Q: Who is the Insurer for the Policy?
A: The Policy is underwritten by United India Insurance Company
Ltd. who is the lead insurer for this policy.
Q: What is Medical Expense?
A: Medical Expenses means those expenses that a member has
necessarily and actually incurred for medical treatment on account
of Illness or Accident on the advice of a Medical Practitioner.
Q: How can I avail of DHS TPA's services?
A: If DHS is appointed by the insurer as the authorized TPA
for administration of the policy, then DHS's services can be
availed. Pls. Check your Policy Copy (Name of TPA printed on
the Policy Copy).
Q: What services would DHS be offering?
A: As the authorized TPA servicing the policy following services
- A personalized Identity Card will be issued to each
member and dependent's to avail of Cashless facilities in
all the network hospitals of DHS.
- Cashless service facility at network hospitals up to
limit the authorized limit as per policy terms & conditions.
- Claims processing of reimbursement of claims
- 24hr X7 Call Center service through toll free telephone
number 1800 210 0201
- Website giving Online facility for generation of E-card,
intimation, filing, upload and tracking of claims and Payment
- Help Desks at various locations across the country
- Grievance Portal to solve all enquiries and grievance
within 24 hours.
Q: In case of need for information, what are the details required
for identification while contacting DHS call center?
A: Policy number, your DHS card or EMP ID number & Bank
Name should be kept handy, while contacting the Call Centre.
Q: What is a Health Identity Card?
A: A Health Identity card will be given to you by your TPA. It will consist of the name of your bank , Your Employee ID, a Unique Identification Number , the Policy period and the TPA contact details. The Health card will help in availing cashless facilities in the TPA network hospitals.
Q: What is my recourse, if ID card is not given to me. ?Will I be able to avail cashless facilities without the same ?
A: Please check with your HR , if you are an enrolled member with the policy. If not kindly make provisions to enroll yourself. Once the HR sends the Information to the Insurance company the TPA will send you the ID card Kit. If you are an enrolled member please call up the TPA call centre and they shall assist you with the same. Cashless cannot be availed without the health ID card.
Q: What is the procedure of Applying for a New Health ID card in case of loss ?
A: Alongwith the ID card a welcome letter will be sent to you with your login ID and password. This will help you to go on the TPA website and download an E-card which will work similar to the Health ID card.
Q: What Is Cashless Facility ?
A: Cashless Facility is a benefit extended by the Insurance Company through a TPA wherein the insured has the option to get admitted to a Network hospital without the burden of payment of the Hospital Bill. The entire bill is settled directly by the insurance company subject to terms and conditions of the policy.
Q: Does cashless hospitalization mean getting treatment free
A: Cashless hospitalization does not mean the free of cost
treatment. DHS will mediate between the hospital and the insurance
company and settle the bills on behalf of the insured as per
the benefits in the policy, coverage under the policy and exclusions
under the policy. Any expenses that are not payable under the
insurance policy will not be authorized during hospitalization
and the same will have to be borne by the patient.
Q: Does cashless hospitalization cover all medical expenses?
A: Expenses like, telephone charges, diet charges, documentation
charges and any other non-medical expenses included in the hospital
bill are not reimbursable. All the other charges related to
the treatment are covered as per the terms & conditions
of the policy.
Q: What is the Procedure to be followed if we approach the Bank Claim Processing Hub?
A : The Insured can approach the Bank Processing Hub in order to avail cashless services. The Process is as Under
- Employee Approaches the bank processing Hub with the details of his hospitalization(The Name of the Hospital , The Admission date , The Ailment and the Estimated Cost
- The Bank Officer Guides him to the TPA Help Desk.
- The Help Desk enters the information and prepares a letter of Authorization
- The Help Desk give a copy of the Authorization letter to the employee and simultaneously sends a copy to the hospital.
- The employee can get admitted to the hospital by showing the Authorization letter at TPA Help Desk
Q: How to avail Cashless? / Procedure of Cashless:
A:The Procedure mentioned below needs to follow while availing
- Choose network Hospital from updated DHS network
list of hospital available on the website.
- Collect Pr-Authorization Form the TPA Counter of the
- Fill up personal details and the rest to be filled up
by the hospital treating doctor along with Contact number.
- Pre-auth form is to be duly filled and it should be
stamped & signed by the hospital authority.
- Hospital will send the fax/ e-mail to DHS.
- Medical and Technical scrutiny is to be done by the
DHS medical team.
- In case of requirement for more details, DHS will send
the query letter to the hospital.
- Hospital shall send the reply to DHS, and accordingly
the request is to be re-processed.
- In case of the details mentioned in the form is enough
to process the cashless, and doesn't fall under any of the
exclusion of the policy, DHS will send the Approval Letter
to the Hospital.
