Page1 HEALTH INSURANCE GUIDE BOOK FOR SERVICING LIC S EMPLOYEES POLICY Vidal Health TPA Pvt. Ltd., Tower No. 2, First Floor, SJR I Park, EPIP Area, Whitefield, Bangalore-560 066 Toll free number - Kerala:1800 425 6268 Toll free number -Tamilnadu: 1800 425 7595 Toll free number -All India : 1800 425 6268 email: lic@vidalhealthtpa.com Web site: www.vidalhealthtpa.com
Page2 Welcome to the Vidal Health Experience Dear Policy Holder, Thank you for choosing Health Insurance to protect yourself and your family. Vidal Health TPA Private Limited has been authorised by your Insurance Company to extend Third Party Administration services to you under the Policy you have availed. Henceforth, we will process all your queries and claims relating to this Health Insurance Policy. The services that we will be offering you are: a. Providing information, relating to the policy taken by you b. Cashless access to Network Hospitals in case of hospitalization (Subject to Terms & Conditions, Exclusions & Limitations of your policy). c) Reimbursement of hospitalisation claims (Subject to Terms & Conditions, Exclusions & Limitations of your policy). We assure you the best quality of services during your policy period. Should you require any assistance, drop us a mail at lic@vidalhealthtpa.com With best wishes, Vidal Health TPA Team
Page3 CONTENTS 1. Important Instructions to Policy holder 2. What is Third party Administration Services? 3. What is cashless access? 4. Hospitalisation Claim Process Flow a. Planned Hospitalization b. Emergency hospitalisation c. GIPSA PPN 5. Billing & discharge 6. Reimbursement for Pre and Post Hospitalization expenses. 7. Coverage 8. Reimbursement in case of Treatment in non-network hospitals. 9. Grievance Cell 10. SMS & E-mail Serviced 11. Special Instructions 12. Various Forms & Download
Page4 1. IMPORTANT INSTRUCTIONS. a) This is your Instruction Booklet. b) In Case you find any discrepancies in the Identity Card, please contact us immediately. c) This Identity Card, only in conjunction with authorization letter issued by Vidal Health TPA allows you cash less access in Network Hospitals for in-patient treatment as per your insurance policy. d) Please quote the Vidal Health TPA ID card number in all your correspondence with us. 2. WHAT IS THIRD PARTY ADMINISTRATION SERVICES (TPA)? The Insurance Regulatory and Development Authority (IRDA) has granted License to Vidal Health TPA Private Limited to provide Third Party Administration Services. We have subsequently been authorized by your Insurance Company to extend our services to you. The scope of services will include; a) Issue of Identity Card to all policy holders. b) Provide information to Policyholders about Network Hospitals c) Provide Cashless access in Vidal Health TPA Network Hospitals. The Network Hospitals List is subject to change over a period of time due to deletions and additions. Please visit our website or call us to check if the hospital is part of the network or not. d) Provide 24/7 customer service 3. WHAT IS CASHLESS ACCESS? Till the TPAs started servicing Health Insurance Policies in 2002, the Health Insurance Policyholders had to pay the hospital for treatment availed and then send the bills to the Insurance Company for reimbursement. The TPAs brought in the cashless facility under which the insured is not required to pay to the Network Hospitals after undergoing treatment. He / She will have to sign the bills and we will pay to the hospital for the treatment availed by you (subject to authorization being taken, bills will be settled directly to the hospital up to the authorized amount), subject to terms, conditions and exceptions under your policy. a) How does this work? Each person covered under the policy serviced by us will be issued an Identity Card. Whenever there is a need for hospitalization the policy holder should submit the request for
