GROUP MEDICLAIM POLICY. Health Insurance. For ENERGY INFRATECH PVT LTD

Transcription

1 GROUP MEDICLAIM POLICY Health Insurance For ENERGY INFRATECH PVT LTD 1

2 About Us Worldwide Insurance Brokers Limited was incorporated in Direct Insurance Broking license has been granted by Insurance Regulatory and Development Authority of India (IRDA) in July Offering wide range of insurance products & services in General Insurance, Life Insurance & Reinsurance. Dedicated, qualified and trained professionals industry specialists, insurance product specialists, re-insurance specialists and customized solution providers. License has been Upgraded from Direct Insurance to Composite Insurance Broker by IRDA in Jan

3 Service Providers Insurance Company: The United India Insurance Co Ltd Brokers:-Worldwide Insurance Brokers Ltd TPA:-Vipul Med Corp 3

4 About Us Affiliation of our Company Member of Global Broker Network Member of Indo-French Chamber of Commerce& Industry National Executive Committee Member of FICCI Member of Confederation of Indian Industry Director of Insurance Brokers Association of India Member of Indian Industries Association 4

5 Our Vision & Mission OUR VISION To be a leading global reinsurance and risk management solution provider by OUR MISSION Building long-term and mutually beneficial relationship. Practicing fair business ethics and values. Use of latest technology in customer servicing Motivating, developing and long term retention of employees. Maximizing growth and profitability to deliver stakeholders expectations. 5

6 Our Competitive Advantage We have team of industry specialists who understand clients business and provide them with customized insurance solutions. 100% client retention - who bring repeat business to us. Highly experienced professionals who have more than a decade of hands on experience in all insurance business. Research and knowledge team who constantly keep watch on changing business scenarios to up-skill on-the-ground staff. High employee retention due to continuous focus on employee skill development and career growth. 6

7 Scope of cover..health Insurance Disease/Injury Treated medically/surgically By Hospitalization At Nursing home/hospital in India as an inpatient 7

8 General Policy Conditions Family Size: Self+ Spouse+ 2 Dep Children+2 Dep Parents Pre Existing Diseases are Covered Waiver of 30 Days & First 2nd & 4th Years Waiver Maternity covered from day one. Maternity Limit :Rs for Normal & Cesarean. New Born baby Covered from Day one 8

9 Continue Room Rent Capping:- 2% Of Sum Insured for Normal or Rs 4000 per day whichever is higher :- No capping on ICU Pre & Post Hospitalization Expenses are Covered for 30 days & 60 days respectively, But not in case of Maternity Pre & Post Natal expenses are not covered. Ambulance charges: Rs 1000 per incident Domiciliary Hospitalization is not covered 9

10 Continue No disease wise capping except Cataract as per policy terms Congenital Internal Disease covered Day care facility Covered Mid term increase in sum insured only due to promotion New dependent addition only in case of newly wedded spouse and new born baby. 10

11 Minimum Criteria of Hospital Min 15 in-patient beds Min 10 when population < 1 million Fully equipped functional operation theatre Round the clock availability of nursing staff/doctors 11

12 Hospitalization Min period of 24 hrs Time limit not applicable for specific treatment requiring less than 24 hours hospitalization Dialysis Chemotherapy Tonsillectomy D & C [Dilatation & Curettage] - procedure involving dilation of the cervix of the uterus and curetting the inner uterine lining. This procedure is payable only if medically necessary and not for termination of pregnancy or diagnostic purpose Eye surgery Lithotripsy (kidney stone removal) Radiotherapy 12 Fracture of any kind ( If hospital confirms)

13 General exclusions Nuclear perils War/war group Spectacles/contact lens/hearing aid Any cosmetic treatment/plastic Surgery Convalescence/general debility Sterility/Infertility treatment Admission only for Investigations or Observation. Admission not leading to any treatment of ailments. Exp on vaccination or inoculation or changes of life or cosmetic or aesthetic treatment of any description such as correction of eye sight are not payable Any Non-medical exp like Registration fees, Admission fees, charges for Medical records, Cafeteria charges, Telephone Charge Service charges, Diet or Food Charges. 13

14 General exclusions Use of intoxicating drugs /alcohol Intentional self injury Psychiatric Treatment HIV & AIDS Psychological Imbalances/Problems Congenital Internal & External Diseases Intentional self-injury, Use of Intoxicating drugs/alcohol Venereal Diseases. Any form of local medication such as Homeopathy & Naturopathy, acupressure, acupuncture, experimental & unproven treatment /therapies such as RFQMR,EECG Diagnostic/laboratory expenses not consistent with treatment Vitamins/tonic inconsistent with treatment Dental treatment or surgery of any kind unless necessitated by accident & requiring hospitalization are excluded under 14 this policy.

