Mediclaim FAQs Pfizer Limited / Pfizer Pharmaceutical India Pvt. Ltd. / Pfizer Products India Pvt. Ltd.
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1 Mediclaim FAQs Pfizer Limited / Pfizer Pharmaceutical India Pvt. Ltd. / Pfizer Products India Pvt. Ltd. 1. What is the definition of family for Hospitalization scheme? A. Married employees can cover Self + Spouse + Children upto the age of 25 years. Unmarried employees can cover Self + Dependant Parents. Should the family member not be covered, at the beginning of the policy year, the expenses will not be reimbursed. 2. What is the sum insured for a family per year? A. The sum insured is Rs. 200,000 per annum for the family as a whole, however, for Maternity claims maximum reimbursement will be Rs. 50,000/- per annum and for Cataract Rs. 40,000/- per annum, within the overall limit. 3. What is the scheme year for Mediclaim? A. September 15 to September Who is the Insurance provider and Third Party Administrator? A. The current Insurance provider is Apollo Munich and the Third-Party Administrator (TPA) is Family Health Plan Ltd. 5. How can I get a card for availing the cashless facility? A. No ID cards will be issued. E-cards would be available, once family data has been updated on the Insurance company site: as follows: Your Member ID will be provided in your salary slip Your Employee ID is ****** (Pfizer employee ID) Steps to access E-Card - 1. Open the website 2. Click on the link Register to open a pop-up window 3. Select the Corporate Employee Radio Button from the options in the pop-up Window 4. Kindly enter the Member Id & Employee Id manually, do not copy and paste 5. Enter Password screen appears. Set the password of your choice 6. Enter the new password, confirm the password and enter your official address and click submit 7. This completes the registration process 8. Now log in again on the home page of Apollo DKV ( by your user ID and new password. Select - Corporate Employee from the drop down menu. Now you can access your E-card 9. Go to Policy -> Click on Policy details -> Click on View details ->Click
2 on the hyperlink under policy number to get the E-card 10. You should print the E-Card for the policy year September 15, 2010 to September 14, For queries/amendments to the dependant data details, the steps given below should be followed : Login -> Go to Request -> Click on Service Request -> Click on endorsement -> Click on change in plan -> Fill in the details and submit. 6. Which are the hospitals where we can avail of the cashless claim facility? A. The list of cashless hospitals is available at get a list of hospitals click on network hospital. 7. What is the procedure for availing Cashless Mediclaim facility? A. Guidelines for claiming hospitalization expenses under the Mediclaim Scheme are given below: - You / your family member are expected to go to a network hospital of Family Health Plan Services (TPA) for cashless facility. - The Pre-authorization form should be filled up along with the Hospital / Doctor. Fax the form to the TPA and get an authorization, Fax no is The authorization confirmation takes at least 72 hours; hence the process should be completed before admission in the hospital, except in case of an emergency. - Please ensure that you carry patient s Photo ID proof and E-Card of Apollo Munich at the time of admission. 8. What is the procedure for filing a Hospitalization (Reimbursement) Claim? A. If cashless facility is not availed from the empanelled hospital, then the claim amount can only be reimbursed subject to providing a letter giving the reason for the non-utilization of the cashless facility. Inform Third Party Administrator (Family Health Limited) immediately of the hospitalization and submit the claim form within 21 days of discharge from the hospital. Claims received at H.O beyond 21 days will not be reimbursed. 9. What are the documents required for Reimbursement of Hospitalisation claims? A. Documents are required in original for reimbursement of claim. The following documents would generally be required, however, you may be required to submit
3 additional documents as required and intimated from time to time by the Third Party Administrator (TPA): 1) Duly filled and signed claim form. 2) Original detailed discharge summary. 3) Original consolidated hospital bill with breakup of each item, duly signed by the insured. 4) Original payment receipt of the hospital bill. 5) First consultation letter and subsequent prescriptions. 6) Original bills, receipts and reports for investigation. 7) Original medicine bills and receipts with corresponding prescriptions. 8) Original invoice/bills for implants with original payment receipt. Attach the Check list, mentioning your Employee ID, address and Contact phone number. The Claim Form along with the documents should be forwarded to HR Division at H.O. for further processing. All expenses incurred, 30 days prior (pre-hospitalization) and 60 days (post hospitalization) after the date of discharge from the hospital may be claimed, except in case of Maternity expenses. 