Page5 cashless facility - Pre-authorisation Request Form (available in all Network Hospitals & you can also download from our website www.vidalhealthtpa.com) to the admission counter in the Network Hospital and the Hospital will obtain an Authorization Letter issued by Vidal Health TPA. The authorization letter will indicate the name of the insured /patient, name of the hospital where treatment is required, the nature of illness/diseases for which treatment is required & the monetary limit upto which the cashless facility is extended under the Policy. b) How to obtain an Authorization letter? The policyholder is required to fill the authorization request form & hand over to concerned insurance coordinator or admission counter of the Network Hospital and hospital will complete the rest of the form in-consultation with your treating Doctor and the Billing Section. The Hospital will submit the completed Pre-authorisation Request Form to Vidal Health TPA either online or through Fax. Vidal Health TPA will scrutinize the request for authorization & convey their decision on admissibility or otherwise of the request based on your policy terms & conditions as well as the information furnished by the hospital. c) Can a Request for Authorization for Cashless be declined? Yes, a request for authorization for cashless access may be declined if, i. Inadequate information is provided and the TPA is unable to get access for further information. ii. The ailment / disease, for which hospitalization is required, is not covered by your insurance policy. iii. The person does not have adequate insured amount left to cover the hospitalization costs. This only means that cashless access is declined, AND IS IN NO WAY TO BE CONSIDERED AS DENIAL OF TREATMENT. The policyholder must obtain the treatment as per his/her treating doctor s advice. The denial of preauthorization letter shall not be construed to mean that the policy holder cannot claim under the terms and conditions of the policy from Vidal Health TPA. In such cases you are advised to file your claim for a possible reimbursement and Vidal Health TPA will process the claim as per your policy terms and conditions. 4. HOSPITALISATION CLAIM PROCESS FLOW: SHOULD YOU REQUIRE HOSPITALISATION
Page6 NETWORK HOSPITALS NON-NETWORK HOSPITALS PLANNED HOSPITALISATION EMERGENCY HOSPITALISATION Claim intimation to be sent to Vidal Health office SUBMIT PRE-AUTHORISATION REQUEST TO VHTPA 4DAYS IN ADVANCE IMMEDIATELY AFTER ADMISSION SEND THE PRE- AUTH REQUEST TO VHTPA After taking treatment all hospitalisation bills to be paid by you to the hospital and claim submitted to Vidal Health with the requisite documents in original VHTPA WILL SCRUTINISE THE REQUEST & ON A CASE TO CASE BASIS Vidal Health scrutinizes the claim papers and reimburses admissible claim amount to you. A discharge voucher is sent to you for your signature APPROVE CASHLESS FACILITY You get treated and prior to discharge complete claim form scrutinize AND sign all relevant bills NOT APPROVE CASHLESS FACILITY Take treatment as recommended by your doctor. Pay the hospital for treatment. Claim papers can be submitted to Vidal Health for reimbursement On receipt of the signed discharge voucher, cheque is sent to you/ EFT made You pay all nonadmissible expenses directly to hospital Vidal Health pays the bills to the hospital PLEASE NOTE THAT INSURERS ARE CREATING THEIR OWN NETWORK OF HOSPITALS FOR PROVIDING CASHLESS FACILITY. CHECK WHETHER THE HOSPITAL YOU ARE GETTING ADMITTED IS IN THE NETWORK OF YOUR INSURER AS OTHERWISE CASHLESS FACILITY MAY NOT BE AVAILABLE IN THE HOSPITAL WHERE YOU PLAN ADMISSION.
Page7 4a) PLANNED HOSPITALISATION: a) The request for Authorization (Pre-Authorization) for planned treatment has to be filled up by the Insured. The Hospital portion of this form has to be filled up by the treating Doctor/ Hospital. The form must be filled completely in Block letters indicating the Doctors Name, Registration Number and Telephone Number. This request must reach Vidal Health TPA office at least 4 days before hospitalization. b) In case our Medical Officer needs any clarification they may contact your doctor before he initiates action on your request. c) The pre-authorization will be sent to respective Network Hospital that has sent the request. d) The authorization is valid only for the Network Hospital to which the approval letter has been sent. e) Any change in the date of hospitalization, Hospital, nature of illness or surgeon who is going to perform the procedure will make the authorization invalid. A fresh authorization has to be taken in case of any changes. Getting Hospitalized: In order to secure admission on the appointed day, you are advised to register your name with the hospital well in advance. a) Contact the admission desk of the Hospital. b) Show your Vidal Health TPA Identity Card issued by Vidal Health TPA and Hospital will verify the same with authorization letter received from us. In case you were issued a non-photo Identity Card you may have to carry some identification documents like a drivers license/voters ID cards