MAX BUPA Health Insurance Company LTD: Claims Manual

Group Personal Accident Claims Manual
MAX BUPA Health Insurance

Company Ltd
Claims Manual
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Table of Contents
1. Purpose of the document 3
2. Overview 4
3. Claims Process 5
4. Claims Review Committee 12
5. Authority Controls 13
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1 PURPOSE OF THE DOCUMENT
This document will serve to function as a Standard Operating Manual for the Claims Team to enable them
to effectively and seamlessly handle all claims pertaining to the Group Personal Accident Product.
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2 OVERVIEW
Claims management will be conducted through a dedicated centralized back-office team which will have
the functional overview of processing all claims as settlements after the event has occurred. No cashless
facility will be available for this product.
The responsibility of the Claims team shall extend to adjudication of claims for Accidental Death,
Accidental Permanent Partial Disability, Accidental Permanent Total Disability, Accidental Temporary
Total Disability claims that have been lodged within the ambit of the policy along with any other available
ancillary benefits specified under the policy.
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3 CLAIMS PROCESS
No cashless facility will be available for the benefits of this product. All claims will be adjudicated after
the occurrence of the event and further submission of documents by the Insured Person. Basic benefits
(Accidental Death, Accidental Permanent Total Disability, Accidental Permanent Partial Disability and
Temporary Total Disability) will be paid out in line with the coverage in the plan and will be irrespective of
the actual costs incurred by the Insured Person. In the Optional Benefits, Education Allowance for
Children, Broken Bones and Last Rites expenses will be paid as a fixed lumpsum amount. All other
Optional Benefits will be paid out as indemnity of actual expenses. The process will be uniform across
network and non network providers of Max Bupa.
Aggregate Limit of Liability per Event if applicable will be applied during claim settlement. Our maximum,
total and cumulative liability for any and all claims made in respect of all Insured Persons under the Policy
arising out of or in relation to a single Accident or event will be limited to Aggregate Limit of Liability per
Event. If the total value of such unpaid claims in respect of all Insured Persons exceed the Aggregate
Limit of Liability per Event, the amounts payable on such outstanding claims shall be reduced pro rata as
necessary to ensure that the Aggregate Limit of Liability per Event is not exceeded.
3.1 Claim notification

All claims will be notified to Max Bupa either telephonically or in written within 48 hours of hospitalization.
If hospitalization has not occurred then notification has to be provided within 7 days of the occurrence of
the accident. In event of the customer holding any other policy with Max Bupa, a single notification will
apply to all the policies. However, policy numbers of all the policies held by the customer must be
mentioned in the notification.
Notifications can be done by telephone to our contact centre, through fax or email. The notification
should preferably be given by the Insured Person himself. However, if the Insured Person is indisposed,
the notification may be provided by any adult member of the immediate family, preferably the spouse or
one of the parents.
The following information is mandated in the notification:
1. Name of Proposer
2. Name of Insured Person in respect of whom the claim has been notified and relationship to
the Proposer
3. Name of Hospital with address and contact number.
4. Cover (Accidental Death / Accidental Permanent Total Disability / Accidental Permanent
Partial Disability / Temporary Total Disability / Fixed Medical Expenses / Variable Medical
Expenses / Education Allowance for children/ Residential Accommodation and Vehicle
Modification Allowance / Family Transportation / Last Rites Expenses) being claimed
5. Approximate amount being claimed for:
3.2 Claim processing

