Cholamandalam MS General Insurance Co. Ltd.

Transcription

1 Cholamandalam MS General Insurance Co. Ltd.

2 Cholamandalam MS General Insurance Co., Ltd A JOINT VENTURE (JV) BETWEEN MURUGAPPA GROUP AND MITSUI SUMITOMO INSURANCE GROUP (JAPAN) (MS & AD Group)

3 Concept of Health Insurance INSURANCE PROTECTION Health Insurance is to provide financial shelter in the event of Medical treatment incurred out of Sickness or injury. RISK MANAGEMENT VALUE ADDITION

4 Policy Parameters Policy Parameter Insurer Cholamandalam MS General Insurance Co. Ltd. TPA Chola MS HELP Policy Start Date 1 st Apr 2017 Policy End Date 31 th Mar 2018 Coverage Type Family Floater Dependent Coverage ( Spouse) Sum Insured As per Tender documents Pre-existing diseases covered 30 days waiting period waived One/two year waiting period waived

5 Policy Benefits 1. Room and boarding 2. Doctors fees 3. Intensive Care Unit 4. Nursing expenses 5. Surgical fees, operating theatre, anesthesia and oxygen and their administration 6. Physiotherapy 7. Drugs and medicines consumed on the premises 8. Hospital services (such as laboratory, x-ray, diagnostic tests) 9. Dressing, ordinary splints and plaster casts 10. Day care procedures like Cataract, radiotherapy, chemotherapy, dialysis etc.

6 Major exclusions Injury or disease directly or indirectly caused by or arising from or attributable to War or War-like situations Congenital external diseases or defects/anomalies HIV and AIDS Hospitalization for convalescence, general debility, intentional self-injury. Injury or disease caused directly or indirectly by nuclear weapons Naturopathy, treatment related to obesity Any non-medical expenses like registration fees, admission fees, charges for medical records, cafeteria charges, telephone charges, etc Cost of spectacles, contact lenses, hearing aids Any cosmetic or plastic surgery except for correction of injury Hospitalization for diagnostic tests only Vitamins and tonics unless used for treatment of injury or disease Any illness/incident caused by use of alcohol/intoxicating agents Accidents due to breach of law OPD, Dental and Domiciliary cover Others as per policy.

7 Coverage Details Category Post held at the time of leaving Service of NFL Insurance Cover (Rs.) A C&MD / Directors 6 Lakhs B C Chief Mgr to Executive Director (E-6 to E-9) Asstt.officer to Sr Mgr (E-0 to E- 5) 5 Lakhs 4 Lakhs D Non- Executives (W0 to W12) 3 Lakhs

8 Room Rent eligibility Delhi/NCR & all State Capitals including UTs Category Post held at the time of leaving Service of NFL Room Rent allowed A C&MD / Directors B Chief Mgr to Executive Director (E-6 to E-9) 8500 C Asstt.officer to Sr Mgr (E-0 to E-5) 6500 D Non- Executives (W0 to W12) 4500 Excluding Delhi/NCR & all State Capitals including UTs Category Post held at the time of leaving Service of NFL Room Rent allowed A C&MD / Directors 5000 B Chief Mgr to Executive Director (E-6 to E-9) 4250 C Asstt.officer to Sr Mgr (E-0 to E-5) 3250 D Non- Executives (W0 to W12) 2250 There is no restrictions on ICU charges

9 Other Benefits Pre Hospitalization Expenses Expenses related and incurred prior to 30 days from the date of hospitalization for which claim is admissible Post Hospitalization Expenses Expenses related and incurred after 60 days from the date of discharge for which claim is admissible Co Payment NA Disease capping NA, as per tender documents

10 Claim Process Claims Process & Network Value adds Web Access & Mobile App Customer Support Awards and Recognitions

11 CHOLA MS HELP Claims Process CHOLA MS HELP is The brand name for the Health claims servicing team of CHOLA MS

12 Salient Feature of Chola MS HELP In-house Centralized processing at Chennai HO with regional coordinators at branches. Reimbursement Processing TAT of 7 Days Cashless issuance TAT is maintained at less than 1 hour. Health claims processing on a workflow (CORDYS) facilitating transparency / stage-wise status at all points. Auto SMS & mailers to customer & web portal updating the claim status at all the stages. App for claim intimation, e-card download.

