my:health Medisure Plus Insurance

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1 my:health Medisure Plus Insurance TYPE OF HOSPITALISATION CLAIM CASHLESS CLAIM - STEP BY STEP GUIDE Step I Planned Hospitalisation Intimate us, at least 7 hours before admission to the hospital* by calling on our Toll-free Number In select cities, Concierge Service (Claims Associate) can be availed at the time of admission and discharge by making a request #. Emergency Hospitalisation Intimate us, immediately but definitely, within 4 hours of admission to the hospital* by calling on our Toll-free Number In select cities, Concierge Service (Claims Associate) can be availed at the time of admission and discharge by making a request #. * Please call on our Toll-free Number or visit our website for cashless hospitals list and intimation. # Please call on our Toll-free Number and request for concierge service. Concierge Service (Claims Associate) available at the time of admission and discharge, can be availed only between 9 am and 9 pm on a working day. Step II Immediately after reaching hospital, fill the Cashless pre-authorization form, available at the Cashless counter at the hospital. Please attach the following along with pre-authorization form- 1. Pre-admission Prescriptions & Medical Reports (if any). Copy of Photo-Id & Health Card The Cashless counter will fax the documents to us, seeking approval or rejection of Cashless Claims. Step III The Claims Reference Number will be sent to you along with the intimation of approval/rejection of Cashless Claim within 6 hours on receipt of complete documents. We will also intimate you of the uncovered expenses (non-medical) if any. In case Cashless Claim is approved please make the payments of the uncovered expenses only and counter-sign all the medical bills & papers (if feasible) before leaving the hospital. In case Cashless Claim is not approved please make the payments of all expenses and file for a Reimbursement Claim. We shall respond within 6 working days from receipt of complete documents. 01

2 Please follow the below mentioned steps in case you are filing for Reimbursement Claims, post non-approval of Cashless Claims - Submit the duly filled Caim form along with the following documents Basic Claim Documents: 1 Original Hospital Main Bill Original Hospital Bill break up (where issued by the Hospital) 3 Original Hospital Bill Payment Receipt 4 Hospital Discharge Card/Summary 5 7 Pre & Post hospitalisation Claim documents: 1 Original Pharmacy Bill with supporting prescriptions Original bills and receipts for claiming Ambulance charges (if any) Duly filled claim form(s) (If claimed separately) 6 8 Medical Investigation report: ECG/X-Ray/USG/CT/MRI/ Histopathology/Pathological and all other medical investigation report in support of diagnosis as advised by the treating doctor All Doctor s consultation note: confirming provisional & final diagnosis/advise for admission/medical complication/ proposed line of treatment/past medical history Pharmacy Bills with supporting prescriptions 3 Medical investigation test reports and payment receipts with doctor s advice note for such investigations 4 All Doctor s consultation note with original bills and receipts for claiming doctors fees By signing the Claim form you are authorising us to collect the following documents from the Hospital. If you have obtained these documents, then please submit the same. Indoor case papers Operation Theatre Notes in surgical cases Bar code sticker & Invoice for implants and prosthesis (if used) In case of Accidental Injuries, Medico Legal Certificate and / or First Information Report, where applicable and self statement giving description of the incident Please refer to policy wording for detailed list of document checklist for claims under critical illness benefit. The above mentioned documents should be submitted to the following address either through courier or in person: Claim Servicing Office L&T General Insurance Company Limited 6th Floor, City, Plot no. 177, CST Road, Near Bandra Kurla Telephone Exchange, Kalina, Santacruz East, Mumbai It is advisable to retain a copy of all the documents sent to us for your records. DO S AND DON TS CASHLESS CLAIMS Do s Carry Health Card, Photo ID and past medical records (if any) of the patient to the hospital. Put in a request for Cashless approval by filling the pre-authorisation form. We promise to respond to your request within 6 hours. Pay all uncovered expenses at the time of discharge. Counter sign and retain copies of all the hospitalisation related documents, bills and papers for your records. It may help you in the post-hospitalisation treatment or resolution of any disputes arising in the future. Don ts Misrepresent or hide any medical or personal information of the patient while filling the pre-authorisation form. Hesitate to seek clarification on the details of deductions made in the Claim amount. 0

