HDFC ERGO General Insurance Company Limited

Claim Manual

Sarv Suraksha Plus (Group)

On the occurrence of any Critical Illness/Surgical Procedure /hospitalization that may give rise to a Claim under this Policy, the Claims Procedure set
out below shall be followed.

Claim Intimation You shall intimate the Claims to us through any available mode of communication as specified in
the Policy, Health Card or ourWebsite, You can register your claim through call to our IPO (Mobile/
Portal) app, e-mail, Call to our call centre.
Claim Intimation Timelines Within 15 days from the date of occurrence of the event (Other than Hospitalization)
Cashless Cashless claims for Hospitalizations Reimbursement
Hospitalization outside India Claims
Cashless Hospitalization Cashless claims
for Hospitalizations
Emergencies Planned outside India
Claim Intimation Timelines
(in case of Hospitalization) Within 24 hours of At least 72 hours Within 24 hours Within 48 hours of
Hospitalization. prior to the planned of the Emergency admission or before
Hospitalization Hospitalization. discharge from the
At least 72 hours Hospital, whichever is
prior to the planned earlier.
Hospitalization

Particulars to be provided to Us for Claim 1. Policy Number,

notification
2. Name of the Insured Person(s) named in the Policy schedule/Certificate availing treatment (if
applicable)
3. Nature of disease/illness/injury (if applicable)
4. Name and address of the attending Medical Practitioner/Hospital (if applicable)
5. Date of admission & probable date of discharge (if applicable)
6. First Information Report and Final Police report, wherever is necessary
7. Any other supporting documents as may be required by the Company
8. Insured Person’s own Indian bank cancelled cheque copy and bank details in attached format
Surveyor’s Responsibilities 1. The Surveyor must issue an ‘ILA’ or initial loss assessment, as soon as his preliminary assessment
is over.
2. He should continue to advice about revision in reserve as his adjustment progresses, till a firm
figure is arrived at.
3. He must submit the reports and photographs both in hard copies and soft copies. Supporting
documents will have to be scanned.
4. He should clearly establish coverage.
5. He must clearly establish Cause of loss.
6. Loss Adjustment should be done in clear financial terms, with attachments certified by a CA if
financial statements are involved.
7. Salvage value.
8. The Surveyor should also determine loss minimization possibilities, by involving experts from
India/Abroad. If so agreed, with the insurers, he will coordinate the activities of these specialists,
MAY 2023

so as to ensure that maximum equipment is made serviceable again.

Condonation of delay If the claim is not notified/ or submitted to Us within the specified time limits, then We shall be
provided the reasons for the delay in writing. We will condone such delay on merits where the
delay has been proved to be for reasons beyond the claimant’s control.
ClaimManual/Ver - 1

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, 165-166 Backbay
Reclamation, H. T. Parekh Marg, Churchgate, Mumbai – 400 020. Health Claim Services Address : HDFC ERGO General Insurance Co. Ltd. Stellar IT Park, Tower-1 , 5th Floor, C
- 25, Noida, Sector 62, 201301, Uttar Pradesh. Service No. 022-62346234 / 0120-62346234 Email: [email protected] Logo displayed above belongs to HDFC
Bank Ltd and ERGO International AG and used by the Company under license. Sarv Suraksha Plus (Group) - HDFHLGP24020V032324. 1
Claims Procedure Applicable to Health Covers

