1. Claim Process- Cashless
Hospital applies for pre-authorization to the TPA within 24 hrs of admission
A query letter sent by TPA through Fax/ to hospital
Denial letter sent by TPA through Fax/ to Hospital
Patient pays the bill and can submit papers for reimbursement process
4 hours prior to Discharge approach TPA Desk of hospital to complete formalities for full and final approval from TPA
Initial Approval letter sent to hospital by TPA by Fax/
Hospital replies to query raised by TPA through /Fax
Get admitted as per hospital norm & contact TPA desk of hospital for cashless
Hospital applies for pre-authorization to the TPA prior to admission
Approach TPA desk of hospital 48 hours prior to admission for cashless
Query (s) by TPA
Denied Cashless by TPA
Approval given by TPA
TPA verifies policy coverage & details and responds to hospital by fax/
Cashless
Hospitalization
Emergency Admission
Planned Admission

2. Claim Process- Cashless
Please Remember the following as regard to cashless services:
Secure your Paramount ID Card and carry it with you at all times or else remember or note your ID
no.
Your Paramount ID Card along with a Photo Id Card will identify you as a beneficiary and will give
you access and cashless benefits across all network hospitals in India.
Get the pre‐authorization done in at least 3-4 days before hospitalization in case of planned
treatments in case of emergency please approach TPA desk immediately.
This is done to determine whether cashless facility can be granted based on all medical information
about your ailment and coverage
Pre‐authorization forms are available at the TPA desk of all network hospitals.
Your treating doctor has to sign the pre authorization form.
You or your family member may have to sign the pre authorization form and suggest you to
provide your mobile number to contact whenever necessary.
For updated list of network hospitals please visit :
Phone No.: / Fax No.:

3. Claim Process- Cashless
Please Remember the following as regard to cashless services:
Cashless facility is always subject to the broader policy guidelines and relevant terms and conditions.
If cashless is denied , a denial letter will be sent to the hospital and inform you the cashless has been denied, you will have to pay the hospital bill and then send the claim for reconsideration through reimbursement process.
Please note that decline of a request for cashless hospitalization is in no way to be treated as denial of treatment or claim. The insured retains the right to get treated and submit the bills for subsequent reimbursement.
Patients seeking treatment under cashless hospitalization are eligible to make claims under pre and post hospitalization expenses. For all such expenses, the bills and other required documents need to be submitted separately as part of non-cashless claims
Please note that deposits at the time of hospital admission is a policy followed by many corporate hospitals and it is nothing to do with insurance policy. This is required for some hospitals even if cashless has been authorized. The TPA or the insurer doesn’t have any control over the same and the refund of the same will be as per the policy of hospital or nursing home.

4. Claim Process- Reimbursement
A Query letter sent by TPA mentioning requirement
Repudiation letter mentioning the reason for rejection will be sent to corporate
TPA/ Insurer arrange for NEFT to employees account corporate OR execute NEFT
Few Reminders at fixed intervals sent by TPA
Get Admitted in the Hospital/ Nursing home as per their Norms
Deficiency / Queries
Rejected/ Denial
Approved
TPA verifies/scrutiny of documents & claim submitted as per the policy coverage & conditions
Reply/ Documents Received
Reply Not Received
Claim Closed without payment
Emergency Admission
Non Network Hospital Admission
Planned Admission
Intimate the claim to TPA
Submit all relevant & mandatory claim documents to prudent brokers/ TPA at the earliest

5. Claim Process- Reimbursement
Please Remember the following as regard to Reimbursement services:
The Policy has claim intimation clause of 48 hrs from date of Admission. Please intimate each and every claim to TPA without fail via following modes:
Toll Free No.s/ Tel No.s :
Address:
Fax No.: /543/784/489
Please ensure that all claim papers pertaining to the claim should reach TPA within 15
days from date of discharge for smooth claim processing. Non compliance of this condition
can cause unprecedented delay in claim settlement OR deduction in claim amount OR denial of
claim as per insurance policy.
All bills with respect to pre hospitalization and post hospitalization should reach TPA within
30 days of discharge from hospital. Post hospitalization bills must be submitted within 7 days
of completion of the hospitalization related treatment or completion of 67 days post discharge,
whichever is earlier.
Online claim status can be seen on:

6. Reimbursement Claim Documents
Claim Form duly signed by the claimant or family member.
First prescription / consultation letter from your doctor.
Copy of the PHS ID Card and photo ID
Original hospital discharge card. Bills should be numbered.
Original hospital bill giving detailed break up of all expense heads mentioned in the bill, like medicines charges, surgeon/ doctor charges, room charges, consultation & visit charges, operation theatre charges, consumables, transfusions etc.
Original money receipt duly signed with a revenue stamp.
All bills of pharmacy, laboratories along with corresponding original prescription duly endorsed by the treating doctor.
All original laboratory & diagnostic test reports. E.g. X‐Ray, E.C.G, Ultrasound, MRI Scan, Haemogram etc.
If you have purchased medicines in cash & not mentioned in the hospital bill please enclose a prescription from the doctor along with medicine bill from the Chemist.
In case of a cataract operation, please enclose the IOL Sticker & lens invoice.
Indoor case papers, if required

