Claims support

Chased by claim number, not by escalation email

A claim stalls quietly. A discharge summary is missing a line, a query letter goes to an inbox nobody owns, and nine days pass before anyone notices. Our desk holds every open claim by number with a named next action and a date, calls the third-party administrator on the ones that have not moved, and tells the employee the outcome so they are not refreshing a portal.

4 days

Median time from intimation to cashless approval on our desk this year. It was nine before we started attaching a date-of-first-diagnosis note at intimation rather than waiting for the TPA to ask.

Daily

Every open claim is reviewed each working morning. Nothing sits for a week because the person handling it was on leave.

Named

Each employer account has a claims coordinator by name, with a manager behind them. Employees speak to a person who already knows the file.

Cashless: a planned admission

The sequence when an employee is admitted at a network hospital and the bill is meant to go straight to the insurer.

Day minus 3 to minus 7 Intimation The employee tells our helpline, or the hospital's insurance desk sends the pre-authorisation form. We open a file, confirm the member is live on the policy, check the sum insured available and any sub-limit that will bite, and tell the employee the expected out-of-pocket before admission rather than after.
Same day Pre-authorisation raised The form goes to the TPA with the treating doctor's note stating the diagnosis and the date of first diagnosis, the estimated cost, the proposed room category and the member ID. That doctor's note is the document twelve of every forty-one queries used to be about, so we send it unprompted.
Within 24 to 48 hours Initial approval or query The TPA either approves an initial amount or raises a query. A query is answered the same working day where the document is with us, and within twenty-four hours where we have to get it from the hospital. We do not forward the query to the employee and wait.
During the stay Enhancement If the bill runs past the approved amount, the enhancement request is raised while the patient is still admitted, not at discharge. Discharge-time enhancements are where families end up paying and claiming back.
At discharge Final approval and settlement Final bill, discharge summary and investigation reports go across. We check the deduction statement line by line: non-payable consumables, proportionate deduction from a room-rent breach, any co-pay. Where a deduction looks wrong, we contest it before the file closes.
Within 2 working days of discharge Explanation to the employee A plain-language note: what was approved, what was deducted and why, and what to do about the pre and post-hospitalisation bills they are still holding.

Reimbursement: when cashless was not possible

An emergency admission at a non-network hospital, a night when the insurance desk was closed, a treatment at a nursing home that has no cashless tie-up. The employee pays and claims back, and the file has to be complete or it will be returned.

We collect the set, check it against the insurer's own checklist before it is couriered or uploaded, and keep the acknowledgement. Where the employee is still in hospital or grieving, we collect from the hospital's records department ourselves.

Post-hospitalisation bills are the ones most often lost. Sixty days after discharge the window shuts, and the physiotherapy or follow-up consultation is unclaimable. Our desk sends a reminder at day thirty and day fifty, per claim, per employee.

The reimbursement file

Completed claim form, signed by the employee and countersigned where the employer's attestation is required.
Original final bill with a detailed break-up, and the payment receipt.
Discharge summary stating diagnosis, date of admission and date of discharge.
All investigation reports and the prescriptions that ordered them.
Pharmacy bills matched to a prescription — unmatched chemist bills are the most common deduction.
For an accident, the police report or a medico-legal certificate.
Cancelled cheque or bank details in the claimant's name, and a copy of the identity proof.

Query and deficiency letters

A deficiency letter is not a rejection. It is the TPA saying a document is missing or a fact is unclear, and it carries a clock — commonly fifteen days, after which the file is closed for want of documents and has to be reopened. We treat every deficiency as ours to close: we read what is actually being asked, get the document from the hospital or the employee, and respond in writing against the claim number with the reference of the original letter. If the same deficiency appears three times across an account, we change what goes in at intimation so it stops appearing at all.

What employees see, what HR sees

The employee

One number to call, answered in Bengali, Hindi or English between 09:30 and 18:30, Monday to Saturday.
An SMS at each stage: intimated, pre-auth raised, query received, approved, settled — with the claim number in every message.
A named coordinator who already has the file open when they call back.
A written explanation of any deduction, in language that does not require reading the policy wording.
No requirement to explain their medical situation to their own HR department.

HR

An open-claims register updated daily: claim number, employee code, hospital, amount intimated, stage, days open, next action and whose it is.
No clinical detail. HR sees that a claim exists and where it stands, not the diagnosis, unless the employee has asked us to involve them.
An alert when a claim crosses ten days open or when a deduction above an agreed threshold is proposed.
A monthly count of claims by stage, feeding straight into the utilisation pack.

Escalation, in order

Level 1 — same day Coordinator to TPA claims processor By phone against the claim number, followed by an email that records what was said and what was promised.
Level 2 — day 3 with no movement Account manager to TPA team lead With the file history attached and the specific question isolated, so the conversation is not a re-reading of the whole claim.
Level 3 — day 7 To the insurer's corporate servicing team The insurer, not the TPA, owns the contract with your company. Most stalled files move here.
Level 4 — rejection we consider wrong Written representation, then grievance A representation to the insurer's grievance officer citing the policy clause relied on. If that fails and the employee wishes to continue, we prepare the file for the Insurance Ombudsman — dates, correspondence, the rejection letter — and hand it over in order. We do not charge extra for this and we do not do it quietly; HR is told each time it happens.

Have a claim that has not moved in a fortnight?

Send the claim number, the TPA name and whatever correspondence exists. We will read it and tell you what is actually being asked and what will close it — whether or not you become a client.

Send the claim details