FAQ'S - Frequently Ask Questions

"TPA" means a Third Party Administrator who is licensed by the IRDAI, for the purpose of providing services to the “Health Insurance – Policyholders” under an agreement with an insurance company.

If there are any alterations in the name, it is to be intimated to your respective insurance company. Endorsement for the change in name needs to be passed by insurance company. This has to be done on priority.

Insured can download E cards from: https://www.paramounttpa.com/Home/InstantEcard.aspx

Hospital means any institution established for in-patient care and day care treatment of illness and/ or injuries and which has been registered as a hospital with the local authorities under the Clinical Establishments (Registration and Regulation) Act, 2010 or under the enactments specified under Schedule of Section 56(1) of the said Act, OR complies with all minimum criteria as under:

  1. has qualified nursing staff under its employment round the clock
  2. has at least 10 inpatient beds, in those towns having a population of less than 10,00,000 and 15 inpatient beds in all other places;
  3. has qualified medical practitioner (s) in charge round the clock;
  4. has a fully equipped operation theatre of its own where surgical procedures are carried out
  5. Maintains daily records of patients and will make these accessible to the Insurance Company’s authorized personnel.

A Hospital, which has an agreement with a TPA for providing Cashless treatment, is referred to as a 'Network Hospital'. Cashless facility is provided ONLY at the network hospitals. Cash less facility cannot be extended to non Network Hospitals.

Please, refer to Network Hospital Section of our Website for updated List.

Link https://www.paramounttpa.com/Home/ProviderNetwork.aspx

Expenses can be claimed on cashless or reimbursement basis.
Cashless: It can be availed only at network hospitals of Paramount Health Services and Insurance TPA Private Limited (Paramount) to the amount of pre-authorisation sanctioned.
Reimbursement: It is a claim where the member pays all the expenses related to the hospitalization and submits the claim to Paramount for reimbursement of expenses.

Please, refer to Network Hospital Section of our Website for updated List.

Link https://www.paramounttpa.com/Home/ProviderNetwork.aspx

In general, the Policy covers reimbursement of Hospital / Nursing Home expenses incurred by the insured as an inpatient for treatment of any disease or bodily injury through an accident. The expense incurred in the policy period, covered up to a maximum of the sum insured in aggregate are:
Room, Boarding Expenses as provided by the Hospital / Nursing Home, Nursing Expenses, Surgeon, Anesthetist, Medical Practitioner, Consultants, Specialists fees.
Anesthesia, Blood, Oxygen, OT Charges, Surgical appliances, Medicine and Drugs, Diagnostic Materials and X-Ray, Dialysis, Chemotherapy, Radiotherapy, Cost of Pacemaker, Artificial Limbs & Cost of Organs and Similar Expenses.

Link https://www.paramounttpa.com/Home/ProviderNetwork.aspx

No Claim / Cumulative Bonus are the bonus or rather a reward that a policyholder gets for not filing a claim. The benefit of cumulative bonus is granted in the year of renewal by making an increase in the sum insured amount, only up to a certain years for every claim-free year or giving discount in the renewal premium. Applicability of cumulative bonus depends on the insurance policy opted by you.

The following procedure should be followed to avail cashless benefits in network hospital:

  1. Intimate Paramount about hospitalization via - Toll free number / Website / Mobile App
  2. Present your Paramount ID Card along with Photo ID proof at the admission counter of the hospital. In absence of physical ID card, you can log in to Paramount portal and print an instant E-card.
  3. Ensure that the hospital sends pre-authorisation request form to Paramount.
  4. Paramount sends the approval to the hospital. Enhancement approvals may be sent based on policy terms and conditions.
  5. After discharge, hospital will send all original documents to Paramount for the cashless claim.
  6. In case the request is denied, you will have to settle full hospital bill and subsequently submit a reimbursement claim to Paramount. (Note: Denial of pre-authorization request must not be construed as denial of treatment or denial of coverage.)

No, certain items of the bill will have to be borne by the insured if it consists of the non- payable amounts that are listed by the insurer. (Link to non-payable items Non Payable List). Also, if there is any Co-payment or Capping applicable in the policy, then these charges will be borne by the insured.

The liability for paying to the hospital will be on the insured. You would have to submit the claim documents to Paramount as mentioned in the checklist for reimbursement (Claim Document Checklist) The Insurance Company will then reimburse the admissible amount to you as per the terms & conditions of the policy.

The claim should be intimated / submitted preferably with Paramount.

Insured can download E cards from: https://www.paramounttpa.com/Home/InstantEcard.aspx

Yes, every hospitalization has to be intimated to the insurance company on its occurrence immediately within 24 hrs or before the timeline mentioned in your policy. Claim intimation means you inform insurance company about your claim, but it does not necessarily mean that your claim will be approved and paid.

