciliary Hospitalization. Please check if this cover is there in your policy.

Age limits vary from policy to policy. It can start from new born baby to an upper age limit. Please check your scheme for the limits.

Yes. Beside this, a family package discount is also available in many policies.

Group policies are available only to homogenous groups (not formed for the purpose of availing health insurance). These could be corporate, institutions or associations.

Groups present a combined risk profile to the insurer, who is willing to underwrite the exposure on this basis. This means that there is a possibility of better terms or rates to the group based on its profile.

Treatments such as Dialysis, cataract, chemotherapy, etc. are covered under a provision called daycare. As technology improves, many illnesses are being sought to be cured without hospitalization (or with minimal stay in hospital). Insurers are ready to provide cover for these through a provision in the policy.

CLAIM

It is a prescribed form, which is required to be submitted when Claim is lodged with Ericson Insurance TPA Pvt. Ltd for payment. It is designed to elicit all the relevant information about the claim. It is a compulsory document and should be placed on the top of claim documents. A Claim Form can be downloaded from our Website.

The purpose of the documents that you submit is two fold to establish that the claim is within the policy and to help assess the amount of settlement. Ericson Insurance TPA Pvt. Ltd or your insurer may want as many documents as necessary to satisfy these. In the normal course, you will require to submit:

  • Hospital Bill with Receipt for payment along with the break up signed by you
  • Surgeons/consultants bills stamped preferably numbered receipt.
  • Doctors prescription and medicine bills
  • Discharge summary sheet from the hospital
  • Pathological reports and other investigation reports along with the doctors authorization
  • Other relevant details and documents connected to hospitalization

Health Insurance policy takes care of medical expenses following Hospitalization/Domiciliary Hospitalization of the insured person(s). The claims are processed as per the Policy Terms, Conditions and Exclusions by the TPA. Claims may be rejected in case of discrepancy in documents, due to non compliance with the policy conditions and as per the Exclusion clause of the Policy.

We will prefer if you could submit the claims with Ericson TPA, though there is no bar, even if you submit the claims to your insurer.

The claim is payable, when treatment is taken from a registered hospital or nursing home. However, in case of non registered hospital or nursing home the treatment can be covered under the policy subject to hospital/nursing home conforming to the following guidelines:

  • The hospital/nursing home should have 15 inpatient beds.
  • It should have qualified nursing staff round the clock.
  • Qualified doctors round the clock.
  • Fully equipped operation theatre.

Yes. Your Mediclaim policy covers 30 days Pre hospitalization expense reimbursement and 60 days Post hospitalization expenses. You may lodge your Pre hospitalization claim along with hospitalization claim. The Post hospitalization claim may be lodged after 60 days of the hospitalization.

You may lodge your claim at any of our offices personally or you can send the same by courier/post etc. On receipt of your claim documents, an acknowledgement letter will be issued to you, which will carry your claim number also. We will identify /track your claim based on the above number. The claim will be put in a folder and after assessment will be stored in our record room. We will have online access to your claim details based on the assigned claim number.

Yes, but only eligible amount as per the terms and condition of the policy shall be paid. The member has to quote the Claim no and Ericson Insurance TPA Pvt. Ltd ID for such resettlement.

The insurance company will insist upon a succession certificate from court of law for disbursing the claim amount. In the alternative insures can deposit the claim amount in the court for disbursement to next legal heirs of the deceased.

The claim form can be obtained in any office of the Insurance Company or with the TPA website www.ericsontpa.com.

Appropriate status is given according to the stage under which the claim is in i.e. being processed; pending for information from member/insurer; processing completed and ready for dispatch or repudiated.

No, this is not allowed as per the guidelines from the Insurance Company. An endorsement is required from the insurance stating the same.

Yes, we can reject / deny your claim based on the evaluation in the light of the policy conditions and if the claim is not found admissible then a rejection letter mentioning the reason for rejection would be sent to you.

The member can appeal to the TPA Cell appointed by Insurance companies at their Respective Regional Offices.

In such a case the hospital needs to mention the same on its letterhead along with the seal and signatures of the treating doctor and the medical administrator. Attested photocopies are also accepted by the TPA in such a case bearing the seal and the signatures of the treating doctor and the medical administrator.

Claim need not be once a year. The insured can claim as many times as he is hospitalized during the period of Insurance but the insurance companies liability in respect of all claims will not exceed the Sum Insured per person.

All claims will be payable in Indian Currency through cheque only.

Original documents can be returned on written request. However, we will stamp the Original Documents before return. Only X-ray films, ECG reports etc. will be returned after approval of the claim.

Normally within 10 days from the date of receipt of complete claim documents / information.

Certain conditions are not covered under the policy and are mentioned there are called exclusions.

As per an exclusion clause of the policy, any disease contracted by the insured person within the first thirty days from the first commencement date of policy, is not payable. However, this does not apply to treatment for accidents.

In a standard health insurance policy certain diseases are not payable in the first one or two years of commencement of insurance cover. These diseases are payable after such exclusion period of continuous cover, if they were not contracted before the commencement of the policy. Typical diseases excluded are Cataract, Benign Prostatic hypertrophy, Hysterectomy for menorrhegia or fibromioma, hernia, hydrocele, congenital internal diseases, fistula in anus, piles, sinusitis and such related disorders.