3 REIMBURSEMENT CLAIMS - STEP BY STEP GUIDE Step I Planned Hospitalisation Intimate us, at least 7 hours before admission to the hospital by calling on our Toll-free Number Emergency Hospitalisation Intimate us, immediately but definitely, within 4 hours of admission to the hospital by calling on our Toll-free Number Step II Get your Claim reference number by submitting the claim intimation along with the following details to us on either the Toll-Free Number or us at myhealthclaim@ltinsurance.com or mail us at the Claim Servicing Office (address mentioned below) or intimate us by visiting our website Policy Number Nature of disease/illness/injury Probable/Actual Date of admission and discharge Any other relevant information 4 6 Name of the person(s) named in the Schedule to this Policy availing treatment Name and address of the attending Medical Practitioner/Hospital Approximate Claim Expenses Step III Complete the treatment procedure in hospital. Settle all expenses & collect all medical bills & receipts. Basic Claim Documents: Claim Form Duly filled with requisite information and signed by Insured & Hospital Original Hospital main bill Original Hospital bill payment receipt Original Pharmacy Bill with supporting prescriptions Original bills and receipts for claiming ambulance charges (if any) Pre & Post hospitalisation Claim documents: 1 3 Duly filled Claim form(s) (If claimed separately) Medical investigation test reports and payment receipts with doctor s advise note for such investigations Step IV Copy of the claim intimation (if any) Original Hospital Bill break up (where issued by the Hospital) Hospital Discharge Card/Summary Medical Investigation report: ECG/X-Ray/USG/CT/MRI/ Histopathology/pathological and all other medical investigation report in support of diagnosis as advised by the treating doctor All Doctor s consultation note: confirming provisional & final diagnosis/advise for admission/medical complication/proposed line of treatment/past medical history Pharmacy Bills with supporting prescriptions All Doctor s consultation note with original bills and receipts for claiming doctors fees 03

4 By signing the Claim form you are authorising us to collect the following documents from the Hospital. If you have obtained these documents, then please submit the same. Indoor case papers. Operation Theatre Notes in surgical cases. Bar code sticker & Invoice for implants and prosthesis (if used). In case of Accidental Injuries, Medico Legal Certificate and / or First Information Report, where applicable and self statement giving description of the incident. Please refer to policy wording for detailed list of claim document checklist for Claims under critical illness benefit. The above mentioned documents should be submitted to the following address either through courier or in person: Claim Servicing Office L&T General Insurance Company Limited 6th Floor, City, Plot no. 177, CST Road, Near Bandra Kurla Telephone Exchange, Kalina, Santacruz East, Mumbai It is advisable to retain a copy of all the documents sent to us for your records. REIMBURSEMENT CLAIMS Do s Don ts Ensure you obtain the documents as given in the Claim process. Collect all vital documents like Medical Papers, Prescriptions, Discharge Summary, Investigation Reports, Bills and Receipts in original from the hospital. Forward all the relevant reports and documents in original for Claim reimbursement within 30 days from the date of discharge along with claim form duly filled at address mentioned below- L&T General Insurance Company Limited, 6th Floor, City, Plot no. 177, CST Road, Near Bandra-Kurla Telephone Exchange, Kalina, Santacruz East, Mumbai Retain copy of all the hospital related documents for your record. Misrepresent or hide any medical or personal information of the patient while filling the Claim form. Provide incomplete information or documents to us. Hesitate to seek clarification on the details of deductions made in the Claim amount. 04

5 NON PAYABLE / NON MEDICAL ITEMS NON PAYABLE ITEMS - NEW HEALTH INSURANCE REGULATIONS Sr. No. Expense Head Special 1 Hair Removal Cream Remarks Baby Charges (Unless Specified/Indicated) 3 Baby Food 4 Baby Utilites Charges 5 Baby Set 6 Baby Bottles 7 Brush 8 Cosy Towel 9 Hand Wash 10 Moisturiser Paste Brush 11 Powder 1 Razor 13 Shoe Cover 14 Beauty Services Essential and may be paid specifically for cases who have 15 Belts/ Braces undergone surgery of thoracic or lumbar spine. 16 Buds 17 Barber Charges 18 Caps 19 Cold Pack / Hot Pack 0 Carry Bags 1 Cradle Charges Comb 3 Disposables Razors Charges Payable for Site Preparations 4 5 Eye Pad 6 Eye Shield 7 / Internet Charges 8 Food Charges (Other Than Patient's Diet Provided By Hospital) 9 Foot Cover 30 Gown 31 Leggings Essential in bariatric and varicose vein surgery and should be considered for these conditions where surgery itself is Payable. 3 Laundry Charges 33 Mineral Water 34 Oil Charges 35 Sanitary Pad 05