10. What should be done in case the entire amount as per the pre-authorization form is not sanctioned? A. In case the entire amount as per the pre-authorization form is not sanctioned, the hospital bill should be settled (less the pre-authorized) by the colleague and the balance amount may be claimed later from the TPA. 11. Are there any charges by the hospital, which are not reimbursable and hence have to be paid by me even after Cashless Service has been authorized for treatment in the network hospital? A. Yes. There are quite a few charges, which are not reimbursable and have to be paid by you even though you have been authorized for Cashless Service at the network hospitals. Some of those charges are enumerated below: Registration/Admission charges Attendant/Visitor pass charges Ambulance charges Special nursing charges not authorized by the attending doctor. Service charges not forming a part of the room rent Charges for extra bed for attendant etc. Bed retaining charges Charges for TV, Laundry, etc. Telephone/Fax charges Food and beverages for attendants and visitors Toiletries etc Purchase of Medicines not related to the treatment or without doctor s prescription/s
4 Stationery, Xerox or certifying charges 12. What happens when I have to undergo treatment and I am discharged on the same day? A. When treatment such as Dialysis, Chemotherapy, Radiotherapy, Cataract, etc is taken in the Hospital/Nursing Home and the patient is discharged on the same day, the treatment will be considered to be taken under Hospitalization Benefit Scheme. 13. What is the time period for settlement of claims? A. The claim settlement would take around working days, provided all the documents are correctly forwarded, Please note, claims should be submitted immediately after discharge from the hospital and in no case later than 21 days after discharge. Should there be a delay in submission of claims beyond the time limit specified, no reimbursement would be made by the Insurance company. 14. Which expenses are not covered under the Mediclaim scheme? A. The following expenses would not be reimbursed under the Mediclaim Scheme: 1) Less than 24 hrs hospitalization 2) Medical Tests & Check ups. Expenses on Diagnostic, X-Ray or Laboratory examinations unless related to the treatment of sickness or injury falling within ambit of Hospitalization 3) Dental surgery 4) Cost of the Spectacles / Contact Lenses 5) Infertility treatment 6) Intentional Self Injury 7) Maternity claim will not be reimbursed for more than two living children 8) External Congenital Diseases 9) Voluntary Termination of Pregnancy 10) Use of Intoxicating drugs/alcohol 11) Circumcision except for disease not excluded here or injury 12) Cosmetic or aesthetic surgery of any description, plastic surgery except for relating to treatment of any description, plastic surgery except for relating to treatment of injury or illness 13) Vaccination or Inoculation 14) General run down condition 15) Any expenses for pre and post hospitalization treatment of following diseases: a. Asthma b. Bronchitis c. Chronic Nephritis and Nephritic Syndrome d. Diarrhoea and all type of Dysenteries including Gastro-enteritis e. Diabetes Mellitus and Insipidus f. Epilepsy
5 g. Hypertension h. Influenza, Cough and Cold i. All types of Psychiatric or Psychosomatic Disorders j. Pyrexia of unknown Origin for less than 20 days k. Tonsillitis, Upper Respiratory Tract infection including Laryngitis and Pharingitis l. Arthritis, Gout and Rheumatism 16) Any expense of any treatment related to Human T Cell Lymph tropic viruses Types III (11TLB-III) or Lymphadinspathy Associated viruses (LAV) or the Mutant derivatives or Variations Deficiency Syndrome or any syndrome or a Condition of a similar kind referred to as AIDS 17) Any expenses on Naturopathy The decision of the TPA / Insurance Company will be final regarding the above. TEMPORARY DISABLEMENT 15. How do I claim expenses incurred due to accident whilst on duty? A. In case of a road accident, an F.I.R. should be filed with the local police station and a copy of the same to be forwarded along with the hospitalization claim. 16. How I claim expenses in case of hospitalization due to the accident? A. In case of hospitalization, the process for claiming the expenses as outlined above should be followed. 17. In case there is no hospitalization, how do I claim such expenses? A. In case of domiciliary expenses, all the bills/vouchers/receipts/prescriptions for expenses incurred towards the treatment of injuries should be attached in original and forwarded to HR department at H.O., along with a copy of the Accident Report signed by RBM / Sales Manager. OTHER POINTS TO NOTE Medical certificate card is not a Discharge card; hence at the time of submission of documents send the Discharge card and not the Medical Certificate. In case of investigation reports only the printed report is required. You need not submit the X-ray, USG plates. In case of any additions/deletions of the family member the details should be intimated to HR at HRopsIndia@pfizer.com within 10 days of the event. In case of reimbursement of claim the colleague should send Original Set, with detailed summary of the documents attached. One copy should always be maintained by the colleague till the time the claim is settled. CONTACT DETAILS: FHTP TOLL-FREE NUMBER
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