GUIDE BOOK


Genins India InsuranceTPA Ltd. is a Third Party Administrator in Health Insurance, Licensed by IRDA to administer health policies issued by insurance companies.

We have been selected by your insurer to provide you with value added services, such as:

i) Cashless Hospitalization.
ii) Expeditious settlement of claim.
iii) 24 hour help-line to answer your queries, related to your policy.

How to Utilize the Service Of Genins India Insurance TPA Ltd. In Case Of hospitalization At Network Hospital (Cashless)

Step 1: The Genins cardholder visits any of the network hospital listed in the guidebook and establishes his/her identity to the hospital by producing the card.
Step 2: The network hospital sends request to Genins for authorization.
Step 3: Genins cardholder’s treatment shall commence after authorization from Genins, in case of planned hospitalization.
Step 4: Authorization should be obtained 7days prior to hospitalization in planned admissions, but in case of emergency, authorization can be obtained after hospitalization, within 24 hrs of admission.
Step 5: Hospital will not charge the card holder for any expenses except the non-payable items, standard deductible, copayment and any other expense specified in the approval letter as per the terms & conditions of your policy.
Step 6: Before discharge, the card holder should check the final bill and discharge summary and correctly fill up insurance claim form and put his signature on all the three documents.

Points to remember
1.  No original documents should be collected from the hospital by the card holder to facilitate direct payment to hospital, in case of cashless treatment.
2.  The authorization is valid for the date of hospitalization as specified in the preauthorization request.
3. For the expenses pertaining to pre and post hospitalization, the card holder will submit the documents containing prescriptions, cash memos, investigation report etc., to Genins directly for reimbursement as per policy terms and conditions.
4.  Do not forget to inform the hospital authorities of availability of insurance cover for hassle free benefit of negotiated discount / packages.
5.  Do not get admitted to hospital for health check-up, investigation or evaluation only.
6.  Do not insist for admission for preoperative work up after admission only.
7.  In case sufficient information in the prescribed pre-authorization format is not given or in case of vague symptoms, where medical team of Genins India InsuranceTPA Ltd. is not sure of eligibility of coverage under the policy, due to inadequate medical information, pre-authorization for cashless can be denied.
8.  The denial of cashless facility does not mean denial of treatment and does not prevent you from seeking necessary medical attention in hospital. The claim can be considered for payment in accordance with terms & conditions of policy.

How to Utilize the Service of Genins India Insurance TPA Ltd. In Case Of hospitalization At Non-Network Hospital (Reimbursement Claim)

Step 1: The card holder will intimate to Genins within 24 hrs of hospitalization, through a letter,
fax or e-mail at gil@geninsindia.com or info@geninsindia.com.
Information to be provided at the time of reimbursement claim intimation
i. Name of the insured patient:
ii. Mobile no.:
iii. Policy No. and / or Genins Card ID No.:
iv. Name of the hospital with address:
v. Date of admission / Proposed date of admission:
vi. Duration of stay (expected):
vii. Class of accommodation:
viii. Provisional / Final Diagnosis (Reason for hospitalization):
ix. Treatment proposed:
x. Cost estimate:
xi. Signature of the insured person:

Step 2: The cardholder can visit our website to download the claim form from our website www.geninsindia.com.
Step 3: The card holder will pay the total expenses directly to the hospital.
Step 4: The card holder will submit the claim for the reimbursement from Genins after discharge from the hospital.
Step 5: Complete set of claim documents should be submitted Genins India Insurance TPA Ltd. within 15 days of discharge.

Points to Remember:
1. The following information to be provided for sending necessary claim processing communication
   i. Claimant’s /Employee Name
   ii. Employee No
   iii. Patient’s Name
   iv. Patient’s Genins Card ID No
   v. Claim No. and /or Policy No
   vi. Mobile no.
   vii. E-Mail ID
2. Do not forget to attach the checklist with the claim documents.
3. Arrange the documents in the same order as in the checklist. This way you can ensure that you have not missed out any document.
4. Please retain copies of all the documents submitted to us for future reference.
5. In case of claim submission beyond the stipulated time period please add self declaration detailing reason for the same.
6. Doctor’s registration number on doctor’s letterhead with signature if not included in hospital documents should be taken. This is applicable for non-network hospitals only.

DOCUMENT CHECK LIST
1. Duly filled and signed Claim Form in original
2. Copy of the claim intimation (In case of delayed / non-intimation, self declaration for reason for the same supported by documentary evidence wherever applicable)
3. Copy of Photo ID other than Genins (e.g. Election / Aadhar / PAN / Ration Card or Passport)in addition to Genins Card
4. Copy of Hospital registration Certificate / Duly filled Format for Hospital certificate (Applicable for non-network hospitals)
5. Original Discharge summary /Death Summary / Day care summary as applicable (Gives the summary of diagnosis and course of treatment in hospital)
6. Copy of Operation theatre notes duly attested by the hospital wherever applicable
7. Implant sticker / invoice wherever applicable (In case of self purchase of Implants used in Cataract, Heart surgeries, Abdominal Surgeries, Knee replacement surgeries etc., vendor invoice and payment receipt also required)
8. Police FIR / Medico Legal Certificate (MLC) (Mandatory for accidental / burns / suicidal / poisoning /other injury cases. In case not done, reason for the same given by the hospital on letter head signed and stamped by the hospital authority required)
9. Original Main Hospital bill with bill no.
10. Original Hospital bill break up (With detailed break up of various heads like Room Rent/OT charges/Nursing etc)
11. Original Hospital Bill Payment Receipt/s with receipt number (With seal & signature of hospital authority)
12. Original Pharmacy and Investigation cash memos / bills (Along with supportive doctor’s prescriptions and Investigation reports & films)
13. Copy of cancelled cheque of claimant /employee (Not applicable if payment is made in favour of corporate)
14. KYC compliance documents if claim is for Rupees One Lakh and above (This includes latest photograph and Address proof in addition to Photo ID. as above. Not applicable if payment is made in favour of corporate)

The following documents can be downloaded from the ‘Downloads’ section on our website www.geninsindia.com :
i. Authorization request form
ii. Reimbursement claim form
iii. Cashless Claim form
iv. Claim Intimation form
v. Hospital Certificate
vi. KYC guidelines for insured