Managing Expectations Handbook on Employee Insurance
Employee Insurance Group Health Insurance Group Personal Accident Insurance
The Policy covers reimbursement of Hospitalization Expenses for illness / diseases or injury sustained In the event of any claim becoming admissible under this scheme, the Insurance Company will pay to the Insured Person the amount of such expenses as would fall under different heads mentioned below, and as are reasonable and necessarily incurred thereof by or on behalf of such Insured Person, but not exceeding the Sum Insured in any one period of Insurance Room, Boarding Expenses as provided by the Hospital / Nursing Home Nursing Expenses Surgeon, Anesthetist, Medical Practitioner, Consultants, Specialists Fees Anesthesia, Blood, Oxygen, Operation Theatre Charges, Surgical Appliances, Medicines & Drugs, Diagnostic Materials and X-Ray, Dialysis, Chemotherapy, Radiotherapy, Cost of Pacemaker, Artificial Limbs & Cost of Organs and similar expense Pre-existing Disease Coverage Maternity from Day One of joining the Insurance Policy but restricted up to a maximum Sum Insured of Rs.25,000/- in case of Normal & Rs.35,000/- in case of C-section for 1 st two children only Pre-natal & Post-natal expenses covered within the scope of Maternity Sum Insured provided the same is taken in a hospital or a nursing home Procedural capping: Infectious Disease (Respiratory Tract Infection and similar diseases, Parasitic Infection, Digestive system infection, UI infection) & various enteric fever capped at Rs.12,000/- per ailment Internal Congenital Disease to be covered under the Scope of Pre-existing Disease Coverage Condition Room Rent capped at 2% of the Sum Insured per day both for Normal & ICU
1 st 30 days & 1 st two year exclusions waived off for all. The Insurance Coverage commences from date of notification about the Insured member to the Insurance Company. During the First Year of the Operation of the Insurance Cover for any Insured Person, the expenses on treatment of diseases such as Cataract, Benign Prostatic Hypertrophy, Hysterectomy for Menorrhagia or Fibromyoma, Hernia, Hydrocele, Congenital Internal Diseases, Fistula in Anus, Piles, Sinusitis and related disorders are not payable, however the same has been waived off by the Insurer in your Policy Any hospitalization induced due to bodily injury sustained due to terrorist activity is generally an exclusion under most Mediclaim Policies. In your case such type of hospitalization is covered Pre-hospitalization (30 days) & Post Hospitalization (60 days) Expenses on Hospitalization for a minimum period of 24 hours are admissible. However, this time limit does not apply to specific treatments like Dialysis, Chemotherapy, Radiotherapy, Eye Surgery, Dental Surgery, Lithotripsy (Kidney Stone removal), Tonsillectomy, DNC taken in Hospital / Nursing Home and the Insured is discharged on the same day, the treatment will be considered to be taken under Hospitalization Benefit. Where hospitalization is less than 24 hours, the following guidelines may be adopted: a) The treatment should be such that it necessitates Hospitalization and procedure involved required specialized infrastructure facilities which are available in the Hospital b) Due to technological advancement, Hospitalization period required is less than 24 hours Day Care Surgeries / Procedures are covered Cashless facility through Third Party Administrator (TPA) on all India basis at more than 3000 network hospitals / establishments
Exclusions: Group Health Insurance The Insurance Company shall not be liable to make any payment under this Policy in respect of any expenses whatsoever incurred by any Insured person in connection with or in respect of: - Injury or Disease directly or indirectly caused by or arising from or attributable to War, Invasion, Act of Foreign Enemy, Warlike Operations (whether war be declared or not) Circumcision unless necessary for treatment of a disease not excluded hereunder or as may be necessitated due to an accident, vaccination or inoculation or change of life or Cosmetic or Aesthetic Treatment of any description, plastic surgery other than as may be necessitated due to an accident or as a part of any illness Cost of Spectacles and Contact Lenses, Hearing Aids Any Dental treatment or Surgery which is a Corrective, Cosmetic or Aesthetic procedure, including wear & tear, unless arising from disease or injury and which requires hospitalization for treatment Convalescence, General Debility, Run-down condition or rest cure, congenital external disease or defects or anomalies, sterility, venereal disease, intentional self-injury and use of intoxicating drugs / alcohol All Expenses arising out of any condition directly or indirectly caused to or associated with Human T- Cell Lymph tropic Virus Type III (HTD-III) or Lymphadinopathy Associated Virus (LAV) or the Mutants Derivative or Variations Deficiency Syndrome or any (HTBB_III) Syndrome or condition of a similar kind commonly referred to as AIDS
Exclusions: The Insurance Company shall not be liable to make any payment under this Policy in respect of any expenses whatsoever incurred by any Insured person in connection with or in respect of: - Charges incurred at Hospital or Nursing Home primarily for Diagnostic, X-Ray or Pathological Tests / Examinations not consistent with or incidental to the diagnosis or treatment of the positive existence or presence of any ailment, sickness or injury for which confinement is required at a Hospital / Nursing Home On Vitamins and Tonics unless forming part of treatment for injury or disease as Certified by the attending Physician Injury or Disease directly or indirectly caused or contributed to by Nuclear Weapons / Materials Treatment directly or indirectly related to management of Infertility / IVF / GIFT (Gamete Intra Fallopian Transfer) etc. Domiciliary Hospitalization & Out Patient s Department
Insurance Company issues Policy Health Card Issuance Insurance company sends Data to TPA H.Q. TAT 21 Working Days ID card printed and dispatched along with Guide Book. Patient approaches Network hospital Hospital faxes Pre Authorization to TPA Request received at TPA Pre Auth dept Cashless Procedure TAT 24 hours (Mon-Sat) Authorization faxed to Hospital Medical Dept checks for Treatment costs and Tariff. Claims Dept checks for coverage and eligibility
Insured submits Claim to TPA Validation of customer Id Document Completion Verification Claims registered and Sum Insured Balance confirmed Re-imbursement Procedure TAT 21 days After submission of All Documents DV &/or Chq with computation Dispatched Claim Approval Claim checked By Medical Professionals Claim checked by Insurance trained executives.
