Claims Administration Process. The fulfillment of the terms and conditions of this Policy (including payment of premium in full and on time) insofar as they relate to anything to be done or complied with by You or any Insured Person, including complying with the following in relation to claims, shall be Conditions Precedent to admission of Our liability under this Policy: (1) On the occurrence or discovery of any Illness or Injury that may give rise to a Claim under this Policy, the Claims Procedure set out below shall be followed. (2) The directions, advice and guidance of the treating Medical Practitioner shall be strictly followed. We shall not be obliged to make any payments that are brought about or contributed to as a consequence of or failure to follow such directions, Medical advice or guidance. (3) If requested by Us and at Our cost, the Insured Person must submit to medical examination by Our Medical Practitioner as often as We consider reasonable and necessary and We/Our representatives must be permitted to inspect the medical and Hospitalisation records pertaining to the Insured Person’s treatment and to investigate the circumstances pertaining to the claim. (4) We and Our representatives must be given all reasonable co-operation in investigating the claim in order to assess Our liability and quantum in respect of the claim. I. Claims Procedure On the occurrence or the discovery of any Illness or Injury that may give rise to a claim under this Policy, then as a Condition Precedent to Our liability under the Policy the following procedure shall be complied with: a. For Availing Cashless Facility i. Cashless Facilities can be availed only at Our Network Providers. ii. We reserve the right to modify, add or restrict any Network Provider for Cashless Facilities at Our sole discretion. Before availing Cashless Facilities, please check the applicable updated list of Network Providers. b. Process for Obtaining Pre-Authorisation for Planned Treatment: (i) We/TPA must be contacted to pre-authorise Cashless Facility for planned treatment at least 72 hours prior to the proposed treatment. Each request for pre- authorisation must be accompanied with all the following details: (1) The health card which We or the associated TPA has issued to the Insured Person supported with the Insured Person’s KYC documents. (2) The Policy number; (3) Name of the Policyholder/Employer; (4) Name and address of Insured Person/Employee/member in respect of whom the request is being made; (5) Nature of the Illness/Injury and the treatment/Surgery required; (6) Name and address of the attending Medical Practitioner; (7) Hospital where treatment/Surgery is proposed to be taken; (8) Proposed date of admission. (ii) If these details are not provided in full or are insufficient for Us or the associated TPA to consider the request, We or the associated TPA will request additional information or documentation in respect of that request. (iii) When We or the associated TPA have obtained sufficient details to assess the request, We or the associated TPA will issue the authorization letter specifying the sanctioned amount, any specific limitation on the claim, applicable Deductibles and non-payable items, if applicable, or We may reject the request for pre- authorisation specifying reasons for the rejection. (iv) The authorization letter shall be issued to the Network Provider within 24 hours of receiving the complete information. (v) Once the request for pre-authorisation has been granted, the treatment must take place within 15 days of the pre-authorization date at a Network Provider and pre-authorization shall be valid only if all the details of the authorized treatment, including dates, Hospital and locations, match with the details of the actual treatment received. For Hospitalization where Cashless Facility is pre-authorised by Us or the associated TPA, We or the associated TPA will make the payment of the amounts assessed to be due directly to the Network Provider. c. Process to be followed for Availing Cashless Facilities in Emergencies: We or the associated TPA must be contacted to pre-authorise Cashless Facility within 24 hours of the Insured Person’s Hospitalization if the Insured Person has been Hospitalized in an Emergency. Each request for pre-authorisation must be accompanied with all the following details: (1) The health card We have issued to the Insured Person supported with the Insured Person’s KYC documents. (2) The Policy number; (3) Name of the Policyholder/Employer; (4) Name and address of Insured Person/Employee/member in respect of whom the request is being made; (5) Nature of the Illness/Injury and the treatment/Surgery required; (6) Name and address of the attending Medical Practitioner; (7) Hospital where treatment/Surgery is proposed to be taken; (8) Proposed date of admission. (9) ▇▇▇▇ completed claim form / pre-authorization form.
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