Policy Coverages

What is the name of the insurance company and TPA (Third Party Administrator) for the proposed health scheme? What is the role of Alliance insurance Brokers?

Name of the Insurance Company is ‘Care health insurance company Limited’. They service the claim through their in-house team. Alliance Insurance Broker will act as an intermediary between the client and Care Health insurance will maintain a clear flow of communication and expediating the claim processes, they will be managing the whole policy.

Who are eligible for this scheme?

Registered Air veterans of Air Force Group Insurance Society are eligible for this scheme.

Whom can you cover? What age group will the insurance policy be covered?
  • The coverage is applicable for Self, Spouse, Children.
  • The insurance policy covers adults from the age 35 – 80 Years. There are two Categories 35-57 years and 58 -80 years.
  • Child is covered from 91 days to 24 years under family floater policy.
Is the scheme applicable for parents?

No, parents are not added in the policy, as this scheme is especially designed for Self, Spouse and Kids.

When the Policy coverage will start?

The policy coverage starts from the Master Policy start date (will be declared during enrolment). Any accidental claim will not have any waiting period. Whereas any Pre-existing disease will have 1 year waiting period.

Policy coverage is valid for how many days?

The policy coverage is valid for 1 year from the Policy start date and this will be renewed on annual basis.

Will this scheme affect the existing ECHS?

This scheme will not be affecting the ECHS scheme, as this is an additional cover being introduced by the Airforce for their veterans over and above ECHS.

Is it for serving personnel as well?

This scheme is only for the ex-servicemen or retired personnel.

Is there any medical check-up that will be required?

No, there is no need for Medical Check Up, but a good health declaration needs to be provided during enrolling for this programme. Below is the Good Health Declaration required:

I hereby declare that we are in good health and not suffering and/or undergoing treatment for any chronic diseases (refer exclusions for list of chronic ailments), neither are any treatments or evaluations planned for the same or Undergone surgery or hospitalization for any illness over 10 days, which are relapsing in nature or suffered from any disease requiring medication for more than 15 days or recurrent follow-ups.

What are the Benefits of proposed scheme?

The proposed scheme covers the below benefits:

  • The scheme has sum insured option for 3 lacs & 5 lacs for Hospitalisation Benefit - Hospitalisation means admission in a hospital for a minimum period of 24 consecutive 'In-patient Care' hours except for specified day care procedures/treatments, where such admission could be for a period of less than 24 consecutive hours.
  • Hospitalisation and Day-care treatment are covered up to Sum Insured limit.
  • Pre and Post hospitalisation expenses are covered for 30-60 days respectively.
  • Optional OPD Benefit limit options of 10k, 15k & 20k are available.
  • Adults up to the age of 80 years can be added in the policy.
  • Children up to age of 24 can be added in the Policy.
  • Newborn baby can be added in the policy after 91 days.
  • Pre-Existing diseases are covered after 1 year waiting period.
  • The ambulance charges per hospitalisation is covered up to INR 8k per case.
  • Single A/c Room Category is allowed and for ICU category there is no capping for per day charges.
  • No disease-wise limit.
  • No co-payment.
  • The treatment is available on cashless + Reimbursement.
  • Video Consultation can also be availed.
Is there any limit for expenditure of any disease?

No, there will be no limit / disease wise capping on expenditure on any particular disease, i.e. the full expense of the disease will be covered up to the sum insured opted except for the consumables items and non-payable item.

What are the Sum Insured options?
  • The Sum Insured options for Hospitalisation Benefit are available for INR 3 Lac & INR 5 Lac.
  • Optional OPD Benefit add on available from INR 10 K , INR 15 K , INR 20 K.
Is there any Provision for Top up options?

No, there is no option of a top up available.

Claims

Are the claims available on cashless basis?

Yes, it is both cashless and Reimbursement. The insurance company has 9400+ network hospitals. Now, Customers can also get cashless benefits even at non network hospitals subject to intimation 48 hours in advance (T&C apply), providing policyholders with an unprecedented level of flexibility and convenience. This initiative aims to eliminate the hassle of complicated reimbursement processes, providing policyholders with seamless and convenient claim experience.

