Frequently Asked Questions (FAQs) on Group Health Insurance Scheme - CHIP

Transcription

1 Frequently Asked Questions (FAQs) on Group Health Insurance Scheme - CHIP 1. Who is our Insurance Company for Group Health Insurance (GHI)? The New India Assurance Co. Ltd 2. Who is our Third Party Administrator (TPA)? Family Health Plan (TPA) Limited (FHPL) 3. Who is our Advisor on Employee Benefits? Marsh India Insurance Brokers Private Limited 4. What is a Group Health Insurance policy? The Group Health Insurance program provides insurance coverage to Vodafone India employees & their dependents for expenses relating to hospitalization due to illness, disease or injury subject to a minimum of 24 hours hospitalization 5. Who is covered under the policy? Employee +Spouse + Children and 2 dependent Parents or Parents-in-Laws 6. What is the coverage amount? Insurance Floater cover per family per annum as per the below mentioned Bands: Sum Insured - Graded (basis the family structure) Grade: G (Floater) a. Employee: 3 Lakhs b. Per Dependent: 1 Lakh Example- Self+Spouse+2 Children+2 Parents /Parents-in-law will result in total sum of INR 8 lakhs family floater Grade F, E and SLT (Floater) a. Employee: 5 Lakhs b. Per Dependent: 1 Lakh Example- Self+ Spouse+ 4Children+ 2 Parents /Parents-in-law will result in total sum of INR 12 lakhs family floater Note: No age limit for any dependents. Children to include adopted kids 7. What are the requirements to avail the same? The mediclaim policy stipulates that a claim is admissible when the insured (beneficiary) is admitted in a hospital for a minimum of 24 hours for the treatment of a positive illness 8. Is the 24 hours applicable for all ailments? Yes, the 24 hours hospitalization is a must. However this time limit is not applied to specific treatments (referred as day care hospitalization) i.e. Dialysis, Eye Surgery, Tonsillectomy etc. taken in the Hospital/Nursing Home and the Insured is discharged on the same day. The treatment will be considered under hospitalization Benefit. Please note that these treatments will have to be necessarily availed as an inpatient only. Refer day care list attached in the Benefit Manual uploaded on your intranet portal

2 9. What expenses are payable by the policy? Expenses such as a. Room & Boarding - Single AC Room with basic amenities like TV, Attendant Bed, etc. In case this category is not available then immediate next level category room can be used. If the employee chooses a higher room rent even if Single AC Room is available, the a pro-rata deduction on medical expenses will be applied b. Doctor Fees, Nursing Expenses, Consultant Specialist Fees c. Anaesthesia, Blood, Oxygen, Operation Theatre Charges, Surgical Appliances, Medicines, Drugs, Diagnostic Materials & X-ray etc d. Ambulance charges (INR 10,000 in case of emergency per incidence Ambulance charges INR 10,000 in case of emergency per incidence) where the patient has to be shifted from residence to hospital in case of admission in Emergency Ward/I.C.U. or from one Hospital/Nursing home to another Hospital/Nursing Home for better medical facilities. These expenses are payable only when registered ambulance is used 10. Are medical expenses prescribed after discharge (pre & post hospitalization expenses) payable? Relevant medical expenses incurred during period up to 60 days prior to hospitalization and the relevant medical expenses incurred up to 90 days after hospitalization is payable 11. Are Pre-existing diseases covered under the policy? Yes, pre-existing diseases are covered under the policy 12. Is maternity covered? Yes - Maternity Benefit up to INR 100,000 for normal and caesarean delivery within the family floater sum insured and max up to first 2 children. In case the second delivery is twins or triplet, they will be covered within INR 100, What do you mean by pre and post natal expenses? Is it covered in the policy? Expenses arising before delivery are known as pre natal expenses and those arising after delivery are known as post natal expenses. Pre and Post-natal expenses covered within the maternity limit (from conception of pregnancy up to 60 days post actual maternity) 14. Is the New Born Baby Covered? Yes, New Born Baby is covered from day one within the family floater subject to declaration given to the Insurer through the TPA portal enrolment 15. Is OPD covered under the policy? OPD is covered for Domiciliary Expenses, Vision, Dental and Health Check-ups. There are limits applicable under each heading and certain terms and conditions defining the benefits 16. What is covered under Domiciliary OPD? Domiciliary expenses is payable up to INR 40,000 per Family over and above hospitalization floater sum insured per year.domiciliary terms and condition- doctor consultation, minor surgery, x-rays, diagnostic tests, prescribed medicines, expenses related to Homeopathy and other alternative treatments are covered.prescription is mandatory for claims more than INR 500 (per claim) 17. What is covered under Dental OPD? Dental expenses is payable upto INR 15,000 per Family over and above hospitalization floater sum insured per year. Dental terms and condition -non-cosmetic procedures (OPD / hospitalization)