6 NON PAYABLE ITEMS - NEW HEALTH INSURANCE REGULATIONS Sr. No. Expense Head Special Remarks 36 Slippers 37 Telephone Charges 38 Tissue Paper 39 Tooth Paste 40 Tooth Brush 41 Guest Services 4 Bed Pan 43 Bed Under Pad Charges 44 Camera Cover 45 Cliniplast 46 Crepe Bandage 47 Curapore 48 Diaper Of Any Type 49 DVD, CD Charges If CD is specifically sought by Insurer, then Payable 50 Eyelet Collar 51 Face Mask 5 Flexi Mask 53 Gauze Soft 54 Gauze 55 Hand Holder 56 Hansaplast / Adhesive Bandages 57 Infant Food Reasonable costs for one sling in case of upper arm 58 Slings fractures should be considered Weight Control Programs / Supplies 59 / Services Cost Of Spectacles / Contact Lenses 60 / Hearing Aids 61 Dental Treatment Expenses That Do Not Require Hospitalisation 6 Hormone Replacement Therapy 63 Home Visit Charges Infertility / Sub fertility / Assisted 64 Conception Procedure 65 Obesity (Including Morbid Obesity) Psychiatric & Psychosomatic Disorders Corrective Surgery For Refractive Error Treatment Of Sexually Transmitted Diseases 06

7 Sr. No. Expense Head Special Remarks 69 Donor Screening Charges 70 Admission / Registration Charges Hospitalisation For Evaluation / 71 Diagnostic Purpose 7 Expenses For Investigation / Treatment Irrelevant To The Disease For Which Admitted Or Diagnosed 73 Any Expenses When The Patient Is Diagnosed With Retro Virus + Or Suffering From HIV / AIDS Etc Is Detected / Directly Or Indirectly 74 Stem Cell Implantation / Surgery And Storage except Bone Marrow Transplantation where covered by policy 75 Ward And Theatre Booking Charges Payable under OT Charges, not Payable separately 76 Arthroscopy & Endoscopy Instruments Rental charged by the hsopital Payable. Purchase of instruments not Payable 77 Microscope Cover Payable Under OT Payable under OT Charges, not Payable separately Surgical Blades, Harmonic Scalpel, 78 Shaver Payable under OT Charges, not Payable separately 79 Surgical Drill Payable under OT Charges, not Payable separately 80 Eye Kit Payable under OT Charges, not Payable separately 81 Eye Drape Payable under OT Charges, not Payable separately 8 Payable under Radiology Charges, not as consumable 83 Sputum Cup Payable under Investigation Charges, not as consumable 84 Boyles Apparatus Charges Payable under OT Charges, not Payable separately Blood Grouping And Cross Matching 85, Part of cost of blood Of Donors Samples 86 Antiseptic Or Disinfectant Lotions, Part of Dressing Charges Band Aids, Bandages, Sterlile 87 Injections, Needles, Syringes, Part of Dressing Charges 88 Cotton, Part of Dressing Charges 89 Cotton Bandage, Part of Dressing Charges 90 Micropore / Surgical Tape, Part of Dressing Charges 91 Blade, Part of Hospital Services / Disposable Linen to 9 Apron be part of OT / ICU Charges 07

8 Sr. No. Expense Head Special Remarks 93 Tourniquet 94 Orthobundle, Gynaec Bundle, Part of Dressing Charges 95 Urine Container Actual tax levied by governmentis Payable. Part of charge 96 Luxury Tax for room sub limits 97 HVAC, part of room charge 98 Housekeeping Charges, part of room charge Service Charges Where Nursing 99 Charge Also Charged, part of room charge 100 Television & Air Conditioner, part of room charge 101 Charges Surcharges, part of room charge 10 Attendant Charges, part of room charge 103 IM IV Injection Charges, part of Nursing charges 104 Clean Sheet, pat of laundry / housekeeping 105 Extra Diet Of Patient (Other Than That Which Forms Part Of Bed Patient Diet provided by hospital is Payable Charge) 106 Blanket / Warmer Blanket, part of room charge 107 Admission Kit 108 Birth Certificate Blood Reservation Charges And Ante 109 Natal Booking Charges 110 Certificate Charges 111 Courier Charges 11 Conveyance Charges 113 Diabetic Chart Charges Documentation Charges / 114 Administrative Expenses 115 Discharge Procedure Charges 116 Daily Chart Charges Entrance Pass / Visitors Pass 117 Charges 118 Expenses Related To Prescription On. To be claimed by patient under post Discharge hospitalization expenses, if admissible 119 File Opening Charges Incidental Expenses / Misc. Charges 10 (Not Explained) 11 Medical Certificate 1 Maintenance Charges 13 Medical Records 14 Preparation Charges 08

