HDFC Ergo Health Insurance Claim Settlement Ratio

The health claim settlement ratio of HDFC Ergo Health Insurance is 97% for the fiscal year 2019. Your insurer’s claim settlement ratio can tell you how trustworthy the company is when it comes to claim settlement.

For health insurance companies, a health claim ratio ranging from 80% to 90% is a good indicator of the insurer’s capability to address its customer’s claims during a financial year.  Read to know more details about HDFC Ergo Health Insurance claim settlement procedure.

Claim Process of HDFC Ergo Health Insurance

You as a policyholder can avail of treatment in both network and non-network hospitals. The procedure for a planned and unplanned hospitalization is different.

For cashless hospitalization treatment needs to be taken in any of the network hospitals. And for hospitalization in non-network hospitals, a claim for reimbursement needs to be registered. The procedure for both cashless and reimbursement claims is given below:

Claim Process for Cashless Treatment

When you undergo treatment in a network hospital the claim procedure goes as follows:

Emergency Hospitalization

Step 1-Get admitted to the hospital and begin with your treatment

Step 2- As soon as possible inform the insurer and Policybazaar’s claim team. Also, coordinate with the hospital to have the detail sent to the insurance provider for cashless service.

Step 3- Get authorization for cashless treatment

Step 4- At the time of getting discharged pay for the non-reimbursable expenses including the co-pay

Step 5- Sign on the authorization letter, verify all the bills and sign them

Step 6- Leave the investigation reports and original discharge summary with the hospital and keep a photocopy with you for records

Step 7- Sign the Claim Form

Planned Hospitalization

Step 1: In case of a planned treatment you need to align with your hospital/doctor and share the details of your treatment, an estimate of the cost involved, etc. the insurer. 7 days before your treatment, another important thing is to indicate the fax number or address to where the authorization is to be sent. Provide your mobile number for all points of communication and to receive authorization and updates related to claims.

Step 2: Once the insurer approves the cashless treatment, you can provide the authorization letter to the hospital with a photocopy of an ID proof

Step 3- When getting discharged you only pay for expenses that are not covered, cross-check your hospital bills, and sign them

Step 4- Leave the investigation reports and original discharge summary with the hospital and keep a photocopy with you for records

Step 5- If authorization for a cashless claim is not provided you can register for claim reimbursement

Claim Process for Reimbursement-

When you undergo treatment in a non-network hospital the claim procedure goes as follows:

Emergency Hospitalization

Follow the process as given below for claims related to emergency hospital admission:

Step 1- Get admitted to a non-network hospital

Step 2- Inform the insurer about the hospitalization or speak to our health insurance customer care team for claim settlement

Step 3- At the time of getting discharged from the hospital; settle your hospital bills, and collect your documents, reports, and bills

Step 4- Lodge your medical insurance claim request with our claim processing team for settlement

Planned Hospitalization

Follow the process as given below for claims related to a planned treatment:

Step 1- Inform the insurer 7 days prior to hospital admission. You can also inform our health insurance claim team regarding this planned treatment at least a week in advance.

Step 2- Get admitted to a non-network hospital

Step 3- When getting discharged from the hospital; settle your hospital bills and collect all the hospital documents, reports, and bills

Step 4- File your health claim request with our claim team for reimbursement

Documents Required for HDFC Ergo Health Insurance

Furnish the following documents as per the nature of the claim:

Documents Required for Cashless Claims:

  • Unique Health Identification card number
  • All the medical/hospital records
  • Identity Proof

Documents Required for Claim Reimbursement:

  • Claim form (duly signed and filled) 
  • Hospital bills and original receipts - with bill number stamped & signed by the hospital, along with an itemized bill
  • Discharge summary/hospital discharge card
  • Doctor's prescription with medical bills and original investigation reports
  • Death certificate from the hospital (in case of death)
  • Follow-up advice from the doctor or letter for further line of action post-discharge from the hospital  
  • In the case of a non-registered hospital, you need to submit a letter on the hospital’s letterhead stating the number of beds and availability of nurses and doctors. Sometimes the registration number of the hospital and the doctor is also required.
  • Your NEFT Details are also required (a copy of the canceled cheque/ copy of the bank passbook confirming the account details).
  • KYC Documents/Identity Proof

For detailed information and understanding, you can get in touch with our medical insurance experts over email, and call.

Written By: PolicyBazaar - Updated: 02 February 2021

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