3 including consultation is covered. Payment Receipt is mandatory for claims more than INR 500 (per claim) 18. What is covered under Vision OPD? Vision expenses is payable upto INR 12,000per Family over and above hospitalization floater sum insured per year. Vision terms and condition -coverage for cost of prescribed lens including cost of frames, contact lenses, doctor consultation which are non-cosmetic in nature. Payment Receipt is mandatory for claims more than INR 500 (per claim) 19. What is covered under Health check-up? Expenses incurred towards health check-up is payable upto INR 10,000per Family over and above hospitalization floater sum insured per year.payment Receipt is mandatory for claims more than INR 500 (per claim) 20. What are the General Policy Exclusions? Injury or disease directly or indirectly caused by or arising from or attributable to War or War-like situations Injury or disease caused directly or indirectly by nuclear weapons Dental treatment of any kind unless done under general anaesthesia and requiring hospitalization at least for 24hrs under in-patient Non allopathic / Naturopathy treatment- except for Ayurvedic Treatment as in-patient by a registered Ayurvedic medical practitioner in government recognized Ayurvedic hospital and hospitals which has registered numbers to carry the practice. Any non-medical expenses like registration fees, surcharge, admission fees, charges for medical records, cafeteria charges, telephone charges, etc. Cost of spectacles, contact lenses, hearing aids under in-patient hospitalization If there is no active line of treatment during the period of hospitalization Hospitalization charges purely for diagnostic purposes (unless related to a particular illness for which the employee underwent hospitalization) i.e. treatment on trial and experimental basis are not covered under the scope of the policy Venereal disease Any cosmetic or plastic surgery except for correction of injury Hospitalization for convalescence, general debility, intentional self-injury, use of intoxicating drugs/alcohol Vitamins and tonics unless used for treatment of injury or disease If there is no active line of treatment given during hospitalization Voluntary termination of pregnancy during first 12 weeks (Medically Termination of Pregnancy) Stem Cell Banks The above are indicative lists only 21. Which are the other expenses that are excluded apart from those mentioned under general exclusion? Registration Fees, File opening fees Telephone, Internet charges Food and refreshments supplied to visitors and attendants Television charges Any other expenses not related to treatment of illness

4 Charges paid to organ donors etc The above are indicative list only 22. Can I continue the insurance coverage if I resign from the company? The insurance contract is arranged by your employer for the benefit of the employees. Employees who resign will not be able to continue enjoying these benefits 23. Will change in names in between policy period matters? Yes, according to the Insurance Company the claim will not be settled (unless prior intimation provided to Insurance company) if there is any alteration in the name. It has to be intimated to your respective Insurance Co. & requisite Endorsement for the change in name needs to be passed by Insurance co. This has to be done first hand and not only if any claim arises. You need to intimate such changes to your HR Department to be forwarded to insurance company and TPA 24. What is an e-id card? It is an identification card, which will entitle you to avail cashless hospitalization and any other negotiated benefits at the network hospitals of TPA on pre - authorization. Please remember that the e-id card is not a credit card. The card does not entitle you to credit towards outpatient treatment. To avoid any misuse of your card, the hospitals may ask you to furnish some identification card (like Voter ID, Credit card etc) 25. How do I get an e-id Card? You can print e-id Card directly from the TPA website. E-ID cards will also be shared by the TPA in a separate mailer post closure of enrolment period and method to download e-id card will be explained in the mailer 26. Suppose the hospital does not accept my e-id card? Please call up the FHPL Team (as mentioned below) immediately for assistance 27. What if I don t remember my e- ID Number or carry my e-id Card whilst hospitalization? In the event you do not remember your e-id card or carry your e-id Card, you may provide the name of your employer and your employee ID to avail cashless hospitalization or contact toll free no 28. What are network hospitals? These are hospitals where FHPLhas a tie up for the cashless hospitalization 29. What is cashless hospitalization? The cashless hospitalization is the benefit given to the insured, where you need not pay the expenses incurred due to hospitalization except for a security deposit (which varies in each hospital) to pay for non-medical expenses. The hospitalization bill will be paid by FHPL to the hospital directly after deducting the non- medical expenses. For the list of hospitals in the network you can visit contact FHPL Relationship Team for details 30. What should I do when I reach the network hospital? Please show your e-id card for identification or provide your employer name and employee number along with your government approved photo ID proof. The pre-authorization form which is available at the Hospital TPA Desk needs to be completed and sent to FHPL through mumbaipreauth@fhpl.netor fax on the same day of admission through the hospital authorities. Upon receipt of duly completed pre-authorization form, FHPL will send a letter of

