1TruCover's Role in Claims
TruCover Wellness acts as a claims support facilitator — NOT as an insurer or TPA. We work alongside the insurer and TPA to ensure that every claim your employee files is handled efficiently, correctly, and with empathy. Our 24/7 claims support is one of the most important services we provide, because that is when employees and agents need help most.
2Types of Claims Supported
2.1 Cashless Hospitalisation Claims
When an employee is admitted to a network hospital, TruCover helps:
- Confirm network hospital status and direct the employee to the right facility
- Initiate pre-authorisation request to the TPA on behalf of the employee
- Follow up with TPA for approval and communicate the outcome to the employee
- Coordinate with the hospital's insurance desk if there are documentation issues
2.2 Reimbursement Claims
When an employee is treated at a non-network hospital or incurs out-of-pocket expenses:
- TruCover provides a personalised document checklist within 4 hours of claim intimation
- Our team reviews submitted documents for completeness before forwarding to insurer
- We follow up with the insurer/TPA every 48 hours until the claim is resolved
- We help employees prepare and submit any additional information requested by the insurer
2.3 Day-Care Procedure Claims
For procedures not requiring 24-hour hospitalisation (e.g., cataract surgery, dialysis):
- TruCover confirms procedure coverage under the specific policy
- Pre-authorisation is obtained where required by the insurer
- Post-procedure documentation support is provided
3Claims Process Flow
| Step | Timeline | Action |
|---|
| 1 | Immediately | Employee calls TruCover 24/7 helpline: +91 95023 47365 |
| 2 | Within 2 hours | TruCover acknowledges claim, assigns a claims coordinator |
| 3 | Within 4 hours | Personalised document checklist sent via WhatsApp and email |
| 4 | Within 24 hours | Pre-authorisation initiated (cashless) or documents reviewed (reimbursement) |
| 5 | Every 48 hours | Status update sent to employee and HR admin |
| 6 | Day 7 | If unresolved, TruCover formally escalates to senior insurer contact |
| 7 | On resolution | Claim outcome communicated; if rejected, TruCover explains next steps |
4Documents Typically Required
4.1 Cashless Claims
- Health card / policy number
- Doctor's advice for hospitalisation
- Government-issued photo ID of patient
4.2 Reimbursement Claims
- Duly filled and signed claim form (insurer-specific)
- Original hospital discharge summary
- Original bills and receipts (hospital, pharmacy, diagnostics)
- Doctor's prescription and investigation reports
- KYC documents of primary insured (PAN/Aadhaar)
- Cancelled cheque or bank account details for reimbursement
TruCover's claims team will provide the specific document list for your insurer within 4 hours of claim intimation. The above is a general guide.
5Claim Rejection & Dispute
If your claim is rejected by the insurer, TruCover will:
- Explain the reason for rejection in plain language
- Advise whether a re-submission with additional documents is possible
- Guide the employee to file a formal grievance with the insurer if appropriate
- Support the employee in approaching the Insurance Ombudsman if the dispute remains unresolved
TruCover does not have the authority to override insurer claim decisions. Claim settlement authority rests solely with the IRDAI-registered insurer.
6Common Exclusions to be Aware Of
Policies vary by insurer, but the following are commonly excluded from group health insurance — please refer to your specific policy document:
- Pre-existing conditions during the waiting period (typically 2–4 years)
- Cosmetic or aesthetic procedures
- Experimental or unproven treatments
- Self-inflicted injuries
- Injuries arising from war, civil unrest, or nuclear events
- Dental treatment (unless resulting from accident — check policy)
7For Agents & Intermediaries
One of TruCover's core value propositions to agents is claims management. When your corporate client has a claim:
- Your client calls TruCover — not you — at 2am
- TruCover handles everything: documentation, follow-up, escalation
- You receive real-time updates via your agent dashboard
- Your client relationship is strengthened, not strained, by the claims experience
- Your reputation as an agent is protected