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You must notify your designated TPA either at the call centre or in writing, in the event of planned or emergency hospitalisation.
Contact details are available on your Health Card and Policy Schedule.
It’s a service offered by COCO by Navi General Insurance to the policy holder where the treatment taken at any of our Network Providers / Hospitals and Payment is directly done by Us for covered services.
A list of these hospitals/ providers is available on our website, our mobile app. and TPA (Third Party Administrator) website
No, there is no 2 years of waiting period for Named Illnesses, It is covered from day One subject to 30% of Co-Pay for each and every claim.
No there is no 30 days of waiting period. All Sickness / Illness related claims falling within first 30 days of the Policy there will be 30% co-pay applicable for each and every claim.
Yes, Pre-Existing Disease is covered from Day one subject to 30% Co-pay for each and every claim.
There is 1% of Sum Insured for Normal and 1.5% for ICU capping on Room, Boarding and Nursing Expenses under the Policy.
Following are covered under this Policy:
Emergency Ambulance / Repatriation of Mortal Remains (RMR) / Funeral expenses
Completed claim forms and documents must be furnished within the stipulated timelines. Failure to furnish such evidence within the time required shall not invalidate nor reduce any claim if You can satisfy that it was not reasonably possible for You to submit / give proof within such time.
Where a rejection is communicated by Us, You may if so desired within 15 days represent to Us for reconsideration of the decision.
You should submit the Pre – Post hospitalisation claim documents within 15 days of completion of Post-hospitalisation treatment or period, whichever is earlier.
We shall settle a Claim including its rejection within 30 days of submission of the last “necessary” document(s) / information that is required for the settlement of the claim.
We shall scrutinize the claim and accompanying documents. Any deficiency of documents, shall be intimated to You and the Network Hospital, as the case may be and subsequent reminders will follow.
We may at our sole discretion decide to deduct the amount of claim for which deficiency is intimated to the insured person and settle the claim if we observe that such a claim is otherwise valid under the policy.
You should carry the Health Card provided with your Policy, along with a valid photo identification proof (Voter ID card / Driving License / Passport / PAN Card / Aadhar card /any other identity proof as approved by Us)
You will receive an update on status of your claim through SMS and Emails on the registered contact. Hence, it is important that your contact details are updated with us at all times.
In case of cashless claims, we will issue the authorisation letter to the hospital through fax or Email.
List of necessary claim documents to be submitted for reimbursement are as follows:
We may call for any additional documents/information as required based on the circumstances of the claim.
You may submit the Claim Form along with the documents for reimbursement of the claim to Our / TPA office. Address of designated TPA are been shared in Health Card / Policy Schedule.
You can obtain a Claim Form from any of our / TPA Offices or download a copy from below:-
For Cashless Claims, the payment shall be made to the Network Hospital whose discharge would be complete and final. For Reimbursement Claims, the payment will be made to the nominee (as named in the Policy Schedule) and in case of no nominee, to the Legal Heir who holds a succession certificate or Indemnity Bond to that effect, whichever is available.
Any number of claims is allowed during the policy period. However the sum insured is the maximum limit under the policy.
If two of more policies are taken by You during the same period from one or more Insurers to indemnify treatment costs and the amount of claim is within the Sum Insured limit of any of the policies, You will have the right to opt for a full settlement of Your claim in terms of any of Your policies.
Where the amount to be claimed exceeds the Sum Insured under a single policy after considering Deductibles, Co-pays (if applicable), You can choose the insurer with which You would like to settle the claim.
You should submit your claim to Our / TPA office not later than 15 days from the date of discharge from the Hospital.
The Company, at its sole discretion, reserves the right to modify, add or restrict any Network Hospital for Cashless services available under the Policy. Before availing the Cashless service, please check the applicable list of Network Hospital on the website of COCO by Navi General Insurance / TPA.
There can be instances where We / TPA may deny Cashless facility for Hospitalisation due to insufficient Sum Insured or insufficient information to determine admissibility in which case You may be required to pay for the treatment and submit the Claim for reimbursement to TPA which will be considered subject to the Policy Terms & Conditions.
At the time of discharge, the Network Hospital may forward a final request for authorization for any residual amount to us along with the discharge summary and the billing format. Upon receipt of the final authorisation letter, You may be discharged by the Network Hospital. Please ensure that you have signed the pre-authorization form at the time of admission and final hospital bill at the time of discharge.
In the event that the cost of Hospitalisation exceeds the authorized limit as mentioned in the authorization letter, the Network Hospital shall request TPA for an enhancement of authorisation limit including details of the specific circumstances which have led to the need for increase in the previously authorized limit. Our TPA will verify the eligibility and in our sole discretion evaluate the request for enhancement on the availability of further limits.
In the event of an Emergency hospitalization:
In Emergency Hospitalisation the patient is admitted to the hospital in an emergency situation. In such event, notify Us or our TPA Within 24 hours of Your admission to Hospital or before discharge whichever is earlier.
The authorisation letter shall be valid only for 15 days from the date of sending the authorization.
When the hospitalization is scheduled well in advance, it is called as planned hospitalization.
The intimation of such hospitalisation should be notified to Us or our TPA immediately and in any event at least 48 hours prior to Your admission.
The following details are to be provided to Us / TPA at the time of intimation of Claim:
You can avail of our cashless facility arrangement with over 4000 + network hospitals across India. Decision of the cashless service will be given to you/hospital within 6 hrs on receipt of last necessary document at the time of hospital admission (i.e last document necessary for us to decide admissibility of cashless). At the time of discharge, we / TPA will confirm the final approved amount.
The deductions on account of non-payable expenses if any will have to paid by you at the time of discharge. Post discharge of patient from hospital, hospital sends us the original claim documents for us to reimburse the expenses to the extent of the approved amount.
Alternatively, you can pay all hospitalisation bills directly and submit the original claims documents post discharge for reimbursement to TPA. Once TPA processes the claim as per the Policy terms and conditions, COCO by Navi GI will pay via NEFT to you for the benefit amount payable under your policy.
Third Party Administrator (TPA) is a company registered with IRDA (Insurance Regulatory and Development Authority), and engaged by COCO by Navi GI for providing health claim services related to health indemnity product.
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