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FAQs

Amicus FAQs

  • I would like to know what Amicus is.

    Amicus is a retail insurance claim consultancy promoted by Claim Experts who are consulting for several Corporate and Insurers. We help policyholders recover their fair claims in line with the terms and conditions of the policies and using the grievance redressal mechanisms stipulated by IRDA or through the Consumer Court.

  • Does Amicus deals other than Health insurance claim?

    Amicus has a team of expertise including Panel of Doctors, Lawyers, Engineers Chartered Accountants, Surveyors and Insurance Experts. The company specializes in all kinds of life insurance and general insurance claims. After being appointed we take care of all aspects of the claim including correspondence, follow-up, and representation with the TPA/Insurers and in different forums such as Ombudsman/Consumer forum.

  • How will it benefit me (Policyholder)

    Amicus helps you get the maximum claim payable under the policy conditions and acts as your own consultant/legal expert who can handle the insurers/TPAs and their legal/medical experts.

  • Why should I enroll In Amicus?

    As an agent, your skills should be utilized for business development. WE help you focus on this aspect of your work, while we take care of all the hassles of handling your clients’ claims. Our experience is that agents who opt for our services are not only able to increase client satisfaction but also see a substantial rise in their time availability for generating new business.

  • Whether Amicus is an insurance company? Or a TPA or any agent or a broker?

    Amicus is neither an insurer, nor a broker or agent or TPA. We are insurance advisors specializing in legal and technical aspects of claims.

  • Whether Amicus is approved by an insurance company or under any govt regulatory body to deal with health insurance claims or counseling?

    “Amicus” is a Service provided by “Magus corporate advisors Pvt Ltd” and is a separate entity registered under ROC. The Company’s core activity is to advise on insurance related claims As an insurance consultant no separate registration/approval is required by IRDA.

  • Will Amicus charge me any fees for Claims Opinion?

    Basic opinion on admissibility will be at No Cost. Fees are charged by us only against payable claims and that too in stages.

  • Basically who are the expert’s team and doctors at Amicus? Are they good enough to give their opinion and expert advice on the admissibility of claim? Will the insurance company or the TPA honor their representation or written statement issued for admissibility of the claim?

    “Magus Corporate Advisors” is an independent body that are experts in their respective field and have over 2 decades of experience in their respective field of insurance claims The promoters are regularly advising some of the country’s largest corporates, insurers and surveyors on insurance claims and claim related litigation. The promoters often lecture at various forums on Insurance Claims. Even the Bombay Chamber of Commerce provides a helpline which is serviced by our promoters.Your claims will be represented based on the policy conditions, IRDA regulations and legal principles to the insurers/TPAs/Ombudsman etc.
    Our team will actively take up the matter with the relevant forum through correspondence/personal meetings etc, to try and expedite settlement.
    Some claims which insurers may not want to settle, but are payable, will normally get settled in due course at the Ombudsman with our help.
    Our experience is that if a claim is considered as being payable by us, the settlement will normally happen at the relevant forum.

  • What would be the charges levied by “Amicus” and whether they guarantee the representation for claim will be admissible by the insurance company or the TPA?

    The charges will be depending on the claim amount and the type of claim for example whether it is a fresh claim, rejected by the insurer or the TPA .Amicus is a technolegal consulting firm, and does not guarantee the amount/period within which the claim will be settled, and that it will be settled 100%. Our confidence in our abilities to deliver can be seen from the fact that we link our fees to the final settlement so that we don’t get our full fees till you get your claim.
    XI) What if we lose the case in such a case is the initial payment refundable.
    On receiving a claim, any of the following can happen :
    We opine that the claim is not payable, in which case we will return your file without any charges.
    We believe the claim is payable, in which case an advance will be collected.This advance will not be refunded.

  • How to Get enrolled with Amicus ?

    A policyholder may call, and provide his claim details. He will automatically be logged into the system. On receipt of the file, we will study the same, and should the claim be payable, we will register your claim for further action, and send you an invoice for the advance fees.

    As an agent there are two ways to get enrolled with ‘Amicus’

    Online

    Agent can visit www.amicusclaims.com

    This can be accessed either by directly typing the above address, or through the AMICUS link in the magus website at www.magusadvisors.com

    Agent can click on the “partner zone” tab and access the registration link.

    Registration form is to be filled in and submitted.

    An auto-generated ID and password will be communicated through email along with a Welcome Letter and E-certificate.

    For subsequent logins, agent can use their auto generated ID and password.

    Offline

    An agent may also register by calling up on the Helpline at 022-22005555 In case the agent calls up, he may be asked to :

    Meet personally and get him enrolled by filling up the form.

    Getting registered with the assistance of the marketing team.

Policy FAQs

  • Who is a TPA?

    TPA (Third Party Administrator) is a Company who has been appointed by Insurance Company to settle claims arising from Mediclaim Policies issued by insurers.