After notification the claim documents will be submitted post fulfillment of the following conditions:
1. Accidental Death: Within 30 days of date of death
2. Accidental Permanent Total Disability: After six months from the date of onset of disability
3. Accidental Permanent Partial Disability: After six months of onset of disability
4. Temporary Total Disability: Within 30 days of the date of completion of the period of disability
5. For all other benefits documents must be submitted within 30 days of the expense having
been incurred.
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The claim will not be denied in event of delayed intimation / submission of documents. Any delay in
intimation / submission of documents will be accompanied by a written justification explaining the
reasons for the delay and will be taken up for further consideration. The documents and guidelines to be
followed to process the claims are as follows:
Accidental Death
1. Duly filled and signed claim form
2. Original Death Certificate (issued by the office of Registrar of Births and Deaths)
3. Copy of First Information Report (FIR) / Panchnama / Inquest report duly attested by the
concerned police station
4. Copy of Medico Legal Certificate duly attested by the concerned hospital.
5. Copy of Post Mortem report wherever applicable (provided Post Mortem was conducted)
6. Newspaper cuttings / news articles covering the accident (if available)
Guidelines
1. Death should occur consequent to an Accident within 365 days of the Accident and the
injuries should be the sole and direct cause of death.
2. The accident should occur while the policy is in force.
3. The maximum payable amount under this benefit will be equal to the Principal Sum Assured
and net of any other claims paid under Accidental Permanent Total Disability, Accidental
Permanent Partial Disability, Temporary Total Disability or Variable Medical Expenses under
Accidental Medical Reimbursement
Accidental Permanent Total Disability

2. Hospital Discharge Summary (in original) / self attested copies if the originals are submitted with
another insurer
3. Medical consultations and investigations done from outside the hospital.
4. Original certificate of Disability issued by a Medical Board duly constituted by the Central and the
State Government.
Guidelines
1. Disability should have been sustained consequent to an Accident and should have occurred
within 365 days of the date of sustaining an injury.
3. Disability certificates only issued by a competent Medical Board are to be accepted.
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4. The maximum payable amount under this benefit will be equal to opted Sum Assured for this
cover. The amount will be net of any other claims paid under Permanent Partial Disability,
Temporary Total Disability or Variable Medical Expenses under Accidental Medical
Reimbursement.
Accidental Permanent Partial Disability

another insurer.
3. Medical consultations and investigations done from outside the hospital.
4. Original certificate of Disability issued by a Medical Board duly constituted by the Central and the
State Government.
Guidelines
1. Disability should have been sustained consequent to an Accident and should have occurred
within 365 days of the date of sustaining an injury.
3. Disability certificates only issued by a Medical Board are to be accepted.
4. The maximum payable amount under this benefit will be equal to Principal Sum Assured
opted for this cover. The amount will be net of any other claims paid under Permanent
Partial Disability, Temporary Total Disability or Variable Medical Expenses (Accidental
Medical Reimbursement) in case the total payout exceeds Principal Sum Assured
Accidental Temporary Total Disability

another insurer.
5. Attendance record of employer / Certificate of employer confirming period of absence
6. Latest salary certificate with grade and designation.
Guidelines
1. The claim will be admissible only when the Insured rejoins work after his period of absence.
2. Periods of hospitalization will be considered as valid period of absence for admitting the
claim.
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4. In case of prolonged absence from work, interim on account payments may be considered
every month.
5. Payouts will be admissible after three continuous days of absence from work and will be
payable from Day 1.
6. The amount will be net of any other claims paid under Permanent Partial Disability,
Temporary Total Disability or Variable Medical Expenses (Accidental Medical
Reimbursement) in case the total payout exceeds Principal Sum Assured
Optional Benefits
1) Accidental Medical Reimbursement
One of the two options stated below will be payable as reimbursement.
a) Fixed Medical Expenses (not linked to basic benefits):

another insurer.
5. Final Hospital bill with receipt
6. Bills with supporting prescriptions and reports for investigations done outside the hospital
7. Bills with supporting prescriptions for medicines purchased from outside the hospital.
Guidelines
1. 20% of the above benefit can be paid as OPD expenses.
2. Benefits are admissible only if the claim arises out of an accident.
b) Variable Medical Expenses (linked to basic benefits):

