LIC Club Agents' Group Mediclaim Policy crea&ng a collabora&ve ecosystem to simplify healthcare

Transcription

1 LIC Club Agents' Group Mediclaim Policy crea&ng a collabora&ve ecosystem to simplify healthcare

2 Life Insurance Corpora0on Of India Ltd. cover from New India Assurance Co. Ltd. serviced by Medi Assist India TPA Pvt. Ltd Medi Assist India TPA Private Limited Private & Confiden&al Not for Circula&on 2

3 Mediclaim Policy Slides Medi Assist India TPA Private Limited Private & Confiden&al Not for Circula&on 3

4 Defini&ons Illness Illness means a sickness or a disease or pathological condi&on leading to the impairment of normal physiological func&ons which manifests itself during the policy period and requires medical treatment Hospital A Hospital means any ins&tu&on established for in-pa&ent care and day care treatment of sickness and / or injuries and which has been registered as a hospital with the local authori&es, wherever applicable, and is under the supervision of a registered and qualified medical prac&&oner and must comply with all minimum criteria as under: has at least 10 inpa&ent beds, in those towns having a popula&on of less than 10,00,000 and 15 inpa&ent beds in all other places; has qualified nursing staff under its employment round the clock; has a qualified medical prac&&oner (s) in charge round the clock; has a fully equipped opera&on theatre of its own where surgical procedures are carried out maintains daily records of pa&ents and will make these accessible to the Insurance company s authorized personnel Medi Assist India TPA Private Limited Private & Confiden&al Not for Circula&on 4

5 Special Features of the Mediclaim Policy Policy Period: 01 st Sept 2015 to 31 st Aug Coverage: For Self only ( Age 18yrs to 85 yrs.) Sum Insured : Various SI depending upon the Grades From Rs. 40K to Rs.1.25 Lakhs Room Restric0on : Normal Room up to 1% and for ICU up to 2% of Sum Insured. Maternity : For Normal delivery Rs.25K and for C sec&on Rs.50 K Pre/Post expenses: 30 days per hospitaliza&on and 60 days post hospitaliza&on charges are covered. Pre exis&ng ailments are covered. Wai&ng period (1st year / 2nd year / 3rd year ) is waived off 30 days wai&ng period not applicable Ambulance charge up to 1 % of SI payable for transporta&on from home to hospital. Ayurvedic /Homeopathic/ Unani Treatment are admissible up to 25% of the sum insured provided the treatment for illness/disease and accidental injuries, is taken in a Government hospital or in any ins&tute recognized by Government Medi Assist India TPA Private Limited Private & Confiden&al Not for Circula&on 5

6 Expenses Payable Room, Boarding, Nursing Charges ICU charges. Surgeon, Anaesthe&st, Consultants, Medical Prac&&oner, Specialist fees. Anaesthesia, Blood, Oxygen, O. T. charges, Surgical Appliances, Medicines & drugs, Ar&ficial Limbs, Cost of Prosthe&c Devices like pacemaker, Implants and Relevant Laboratory/Diagnos&c test and Similar expenses Pre Hospitaliza&on Expenses: Expenses incurred 30 days prior to date of admission( Consulta&on / Test Charges) Post Hospitaliza&on: Expenses incurred up to 60 days from the date of discharge. Medi Assist India TPA Private Limited Private & Confiden&al Not for Circula&on 6

7 The Company will pay to the Insured Person expenses of: Room, Boarding, Nursing Charges ICU charges. Surgeon, Anaesthe&st, Consultants, Medical Prac&&oner, Specialist fees. Anaesthesia, Blood, Oxygen, O. T. charges, Surgical Appliances, Medicines & drugs, Ar&ficial Limbs, Cost of Prosthe&c Devices like pacemaker, Implants and Relevant Laboratory/Diagnos&c test and Similar expenses Pre Hospitaliza&on Expenses: Expenses incurred 30 days prior to date of admission( Consulta&on / Test Charges) Post Hospitaliza&on: Expenses incurred up to 60 days from the date of discharge. As a SPECIAL PREVILEGES Proportionate deduction waived off Medi Assist India TPA Private Limited Private & Confiden&al Not for Circula&on 7

8 Expenses Not Payable (Cashless & Reimbursement) Admission/Registra&on Telephone charges Akendant's charges Home Visit/Nursing charges - at residence amer discharge Assistant fee/follow up charges in advance Sundry/Medico Legal Charges/Diabe&c chart charges Thermometer Charges Container for Specimen/Disposable Bag charges Admission Kit External Surgical Aids: Lumbo-sacral/Collar belt /Knee cap/knee brace/ walker/hot water bag/baby kit/urine pot / trac&on kit/ folding commode etc. Inhaler/ Nebulizer /Glucometer or any other equipment's Diet charges Special/protein diet/health drinks unless prescribed by the doctor Documenta&on/Folder/Sta&onery/In Pa&ent chart charges Medi Assist India TPA Private Limited Private & Confiden&al Not for Circula&on 8

