KARVY Group Mediclaim FAQs

Transcription

1 KARVY Group Mediclaim FAQs Q. What is Group Med claim Policy? This is intended to provide medical treatment to the employees. Q. Who are eligible under the scheme? This coverage is for all employees, excludes those covered under ESIC benefits. Q. Are they employee dependents also covered? Yes Spouse and maximum of two children Q. When can I inform for family addition You can inform addition of family members within 7 days from the change to vijaya.krishna@karvy.com at HR failing which dependents are not eligible for benefits during policy period Q. Who will pay the premium? Employer pays the premium. Q. What is the Sum Insured for various categories of employees? Level / Grade Not covered under ESI Scheme - Upto S7 Sum Insured Rs lakhs S8, S9, S10, S11 Rs lakhs S12, S13, S14, S15 Rs lakhs S 16 and above Q. What are the benefits under this scheme? Rs 5.00 lakhs All the medical benefits under Inpatient category are covered. Q. When will get the Identity Card / Mediclaim Card No? You can check HRIS during by 25th of month once salary is processed for the first month on joining the company Q. How can I obtain Identity Card?

2 You can login TPA website ( and obtain your e identity ID card/s and produce the same as proof. For login TPA User name is your Mediclaim Card No and password is 1234 Q. How can employee get their mediclaim card? Please visit HR Portal Employee information Group Mediclaim, for GHPL Mediclaim cards and more information about policy details for your ready reference. Q. Required details for Hospitalization? Before Hospitalization member should have mediclaim card, otherwise claim will not payable Q. What should I do incase of cash less treatement / reimbursement of bills? a. Cashless: On admission to Hospitals which are under TPA network, insurance executive at hospital will coordinate with TPA for cashless procedure and further follow up is also needed by insured person for speedy process Please carry patent Mediclaim card and identity card b. Reimbursement: Send the all required medical documents along with claim form within 10 days to Head office from the date of discharge Mr. J VIJAY KRISHNA - HRD KARVY NAINA TOWERS 46, AVENUE 4, STREET NO. 1, BANJARA HILLS HYDERABAD Ext no: 7514 In both cases - Insured person should inform to TPA within 24 hours on admission to hospital this is mandatory (Mail ids are customer.care@ghpltpa.com & ajay.saxena@ghpltpa.com) c. Query letter: On receipt your reimbursement documents for any short fall, a query letter is generated (visit ghpltpa.com) Produce all short fall (Query) documents against your reimbursement raised by TPA as mentioned in your query letter/s within 45 days from the date of discharge, failing which your reimbursement claim will get rejected and further closure of the claim Q. Where can I get the details of the network hospitals? Visit TPA web site Q. Can I get admitted into any of the rooms irrespective of the charges?

3 Room rent (Room, Boarding, Nursing Expenses ) restricted to 1% of Sum Insured for Non ICU and 2% of Sum Insured for ICU on Sum Insured All other related and associated charges in accordance with room rent is restricted incase Insured person opts for room higher than the eligibility Insured person shall bear the Proportionate % in the proportion of the difference The room actually incurred and the room rent limit/ eligible and this excludes pharmacy/medicine bills Q. Is the maternity benefit extended in the policy? Maternity benefit available for Normal delivery and Caesarian Section Amounts payable for maternity claims are subject to some limit. (Normal delivery is limited to Rs.25,000 and for C-Sec: Rs.35,000/-) Note: Opted higher room rent proportionate deduction will be deducted as per Room rent clause This benefit is available from day one for the first two children Pre & Post expenses are not applicable to maternity benefit Cover for new born child is from day one and employee has to inform within seven days to corporate HR about new born vijaya.krishna@karvy.com Gender, Date of Birth. Q. Do I need to pay for admission when I get admitted? In order to ensure speedy admission process, initially you need to pay and the will be returned once you get the approval from TPA as per policy terms TPA will arrange payment to the hospital and there is no need for the Insured person to make any payment unless it is exceeding the Sum Insured / beyond sub limits Procedure for Hospitalization (NETWORK HOSPITALS) For list of net work hospitals - please visit Q. What is the Procedure for Hospitalization (NON-NETWORK HOSPITALS)? Keep TPA informed about the admission within 24 hours from the time of admission in hospital failing which reimbursement will get rejected by TPA