In addition to the documents required for the Basic Benefit (AD/PTD/PPD/TTD whichever is
applicable):
1. Final Hospital bill with receipt /copies attested by other insurer if the originals are submitted with
them.
2. Original bills with supporting prescriptions and reports for investigations done outside the hospital/
copies attested by other insurer if the originals are submitted with them.
3. Original bills with supporting prescriptions for medicines purchased from outside the hospital./
copies attested by other insurer if the originals are submitted with them.
Guidelines
1. Benefits are admissible only if the claim arises along with claim of Accidental Death,
Accidental Permanent Total Disability, Accidental Permanent Partial Disability or Temporary
Total Disability out of an accident.
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2) Educational Allowance
The amount is payable in case of Accidental Death or Accidental Permanent Total Disability of the
Primary Insured.
1. Duly filled and signed claim form.
2. Documents required for Accidental Death or Accidental Permanent Total Disability (whichever is
applicable).
Guidelines
1. Benefit will be payable as a lumpsum amount for upto 2 legally dependent children.
2. Benefit would be payable as an additional benefit over the Principal Sum Assured.
3) Residential accommodation and Vehicle Modification allowance

2. Documents required for Permanent Total Disability (if not already submitted).
3. Bills of residential or vehicle modification
Guidelines
1. Benefit will be payable only in case of Permanent Total Disability.
2. Benefit will be paid as Indemnity and would be payable for claims for modifying the house or
vehicle to adapt to the altered lifestyle arising out of the permanently disabled condition.
Example: Modification of residence to build ramps etc.
4) Family Transportation
2. Documents required for Accidental Death or Accidental Permanent Total Disability (whichever is
applicable)
3. Reimbursement will be provided for return tickets of one member of the family on admissibility of
one of the two basic benefits (Accidental Death or Accidental Permanent Total Disability)
4. Insured should be hospitalized in a city away from his residential city. For the purpose of this
benefit the following geographical areas will be considered individually as single cities - NCR,
Mumbai (with suburbs), Hyderabad (with suburbs) and Pune (with suburbs).
5. Journey should commence within 5 days of the date of accident.
6. Benefit would be paid as an additional amount over and above the Principal Sum Assured.
7. Claim will be limited to the cost of the return airfare by economy class.
5) Last Rites Expenses:

2. Documents required for Accidental Death (If not already submitted)
3. Payable as a lumpsum amount in case of Accidental Death
4. Benefit would be paid as an additional amount over and above the Principal Sum Assured
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6) Terrorism Cover:
This benefit will pay for the all benefits arising out of a terrorist attack if the customer opts for this
benefit by paying an additional premium.
7) Broken Bones Cover:

another insurer / Consultation notes (if hospitalization has not occurred)
3. X-Ray and MRI films along with reports
5. Copy of Medico Legal Certificate (MLC) duly attested by the concerned hospital.
6. Narration of events of accident if no FIR / MLC available
Guidelines
1. Benefits will be paid as a lumpsum amount in accordance with the defined grid.
2. OPD management of fracture will be admissible as a claim.
3. The cover is not linked to the basic benefits.
3.3 Claim decisions

Claims would typically have the following decision outcomes
1. Approved
The claim is approved in accordance to the plan opted for by the Proposer. The request for
payment will be forwarded to Finance who will then effect the payment. The claim settlement will
be done either through cheaque or a bank transfer in accordance with the Insured Person’s
request.
2. Declined
The reason for declination of the claim will be stated in the Letter of Declination.
3. Further Information Requested
Any other document or further information will be requested on the basis of which a final decision
would be taken.
3.4 Communication of Decision

The decision on the claim will be communicated to the Insured Person/Nominee through a letter,
SMS and email.
3.5 Service Standards

All claims will be decided within 15 days of the claim being received. The above timelines shall not
apply in event of any further information being requested or in event of the claim being assigned for
investigation in cases of suspected fraud. The Insured Person/Nominee will be informed of an
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imminent delay in claims decision and the claim will be decided within 15 days of the requested
information being received.
In event of further information being requested from the Insured Person the first letter seeking such
information will be sent out within five working days of the claim documents being received.
Reminders for the same will be sent every fifteen days. After three such reminders, the claim will be
moved into a state of suspension. No further reminders will be sent to the Insured Person and the
claim will be attended to once again only on receipt of the requisite information from the Insured
Person.
Under exceptional circumstances of fraud suspected to be having being committed by the Insured
Person claims will be investigated through the Fraud and Investigations Team. All investigations will
be completed within twenty one days of the investigation being assigned. The Insured Person will be
informed of the imminent delay in decisioning of the claim.
3.6 Exception Handling

