Presentation on Group Mediclaim policy benefits for students of SIDDAGANGA INSTITUTE OF TECHNOLOGY

Transcription

1 Presentation on Group Mediclaim policy benefits for students of SIDDAGANGA INSTITUTE OF TECHNOLOGY

2 About Group Mediclaim Group Health Insurance covers hospitalization and medical expenses incurred as an inpatient by students who are covered under the Group Medicalim policy of SIT students. 2/5/2018

3 Group Mediclaim The policy is issued by the National insurance co. ltd. The policy is valid for a period of 1 year. Vidal Health TPA (Formerly known as TTK Health Care TPA Pvt. Ltd.) is the Third party Administrator to serve this policy (i.e. enrolling the members, processing cashless & claims on behalf of insurance Co.)

4 About Us Vidal Health TPA Pvt. Ltd. ( formerly Known as TTK Health Care TPA Pvt Ltd )was established in April 2002; with the mission to provide top quality TPA services to Medi claim policyholders and be the most preferred TPA in India. We are licensed by IRDA (Insurance Regulatory & Development Authority - License No. 016) and have been empanelled by leading insurance companies, both public sector and private, across different regions of the country. We, at Vidal Health TPA Pvt. Ltd. (Formerly known as TTK Health Care TPA Pvt Ltd), believe customer satisfaction is of utmost importance and constantly strive to achieve the same. We have a pan India presence with 14 branches with team of more than 1400 members. Our Corporate & head Office is located at Bangalore. 4

5 Role of TPA Providers Vidal Health TPA Desiring less administrative burden, greater autonomy, faster payments Insurance Co Striving to reduce premiums. Make better policies. Aim at Claims Control Policy Holders Demanding better service, more information, and greater convenience

6 Policy Coverage details Coverage only to students of SIT. Covers only the inpatient hospitalization treatment. Sum Insured : maximum Rs.75000/- per year. 1ABC Clause is applicable : 1A.:-Maximum limit under Section 1 A - 25% of the sum insured per illness / injury Room charges subject to 1% of sum insured per day and Intensive care unit (ICU) charges subject to 2% of sum insured per day (including nursing care, RMO charges, IV fluids / blood transfusion / injection administration charges). 1B :- Maximum limit under Section 1 B - 25% of sum insured per illness / injury. Surgeon, Anesthetist, Medical Practitioner, Consultants, Specialists Fees. 1 C :- Maximum limit under Section 1 C - 50% of sum insured per illness / injury. Anesthesia, Blood, Oxygen, OT charges, Surgical appliances (any disposable surgical consumables), Medicines, drugs, Diagnostic material & X-Ray, Dialysis, Chemotherapy, Radiotherapy, cost of pacemaker, artificial limbs, Cost of Stent & Implants 2/5/2018 6

7 Policy Coverage details The coverage holds valid from the day one of policy. Ambulance Charges covered up to Rs.750/ Room rent is restricted to maximum of Rs.750/- per day, in case of ICU Rs.1500/- per day. The treatment should be only in registered hospitals. Hospital should be of Minimum 15 beds.

8 Standard Hospitalization Reimbursement expenses covered Room and boarding Doctors fees Intensive Care Unit Nursing expenses Surgical fees, operating theatre, anesthesia and oxygen and their administration Drugs and medicines consumed on the premises Laboratory and diagnostic charges Dressing, ordinary splints and plaster casts Costs of prosthetic devices if implanted during a surgical procedure Radiotherapy and chemotherapy A) The expenses shall be reimbursed provided they are incurred in India and within the policy period.. B) Expenses on Hospitalization for minimum period of 24 hours are admissible. However this time limit will not apply for specific treatments i.e. Dialysis, Chemotherapy, Radiotherapy, Eye surgery, Dental Surgery, Lithotripsy (kidney stone removal), Tonsillectomy, D & C taken in the Hospital/Nursing home and the insured is discharged on the same day of the treatment will be considered to be taken under Hospitalization Benefit. 2/5/2018 8

9 Pre & Post Hospitalization Expenses Applicable Pre-hospitalization Expenses Definition If the client is diagnosed with an Illness which results in his or her Hospitalization and for which the Insurer accepts a claim then the Insurer will reimburse the Insured Person s Pre-hospitalization Expenses for up to 30 days prior to his/her Hospitalization as long as the 30 day period commences and ends within the Policy Period. Applicable Yes Duration 30 Days Post-hospitalization Expenses Definition If the Insurer accepts a claim under immediately following the Insured Person s discharge, he requires further medical treatment directly related to the same condition for which the Insured Person was Hospitalized, the Insurer will reimburse the Insured Person s Post-hospitalization Expenses Applicable Yes Duration 60 Days 2/5/2018 9