4 When the discharge takes place before the approval is given to the hospital by TPA and if the location is in remote area where there is no communication facility, bills are required to be submitted for reimbursement to TPA. These bills are reimbursed subject to the satisfaction of Insurance Company Claims for reimbursement should be sent within 7 days from the date of discharge from the hospital to Mr Vijaya Krishna HR at HO. Claim form and original documentations check list can be obtained from HRIS Please quote your emp ID and mobile no on the claim form Set of Photocopy of all original documents can be retained for future reference. Produce all shortfall documents against queries within 45 days to the satisfaction of TPA, Failing which your claim will get rejected or closed. Visit for claim status /Query related Q. What is the validity of the coverage and who will renew the validity? The validity is for a period of one year which will be renewed on 24th July of every year. Q. What is the age limit for children? Son - till 21 years and Daughter - till 25 years or till such time they are dependent on their parents. Q. How the sum assured is distributed to the employee and his/ her dependants? The sum insured is on floater basis for the employee and family members. Any one or more can utilize the benefit up to the maximum of SI. Q. Pre & Post expenses are paid? Pre and Post Hospital expenses: Pre and Post Hospital expenses for 30 & 60 days are subject to a maximum of 10% Sum Insured. During a period 30 days immediately prior to the date of insured person s admission to the hospital During a period 30 days immediately following the date of insured person s discharge from the Hospital

5 Provided that the medical expenses relate to the same illness Original Bills & Photocopy of discharge summary needs to enclosed for claiming pre and post hospitalization expenses separately Pre & Post expenses are not applicable to maternity Q. Are the pre-existing diseases covered under this policy? Yes. All pre-existing diseases are covered under this policy. Q. When can I think of availing the med claim facility? When there is any emergency / accident / disease. When a Doctor suggested certain treatment / surgical procedure. 24 hours hospitalization as a inpatient is necessary to become eligible Q. What are the limitations of this scheme? Sum insured is the limit during the policy period for entire family and following are exclusions Circumcision unless necessary for treatment of a disease. Cost of spectacles, contact lenses, hearing aids and any cosmetic treatment Dental treatment /surgery unless requiring hospitalization, Convalescence, general debility, congenital external defects, V.D., intentional self injury, accident while driving under the influence of intoxicating liquor and drugs AIDS, expenses for diagnosis X - ray or tests not consistent with the disease requiring hospitalization. Naturopathy treatment Q. Who is insurer insurance who extends this facility? M/s. UNITED INDIA INSURANCE CO. LTD - HYDERABAD. Q. Can I approach the insurance company for my claims? No, You need to approach TPA only. Q. Who is TPA?

6 M/s. Good Health Plan Ltd - Hyderabad Q. How can I approach the hospital? You have to carry e-identity card issued by TPA & any Photo Identity Card issued by Govt. Q. In case of accident? Accidental cases where medico legal certificates are required Q. What if I fall sick during this period before I get the Mediclaim Card? You may contact Corporate HR at Hyderabad for any assistance and advice Q. What should I do if I am admitted as inpatient? When the Doctor suggests for inpatient treatment, you need to meet the Front Office staff at the Hospital reception counter. They will direct you to the Local Insurance Service Coordinator as available in the hospital. Please do remember to carry the Mediclaim identity card before meeting Insurance coordinator. Q. What are the Policy Exclusions? Circumcision unless necessary for treatment of a disease. Cost of spectacles, contact lenses, hearing aids and any cosmetic treatment Dental treatment /surgery unless requiring hospitalization, Convalescence, general debility, congenital external defects, V.D., intentional self injury, accident while driving under the influence of intoxicating liquor and drugs AIDS, expenses for diagnosis X- ray or tests not consistent with the disease requiring hospitalization Naturopathy treatment. Q. What if I prefer better room than my eligibility? You should pay the difference of the overall expenses directly to the hospital at the time of discharge. Q. What is the required proof for cataract reimbursement? You need to submit IOL stickers for cataract reimbursement