Health policies normally do not cover the following:

  • Expenses incurred on cost of Spectacles, Contact Lenses, Hearing Aids, Dental Treatment unless requiring Hospitalization, Sterility, Intentional self injury and other exclusion clauses mentioned in the policy.
  • Expenses incurred at Hospitals/Nursing Homes primarily for Diagnostic, X-rays or Laboratory examination, which are not consistent with or incidental to the diagnosis and treatment of the positive existence of any ailment.
  • Ambulance charges, registration / admission / file charges, extra food charges, attendant charges etc. Please check your policy for the exact list.

Your health insurance policy pays for reasonable and necessary medical expenditure. There are several items that do not classify as medical expenses during hospitalization. These items will not be payable and expenditure towards such items will have to be borne by you. Some common examples of non-medical expenses are listed for your reference:

  • Telephone expenses
  • Food for patient
  • Attendant
  • Toiletries such as soap, razor, shaving cream, comb, etc.
  • Double occupancy two hospital beds occupied for one patient
  • Rehabilitative aids such as crutches, slings, orthopedic belts, etc.
  • Water bed,
  • Registration charges
  • Documentation charges
  • Administrative expenses
  • Admission fee

Some policies introduced of late have a predefined reimbursement for such expenses.

No! Dental treatment of any kind is not typically covered unless arising out of an accident and requiring hospitalization.

Maternity expenses are not normally covered in a health insurance policy. Some policies (especially corporate policies) cover this by paying specific premium.

No! Typically Health insurance is linked to the allopathic system of medicine. Some policies do cover other systems with a specific limit.

No! Typically expenses arising out of any condition directly or indirectly attributable to any syndrome or condition commonly called AIDS are not covered.

If there is a hospitalization, diagnosis preceding the hospitalization, during the period and post discharge are covered in pre and post hospitalization covers. You will need to check the policy if these are covered and if so for how many days. However, a hospitalization which is intended to predominantly carry out diagnosis is not covered in most of the policies.

Health policies associate themselves with hospitalization (or inpatient) treatment. There are some policies which cover the Outpatient treatment as well.

Yes! Insurance cover is available if a person has suffered an accidental injury and requires hospitalization. However the accident should not be as a result of alcohol / drug abuse. Also Injury/disease directly or indirectly caused by or arising from or attributable to War invasion, Act of Foreign Enemy, Warlike operation Injury or Disease directly or indirectly caused by or contributed to by nuclear weapons/materials are any acts of terrorism are not covered in the scope of the policy

Some policies cover Domiciliary Hospitalization if you fulfill the following conditions: Medical Treatment must exceed 3 Days and Condition of the patient is such that he cannot be removed to a Hospital / Nursing Home or Accommodation in a Hospital / Nursing Home not available. The Domiciliary Hospitalization Benefits do not cover the following Diseases: Asthma, Bronchitis, Chronic Nephritis and Nephritic syndrome, Diarrhea and all type of Dysenteries including Gastroenteritis, Diabetes Mellitus and Insipidness, Epilepsy, Hypertension, Influenza cough and cold, all Psychiatric and Psychosomatic Disorders, Pyrexia of unknown origin for less than 10 days, Tonsillitis and upper Respiratory Tract infection including Laryngitis and Pharingitis, Arthritis, Gout and Rheumatism.

Cash less may be denied if found non payable as per the Policy Terms, conditions and exclusions and in some cases where the member identity is not fully established. Decisions on cashless requests are made on the basis of only few available documents and in case of incomplete documents to establish the request in a particular case the request may be rejected. Cash less request may also be rejected in doubtful cases.

GENERAL

Yes it is possible to shift the patient to another Hospital for requirement of better medical facilities. However, since the cashless facility has been approved for the present provider, you may have to take a fresh authorization with the new provider. Please keep Ericson Insurance TPA Pvt. Ltd informed about same.

Not normally, since Health Policies do not cover the OPD treatment. The TPA Card is issued to you against your Health Policy to avail Cashless Service for Hospitalization at Network Hospital.

Yes, there is a rebate in Income Tax available under section 80 D on Health insurance premium up to Rs. 15,000/ (an additional Rs. 5,000 when Senior citizens are covered).

Typically Health insurance policies cover people citing individual sums insured against each. A slightly modified concept is that of floater, where a single sum insured is shared by a group, typically a family. This means that the sum insured is available to any member of the family and any claim reduces the families sum insured. For instance, if the floater sum insured is Rs. 2 lacs for a family of four, it means that either one person can use the entire 2 lacs or two people can use Rs. 1 lac each and so on. Some of the floater policies also have sub limits for each member.

Please contact your insurer, who will be happy to do the needful.

Yes, provided we are the nominated TPA in the policy covering the spouse or family members.

No! Such expenses are not normally covered by most policies. Many insurers are willing to cover this after four (or in some cases three) continuous and claim free years with their scheme.

No but typically protection is available for illness / disease / injury contracted anywhere in the World provided the treatment is taken in India.

You may approach the Insurance Company for your policy renewal. New ID card will be issued to you by Ericson Insurance TPA Pvt. Ltd After every renewal, your data will be sent to us by the Insurance Company, and the same will be updated in our records.

Corporate do negotiate their health insurance schemes with the insurers. It can be done as part of the negotiations.

The TPA is appointed by the insurer. You may contact your insurer with the request.

Health policies cover treatment only at registered hospitals and/to those with some minimum facilities. To establish this, it is easier if you could get the registration number /certificate, Ericson Insurance TPA Pvt. Ltd will have to get it from the hospital that may not always cooperate. This will result in delay of settlement of claim.

If hospitalization is less than 24 hours, the claim is not reimbursable unless for some specific treatments like dialysis, chemotherapy, eye surgery, dental surgery, lithotripsy, tonsillectomy and D&C.