FAQ. hospitals. documents

Transcription

1 FAQs FAQ Q1: What are the services available to me from the TPA? Answer A: You can avail of the following services : e-card against your policy, which would give you access to our TPA services. authorized by Mediclaim / Hospitalization Insurance hospitals -network hr access to our Call Center through our Toll Free line and IVR and location spoc. documents Q2: When I call Vipul MedCorp TPA's Call Center/IVR/Office, how will you identify me? Q3: What if I don t remember my Card Number and my Policy Number and I am in an emergency situation? Can I use my employee ID no.? A: Please mention your Vipul e-card Number to the Call Center Executive, IVR, location SPOC. The executive may verify other details like your Date of Birth, Employer Details etc. On establishing your identity, we will be happy to answer your queries. A: In case you are in an emergency situation, we can search your details through our website ( based on your company name and Emp ID. Also, you can speak to our location spoc to help you. Q4: How do I avail of Cash Less Facility? Cash Less facility is available only in network hospitals To avail cashless facility, the member has to visit any of the network hospital (network hospital list available on Vipul MedCorp website) Insured has to produce his TPA card at the reception/tpa desk. He will have to fill a pre-authorization request form The preauthorization form will be duly signed by the treating doctor and will be faxed/ ed to Vipul by the hospital Vipul doctor will process the documents based on eligibility/policy condition and send a final authorization to hospital. There may be some deductions of non-payable items like registration fees, personal items etc. for which the hospital may insist on a refundable nominal deposit. Q5: What documents do I need to send for processing claims if the treatment has been done in a non-net work hospital / In a network hospital where cash less facility was not granted / availed? Q5A. Where do I submit my cla ims On the date of discharge, hospital will fax/ the f inal bill and discharge summary to TPA and patient/dependents of patient needs to sign all original documents, which will be retained by the hospital for onward submission to TPA. Patient should retain Xerox of all documents for future reference. A: Following documents are required for processing your claims on reimbursement basis: a. Online Claim Form to be filled thru Self Care Portal. b. Discharge Summary from the hospital(in case of hospitalisation) c. All original documents pertaining to the illness d. Main Hospital Bill. e. Payment Receipt. f. Relevant reports/films of diagnostics tests. A A: you can submit the claims to the Vipul Help Desk Executive along with print out of the online claim form 1

2 Q6: When will my claim be reimbursed? A: The claim will be reimbursed within - 15 days after receipt of complete documentation from the client / Corp HR. Q7: What documents should we obtain before discharge from the hospital in case of cash less facility availed? Q8: Is there any exclusion in the policy A: Yes. As per policy T & Cs A: All bills in original and a discharge certificate are to be left with the hospital prov iding cashless treatment. The patient has to countersign all bills and fill the claim form and also leave the same with the hospital at the time of discharge. A copy of the bills & Discharge Summary can be carried by the patient for his records and for submission along with Pre & Post Hospitalization bills. Q9: Can I get the salient features of our Policy coverage A: The salient features of the policy can be viewed by visiting the Vipul MedCorp website ( Q10: Can Vipul MedCorp TPA reject my claim? Do I have any remedy? Q11: How do I get a list of network hospitals of Vipul MedCorp TPA Pvt. Ltd.? Q12: Can I lodge more than one claim for the same disease? A: Yes, the TPA can reject / deny your claim based on their evaluation / analysis on justif iable grounds. The rejection letter will cover the reasons for rejection of the claim. Remedy :- In case you are not satisfied by the reasons for rejection, you can represent to the insurer/tpa within 15 days of such denial. A: The list of hospitals is available on the Vipul MedCorp website under the "Hospital Network" section A: Yes, your mediclaim policy covers 30 days Pre-hospitalization expense reimbursement and 60 days Post-hospitalization expenses. You may lodge your Pre-hospitalization claim along with hospitalization claim. The Post-hospitalization claim may be lodged after 60 days of the hospitalization. However, please quote your Vipul ID Number for easy referral and sorting. Q13: How will you keep track of my claim? A: You may lodge your claim online with us and submit the claim through our Helpdesk and it should be mapped with the checklist and the claim status can be v iewed online through self care portal. Q14: In case I require my original medica l papers back for future reference, what should I do? Q15: During the course of my treatment, can I change the hospitals? Q16: Can I get outpatient treatment using my TPA Card? A: Please carry a complete set of photocopied documents when you lodge your claim. The relevant original documents will be returned to you after verification. We will however stamp the original documents [Vipul MedCorp TPA - Claim Processed on Xeroxed copy ]. Please note that normally, the original doctor prescription, medicine bills and discharge summary along with the hospital bills will be retained by us. Only X-ray films, ECG, other medical records will be returned to you as a special case after verification / approval of our medical team. A: Yes it is possible to shift to another hospital for reasons of requirement of better medical procedure. However, this will be evaluated on the merits of the case and as per policy terms and conditions. A: No. The TPA Card is issued to you against your mediclaim policy which only covers hospitalization expenses. The outpatient expenses pertaining to the treatment of disease which is the cause of hospitalization is however covered in Pre & Post Hospitalization benefits. Q17: I have received my e-card but there are mistakes. What should I do? A: For any changes, please contact your People Engagement Manager or raise your queries through ASSIST. Q18: I am not happy with the services of Vipul MedCorp TPA or if I have a query. A: You can access our online Query module through self care and we shall resolve your queries within 48 hours. In case you face