Claims Documents to be submitted for Major 1. Duly filled Claim Form with signature of claimant.
Illness and Permanent Total Disablement
due to Illness. 2. Copy of Discharge Summary / Discharge Certificate / Death Certificate (in case insured expired);
3. First consultation letter from treating Medical Practitioner
4. Medical certificate confirming diagnosis, and the treatment from Medical Practitioner
5. certificate from treating Medical Practitioner, specifying the duration and aetiology
6. OT Notes in case of Surgery
7. Medical certificate from treating Medical Practitioner specifying the diagnosis and need for the
surgery
8. MLC/FIR copy/ certificate regarding abuse of Alcohol/intoxicating agent if applicable
9. All pathological/Histopathological and radiological Investigation Reports
10. NEFT details & cancelled cheque of Claimant or Nominee (in case claimant expired), Provide
legal heir certificate in case nominee is minor.
11. Provide KYC ( Know your customer ) form along with photocopy of any one of following KYC
documents for all claims amounting to Rs 1 lakh and above (Aadhaar Card, Passport, Driving
License Voter ID, etc)
12. Other necessary document as required by the Company
We may require the Insured Person to undergo medical examination by Medical Practitioner
authorized by Us to obtain an independent medical opinion for the processing of the claim. Any
cost towards such medical examination will be borne by Us.
Claims documents and procedure for 1. Duly filled claim form along with the copy of all medical reports including investigation reports
Second Opinion and discharge summary (if any)
2. Select Our network Medical Practitioner from whom you would prefer to take the second opinion.
(Please refer our Website or call at 24X 7 toll free line to obtain the list of Our panel doctors).
3. On receipt of the complete set of documents, We will forward the same to the concerned doctor.
4. The Second Opinion shall be forwarded to the member within 15 working days of receipt of the
complete set of documents.
5. Where Claim is on reimbursement basis – Diagnostic report and invoice from Medical Practitioner
Claims Documents to be submitted for Loss 1. Duly completed claim form;
of Income due to termination
2. Certificate if applicable from the Bank stating the amortization schedule, the EMI Amounts,
Principal Outstanding, etc.
3. Certificate from the employer of the insured confirming the termination with date of and period
of termination.
4. Form 26 AS
5. Any other necessary document as may be required by the Company.
6. NEFT details & cancelled cheque of Claimant or Nominee (in case claimant expired), Provide
legal heir certificate in case nominee is minor.
Claims Documents to be submitted for Loss 1. Duly completed claim form;
of Income due to resignation due to CI
2. Certificate if applicable from the Bank stating the amortization schedule, the EMI Amounts,
Principal Outstanding, etc.
3. Resignation Letter/ Resignation Acceptance letter
4. NEFT details & cancelled cheque of Claimant or Nominee (in case claimant expired), Provide
legal heir certificate in case nominee is minor.
Claims Documents to be submitted for 1. Duly filled Claim Form with signature of claimant.
Loss of Income due to resignation due to
Accidental Permanent Total Disablement 2. Copy of Discharge Summary / Discharge Certificate
3. First consultation letter from treating Medical Practitioner
4. Certificate from treating Medical Practitioner, specifying the duration and etiology
5. OT Notes in case of Surgery
6. Medical certificate from treating Medical Practitioner specifying the diagnosis and need for the
surgery
7. MLC/FIR copy/ certificate regarding abuse of Alcohol/intoxicating agent if applicable
8. NEFT details & cancelled cheque of Claimant or Nominee (in case claimant expired), Provide
legal heir certificate in case nominee is minor.

