Ultimate Guide to Health Insurance TPA Claim Process

Health Insurance TPA of India Ltd. is a joint venture of public sector Non-life insurance companies – National Insurance Co. Ltd, The Oriental Insurance Co. Ltd, The New India Assurance Co. Ltd, United India Insurance Co. Ltd and GIC of India.

It was incorporated on August 14, 2013 with two key objectives - to enhance customer experience and to bring in greater efficiency in health insurance claims processing. The company’s headquarters is in New Delhi and is planning to develop its branches in different cities in due course.

Procedure for Cashless Claims Process

  • Show the Member ID card at the network hospital TPA desk.
  • Fill the Pre-Authorization Request form for cashless claim. Get it signed by the treating doctor.
  • Fill up the HI TPA claim form after paying towards co-pay, non-payable items etc., when you get discharged.
  • HI TPA team will process the claim documents and the insurance company will make the payment to the hospital.
  • You can also claim pre- and post- hospitalisation expenses as per policy terms and conditions from HI TPA by submitting claim documents, relevant bills etc.
  • If, due to any reason, the cashless facility is not availed or is not approved you have to pay for the treatment upfront. Reimbursement of claim shall be filed with HI TPA after submission of claim documents.
View the Heritage Health Insurance TPA Network Hospitals here.

Procedure for Reimbursement Claims Process

  • Intimate the HI TPA/Insurer within 24 hours of hospitalisation. If the hospitalization is planned, inform the TPA 3 to 4 before the admission.
  • You have to make the payment to the hospital, collect all original bills & reports and get claim form filled and signed by the treating doctor.
  • Submit the copy of Member ID card, original claim form, original bills, reports, etc., to HI TPA.
  • Claim is processed as per policy T&C and payment is made to the Insured through NEFT.

Documents Required for Health Insurance TPA Claim

Health Insurance TPA claim documents are divided in 4 categories:

KYC Documents

The TPA needs these documents to establish the identity of the patient and the policyholder.

  • Patient’s Aadhar card copy
  • A PAN card copy or some other govt. ID proof of the policyholder
  • Policyholder’s original cancelled cheque
  • Health Insurance TPA e-card copy or the insurance certificate copy

To generate your Health Insurance TPA E-card online, click here

Hospitalization Documents

  • Hospital Main Bill
  • Hospital Break-up Bill
  • Hospital Discharge Summary
  • Pharmacy Bill
  • Hospital Bill Payment Receipt
  • Doctor’s Prescriptions
  • Operation Theater Notes

Additional Package breakup, if added in the bill, should be on network hospital’s letterhead. Just a plain paper and official seal can do too. For pre and post hospitalisation health Insurance claim, just the discharge papers with the doctor’s original prescription is required.

Investigation Reports

Submit the original lab investigation reports on the letterhead. A plain paper document with hospital’s seal will not be accepted by Health Insurance TPA. If the reports are missing from the claim, then:

  • It will lead to deduction in the claim amount.
  • A query in response to the claim will be raised.

In case the reports are actually missing, add a cover-note on top of the form with the list of reports not available. Also, in case of pre-hospitalization and post-hospitalization claim, add the doctor’s prescription to support the reports on a letterhead or a lab requisition slip.

Accident Details, if Applicable

  • Medico Legal Certificate
  • FIR (if you report the injury or accident)

The patient must also sign a detailed letter explaining the accident or injury to ensure that it isn’t the case of self-harm.

Health Insurance TPA Claim Form

Download Health Insurance TPA Claim Form

How to Fill Health Insurance TPA Claim Form

Section A-C

Section A to C contain the personal information of the primary policyholder and the patient including name, address and other details.

Section D

Details such as admission date, discharge date, date of diagnosis, the type of treatment or the nature of treatment, etc. go into section D.

Section E-F

Section E contains information about:

  • Pre-hospitalization – Amount incurred before the treatment
  • Hospitalization – Amount incurred during the treatment
  • Post-hospitalization – Amount incurred after the treatment

Extra expenses for ambulance, health check-ups, daily hospital cash, etc. are filled in the separate fields in this section. There is a space for 10 bills in this section. Use this space to list the details in the sequence – pre-hospitalization, hospitalization, post-hospitalization. Section F will take the similar information in a different format.

Section G-H

Section G is for bank details of the insured. Ensure the name filled in the form is exactly how it is written on the cheque or the DD payable details.

Section H requires you to sign the declaration.

Avoid common mistakes done when filling Health Insurance TPA claim form – Get Expert Help Now

Health Insurance TPA Submission Timeline

You will usually get a 15 to 30-day time period to submit the claim. However, different TPAs have different deadlines. So, to be on a safer side, submit the claim as soon as the patient gets discharged. You will get enough time until the TPA raises a query and you are asked to resolve it. You can then add the remaining documents later.

To ensure that you don’t miss the query request, keep checking Health Insurance TPA claim status.

Claim Submission Address

Employees who have the corporate policies are the main policyholders and can submit their claim in their workplace to an HI TPA agent or representative.

Get the list of all the HI centres here.

Make sure that you do not lose the receipt after you submit the claim until the claim is settled. Moreover, technical jargons in the claim form can get you confused and lead to claim rejection or a huge deduction in the claim amount.

Frequently Asked Questions

In cases of planned admissions, claim intimation should be done 72 hours prior to admission. For emergency or unplanned hospitalization, intimate Health Insurance TPA within 24 hours of the admission. You can contact HITPA by calling at the Toll Free number (1800 180 3600 / 1800 102 3600) or by filling the form here https://hitpa.co.in/Intimate-Claim

For your claim to be approved, it ideally takes 2-3 weeks from the submission date. Thereafter, HITPA intimates the insurance company regarding the claim approval and the amount that’s approved. The insurance company then transfers the amount approved to the account number mentioned in the claim form.

But if there are any queries raised and depending on the type of query raised, you can expect the claim to be delayed by another 4 to 8 weeks.

No. You just need to fill Part A form of Health Insurance TPA. This form is the same as the IRDA Claim Form part A.

Click here to track your claim status. Enter your claim number and mobile number to know or track the status of your claim.

The ideal time to submit your claim to HITPA is 7-15 days after discharge from the hospital. Although it varies from insurer to insurer.

If you are near your submission deadline and are still waiting for some documents, submit the claim form with whatever documents that are available with you. By doing this, you’ll meet your deadline and once the claim is in processing, HITPA will raise a query asking you to submit the missing documents. You’ll then have ample time to arrange and submit the documents.

If you have exhausted the sum insured in HITPA, you can claim the unclaimed amount from your second insurance policy. Once Health Insurance TPA settles your cashless claim, write to them asking for the hard copies of the following documents: Cashless claim settlement letter and attested copies of the claim documents that include the hospital bill and its breakup bill, lab investigation reports, discharge summary, hospital bill, and payment receipts.

Once you receive these documents from HITPA, submit them to your second insurance company to claim the unclaimed amount.

Submit your claim preferably to the TPA only.

Yes, you can. Medical expenses can be claimed for a period ranging from 30 days prior to date of hospitalisation up to 60 days to 90 days (as specified in the policy) from the date of discharge, provided they are related to the ailment for which you were hospitalized.

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