13 Hospital Networking States Network Strength MAHARASHTRA GUJARAT ANDHRA PRADESH RAJASTHAN PUNJAB DELHI WEST BENGAL BIHAR South West North East Central NE No of Hospitals No Cities JHARKHAND CHATTISGARH CHANDIGARH GOA JAMMU AND KASHMIR ANDAMAN AND NICOBAR TRIPURA ~5800 hospitals on Panel 33 States & UTs covered Presence in more than 800 cities. MEGHALAYA ARUNACHAL PRADESH Will have more than 6000 hospital by Mar,17 end covering ~900 cities 13

14 Value Adds Apollo Pharmacy :- 10% discount on medicines and 15% discount on Apollo labeled products and 5% discount on FMCG. Thyrocare :- upto 50% discount on blood investigations and free sample collection at home. Health camps/health Talks Discounted Specialty consultations at selected hospitals Vaccination camps as required at discounted rates Master Health check up discount vouchers Any special requirement as per need.

15 Types of Claims 1. Cashless Through Network Hospitals 2. Reimbursement From Any Hospital as per IRDAI guidelines 3. Pre & Post hospitalization claim 4. Daycare procedures Claims

16 Claim Processing Claim Intimation In case of emergency, please intimate us to Chola MS HELP within 24 hours of hospitalisation. If planned hospitalisation, intimate us 48 hours prior to your admission. Toll free Fax Cashless Request for Pre-Authorisation Complete the pre-authorisation form available at the hospital's insurance/tpa Desk and send us through /fax. This form can also be downloaded from Website Approved letter sent by the claim management team Re-imbursement Claim Form Submission Submission of claim form along with required documents, as per the policy terms & conditions. The form can be downloaded from website. Approved letter sent by the claim management team Hospital/Insurance to respond to any query raised by the claim management team Hospital/Insurance to respond to any query raised by the claim management team You may initiate the treatment and file for reimbursement claim You may initiate the treatment and file for reimbursement claim

17 Mandatory documents for claim: Claim form duly filled and signed. Hospital final bill along with payment receipt. Detailed discharge summary Medical bills along with supporting prescriptions. All investigation reports along with bills. Invoice or sticker for implants used in surgery. Copy of policy certificate / health card. Medico Legal Certificate (MLC) / FIR in case of road traffic accidents (RTA) Note: Bills and receipts has to be submitted in original Cont...

18 Web Access Online E-Cards and claims status on To access the E-cards and claims status follow the below mentioned Steps. Step 1 - Go To e-card Step 2 - Click on individual Login Icon Step 3 - Enter Policy Certificate Number as Login ID Step 4 - Enter Policy Certificate Number as Password Promise of complete transparency with necessary details available on Web

19 Mobile App ( Wellness on the Go)- Health Claims 1)Download Procedure: Log on to website or from play store Please click on Chola MS Wellness on the go app for downloading (down arrow) in to your mobile. Once you click on the app for downloading, it will ask you to enter your name and mobile number to download. Once the app is downloaded, Install the same in your mobile Note: This app has to be downloaded from the above mentioned URL only and it is not available in play store (Android app store). Cont

20 Mobile App ( Wellness on the Go)- Health Claims 2)Registration: After downloading and installation of the app, you have to register the same to login in to the app. Please enter the policy number followed by employee ID. Then it will prompt you to login through face book, google or with your own PIN opted. If you wish to login to through own PIN, you have to chose 6 digit PIN of your own choice, and alternatively you can login using your face book or google account. Note: You need to have GPRS facility in your mobile in order to access the above facilities except for My policy details, health card, storage of medical documents & BMI which works offline also. Cont

21 Mobile App ( Wellness on the Go)- Health Claims Salient features of the app are as followed: Health Card on mobile Nearest Network hospitals details on google map Nearest Ambulance services details on google map Store Medical files and Pill reminder Value added services Nearest Services (Labs, Pharmacy and scan centre) BMI calculator Pedometer BP/Sugar reading /Trend My contact Contact Chola MS Care Policy details Cover Benefits Claim intimation

22 Customer Support Chola MS HELP line customer support operates 24/7 basis. Toll Free Phone No: Toll Free FAX No: Mail: Claim can be submitted to Chola MS HO at Chola MS General Insurance, Claims Processing Centre, New # 319, Old # 154, Shaw Wallace Building, 2nd Floor, Tambu Chetty Street, Parrys Corner, Chennai Or To the nearest regional offices. 22