etc., c) As per the IRDA norms, for claim value exceeding Rs. 1 Lakh, the Insured must file ID Proof as well as the Address Proof as below: The ID Proof to be submitted: i. Passport ii. PAN Card iii. Voter s Identity Card iv. Driving License v. Adhar card vi. Letter from a recognized Public Authority (as defined under Section 2 (h) of the Right to Information Act, 2005) or Public Servant (as defined in Section 2(c) of the The Prevention of Corruption Act, 1988 ) verifying the identity and residence of the customer vii. Personal identification and certification of the employees of the insurer for identity of the prospective policyholder. viii. Letter issued by Unique Identification Authority of India containing details of name, address and Aadhar number
Page8 d) Some hospitals may ask for a nominal deposit towards non-admissible expenses which are not covered in your policy. You need to make the payment for such expenses which are not covered in your policy. e) In case you wish to know more on expenses that is not covered by your polic y please check for the List of Non-admissible Expenses in the annexure B of this document f) Get admitted. 4b) EMERGENCY HOSPITALISATION: The policyholder is advised to get admitted in all emergency situations without waiting for approval of the cashless facility. In case of admission to a Network Hospital, the hospital will admit the patient as per the procedure of the hospital. If you are requesting cashless facility and show them the Vidal Health TPA ID Card, the hospital will then send us a request for authorization of cashless facility. Vidal Health TPA will revert within 6 hours of receipt of the request. No cashless approval can be extended if the patient is discharged before the Preauthorisation is obtained. In case cashless access is declined, this is in no way to be considered to be denial of treatment. The policyholder must obtain the treatment as per his/her treating doctor's advice. The denial of pre-authorization facility shall not be construed to mean that the policyholder cannot claim under the terms and conditions of the policy from Vidal Health TPA. In such cases you are advised to file your claim for reimbursement and Vidal Health TPA will process the claim as per your policy terms and conditions. In case the policy holder gets admitted to a Non-Network Hospital, then the hospitalization bills will be reimbursed subject to terms, exclusions, conditions and limitations of your policy. 4c. GIPSA PPN (Applicable only to those Insured with Public Sector Insurers) Preferred Provider Network (PPN) means a network of hospitals which have agreed to a cashless packaged pricing for certain procedures for the insured person. The General Insurance Public Sector Association (GIPSA), umbrella organisation for the four public sector insurance companies - New India Assurance, Oriental Insurance, United India Insurance and National Insurance - introduced the PPN in July 2010 to cap rates charged for certain commonly claimed surgeries. GIPSA PPN includes hospitals who have agreed to allow cashless benefit to the insured of all four GIPSA companies within the agreed package rates for specified procedures.
Page9 Cashless facility shall be available only in GIPSA PPN enlisted hospitals except in trauma and emergency cases In case of trauma and emergency cases, cashless facility may be provided by the TPA s in hospitals other than GIPSA PPN list provided they are within their respective network of hospitals All policies including Bank Assurance issued by public sector insurers fall under PPN At centres where no GIPSA PPN hospital is available the cashless shall be available at the respective TPA s network PPN is already in place in the cities of MUMBAI, DELHI, CHENNAI, BANGALORE, AHMEDABAD, HYDERABAD, CHANDIGARH and recently it has been extended to KOLKATA & COIMBATORE. Agreed PPN rates are all inclusive rates and only excludes implant cost, if any In case insured opts for higher room category than entitled one he/ she needs to bear the difference of the two package charges. Claims both cashless and reimbursement shall be payable as per entitled room category in the PPN hospitals. Claims for reimbursement for the procedures covered under GIPSA PPN availed at nonnetwork hospitals also shall be at the GIPSA PPN rates. List of PPN hospitals are available on the respective web sites of all TPA s and 4 GIPSA companies and shall be updated as and when new hospitals join the PPN network Insured need to check / confirm the presence of particular hospital in the PPN list of the particular city if he/ she wants to avail cashless facility either through insurance companies / TPA s web site or calling on the respective toll free number List of procedures and PPN list is dynamic and any addition/ deletion shall be accordingly updated on the website from time to time 5. BILLING AND DISCHARGE: a) Sign the final bill and check for correctness before you are discharged. Vidal Health TPA reserves right to recover any amount due from the insured person for billed services which are not covered by the policy. b) Ensure that all supporting documents are attached to the bill. c) You must pay all bills not associated with the condition for which hospitalization was authorized and the amounts in excess of the approved limit as well as amount of co-pay, if any, under your policy. d) Obtain a copy of the Final Bill and Discharge Summary as well as receipt for the amount paid by you. e) Get your Deposit account with the hospital, if any, settled
Page10 6. REIMBURSEMENT FOR PRE AND POST-HOSPITALISATION EXPENSES The health insurance policy allows reimbursement of medical expenses incurred towards the ailment/disease for which hospitalization was necessitated prior to hospitalization and up to certain number of days after discharge. This is subject to the limits, as described in the policy. The medical expenses incurred prior to hospitalization are called pre-hospitalization expenses and those incurred subsequent to discharge as post-hospitalization expenses. Send all bills in original with supporting documents along with Claim Form Part A, a copy of the Discharge Summary and a copy of the authorization letter to the nearest Vidal Health TPA office to claim. Vidal Health TPA will scrutinize the claim and settle the bills subject to the overall limit of the policy, the bills must be sent to Vidal Health TPA within 7 days from completion of treatment. 7. COVERAGE This insurance policy can be used to protect the insured against expenses incurred towards hospitalization for illness/injury/diseases (as well as domiciliary hospitalization, wherever covered) as defined in the respective policy. The Health Insurance Policy covers hospital room rent, Professional Charges of the Consultant/ Surgeon/ Anaesthetist, operation theatre charges, diagnostic tests, cost of medicines, blood transfusion and oxygen as well as cost of appliances like pacemakers, artificial limbs, etc. subject to exclusions as per your policy. Please check the exact coverage wording in the policy issued by your insurance company. The wording in the policy issued to you is final. 8. REIMBURSEMENT IN CASE OF TREATMENT IN NON-NETWORK HOSPITALS Cashless hospitalization is available only in network hospitals. In case you avail treatment in a non-network hospital, Vidal Health TPA will reimburse you the hospitalisation expenses subject to the terms, conditions and exclusions under the policy taken by the policyholder. You must intimate hospitalisation to Vidal Health TPA or your Insurer in writing immediately on admission with details of Vidal Health TPA card number, nature of illness, name & address of the Hospital / Nursing home, attending Doctor, Bed number etc. In the event of an emergency hospitalisation, the intimation about hospitalisation should be made within 48 hours of hospitalisation but in any case before the patient is discharged. The Claim Form Part A & Part B - can be collected from the nearest branch of insurance company/vidal Health TPA office. It can also be downloaded from our website. The claim form must be completed in all respects, signed and sent to the nearest Vidal Health TPA
Page11 office along with the claim documents as per the list given in Annexure A. Note: Only expenses relating to hospitalization will be reimbursed as per the policy. All nonadmissible expenses will be disallowed. 