  • Do all insurers have external TPAs?

    No. Many of the private insurers have an inhouse TPA, who handles all the claims for that insurer.

  • What can you claim for?

    You can Claim for disease / illness / injury requiring treatment in a Hospital or, in case of certain policies, requiring domiciliary hospitalization.

  • In case of hospitalization can I claim only the hospitalization costs?

    TPA (Third Party Administrator) is a Company who has been appointed by Insurance Company to settle claims arising from Mediclaim Policies issued by insurers.

  • What is a Hospital?

    Treatment at all hospitals / nursing homes is not covered. For the treatment to be eligible the Hospital must be licenses with the appropriate authorities, or meet the minimum specified criteria.

  • What is the difference between cashless claims and reimbursement claims?

    Your policy can pay either directly to the hospital or may reimburse you. For the claim to be paid to the hospital directly, the hospital must be a Network Hospital, and the claim must be considered as eligible under the policy terms.

  • What is a Network Hospital?

    A Network hospital is one which is empanelled by the TPA to provide Cashless Facility to you.

  • What is Hospitalization?

    Any Treatment taken as An Inpatient in a Hospital / Nursing Home with a minimum of 24 hours stay except in certain cases. Normally insurers do not cover Outpatient treatments unless specified in the policy.

  • When is Hospitalisation not required?

    Hospitalisation is not required in case of certain treatments/procedures wherein technological advances have resulted in procedures not requiring hospitalization and/or where surgical procedure involved has to be done under General Anaesthesia.

  • Are Investigation / Diagnostic test covered under the Policy?

    Yes the Diagnostic test done during Hospitalization and pre Hospitalization 30 days and Post Hospitalization 60 days are covered under the Policy. Only Investigation done without Hospitalization or not followed by active line of treatment, may not be covered by your insurers.

  • Are Implants / Stents covered under the Mediclaim Policy?

    Yes stents / Implants are covered under the Policy but with the claim file you need to submit the Bar code of the stent / Implants and Invoice of the Implants used.

  • What is Domiciliary Hospitalization?

    Domiciliary hospitalization means treatment at home. The policies normally define this as medical treatment for a period exceeding 3 days for Such illness / Disease / Injury which in Normal course would require care and treatment in the Hospital / Nursing Home as in-patient but actually taken whilst confined at Home in India under any of the Following Circumstances namely;
    • The Condition of the patient is such that he / she cannot be removed to the Hospital / Nursing Home.
    • The Patient cannot be moved to the Hospital / Nursing Home due to Lack of accommodation in any Hospital in that City / Town / Village.

  • What is not covered in my Policy?

    Pre-existing Diseases / condition, 30- day Exclusion, Waiting period for specified diseases / aliments / conditions, but these will be covered after specified period of Policy. Some disease will be permanently excluded; Cosmetic treatment, Naturopathy, all type of dental Treatment except arising out of accident, Self inflicted injury, Sexually transmitted disease, Vaccination & Inoculation, Genetic disorder, Infertility, Treatment outside India.

  • What is pre-existing Disease?

    All diseases / injuries / conditions, which are pre-existing when the cover incepts for the first time. Any complication arising from Pre-existing disease / ailment / injury will be considered as a part of pre-existing condition. This exclusion will be deleted after four consecutive claim free policy year provided there was no hospitalization for the pre-existing disease / aliment / condition / injury during the said four years of insurance with our company. Please note, each insurer definition may slightly vary, as will their coverage of pre-existing ailments.

  • What is 30- days Exclusion?

    Any disease contracted by the insured person during first 30 days from the commencement date of the policy is excluded. This exclusion will not apply if the policy is renewed without any break. The exclusion does not also apply to treatment for accidental injuries.

  • What is a waiting period for Specified ailment?

    From the time of inception of the cover, the policy not covers certain Diseases / aliments conditions for Specific duration. This exclusion will be deleted after the specific duration lapsed, provided the policy has been continuously renewed with insurance Company without any break.

  • What are capping in My Policy?

    While each policy need not have caps, the current trend is for insurers to subject the claims to a general capping of Room rent and Nursing Charges @ 1% of Sum Insured and ICU 2% of Sum Insured and Caps for Certain Disease.

  • What is the Sum Insured?

    It is the Amount of Cover you have taken for Your Mediclaim Policy, and it is the maximum amount that the insurers will pay out to you over one or more claims during the policy year.

  • Is Ayurvedic treatment covered?

    Ayurvedic / Naturopathy and other alternate treatments may be excluded or partially covered depending on your policy. Please see the relevant provision in your policy.

Claim FAQs

  • What is Intimation of Claim?

    Whenever any person covered under a policy is hospitalized/ requires treatment covered under the policy, he/she is required to inform the insurers. This information must be give at the earliest. Most policies require intimation within 48 hours.

  • Is timely Intimation Compulsory?