3.6.1 Settlement of the claim in event of death of the Insured Person (other than
claims of Accidental Death)
In event of death of the Insured Person the claim settlement, if any, shall be made in favour
of the nominee. However, in event of the death of the nominee also a Succession
Certificate / Legal Heir Certificate will be called for to decide the recipient of the claim
settlement amounts, if any.
In event of person(s) other than the nominee submitting a stake to the claim settlement
amount, if any, Max Bupa shall make all requisite payments to the nominee only. However,
in event of the nominee dying before the claims decision is taken the payments will be
made to the legal heirs of the Insured Person, upon submission of succession certificate or
legal heir certificate or any other legally viable document.
3.6.2 Review of Claims
Review of all decided claims will be initiated only on receipt of a written request for the
same from the adult Insured Person / policy holder. Requests from the nominee will be
accepted under circumstances of the Insured Person being physically unable to make such
a request or having expired before submitting the request.
3.6.3 Legal Reference
On any matter involving points of law a reference shall be made to the Legal Department.
The Claims team then shall act in accordance with the directions of the Legal Department.
3.6.4 Ex-gratia claims settlement
Ex-gratia claim settlements are made outside the scope of the policy’s terms of coverage.
Such requests for ex-gratia settlements will have to be initiated in written form by the
Insured Person or from Sales. Such requests would have to be confirmed by the Chief
Operating Officer.
All decisions on requests for ex-gratia claims settlements will be taken within thirty days of
receipt of such a request.
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4 CLAIMS REVIEW COMMITTEE
The committee will comprise of the following members:

1. Chief Operating Officer (Chair)
2. Head of Legal
3. Head of Compliance
4. Head of Customer Service and Operations
5. Head of Actuarial
6. Head of Underwriting
7. Head of Claims
8. Head of Healthcare Purchasing Team
The following would comprise the minimum quorum that would be required for the Committee to meet:
1. One representative from Legal and Compliance department.
2. Head of Claims
3. Head of Underwriting
4. Head of Customer Service and Operations
5. One representative from Actuarial Department
6. One representative from Healthcare Purchasing Team
The committee will meet on a regular basis to discuss any items related to claims. The scope of
discussions will include any claims under process or any impact of regulations, laws and market
developments that may impact the claims philosophy of Max Bupa.
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5 AUTHORITY CONTROLS
Position Amount (INR)

Executive/Sr. Executive Claims Up to 30,000
Assistant Manager Claims Upto 60,000
Manager Claims Upto 150,000
Senior Manager Claims Upto 250,000
Head Claims Upto 350,000
Head Customer Service and Operations Upto 500,000
Chief Operating Officer More than 500,000
Any exceptional decision or a business override needs to be approved by Chief Operating Officer.
Note: Utilization of the Corporate Floater will have to be approved by the HR of the group in written.
Page 13 of 13

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Group Personal Accident Claims Manual

MAX BUPA Health Insurance

4. Claims Review Committee 12

1 PURPOSE OF THE DOCUMENT

3.1 Claim notification

The following information is mandated in the notification:

3.2 Claim processing

Accidental Permanent Total Disability

Accidental Permanent Partial Disability

Accidental Temporary Total Disability

3. The accident should occur while the policy is in force.

a) Fixed Medical Expenses (not linked to basic benefits):

b) Variable Medical Expenses (linked to basic benefits):

3) Residential accommodation and Vehicle Modification allowance

5) Last Rites Expenses:

7) Broken Bones Cover:

3.3 Claim decisions

3.4 Communication of Decision

3.5 Service Standards

3.6 Exception Handling

4 CLAIMS REVIEW COMMITTEE

The committee will comprise of the following members:

Position Amount (INR)

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