Key Features of cashless anywhere:

  • Freedom from Network Limitation
  • Choice of Treatment
  • Stress Free Hospitalization
  • Treatment without Financial worries

By going cashless anywhere, we aim to enhance accessibility, reduce processing times, and provide a more user-centric experience.

There are certain steps which needs to be followed when you visit a Network Hospital for an IPD treatment where the hospital should be empanelled with the insurance company and TPA. They are:

  • Member gets admitted in the hospital by showing Health card and valid Identity proof. (Aadhar Card, Driving License, Passport, etc)
  • Member / Hospital applies for pre-authorisation to the Insurer within 24 hours of admission.
  • Insurer verifies applicability of the claim to be registered and issue pre-authorization.
  • Member gets treated and discharged after paying all non-entitled benefits like refreshments, etc

We will provide EB360 portal link to check the network hospital with the name of the city and state during enrolment.

IPD

What will be the claim settlement process on reimbursement basis for In-patient (Hospitalisation) Treatment?

In case of a reimbursement claim following process need to be followed:

  • Member intimates Insurer before or as soon as hospitalisation occurs within 24 hours.
  • Insured admitted as per Hospital room norms.
  • All payment made by member.
  • Documents received by Insurer within 30 days from the date of Discharge.
  • Insurer Performs medical scrutiny of the documents for admissibility of the claim.
  • Insurer checks for document sufficiency.
  • In case of deficiency in documents, Insurer intimates via email / SMS for re-submission of remaining documents.
  • Once documents complete as required claims are processed and claim amount is credited to Employee’s A/c.
What all documents are required to apply for a Reimbursement of an In-patient (Hospitalisation) claim?

At times, it happens you must be admitted to a non-network hospital for treatment. The reimbursement claim needs certain documents which needs to be submitted within a stipulated period for smooth and quick claim settlement process:

  • Duly filled and signed Claim Form
  • Address proof of proposer along with recent passport size photo (in case claim amount above 1 Lac)
  • Hospital Bill with breakup
  • Payment Receipt
  • Discharge Card/ Discharge Summary/Daycare Summary
  • All Investigation Reports (MRI, CT, Xray , pathology etc)
  • Bills & Receipts for Investigations
  • Pharmacy Bills along with Rx
  • Breakup of bills in case of single amount claimed against multiple purchases.
  • FIR/MLC and Alcohol Intoxication declaration (in case of RTA)
  • Any other document which may be necessary for adjudication of claim
  • Personalized cancelled cheque (name printed) of proposer.
What is a Pre-Existing Disease?

Pre-existing conditions are those medical illnesses or injuries that the intended policyholder has before starting a healthcare plan or policy. This factor plays a significant role in your health insurance as you already suffer from these ailments. Conditions like diabetes, chronic obstructive pulmonary disease (COPD), cancer may be examples of pre-existing health conditions. They tend to be chronic or long-term.

Where to check network Hospitals for IPD and Out-Patient (OPD)?

It is very easy to check the nearest cashless network hospital by entering the city and state name by clicking on the EB360 link provided during Enrolment.

