Employee, Spouse & Children Group Mediclaim Policy 1 st April st March 2017

Transcription

1 Employee, Spouse & Children Group Mediclaim Policy 1 st April st March 2017 Employee Benefits Practice Almondz Insurance Brokers Private Ltd.

2 SUMMARY Page No. What is covered as part of the CIPLA Mediclaim Program? What are the Exclusions in CIPLA Mediclaim Program? How do you bring your dependents under coverage? What are cashless and Reimbursement procedures? Whom can I contact in case of claim related support? Which all forms would you require for Claims under this policy? What are the list of Documents required for reimbursement claims? Which hospitals are empanelled for Cashless Facility?

3 GROUP MEDICLAIM PROGRAM POLICY DETAILS DESCRIPTION Policy Holder CIPLA LTD Policy Start & End Date 1 st April 2016 to 31 st March 2017 Insurer Third Party Administrator (TPA) The New India Assurance Co. Ltd. Medi Assist India TPA Sum Insured Sum Insured Rs 1.00 lakhs Per Family Eligibility Criteria Basic Salary below & up-to Rs 10,000 p.m Rs 3.00 lakhs Per Family Basic Salary Rs 10,001 - Rs 30,000 p.m Rs 5.00 lakhs Per Family Basic Salary Rs 30,001 p/m & above Covered Members Employee +Spouse + Children Employee & Spouse Covered Children Covered (as Male child up to 25 yrs and female child till age of 25 yrs or till she is married whichever is earlier.) 2

4 WHAT DOES YOUR MEDICLAIM POLICY COVER? Benefits Details Pre-existing Diseases Covered Domiciliary Hospitalisation Excluded Pre & Post Hospitalization Expenses Covered (30 days & 60 days respectively) Room Rent 2% of Sum Insured for Normal and 4% of Sum Insured for ICU Maternity Covered (only as reimbursement upto maximum of Rs. 30,000) New Born Baby Cover from Day 1 Covered Co-Payment Not Applicable Terrorism Hospitalization due to terrorism is covered. Ambulance Upto Rs.2000/- to be paid (To & Fro - Both way home/accident site etc) Day Care Procedures There are 172 day care procedures covered under the policy, which do not require 24 hours hospitalization. List of all such procedures is available on Sambandh. 3

5 WHAT DOES YOUR MEDICLAIM POLICY COVER? Benefits Details Other Benefits Terrorism related prolonged treatment/other wise covered, Robotic surgery, Stem Cell therapy & Cyber Knife procedures/hospitalization to be covered. RMO charges, Surgery attendants charges, consultation fees for the Dr, registration charges up to Rs. 500 covered. Additional Covers 1. Upfront payment of Rs. 25,000 on diagnosis of Critical Illness 2. Infertility treatment for employees to be covered upto Rs. 100,000 including OPD 3. Loss of pay coverage for the on duty accidental claims upto Rs. 5,000 per week ( Maximum limit upto 25 weeks) 4. OPD benefit to be extended to disabled children upto the age of 5 years Rs Sleep Apnoea and pulmonary disorder to be covered for employees only 6. Bariatric surgery is covered for employees with BMI > Ayurvedic, homeopathy & unani treatments are covered if hospitalization is done in government hospitals 4

6 WHAT IS EXCLUDED FROM YOUR MEDICLAIM POLICY? Natural Disasters & National Emergencies: Cosmetics & Non Medically required procedures Intentional self injury and use of intoxicating drugs/alcohol Congenital external disease or defects or anomalies except life threatening Treatment done with no active line of treatment Cost of Spectacles, Contact Lenses, Hearing Aids Voluntary medical termination of pregnancy during first 12 weeks from the date of conception Naturopathy treatment Vaccination & Inoculation Hospitalization done for diagnostic purposes All types of Dental treatments except arising out of an accident Vitamins and tonics unless forming part of treatment for injury or disease as certified by the attending physician Any Domiciliary Hospitalization / Treatment Treatment taken outside India Detailed file with the list of all the exclusions is available in Sambandh. 5

7 CONDITION OF MEMBERSHIP The Insurance cover will be extended to: All CIPLA employees and their Nominated Family Members as per eligibility Coverage will be as per the policy and guidelines presented above and any other guideline to be issued in due course of time. Cover Expiries : The moment an Employee leaves the organization Death of the employee All employees will be required to provide necessary information regarding their family members to be covered under the policy, within the allowed enrolment window This will be a one time option for all the existing employees (joined/eligible for mediclaim cover on or before 31st March 2016) for the policy period i.e. 1st April 2016 to 31st March 2017 In case any employee miss to enroll the dependents during the stipulated window then he/she will not be eligible for mediclaim cover for this policy period i.e April 2016-March 2017 for his/her dependents. 6