- Get admitted, take treatment and get discharge without
payment of bill.
- Please ensure Claim form is filled and duly signed and
final bill is signed, before discharge.
- Hospital Authority will submit all the bills along with
claim form to DHS.
- Payment will be made to the Hospital/Nursing Home directly
Q: What are the documents required to avail Cashless facility
A: Cash Less facility is available only in network hospitals.
The following documents will be required before issuing cashless
- Duly filled, Signed & Stamped Pre Authorization
Form from the hospital.
- Investigation Reports & Previous Consultation Papers
- Photo Id Proof
- DHS Id Number / Policy Number / Employee Number (Pls.
mention on the form / provide a copy).
Q: How to avail Reimbursement of claim? / Procedure of Reimbursement
A: The process is listed below:
- Claim Intimation to be sent (Telephonically/ e-mail/
fax/ online intimation) prior to the Hospitalization or
in case of emergencies immediately upon hospitalization
but prior to discharge).
- Insured gets admitted to the hospital, take treatment
and pay the bill after collecting all the original documents
from the hospital.
- Insured can get admitted in any hospital (Network /
- Claim documents to be submitted to Help Desk , Bank
Claim Processing Office or nearest DHS office as per the
convenience of the employee
- Unique claim number for all the individual hospitalization
/ insured will be auto-generated in DHS System after intimating
the details in system.
- Medical / technical Scrutiny is to be done.
- The claim is processed on the basis of the terms and
conditions laid down in the policy, and NEFT will be done
directly to the employee.
- In case, the claim does not fall within the terms &
conditions of the Policy after medical / technical scrutiny,
the claim will be recommended for repudiation in front of
the committee appointed by the bank and Insurance Company
. The Committee will be the final authority for repudiation
and the ltter of denial will then be sent by the insurance
Q: Is there any scope of Repudiation of Claim ?
A: If the Ailment is not covered in the terms and conditions of the policy, the claim may be repudiated. (For details of the policy terms and condition, Kindly log into the TPA website). In case of Repudiation , the claim will be first put up before the committee and then repudiated.
Q: What documents are needed for processing claims that have
to be reimbursed?
A: Following documents are required for processing reimbursement
- Claim Form duly filled and signed by the claimant.
- Final Bill & Discharge Card from the hospital.
- All documents pertaining to the onset from the date it was
- All relevant bills and receipts in originals
- Medicine / Chemist Bills supported by prescriptions
- Original Receipt and diagnostic test reports to be supported
by a letter from the consulting doctor prescribing such
- In case of surgery a certificate issued by the operating
surgeon (OT Note) detailing the nature & Grade of the
operation performed and attached along with relevant bill
and receipt is required in original with Bifurcations.
- Certificate from the attending medical practitioner
/ surgeon that the patient is fully cured.
- DAMA / Transfer Certificates in case the patient has
been shifted from one hospital to another.
- Bank Details with copy of Cancelled Cheque (Only For
Individual Policy Holder).
Apart from the documents listed above - Disease specific
documents: *For any accidental / fracture case: MLC Copy and
letter from hospital / treating doctor stating details of accident,
alcohol or any intoxicating drugs history. *Complete obstetric
history (anti natal card) with GPLA status in case of pregnancy
/ delivery / maternity. If it is LSCS then necessity for the
same is required to be mentioned on discharge card along with
the indication of LSCS. *IOL sticker showing serial number in
case of cataract operation. *Serial Number sticker in case of
insertion of "stent" for Heart operation. *Invoice for any of
the implant surgery.
Q: Whether treatment is allowed in any of the hospitals or nursing
A: A 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 the 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 in-patient beds in towns having
a population of less than 10 lacs and at least 15 in-patient
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;
daily records of patients and makes these accessible to the
insurance company's authorized personnel.
The term "Hospital
/ Nursing Home" shall not include an establishment which
is a place of rest, a place for the aged, a place for drug-addicts
or place for alcoholics, a hotel or a similar place. This clause
will however be relaxed in areas where it is difficult to find
Q: What is pre-post hospitalization & how much amount /
limit / number of days are covered for the same?
A: Pre- Hospitalization: Pre-Hospitalization means relevant
medical expenses incurred during a period up to 30 days prior
to Date of Admission for an illness or bodily injury sustained
and considered a part of claim admissible under the policy.
Post-Hospitalization: Post-Hospitalization means relevant
medical expenses incurred during a period up to 60 days after
the Date of Discharge for an illness or bodily injury sustained
and considered a part of claim admissible under the policy.
Q: What is Pre-Existing disease? Is it covered in my policy?
A: Pre Existing Disease is any condition, ailment or injury
or related condition(s) for which you had signs or symptoms,
and/or were diagnosed, and/or received medical advice/treatment,
prior to the first policy issued by the insurer. Pre-existing
diseases are covered in the policy
Q: How can one know more about terms and conditions of the Mediclaim
A: Information about terms of specific policy is available
in the member page on the website. Alternative one can call
up on the toll free number and seek the necessary information.