  1. Immediately intimate Paramount about the claim via Call / email / mobile app / website,
  2. Submit the original documents to Paramount within 7 days from the date of discharge or before the eligible submission period mentioned in the policy.

Paramount team processes the claim and sends it to your insurance company. If approved, payment is done through NEFT and if rejected, rejection letter is sent to you by insurance company.

You may submit the claim documents as per the checklist along with a letter mentioning the reason for delayed submission. These documents will be sent to insurer delay condonation.

Documents that you need to submit for reimbursement claim are:

  1. Original completely filled & signed IRDAI Claim form
  2. Covering letter stating Schedule of Expenses
  3. Copy of the PHS ID card or current policy copy and previous years' policy copies (if any)
  4. Original Discharge Card/ Summary
  5. Original hospital final bill
  6. Original numbered receipts for payments made to the hospital
  7. Complete detailed breakup of the hospital bill
  8. Original bills for investigations done with the respective investigation reports and films
  9. Original bills for medicines supported by relevant prescriptions
  10. NEFT details of the proposer.
  11. Valid Photo Id proof
  12. KYC document(details)

You may also refer to Claim Document Checklist. You are advised to keep photo copy of the entire set of claim documents submitted to us.

Reimbursement claims can be submitted to us through registered post / courier or handed over at any of our branch offices.

Reimbursement claims can be submitted to us through registered post / courier or handed over at any of our branch offices.

Yes, you can claim medical expenses incurred 30 days before and 60 days to 90 days after hospitalization (as specified in your policy), provided they are related to the ailment / accident for which you were hospitalized. Such expenses are termed as pre and post hospitalization.

Usually, it is not covered as per terms and conditions of policy unless arising out of accidental injury.

Typically, there is a waiting period of 30 days, within which the insured cannot claim for any hospitalization expenses except accidental claims. This waiting period may vary from insurer to insurer. (Please refer your policy document)

There is no limit to the number of claims per policy period but there is a limit to the amount that you can claim in a year. Usually, the maximum amount that you can claim in a year is limited to the sum insured.

Yes, There is 30 days waiting period for all ailments except accident on the inception of the fresh policy. Pre-existing diseases & certain aliments will have a waiting period from 1 to 4 years depending upon the policy terms and conditions. Refer your policy document for complete list and waiting period.

Yes, your health insurance policy is valid all over the country. (Some policies have zone wise limitations)

Expenses incurred at a hospital or a nursing home for diagnostic purposes such as X-rays, blood analysis, ECG, etc. will be reimbursed if they are related to the ailment for which the policy-holder has been hospitalized.

Yes, claims will be reimbursed even if insured is not treated in a network hospital. The hospital should fall under the definition as described in Q4.

Typically, the insured can claim if he/she is hospitalized for more than 24 hours. However, for certain treatments, such as dialysis, chemotherapy, eye surgery etc. the stay could be less than 24 hours which is treated as day care. (Refer your policy document for complete list of day care procedures)

If the insurance limit i.e. the sum insured is exhausted in a particular year, the insurer is not liable to bear/reimburse the insured for any further expenses.

An ailment for which a claim has been paid does not become a pre-existent disease in the next term, if the policy is renewed without break for the same sum insured.

The claim amount is paid to the registered nominee of the insured mentioned on the policy copy.

Co-pay is the percentage applied on admissible amount which the policy-holder has to bear, as per policy terms and conditions.

In case of an emergency or unplanned admission, the hospital must send the pre-authorization request to Paramount within 24 hours from the time of admission. In case of a planned hospitalization, it is prudent to send the pre-authorization request to Paramount at least 72 hours prior to the admission date. This will ensure a hassle-free cashless admission procedure for you at the hospital. Cashless Email Id: al.request@paramounttpa.com

The claims are processed as per the Policy Terms, Conditions & Exclusions. A claim may be rejected if it falls under the exclusions mentioned in the policy or due to non- compliance with the policy conditions or discrepancy in the submitted documents.

This is a letter sent for requirement of additional information / non submitted documents to conclude the coverage of claim submitted by insured. These documents should be sent within 7 days from the notification of insufficient documentation. Insured can submit these documents to the nearest Paramount branch.

If there is a sub-limit on rooms and the policyholder occupies a room with a tariff that’s more than what he is eligible for, the proportionate deduction on ‘associated medical expenses’ are the incremental charges which the insured has to pay.

Paramount makes all the efforts to ensure that the policyholders are given the utmost priority. Processing and settlement of claims with other allied activities are done at the earliest. However, even after putting in enough efforts to satisfy our valued Insured, the possibility of a grievance cannot be avoided. We have established a dedicated cell to redress such grievances. You may mail to: contact.phs@paramounttpa.com

You can contact Paramount via Call / Emails:-
Contact number: 1800 22 66 55 (Tollfree) & 022-66620808 (24x7)
Email: contact.phs@paramounttpa.com