8 PROCESS TO GENERATE E-CARD Steps to Login Please use the following link and login your MediBuddy portal Link: Login Details: Username: Password: your date of birth in DDMMYYYY format (this password is only applicable for employees who are logging in for the first time, others have to login using their changed password) For Example if your employee ID is 1234 and date of birth is 01 June 1980 than your user ID and password will be as follow Username: Password : Refer to the detailed visual guide available in Sambandh for enrolment of spouse & children. In case of newly married employee, name of spouse needs to be enrolled within 30 days from the date of marriage In case of new born child, enrolment needs to be done within 30 days from the date of birth 7

9 PROCESS TO GENERATE E-CARD- STEP 1 Click here for login 8

10 PROCESS TO GENERATE E-CARD- STEP 2 Username: EmployeeCode@cipla.com Password: your date of birth in DDMMYYYY format 9

11 PROCESS TO GENERATE E-CARD- STEP 3 Click here to download E cards 10

12 PROCESS TO GENERATE E-CARD - STEP 4 E-Cards generated in.pdf format 11

13 Group Mediclaim Policy NETWORK HOSPITALISATION - CASHLESS Emergency Hospitalization Identify Network Hospital via mobile app/ website /helpline Visit hospital Insurance Help desk & fill the preauthorization form Hospital will seek approval from Medi Assist (Provided within 2 hrs) You will receive SMS confirmation Pay for Non Medical Expenses if any Planned Hospitalization At the time of discharge Hospital will send final request to Medi Assist for approval (Provided within 2 hrs) You will receive SMS confirmation On successful approval admission happens & treatment starts In case of Planned Hospitalization, authorization should be taken prior, which will be valid for 15 days to avoid delay /inconvenience at the time of hospitalization. 12

14 NETWORK HOSPITALISATION CASHLESS Before Admission : Check for the nearest network hospital for availing the Cashless hospital. Pre-authorization form is mandatory to be sent to Medi Assist by network hospital During Admission : Inform the Medi Assist call center immediately about the hospitalization & seek preauthorization. Medi Assist will send pre-authorization letter for the minimum amount of expected expenses to the hospital In case of denial, the same will be communicated to the Hospital with proper reasoning During Discharge : The bill will be sent by Hospital to Medi Assist Upon final approval on cashless by Medi Assit to hospital you/patient can proceed with discharge by paying for Non Medical Expenses. 13

15 NON NETWORK HOSPITALIZATION - REIMBURSEMENT Activity done by employee Activity done by Medi Assist Intimate Medi Assist regarding claim on the day of hospitalization or within 7 Days from the date of admission Submit Claim documents within 30 days from the date of discharge Documents can be submitted at the drop box of each location or handed over to Help Desk You will receive SMS confirmation for document receipt Reason of Rejection will be communicated Claim not permissible Medi Assist will check for the eligibility and admissibility of the claim as per policy terms You will receive SMS confirmation 3 Reminder mails sent every 15 days Medi Assist will ask for the additional/missing documents You will receive SMS confirmation Deficiency Documents are sent You will receive SMS confirmation Documents incomplete No Is claim payable? Yes Medi Assist will process the claim and send the reimbursement by ECS, along with the settlement letter 14

16 INTIMATION FOR REIMBURSEMENT CLAIM 1. Claim intimation to be give on within 7 days of admission. should contain : I. Company Name, II. Policy No. III. Mediclaim ID no: IV. Employee code: V. Name of employee VI. Name of patient VII. Date of Admission VIII. Name of hospital IX. Approximate claim amount etc. This intimation can be given through various modes like /helpline/medibuddy portal. Against this intimation you will receive intimation no for your claim. Which you can use while submitting claim documents. 15