9 Day care procedures/treatments payable under the policy An& Rabies Vaccina&on Appendectomy Coronary Angiography Coronary Angioplasty Dental surgery following an accident Dilata&on & Curekage (D & C) of Cervix Eye surgery Fracture / disloca&on excluding hairline Fracture Gastrointes&nal Tract system Haemo-Dialysis Hydrocele Hysterectomy Inguinal/Ventral/Umbilical/Femoral Hernia Lithotripsy (Kidney Stone Removal) Parenteral Chemotherapy Piles / Fistula Prostate Radiotherapy Stone in Gall Bladder, Pancreas, and Bile Duct Tonsillectomy, Urinary Tract System Sinusi&s Medi Assist India TPA Private Limited Private & Confiden&al Not for Circula&on 9

10 Pre-Authoriza&on (PA) & Reimbursement claim Process Pre-Authoriza0on (PA) Process Customer visits the Medi Assist network hospital for admission, hospital sends PA request with copy of photo ID proof to Medi Assist Reimbursement claims Process Post hospitaliza&on customer to submit duly filled claim form along with all original documents to Medi Assist Medi Assist registers Pre-Auth request and Liability checks done as per policy terms and condi&ons If more informa&on required, Medi Assist to seek Informa&on Required from hospital. Medi Assist registers the claim and send acknowledgement to customer through SMS/ Valida&on of claims and liability checks done as per policy terms and condi&ons Medi Assist to process Pre-Authoriza&on (Approved/Denied) Medi Assist to approve Pre- Authoriza&on. In case denied, will claim for possible Reimbursement. Hospital to send the Discharge summary and Final bills to Medi Assist for PA seklement If more informa&on required, Medi Assist to send Informa&on Required (IR) leker to customers. Medi Assist to process Reimbursement claims (Approved / Denied) Payment done through NEFT and sekled. If denied, Denial leker is sent. Medi Assist India TPA Private Limited Private & Confiden&al Not for Circula&on SMS & s are triggered at below Claims stages Queries Registra&on Approval Denial Seklements Informa&on required 10

11 Medi Assist Documents Required for Reimbursement Claim 1. Duly Filled & Signed Claim Form 2. Original Discharge Summary 3. Original hospital bills/ receipts & suppor&ng annexures, detail breakup of the main bill. 4. Copy of Indoor case paper. 5. All inves&ga&on & test reports- including ECG, X-Ray, Ultra-Sound, CT Scan, MRI 6. All pharmacy bills & prescrip&ons 7. Cancelled cheque. 8. For claim above Rs.1 lac, Pan Card Copy is also required. Medi Assist India TPA Private Limited Private & Confiden&al Not for Circula&on 11

12 How to download E Card Step 1. Type on web browser Step 2 Click on E-Cards op0on on top right sec0on Step 3:- Select any desired op0on from the choice to enter the specific detail: Step 4:- Enter your Employee ID/Agent code Step 5: Once the details are entered, you get the E-card Step 6: Save the E-card to u0lized at the 0me of hospitaliza0on. Medi Assist India TPA Private Limited Private & Confiden&al Not for Circula&on 12

13 How to view claim status Online Step 1 : Type on web browser Step 2 : Click on Track your claim op0on on top right sec0on: Step 3: Select any desired op0on from the choice to enter the specific detail Step 4: Enter your Employee ID/Agent code or if know the MAID number or claim number: Step 5: If any addi0onal documents are requested please submit the documents to your nearest Medi Assist Branch. Step 6: Once the documents are received and query is completed the claim will be processed. Medi Assist India TPA Private Limited Private & Confiden&al Not for Circula&on 13

14 Medi Assist Toll free call centre services Ø Interac&ve Voice Response System (IVRS ) Ø State of art call centre located at Bangalore suppor&ng PAN India Call Centre opera&ons Ø 24x7 availability Ø Coopera&ve and Mul&lingual speaking staff Ø Toll free numbers Ø Recording and Monitoring of all calls Ø Regular training to all execu&ves to sensi&ze towards various policies & issues Contact Details Medi Assist India TPA Private Limited Private & Confiden&al Not for Circula&on 14

15 Happy to partner Medi Assist India TPA Pvt Ltd. Sri Krishna Arcade, 47/1, 9th Cross, 1st Main Road, Sarakki Industrial Layout, 3rd Phase, J P Nagar, Bangalore Tel: info@mediassis&ndia.com Medi Assist. All rights reserved. Disclaimer: Integrated Web Portal, Medibuddy, HRA and other Medi Assist products and services men&oned herein as well as their respec&ve logos are trademarks or registered trademarks of Medi Assist or its affiliate companies. All other product and service names men&oned are the trademarks of their respec&ve companies. Data contained in this document serves informa&onal purposes only. Some of the illustra&ons indicated in this document are only for informa&onal purposes and may not have rela&on to Medi Assist s products or services. These materials are subject to change without no&ce. These materials are provided by Medi Assist and its affiliated companies ( Medi Assist Group ) for informa&onal purposes only, without representa&on or warranty of any kind, and Medi Assist Group shall not be liable for errors or omissions with respect to the materials. The only warran&es for Medi Assist Group products and services are those that are set forth in express warranty statements accompanying such products and services, if any. Medi Assist shall in no event be held liable to any party for any direct, indirect, implied, puni&ve, special, incidental or other consequen&al damages arising directly or indirectly from any use of this material, which is provided as is, and without warran&es. Medi Assist India TPA Private Limited Private & Confiden&al Not for Circula&on 15