HIS CLAIMS GUIDELINES

This document is intended to assist an associate in understanding the HIS claim process. In case wherein any litigation arises in the comprehension of this document, the Policy document issued by New India Assurance will be used as the sole basis of settlement. All reimbursement claims should be raised against the appropriate heads of Domiciliary or Hospitalisation in the portal within 90 days from the date of expense (in case of domiciliary claims) or within 90 days from the date of discharge (in case of hospitalisation claims), in the same financial year. If a window of 90 days is not available during the end of financial year, all claims must be submitted by the date mentioned by the corporate team.

Claiming Process:
A separate claim should be raised for every illness. For example, if you are treated for Fever this week and Bronchitis in the next month, you should raise two separate claims (with attached documents supporting the same) for each of the illnesses. Single claims for multiple illnesses will be denied as Date Range Claims. Associates can raise multiple claims for the same (continuous) treatment. For example, Heart patients who take medicines every day can raise multiple claims for the same treatment to ensure that the claims are raised within 90 days from the expense date. Remember - The basis of quick settlement of claims is correct documentation!

Domiciliary:
Domiciliary treatment will cover all illnesses (subject to policy conditions) that do not require hospitalisation including treatments taken either from a Physician or at the OPD in a hospital. To raise a domiciliary claim, you need to submit these documents in the mentioned order: 1. Claim form

2. Doctors prescription: This must contain the Nature of ailment, Line of treatment and period of treatment with details of medicines dispensed or prescribed to the Patient. A prescription should not contain payment details.

3. Pre numbered doctors bill from doctors official bill book (original) 4. Chemist bills/ Cash memos for medicines purchased from a Chemist (original)
5. Copies of all LAB and other test reports if applicable Doctors Prescription: This must contain the Line of treatment with details of medicines dispensed or prescribed to the Patient. Cost of medicines prescribed and/or dispensed must be in line with the cost of medicines available in the market. Also, the quantum of medicines dispensed must be in line with medicines normally consumed for the illness. For example : If an Antibiotic is dispensed for a Chest Infection for 5 days, the medicine dispensed should be for 5 days and not for an extended period of days/time. Any inflated medicine would automatically be curtailed to a Reasonable and Customary amount. Please note that a prescription should not contain payment details. Chemist Bills: Please attach Chemist bills for the medicines which have been prescribed. Chemist bills for medicines not prescribed will be denied. Please note that the date on Chemist bills should fall within the Policy Period and during the course of the treatment. Any bills before and after the Policy Period will be denied.

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Chemist bills should also have Valid VAT / Drug Licence No. Unlicensed bills will not be acceptable to the Insurance Company. Please note: All bills must be numbered and preformatted. Rubber Stamp bills will be denied. Doctors Bills and Receipts: This document should be from the Doctors Official Receipt Book, which contains pre-printed doctors information and receipt number. Blank document with Doctors Signature and Stamp will not be admissible as receipt proof. If payment details are mentioned in the prescription, the Insurance Company may at its discretion accept the same as payment proof subject to the following conditions: The amount is less than Rs 500 The Prescription is submitted in original

For amount greater than Rs 500 a proper receipt is required from the Doctor. Kindly note that Letter Head Bills of Doctors will not be acceptable to the Insurance Company Referral for Tests: Every test carried out should be referred by a Doctor. Broad Spectrum Tests generally carried out as Master Health check up and Executive check up will not be entertained by the Insurance Company. It is mandatory to submit photo copies of all LAB and other test reports (if applicable), specially if the total claim amount includes the expenses towards the same.

Hospitalisation:
Hospitalisation benefits are applicable only if the insured person is admitted to a hospital continuously for a minimum of 24 hours. (exception is Day Care Procedures mentioned in the policy) To raise a Hospitalisation claim, you need to submit these documents in the mentioned order: 1. Claim form

2. Printed and detailed admission/ discharge card issued by the hospital (original)
3. Detailed Hospital bill showing all break ups

4. Printed and numbered bill receipt issued by the hospital (original)

5. Copies of all LAB and other test reports if applicable

6. Cash memos for medicines properly arranged if purchased from chemist with prescriptions
(original) Please number all the documents /pages so that no page is lost. Also, please note: In case of Road Traffic Accident (RTA) copy of FIR and / or MLC is a must. In claims towards expenses incurred outside India, EOB issued by CIGNA / overseas insurance policy is a must in addition to all above documents (claim documents should be sent directly to Mumbai address).

Ideally Hospitalisation claims should be submitted immediately after discharge and pre/post claims if any can be claimed subsequently.

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The documents arranged serially as mentioned above while submitting the claim will help in easy and smooth processing of claims and will prevent documents from getting misplaced. It is suggested that you mention your employee number or claim number on each document or on the envelope containing the documents. Documents along with dully filled claim form can be dropped in the drop box in your / nearest TCS office locations. Alternatively, documents can be sent to any one of the (nearest) addresses mentioned in the claim form. Associate should retain scanned or photo copies of all the documents, so that the same can be produced if/ when required.

Exclusions:
The following Illnesses /medical conditions are not payable under the HIS Policy:

1. Vaccination and Inoculation: MMR/BCG/Polio/Anti Typhoid and any other vaccination 2. Circumcision: This excludes Phimosis or any Circumcision due to Medical reasons 3. Change Of Life: Any treatment for Menopause/General debility 4. Beauty Treatment:
Plastic Surgery unless necessitated by an accident Hair Loss/Alopecia and its treatment Weight Loss/ Height Gain treatment Acne/ Pimples Treatment Congenital birth defects like Cleft Lips Nervous Breakdown/ Instability /Self Injury

5. Run Down/ General Weakness / Convalescence: Anemia and supplementary tonics for
the above-mentioned Beauty treatments are not payable. If the above condition exists due to an illness, it is payable.

6. Congenital Illness: Illnesses that a patient was born with 7. Alcohol/ Drug Abuse: Cirrhosis due to Alcohol abuse/ Addiction /De Toxification is not
payable. Also, any illness or death caused due to Alcohol or drug abuse is not payable. Decease (STD) illnesses like Syphilis/Veneral Decease are not payable.

8. AIDS/HIV: AIDS/HIV or any of its derivatives are not payable. Sexually Transmitted 9. Spectacles/Eye Glass/Frame/Contact Lens 10. Insanity/ anxiety / Mental Illness or its treatment
11. General Check Up / General Diagnostic Check Up /Pregnancy Check Up

12. Diagnostics are not payable if not necessitated by an illness/death. Submission of a copy
of Diagnostic reports in all cases is mandatory.

13. Dental Expenses for Scaling, polishing and bleaching of teeth are not covered. Whereas

extraction, fillings, medicines, consultants fees, and x-rays only are reimbursed under Domiciliary.

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