Q 1 : What is a TPA?
"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.
Q 2 : If there is a change in name of the policyholder, will it affect the policy?
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.
Q 3 : How can I get my E-card?
Insured can download E cards from : https://www.paramounttpa.com/Home/InstantEcard.aspx
Q 4 : What is the definition of the hospital with regards to the health insurance
policies?
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 :
- has qualified nursing staff under its employment round the clock
- 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;
- has qualified medical practitioner (s) in charge round the clock;
- has a fully equipped operation theatre of its own where surgical procedures are
carried out
- Maintains daily records of patients and will make these accessible to the Insurance
Company’s authorized personnel.
Hospital shall not include an establishment which is a rest home or convalescent
home for the addicted, detoxification centre, sanatorium, home for the aged, mentally
disturbed, remodeling clinic or similar institution
Q 5 : What is a Network Hospital?
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
Q 6 : What are the different ways to claim the expenses under the policy?
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.
Q 7 : What is the coverage of a mediclaim policy?
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.
Q 8 : What is No Claim / Cumulative bonus?
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.
Q 9 : What is the procedure for availing cashless facility?
The following procedure should be followed to avail cashless benefits in network
hospital :
- Intimate Paramount about hospitalization via - Toll free number / Website / Mobile
App
- 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.
- Ensure that the hospital sends pre-authorisation request form to Paramount.
- Paramount sends the approval to the hospital. Enhancement approvals may be sent
based on policy terms and conditions.
- After discharge, hospital will send all original documents to Paramount for the
cashless claim.
- 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.)
Q 10 : If I avail the cashless facility, will the insurance company pay the entire
bill at the hospital?
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.
Q 11 : What happens in case of an Emergency hospitalization where Cashless facility
is not authorized to me?
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.
Q 12 : Where should the claim be intimated/submitted, the Insurance company or Paramount?
The claim should be intimated / submitted preferably with Paramount.
Q 13 : If I have not utilized my permissible eligibility amount in a particular policy
period will it get carried forward to the next policy period?
The amount will not be carried forward to subsequent periods.
Q 14 : Whether intimation is necessary for every hospitalization?
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.
Q 15 : How do I intimate & submit a reimbursement claim?
- Immediately intimate Paramount about the claim via Call / email / mobile app / website,
- 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.
Q 16 : What should I do, if I am not able to submit the claim documents within the
eligible submission period?
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.
Q 17 : What are the documents required to be submitted to Paramount for a reimbursement
claim?
Documents that you need to submit for reimbursement claim are :
- Original completely filled & signed IRDA Claim form
- Covering letter stating Schedule of Expenses
- Copy of the PHS ID card or current policy copy and previous years' policy copies
(if any)
- Original Discharge Card/ Summary
- Original hospital final bill
- Original numbered receipts for payments made to the hospital
- Complete detailed breakup of the hospital bill
- Original bills for investigations done with the respective investigation reports
and films
- Original bills for medicines supported by relevant prescriptions
- NEFT details of the proposer.
- Valid Photo Id proof
- 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.
Q 18 : How to send reimbursement claims to Paramount?
Reimbursement claims can be submitted to us through registered post / courier
or handed over at any of our branch offices.
Q 19 : What are "Non Admissible Expenses / Non Payable Expenses"?
Your health insurance policy pays for reasonable and necessary medical expenditure.
There are several items that do not classify as medical expenses during hospitalization.
These items will not be payable and expenditure towards such items will have to
be borne by you. Non Admissible Expenses / Non Payable Expenses are listed in this
link for your reference : Non Payable List.
Q 20 : Can I claim medical expenses incurred before and after the hospitalization?
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.
Q 21 : Can I claim my dentist's bills?
Usually, it is not covered as per terms and conditions of policy unless
arising out of accidental injury.
Q 22 : Will medical costs be reimbursed from day one of the insurance cover?
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)
Q 23 : Are there any limitations for claiming under health insurance policy?
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.
Q 24 : Is there any waiting period applicable for ailments under the policy?
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.
Q 25 : If I have a health insurance policy in Mumbai, can I make a claim if I am
transferred to Delhi?
Yes, your health insurance policy is valid all over the country. (Some policies
have zone wise limitations)
Q 26 : Are all the diagnostic tests prescribed by the doctor at a hospital reimbursed
under the Health Insurance Plan?
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.
Q 27 : If I do not get admitted in a network hospital, am I still eligible to claim
the expenses?
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.
Q 28 : Is there a minimum time limit for stay within the hospital under the health
insurance plan?
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)
Q 29 : What happens when the limit of insurance is exhausted under a Health Insurance
Policy?
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.
Q 30 : If a claim has been paid for a particular ailment during the policy period,
does it become a pre-existing disease for the next policy term?
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.
Q 31 : Who will receive the claim amount if the insured dies at the time of treatment?
The claim amount is paid to the registered nominee of the insured mentioned
on the policy copy.
Q 32 : What is Co-pay?
Co-pay is the percentage applied on admissible amount which the policy-holder
has to bear, as per policy terms and conditions.
Q 33 : What is the time limit to submit pre-authorization request to Paramount?
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
Q 34 : When can a claim be rejected?
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.
Q 35 : What is Deficiency Letter?
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.
Q 36 : What are the incremental / proportionate charges?
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.
Q 37 : How can I contact Paramount TPA?
You can contact Paramount via Call / Emails :-
Contact number : 022-66620808 (24x7)
Toll Free Number : 1800226655
Email : contact.phs@paramounttpa.com
Q 38 : What is the definition of a deductible in a health insurance policy?
Deductible : means a cost-sharing requirement under a health insurance policy that provides that the Insurer will not be liable for a specified rupee amount in case of indemnity policies and for a specified number of days/hours in case of hospital cash policies, which will apply before any benefits are payable by the insurer. A deductible does not reduce the sum insured
Q 39 : What are "Reasonable and Customary Charges" in the context of health insurance?
Reasonable and Customary Charges” means the charges for services or supplies, which are the standard charges for the specific provider and consistent with the prevailing charges in the geo-graphical area for identical or similar services, taking into account the nature of the illness / injury involved.
Q 40 : What is a Top Up policy in health insurance?
Top Up policy : A top-up health insurance plan is an indemnity policy that provides additional medical coverage to people with an existing health insurance policy or an employer mediclaim policy. It allows people to get their medical expenses covered even if they have exhausted the sum insured of their regular health insurance policy.
Q 41 : What is a Super Top Up policy in health insurance?
Super Top Up policy : Indemnity-based health insurance product with annual aggregate deductible (threshold) for accumulated medical expenses during the policy period for you and your family that offers a wide cover above the opted Threshold level.