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, 165-166 Backbay
Reclamation, H. T. Parekh Marg, Churchgate, Mumbai – 400 020. Health Claim Services Address : HDFC ERGO General Insurance Co. Ltd. Stellar IT Park, Tower-1 , 5th Floor, C
- 25, Noida, Sector 62, 201301, Uttar Pradesh. Service No. 022-62346234 / 0120-62346234 Email: [email protected] Logo displayed above belongs to HDFC
Bank Ltd and ERGO International AG and used by the Company under license. Sarv Suraksha Plus (Group) - HDFHLGP24020V032324. 2
Claims documents to be submitted for 1. Medical Practitioner’s Report
Accidental Death
2. Medico Legal Certificate
3. Death certificate
4. Post mortem if conducted/FSL (Forensic science laboratory)report – To check for drug abuse/
intoxication
5. MLC/FIR copy/ certificate regarding abuse of Alcohol/intoxicating agent if applicable
Claims documents to be submitted for 1. Medical Practitioner’s Report
Permanent Disablement
2. Medico Legal Certificate
3. Investigation Reports like Laboratory test, X-rays and reports essential of confirmation of the
Injury;
4. Disability certificate from a government certified Medical Practitioner or government Hospital
confirming the extent and nature of disability;
5. Discharge summary from the Hospital Medical reports, case histories, investigation reports,
treatment papers as applicable.
6. Letter from treating Medical Practitioner mentioning the reason and date for disablement and
confirming the disablement.
7. MLC/FIR copy/ certificate regarding abuse of Alcohol/intoxicating agent if applicable
Claims documents to be submitted for 1. Medical Practitioner’s Report
Temporary Total Disablement
2. Medico Legal Certificate
3. Investigation Reports like Laboratory test, X-rays and reports essential of confirmation of the
Injury;
4. Discharge summary from the Hospital
5. Medical reports, case histories, investigation reports, treatment papers as applicable.
6. Letter from treating Medical Practitioner mentioning the reason and date for disablement and
confirming the disablement. And advised days of rest.
7. Leave certificate from the employer (If Employed)
8. Fitness certificate from Medical practitioner
9. Insured’s own Indian bank cancelled cheque copy and bank details in attached format
10. MLC/FIR copy/ certificate regarding abuse of Alcohol/intoxicating agent if applicable
Claims documents to be submitted for 1. Copy of Discharge Summary / Discharge Certificate along with time of admission and discharge
Hospital Cash for Hospital cash benefit
2. First consultation letter from treating Medical Practitioner
3. Certificate from treating Medical Practitioner, specifying the duration and etiology
4. MLC/FIR copy/ certificate regarding abuse of Alcohol/intoxicating agent if applicable
5. NEFT details & cancelled cheque of Claimant or Nominee (in case claimant expired), Provide
legal heir certificate in case nominee is minor.
Claims documents to be submitted for 1. Medical Practitioner’s Report
Broken Bones
2. Investigation Reports like Laboratory test, X-rays and reports essential of confirmation of the
Injury;
3. Disability certificate from a government certified Medical Practitioner or government hospital
confirming the extent and nature of disability;
4. Original Discharge summary from the hospital
5. Medical reports, case histories, investigation reports, treatment papers as applicable.
6. MLC/FIR copy/ certificate regarding abuse of Alcohol/intoxicating agent if applicable
7. Relevant treatment papers clearly mentioning the areas of fracture with their severity.
Claims documents to be submitted for 1. Consultation note or Emergency Room’s Medical Practitioner medical report
Medical Evacuation
2. Copy of the passport showing the date of entry and exit related to journey (to & fro) from India.
3. All relevant Original Invoices for the expenses incurred towards ambulance facility.
4. A covering letter from claimant mentioning the details of loss.