    Yes it is compulsory. You may need to ask for specific condonation of delay from your insurers for a delayed intimation to result in a claim settlement.

  • When I need to Submit My Claim?

    Normally insurers require you to submit the Claim within 7 days of Discharge from the Hospital or stipulated time mentioned as per the policy terms.

  • If timelines for Intimation are crossed whom should I Approach ?

    You need to inform to the Insurance Company they have the rights to condone the Delay.

  • What are the Documents required for a claim?

    • Policy Copy
    • Duly signed and filled claim form
    • Original Hospital Discharge Card
    • Original Hospital Final Bills & Stamp Receipts along with hospital registration No/,
    • Original Medicines Bills along with the prescriptions
    • All original Pathology and X-Ray Reports with payment Receipts & Films and prescription for investigation
    • Consulting Doctor Certificate
    • IOL Sticker for lens or Implants
    • Indoor Case Papers (If necessary)
    • Cancelled Cheque
    • ECS form duly filled and signed

  • What if my cashless is denied?

    Denial of cashless doesn’t mean denial of treatment or claim you can take the treatment and submit the documents for reimbursement claim.

  • What are the deductions made under my Claim?

    Room Rent exceeding 1% of Sum insured per day, ICU exceeding 2% of Sum Insured Per day, , Surcharge, Service charges, Telephone, Fax, Food, RMO, Private Nurse, Registration Charges, Doctor Home visit, Travelling Charges, Camera Cover, Sponge, Gloves, Blade, Attendant Charges, Gloves, hearing Aid, Dark Glasses, Clutches, Lumbar Belt, Wheel Chair, CD, equipment Charges, Thermometer, Blanket, One touch machine, Nebulizer, C-pap Machine, Oxygen Concentrator, Cotton, Sanitary Pad, Diapers, Weight Machine

Grievance FAQs

  • What if my claim is partly settled?

    You can represent the case to TPA and to Insurance Company.

  • What do I Do if my claim is rejected?

    In case your claim is rejected you can represent the case to Insurance Company, grievance cell, Ombudsman, Consumer Court.

  • What is a Grievance cell?

    It is a Committee in the Insurance Company where in you can represent your claim if you have not received a satisfactory reply from the TPA or the Policy Issuing Office.

  • What is IGMS?

    The Integrated Grievance Management System (IGMS) facilitates online registration of policyholders’ complaints and helps track their status.

  • What if there is no response from the insurer?

    In case the complaint is not fully attended to by the Insurer within 15 days of lodging it, you may use the IGMS for escalating the complaint to IRDA.

  • What is Ombudsman?

    With an objective of providing a forum for resolving disputes and complaints from the aggrieved insured public or their legal heirs against Insurance Companies.

  • What are the complaints that are entertained by the Ombudsman?

    Complaints pertaining to repudiation of claims totally or partially, delay in settlement of claims, in so far as such disputes relate to claims, disputes regarding premiums paid / payable and non-issue of insurance documents.

  • How is the complaint to be lodged?

    The Complaint is to be made in writing and may be lodged through personal approach or through post / fax / email (followed by hard copy).

  • Is there any time limit to approach the Ombudsman?

    Yes. Within one year of the rejection by the insurer of the representation of the complainant or the Insurer's final reply to the representation.

  • Can a complainant, who has already approached Consumer Forum/court on the same subject, approach
    the Ombudsman?

    No Any complainant, whose complaint on the same subject matter is or was before a Court/Consumer Forum cannot approach Ombudsman.

  • What are the pre-requisite conditions in short, for lodging a complaint?

    • A representation should stand made to the Insurance Company and either an unsatisfactory reply should have been received or the representation should stand unreplied for at least 1 month.
    • The complaint must be lodged within 1 year of the events.
    • The total relief sought must be within an amount of Rs.20 lakhs.
    • The subject matter of the complaint should not currently be or have earlier been before a Court/Consumer Forum.

  • Should a complainant approach the Ombudsman through a lawyer?

    No as no court procedures are involved.

  • What is the Documentation required for Filling a complaint?

    Photocopies of the entire claim Papers Submitted, (Discharge Card, Final Hospital Bill, Investigation reports, Medical Bills, Consultations Letter Photo Copies of all the Policy Copy available, Photo copy of all the Communication and complaints letter made to the TPA Insurance Company, Grievance cell.

  • Can I approach a Consumer Court?

    You can always approach a Consumer Court for any deficiency in service by the insurers including delays, deductions and repudiations.

  • When should I approach a Consumer Court?

    You can approach a consumer court anytime within 2 years of date of claim. However, considering the other options such as IGMS and Ombudsman, it is better that the same are approached first, considering that the Consumer Court is a more time consuming and expensive recourse.

  • What happens if I am not satisfied by the Ombudsman Award?

    If you are not satisfied with the Ombudsman’s Award, you may refuse to accept it, and file with the Consumer forum as given above.
 
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