Q: In the event of loss of DHS Mediclaim card, what is the procedure
to get a duplicate card issued?
A: A request can be put up on our website, at the help desk
or on the exclusive email id provided for duplicate ID card,
mentioning DHS ID number , or Employee number and name of the
bank. A duplicate card will be issued at no cost within 48 hours
Q: What if original medical documents are required by the patient/insured
for future medical follow ups?
A: Original documents are required to settle any claims.
However Original Investigation reports can be returned back
after verification with the stamp originals verified. All original
bills and discharge card will be retained by us
Q: Can outpatient treatment be availed under the Mediclaim policy?
A: Medical expenses incurred in case of the following diseases
which need Domiciliary Hospitalization /domiciliary treatment
as may be certified by the attending medical practitioner and
/ or bank's 'medical officer shall be deemed as hospitalization
expenses and reimbursed to the extent of 100% Cancer , Leukemia,
Thalassemia, Tuberculosis, Paralysis, Cardiac Ailments , Pleurisy
, Leprosy, Kidney Ailment , All Seizure disorders, Parkinson's
diseases, Psychiatric disorder including schizophrenia and psychotherapy
, Diabetes and its complications, hypertension, Hepatitis-B
, Hepatitis-C, Hemophilia, Myasthenia gravis, Wilson's disease,
Ulcerative Colitis , Epidermolysis bullosa, Venous Thrombosis(not
caused by smoking) Aplastic Anaemia, Psoriasis, Third Degree
burns, Arthritis , Hypothyroidism , Hyperthyroidism expenses
incurred on radiotherapy and chemotherapy in the treatment of
cancer and leukemia, Glaucoma, Tumor, Diptheria, Malaria, Non-Alcoholic
Cirrhosis of Liver, Purpura, Typhoid, Accidents of Serious Nature
, Cerebral Palsy, Polio, All Strokes Leading to Paralysis,
Haemorrhages caused by accidents, All animal/reptile/insect
bite or sting , chronic pancreatitis, Immuno suppressants, multiple
sclerosis / motorneuron disease, status asthamaticus, sequalea
of meningitis, osteoporosis, muscular dystrophies, sleep apnea
syndrome(not related to obesity), any organ related (chronic)
condition, sickle cell disease, systemic lupus erythematous
(SLE), any connective tissue disorder, varicose veins, thrombo
embolism venous thrombosis/venous thrombo embolism (VTE)], growth
disorders, Graves' disease, Chronic obstructive Pulmonary Disease,
Chronic Bronchitis, Asthma, Physiotherapy and swine flu shall
be considered for reimbursement under domiciliary treatment.
The cost of Medicines, Investigations, and consultations, etc.in
respect of domiciliary treatment shall be reimbursed for the
period stated by the specialist and / or the attending doctor
and / or the bank's medical officer, in Prescription. If no
period stated, the prescription for the purpose of reimbursement
shall be valid for a period not exceeding 90 days.
Q: What is critical illness cover under the policy ?
A: Critical Illness cover is provided to the employee only
subject to a sum insured of Rs. 1,00,000/- . Cover starts on
inception of the policy. In case an employee contracts a Critical
Illness as listed below, the total sum insured of Rs.1,00,000/-
is paid, as a benefit. This benefit is provided on first detection/diagnosis
of the Critical Illness.
- Cancer including Leukemia
- By Pass Surgery
- Major Organ Transplant
- End Stage Liver Disease
- Heart Attack
- Kidney Failure
- Heart Valve Replacement Surgery
Hospitalization is not required to claim this benefit. Further
the Employee can claim the cost of hospitalization on the same
from the Group Mediclaim Policy as cashless / reimbursement
of expenses for the treatment taken by him.
Q: What action needs to be taken if a network hospital denies
A: Please make a call to the DHS call center, providing details
of the hospital. The concerned department at DHS will immediately
contact the medical provider and resolve the issue.
Q: Can Mediclaim benefits be availed across India?
A: DHS TPA services are offered all over India. For detailed
list of network hospitals , please check the Hospital Network
list on the website or contact the call centre.
Q: What is the time limit for submission of documents in case
of reimbursement claims ?
A: All the documents need to be submitted within 30 days
of Discharge. For the Post Hospitalization - 90 days from Date
Q: What is Day Care Treatment?
A: Day care Treatment refers to medical treatment and or
surgical procedure which is
- undertaken under general or local
anesthesia in a hospital/day care Centre in less than a day
because of technological advancement, and
- Which would have otherwise
required a hospitalization of more than a day?
taken on an out-patient basis is not included in the scope of