REQUIREMENTS MANDATORY TO PROCESS CLAIM (re-imbursement) MAIN HOSPITALIZATION Intimation of hospitalization to the TPA within 72 hours is COMPULSORY Filled up Claim Form mentioning TPA I.D. No. duly signed Original Discharge Summary must have Date of Admission and Date of Discharge, presenting complaints & their duration, final diagnosis, line of treatment given & advice on discharge. Time of admission & discharge should be mentioned in Discharge Summary Original final hospital bill in a proper bill format along with Original Receipt of payment made by the patient to the hospital. Break up of medicine / pharmacy / drugs / Operation Theatre (OT) drugs charges as mentioned in final bill. Break up of investigation amount along with original reports for the same. X-ray films mandatory in fracture/rta & stone cases. USG / C.T. Scan / M.R.I films mandatory along with reports
REQUIREMENTS MANDATORY TO PROCESS CLAIM MAIN HOSPITALIZATION CLAIMS In Road Traffic Accident (RTA) / Fracture cases a certificate from doctor required mentioning circumstances leading to injury / fracture. Was patient under the influence of alcohol / epilepsy / intoxication? Treating Doctor to issue certification to this effect. Was Medico Legal Case (MLC) registered / made? If Yes, certified copy of MLC has to be attached All the bills must be submitted within 15 days from Date of Discharge from the hospital SUBMISSION OF PRE-POST HOSPITALIZATION CLAIMS Submit all the relevant bills related to investigation, consultation and any other medical treatment done relating with the ailment for which admission was taken in the hospital The pre and post hospitalizations bills submitted must relate to period 30 days prior to the main hospitalization and 60 days subsequent to discharge after the MAIN HOSPITALIZATION
REQUIREMENTS MANDATORY TO PROCESS CLAIM SUBMISSION OF DEFICIENCY RETRIEVALS Please attach Xerox of Deficiency letter along with the documents required to clear your file. The same has to be submitted within 15 days from the date of deficiency letter Note: Xerox Copy of the documents should be kept with the insured at alla times for the documents submitted to PHS
Group Personal Accident Insurance Permanent Partial Disability 1. Loss of toes all 20% 2. Loss of toes great both phalanges 05% 3. Loss of toes other than great, if more than one toe lost each 01% 4. Loss of hearing - both ears 75% 5. Loss of hearing one ear 30% 6. Loss of 4 fingers & thumb of one hand 40% 7. Loss of 4 fingers 35% 8. Loss of thumb both phalanges 25% 9. Loss of thumb one phalanx 10% 10. Loss of index finger 3 phalanges or 2 or 1 phalanx 10% 11. Loss of middle finger 3 phalanges or 2 or 1 phalanx 06% 12. Loss of ring finger 3 phalanges or 2 or 1 phalanx 05% 13. Loss of little finger 3 phalanges or 2 or 1 phalanx 04% 14. Loss of metacarpals 1 or 2 (additional) or 3, 4 or 5 (additional) 03% 15. Any other permanent partial disablement % as assessed by the panel of doctors of Insurance Company
Group Personal Accident Insurance Insured submits Claim to Insurer Validation of customer Id Document Completion Verification Papers handed to Investigation Team Re-imbursement Procedure TAT 8 weeks After submission of All Documents Payment released to Insured Claim Approval Claim checked by Panel of Doctors Claim Papers checked by Insurance trained executives.
Group Personal Accident Insurance Requirement mandatory for processing of a Claim Accidental Death Claim Certified True Copy of the F.I.R lodged by Police Authorities Post Mortem Report in Original or certified true copy Certified True Copy of Death Certificate issued by the Municipal Authorities Local Newspaper clipping if the accident has been reported or Eye e Witness s version of the accident (this is not mandatory but it s s presence reduces the TAT of the Investigating Agency) Claim form duly filled in, certified Temporary Total Disablement Original Certificate from the treating doctor certifying the circumstances cumstances & extent of the injury & period of bed rest advised Original Fitness Certificate from the same doctor mentioning that t the claimant is fit to resume duty Original Certificate from the Employer acknowledging the leave of absence
Group Personal Accident Insurance Death only - 100% of C.S.I (Capital Sum Insured) Loss of two limbs / two eyes or one limb & one eye - 100% of C.S.I Loss of one Limb or one Eye - 50% of C.S.I Permanent Partial Disablement - as % of C.S.I (mentioned in the Policy Document) Permanent Total Disablement (other than those named above) - 100% of C.S.I Temporary Total Disablement - 1% of C.S.I per week or Rs.5,000/- which ever is less for a maximum of 100 weeks Children Education Benefit up to Rs.10,000/- (Max.) per living child (max. 2 children) Carriage of Dead Body - 2% of C.S.I subject to a maximum Rs.5,000/- Exclusion on account of Loss / Damage / Liability due to terrorism activity shall stand waived off Worldwide Coverage on 24X7 basis