Insurance claim process

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Insurance claim process by Pousse

Re-imbursement Procedure (Cashless Procedure)

[TAT- 8 week After submission of all Documents]


Employee submits to claim forms to PMS


PMS checks on all the documemts & submits


Unisons validates the Customer ID


Document Completion Verification


Papers handed to Investigation Team


Claim Papers checked by Insurance trained


Claim checked by Panel of Doctors


Claim Approval


Payment released tp PMS


PMS releases the cheque to the Employee

E-Cashless Procedure

[TAT 24 hours (Mon-Sat)


Employee/ Employees relative needs to inform PMS on the case


Employee approaches network hospital with their Insurance card


Hospital faxes Pre Authorization to TPA


Request recived at TPA Pre Auth Dept


Claims Dept checks for coverage and eligibility


Medical Dept checks for Treatment costs and tariff


Authorization faxed to Hospital

Documents Requirement mandatory for processing of a Claim

Accidental Death Claim

Certified True Copy of the F.I.R lodged by Police Authorities

Post Mortem Report in Original or certified true copy

Certified True Copy of Death Certificate issued by the Municipal Authorities

Local Newspaper clipping if the accident has been reported or Eye Witness’s version of the accident (this is not mandatory but it’s presence reduces the TAT of the Investigating Agency)

Claim form duly filled in, certified

Temporary Total Disablement

Original Certificate from the treating doctor certifying the circumstances & extent of the injury & period of bed rest advised

Original Fitness Certificate from the same doctor mentioning that the claimant is fit to resume duty

Original Certificate from the Employer acknowledging the leave of absence

Documents Requirement mandatory for processing of a Claim (Re-imbursement)

Main Hospitalization

Signed Claim mentioning TPA I.D. No.

Original Discharge Summary must have Date of Admission and Date of Discharge, presenting complaints & their duration, final diagnosis, line of treatment given & advice on discharge.

Time of admission & discharge should be mentioned in Discharge Summary

Original final hospital bill in a proper bill format along with Original Receipt of payment made by the patient to the hospital.

Break up of medicine / pharmacy / drugs / Operation Theatre (OT) drugs charges as mentioned in final bill.

Break up of investigation amount along with original reports for the same.

X-ray films mandatory in fracture/RTA & stone cases.

USG / C.T. Scan / M.R.I films mandatory along with reports

Main Hospitalization Claims

In Road Traffic Accident (RTA) / Fracture cases a certificate from doctor required mentioning circumstances leading to injury / fracture. Was patient under the influence of alcohol / epilepsy / intoxication? – Treating Doctor to issue certification to this effect. Was Medico Legal Certificate (MLC) done? If Yes, certified copy of MLC has to be attached

All the bills must be submitted within 15 days from Date of Discharge from the hospital

Submission of pre-post hospitalization claims

Submit all the relevant bills related to investigation, consultation and any other medical treatment done relating with the ailment for which admission was taken in the hospital

The pre and post hospitalizations bills submitted must relate to period 30 days prior to the main hospitalization and 60 days subsequent to discharge after the MAIN HOSPITALIZATION

Submission of deficiency retrievals

Please attach Xerox of Deficiency letter along with the documents required to clear your file

Note: Xerox Copy of the documents should be kept with the insured at all times for the documents submitted to PHS

You can print an e-card from internet; please follow the following procedure:

Then go to

Choose Vipul Medcorp as the insurance company

Policy Type – Group

Provide your name & employee no: (PMS ID)

You will be able to view particulars of yourself at the bottom of the page

On the right side (beside your particulars) there is a link for "Details"

Please click on details; it will show entire policy details along with all dependants insured (if any)

Against names of each member there is an option to view e-card; you can open the e-card from that link and can also print the same