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Raksha

TPA

Health Insurance Policy(Employees Policy)

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Raksha

TPA

PROCESS FLOW - CASHLESS

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Raksha

TPA

How to avail Cashless Services

Emergency

Planned
Approach Network Hospital
Identification via UHID Cards
Pre-authorization request to
Raksha TPA from Provider

Raksha TPA Pvt Ltd


VERIFIED BY
DOCTOR

Authorization Issued

Queries Raised for


further Clarification

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Pre Authorization Request Denied


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Raksha

TPA

PROCESS FLOW - REIMBURSEMENT

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Raksha

TPA

Hospitalization through Non-Network Provider


(Reimbursement Claims)

EMERGENCY

PLANNED

APPROACH TO NON - NETWORK HOSPITAL

INTIMATE WITHIN 24 Hours from


ADMISSION or BEFORE
DISCHARGE

SUBMIT DOCUMENTS IN 7 DAYS


FROM D.O.D

INTIMATE 3-4 DAYS


BEFORE ADMISSION

Raksha TPA Pvt Ltd


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Raksha

TPA

PROCESS FLOW - CLAIMS

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Raksha

TPA

RAKSHA PROCESSING OF NON-NETWORKING CLAIMS


INSURED (REIMBURSEMENT with
intimation in 24 hours from admission

CLAIM RECEIVED BY RAKSHA


TPA PVT. LTD (within 15 days
from D.O.D.)

AUDITING

ENTRY ON LOCAL
WEBSITE

DOCTORS OPINION

NON PAYABLE

PASSED

QUERY

FINANCE
DEPARTMERNT

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Raksha

TPA

MUST KNOW

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Raksha

TPA

DOS (Cashless Services)


Pre-auth form should be sent along with insured/attendant cell no. duly signed

by treating doctor/hospital.

Avail cashless treatment at Network hospitals for the covered ailments within

eligible amount under the policy.

Leave back all the original documents and signed claim form with the network

hospitals at the time of discharge.

Contact local Raksha office in case of any query.


Make payment to the network hospital for the expenditure over and above sum

insured/ specified limit for any disease, and for the expenses/treatment not
covered under the package

For current status of empanelment/de-empanelment of networking hospital,

please refer our website: www.rakshatpa.com


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Raksha

TPA

DONTS (Cashless Services)


Dont insist upon admission for investigations or evaluation or health

check-ups.
Dont carry back any original document at the time of discharge from the

hospital.
Dont forget to sign on claim form.

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Raksha

TPA

Document Checklist (Re-imbursement)


After discharge policy holder has to submit the following documents to Raksha
TPA within 15 days.
Original detailed discharge summary
Payment receipt in original
Copy of ID card
Original hospital bill with breakup
Package break-up (if applicable)
Original investigation reports
Pharmacy bills with prescription

Claim form duly signed


Hospital registration certificate
Scan copy of cancelled cheque to be mailed at abhijit@rakshatpa.com
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Raksha

TPA

Day Care Treatments covered under Policy


Expenses on Hospitalisation for minimum period of 24 hours are admissible. However, this time
limit is not applied to specific treatments, such as:

Appendectomy
Haemo dialysis
Coronary angiography
Hydrocele
Coronary angioplasty
Hysterectomy
Inguinal/ventral/ umbilical/femoral hernia
D&C
Parenteral chemotherapy
Eye surgery
Piles/ fistula
Fracture/ dislocation excluding hairline fracture

Sinusitis
Lithotripsy
Tonsillectomy
Incision and drainage of abcess
Liver aspiration
Colonoscopy
Sclerotherapy
Prostrate
Radiotherapy
Or any other surgeries / procedures agreed by the
TPA/ Company which require less than 24 hours
hospitalisation and for which prior approval from
TPA is mandatory.

Note: Procedures/treatments usually done in out patient department


are not payable under the policy even if converted as an in-patient in
the hospital for more than 24 hours
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Raksha

TPA

Eligibility for Hospital / Nursing Home

Minimum 15 in-patient beds (in metros) & 10 in Remote


areas.
Fully equipped OT
Fully qualified nursing staff round the clock
Fully qualified & registered doctor(s) round the clock

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Raksha

TPA

General Exclusions Under the Policy

Domiciliary Hospitalization
OPD treatment
Treatment related to infertility, Voluntary Termination of
Pregnancy
External Accessories (e.g.) Walking Stick, Crepe bandage,
Spectacles, contact lens, hearing Aids etc.
Non Medical Expenses (e.g.) Telephone Charges, Food Charges,
Registration Charges, Accommodation Charges for Relatives.
Naturopathy Treatment , Homeopathic & Ayurvedic Treatment
War Like operations whether declared or not
Circumcision unless necessary for treatment of disease
Cosmetic treatment
Plastic Surgery

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Raksha

TPA

General Exclusions Under the Policy

Dental Treatment other than arising due to Accident requiring


hospitalization
Intentional Self Injury, Intoxicating Drugs, Alcohol, Congenital External
Disease, sterility etc
Hospitalization meant for Oral Medication, primary Investigation is
non Payable
Vitamins And Tonics unless part of treatment
Hospitalization Less than 24 hrs other than day care treatments
Pre & Post Hospitalization charges for Maternity is Non Payable
All Expenses related to the treatment of AIDS is not covered.

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Raksha

TPA

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