3 What should I do? Q19: I went to one of your net work hospitals and they did not entertain me. How should I proceed? Q20: I am not keen to avail of Cash Less facility. Can I go in for reimbursement? any service issues, please escalate to your HR SPOC or to Vipul SPOC/Escalation Matrix contacts A: You may immediately call our location spoc, giv ing details of such hospitals/medical providers. Our network department will immediately contact the concerned medical provider and sort out the matter. A: Yes. Under the Mediclaim Policy, you can opt for Cash Less as well as Reimbursement. We would adv ise that in case you are taking treatment from a network hospital, then you should avail of the Cash Less facility. This will give you the financial advantage of not paying for your hospital treatment and also gives you more cushion to meet your post-hospitalization expenses, as we have package/discounted rates with the network hospitals. Q21: In case the child after birth suffers from any disease is the expense covered. If yes, how will the enrolment be done when the child has not been named? Q22: If the member suffers from any complication due to her maternity, is it covered and up to what limit? Q23: How do I access the relationship/escalation matrix? Q24: If a net work hospital does not cooperate with me, what recourse do I have? Q25: What do you mean by pre-existing coverage? A: The new born is covered from day 1 in case of hospitalization (Subject to free slot availability) and justified treatment is administered. In case of cashless, the hospital needs to prepare bills and send cashless request in the name of B/o <mother s name> for processing. For reimbursement, the child has to be enrolled with Vipul first in order to process the claim through our enrollment module. Congenital ailments are not covered. A: The complications arising out of maternity are covered under the maternity benef its and upto the limit of the maternity sum insured. A: Please refer to the Self care module to view the Relationship matrix. A: Employees are advised to contact the Vipul representatives in case the hospital does not co-operate. A: Any disease existing prior to the inception of policy Q26: What is floater cover? A: Family floater of maximum 4 members (inclusive of employee). Sum Insured can collectively be utilized by any member in the family. Q27: What do you mean with the term hospitalization? Q28: Can I go to any hospital or clinic for taking treatment? A: The duration of indoor stay in the hospital should be more than 24 Hrs. However, this time limit will not apply for specific treatments i.e. dialysis, chemotherapy, radiotherapy, eye surgery, lithotripsy, tonsillectomy, D&C, etc. A: Yes, but please ensure that the hospital is well equipped to handle medical emergencies. Q29: What is called maternity benefits? A: Any expense related to maternity expenses related to hospitalization only. These expenses are payable only if insured has less than 2 living children. Postnatal & prenatal expenses are not covered. Q30:Will claims prior to 1 st Feb 2014 be settled under cashless scheme by Vipul? Q31: Will I get the entire amount of the claim always? Q32: If I have not utilized my permissible eligibility amount in a particular policy period will I get any benefits like carry forward for the next period if I renew the policy? Q33: In case of employee transfer to another location in there any procedure involved to continue the scheme? Q34: Will the change in names in bet ween policy period matters? A: Cashless facility is available for admissions on or after 1 st Feb Admission prior to this period will go thru existing reimbursement process. A: The insurance company will pay the entire amount of the claim if it is related with the medical treatment and is supported by proper documentations and within the limits. However, all the claims should stand testimony to medical professional jurisdiction. Failing this only that part of the claim that is justif ied will be payable. There is 10% co-pay applicable on each and every claim of parents/siblings. Non payable item list can be referred through self care module. A: The amount will not be carried for ward to subsequent periods A: Change of location, within India does not affect the coverage as your policy coverage is PAN India and Vipul MedCorp provides cashless facility on PAN India basis A: Yes. According to insurance company the claim will not be settled (unless prior intimation to TPA and the Insurance