5 authorization to the hospital to make sure that they extend the cashless benefit. You may be required to pay security deposit with the hospital. All non-medical/non-payable expenses and nonadmissible expenses will be deducted from the security deposit by the hospital If the cashless is denied, you can submit all relevant document, reports, admission & discharge card and bills for possible reimbursement. You can submit the claim along with claim form and all the necessary supporting documents to FHPL through your Mediclaim drop box located in your office premise or courier it to FHP at the address mentioned below For any assistance you may also reach out to the dedicated ID or dedicated Relationship Managers mentioned below Dedicated id for Vodafone: 31. Is pre authorization necessary? Yes. This will help you in the following ways: You will be able to avail cashless facility for hospitalization You will be informed in advance regarding the limit of coverage for your treatment so that your claim does not get rejected at a later stage and you do not end up paying more than required out of pocket It will help you ensure that the treatment cost is appropriate and not inflated This will also help FHPLin planning your hospitalization expenditure such that you do not run out of the cover that you are entitled to 32. What is the procedure for availing cashless facility? In case of planned hospitalization, insurers require the first prescription with the details of the case history indicating following details: Provisional diagnosis or reason for getting admitted in hospital Proposed date of admission Approximate expenses Name of the hospital and consultants Approximate duration of stay at the hospital Attached doctor's prescription with admission note The above documents along with pre-authorization form need to be delivered to FHPL at least 48 hours before admission In case of emergency hospitalization, insured will get admitted to the network hospital and avail the treatment. Pre-authorization form need to be faxed by the family to FHPL as soon as possible (within 24 hours) and get cashless approval 33. If I avail of the cashless facility, will the insurance company pay the entire bill at the hospital? No, a part of the bill will have to be borne by the insured if it consists of the non-admissible and nonmedical expenses that are listed in your policy terms All members are entitled for a Single AC Room with basic amenities like TV, Attendant Bed, etc. In case this category is not available then immediate next level category room can be used. However, in the even a Single AC room is available and you choose to opt for a higher room, then a pro-rata deduction of room rent and associated medical costs will be deducted from your admissible claim amount

