Customer Guide Book. EasyHealth

Transcription

1 Customer Guide Book EasyHealth Apollo Munich Health Insurance Company Limited (AMHI) congratulates you on your health insurance choice and welcomes you into the select group of Easy Health policyholders. Apollo Munich Health is glad to provide you Easy Health benefits and assures you of high quality customer service and responsiveness. Key benefits and services covered under Easy Health policy are In-patient hospitalization coverage with both network and out of network hospitals for various diseases Cashless Service (Customers do not need to pay for treatment or file claims) for treatment at any of our network providers Ready access to customer service Please review the following as soon as you receive the welcome kit: Your card for any discrepancies. Please bring discrepancies to the notice of our office or return the card for rectification. Please keep a photo copy of the card before returning it to Apollo Munich Health. The guidebook to familiarise yourself with the procedures to be followed while availing various services offered by Apollo Munich Health. Your Easy Health policy. You should familiarize yourself with benefits available and the exclusions. For any doubts or clarifications and/or information, please call our Toll free line at or log-on to our website The Easy Health policy, your Apollo Munich Health card and the guidebook are important documents. Please keep them in safe custody and carry them with you whenever you go to a hospital for admission. Please quote your card number and / or policy number in all your correspondence. AVAILING OF INPATIENT HOSPITALISATION SERVICES In case you need to avail inpatient hospitalisation services, you can go to any hospital of your choice, i.e. a hospital in our network or a hospital outside the network. The difference between the two is that with a network hospital you can use Cashless Services, whereas for a non network hospital, you will have to settle the bills and claim for reimbursement

2 Please follow the detailed procedures listed below to get the services in different situations: 1) Hospitalisation in Non Network Hospitals Emergency Step 1: Get admitted into the hospital Step 2: As soon as possible, inform the TPA about the hospitalisation Step 3: At the time of discharge, settle the hospital bills in full and collect all the bills, documents and reports Step 4: Lodge your claim with our TPA for processing and reimbursement Planned Step 1: Inform the TPA about the planned hospitalisation 5 days prior to the admission (see Pre- and Post-hospitalisation extension benefit). Step 2: Get admitted into the hospital. Step 3: At the time of discharge, settle the hospital bills in full and collect all the bills, documents and reports. Step 4: Lodge your claim with our TPA for processing and reimbursement. 2) Hospitalisation in Network Hospitals Emergency Step 1: Get admitted into the hospital. Step 2: As soon as possible inform the TPA and coordinate with the hospital to have the details sent to the TPA for authorization for cashless service. Step 3: A) In cases of a very short stay at the hospital or if the authorisation for Cashless Service was not received from the TPA or if Cashless Service was denied by the TPA a) At the time of discharge settle the hospital bills in full and collect all the bills documents and reports. b) Lodge your claim with the TPA for processing and reimbursement. OR B) If authorisation for Cashless Service from the TPA has been received at the time of discharge a) Pay for those items that are not reimbursable under the Easy Health policy. b) Verify the bills and sign on all the bills and the authorisation letter. 2

3 c) Leave the original discharge summary and other investigations reports with the hospital. Retain a Photo copy for your records. d) Sign the Claim Form. Planned Step 1: Please co ordinate with your doctor and the hospital and send in all the details of your planned hospitalisation including the plan of treatment, cost estimates etc. to our TPA. Also indicate the address or fax number to where the authorisation is to be sent along with the mobile no. to receive updates on your claims and authorisations This should be sent to the TPA at least 5 days prior to the admission (see Pre- and Post-hospitalisation extension benefit). Step 2: A) If authorisation for Cashless Service from the TPA has been received by you At the time of admission, hand in the authorisation letter and a photocopy of your ID card to the hospital. At the time of discharge: a) Pay for those items that are not reimbursable under the Easy Health policy b) Verify the bills and sign on all the bills c) Leave the original discharge summary and other investigations reports with the hospital. Retain a Photo copy for your records d) Sign the Claim Form OR B) In case Cashless Service was denied by the TPA At the time of discharge settle the hospital bills in full and collect all the bills documents and reports and Payment Receipt. If you wish, lodge your claim with our TPA for processing and reimbursement. Process for lodging claim with Apollo Munich Health for processing and reimbursement Within 7 days after discharge, please lodge your claim with our TPA for processing. Send the filled and signed Claim Form you can download the Claim Form from our or TPA s website. When lodging your claim with our TPA, please make sure that all the documents listed below are sent. 3

4 The following documents are required for the processing of the claim for different kind of expenses CHECK LIST OF ENCLOSURES FOR SUBMISSION OF CLAIMS General Hospitalisation/Day Care expenses Duly filled and signed Claim Form. Photocopy of ID card / Photocopy of current year policy. Original Detailed Discharge Summary / Day care summary from the hospital. Original consolidated hospital bill with break up of each Item. signed by the insured. Original payment receipt of the hospital bill. First Consultation letter and subsequent Prescriptions. Original Bills, receipts and reports for Investigation. Original Medicine bills and receipts with corresponding Prescriptions. Original invoice/bills for Implants (viz.stent/phsmesh/iol etc.) with the payment receipt. Road Traffic Accident in addition to the general hospitalization documents: Copy of the First Information Report from Police Department / Copy of the Medico-Legal Certificate. In Non Medico legal cases Treating doctor s certificate giving details of injuries (How, when and where injury sustained) In Accidental Death cases Copy of the Post Mortem Report For Death Cases In addition to the general hospitalization documents: Original Death Summary from the hospital. Copy of the Death certificate from competent authority. Copy of the Legal heir certificate, if the claim is for the death of the principle insured. Pre- and Post-hospitalization expenses Duly filled and signed Claim Form. Photocopy of ID card / Photocopy of current year policy. Original documents during Pre and post hospitalization period. Original Medicine bills with prescriptions. Original Investigations bills with prescriptions and report. Original Consultation bills with prescription. Original Payment Receipt. Maternity In addition to the general hospitalization documents Obstetric history (Gravida, Para, Living children, Abortions) from treating doctor. Critical Illness Duly filled and signed Claim Form. Photocopy of ID card / Photocopy of current year policy. A medical certificate confirming the diagnosis of critical illness from a doctor not less qualified than MD/MS. Reports/ other related documents reflecting the critical illness diagnosis. 4

