Health Benefit plan 2017 2018 EXCERS TECHNOLOGIES PVT LTD Family Health Plan (TPA) Limited Hyderabad
Hospitalization Insurance Cover Insurer: The Bharti Axa General Ins. Co. Ltd Coverage: 27 January 2017 to 26 January, 2017 TPA : Family Health Plan(TPA) Limited. Beneficiaries: 1+3 (Employee + Spouse+ 2Children) Sum Insured: Rs.2,00,000 & Rs.3,00,000 Policy Type: Floater policy. Waiting Period & 1 st and 2 nd Year Exclusion: No waiting Period & Coverage from Day 1 or from DOJ. Includes: - Inpatient hospital expenses reasonable and justified with active line of treatment. - 30 days pre and 60 days post hospitalization Excludes: - Non Medical expenses. Registration/Admission fees, hospital surcharge, Assistant doctor charges, food bills, telephone charges, pharmacy charges for non-medical items etc.) - Other standard exclusions
Maternity Benefits There is no 9 month waiting period for maternity. Rs.30,000 is the maximum limit for normal delivery & Rs.40,000 for C-Section. Child covered from day 1 upto 90 days within family floater. Pre and Post Natal charges covered upto Rs. 5000 within maternity limit as in patient only. Other Limits Room rent is restricted to 1% of Sum Insured or Rs.5000 which ever is less for Normal and 1.5% for ICU of Sum Insured or Rs.5000 which ever is less. (if the member is opting for a higher category, then the incremental charges would be applicable proportionately. Emergency Ambulance Charges: Rs.1000 Cataract treatment covered for Rs.15000 per eye
What is an active line of treatment? Justified hospitalization - based on clinical condition and treatment provided. Hospitalization for treatment which: - cannot be taken on an out patient basis - cannot be taken at home - requires Doctor s supervision - is not only oral medication ( tablets) - not only for evaluation and observation.
Definition of Hospitalization : Minimum period of 24 hrs of admission in a hospital for a proper medical/ surgical management. Day care treatment were in 24 hrs is not applicable : Time limit not applicable for specific treatments like Dialysis Chemotherapy & Radiotherapy Tonsillectomy Eye surgery (Cataract capping Rs.15000) Dental surgery ( Necessitated by an accident leading to hospitalization) D & C (dilatation & curettage)
Standard Exclusions Circumcision unless necessary for treatment of diseases Hospitalization for convalescence, general debility, intentional self-injury, use of intoxicating drugs/ alcohol. HIV and AIDS & Venereal diseases & Naturopathy & Infertility treatment, family planning methods. Lasik treatment for correction of vision Hospitalization for diagnostic tests only even if it is prescribed by a physician during hospitalization. Cost of Spectacles, Hearing Aids, crutches or any external implants are not covered. There is no Dental Coverage except in case of a Road traffic accident, which warrants hospitalization & requires surgery under general anesthesia. Any kind of Cosmetic surgeries are not covered. Investigation, evaluation & observation will not be admissible, even if hospitalization is for more than 24 hrs. Vaccinations are not covered. Medical termination of pregnancy is not covered.
Standard Exclusions Registration / Admission fees/ Admission charges Food & beverages Telephone / Fax charges Attendant Charges Medical records fees Luxury Tax Special Nursing Charges Extra bed/ Bed retaining Charges, TV, Laundry etc. Medicines not related to treatment stationery Photocopying or certifying charges Medical & Surgical consumables NOTE: This list is not exhaustive.
FAMILY HEALTH PLAN TPA Ltd SERVICE OFFERINGS
Health Plan Services that includes : Electronic Fund Transfer (EFT). Cashless Hospitalization through Network Hospitals. 24 hours telephonic Call centre. Pre-auth team operating from 9am 9pm all the 365days. SMS updates for pre-authorization status.
Process to view the list of Network Hospital Log on to our website :- www.fhpl.net,
Follow the below process to get hospital list
How does the plan work? Hospitalization event can be covered in 2 ways: Cashless -Planned or Emergency at Network Hospital. OR Non-Network Hospital pay from pocket.
Cashless Hospitalization Cashless hospitalization means the TPA / insurer may authorize upon a Policyholder s request for direct settlement of eligible services and it s according charges between a Network Hospital and the TPA / insurer. In such cases the TPA / insurer will directly settle all eligible amounts with the Network Hospital and the Insured Person may not have to wait for the commencement of the treatment or bills after the end of treatment to the extent as these services are covered under the Policy. FHPL Hospital Network list https://www.fhpl.net/networkhospitals/nwhospitals.aspx Toll Free Number: 1800-425-4033
Pre-authorization Process for Cashless Member approaches Hospitals with FHPL ID Card + Photo ID proof of the patient Hospital sends Intimation to FHPL Eligibility Covered Not Covered Out of Pocket payment Authorization as per eligibility Cashless treatment at NWH If the hospital doesn t get reply from FHPL within 3 hrs then please call our help line no for status.