9 Sr. No. Expense Head Special Remarks 15 Photocopies Charges Patient Identification Band / Name 16 Tag 17 Washing Charges 18 Medicine Box 19 Mortuary Charges Payable upto 4 Hours. Shifting charges not Payable Medico Legal Case Charges (MLC 130 Charges) 131 External Durable Devices 13 Walking Aids Charges 133 Bipap Machine 134 Commode 135 CPAP / CAPD Equipments 136 Oxygen Cylinder (For Usage Outside 137 The Hospital) 138 Pulse Oxy meter Charges 139 Spacer 140 Spiro meter 141 Sp0 Probe 14 Nebulizer Kit 143 Steam Inhaler 144 Arm Sling 145 Thermometer 146 Cervical Collar 147 Splint 148 Diabetic Foot Wear 149 Knee Braces (Long / Short / Hinged) 150 Knee Immobilizer / Shoulder Immobilizer 151 Lumbo Sacral Belt 15 Nimbus Bed Or Water Or Air Bed Charges Payable For Any ICU 153 Ambulance Collar 154 Ambulance Equipment 155 Micro shield Essential and may be paid specifically for cases who have undergone surgery of lumbar spine. Payable for any ICU patient requiring more than 3 days in ICU, all patients with paraplegia / quadriplegia for any reason and at reasonable costof approximately Rs. 00 / day 09

10 Sr. No. Expense Head Special Remarks 156 Abdominal Binder Essential and should bepaid in post surgery patients of major abdominal surgery including TAH, LSCS, incisional hernia repair, exploratory laparotomy for intestinal obstruction, liver transplant etc. 157 Betadine \ Hydrogen Peroxide \ Spirit \ Disinfectants Etc. May be Payable when prescribed for patient, not Payable for hospital use in OT or ward or for dressings in hospital 158 Nursing Charges Post hospitalization nurisng charges not Payable 159 Dietician Charges / Diet Charges Payable. Sugar free variants of admissible medicines are 160 Sugar Free Tablets not excluded Toiletries are not Payable, only prescribed medical 161 Creams Powders Lotions pharmaceuticals Payable 16 Digestion Gels Payable when prescribed 163 ECG Electrodes Upto 5 Electrodes Are Upto 5 electrodes are required for every case visiting OT or ICU. For longer stay in ICU, may require a change and at least one set every second day must be Payable. 164 Gloves Sterilized Gloves Payable. Unsterilized Gloves not Payable 165 Hiv Kit Payable for pre operative screening 166 Listerine / Antiseptic Mouthwash Payable when prescribed 167 Lozenges Payable when prescribed 168 Mouth Paint Payable when prescribed 169 Nebulisation Kit If used during hospitalization is Payable reasonably 170 Novarapid Payable when prescribed 171 Volini Gel / Analgesic Gel Payable when prescribed 17 Zytee Gel Payable when prescribed Routine Vaccination not Payable. Post Bite Vaccination 173 Vaccination Charges Payable 174 AHD. Part of hospital's own internal cost 175 Alcohol Swabs. Part of hospital's own internal cost 176 Scrub Solution / Sterillium. Part of hospital's own internal cost 177 Vaccine Charges For Baby 178 Aesthetic Treatment / Surgery 179 TPA Charges 180 Visco Belt Charges 10

11 Sr. No. Expense Head Special Remarks 181 Any Kit With No Details Mentioned [Delivery Kit, Orthokit, Recovery Kit, Etc] 18 Examination Gloves 183 Kidney Tray 184 Mask 185 Ounce Glass Outstation Consultant's / Surgeon's, except for telemedicine consultations where 186 Fees covered by policy 187 Oxygen Mask 188 Paper Gloves 189 Pelvic Traction Belt 190 Referral Doctor'S Fees pre hospitilasation or post hospitalisation / 191 Accu Check (Glucometery/ Strips) Reports and Charts required 19 Pan Can 193 Sofnet 194 Trolly Cover 195 Urometer, Urine Jug 196 Ambulance shifts is Payable / RTA as specific requiremen t is Payable 197 Tegaderm / Vasofix Safety 198 Urine Bag Payable where medically necessa maximum 1 per 4 hrs 199 Softovac 00 Stockings Essential for case like CABG etc. where it should be paid. 11