The Policyholder's Guide to Focus Health Services TPA Claim Process

Focus Health Insurance TPA Private Limited is headquartered in Delhi with branches spread across metro cities in India. It has a hospital network of 2500+ hospitals with a dedicated panelof doctors for quality and comprehensive medical treatments.

This guide will assist you in completing the claim process flawlessly.

Focus HealthTPAClaim Process- Cashless

Cashless claim is a preferred choice among policyholders since it allows them to get the medical treatment without having to pay out of their pocket. And taking the terms and conditions of the policyand the deductibles into account, the insurance company pays the amount the insured is eligible for directly to the hospital.Below is the cashless claim process to help you understand better.

  • The insured visits a network hospital of Focus Health TPA
  • The hospital asks insured for the policy card so that they can send out a pre-authorization request to Focus Health TPA.
  • Once the hospital’s request is approved, the TPA sends the network hospital an authorization letter promising the payment.
  • The hospital then sends all your original medical documentsto Focus TPA and is paid directly.
  • In case of cashless treatment, don’t collect the original documents from the hospital. The insurance provider will directly pay the hospital.

Focus HealthTPAClaim Process – Reimbursement

In case of reimbursement claim, the TPA must be informed beforehand. So, the policyholder intimates Focus Health TPA 3-4 days before the admission date of the patient. If the admission wasn’t pre-planned, then intimation within 24 hours of admission is required. Here are the steps you need to follow to file a reimbursement claim.

  • Intimate Focus Health TPA about the claim.
  • Fill the Focus Health TPA claim form within 7 days after the patient is discharged.
  • Attach the documents and bills you have received from the hospital to justify the treatment with the claim form and send it to the TPA.
  • Check claim statusfrequently until you receive the claim amount from the insurance company.
  • If a query is raised by Focus Health TPA, then resolve it by attaching the documents asked for.

Documents required for Focus Health TPA Claim

The documents you will need to submit to the TPA to claim are divided in 4 categories:

KYC Documents

  • Patient’s Aadhar card copy
  • A government ID copy or the PAN card copy of the insured
  • A copy of insurance card
  • Main policyholder’s cancelled cheque

These documents allow Focus Health TPA to establish your identity to be able to settle the claim amount.

Hospitalization Documents

  • The discharge summary
  • Summary of all the bills
  • Detailed bill breakup
  • Payment receipt
  • Operation theatre notes
  • Prescription by the doctor
  • Pharmacy bills
  • Bill breakup of additional packages

All documents except the additional package bill must be on hospital’s letterhead. The additional package bill printed on plain paper with hospital’s seal can be submitted.

Investigation Reports

The original investigation reports, printed on hospital’s letterhead,must be submitted to Focus Health TPA. Pre and post hospitalization bills must be backed by the doctor’s prescription on the letterhead or the lab requisition slip.

Accident Details, if Applicable

  • Medico Legal Certificate
  • FIR (If you have filed a report)

These documents are required only in case of an accident. To prove that the injury isn’t caused by self-harm, the patient must write and sign the detailed explanation of the incident.

Focus Health TPA Claim Form

Attach the originals of the documents mentioned above with this form.

Download Focus Health TPA Claim Form

How to Fill Focus Health TPA Claim Form

The form is divided in 8 sections from section A to section H.

Section A

Fill the contact information of the policyholder in this section.Be extra careful while filling this section because a Focus Health TPA representative will contact the policyholder based on the information filled.

Section B

Fill this section if the patient is covered under any other policy as well.

Section C

Fill the demographic information of the patient in the section C. Enter name, age, gender, occupation, and how the patient is related to the policyholder.

Section D

All the information regarding where the patient was admitted, the category of room chosen, the date of admission, the date of discharge, FIR, Medico-Legal, the type of illness or injury, etc. needs to be covered in section D.

Section E

Fill the details regarding hospitalization expenses in section E. Fill the total bill amount in this section and separately fill the amount incurredin non-stay services including pharmacy, blood bank, ambulance service, etc.

Section F

In section F, list down all the bill amounts separately. There are 10 spaces for bill details which can be used for pre and post hospitalization charges. If the number of bills exceed, you can use a separate page to list more. Get a sum total of these amounts and mention them on the right side of the form. Mention the pharmacy bill amount separately in the 4th row.

Section G

Fill the policyholder’s bank details in section G. Ensure that the details match the ones on the cheque or DD payable.

Section H

In section H, the claimant signs the declaration with thedate and time.

Avoid common mistakes done when filling Focus Health TPA claim form

Focus Health TPA Submissions Timeline

You can submit your claim form within 15-30 days of discharge. If you think you may suffer a delay due to unavailability of the original documents, send the form with only the available documents attached. Add a cover note which must contain the list of documents not attached with the form. The TPA will take some time to verify your claim before raising a query. You can use this time to source the remaining documents so that you can resolve the query. Keep checking the status of your claim so that you don’t miss seeing the query and resolving it.

To check the status of your claim, please visit this link.

Claim Submission Address

Corporate employees can submit their claim forms to a Focus TPA representative.

Other policyholders can send the form on the addresses given on this page.

Small and silly mistakes can result in huge deductions in claim amount. Sometimes these mistakes can even lead to claim rejection. And we agree, even the first step, filling the claim form, can get complicated.

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 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.

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