10 Room Rent Restriction Room Rent Room Rent Normal Room permitted maximum per day is :1% of Sum Insured :- 750 per day. I.C.U :ICU rent permitted maximum per day is :2% of Sum Insured : per day. Please remember, higher the room category, higher will be the cost of treatment. 2/5/

11 General Exclusions Injury or disease directly or indirectly caused by or arising from or attributable to War or War-like situations Circumcision unless necessary for treatment of disease Dental treatment of any kind unless requiring hospitalization Congenital external diseases or defects/anomalies HIV and AIDS Hospitalization for convalescence, general debility, intentional self-injury, use of intoxicating drugs/ alcohol. Venereal diseases Injury or disease caused directly or indirectly by nuclear weapons Naturopathy, Ayurvedic, Homeopathy Any non-medical expenses like registration fees, admission fees, charges for medical records, cafeteria charges, telephone charges, TV 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 Infertility treatment Voluntary termination of pregnancy during first 12 weeks (MTP) Luxury tax, Service tax, sales tax etc. Hired attendants, Barber charges etc 2/5/

12 Cashless Hospitalization Cashless hospitalization means the TPA may authorize upon a Policyholder s request for direct settlement of eligible services and it s according charges to a Network Hospital. In such case the TPA will directly settle all eligible amounts to the Network Hospital to the extent of these services covered under the Policy. 2/5/

13 Cashless Process Hospital sends Cashless request to VIDAL Request received at VIDAL & the same is acknowledged to hospital & an SMS to client. Client approaches VIDAL Network hospital to avail cashless. Deficiency Query is communicated to hospital. Processing team scrutinizes the documents checks for coverage and eligibility. Decision communicated to Hospital & client (approval / rejection). All documents are fulfilled to take decision. Medical Dept. checks for Treatment, costs and policy conditions.

14 Reimbursement Claim Process In case the treatment is taken by client by paying the hospitalization expenses by him the claim need to be submitted to Vidal for reimbursement within 15days from the date of discharge. Please ensure all documents related to hospitalization is submitted to us in original like : Discharge Summary, IP Bill with detailed breakup, Cash paid receipts, lab reports, images & films etc. Note: Please retain with you photocopies of all documents submitted to us.

15 Reimbursement Claim Process Documents received at VIDAL Payment made to SIT account through NEFT. Validation of customer Id Claims registered and computation completed. Deficiency Query is communicated to Client. DocsInsufficient complete Documents to andproceed claim. Payable Claim Approved. Settlement letter sent to insured. Document Verification completed. Scrutiny of claim on fitment of policy TnC by Claims Officers. Scrutiny of claim By Medical officers. Docs Documents fulfilled to Incomplete take decision. Claim denied and the file referred to insurer.

16 Claim form & Checklist for reimbursement claims Claim form A:- Claim form B:- Detailed Checklist of documents needed :-

17 Vidal Health Vire Vidal Health TPA brings its service now on your finger tip Anytime & Anywhere

18 How To Download Android & ios Play Store & App Store For internal use only and should not be distributed without permission

19 Login For internal use only and should not be distributed without permission

20 Vidal Health Vire Download Vidal Health Mobile App and get the following services on your finger tips Health E card Enables you to view, share and save on your mobile. 20

21 Vidal Health Vire Hospital Search Search by Name, Distance & Location 21

22 Vidal Health Vire Claims Intimate claims and check your Cashless & Reimbursment Claim status 22

23 Vidal Health Vire Claim Status Check your claims status with specific remarks on the claim and any shortfalls 23

24 Vidal Health Vire Contact Us The Branch Address and Contact number for reference. 24

25 Vidal Health Vire Document Checklist for both Pre-authorization and Reimbursement 25

26 Vidal contact details Emergency Contact number : X7 For Claim intimation please write to / call & inform to : intimation@vidalhealthtpa.com / toll free For any general queries : blrcs@vidalhealthtpa.com Vidal website : Phone number : Vidal branch address: Vidal health TPA Pvt. Ltd. 1st floor, Tower 2, SJR I Park, EPIP Area, Whitefield,Bangalore

27 Thank you 2/5/2018