BENEFIT FAQ S GROUP MEDICAL INSURANCE

Transcription

1 BENEFIT FAQ S GROUP MEDICAL INSURANCE INSURANCE COVERAGE GROUP HEALTH INSURANCE (GHI) PLAN CONTACT DETAILS FAQs GROUP HEALTH INSURANCE

2 INSURANCE COVERAGE - GROUP HEALTH INSURANCE (GHI) PLAN PLAN BENEFITS PARAMETER DESCRIPTION Sum Insured INR 1.5L per family per year (Students & Trainees) INR 3L per family per year for Senior Managers and below (excluding Students and Trainees) INR 5L per family per year For Technical Directors and above Family Covered Employee (self plus 5): Spouse, two unmarried dependent Children (upto 25 years of age) + one set of two dependent Parents/ Parents in Law upto the age of 95 years. Room Rent Limit Student, PS & Non-PS:- INR 6500 per day Directors & Partners: INR 8000 per day for Normal Hospitalization No capping for I.C.U. Note: If the insured is admitted in a higher category, please note that Nursing Charges, Doctor s Fees, will proportionately increase based on the Room Rent Charges. Co- Pay Assistant Manager & below: 10% of the Admissible claim amount Manager & above: 20% of the Admissible claim amount For Each & Every Parental claim: 25% of the Admissible claim amount Note: This copay clause is not applicable on maternity claims 1st, 2nd & 3rd year Exclusions 1st 30 day exclusion for payment of claim Preexisting Diseases Waived for all Ambulance INR 2,000 per person per policy Pre-Hospitalization Expenses Post-Hospitalization Expenses 30 days 60 days Maternity Limit Maternity Limit INR. 80,000/- for Normal and INR 100,000 for C-Section

3 INSURANCE COVERAGE - GROUP HEALTH INSURANCE (GHI) PLAN PARAMETER DESCRIPTION New Born Baby Coverage Pre/ Post Natal Expenses 9 month Waiting Period for Maternity Covered from Day 1 (i.e. Date of birth) Note: Please see FAQs for more information on New Born Coverage Coverage period for Pre Natal 90 days and Post Natal 30 days on OPD Basis & no time limit for inpatient cases within maternity limit Waived for all Special Conditions Congenital External Disease covered All treatment on account of advancement of modern science / technology are covered Reimbursement Claim Submission Period Domiciliary Hospitalization Claim reporting /submission period to be extended for 60 days from the Date of Discharge Not Covered MID-TERM ENROLMENT OF NEW DEPENDENTS Allowed to include newly-wed spouse and new born baby, within 30 days from the date of event

4 FAQS GROUP HEALTH INSURANCE 1. What are the treatments that are covered under day care hospitalization? Please contact your Local Insurance Advisor for updated list 2. What do you mean by pre and post-natal expenses? Is it covered in the policy? Expenses arising before delivery are known as prenatal expenses and those arising after delivery are known as post-natal expenses. These expenses are covered within the designated maternity Limit 3. If I have recently got married how do I get coverage for my spouse? You would need to register your spouse at portal (to be launched shortly). Intimation window will be allowed for a period of 30 days. Coverage for that person becomes effective on the date of intimation. 4. How do I get coverage for my new born child? You would need to register your child by intimating your HR within 30 days of the birth of the child. Coverage for the child becomes effective from day one. You can get in touch with the Local Insurance Advisor for further queries related to Spouse/ Newborn Child enrolment. 5. What is an e-card? It is an identification card, which will entitle you to credit towards hospitalization and any other negotiated benefits at hospitals on the panel of TPA on pre - authorization. Information on this is available with the customer service. Please remember that the ID card is not a credit card. The card does not entitle you to credit towards outpatient treatment. To avoid any misuse of your card, the hospitals may ask you to furnish some photo identification card (like Voter ID, license, passport etc.). Your E Cards would be made available to you within working days of Policy Issuance 6. Suppose the hospital does not accept my e-card? You can get in touch with the Local Insurance Advisor for any query regarding the same. 7. What are network hospitals? These are hospitals where TPA has a tie up for the cashless hospitalization & where all policy holders get preferred cashless treatment.

