Religare Health Insurance Co. Ltd

Transcription

1 Presentation on, Religare Group Care Presentation on Group Health Religare Insurance Group Policy Care For ServiceMax Technologies Pvt Ltd Group Health Insurance Policy For HITACHI PAYMENT SERVICES PRIVATE LIMITED Religare Health Insurance Co. Ltd 9/12/2017 Religare Health Insurance 1

2 Medical Benefit Coverage Details For Employee Policy Policy Parameter Insurer TPA Insurance Advisor Policy Period Coverage Type Dependent Coverage (For Assistant Managers & Above) Sum Insured Religare Health Insurance Co. Ltd. Religare Health Insurance Co. Ltd. Indusind Bank From 28-Jul-2017 To 27-Jul-2018 Floater basis Self, Spouse, 2 Dependent Children upto 25 years or 2 Dependent Parents upto 80 years (Self + Any 3) Graded SI Benefits / Extensions Standard Hospitalization Pre existing diseases Waiver on 1 st year exclusion Waiver on 1 st 30 days excl. Maternity benefits Waiver of 9 month waiting for maternity benefit. Coverage Yes. Yes. Yes. Yes. Rs. 35,000/- for Normal and Rs 45,000/- for LSCS Yes Lasik treatment Baby cover day 1 Day Care Covered Ailment capping No Capping 9/12/2017 Religare Health Insurance PPN Clause Applicable 2 OPD Room Rent Capping Pre-Post Hospitalization Exp. Health Check-up Ambulance Services YES Yes Not Covered Room Rent: 1% of sum insured for normal & 2% of sum insured for ICU Yes Not Covered Rs.1000/- per claim

3 Medical Benefit Dependent Coverage* Maximum no of Members insured in a family Employee Spouse Children Parents Siblings Others Mid Term enrollment of existing Dependents Mid Term enrollment of New Joinees (New employees) Mid term enrollment of new dependents (Spouse/Children) 4 (Employee+ Spouse+ Dependent children or 2 Dependent Parents upto 80 years ) Yes Yes Yes Yes No No Disallowed Allowed Allowed within a reasonable time * Dependents covered only for Assistant Managers & Above 9/12/2017 Religare Health Insurance 3

4 Maternity Benefits Benefit Details For Normal Delivery Rs. 35,000/- for Normal For C Section / Cesarean Delivery Rs. 45,000/- for Normal 9 Months waiting period Waived off These benefits are admissible in case of hospitalization in India. Expenses incurred in connection with voluntary medical termination of pregnancy during the first 12 weeks from the date of conception are not covered. Maternity benefit is allowed only for the first two children 9/12/2017 Religare Health Insurance 4

5 Room Rent Benefit Details For Normal 1% of sum insured for Normal For ICU Proportionate clause 2% of sum insured for ICU Not Applicable PPN Clause Applicable 10% Co Pay will apply if the benefits are used outside PPN Hospital List 9/12/2017 Religare Health Insurance 5

6 Group Medical Coverage In Patient Treatment: Treatment for which you have to stay in a hospital for more than 24 hours. Hospital accommodation Pre-hospitalization Medical Expenses Post-hospitalization Medical Expenses- Day-Care Procedures- Medical Expenses for procedures which are undertaken by an Insured Person as an In-patient in a Hospital for a continuous period of less than 24 hours. Emergency ambulance- Rs.1000/- per claim 9/12/2017 Religare Health Insurance 6

7 Medical Benefit Standard Coverage Covers Expenses related to 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 Hospital miscellaneous services (such as laboratory, x-ray, diagnostic tests) Costs of prosthetic devices if implanted during a surgical procedure Radiotherapy and chemotherapy A) The expenses are payable provided they are incurred in India and within the policy period. Expenses will be reimbursed to the covered member depending on the level of cover that he/she is entitled to. 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, 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. 9/12/2017 Religare Health Insurance 7

