Frequently Asked Questions

Enrolment:

Q 1: If there is a change in name of the policyholder, will it affect the policy?

• If there are any alterations in the name, it has to be intimated to your respective insurance company and requisite endorsement for the change in name needs to be passed by insurance company. This has to be done on priority and need not wait till claim arises.

Provider:

Q 2: What is the definition of the hospital with regards to the health insurance policies?

• Any institution established for indoor care and treatment of sickness and/or injuries, which is duly registered and supervised actively by a registered medical practitioner.

OR

• Any establishment that satisfies the following criteria can qualify as a hospital :

  1. With at least 15 patient beds
  2. With a fully equipped operation theater of its own if surgical procedures need to be carried out
  3. Employing fully qualified nursing staff around- the- clock
  4. Having fully qualified doctors in charge around- the- clock

• Note: For Class 'C' towns the number of beds is relaxed to ten.

Q 3: What are the types of claims?

• Cashless: It can be availed only at network hospitals of Paramount Health Services and Insurance TPA Private Limited (Paramount) to the amount of pre-authorisation sanctioned .

• Reimbursement: It is a claim where the member pays all the expenses related to the hospitalization and submits the claim to Paramount for reimbursement of expenses.

Cashless Claims:

Q 4: What is the procedure for availing cashless facility?

• The following procedure should be followed to avail cashless benefits:

  1. Intimate Paramount about hospitalization.
  2. Present your Paramount ID card at the admission counter of the hospital. In absence of physical ID card, you can log in to Paramount portal and print an instant E-card.
  3. Ensure that the hospital sends pre-authorisation request form to Paramount.
  4. Paramount sends the approval to the hospital. Enhancement approvals may be sent based on policy terms and conditions.
  5. In case the request is denied, you will have to settle full hospital bill and subsequently submit a reimbursement claim to Paramount.
    (Note: Denial of pre-authorization request must not be construed as denial of treatment or denial of coverage.)
  6. After discharge, hospital will send all documents to Paramount.

Q 5: If I avail the cashless facility, will the insurance company pay the entire bill at the hospital?

• No, a part of the bill will have to be borne by the insured if it consists of the non- payable amounts that are listed by the insurer. (Link to non-payable amounts to be given). Also, if there is any co-payment applicable in the policy, then those charges will be borne by the insured.

Q 6: What happens in case of an Emergency hospitalization where Cashless facility is not authorized to me?

• The liability for paying the hospital will be on you. You would have to submit the claim documents to Paramount as mentioned in the checklist Claim Document Checklist for reimbursement. The Insurance company will then reimburse the admissible amount to you.

Reimbursement Claims:

Q 7: With whom should the claim be submitted, the Insurance company or Paramount?

• The claim should be submitted preferably with Paramount

Q 8: If I have not utilized my permissible eligibility amount in a particular policy period will it get carried forward to the next policy period?

• The amount will not be carried forward to subsequent periods.

Q 9: How do I submit a reimbursement claim?

  1. Intimate Paramount about a claim.
  2. Submit your reimbursement claim online within 7 days of discharge.
  3. Send the original documents to Paramount within 15 days from the date of discharge.
Paramount team processes the claim and sends it to your insurance company. If approved, payment is done through NEFT and if rejected, rejection letter is sent to you by insurance company.

Q 10: What are the documents required to be submitted to Paramount for a reimbursement claim?

• Documents that you need to submit for reimbursement claim are:

  1. Original completely filled Claim form
  2. Covering letter stating Schedule of Expenses
  3. Copy of the PHS ID card or current policy copy and previous years' policy copies (if any)
  4. Original Discharge Card/ Summary
  5. Original hospital final bill
  6. Original numbered receipts for payments made to the hospital
  7. Complete breakup of the hospital bill
  8. All bills for investigations done with the respective investigation reports
  9. All bills for medicines supported by relevant prescriptions

You may also refer to Claim Document Checklist. You are advised to keep photo copy of the entire set of claim documents submitted to us.

Q 11: How to send reimbursement claims to Paramount?

• Reimbursement claims can be submitted to us through registered post / courier or handed over at any of our branch offices.

Q 12: What are "Non- Admissible Expenses"

• 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- admissible expenses are listed in this link for your reference : Non Payable List

Q 13: Can I claim medical expenses incurred before and after the hospitalization?

• You can claim medical expenses incurred 30 days before and 60 days to 90 days after hospitalization ( as specified in your policy), provided they are related to the ailment/accident for which you were hospitalized. Such expenses are termed as pre and post hospitalization.

Q 14: Can I claim my dentist's bills?

• No, it’s not covered as per your policy terms and conditions.

Q 15: Will medical costs be reimbursed from day one of the cover?

• Typically, there is a waiting period of 30 days, within which no claims by the insured are allowed by the insurer. This waiting period may vary from one insurance company to other. Do read your policy document carefully.

Q 16:Are there any limitations for claiming under health insurance plan?

• There is no limit to the number of claims per policy period but there is a limit to the amount that you can claim in a year. Usually, the maximum amount that you can claim in a year is limited to the sum insured.

Q 17:If I have a health insurance policy in Mumbai, can I make a claim if I am transferred to Delhi?

• Yes, your health insurance policy is valid all over the country.

Q 18:Is there any waiting period applicable for ailments under the policy?

• Yes. There is 30 days waiting period for all ailments except accident. Pre-existing diseases will have a waiting period from 1 to 4 years depending upon the policy terms and conditions.

Q 19:Are all the diagnostic tests prescribed by the doctor at a hospital reimbursed under the Health Insurance Plan?

•Expenses incurred at a hospital or a nursing home for diagnostic purposes such as X-rays, blood analysis, ECG, etc. will be reimbursed if they are related to the ailment for which the policy-holder has been hospitalized. In any other scenario, these expenses will not be reimbursed.

Q 20:If I do not get admitted in a network hospital, am I still eligible to claim the expenses?

• Yes, claims will be reimbursed even if insured is not treated in a network hospital. The hospital should fall under the definition as described in Question no. 2.

Q 21:Is there a minimum time limit for stay within the hospital under the health insurance plan?

•Typically, the insured can make a claim if he/she is hospitalized for over 24 hours. However, for certain treatments, such as dialysis, chemotherapy, eye surgery etc. the stay could be less than 24 hours.

Q 22:What happens when the limit of insurance is exhausted under a Health Insurance Policy?

• If the insurance limit i.e. the sum insured is exhausted in a particular year, the insurer is not liable to bear/reimburse the insured for any further expenses.

Q 23:If a claim has been made for a particular ailment during the policy period, does it become a pre-existing disease for the next policy term?

• An ailment for which a claim has been made does not become a pre-existent disease if it is renewed without break with the same sum insured.

Q 24:Who will receive the claim amount if the insured dies at the time of treatment?

• The claim amount is paid to the registered nominee of the insured.

Q 25:What is Co-pay?

• Co-pay is the percentage applied on payable amount which the policy-holder has to bear.

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