Procedure of availing Cashless benefit from a network hospital:-

Step 1:- Insured or Patient needs to confirm whether the hospital in which he/she is seeking treatment
is on Raksha Health Insurance TPA network either by logging on to our website
www.rakshatpa.com and navigating to the tab “Network Hospital” or calling on our 24X7 Call
Centre.

Step 2:- If hospital is on network then patient/insured needs to carry his/her physical or E-card along
with a government photo id proof ( preferably Aadhaar Card), Pan Card as per KYC & AML
norms along with treatment related documents like first OPD prescription, medication papers,
investigation reports (if any) or any other medical documents related to treatment.

Step 3:- Insured/Patient needs to declare at hospital details of insurance cover he/she has with
insurance co. along with TPA details, post which the Hospital TPA Support Desk would provide
a pre-authorization form in which personal details need to be filled by insured/patient and rest
of details need to be filled by treating doctor and hospital staff. Insured/Patient needs to opt
for room as per their policy eligibility only. A declaration form also needs to be signed by
insured/patient .Insured/Patient needs to submit treatment related documents (OPD
prescription, medication documents or investigation reports) at the Hospital TPA Helpdesk.
Preauthorization form needs to be signed by the patient or his family member.

Step 4:- Hospital would fax/email the duly completed, signed (by insured and treating doctor) and
stamped (having diagnosis details, estimated cost, room rent opted) along with declaration
form, past medical records (if any), Raksha card copy and govt. identity card copy (duly
stamped) for consideration. Insured/Patient can take approval 7 days prior to hospitalization in
case of planned hospitalization and within 24 hours of hospitalization in case of emergency
hospitalization.

Step 5:- After receiving fax/email, a validation of coverage through policy no./Raksha Member ID on
card, the request will be registered and unique cashless claim no. would be generated.

Step 6:- The claim documents will be reviewed by claim processor/s and admissibility will be governed
by the policy terms and conditions along and on basis of medication protocol, hospital agreed
tariff.

Step 7:- After review, if claim is admissible an Authorization Letter (A/L) would be issued to respective
network hospital confirming the interim authorized amount. Insured/Patient should note that
this A/L is not final confirmation on admissibility of claim which can only be concluded once
discharge summary having detailed treatment given along with hospital final bill is shared.

Step 7 (i):- In case of any deficiency, Raksha will raise query to hospital. The query should be resolved
within 24 hours. Once reply is received, the claim will be re-assessed based on merits and as
per your policy terms and conditions and claim processing guidelines of your insurance
company.
Step 7 (ii):- If admissibility of the claim cannot be established based upon the documents provided at
the time of cashless request, the cashless facility shall be denied. However please note that
denial of authorization for cashless benefit does not mean denial of claim or denial of
treatment and does not in any way prevent you from seeking necessary medical attention or
hospitalization. The insured/patient can submit the claim documents for reconsideration in
reimbursement along with duly completed claim form within 7 days from date of discharge
from the hospital.

Step 8:- At time of discharge, hospital would send all hospitalization related documents along with
discharge summary, final bill, reports, medicine details etc. & claim would be processed as per
step 7 with consideration of hospital tariff, package or schedule of charges, mutually agreed
upon with either Raksha/GIPSA or Private Insurance Companies, whichever is applicable as per
policy. Insured should note that the policy may contain certain exclusions &/or restrictions
which will be applied at the time of initial & final authorization. Non-medical expenses (NME)
are not payable and will be deducted.

Procedure of claiming a reimbursement claim:-

Step 1:- Reimbursement claim can be submitted to Raksha Health Insurance (P) Ltd. through courier,
post or hand delivered at any of our branch offices or at our helpdesk in case of corporate
clients.

Step 2:- Claim intimation with patient details, employee code/member id, date of hospitalization,
diagnosis, treatment details & estimated cost to be intimated to us via email or by calling on
our call center within 24 hours of admission.

Step 3:- Claim Documents (in original) along with duly filled and signed claim form to be submitted
within 7 working days from date of discharge to Raksha Health Insurance TPA (P) Ltd. office.

Step 3 (i):- Documents submitted should be as per enclosed checklist.

Step 4:- On receipt of claim documents at Raksha office, claim would be scrutinized as per terms and
conditions of your health insurance policy. Please note non-medical expenses or expenses not
admissible as per policy terms and conditions will not be payable.

Step 5:- On scrutiny of your claim if there are any further requirements of documents for compliance or
ascertaining admissibility, we may request for further additional information. This additional
information needs to be submitted to us within stipulated time period.

Step 6:- On receipt of complete documents, an appropriate claim decision will be recommended to your
insurance company.

Step 7:- On approval of admissible claim amount, insurance company will directly credit your bank
account with the net payable amount thru NEFT.

Step8:- Upon rejection of claim, Repudiation Letter quoting the reason for rejection will be sent to you
by your insurance company.