Ultimate Guide to East West Assist TPA Claim Process

East West Assist TPA PVT Ltd was licensed by the Insurance Regulatory & Development Authority (IRDA) on May 16, 2002 to work as a dedicated insurance Third Party Administrator (TPA). It has a vast experience and a team of experts with the right skills who offer smooth and reliable TPA services in the healthcare insurance industry.

Documents Required for East West TPA

KYC Documents

Before reviewing your case, the insurance company establishes your identity using the KYC documents. So, you will need to submit:

  • Patient’s Aadhaar card copy
  • The insured person’s PAN card copy
  • East West TPA card or policy certificate
  • Policyholder’s cancelled original cheque

You can get your East West TPA e-card by clicking here.

Hospitalization Documents

Submit all the original hospitalization documents, i.e. documents on the letterhead of the hospital. Documents include:

  • Bill summary
  • Bill break up
  • Discharge summary
  • Payment receipts
  • Additional package breakup
  • Doctor’s prescription
  • Pharmacy bills
  • Operation theatre notes, etc.

For pre and post hospitalization claims, you don’t need to submit the bill breakups; you can just submit the discharge summary. In this case, ensure that you submit the lab bills, pharmacy bills, and consultation bill with your East West TPA reimbursement claim form.

Investigation Reports

Reconcile the investigation bills with your reports. Make sure that the reports are original, i.e. on the hospital’s letterhead. East West TPA will not accept reports printed on a plain paper with the seal.

If you’re unable to submit the investigation reports right away with the reimbursement claim form, then add a cover note and list of reports in the correct date-wise order with the form.

For pre and post hospitalization, the investigation reports must be attached with the doctor’s original prescription printed on the letterhead or the lab requisition slip.

Accident Details, if Applicable

  • Medico Legal Certificate
  • FIR, if you have reported the incident

If it’s the case of self-harm or an injury caused due to self, then enclose a letter with the details of the incident and the patient’s signature.

East West TPA Reimbursement Claim Form

Download the form and enclose the documents mentioned above with the correctly filled form.

Download East West TPA Claim Form

How to Fill East West TPA Claim Form

There are 8 sections in the East West TPA claim form known as Part A form.

Section A

Section A takes the policyholder’s details, i.e. the details of the one who pays the premium. In corporate policies, the employee is the policyholder.

Section B

If the patient has insurance coverage from any other policy as well, then fill the details of that policy in this section. Ignore this section if that’s not the case.

Section C

Section C takes patient’s demographics that include the age of the patient, their gender, their relation with the primary policyholder, etc.

Section D

Fill the hospitalization details including the hospital’s name, room category, admission & discharge date, type or nature of the illness or injury, and FIR & Medico-Legal Certificate if the injury is due to an accident.

Section E

Enter the total amount of all the bills during the hospital stay. The amount should combine all the bill amounts including blood bank charges, pharmacy charges, diagnosis charges, etc.

In the ‘pre-hospitalization’ section, fill the amount incurred prior to the hospitalization and in the ‘post-hospitalization’ section, enter the total amount incurred after the hospitalization.

Fill additional expenses including health check-up, blood-bank, ambulance charges, etc. in the separate field in this section.

Section F

List all the expenses in this section. You can list 10 bill amounts in this section as per the space given. If the number of the bills exceed 10, use a separate page altogether. Under the ‘Towards’ column, list the hospitalization expense in the first row, pre-hospitalization expense in the second row, the post-hospitalization expense in the third row, and the pharmacy expense in the fourth row.

Section G

Enter the bank information of the policyholder in this section correctly because the insurance company will credit the claim amount in your bank account as per the account details filled in this section of the form. If the total expense exceeds 1 Lakh, it is advisable to add the PAN card number of the policyholder.

Section H

The claimant must sign the declaration in this section.

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East West TPA Claim Submission Timeline

There is usually a 15 to 30 day submission timeline, and the delay in submitting the form as well as the documents can lead to deduction, and in worst case, rejection.

If you don’t have all the documents required to get the claim settled, then submit the documents that you have currently. The insurance company will raise a query, and by then, you will get enough time to get hold of all the original documents.

Claim Submission Address

Corporate policyholders can submit the form and the documents in their office premises to an East West TPA representative. Non-corporate policyholders can click on this link to get the address – http://eastwestassist.com/

Note: Keep the receipt intact and do not lose it until your claim is settled. Also, keep checking the East West TPA claim status by clicking here, so that you can resolve the query, if raised, in time.

Claimants often make a lot of mistakes while filling the form or attaching the required documents. And these mistakes result in huge deductions. So, make sure you’re very careful and follow the procedure correctly.

Frequently Asked Questions

For planned hospitalization, intimate 48 hours before admission. For unplanned or emergency hospitalization, intimate the TPA after the admission. Click here for the intimation link, or call Focus Health Insurance TPA customer care.

In a reimbursement claim, the TPA approves the claim within 2 to 3 weeks from the date of submission. Focus Health Insurance TPA then informs the insurance company about the claim approval and the claim amount that’s approved. The insurance company takes around 2 to 4 weeks to process the payments and transfer the amount in the bank account mentioned in the claim form. If the claim lacks any information or misses some documents, the claim gets delayed by another 4 to 8 weeks.

No. You need to fill only Part A of the Focus Health Insurance TPA claim form (the same as the IRDA Claim Form Part A).

Visit http://www.focustpa.com/ClaimStatus.aspx to track the claim status. Enter your Focus Health Insurance TPA card ID, policy number and policyholder’s name to track the claim status.

You can submit your claim within 15-30 days after discharge. If you miss your deadline, you can still send your claim along with a letter stating the reason for the delay. If Focus Health Insurance TPA finds your reason justifiable, they’ll process your claim.

We highly recommend claiming insurance regardless of how much time has elapsed since the discharge. If you have valid reasons, who knows, you might get lucky and your claim may get approved.

While submitting your claim, if you realise that you don’t have all the documents that are needed to file the claim, we advise you to file the claim with the documents you already have. It has two benefits: you submit your claim on time and when your claim file is in processing with the TPA, a query will be raised asking you to submit the documents, giving you enough time to arrange for the missing documents. Once you submit the missing documents, the claim processing continues as normal.

Yes. You can claim the unclaimed amount through your second insurance policy. However, you need to make sure that you have all the necessary documents to submit your claim to the second insurance company. For that, first you need to write to Focus Health Insurance TPA and ask them for hardcopies of the following documents:

  • Cashless Claim Settlement Letter
  • Attested copies of the claim documents (discharge summary, hospital bill, hospital bill breakup, lab and other investigation reports, and payment receipts).

Once you get all the documents, submit them to the other insurance company to claim the remaining hospital bill amount.

The minimum period of hospitalization required to be eligible for the claim is 24 hours. However, this period may be relaxed in case of day procedures like cataract and other eye surgery, tonsillectomy, radiotherapy, kidney stone removal, dialysis, D&C, chemotherapy, and other diseases. So, please read your policy document to figure out the eligibility for such types of claims.

Typically, there is a waiting period of 30 days. For further details, please refer to your policy document.

Typically, there is a waiting period of 30 days. For further details, please refer to your policy document.

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