What are the Standard Exclusions in the Hospitalisation on In-patient (Hospitalisation) basis?
  • List of chronic illness for Good Health Declaration: Intended policyholder before starting a healthcare plan or policy should not have Pre-existing conditions for any of below listed conditions.
    • Cancer or Malignant Tumor or Lump or Malignant Cyst
    • Chronic Kidney conditions except non recurrent urinary tract infections
    • Heart Diseases or Peripheral Vascular conditions
    • Chronic Lung Disorders except respiratory tract infections requiring medications not exceeding 7 days.
    • Chronic Lung Disorders except non recurrent tuberculosis of the lungs treated > 5 years back.
    • Chronic Liver Disease or Pancreatitis
    • Hepatitis B or Hepatitis C
    • Brain and nerves related complains.
    • Diabetes with insulin or complications ( e.g Diabetic kidney disease , diabetic retinopathy diabetic foot , diabetic neuropathy etc.)
    • Hypertension / High Blood Pressure for more than 20 years
    • Auto Immune diseases like Ankyloses, Rheumatoid Arthritis, Systemic Lupus Erythromatoses, Sjogren's or any other.
    • Paralysis with neurodeficit or Parkinson's or Alzheimer’s
    • Extra Pulmonary Koch’s
  • Investigations and Evaluation:
    • Expenses related to any hospitalisation primarily for diagnostics and evaluation purposes only are excluded.
    • Any diagnostic expenses which are not related or not incidental to the current diagnosis and treatment are excluded.
  • Rest cure, Rehabilitation and respite care: Expenses related to any admission primarily for enforced bed rest and not for receiving treatment. This includes -Custodial care either at home or in a nursing facility for personal care such as help with activities of daily living such as bathing, dressing, moving around either by skilled nurses or assistant or non-skilled persons. Any services for people who are terminally ill to address physical, social, emotional and spiritual needs.
  • Weight management programs or treatment in relation to the same including vitamins and tonics, treatment of obesity excluding surgical treatment for morbid obesity with BMI greater than or equal to 40, subject to terms and conditions.
  • Change of Gender treatment: Expenses related to any treatment, including surgical management, to change characteristics of the body to those of the opposite sex;
  • Cosmetic surgery, aesthetic and re-shaping treatments and Surgeries. Plastic Surgery or cosmetic Surgery or treatments to change appearance unless medically necessary and certified by the attending Medical Practitioner for reconstruction following an Accident, cancer or burns.
  • Hazardous or Adventure sports: means any sport or activity or Adventure sport, which is potentially dangerous to the Insured whether he is trained or not. Such sport/activity includes stunt activities of any kind, adventure racing, base jumping, biathlon, big game hunting, black water rafting, BMX stunt/ obstacle riding, bobsleighing/ using skeletons, bouldering, boxing, canyoning, caving/ pot holing, cave tubing, rock climbing/ trekking/ mountaineering, cycle racing, cyclo cross, drag racing, endurance testing, hand gliding, harness racing, hell skiing, high diving , hunting, ice hockey, ice speedway, jousting, judo, karate, kendo, lugging, risky manual labor, marathon running, martial arts, micro – lighting, modern pentathlon, motor cycle racing, motor rallying, parachuting, paragliding/ parapenting, piloting aircraft, polo, power lifting, power boat racing, quad biking, river boarding, scuba diving, river bugging, rodeo, roller hockey, rugby, ski acrobatics, ski doo, ski jumping, ski racing, sky diving, small bore target shooting, speed trials/ time trials, triathlon, water ski jumping, weight lifting or wrestling of any type. any sports declared as hazardous / Adventurous by the insurer.
  • Breach of Law: Expenses for treatment directly arising from or consequent upon any Insured Person committing or attempting to commit a breach of law with criminal intent.
  • Excluded Providers: Expenses incurred towards treatment in any hospital or by any Medical Practitioner or any other provider specifically excluded by the Insurer. and disclosed in its website / notified to the policyholders are not admissible. However, in case of life-threatening situations or following an accident, expenses up to the stage of stabilization are payable but not the complete claim
  • Treatment for Alcoholism, drug or substance abuse or any addictive condition and consequences thereof.
  • Treatments received in heath hydros, nature cure clinics, spas or similar establishments or private beds registered as a nursing home attached to such establishments or where admission is arranged wholly or partly for domestic reasons;
  • Dietary supplements and substances that can be purchased without prescription, including but not limited to Vitamins, minerals and organic substances unless prescribed by a medical practitioner as part of hospitalization claim or day care procedure;
  • Correction of eyesight: Treatment for correction of eyesight due to refractive error including routine examination.
  • Unproven / Experimental treatment: Expenses related to any unproven treatment, services and supplies for or in connection with any treatment. Unproven treatments are treatments, procedures or supplies that lack significant medical documentation to support their effectiveness;