15 Conditions.. Dependent to be declared at the time of Inception of the policy. No mid term inclusion of dep allowed except for spouse after marriage and child by birth. Additions deletion of employees will be done on prorate basis from day 1 for additions sub to sufficient CD balance being maintained. Dependent Children max up to age of 25 only will be insured if they are in full time education. No change of SI allowed after commencement of the policy. No additions of new slabs for SI allowed after commencement of the policy. Self/ Spouse below 18 yrs will not be covered. Siblings not covered. New joining premium to be charged on pro-rata basis for the insurance period. 15

16 16

17 Web Access We also give online access to insurer, insured and hospitals through our website: We give access to following online modules: Enrollment data and card status & E Cards Claims intimated, processed and settled Claims Analysis(Disease wise, Age wise & Geography wise, Relation, Hospital, Cost Breakup) Incurred Claims ratio The Client can access following details through our website Claim Intimation Banking Details for NEFT Mobile/ Reg Grievance Intimation Network/PPN Hospital List SelfCare ( E Cards, Claims intimation, online claims submission, Claim settled details, Scanned Documents, relationship matrix, grievance intimation ) 17

18 Short SMS Service 18

19 Online Enrollment Process Corporate will give soft data of employees to Vipul MedCorp TPA Vipul will upload the data in the back end on its Enrollment portal Clients will get access to enrollment module user interface employees wise, to allow them online facility for additions, modification of dependents. They can also upload photos Authority will be given for Corporate HR/Admin to authorize/compile the data The above process would also be followed for monthly additions /Deletion data. Insurer will release an endorsement covering the members in the compiled portal data 19

20 Services TAT Value Added Services Cash less Within 2 hrs SMS Alerts/Mobile App interface for E-card Within 72 hrs cash less and claims. Web Access for online data Laminated Cards within 7 days transaction. Query Generation 4-7 days Discounts in leading Pharmacy Claims Settlement 7 days hospitals for Pharmacy /Health Payment Within 2 days ECS Check up and OPD treatments. Online Grievance/Query Module and redressal. Help desks and orientations 24/7 mobile, Call center supported on IVR with online interface. Second Medical Opinion (SMO) Electronic Medical Record Management (EMRM) Health Risk Assessment (HRA) 20 Health Camps /Talks

21 Operational Flow 21

22 Claims Intimation (Required both for Cashless & Reimbursement Claims) In case of a proposed hospitalization insured should intimate by mail/fax/letter/phone to Vipul MedCorp. All intimations are recorded and a Claim Kit (Claim Form & Procedure note) is sent to Insured with the request to submit following documents: Policy Copy [Retail Clients Only] Claim Form ID Card Copy Doctor s First Prescription Chemist Bills with Prescription Discharge Summary Hospital Bills Investigation Reports 22

23 In case insured avails treatment at non-network hospital, he pays the treatment cost and claim a reimbursement from TPA. 30 days pre and 60 days post hospitalization can also be claimed for both cashless and reimbursement hospitalization. Insured to fill-up claim form and submit along with following original documents: Doctors first prescription Discharge summary Hospital bills with all break-up Investigation reports (x-ray, ECG, etc.) All relevant medicine bills, pharmacy prescriptions, etc. Vipul MedCorp will process the claim and /courier discharge voucher along with claim break-up to HR/employee, which will be signed and returned back to us. Cheque will be dispatched to insured/hr. Claims Reimbursement 23

24 Document Checklist (Re-imbursement) After discharge policy holder has to submit the following documents to Vipul TPA within 7 working days. Original detailed discharge summary Payment receipt in original Copy of ID card Original hospital bill with breakup Package break-up (if applicable) Original investigation reports Pharmacy bills with prescription Claim form duly signed Hospital registration certificate 24

25 Contact Us Head Office : Worldwide Insurance Brokers Ltd. B-42, Sector-63, Noida Delhi-NCR, INDIA Phone : , and Mobile : Mumbai Office : reinsurance@wibl.in, bima@wibl.in : Crystal Plaza, 2 nd Floor, Unit 204, Hargovindji Road, Chakala, Andheri (East), Mumbai , INDIA Phone : Mobile : Web : 25

26 THANK YOU 26