7 Q. What are the Expenses covered in this policy? The Policy covers expenses incurred under the following heads, subject to overall ceiling of the sum insured for all claims during the policy period. Room, food expenses for the patient as provided by the hospital. Nursing care Expenses. Doctors Fees which includes: Surgeon, Anesthetist, Medical Practitioner, Consultants or any other Specialists. Anesthesia, Blood, Oxygen, Operation Theatre Charges, Surgical Appliances, Medicines & Drugs, Diagnostic Material and X-Ray, Dialysis, Chemotherapy, Radiotherapy, Cost of pacemaker, artificial limbs & Cost of Organs and similar expenses. Expenses in respect of the following specified illnesses will be restricted as detailed below: Major surgeries include cardiac surgeries, brain tumor surgeries, pace maker implantation for sick sinus syndrome, cancer surgeries, hip, knee, joint replacement surgery. Hospitalization Benefits Cataract, Hernia,Hysterectomy Major surgeries Limits as per surgery RESTRICTED TO Actual expenses incurred or 25% of the sum insured whichever is less Actual expenses incurred or 70% of the Sum Insured whichever is less subject to maximum of Rs. 2,00,000/- Note: Lasik and Multifocal lenses are not covered Q. What expenses are not covered in the hospital bill? Facilities / luxuries over and above the treatment. Food expenses of patient s attendant s are not covered. Q. What if, we do not have a network hospital at our place? You can go ahead with your treatment in the nearby best hospital. Q. How will I claim the expenses incurred in such cases?

8 Please send all the related documents along with TPA claim form to HO in order to forward the same to TPA for processing. Q. What is the procedure for reimbursement? Inform TPA within 24 hours getting admitted into hospital You need to forward the original bills, medical prescriptions / discharge summary and all other relevant documents along with the duly filled in claim form within 07 days from the date of discharge. Retain a photocopy of all the original documents for your future reference. Claim will be cleared subject to satisfaction of the Insurance Company as per policy terms and conditions Produce all shortfall documents against queries within 45 days to TPA, failing which your claim will get rejected/ closed. Visit for claim status /Query related Q. When will I get my claim? Will take three weeks from the date of receipt of the documents by HO, if the documents are in order Q. How do I know if the documentation is not in order? Visit ghpaltpa.com for the deficiency details TPA has right to close the file if short fall details are not given with in time period against reminder / query letters raised by TPA Q. Can Insurance company deny the claim in its totality or partly? If so, under what circumstances? Yes. Insurance Company can deny the claim in total or part of the claim under the following circumstances: In a network hospital, if the treatment is not pre approved before admission and the admission is not according to laid down procedure. If the claim is not submitted with all original documents. Bills, Report.etc Prescription, Food Bills and other related expenses.

9 Not responding to the queries raised by Insurance Company within the time limits. When unrelated test/ medicines were included. Doctor from TPA will validate every claim and he may disallow certain tests / procedures / medicines. Not informing to TPA with in24 hours on hospitalization Q. Can I get admitted / reimbursed for the hospitalization if I am at a different location? Yes. You may join the nearest hospital. In case of no network hospital in the nearby location, you will be entitled for reimbursement as per the terms. Q. Is the day care treatment covered? Yes. Expenses on Hospitalization for minimum period of 24 hours are admissible. However, this time limit is not applied to specific treatments, few as Appendectomy Coronary angiography Coronary angioplasty Dental surgery D&C Eye surgery Fracture/ dislocation excluding hairline fracture Radiotherapy Lithotripsy Incision and drainage of abscess Colonoscopy Haemo dialysis Hydrocele Hysterectomy Inguinal/ventral/ umbilical/femoral hernia Parenteral chemotherapy Piles/ fistula Prostrate Sinusitis Tonsillectomy Liver aspiration Sclerotherapy Note: Procedures / treatments usually done in outpatient department are not payable under the policy even if converted as an in-patient in the hospital for more than 24 hours

10 Any one illness means continuous period of illness and it includes relapse within 45 days from the date of discharge from the Hospital / Nursing Home where treatment has been taken. Occurrence of the same illness after a lapse of 45 days will be considered as fresh illness for the purpose of this policy. For further clarifications / guidance, please contact the following: PBSS Ravi Kumar - HR Mobile No : Direct No. : ravihr@karvy.com TPA related services Mr. Ajay Saxena : Toll free no: Fax Note: If any queries and emergencies please get in touch with your respective HR Coordinators