Ultimate Guide to Raksha TPA Health Insurance Claim Process

Raksha TPA is one of the leading Health Insurance third party administrators (TPA) in the Indian insurance industry. It has a wide network of hospitals as part of its cashless network.

However, when a policyholder does not get a cashless facility, they have an option to claim their treatment expenses through reimbursement claim.

At SureClaim, we have provided a solution to many policyholders and resolved their claim related issues. In this article, we will discuss in detail various aspects of Raksha TPA reimbursement claim process. We’ll take these topics one by one in this guide.

Raksha TPA Cashless Claim Process

  • The insured must carry the physical ID proof or Raksha TPA E-card along with government photo ID proof and necessary documents.
  • The pre-authorisation form must be collected from the TPA desk in the network hospital and signed by the treating doctor after filling it correctly.
  • The hospital would then email the duly filled and stamped form with the declaration form to the insurance company. The insured can take approval 7 days prior to hospitalisation, in case of planned hospitalisation and within 24 hours of hospitalisation in case of emergency hospitalisation.
  • After receiving fax/email, a validation of coverage through policy no./Raksha Member ID on card, the request will be registered and unique cashless claim number would be generated.
  • The claim documents will be reviewed by claim processor/s and admissibility will be governed by the policy terms and conditions and on the basis of medication protocol, the hospital agreed tariff.
  • If the claim is inadmissible, an Authorisation Letter would be issued to respective network hospital confirming the interim authorised amount.
  • At the time of discharge, the hospital would send all hospitalisation-related documents along with discharge summary, final bill, reports, medicine details etc., and the cashless claim would be processed.

While seeking admission in a hospital, make sure it is a Raksha TPA Network Hospital. Click here to get the complete list of network hospitals for hassle-free treatment.

Raksha TPA Reimbursement Claim Process

  • Claim intimation with patient details, employee code/member ID, date of hospitalisation, diagnosis, treatment details & estimated cost has to be intimated to Raksha via email or phone.
  • Claim document along with duly filled and signed claim form must be submitted within 7 working days from the date of discharge to Raksha Health Insurance.
  • On receipt of claim documents at Raksha office, the claim would be scrutinized as per terms and conditions of your health insurance policy. Non-medical expenses or expenses not admissible as per policy terms and conditions will not be payable.
  • On receipt of complete documents, an appropriate claim decision will be recommended to your insurance company.
  • On approval of admissible claim amount, the insurance company will directly credit your bank account with the net payable amount through NEFT.

Documents Required for Raksha TPA Insurance Claim

KYC Documents

Know Your Customer (KYC) verifies and establishes the identity of the policyholder. Submit these KYC documents:

  • Patient’s Aadhaar card copy
  • Policyholder’s PAN card copy (or government ID proof)
  • Raksha TPA card or policy certificate
  • An original cancelled cheque of the policyholder’s bank account

Generate your Raksha TPA E-card using this link - https://www.Rakshatpa.com/WebPortal/Login/Anonymous/ECard.

Hospitalization & Treatment Documents

The original documents (printed on the hospital’s letterhead) such as discharge summary, payment receipts, hospital bill, package breakup, bill breakup, etc. issued by the hospital have to be submitted along with the claim form. Consider these checkpoints while gathering the documents from the hospital for the claim.

  • The hospital bill is usually a summary of all expenses incurred during hospitalization. Ask the hospital to give you a breakup of the bill.
  • If a surgery package reflects in your hospital bill, ask for the package break up on the hospital’s letterhead or with the hospital’s seal on it.
  • Ask for receipts for the payments you made to the hospital. Tally the receipt amounts with the final hospital bill amount.
  • For pre and post-hospitalization claims, all you need is a photocopy of the discharge summary. The hospital bill or its breakup is not needed.
  • Check the policy document for duration eligibility in case of pre and post-hospitalization. Include original pharmacy, lab, and consultation bills in your claim.
  • The doctor’s prescriptions have to be submitted in original to support all your pre and post-hospitalization bills. Otherwise, Raksha TPA may reject your pre and post-hospitalization claims.

Investigation Reports

Carefully examine the lab investigations that the hospital has billed you. Then reconcile them with your reports. All the reports have to be in original printed on the hospital’s letterhead or the lab’s letterhead. Raksha TPA may not accept the reports printed on a plain paper with the seal of hospital/lab on it. If you don’t have some reports, the best thing to do is write a cover note with a date-wise list of reports you are not going to submit. Raksha TPA may deduct the amount billed for the investigations from the claim amount. Or, it may raise a query to intimate you to submit the missing reports.

For pre and post-hospitalization claims:

  • Submit investigation/lab bills with the investigation reports.
  • Support the investigation reports with the doctor’s prescription that’s written/printed on their letterhead/lab requisition slip.

