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Health Insurance Policy(Employees Policy)
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Raksha TPA
PROCESS FLOW - CASHLESS
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Raksha TPA
How to avail Cashless Services
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Emergency
Identification via UHID Cards
Approach Network Hospital
Planned
Pre-authorization request to
Raksha TPA from Provider
Raksha TPA Pvt Ltd
VERIFIED BY
DOCTOR
Authorization Issued Pre – Authorization Request Denied Queries Raised for
further Clarification
Raksha TPA
PROCESS FLOW - REIMBURSEMENT
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Raksha TPA
EMERGENCY
APPROACH TO NON - NETWORK HOSPITAL
PLANNED
INTIMATE 3-4 DAYS BEFORE ADMISSION
INTIMATE WITHIN 24 Hours from ADMISSION or BEFORE
DISCHARGE
Hospitalization through Non-Network Provider (Reimbursement Claims)
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Raksha TPA Pvt Ltd
SUBMIT DOCUMENTS IN 7 DAYS FROM D.O.D
Raksha TPA
PROCESS FLOW - CLAIMS
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Raksha TPA
RAKSHA PROCESSING OF NON-NETWORKING CLAIMS INSURED (REIMBURSEMENT with
intimation in 24 hours from admission
CLAIM RECEIVED BY RAKSHA TPA PVT. LTD (within 15 days
from D.O.D.)
AUDITING
ENTRY ON LOCAL WEBSITE
DOCTOR’S OPINION
PASSED
QUERY NON PAYABLE
FINANCE DEPARTMERNT
Raksha TPA
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MUST KNOW
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Raksha TPA
DO’S (Cashless Services) Pre-auth form should be sent along with insured/attendant cell no. duly signed
by treating doctor/hospital.
Avail cashless treatment at Network hospitals for the covered ailments within eligible amount under the policy.
Leave back all the original documents and signed claim form with the network
hospitals at the time of discharge.
Contact local Raksha office in case of any query.
Make payment to the network hospital for the expenditure over and above sum insured/ specified limit for any disease, and for the expenses/treatment not covered under the package
For current status of empanelment/de-empanelment of networking hospital, please refer our website: www.rakshatpa.com
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Raksha TPA
DONT’S (Cashless Services) Don’t insist upon admission for investigations or evaluation or health
check-ups.
Don’t carry back any original document at the time of discharge from the hospital.
Don’t forget to sign on claim form.
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Raksha TPA
Document Checklist (Re-imbursement) After discharge policy holder has to submit the following documents to Raksha
TPA within 15 days.
Original detailed discharge summary
Payment receipt in original
Copy of ID card
Original hospital bill with breakup
Package break-up (if applicable)
Original investigation reports
Pharmacy bills with prescription
Claim form duly signed
Hospital registration certificate
Scan copy of cancelled cheque to be mailed at abhijit@rakshatpa.com
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Raksha TPA
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Day Care Treatments covered under Policy
Expenses on Hospitalisation for minimum period of 24 hours are admissible. However, this time limit is not applied to specific treatments, such as:
Appendectomy
Haemo dialysis
Coronary angiography
Hydrocele
Coronary angioplasty
Hysterectomy
Inguinal/ventral/ umbilical/femoral hernia
D&C
Parenteral chemotherapy
Eye surgery
Piles/ fistula
Fracture/ dislocation excluding hairline fracture
Sinusitis
Lithotripsy
Tonsillectomy
Incision and drainage of abcess
Liver aspiration
Colonoscopy
Sclerotherapy
Prostrate
Radiotherapy
Or any other surgeries / procedures agreed by the TPA/ Company which require less than 24 hours hospitalisation and for which prior approval from TPA is mandatory.
Note: Procedures/treatments usually done in out patient department are not payable under the policy even if converted as an in-patient in the hospital for more than 24 hours
Raksha TPA
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Eligibility for Hospital / Nursing Home
Minimum 15 in-patient beds (in metros) & 10 in Remote areas.
Fully equipped OT
Fully qualified nursing staff round the clock
Fully qualified & registered doctor(s) round the clock
Raksha TPA
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General Exclusions Under the Policy
Domiciliary Hospitalization OPD treatment Treatment related to infertility, Voluntary Termination of
Pregnancy External Accessories (e.g.) Walking Stick, Crepe bandage,
Spectacles, contact lens, hearing Aids etc. Non Medical Expenses (e.g.) Telephone Charges, Food Charges,
Registration Charges, Accommodation Charges for Relatives. Naturopathy Treatment , Homeopathic & Ayurvedic Treatment War Like operations whether declared or not Circumcision unless necessary for treatment of disease Cosmetic treatment Plastic Surgery
Raksha TPA
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General Exclusions Under the Policy
Dental Treatment other than arising due to Accident requiring hospitalization
Intentional Self Injury, Intoxicating Drugs, Alcohol, Congenital External Disease, sterility etc
Hospitalization meant for Oral Medication, primary Investigation is non Payable
Vitamins And Tonics unless part of treatment
Hospitalization Less than 24 hrs other than day care treatments
Pre & Post Hospitalization charges for Maternity is Non Payable
All Expenses related to the treatment of AIDS is not covered.
Raksha TPA
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Raksha TPA
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