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, 165-166 Backbay
Reclamation, H. T. Parekh Marg, Churchgate, Mumbai – 400 020. Health Claim Services Address : HDFC ERGO General Insurance Co. Ltd. Stellar IT Park, Tower-1 , 5th Floor, C
- 25, Noida, Sector 62, 201301, Uttar Pradesh. Service No. 022-62346234 / 0120-62346234 Email: [email protected] Logo displayed above belongs to HDFC
Bank Ltd and ERGO International AG and used by the Company under license. Sarv Suraksha Plus (Group) - HDFHLGP24020V032324. 3
Claims documents to be submitted 1. Consultation note or Emergency Room’s Medical Practitioner medical report.
for Emergency Medical Expenses and
Accidental Hospitalization 2. Relevant treatment papers or Discharge Summary.
3. Copy of the passport showing the date of entry and exit related to journey (to & fro) from India.
4. MLC/FIR copy/ certificate regarding abuse of Alcohol/intoxicating agent if applicable
5. All relevant Original Invoices for the expenses incurred.
Claims documents to be submitted for 1. Consultation Note OR Emergency Room’s Medical Practitioner medical report OR
Dependent Child Education Benefit and
Parental Care Benefit 2. Relevant Treatment Papers OR Discharge Summary. .
3. Letter from treating Medical Practitioner, mentioning the cause of death if death occurred after
a long period from the date of incident.
4. Disability certificate from a government certified Medical Practitioner or government hospital
confirming the extent and nature of disability;
5. Death certificate
6. Final police investigation report
7. Post-mortem Report or Coroner’s Report
8. MLC/FIR copy/ certificate regarding abuse of Alcohol/intoxicating agent if applicable.
Claims documents to be submitted for 1. Duly completed and signed claim form.
Mobility Extension Cover
2. Policy/Certificate Copy
3. Expenses incurred towards supporting equipment (wheel chair, railings, customized motor
vehicle)
4. Consultation Note Or Emergency Room’s Medical Practitioner medical report OR Relevant
Treatment Papers OR Discharge Summary.
5. All relevant Invoices for the expenses incurred.
6. Letter from treating Medical Practitioner mentioning the reason for disablement and confirming
the disablement.
7. Details of home, office and /or vehicle or towards purchase of an Artificial limb/wheelchair/or
any limb during claim processing.
Claims documents to be submitted for 1. Medical Practitioner’s Report
Chauffeur Benefit
2. Medico Legal Certificate
3. Investigation Reports like Laboratory test, X-rays and reports essential of confirmation of the
Injury;
4. Original Discharge summary from the Hospital
5. Medical reports, case histories, investigation reports, treatment papers as applicable.
6. Letter from treating Medical Practitioner mentioning the reason and date for disablement and
confirming the disablement.
7. Original invoices of transport
Claims documents to be submitted for Last 1. Claim Form duly completed
Rites Cover
2. Death certificate
Claims documents to be submitted for 1. Attested copy of certificate from treating Medical Practitioner specifying type of burns with
Burns percentage of burns
2. Attested copy of FIR. (If any)
3. All X-Ray / Investigation reports and films supporting to disability.
Particulars to be provided for 1. Policy Number
pre-authorization
2. Name of the Insured person(s) named in the Policy schedule availing treatment
1. Nature of disease/Illness/Injury
2. Name and address of the attending Medical Practitioner/Hospital
3. Date of admission & probable date of discharge
4. Approximate Claim Expenses
Any other relevant information as required