6 34. What are claim reimbursements? In the event where you are hospitalized in a non-network hospital or where cashless hospitalization is not availed, you will pay the claim amount to the hospital post verifying the bills and charges and then claim through reimbursement. You need to submit all the original bills along with the Claim Form to FHPL and the hospitalization expenses will be reimbursed to you. Please fill the claim form (claim form provided in your employee portal) and submit the same along with claim documents to FHPL at the contact address mentioned below or put it in your mediclaim drop box in your office premises or handover the same to FHPLHelpdesk 35. How can I claim my pre & post hospitalization expenses? The policy covers pre-hospitalization expenses incurred prior to 60 days of hospitalization and incurred towards the same illness/ disease due to which hospitalization happens. It also covers all medical expenses for up to 90 days post discharge as advised by the Medical Practitioner. All the bills with summary along with a filled in claim form stating PRE-POST to be sent to FHPL for reimbursement within 15 days from 90 days post discharge. All supporting documents including doctor consultation, prescription, bills, reports etc. should be submitted along with the completed signed Claim Form 36. What are the documents required to be submitted to FHPL to claim under reimbursement procedure? Documents that you need to submit for a hospitalization reimbursement claim are: 1. Original detailed discharge summary/death Summary, Discharge summary reference points are as given below. 2. Original investigation reports along with bills. 3. Original Hospital Bill-consolidated and with detail breakup of every component of the bill. 4. In case of surgical packages like Cataract, Maternity, Angioplasty, Hernia etc. detail breakup of the package. Along with the sticker of the lens/implant and the Invoice of the Implant/Lens. 5. Medicine bills with prescriptions. 6. Claim Form (available on FHPL website 7. Medico Legal Case Certificate from the hospital or First Information report from Police station in the case of Road traffic accident. Or a certificate from the treating doctor mentioning whether the patient was under the influence of alcohol at the time of Accident or not. 8. Obstetric history (GPLA) in the case of maternity claims, which means that which pregnancy is it, how many no. of living children s are there before this pregnancy, was there any case of abortion. 9. Payment receipt for the payment done to the hospital. 10. Cancelled Cheque copy for NEFT of the claim settlement amount. 11. Photo Id proof and residence proof of the patient, in case the claimed amount is more than INR 1 lakh *60 Days pre & 90 Days Post hospitalizations 1. Original investigation reports along with bills & receipts. 2. Consultation receipts along with the Doctor s Prescription. 3. Medicine bills with prescriptions. 37. How to send reimbursement claims to FHPL (TPA)? Reimbursement claims can be put in your Mediclaim drop box located in your office premises or can be submitted directly to FHPL through registered post/courier at the office address mentioned below (refer contact details). Where FHPL Helpdesk is available, you may handover the documents directly to the Helpdesk

7 38. Are there limits to the number of claims on a Health Insurance Plan? There is no limit to the number of claims per annum but there is a limit to the amount that you can claim in a year. The maximum amount that you can claim in a year is limited to the member sum insured as applicable 39. If I have a health insurance policy in Mumbai, can I make a claim if I am transferred to any other location? Yes, your health insurance policy is valid all over the country 40. Will my claims be reimbursed even if I do not get myself treated at a network hospital? Yes, claims will be reimbursed even if insured is not treated in network hospital Important: Hospital should have a registration number 41. Are there any special criteria for seeking admission/ treatment in the hospitals/ nursing home? Yes, Should comply with minimum criteria as under a) Hospital should have at least 15 inpatient beds. In class C town s condition of number of beds may be reduced to 10 b) Fully equipped Operation of its own (wherever surgical operations are carried out) c) Fully qualified nursing staff under its employment round the clock d) Fully qualified doctor(s) should be in charge round the clock 42. What happens when the limit of insurance is exhausted under a Health Insurance Policy? If the insurance limit i.e. the sum insured is exhausted in a particular year due to large medical expenses, the insurer is not liable to bear/reimburse the insured for any further expenses 43. Should the claim be submitted with the insurance company or with FHPL (TPA)? Claim to be submitted with FHPL only 44. Who will receive the claim amount if the insured dies at the time of treatment? The claim amount is paid to the nominee of the insured. If no nominee has been assigned under the policy, the insurance company will insist upon a succession certificate from a court of law for disbursing the claim amount. Alternatively, the insurers can deposit the claim amount in the court for disbursement to the legal heirs of the deceased 45. Will location of dependent family matter in availing services under FHPL (TPA) network hospitals? No, Location does not affect the operational activities, main member or the dependant member can avail same and equal benefits irrespective of their location. FHPL (TPA) Network of Healthcare Service Providers is across the country 46. What is time frame for the submission of Reimbursement Claims? The claim needs to be submitted within 60 days from the date of discharge 47. Where do employees / dependents contact for any assistance? FHPL Contact Details Dedicated id for Vodafone: vodafonechip@fhpl.net

8 Designation Name Contact No ID Relationship Manager Sonal Karalkar Relationship Manager Shweta Barve Escalation Contact 1 Manoj Rewale manojrewale@fhpl.net Escalation Contact 2 Abhishek Yadav abhi@fhpl.net Escalation Contact 3 Dr. Nitin Ghadi dr.nitin@fhpl.net For all reimbursement related claims, you may drop in your reimbursement documents at the Vodafone Mediclaim Drop Box stationed at your office, or you may courier the same to the below mentioned address of FHPL for processing of your claim Family Health Plan (TPA) Ltd. Neelkanth Corporate Park Office No. 710 & 711, 7th Floor Kirol Road, Opp.Vidyavihar Railway station (West) Mumbai