Network Sensitivities Recommend you to obtain Pr-Authorizations at least 48 hours in advance for all elective cases. Please do mention your Mobile No in the Pre Authorization form, the Status would be updated through SMS. Always carry Insurance card. Please do have a photo ID proof while admission. Provide the correct details to the hospital like Name, Age & Card number. As to approve a cashless hospitalization request, FHPL requires certain details and accurate information. Our medical panel requires precise / authentic details for validation purpose and the same needs to be provided by the hospitals and by the patient. In case proper details are not provided, then our medical panel will not be in a position to approve the case upfront. However, The patient can opt for claim processing mode i.e., Get the expenses settled and subsequently submit the bills to FHPL for claim processing. Do not share the Sum Insured Details with the Hospitals.
Non-Cashless Hospitalization Admission procedure: In case you choose a non-network hospital you will have to liaise directly for admission. Discharge procedure : In case of non network hospital, you will be required to clear the bill and submit a claim to insurer for reimbursement. Please ensure that you collect all necessary documents such as discharge summary, investigation reports etc. for submitting your claim. FHPL will not collect additional documents' from hospital for reimbursement cases. Member would need to collect it from hospital and submit us the same. 16
Claim Intimation: Admission procedure: In case you choose a non-network hospital, you will have to liaise directly for admission. However, you are advised to follow the Claim Intimation procedure to ensure eligibility for reimbursement of hospitalization expenses from the insurer. In cases of reimbursement claim (PLANNED Hospitalization), the employee/hr should intimate 48 hours before the admission of the patient to FHPL TPA via writing mail to intimation@fhpl.net or by calling 1-800-425-4033. FHPL TPA would be providing an Intimation ID/number, which needs to be written on the claim at the time of Submission. In cases of reimbursement claim (EMERGENCY Hospitalization), the employee/hr should intimate with in 48 hours after the admission of the patient to FHPL TPA via writing mail to intimation@fhpl.net or by calling 1-800-425-4033. FHPL TPA would be providing an Intimation ID number, which needs to be written on the claim at the time of Submission. 1 7
Claims Document List- All to be given Original A. Documents required in case of General Hospitalization: Claim form duly filled & Photo copy of FHPL card of the patient & Cancelled Cheque copy Patient id proof copy (PAN CARD, Voter id card or any other proof) Detailed Discharge Summary with Complaints, Diagnosis, Detail line of treatment, Investigation, Future advice on discharge. Pre printed Hospital Final Bill / Consolidated hospital bill with bill number Break up of Final Bill / Consolidated bill Pre printed Payment Receipt of final bill and advance paid with receipt number Investigation Reports (if any) Attested copies of Indoor Case Papers of hospitalization with admission notes and nurses notes (if required) B. Documents required in case of Maternity Hospitalization: All above mentioned documents to be submitted Letter from treating doctor stating Obstetric history (Gravida, Para, Living children, Abortion) C. Documents required in case of Accidental Case: All above mentioned documents to be submitted w.r.t Point A Attested copy of FIR or MLC (Medico Legal Certificate) Letter from treating doctor stating circumstances and injuries sustained due to RTA (Road Traffic Accident) Letter from treating doctor for any evidence of alcohol / other sedative substance during accident. X-ray report. *Please retain photocopies of all documents submitted
D. Documents required in case of Dialysis: Attested copies of dialysis chart along with dialysis bills Treating doctor's prescription for dialysis Investigation reports (if any) E. Pre and Post Hospitalization expense: (30 days & 60 days after) Original Medical reports + bill and doctors advice letter. Original Pharmacy bill along with doctors advice letter. Original Consultation bills, payment receipt with prescription. Copy of Discharge Summary of the main claim NOTE: (A) In case of reimbursement process, documents has to be submitted to FHPL within 15 days from the date of discharge. (B) Above mentioned all documents has to be submitted in original with Hospital seal & doctor's signature. (C) Please retain photo copy of all documents with you for future reference.
Photo ID Proof/ Address proof To process the claim, it is mandatory to establish the identity of the beneficiary. Below mentioned documents are required for this purpose:- Insurance Health ID card Pan card/ Any Valid Proof Employee ID Proof Cancelled Cheque copy (Name has to be on cheque) 2
Member Reimbursement Process Flow Member avails treatment at any hospital and makes upfront payment Member submits bills to FHPL within 15 days from DOD (Date of Discharge) FHPL Verifies the documents submitted In case of incomplete documents member will be intimated for the same and should be submitted within 3 working days FHPL processes claims Settle/Disallow/Reject with in 15 working days Claim Payment is made to the member in next 10 working days P
Escalation Matrix FHPL For all Queries for coverage and claims 247 Toll Free No & Help line no 1-800-425-4033 Cashless Request Cashless Request 040-69000183
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