Claims

One workflow, four benefit buckets

OPD, IPD-Sickness, IPD-Accidental, and Life Coverage share a status-driven path. Amount formulas and annual ceilings differ. Complete claims target settlement within 14 working days.

TCCF benefit schedule

Amount calculation

Claim typeAmount formulaBenefit bucket

Each claim receives a serial in the form CLM-YYYYMMDD-NNNN. Remaining balances are calculated for the calendar year by deducting settled amounts from the package ceiling for that claim type.

From submission to a terminal state

  1. 1
    Pending

    The policyholder or a Pragati Partner submits the claim on mobile or web.

  2. 2
    Checking

    An administrator or the insurer reviews eligibility, documents, remaining balances, and exclusions.

  3. 3
    Documents required

    The operator asks for more evidence. The holder or partner resubmits.

  4. 4
    Approved

    Eligibility and the payable amount are confirmed.

  5. 5
    Disbursed or declined

    Both are terminal. A declined claim should carry a note that explains the reason. The target for a complete file is 14 working days.

Cashless and reimbursement

Cashless

Treatment at authorised network hospitals and providers can be settled without the beneficiary paying the covered amount upfront.

Network facilities

Reimbursement

Treatment outside the network is reimbursed against supporting documents, after the same eligibility and exclusion checks.

Non-network facilities

Major exclusions

Alternative treatments (Ayurvedic, Homeopathic, Unani, Herbal) are excluded. So is treatment by a doctor who is not registered with the Bangladesh Medical and Dental Council, and a prescription without the appropriate registration number or signature.

Pre-existing conditions, HIV/AIDS, tuberculosis, Hepatitis B and C, cancer, and dialysis are excluded. Injuries from illegal activity, and accidents while driving without a valid licence, are excluded.

Those rules are why BMDC registration numbers, prescription images, and catalog-checked medicine lines matter: they are the evidence on which a claim is approved or declined. Prescription AI exists to structure that evidence. It is not yet a step inside the mobile claim form.

Exclusions are a summary of the facility terms in the system overview, not a substitute for the policy wording.