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, 165-166 Backbay
Reclamation, H. T. Parekh Marg, Churchgate, Mumbai – 400 020. Health Claim Services Address : HDFC ERGO General Insurance Co. Ltd. Stellar IT Park, Tower-1 , 5th Floor, C
- 25, Noida, Sector 62, 201301, Uttar Pradesh. Service No. 022-62346234 / 0120-62346234 Email: [email protected] Logo displayed above belongs to HDFC
Bank Ltd and ERGO International AG and used by the Company under license. Sarv Suraksha Plus (Group) - HDFHLGP24020V032324. 4
 Process for obtaining Pre-Authorization i. If the particulars are not provided in full or are insufficient for Us to consider the request, We
will request additional information or documentation
ii. On receipt of duly filled pre authorization form from the Network Provider along with other
sufficient details to assess the request, We may; Issue the authorization letter specifying the
sanctioned amount any specific limitation on the claim and non-payable items, if applicable
or
Reject the request for pre-authorization specifying reasons for the rejection.
Condonation of Delay If the claim is not notified/ or submitted to Us within the specified time limits, then We shall be
provided the reasons for the delay in writing. We will condone such delay on merits where the
delay has been proved to be for reasons beyond the claimant’s control
Claims Procedure Applicable to Section 6 – Property Cover
Documents required for processing of 1. Policy/Underwriting documents.
claim
2. Survey Report with Photographs
3. Claim Form, duly completed.
4. Log book / Asset register / Capitalised item list
5. Repair / Replacement invoices with receipt
6. All Applicable valid Certificates
Claims Procedure 1. Detailed description of the acts in chronological order which has resulted in the loss (details of
the quantum of loss to be mentioned and the basis at which it is arrived) giving rise to a claim.
2. First Information Report /charge sheet filed by the police
3. Internal Investigation report, if any, from the Insured giving an Insight into the loss.
4. Any other relevant documents which would be construed as material information to the case.
5. An acknowledgement with respect to the claim intimation is given to the insured, once we are
in receipt of any claim intimation from the insured.
6. Based on the information submitted in the claim intimation letter, if required, we may procure
more information from the insured depending on the facts mentioned therein, upto the satisfaction
of the Company.
7. Surveyor / Investigator may be appointed if required.
This requires that when a Surveyor is considered for appointment the following factors should
be looked at:
• The nature of loss
• The nature of material lost
• The geographical location of the loss
• The Surveyors credentials, which would comprise of:
o His qualifications
o His experience
o The quantum of loss assed by him in earlier surveys
o His Certification by IRDA
8. Apart from surveyor/investigator, opinions of legal experts are sought, if required.
9. Based on the investigation and documentations provided, the decision with respect to the claim
would be taken and accordingly conveyed to the insured
1. List of documents for Reimbursement Claims
i. Completely filled claim form, duly signed (by claimant/proposer) and stamped (by Hospital).
ii. Government Approved Photo ID & Age Proof
iii. Copy of claim intimation letter / reference of Claim Intimation Number in the absence of main claim documents
iv. Copy of the Hospital’s Registration Certificate/Hospital Registration number in case of Hospitalization in any non-network hospital of HDFC
ERGO GIC or certificate from Hospital authorities providing facilities available including number of beds.
v. Discharge Card / Day Care Summary / Transfer Summary
vi. Final hospital bill with all deposit and final payment receipt and refund receipt(s), if advance amount refunded
vii. Invoice with payment receipt and implant stickers for all implants used during surgeries e.g. lens sticker and invoice in cataract Surgery, stent
invoice and sticker in Angioplasty Surgery.
viii. All previous consultation papers indicating history and treatment details for current Illness and advice for current hospitalization.
ix. All diagnostic reports (including imaging and laboratory) along with prescription by Medical Practitioner and invoice / bill with receipt from
diagnostic centre