17 SUPPORT CONTACT POINTS FOR CLAIMS - Medi Assist TPA Customer Care Details I. id for claim intimation claimsupport@mediassistindia.com II. 24 x 7 Help line for cashless and Reimbursement intimation Below are the details of Helpdesk which are located at respective location. These helpdesk will be available between 10am to 6pm on all working day of respective location: HO HELPDESK MUMBAI Name Ms. Suvarna Khandagle Phone No : ID HealthHelpdesk@Cipla.com HELPDESK : Manufacturing Unit of INDORE Name : Mr. Salik Ahmed Phone No : ID : Medihelpindore@Cipla.com HELPDESK : Manufacturing Unit of Goa Name : Mr. John Rodrigues Phone No : ID : Goa.Healthhelpdesk@Cipla.com HELPDESK :Manufacturing Unit BANGALORE Name : Mr. Sowdahmed Anwar Phone No : ID : sowdahamad.anwar@mediassistindia.com HELPDESK : DELHI CP office Field Staff Name Mr. Anuj Sharma Phone No : ID anuj.sharma@mediassistindia.com HELPDESK : KOLKATA Depot Field Staff Name : Ms. Rimpa Paul Phone No : ID : rimpa.paul@mediassistindia.com 16

18 WHERE DO I SUBMIT CLAIM DOCUMENTS? All the employees (field/non-field) can handover their claim documents to the helpdesk as per their reach and convenience. The local helpdesk setup is as follows: 1. Helpdesk at Head office, Lower Parel, Mumbai. 2. Indore Manufacturing Unit 3. Goa Manufacturing Unit 4. Bangalore Manufacturing Unit 5. Delhi CP Regional Office 6. Kolkata Depot Employees who cannot submit their reimbursement claim documents to the helpdesk can send the documents to HO address with below mentioned mandatory details : Superscibe the envelope with (Hospitalization Claim) To, HR Mediclaim Team Cipla Ltd. Peninsula Business Park, Tower- A, 1 st Floor, Lower Parel, Ganpatrao Kadam Marg, Mumbai From, Your name, Employee Code, Contact number, Current address Pin code. 17

19 HELP DESK ASSISTANCE To understand Enrollment Procedure To understand Claim Procedure Assistance during cashless claims Assistance for Submitting Reimbursement claims Submission of claim Documents Knowing your Claim Status 18

20 ESCALATION MATRIX Any Assistance? (Claim /Enrollment) Call the Toll free no Query Resolved Query Unresolved Speak to Local Help Desk Representative Query Resolved Query Unresolved Write : claimsupport@mediassistindia.com Query Resolved Query Unresolved Write : sunil.shinde@almondz.com 19

21 CASHLESS/REIMBURSEMENT CLAIM FORM Cashless claim form : This form is filled by the Hospital Authorities. The Employee/ members accompanying the patient has to sign the Authorization letter. Reimbursement claim form: Refer to the detailed presentation on the process of filling the claim form separately uploaded on Sambandh Network Hospital for Cashless Hospitalizations: Refer to the detailed Hospital list on Sambandh for the listing of Hospitals in various categories. 20

22 DOCUMENTS REQUIRED FOR REIMBURSEMENT Claim form duly signed and properly filled in Main Hospital bills in original (with bill no; signed and stamped by the hospital) with all charges itemized and the original receipts Original Payment Receipt Original Discharge Summary Attending doctors bills and receipts and certificate regarding diagnosis (if separate from hospital bill) Original reports, Bills and Receipts for Medicines, Investigations along with Doctors prescription in Original Consultation letter, Follow-up advice or letter for line of treatment after discharge from hospital, from Doctor. Break up with details of Pharmacy items, Materials, Investigations even though it is there in the main bill In case the hospital is not registered, please get a letter on the Hospital letterhead mentioning the number of beds and availability of doctors and nurses round the clock. In non- network hospitalization, you may have to get the hospital and doctor s registration number in Hospital letterhead and get the same signed and stamped by the hospital, if required. Cancel copy of cheque & NEFT details of the employee. Note the above list is indicative and TPA may ask for any additional document on case to case basis. In case of pre & post hospitalization all the bills, test reports, consultation letter coming under the window(30 days before discharge for pre & 60 days after discharge for post) needs to attached along with the reimbursement claim form, with the accurate claim number. 21

23 Detail/ Description COMPLETE ASSISTANCE ADD SAMBHADAN Snap shot SAMBANDH MEDI ASSIST WEBSITE CENTRAL HELP DESK A detailed presentation on : Mediclaim Coverage's Exclusions in Policy Enrollment Process Cashless Process Reimbursement Process List of Network Hospitals 172 Day Care Procedures FAQ s Guidelines to fill the claim forms Assistance on: Generating E- Cards Know the Network of Hospital Enroll Dependents Check for the Claim Status CONTACT POINTS FOR CLAIMS: 24 x 7 Help line for cashless and Reimbursement intimation GENERAL QUERIES: claimsupport@mediassistindia.com 22

24 Employee Benefits Practice THANKS & STAY HEALTHY