5 FAQS GROUP HEALTH INSURANCE 8. What should I do when I reach the hospital (NETWORK)? Network Hospitals provide Cashless Facility for Claims. To avail this, please show your e-card for identification. TPA will also send a letter of credit (on pre-authorization) to the hospital to make sure that they extend credit facility. You may not need to pay any cash except for non-medical expenditure as explained under the policy heading. If the pre-authorization is not done, you must collect all reports and discharge card when you get discharged. Please make sure that you sign the hospital bill before leaving the hospital. You can then submit the claim along with all the necessary supporting documents to TPA Advisor at your facility for reimbursement. If the hospitalization is planned or on Emergency basis at a Network Hospital, payments would be processed on Cashless basis as described above. For information on nearest Network Hospital, please get in touch with your Designated Insurance Advisor. 9. What happens if I forget to bring my e-card at the network hospital? Please show your Company ID card to the hospital and immediately call your Designated Insurance Advisor for assistance. 10. What if I go to a non- network hospital? Please fill the claim form, attach the relevant original documents & send to TPA for reimbursement post treatment. Claim forms & document checklist are available with your designated insurance advisor. If you wish to plan in advance for your hospitalization, then availing Cashless facility through a Network Hospital is preferred. Please get in touch with your Designated Insurance Advisor to know about the nearest Network Hospital. For Emergency admissions, payments will be processed on reimbursement basis. Please see point 13 below for details. 11. What are the expenses that are excluded apart from those mentioned under general exclusion? Registration Fees, File opening fees Telephone, internet charges, Television Charges Food and refreshment for attendants and visitors Any other expenses not related to the treatment of illness Please talk to your Designated Insurance Advisor for more details

6 FAQS GROUP HEALTH INSURANCE 12. Is pre authorization necessary? Yes. This will help you in the following ways: You will be informed in advance regarding the coverage for your treatment so that your claim does not get rejected at a later stage and you do not end up paying out of pocket. It will help you ensure that the treatment cost is appropriate and not inflated. This will also help us in planning your hospitalization expenditure such that you do not run out of the cover that you are entitled to. It will help in quicker processing of your claim. 13. What are claim reimbursements? In the event where cashless hospitalization in not availed, you need to get in touch along with all the original bills & the claim form to your Designated Insurance Advisor and the hospitalization expenses will be reimbursed to you after Insurer s decision on the same 14. How can I claim my pre & post hospitalization expenses? The policy covers pre-hospitalization expenses made prior to 30 days of hospitalization and incurred towards the same illness/ disease due to which hospitalization happens. It also covers all medical expenses for up to 60 days post discharge as advised by the Medical Practitioner. All the bills with summary have to be sent to client. 15. Within how many days should a claim be registered? Within 60 days from the date of discharge failing which the claim may be closed. 16. My Dependent met with an accident. Is my dependent eligible for benefits under Mediclaim? Yes, as long as he/ she is covered under the family definition & enrolled in the scheme 17. Can I continue the insurance coverage if I resign from the company? The insurance contract is arranged by your employer for the benefit of the employees. Employees who resigned will not be able to continue enjoying these benefits. 18. I have not made any claims under Mediclaim last year. Will the unutilized amount be carried forward to this year? No. Your benefit amount is only valid for one year

7 CONTACT DETAILS FOR ANY FURTHER QUESTIONS NOT COVERED HERE, YOU MAY CONTACT THE DESIGNATED INSURANCE ADVISOR. Contact Details of your Designated Insurance Advisors Primary Contact Representative for Delhi/NCR, Chandigarh, Kolkata & Overall ALL KPMG Locations Mr. Mohammed Quasim Phone: Centralised for all queries: Secondary Contact Representative for Mumbai, Pune, Ahmedabad & Goa Mr. Abhinav Jadhav Phone: Secondary Contact Representative for Bangalore, Hyderabad & Chennai Mr. Rebanta Sanyal Phone: Secondary Contact Representative for Kochi Mr Jijo Joseph/ Mr Praveen Kumar Phone: / For Cashless Intimation, You may also contact the Paramount 24X7 Helpline Number PROVIDER S DETAILS Group Medical Insurance: Insurance Company: Oriental Insurance Company Limited. TPA Name: Paramount Health Services (TPA) Pvt. Ltd. CONTACT DETAILS FOR ESCALATIONS Contact Level 1 Mr Deepanshu Karnwal Senior Manager. Marsh India Insurance Brokers Pvt. Ltd. Phone: deepanshu.karnwal@marsh.com Contact Level 2 Mr Ankur Gupta Assistant Vice President Marsh India Insurance Brokers Pvt. Ltd. Phone: ankur.g@marsh.com