23 Escalation Matrix For any issue related to claim NFL team can get in touch with Dr Manish manishbatra@cholams.murugappa.com # or business team. If not resolved, case can be escalated as per below matrix. Reimbursement Claims Escalation Name Contact Number Level 1 Sathish G R / sathishgr@cholams.murugappa.com Level 2 Dr Rajesh Kanna P / rajeshkannap@cholams.murugappa.com Level 3 Dr Bharathi S / bharathis@cholams.murugappa.com Level 4 Dr Basant Kumar / basantkumar1@cholams.murugappa.com Cashless Approvals Escalation Name Contact Number Level 1 FAX Health / Dr. Sreenivasulu / faxhealth@cholams.murugappa.com / sreenivasuluk@cholams.murugappa.com Level 2 Dr Bharathi S / bharathis@cholams.murugappa.com Level 3 Dr Basant Kumar / basantkumar1@cholams.murugappa.com

24 Claim process in the beginning of the Policy Membership card not available :- For cashless :- Insured can approach network hospital with employee ID card and to inform them that they have policy with CHOLA MS. Hospital will do rest of the process related to approval. If insured details are not available with CHOLA MS then mail will be triggered to NFL HR for confirmation of coverage at:- Ms. Vaishali Tayade, Asstt. Manager (HRD) vaishali.tayade@nfl.co.in Mrs. Promila Goyal, Sr. Manager (Coord), NFL, promilagoyal@nfl.co.in; Mr. D.R. Choudhary, Chief Manager (HR) drchoudhary@nfl.co.in; Post confirmation of coverage,cashless will be processed as per policy T&C. In absence of coverage, denial letter will be send. For Reimbursement :- Insured can file claim for reimbursement with employment details.post confirmation from NFL HR, claim will be processed. Chola MS business team will be kept in loop in all above communications.

25 Awards and Recognitions Health Claims process at Chola MS HELP is now ISO 9001:2008 certified

26 Health Insurer Claims Team of the Year for the year 2013

27 Thank You

28 Annx.

29 Cashless Claim 1) Fresh pre authorization request: Cashless access is possible only at Chola MS HELP network hospitals (Approximately 5800 in number). Please refer our website for updated list of network hospitals. Insured should approach the hospital insurance desk, with the health card issued by Chola MS HELP along with a valid photo ID proof. Insured can avail advance pre-authorisation ( 7 days ) in case of Planned hospitalisation. Hospital will send filled pre authorization request, copy of health card, valid photo ID proof and all necessary medical records (prior consultations, lab reports) through toll free FAX ( ) to Chola MS HELP. Cashless approval will be provided by Chola MS HELP with in 2 hours, if the claim is admissible under policy terms & conditions. Cont..

30 2) Query Process : In case of any deficiency of necessary documents, Chola MS HELP will raise a query to the hospital, within 2 hour of receipt of the cashless request. On receipt of the query response from the hospital, the same will be processed within 1 hour. 3) Enhancement Process: If the expenses of treatment exceeds the initial cashless approval, hospital will send enhancement request to Chola MS HELP along with the necessary documents (Bills and treatment summary) Enhancement request will be processed within 1 hour from the time of receipt of the necessary documents from the hospital

31 Reimbursement Claim All reimbursement claims should be intimated to Chola MS HELP immediately or before discharge from the hospital, through toll free number or at Reimbursement claim should be submitted with in 30 days from the date of discharge at any regional office of Chola MS or HO. Claims submitted at regional offices will be registered on the same day and forwarded to Chola MS head office for adjudication. Chola MS HELP team will scrutinize the claim and it will be processed within 30 days of receipt of the documents, if the claim documents are complete and claim is payable as per the policy terms and conditions. Cont..

32 Query Process: In case of any deficiency of necessary documents, Chola MS HELP will raise a query to the insured / corporate, within 3 working days of receipt of the claim at HO. Query follow up will be done as mentioned below: 1 st Query letter Day 1 Reminder letter 15 th day after 1 st query Final reminder cum closure letter 30 th day after 1 st query Claim will be closed on 45 th day in the absence of query response from the insured.

33 Pre & Post and Day Care Procedures Pre & Post Claim: Pre & post hospitalization bills should be submitted within 30 days from the time of completion of the treatment or post hospitalization period defined in the policy, which ever is earlier. Claims is payable, if the main claim is admissible under the policy subject SI availability Daycare Procedures: No need for 24 hrs hospitalization for these procedures. Prior intimation and approval from Chola MS HELP is mandatory. Procedures defined under the policy only payable.