8 Pre & Post Hospitalization Expenses Pre-hospitalization Expenses- Up to 100 % SI Definition Covered Duration If the Insured member is diagnosed with an Illness which results in his / her Hospitalization and for which the Insurer accepts a claim, the Insurer will also reimburse the Insured Member s Pre-hospitalisation Expenses for up to 30 days prior to his / her Hospitalization. Yes 30 Days Post-hospitalization Expenses- Up to 100 % SI Definition If the Insurer accepts a claim under Hospitalization and immediately following the Insured Member s discharge, further medical treatment directly related to the same condition for which the Insured Member was Hospitalized is required, the Insurer will reimburse the Insured member s Post-hospitalisation Expenses for up to 60 day period. Covered Duration Yes 60 Days 9/12/2017 Religare Health Insurance 8

9 Card Type E Card Open URL: Click on register button. 9/12/2017 Religare Health Insurance 9

10 Select corporate tab and press submit. 9/12/2017 Religare Health Insurance 10

11 Enter your details mentioned in the form below and press submit GMC Policy Number : /12/2017 Religare Health Insurance 11

12 It will redirect you to the login page. Select corporate tab, enter your id and password. And you will be able to login to the customer portal. 9/12/2017 Religare Health Insurance 12

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14 Permanent Exclusions Any Claim in respect of any Insured Member for, arising out of or directly or indirectly due to any of the following shall not be admissible, unless expressly stated to the contrary elsewhere in the Policy terms and conditions (i) Any condition directly or indirectly caused by or associated with any sexually transmitted disease, including Genital Warts, Syphilis, Gonorrhoea, Genital Herpes, Chlamydia, Pubic Lice and Trichomoniasis, Acquired Immuno Deficiency Syndrome (AIDS) whether or not arising out of HIV, Human T-Cell Lymphotropic Virus Type III (HTLV III or IITLB-III) or Lymphadinopathy Associated Virus (LAV) or the Mutants Derivative or Variations Deficiency Syndrome or any Syndrome or condition of a similar kind. (iii) Any treatment arising from or traceable to any fertility, infertility, sub fertility or assisted conception procedure or sterilization, birth control procedures, hormone replacement therapy, contraceptive supplies or services including complications arising due to supplying services or Assisted Reproductive Technology. (iv) Any dental treatment or surgery unless necessitated due to an Injury. (v) Treatment taken from anyone who is not a Medical Practitioner or from a Medical Practitioner who is practicing outside the discipline for which he is licensed or any kind of self -medication. (vi) Charges incurred in connection with cost of spectacles and contact lenses, hearing aids, routine eye and ear examinations, laser surgery for correction of refractory errors, dentures, and artificial teeth and all other similar external appliances and/or devices whether for diagnosis or treatment. 9/12/2017 Religare Health Insurance 14

15 (vii) Experimental, investigational or unproven treatments which are not consistent with or incidental to the diagnosis and treatment of the positive existence or presence of any Illness for which confinement is required at a Hospital. Any Illness or treatment which is a result or a consequence of undergoing such experimental or unproven treatment. (ix) Any expenses incurred on prosthesis, corrective devices, external durable medical equipment of any kind, like wheelchairs, walkers, belts, collars, caps, splints, braces, stockings of any kind, diabetic footwear, glucometer/thermometer, crutches, ambulatory devices, instruments used in treatment of sleep apnea syndrome (C.P.A.P) or continuous ambulatory peritoneal dialysis (C.A.P.D.) and oxygen concentrator for asthmatic condition, cost of cochlear implants. (x) Weight management services and treatment, services and supplies including treatment of obesity (including morbid obesity) (xi) Any treatment related to sleep disorder or sleep apnea syndrome, general debility convalescence, cure, rest cure, health hydros, nature cure clinics, sanatorium treatment, Rehabilitation measures, private duty nursing, respite care, long-term nursing care, custodial care or any treatment in an establishment that is not a Hospital. (xii) Treatment of all external Congenital Anomaly or Illness or defects or anomalies or treatments relating to birth defects.. (xiii) Treatment of mental illness, stress, psychiatric or psychological disorders. (xiv) Aesthetic treatment, Cosmetic Surgery and plastic surgery or related treatment of any description, including any complication arising from these treatments, other than as may be necessitated due to an Injury, cancer or burns 9/12/2017 Religare Health Insurance 15