Accident Details, if Applicable

A medico-legal Certificate (MLC) from the hospital and an FIR copy (if reported to police) are needed. If the accident is self-injury, a letter needs to be drafted explaining the details of the injury. This letter has to be signed by the patient.

Raksha TPA Claim Form

Submit the above-mentioned documents with Raksha TPA Claim Form.

Download Raksha TPA Claim Form

How to Fill Raksha TPA Claim Form

Part A of the reimbursement claim form has eight sections. The information you fill will be useful for Raksha TPA to process your claim and you must attach all the supporting documents along with claim form.

Let’s look at all the information you require to fill the Raksha TPA claim form part A.

Section A-C

In section A, B and C, fill the primary policyholder’s and patient’s insurance details. For corporate health insurance plan, the corporate employee is the primary policyholder.

Section D

In section D, fill the patient’s age, gender, occupation, and relationship with the primary policyholder. The treatment information will include hospital name where treatment took place, room category used for the hospital stay, admission and discharge dates and the date of delivery or accident or the estimated date when the disease was first diagnosed as per applicability in the claim.

Section E-F

The claim form has space for 10 bills, so if you have more than 10 bills, use a separate sheet to mention details of all of them. Bill date, value and issuing hospital/shop is what you need for the bills. Make sure the bills are pre-numbered otherwise Raksha TPA will accept them. Do a total of bill values for expenses from the date and time of admission till date and time of discharge. This is called hospitalization expenses. All other bills before date and time of admission are considered pre-hospitalization expenses. Similarly, all bills after the date and time of discharge are considered post-hospitalization expenses. Fill this total in requisite fields.

In section F of the form, the total of these bills has to be mentioned in a slightly different way. You carry out a total of all pharmacy bills separately and mention that in the required field. Reduce the pharmacy bills from hospitalization, pre and post hospitalization totals when you fill this information in section F.

Section G-H

Bank account details of the primary policyholder need to be mentioned in the claim form as the settlement amount will only come to their account. If you give account details of the patient, who is not the primary himself or herself, then Raksha TPA will hold the payment till you give the account details of the primary. Thus, you will get your claim money faster if you mention account details correctly. Please note that the exact name of the bank account holder needs to be filled against the field ‘Cheque / DD payable details.’
Sign the declaration in section H.

Avoid common mistakes most claimants make while filling Raksha TPA claim form

Raksha TPA Claim Submission Timeline

Although different insurance TPAs have different timelines for claim submission, they typically fall 15-30 days after the discharge of the patient from the hospital. You need to follow the timeline given by your insurance TPA, otherwise, you claim can get rejected.

However, if you have a reason to justify your late submission, and if Raksha TPA is convinced with the reason, your claim can be accepted.

If you are nearing your submission deadline and you don’t have all the documents, submit your claim with whatever documents are available with you. By doing so, you’ll submit the claim form on time and when Raksha TPA gets to your claim, it’ll raise a query to submit the missing documents giving you time to procure those documents.

Claim Submission Address

Locate the Raksha TPA branch in your city here to send your claim documents.

Corporate employees can submit the claim form to the Raksha TPA representative visiting their office.

Track your Raksha TPA claim status here.

Most claimants make mistakes while filling the claim form. It could be either because they find the form confusing or they do not enough information to fill the form. Mistakes in the claim form can be costly as they can put your claim at risk of getting a reduced payout, delayed payment or worse – a claim rejection.

Frequently Asked Questions

The claim intimation must be made at least 3-4 days before the admission in case of planned hospitalization. However, if the hospitalization is an emergency case, Raksha TPA must be intimated within 24 hours of hospitalization.

Raksha TPA approves your claim usually within 3-4 weeks after it is submitted. But this is the case only when all the original documents required have been submitted.

Once the claim is approved, the TPA informs the insurance company about the same. The insurance company then again takes 2-4 weeks of time to transfer the amount in your bank account.

Documents that must be attached with Raksha TPA claim form are:

  • Raksha card photocopy
  • A copy of the policy certificate
  • First prescription/document with advice on admission
  • Investigation reports that Raksha TPA has requested

There could be many reasons that your claim may be denied such as incomplete documentation, unavailability of original bills, delay in submitting the claim, etc. However, if you think that the decision of the TPA can be reversed by a valid justification, then you can lodge a grievance. Click here to lodge a grievance at Raksha TPA.

Raksha TPA can claim status can be checked here.

You can get your Raksha TPA e-card here. All you need to fill in is the policy number.

No. Raksha TPA has a single form which is exactly the same as Part A of IRDA claim form.

Visit this link https://www.rakshatpa.com/WebPortal/Login/Anonymous/checkCoverage and enter your policy number to check the coverage details.

Policyholders usually have to submit the claim within 7 days after the discharge. The documents can then be submitted within 15 days after the discharge. If you do not have all the original documents, you can send the ones that you have. Raksha TPA will then raise a query and you can resolve the query with the documents that you collect in the meantime.

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