  • Expenses related to Sterility and Infertility;
  • Maternity and related expenses;
  • Any item or condition or treatment specified in List of Non-Medical Items.;
  • Any condition directly or indirectly caused by or associated with any sexually transmitted disease, including Genital Warts, Syphilis, Gonorrhoea, Genital Herpes, Chlamydia, Pubic Lice and Trichomoniasis, Acquired Immuno Deficiency Syndrome (AIDS) ;
  • Any treatment directly related to surrogacy whether the member is acting as surrogate, or is the intended parent;
  • Any treatment begun or for which the need has arisen during the first ninety (90) days after birth, for any child conceived by artificial means or any form of assisted conception or if the child is born via surrogacy;
  • Treatment taken from anyone who is not a Medical Practitioner or from a Medical Practitioner who is practicing outside the discipline for which he is licensed or any kind of self-medication.
  • Charges incurred in connection with routine eye examinations and ear examinations, dentures, crowns, artificial teeth, and all other similar external appliances and / or devices whether for diagnosis or treatment.
  • Any expenses incurred on providing or fitting any external prosthesis or orthosis or appliance or medical aids or durable medical equipment of any kind, like wheelchairs, walkers, crutches , ambulatory devices, unless allowed under the Policy, cost of Cochlear implants;
  • Any treatment related to sleep disorder or sleep apnea syndrome, general debility convalescence and any treatment in an establishment that is not a Hospital;
  • Treatment of any external Congenital Anomaly or Illness or defects or anomalies including their associated medical conditions or chronic medical conditions or vegetative state cover ( on the basis of declaration by the treating doctor) or treatment relating to external birth defects;
  • Treatment whilst staying in a hospital for more than ninety (90) continuous days for permanent neurological damage on the basis of declaration by the treating doctor. It is stated that treatment up to 90 days for permanent neurological damage will be covered under this Policy;
  • Treatment of mental retardation, arrested or incomplete development of mind of a person, subnormal intelligence or mental intellectual disability;
  • Out-patient treatment unless OPD benefit is opted;
  • Treatment received outside India;
  • Domiciliary hospitalization or treatment.
  • An Insured Member operating or learning to operate any aircraft, or performing duties as a member of the crew on any aircraft or Scheduled Airline or any airline personal;
  • An Insured Member flying in an aircraft other than as a fare paying passenger in a Scheduled Airline;
  • Participation in actual or attempted felony, riot, civil commotion or criminal misdemeanor or activity;
  • Professional fees charged by a member of the Insured Member's immediate family or by a person normally resident in the household of the Insured or under his employment;
  • Training for or participating in professional sport of any kind or any sport for which the insured receives a salary or monetary reimbursement, including grants or sponsorship;
  • Radioactive contamination whether arising directly or indirectly ionizing radiation, toxic, explosive or other hazardous properties of nuclear material;
  • Circumcision unless necessary for treatment of an Illness or as may be necessitated due to an Accident;
  • All preventive care, Vaccination including Inoculation and Immunizations (except in case of post- bite treatment) and tonics;
  • Non-Allopathic Treatment or treatment related to any unrecognized systems of medicine;
  • War (whether declared or not) and war like occurrence or invasion, acts of foreign enemies, hostilities, civil war, rebellion, revolutions, insurrections, mutiny, military or usurped power, seizure, capture, arrest, restraints and detainment of all kinds. Any Hospitalisation which has resulted because of above shall not be admissible under the policy.
  • Act of self-destruction or self-inflicted Injury, attempted suicide or suicide while sane or insane or Illness or Injury attributable to consumption, use, misuse or abuse of tobacco, Areca nut intoxicating drugs and alcohol or hallucinogens;
  • Any charges incurred to procure documents related to treatment or Illness pertaining to any period of Hospitalization or Illness or any administration costs or any other charges of a non-medical nature in connection with the provision and/or performance of medical supplies and/or services;
  • Personal comfort and convenience items or services including but not limited to T.V. (wherever specifically charged separately), charges for access to cosmetics, hygiene articles, body care products and bath additives, as well as similar incidental services and supplies;
  • Expenses related to any kind of RMO charges, Service charge, Surcharge, night charges levied by the hospital under whatever head or any room upgrades, menu items not included as standard or visitors meals;
  • Nuclear, chemical or biological attack or weapons, contributed to, caused by, resulting from or from any other cause or event contributing concurrently or in any other sequence to the loss, claim or expense; For the purpose of this exclusion:
    • Nuclear attack or weapons means the use of any nuclear weapon or device or waste or combustion of nuclear fuel or the emission, discharge, dispersal, release or escape of fissile/ fusion material emitting a level of radioactivity capable of causing any Illness, incapacitating disablement or death;
    • Chemical attack or weapons means the emission, discharge, dispersal, release or escape of any solid, liquid or gaseous chemical compound which, when suitably distributed, is capable of causing any Illness, incapacitating disablement or death;
    • Biological attack or weapons means the emission, discharge, dispersal, release or escape of any pathogenic (disease producing) microorganisms and/or biologically produced toxins (including genetically modified organisms and chemically synthesized toxins) which are capable of causing any Illness, incapacitating disablement or death;
    • In addition to the foregoing, any loss, claim or expense of whatsoever nature directly or indirectly arising out of, contributed to, caused by, resulting from, or in connection with any action taken in controlling, preventing, suppressing, minimizing or in any way relating to the above is also excluded.
  • Impairment of an Insured Person's intellectual faculties by abuse of stimulants or depressants unless prescribed by a medical practitioner;
  • Continuous ambulatory peritoneal dialysis (CAPD): Coverage for 'Continuous ambulatory peritoneal dialysis' is available on OPD basis and as part of Pre-Post hospitalization expenses; subject to main hospitalisation claim being admissible.
  • Charges for items not listed in the policy schedule applicable to the member or considered as not medically necessary or which may be considered as elective;
  • Alopecia wigs and/or toupee and all hair or hair fall treatment and products including any investigations; all forms of acne;
  • Any treatment taken in a clinic, rest home, convalescent home for the addicted, detoxification center, sanatorium, home for the aged, remodelling clinic or similar institutions;
  • Any medical or physical condition or treatment or service, which is specifically excluded under the Policy Schedule including the associated medical conditions shown on the endorsement;
  • Cryopreservation or harvesting or storage of stem cells as a preventive measure against possible disease measure against possible disease/illness/injury, or implantation or re-implantation of living cells or living tissue whether autologous or provided by a donor;
  • Any other weight management services, treatment and supplies unless requires hospitalization and surgery;
  • Hormone Replacement Therapy;
  • The evacuation would involve moving Insured Member from a remote location where there is no or limited access;
  • Dental, Orthodontics, Periodontics, Endodontics or any preventative dentistry no matter who gives the treatment;
  • Charges for residential stays in Hospital which are not medically necessary or are incurred for social or domestic reasons or for reasons which are not directly connected with treatment or where the Hospital has effectively become the place of domicile or permanent abode;
  • Any charges made by the medical practitioner, hospital, laboratory or any such medical services which are not reasonable and customary; Reasonable and customary (R&C) means charges or treatment for medical care which shall be considered by the Company or by Company's medical advisers to be reasonable and customary to the extent that they do not exceed the general level of charges or treatment being made by others of similar standing in the locality where the charges or treatment are incurred when giving like or comparable treatment. If the charges are higher than customary or the treatment is not reasonable and customary, the Company will only pay the amount which is, in the Company's experience, customarily charged and Insured has to pay the rest.
  • Genetic tests undertaken to establish whether or not the Insured may be genetically disposed to the development of a medical condition in the future unless requires for current medical treatment;
  • Insured Person suffering from or has been diagnosed with or has been treated for Down's Syndrome/ Turner's Syndrome/Sickle Cell Anaemia/ Thalassemia Major/G6PD deficiency prior to the first Policy Start Date, then costs of treatment related to or arising from the disorder whether directly or indirectly will be treated as a Pre-existing Disease and will not be covered within first 48 months from the date of first issuance of the Policy;
  • Ear or body piercing and tattooing or treatment needed as a result of any of these;
  • Any charges for treatment incurred during a period for which the premium is not paid;
  • Any claim or part of a claim in which the member has to pay a deductible or co-insurance (where applicable). In such a claim, we will only pay the balance of the claim after we have deducted the excess (or deductible or co-insurance) amount;
  • All bank or credit or foreign exchange charges when the claims payment is made in a currency other than the policy currency upon the member's request;
  • Bacterial infections (except pyogenic infection which occurs through an Accidental cut or wound);