16 (xv) Any treatment or surgery for change of sex or gender reassignments including any complication arising from these treatments. (xvi) Circumcision unless necessary for treatment of an Illness or as may be necessitated due to an Accident. (xvii) All preventive care, vaccination, including inoculation and immunizations (except in case of post-bite treatment), vitamins and tonics (xviii) Artificial life maintenance, including life support machine use, where such treatment will not result in recovery or restoration of the previous state of health (xix) Any travel or transportation expenses including Ambulance charges. (xx) All expenses related to donor screening, treatment, including surgery to remove organs from the donor, in case of transplant surgery. (xxi) Treatment received outside India. 9/12/2017 Religare Health Insurance 16

17 (xxv) Charges incurred at a Hospital primarily for diagnostic, X-ray or laboratory examinations not consistent with or incidental to the diagnosis and treatment of the positive existence or presence of any Illness or Injury, for which In-patient Care/Day Care Treatment is required. (xxvi) War (whether declared or not) and war like occurrence or invasion, acts of foreign enemies, hostilities, civil war, rebellion, revolutions, insurrections, mutiny, military or usurped power, seizure, capture, arrest, restraints and detainment of all kinds. (xxvii) Any Illness or Injury directly or indirectly resulting or arising from or occurring during commission of any breach of any law by the Insured Member with any criminal intent. (xxviii) Act of self-destruction or self-inflicted Injury, attempted suicide or suicide while sane or insane or Illness or Injury attributable to consumption, use, misuse or abuse of tobacco, intoxicating drugs and alcohol. (xxix) Any charges incurred to procure any medical certificate, treatment or Illness related documents pertaining to any period of Hospitalization or Illness. (xxx) Personal comfort & convenience items or services including but not limited to T.V. (wherever specifically charged separately), charges for access to telephone and telephone calls (wherever specifically charged separately), foodstuffs (except patient s diet), cosmetics, hygiene articles, body/baby care products and bath additive, barber or beauty service, guest service as well as similar incidental services and supplies. 9/12/2017 Religare Health Insurance 17

18 xxxi) Stem Cell implantation, harvesting, storage or any kind of treatment using stem cells (xxxii) Expenses related to any kind of RMO charges, service charge, surcharge, admission fees, registration fees, night charges levied by the Hospital under whatever head. (xxxiii) Any Hospitalization primarily for investigation and/ or diagnosis purpose. (xxxiv) Nuclear, chemical or biological attack or weapons, contributed to, caused by, resulting from or from any other cause or event contributing concurrently or in any other sequence to the loss, claim or expense. For the purpose of this exclusion: I Nuclear attack or weapons means the use of any nuclear weapon or device or waste or combustion of nuclear fuel or the emission, discharge, dispersal, release or escape of fissile/ fusion material emitting a level of radioactivity capable of causing any illness, incapacitating disablement or death. II Chemical attack or weapons means the emission, discharge, dispersal, release or escape of any solid, liquid or gaseous chemical compound which, when suitably distributed, is capable of causing any illness, incapacitating disablement or death. III Biological attack or weapons means the emission, discharge, dispersal, release or escape of any pathogenic (disease producing) micro-organisms and/or biologically produced toxins (including genetically modified organisms and chemically synthesized toxins) which are capable of causing any illness, incapacitating disablement or death. In addition to the foregoing, any loss, claim or expense of whatsoever nature directly or indirectly arising out of, contributed to, caused by, resulting from, or in connection with any action taken in controlling, preventing, suppressing, minimizing or in any way relating to the above shall also be excluded. (xxxv) Impairment of an Insured Member s intellectual faculties by abuse of stimulants or depressants. 9/12/2017 Religare Health Insurance 18

