Health Insurance Benefit plan 2016 2017 Monster.com India Pvt Ltd. Family Health Plan (TPA) Limited Hyderabad
Medical Benefit Coverage Details Enrolment in the program Cashless Process Non-Cashless Claims Process Claims Document List General Exclusions GMC Contact Details
Definition of Hospitalization : Minimum period of 24 hrs of admission in a hospital for a proper Line of treatment/ surgical management. 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 & nor cannot be taken at home - requires Doctor s supervision - is not only oral medication ( tablets) & not only for evaluation and observation. Day care treatment were in 24 hrs is not applicable and it is covered : Time limit not applicable for specific treatments like Dialysis Chemotherapy & Radiotherapy Tonsillectomy Eye surgery (Rs.50,000 per eye) Dental surgery ( Necessitated by an accident leading to hospitalization)
Hospitalization Insurance Cover Insurer: The Oriental Insurance Company Limited. TPA : Family Health Plan(TPA) Limited. Beneficiaries: 1+3 only ( Employee + Any 3 Dependents (Spouse+ 2 Dep Children+2 Dep Parents). Sum Insured: Rs.1,50,000 Policy Type: Floater policy. Coverage: 19 th April 2016 to 18 th April 2017 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
Other Limits Room rent is restricted to Rs.3000 per day and Rs.6000 for ICU per day. (if the member is opting for a higher category, then the incremental charges would be applicable proportionately.) Maternity Benefits There is no 9 month waiting period for maternity. Only first 2 maternity are covered. Rs.50,000 Normal delivery & for C-Section. Pre and Post Not payable Child covered from day. New Born Baby Expenses are covered from Day 1subject to Intimation to HR within 20 days. & subject to availability of slot
Important Note on Room Rent: Hospital Room Rent eligibility per day: Daily Room Rent: Utilise the room as per the eligibility Daily ICU Room Rent: : Utilise the room as per the eligibility Important Note: In case insured person utilizes a room of higher rent than eligible he/she has to bear the difference in the room rent and also other expenses charged by the Hospital (Dr s fee, OT Charges, Nursing fees, etc) In other words, the total Hospitalization claim shall be reduced in proportion based upon the eligible as per the room rent. Employee would have to pay the balance or to say difference of amount to the Hospital at the time of discharge. The above said details are applicable to all Hospitalization cases such as Maternity, knee Replacement and for all other hospitalization cases etc. Hence, please utilize a room as per the Room rent eligibility.
Enrollment Process All new employees are enrolled from their date of joining as per data given by HR. Employees must enroll eligible dependents in order to obtain coverage via HR. All the employees have to provide their dependent data to HR at the time of joining the company failing which dependent will not be covered later. Please notify your HR within 15 days whenever there is a new dependent i.e. in your family i.e., spouse by marriage or baby by birth. The New born baby will be named as per spouse or father name( Baby of abc or xyz). If employees fail to enroll within the defined timelines, the enrollment can be done only at next renewal. Enrollment details sent to FHPL Generation of ID Card Data Verification FHPL Generation of UHID Plan Details
FAMILY HEALTH PLAN TPA Ltd SERVICE OFFERINGS
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
Process to view the list of Network Hospital Log on to our website :- www.fhpl.net
Follow the below process to get hospital list
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. 15
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 20 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) 1
Member Reimbursement Process Flow Member avails treatment at any hospital and makes upfront payment Member submits bills to FHPL within 20 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
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.
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 To Download the claim form please click the link: https://www.fhpl.net/forms Single Point of Contact at Emedlife Contact Name Location Mob No E-Mail ID A Sreenivasu Hyderabad 98661-44881 a_sreenivasu@emedlife.in Escalation Point of Contact at FHPL Contact Name Location Mob No E-Mail ID Mr.Veneet Mathur Hyderabad 92461-01699 Veneet.mathur@fhpl.net
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