7. Reimbursement Claim Documents PLEASE NOTE (IMPORTANT):
12. If you have paid cash for diagnostic or radiology tests and it has not been reflected in the
hospital bill, please enclose a prescription from the doctor advising the tests, the actual test
reports and the bill from the diagnostic centre for the tests.
13. For accident cases only ‐ A declaration statement by the claimant or his/her family member
explaining how the accident occurred. (The First Information Report ‐ FIR Copy and Medico Legal
Certificate ‐ MLC if available should also be attached)
14. In case the hospital is not registered, please get a letter on the hospital letterhead mentioning
the number of beds and availability of doctors and nurses round the clock.
15. X-ray plates and films are required only in case of claims for accident and fracture.
PLEASE NOTE (IMPORTANT):
All documents pertaining to claim need to be submitted in ORIGINAL and suggest to keep a photo-copy of all documents that are being submitted to the TPA for your records.
There may be additional documents other than the above mentioned list, required by the TPA, based on specific treatments.

8. Frequently Asked Questions (FAQs)
Q 1. Within how many days will I get my Cashless/Wellness Card?
Ans: You will receive the cashless cards via e‐mail within 30 days after your details are received by us.
Q 2. What if there is an error on my Cashless/Wellness Card?
Ans: For any error in cards or correction required, you can immediately mail to us through your HR with required correction.
Q 3: How does the hospital verify the cardholder is genuine?
Ans: Since the card issued by TPA is not a photo card you are always requested to submit a photo ID to verify the genuineness of the identity at the admission desk of the hospital. The photo ID can be your Company’s ID card, Driving License or any other such card.
Q 4: Where Do I procure the Admission Request Note form?
Ans: The “Admission Request Note” is available at the TPA desk with the network hospitals.

9. Frequently Asked Questions (FAQs)
Q 5: How to Fill the Admission Request Note?
Ans: a) To be filled by the treating doctor – ID no. as printed on the card, signs and symptoms of the
present ailment, duration of the ailment, diagnosis, pre-existing conditions if any, proposed line
of treatment, date of admission, duration of stay and approx. cost of hospitalization.
b)To be filled by the claimant – consent of the claimant to the terms and conditions of TPA,
authorizing them to obtain details of treatment from hospital and also authorize TPA to pay the hospital bill.
Q 6. What are the circumstances under which a request for cashless hospitalization can be declined?
Ans: a)If the information contained in the request is insufficient for TPA to arrive at a decision and further information is not available for any reason.
b) The ailment for which hospitalization is sought is not covered under the policy or is a part of an exclusion.
c) The insured person has exhausted his sum insured for the year.

10. Frequently Asked Questions (FAQs)
Q 7. What if I have not got your cashless E card yet? Am I covered? What do I need to do to get cashless treatment?
Ans: The claims would be settled without the E cards provided the claimant (the employee or the dependent) is endorsed/ covered in the policy. You would be entitled to cashless treatment but in such case you are requested to get in touch with Paramount/HR, before the hospitalization.
Q 8. If I avail cashless facility, will the Insurer pay the entire amount or will I be required to bear part of the bill at the hospital?
Ans: All expenses that are covered under the insurance policy will be paid for by the insurer. However, you will be required to pay for non admissible expenses, if any, such as registration charges, charges incurred on account of person accompanying you, etc. Further, you will also bear the amount deducted on account of any restriction in the policy like standard deductions co-pay, etc.

11. Frequently Asked Questions (FAQs)
Q 9. Are there any norms related to the hospital where treatment is sought which are mandatory for admissibility of claim?
Ans: In case you choose to get treated at a non-network hospital, you will have to pay the cost of treatment up front. The selected hospital/ nursing home must fulfill the following criteria:
It should have at least 15 inpatient beds.
Fully qualified doctor(s) should be in charge round the clock.
Should be registered with the relevant governmental and regulatory authorities. The registration number should be printed on discharge summary and / or receipt of the Hospital.
Further, it necessarily should not be blacklisted with the TPA.
Q 10. What if I undergo major hospitalization in 2 different hospitals? Will the policy reimburse expenses incurred?
Ans: Yes. The expenses are reimbursed up to the limit of sum insured and if they satisfy the terms and conditions of the policy and proper documents required for both the hospitalization (Discharge Summary from both the hospital is must)

12. Frequently Asked Questions (FAQs)
Q 11. Can I file more than one claim in a year?
Ans: You can claim as many times you are hospitalized during the period of Insurance but the insurance company's liability in respect of all claims put together shall not exceed the sum insured.
Q 12. Will my hospitalization be covered under Health Insurance, if I have been admitted under doctor’s instructions but no treatment is given?
Ans: No. Hospitalization not accompanied with active line of treatment and if the hospitalization is not justified the same will not be covered under health insurance.
Q 13. Will I get my claim papers back?
Ans: No, you will not get the claim papers back even after settlement of the claim. You are expected, to keep a photocopy of the same for your future reference, before submitting the papers. Certain high end or complicated or specific reports will be returned back with a special request on case to case basis 15 days after settlement of claims.

13. Contact Details
Location NAME CONTACT NO
Mumbai Vinayak Yadav
Mansi Sawant
Roshni Ganjawala
Pune Gulab Kherade
Dipti Patil
Kakinada Dipti Patil

14. Thank you! Stay healthy.