19 (xxxvi) Alopecia, wigs and/or toupee and all hair or hair fall treatment and products. (xxxvii) Any medical or physical condition or treatment or service, which is specifically excluded under the Policy Certificate. (xxxviii) Any treatment taken in a clinic, rest home, convalescent home for the addicted, detoxification Centre, sanatorium, home for the aged, mentally disturbed, remodeling clinic or similar institutions, unless specifically provided for. 9/12/2017 Religare Health Insurance 19

20 Servicing- Religare Health Insurance 9/12/2017 Religare Health Insurance 20

21 Cashless / Pre Authorization Process Preauthorization request form is available with Network hospitals or on For planned admission request to be sent 48 hours prior to admission In case of Emergency admission request needs to be sent within 24 hours from admission Request received will be processed within 4 hours from receipt Case might be approved/denied or further clarifications might be sought Clarification letter will be sent to hospital and decision will be taken once the clarification is received Authorization letter sent by Religare Health Insurance to the hospital Insured will be intimated of decision/deficiency through a call/sms Company will settle the claim to the hospital directly 9/12/2017 Religare Health Insurance 21

22 Contacts insurance hospital Insurance Desk PA form is faxed to RHICL team Claims Team Patient admitted Fills up the PA form Claims team receives the form In House claims team processes the PA request. Fax sent to the hospital. Query RHICL Doctor reviews the case 9/12/2017 Religare Health Insurance 22

23 Reimbursement Claims Process Insured admitted to non network hospital for treatment For planned admission intimation to be sent 48 hours prior to admission In case of Emergency admission intimation needs to be sent within 24 hours from admission Intimation can be done at Toll Free Number: ID: Insured settles the bill and collects the original discharge summary & bills from the hospital All necessary documents to be submitted along with completed claim form In case further documents are needed, the claims team will contact the customer through phone/mail and resolve the same 9/12/2017 Religare Health Insurance 23

24 Reimbursement Claims Process Mandatory Documents: Duly filled claim form signed by the insured Original bills, receipts and discharge card from the Hospital / Medical Practitioner Original bills from chemists supported by proper prescription Original investigation test reports and payment receipts Implant invoice/stickers MLC/FIR copy in case of accident cases Any other document required for processing of claims Claims to be processed within 15 working days of receipt of complete information All Documents to be sent to the below mentioned address IPD Claims Team, Religare Health Insurance Co. Ltd, Vipul Tech Square Sec.43 Tower C, 3rd Floor Golf course Road - Gurgaon T: /12/2017 Religare Health Insurance 24

25 Avails treatment and settles bills Fills up the claim form and forwards same to In house claims team Claims Team Patient admitted in non network hospital Insured collects original discharge summary and original bills Claims team receives the claim In House claims team processes the claim. Claim decision taken as per policy terms and conditions and insured intimated of the same. Query RHICL Doctor reviews the case 9/12/2017 Religare Health Insurance 25

26 Servicing Phone Call Religare Health Toll free no Send to Service request to be replied within 24 hours Online Information through Tractus Member enquiry Health Card Network Hospitals Claims Enquiry and Status Claims & Preauthorization forms 9/12/2017 Religare Health Insurance 26

27 Escalation Matrix Escalation Name ID Contact number Level 1 Customer care customerfirst@religarehealthinsurance.com Level 2 Ramareddy K N ramareddy.kn@religare.com Level 3 P. Suresh Babu sureshbabu.p@religare.com /12/2017 9/12/2017 Religare Health Insurance 27

28 GPA BENEFITS 9/12/2017 Religare Health Insurance 28

29 BENEFITS Accidental Death Covered Permanent Total Disability Covered Permanent Partial Disability Covered Total Temporary Disability - 1% of Sum Insured maximum upto Rs or actual weekly salary whichever is less up to 104 weeks Medical Expenses (Accidental Hospitalization) - 10% of SI or 40% of admissible claim amount or actuals whichever is lower Religare Health Insurance 9/12/

30 Policy Parameter Insurer Religare Health Insurance Policy Start Date 28 Jul 2017 Policy End Date 27 Jul 2018 Coverage For Employees only 9/12/2017 Religare Health Insurance 30

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32 Thank You 9/12/2017 Religare Health Insurance 32