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, 165-166 Backbay
Reclamation, H. T. Parekh Marg, Churchgate, Mumbai – 400 020. Health Claim Services Address : HDFC ERGO General Insurance Co. Ltd. Stellar IT Park, Tower-1 , 5th Floor, C
- 25, Noida, Sector 62, 201301, Uttar Pradesh. Service No. 022-62346234 / 0120-62346234 Email: [email protected] Logo displayed above belongs to HDFC
Bank Ltd and ERGO International AG and used by the Company under license. Sarv Suraksha Plus (Group) - HDFHLGP24020V032324. 5
x. All medicine / pharmacy bills along with prescription by Medical Practitioner
xi. MLC / FIR Copy – in Accidental cases only
xii. History of alcohol consumption or any intoxication certified by first treating doctor in case of accidental cases.
xiii. Copy of Death Summary and copy of Death Certificate (in death claims only)
xiv. Pre and Post-Operative Imaging reports
xv. Copy of indoor case papers with nursing sheet detailing medical history of the patient, treatment details, and patient’s progress (to be submitted
wherever required by the insurer).
xvi. Invoice for Vaccination and payment receipt
xvii. KYC documents (in all claims above Rs 1 lakh) - (Ration Card/ Driving License/ Aadhar Card/ Passport /any other Government authorized identity
proof of the Claimant carrying name, photograph & address) and duly filled KYC form with 1 signed across passport size coloured photograph
of the Claimant ***
xviii. Duly filled NEFT form with cancelled blank cheque (with IFSC code, A/C number, and name mentioned on cheque leaf)
xix. Settlement letter(s), copy (-ies) of payment receipts, and entire certified copy of paid claims in case of partial claim settlement from other insurer.
*** In case of death of Insured Person, the same document reuqirement would be for nominee/legal heir of Insured Person(NOC in favour of 1 or more
than 1 undisputedly selected legal heir(s) by remanining legal heir(s).
2. Conditions for obtaining Cashless facility
i. Cashless facility can be availed only at Our Network Provider. The complete list of Network Providers and empanelled Service Providers is
available on Our website and can be obtained by contacting Us.
ii. We reserve the right to modify, add or restrict any Network Provider for Cashless Facilities at Our sole discretion. The same shall be duly updated
on Our website. You shall check the updated list of Network Providers before applying for Cashless Claim.
iii. Pre-authorization is valid for 15 days from date of issuance and if all the details of the Hospitalization/treatment, including dates, Hospital and
locations match with the details as per Cashless authorized.
iv. We will make payment for the Cashless authorized amount directly to the Network Provider.
v. If the claim is not notified to Us within the specified time limits, then We shall be provided the reasons for the delay in writing. We will condone
such delay on merits where the delay has been proved to be for reasons beyond the claimant’s control
3. Payment of a Claim
i. If there are any deficiencies in the necessary claim documents which are not met or are partially met, We will send a maximum of 3 (three)
reminders following which We will send a closure letter or make a part-payment if We have not received the deficiency documents after 45 days
from the date of the initial request for such documents
ii. The Company shall settle or reject a claim, as the case may be, within 30 days from the date of receipt of last necessary document.
iii. In the case of delay in the payment of a claim, the Company shall be liable to pay interest to the Policyholder from the date of receipt of last
necessary document to the date of payment of claim at a rate 2% above the Bank Rate.
iv. However, where the circumstances of a claim warrant an investigation in the opinion of the Company, it shall initiate and complete such investigation
at the earliest, in any case not later than 30 days from the date of receipt of last necessary document. In such cases, the Company shall settle
or reject the claim within 45 days from the date of receipt of last necessary document.
v. In case of delay beyond stipulated 45 days, the Company shall be liable to pay interest to the Policyholder/Insured Person at a rate 2% above
the Bank Rate from the date of receipt of last necessary document to the date of payment of claim.
vi. If We, for any reason decide to reject the claim, the reasons regarding the rejection shall be communicated to You in writing within 30 days of
the receipt of documents.
vii. If requested by Us, at Our cost, the Insured Person must submit to medical examination by Our Medical Practitioner as often as We consider
reasonable and necessary and We/Our representatives must be permitted to inspect the medical and Hospitalization records pertaining to the
Insured Person’s treatment and to investigate the circumstances pertaining to the claim.
viii. We and Our representatives must be given all reasonable co-operation in investigating the claim in order to assess Our liability and quantum in
respect of the claim.

Contact Us

Within India Outside India

Toll Free No: 800 08250825
Customer Service No. 022-62346234 / 0120-62346234 Global Toll Free No : +800 08250825 (accessible
Claim Intimation: Email:[email protected] from locations outside India only)
Landline no (Chargeable): 0120-4507250
Email: [email protected]
HDFC ERGO General Insurance Co. Ltd.
Claim document
submission Stellar IT Park, Tower-1
at address
5th Floor, C - 25, Noida, Sector 62, 201301, Uttar Pradesh

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, 165-166 Backbay
Reclamation, H. T. Parekh Marg, Churchgate, Mumbai – 400 020. Health Claim Services Address : HDFC ERGO General Insurance Co. Ltd. Stellar IT Park, Tower-1 , 5th Floor, C
- 25, Noida, Sector 62, 201301, Uttar Pradesh. Service No. 022-62346234 / 0120-62346234 Email: [email protected] Logo displayed above belongs to HDFC
Bank Ltd and ERGO International AG and used by the Company under license. Sarv Suraksha Plus (Group) - HDFHLGP24020V032324. 6