5 Ambulance Expense Benefit Duly filled and signed Claim Form. Photocopy of ID card / Photocopy of current year policy. Original Bill with Payment Receipt. Treating Doctor s consultation indicating Emergency Hospitalization. Outpatient Benefit Duly filled and signed Claim Form Photocopy of ID card / Photocopy of current year policy. Original Medicine Bills and Payment Receipts. Original Investigation bills and receipts with Reports. Original Consultation bills and receipts with prescription. Daily Cash Benefit Duly filled and signed Claim Form. Photocopy of ID card / Photocopy of current year policy. Expenses for spectacles/contact lenses/ hearing aids Duly filled and signed Claim Form. Photocopy of ID card / Photocopy of current year policy. Prescription of the Treating Doctor. Original Invoice/bills of the device, appliances, lens etc with the payment receipts. Health Check up Duly filled and signed Claim Form. Photocopy of ID card / Photocopy of current year policy. Original Investigation bills and receipts with Reports. Original Consultation bills and receipts with prescription. Organ Transplantation/Donation In addition to the documents of general hospitalization Function test / blood test proving organ failure Treatment Certificate issued by the Transplant Surgeon of the hospital concerned Key Definitions Cashless Service: With our cashless service, you don t need to pay out of pocket before hospitalisation or the hospital bills at the end of treatment/discharge except for the non-medical and uncovered items. This facility is available only at the Network Providers. To avail the Cashless Service you need to get an authorisation from the TPA of Apollo Munich Health. You can request this with the Preauthorisation form which is available, from our Network Provider / TPA s website. The authorisation along with a copy of the card issued by Apollo Munich Health has to be given to the Network Provider at the time of admission. The cashless access at the network of providers is merely a facility extended to the insured and does not guarantee the availability, quality & outcome of the treatment. Choosing of a network or a non-network hospital is prerogative of the patient/insured. 5

6 Third Party Administrator: TPA shall mean a Third Party Administrator who is licensed by Insurance Regulatory and Development Authority (IRDA) and is engaged, for a fee or remuneration with an insurance company, for administration of health insurance policies. Network Providers: Network providers are Hospitals and Nursing Homes who have contracted with our TPA to provide cashless service for Inpatient treatment, for ailments, diseases and medical conditions covered under the Easy Health policy, to all those who are insured. The list of our Network Providers is attached to this guidebook. Please note that the TPA adds or deletes network providers regularly, hence to get the most current list of Network Providers, please call us on our Toll free Number or log-on to our website Authorization: It means a written approval by Apollo Munich Health or the TPA for a cashless service to the network provider for the covered expenses. Intimation: A communication by the insured or its representatives to Apollo DKV or its TPA for a prospective claim or treatment mentioning the details of treatment, estimated costs, place of treatment, date and duration of treatment. Reimbursement Claim: For all types of claims where the insured has paid for treatments especially at not network providers and has not availed the cashless service at the network providers of Apollo Munich Health, the insured can claim for reimbursement for the eligible expenses up to the limit of the sum insured and within the terms and conditions of the policy. You are encouraged to intimate us as early as possible for planned hospitalisation, to avoid delays and to ensure smooth processing. When you intimate us five days in advance, you are entitled to an additional benefit of 30 days of pre and post hospitalisation expenses when confirmed by Apollo DKV / TPA (i.e. 60 pre / 90 post) Intimation can be done by sending the Intimation Form which is available, as part of the policy kit to the insured and from our or TPA s website to the TPA through: Fax In person Post Courier Through Apollo Munich Health website Telephone 6

7 Please Note: The TPA will authorise Cashless Service but it may be denied in the following situations e.g: In case of any ambiguity in the coverage of the present ailment with respect to the policy terms and conditions based on the documents / information sent to the TPA or Apollo Munich Health Any false, manipulated or forged documents and information presented to the TPA. The ailment/condition etc. not being covered under the policy. The insured amount not being sufficient to cover the hospitalisation expenses. If the request for preauthorisation is not received by the TPA in time. If the information / documents sent to the TPA is insufficient to confirm coverage. Denial of Cashless Service is not denial of treatment. You can continue with the treatment, pay for the services to the hospital, and later send the claim to the TPA for processing and reimbursement. It will be processed and reimbursed as per the merit of the case. We appreciate your trust in choosing Apollo Munich Health as your Health Insurance provider. We wish good health for you and your family. Your Designated Third Party Administrator (TPA) is : FAMILY HEALTH PLAN (TPA) LIMITED Srinilaya Cyber Spazio, Ground Floor, Road No. 2, Banjara Hills, Hyderabad Phone No.: , Fax no: Toll Free : , 7