9. GRIEVANCES CELL We have a dedicated Grievance Cell to address your concerns. You can contact the Grievance Cell for any problem / deficiency in services rendered by Vidal Health TPA. A senior person will address your concerns within appropriate time span. Please send your grievances to lic@vidalhealthtpa.com. 10. Documents Collection, SMS & E-MAIL SERVICE We have appointed the district co-ordinators for each of the Divisional offices in tamil nadu and Kerala. The claim documents would be collected weekly/biweekly from the divisional officies of LIC We shall be able to send you automated SMS and e-mail alerts to you for the following Cashless Pre-authorisation & Claim Reimbursement scenarios: a. Cashless Pre-authorisation Status Registration b. Pre-authorisation Shortfall c. Pre-authorisation Shortfall Received d. Pre-authorisation Request Approved e. Pre-authorisation Enhancement Approval f. Pre-authorisation Request Rejection g. Claim Inward Member Reimbursement h. Claim Status Member Reimbursement i. Claims Shortfall Member Reimbursement j. Claim Shortfall Received Member Reimbursement k. Claim Approved Member Reimbursement l. Claim Rejected Member Reimbursement To avail the above services, kindly register your Mobile Number as well as the E-mail ID with your Insurer while submitting the Proposal Form for Insurance. 11. VARIOUS FORMS & DOWNLOADS Please note that the following items can be downloaded from our website www.vidalhealthtpa.com : i. Claim Form Part A (IRDA Format) ii. Claim Form Part B (IRDA Format) iii. Cashless Pre-authorisation Form IRDA Format iv. Standard Discharge Summary Format (Based on IRDA Guidelines) v. Office of the Ombudsman vi. List of Non-admissible Expenses
Page12 12. SPECIAL INSTRUCTIONS i. PROPORTIONATE DEDUCTION: If Policies have Room Rent & ICU Capping, in the event you admit in a room higher than your policy entitlement, many policies will consider the other hospitalisation expenses incurred (excluding Pharmacy & Cost of Implants) in the same proportion the entitled Room Charges bear to the actual Room Charges. Hence, please avoid getting admitted to rooms higher than entitled category. ii. CLAIM CLOSURE: In the event we have asked for additional claim documents and you do not submit the same in spite of reminders, the claim would get closed and no liability devolves on the TPA as well as the Insurer in respect of the claim. Hence, kindly ensure that you comply with the requirements without loss of time. iii. NON-UTILISATION OF CASHLESS FACILITY: In the event you have received the Pre-auth Approval for the hospitalisation but do not utilize cashless, while submitting your claim for reimbursement, please obtain and submit confirmation from the hospital for not availing the cashless facility in respect of the hospitalisation. iv. HOSPITALISE WHEN YOU MUST: Kindly note that the Health insurance Policy takes care of reasonable, necessary and customary expenses for treatment of an ailment or an injury. Hospitalisation to cover routine medical expenses or to cover the costly diagnostic charges or where there is no active line of treatment requiring inpatient admission will fall outside the scope of the policy and such claims would get denied.
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Page14 Annexure A LIST OF DOCUMENTS TO BE SUBMITTED No A B C D E F G H I J K L M N O P Q R S T U V W X Y Z AA AB AC AD AE AF AG DOCUMENT TO BE SUBMITTED CLAIM FORM PART A: DULY COMPLETED BY THE INSURED ON THE PRESCRIBED FORMAT CLAIM FORM PART B: DULY COMPLETED AND SIGNED BY THE HOSPITAL AUTHORITIES ADMISSION NOTES TPA ID CARD ANY OTHER ID PROOF 1. VOTER ID 2. DRIVING LICENSE 3. PASSPORT 4. AADHAAR CARD 5. RATION CARD 6. ANY OTHER (SPECIFY) REFERRAL LETTER, IF ANY, TO HOSPITAL OPD CONSULTATION PAPER CONSULTATION BILL/ RECEIPT DETAILED DISCHARGE SUMMARY DEATH SUMMARY (INSTEAD OF Discharge Summary) INVESTIGATION REPORTS / LAB REPORTS HISTOPATHOLOGY REPORT BILL FOR INVESTIGATION/ LAB TESTS OPERATION THEATRE (OT) NOTES MLC REPORT POLICE FIR STICKER FOR THE IMPLANTS USED SUPPPORTING INVOICE FOR THE IMPLANTS USED HOSPITAL MAIN BILL BREAK-UP BILL FOR THE HOSPITAL MAIN BILL DETAILED BILL FOR THE NON-ADMISSIBLE AMOUNTS COLLECTED FROM THE PATIENT RECEIPT FOR THE AMOUNT COLLECTED FROM THE PATIENT RECEIPT FOR THE CO-PAY COLLECTED FROM THE PATIENT PRE-AUTHORISATION REQUEST PRE-AUTHORISATION APPROVAL LETTER PRE-AUTHORISATION DENIAL LETTER, IF ANY, FOR CASHLESS DENIED CONFIRMATION FROM HOSPITAL FOR NON-UTILISATION OF CASHLESS SANCTIONED PRESCRIPTIONS FOR MEDICINES PURCHASED DURING HOSPITALISATION PHARMACY BILLS FOR MEDICINES PURCHASED LIST OF BILLS SUBMITTED WITH THE AMOUNT UNDER EACH BILL DOCUMENTS FOR NATIONAL ELECTRONIC FUND TRANSFER (NEFT) a. NEFT FORMAT b. PAGE OF BANK PASS BOOK WITH A/C NUMBER & NAME/ ADDRESS OF A/C HOLDER. c. CANCELLED CHEQUE COVERING LETTER AND THE LIST OF DOCUMENTS ATTACHED ANY OTHER DOCUMENT (SPECIFY):
Page15 Annexure B List of Non admissible amounts
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Page19 Annexure C Claim form
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