OPD

What does OPD cover include?

OPD cover include various options which can be opted by paying additional premium. It will include dental, vision, pharmacy, diagnostics and consultations. It will be on a floater basis (Combine limit as per the selected plan). OPD Services Are available on Allyve Health Platform

  • In clinical Consultations (All)- General Physician/Specialist- Available under both Cashless and Reimbursement
  • Dental (Dental Examination/ Xray/ Fluoride treatment/ Filling/ Prophylaxis/Root Canal Treatment/ Extractions/ Oral Surgery/ Crowning)- Available under both Cashless and Reimbursement
  • Vision (Covers Vision check-up along with prescribed lens)- Available under both Cashless and Reimbursement
  • Prescribed Diagnostic and Pharmacy- Available under both Cashless and Reimbursement
How does one file a reimbursement claim for Out-Patient (OPD) expenses under a health insurance plan?

Upon completing the OPD treatment, you need to upload the doctor’s prescription and the original bill by logging in to your account via website or mobile app to process the reimbursement.

Reimbursement of Out-Patient (OPD) through Alyve app

You can follow this process after logging in your Alyve Health app - Dashboard -> OPD Card -> Reimburse Now button -> Fill the details -> Submit

Are medicine expenses covered under Out-Patient (OPD)?

Only Date wise, Pre-numbered Prescribed Pharmacy expenses are covered under OPD on both Cashless and Reimbursement through Alyve Platform.

What are the exclusions of an Out-Patient (OPD) cover?

Some common exclusions that apply to an OPD cover:

  • Cosmetic Procedures: Cosmetic surgeries or treatments such as plastic surgeries or Botox injections are typically excluded from OPD cover. - Cosmetic Surgery or Treatment means surgery or medical treatment solely or primarily to improve or preserve physical appearance, but not physical function or treatment of an underlying ailment/conditions (Example - Chemical peel treatment, Laser hair removal and others. The exact nature of the procedure will be determined by program administrators at the time of processing the claim)
  • Non-Medical Expenses: OPD coverage does not cover non-medical expenses such as registration fees, admission charges, toiletries, etc during hospital visits.
  • Non-Prescribed Medications and Treatments: Expenses incurred for non-prescribed medications, over-the-counter drugs, and treatments that are not recommended by a certified medical practitioner are usually not covered under OPD plans.
  • Self-Inflicted Injuries: Injuries resulting from intentional self-harm or accidents caused under the influence of drugs or alcohol are not covered under OPD health insurance plans.
  • Routine Health Check-ups
  • IVF, Sterility, Infertility, and other related conditions
  • Pregnancy Complications and Miscarriages, etc
  • Treatment for alopecia, baldness, wigs, or toupees, and all treatment related to the same and all treatment related to the same are not mentioned.
  • Naturopathy and related treatments/expenses are not covered.
  • Expenses related to any treatment necessitated due to participation in hazardous or Hazardous or Adventure sports: means any sport or activity or Adventure sport, which is potentially dangerous to the Insured whether he is trained or not. Such sport/activity includes stunt activities of any kind, adventure racing, base jumping, biathlon, big game hunting, black water rafting, BMX stunt/ obstacle riding, bobsleighing/ using skeletons, bouldering, boxing, canyoning, caving/ pot holing, cave tubing, rock climbing/ trekking/ mountaineering, cycle racing, cyclo cross, drag racing, endurance testing, hand gliding, harness racing, hell skiing, high diving , hunting, ice hockey, ice speedway, jousting, judo, karate, kendo, lugging, risky manual labor, marathon running, martial arts, micro – lighting, modern pentathlon, motor cycle racing, motor rallying, parachuting, paragliding/ parapenting, piloting aircraft, polo, power lifting, power boat racing, quad biking, river boarding, scuba diving, river bugging, rodeo, roller hockey, rugby, ski acrobatics, ski doo, ski jumping, ski racing, sky diving, small bore target shooting, speed trials/ time trials, triathlon, water ski jumping, weight lifting or wrestling of any type, etc or any sports declared as hazardous / Adventurous by the insurer.
  • Treatments received in heath hydro’s, nature cure clinics, spas or similar establishments.
  • Expenses related to treatment of cancers (including but not limited to procedures, medications, drugs etc.)
  • Cost of spectacle frames * Cosmetic lenses and procedures excluded * Protein shakes and other supplements even if prescribed * Hearing Aid * Consultations & Treatment related to Obesity * Cataract / Lasik Surgery * Day care treatment list of IPD cover * Advance receipt/co-pay/Day -care/IPD deductions * Physiotherapy expenses * Any claim for dependents Other than covered under the policy.
  • Food, Food Supplements or Dietary Pills (Example – Horlicks, Glucose, Whey Protein, etc.)
  • Dietary supplements and substances that can be purchased without prescription, including but not limited to Vitamins, minerals and organic substances unless prescribed by a medical practitioner as part of treatment
  • All non-medical expenses or standard deductions incurred during inpatient hospitalization or day-care treatments will not be covered under OPD Policy.
  • Any ailment with sublimit in Group medical plan coverage cannot be claimed under OPD Policy. For. Ex. Mental health related treatment is covered Upto INR 1Lac in Group medical plan. Any expenses incurred beyond INR 1Lac cannot be claimed in OPD policy.
  • Procedure fee or any type of procedures fees paid during an OP consultation are not covered. Example - wound cleaning/dressing
  • Diagnostics/Investigations done without doctor’s prescriptions are not covered.
  • Pre & post-natal expenses or any maternity related expense will not be covered under OPD as the same is covered under group medical plan.

Service

How does one file a reimbursement claim for Out-Patient (OPD) expenses under a health insurance plan?

Upon completing the OPD treatment, you need to upload the doctor’s prescription and the original bill by logging in to your account via website or mobile app to process the reimbursement.

Reimbursement of Out-Patient (OPD) through Alyve app

You can follow this process after logging in your Alyve Health app - Dashboard -> OPD Card -> Reimburse Now button -> Fill the details -> Submit

What all documents are required to apply for a Reimbursement of an In-patient (Hospitalisation) claim?

At times, it happens you must be admitted to a non-network hospital for treatment. The reimbursement claim needs certain documents which needs to be submitted within a stipulated period for smooth and quick claim settlement process:

  • Duly filled and signed Claim Form
  • Address proof of proposer along with recent passport size photo (in case claim amount above 1 Lac)
  • Hospital Bill with breakup
  • Payment Receipt
  • Discharge Card/ Discharge Summary/Daycare Summary
  • All Investigation Reports (MRI, CT, Xray , pathology etc)
  • Bills & Receipts for Investigations
  • Pharmacy Bills along with Rx
  • Breakup of bills in case of single amount claimed against multiple purchases.
  • FIR/MLC and Alcohol Intoxication declaration (in case of RTA)
  • Any other document which may be necessary for adjudication of claim
  • Personalized cancelled cheque (name printed) of proposer.
Where to check network Hospitals for IPD and Out-Patient (OPD)?

It is very easy to check the nearest cashless network hospital by entering the city and state name by clicking on the EB360 link provided during Enrolment.