4 Q35: Can I change or add my dependents name in bet ween the policy period? Q36: In case of part settlement of claims, can the member claim for the ba lance by producing the required documents? company) if there is any alterations in the name and in bills/reports (documents) submitted by member/hospital A: As of now it is not allowed however you may get in touch with your HR spoc for such a facility. A: Yes. But only eligible amount as per the terms and conditions of the policy shall be paid. Original settlement letter and attested copies of the claim document from the other Service provider is required as per policy norms. Q37: What about dental treatment? A: All expenses related to dental treatment shall not be covered under the group hospitalization policy unless it is an accidental case. Q38: What about termination of pregnancy? A: This will be covered under the hospitalization limits. But only if done on the advice of a qualified doctor and on account of medical reasons. Expenses arising out of voluntary termination of pregnancy are not covered. However, medical expenses arising out of termination of pregnancy (commonly termed as miscarriage) will be covered, within maternity sum insured. Q39: What happens when a ne wborn child has to undergo treatment in the nursery? Q40: What happens when I have to undergo a treatment like dialysis when I an discharged on the same day? Q41: Do we require any photo ID Proof in cashless facility? What is the purpose of photo ID proof? Q42: In case of non availability of photo ID proof, what should we do? Also, please advise on children if they get hospitalized? A: Expenses of newborn child is covered under the policy in case a justif ied hospitalization has been administered. A separate bill and discharge summary would be issued for the baby by the hospital and stay in the hospital should be as per the policy terms and conditions. A: When treatment such as dialysis, chemotherapy, and radiotherapy etc. is taken in the hospital/nursing home and the insured person-patient is discharged on the same day, the treatment will be considered to be taken under hospitalization benefit A: Vipul will issue a laminated Photo ID card to all the covered members and If you are not carrying the Vipul laminated card and are seeking cashless through ecard, we need a valid photo ID proof, which may be, Pan Card, Driving License, Ration Card, etc. It is to validate the identity of the patient A: You can contact Vipul SPOC in your area and give your Employee ID or Inform the Hospital that you are covered under Vipul service and they can mention the Employee ID and Vipul SPOC will provide the Vipul ID no. For children, school ID proof is admissible or Parents ID is also admissible Q43: In case if I need original reports /films, can I retain the same for further treatment and can I get the claim on submission of Xerox reports? Q44: What if my bill exceeds the covered amount / sum insured? Q45: In how many hospitals Vipul has packages and where can I see the list of such hospitals? Q46: Will Vipul Packages with hospitals affect the quality of the treatment/ implants? Q47: If the employee does not opt for packages, will he get the cashless / reimbursement on open billing amount? Q48: Can the employee get advance payment in case the hospital is not on A: Yes, you may retain the original films and retain a Xerox of the reports, but the bills have to be submitted in originals along with original bills, discharge summary and original reports. In case there is a need to retain the original reports also, then you may show the original reports to the claims pick up executive and submit a Xerox of the same along with the claim Docket A: Vipul shall authorise the cashless / reimbursement claim upto the sum insured and deductions would be made as per policy sublimits /co pay ment clause/non payable items. A mount exceeding the settled amount/sum Insured, has to be be borne by the employee. A: Vipul has package rates with hospitals and the hospital list can be v iewed as PPN LIST on A: The quality of treatment / implants will not be affected due to packages. A: We would always advise to go for packages as this will help you in getting more benefits in your future claims for pre & post hospitalization, however you are free to go in for open billing also. A: Vipul cannot make the advance pay ment, but you may draw an advance from your employer company and Vipul will

5 network of Vipul? reimburse the same to the Employer Company Q49: Do we have provision of discounts in pharmacy of hospitals or open pharmacy / diagnostic centers? We have discounts in Stand alone pharmacy and diagnostic centers as available in the wellness portal, which is updated by us on real time basis. Some of the hospitals do give discounts in their in house pharmacy /OPD and the list would be viewed from the Vipul Wellness portal Q50: What if any new joinee who is not yet enrolled needs a cashless, how will he avail the cashless benefit? Q51: Will the resigned employees get the continuity benefit of the policy? Q52: Will the family members of employees travelling or working overseas get the medical benefit? Q53: Can the employee view the claim documents on vipul portal? Q54: Will I get discount in medical checkup through Vipul Wellness? Q55: What are the services, we can get from Vipul Wellness portal. Will it be on FOC basis? Q56: Since you have package rates with hospitals under 3 categories viz, Single room, Semi Private and Ward, ca n We opt for any room category A: After validation through location HR, Vipul shall authorise cashless, out of system to the hospital for the new joinee as per policy terms and conditions in network hospital. If such a situation arises, please get in touch with Vipul SPOC A: If they take the policy from the current Insurer, then they can get a continuity benefit subject to the agreement with the Insurance Co. In such a case the existing Corporate GMC card would be cancelled and Vipul will issue a new cards, on receipt of the new policy A: If the employees are listed in your policy and he /she is on oversees posting, and their family members are residing in India, then the family members can avail the benef it of the policy. If the entire family along with the employee are residing overseas then they may be covered in a separate Overseas Mediclaim Policy. A: Yes, the employee can view the scan documents through self care portal A: Yes, you can book through Vipul Wellness for medical checkup and can avail a discount ranging from 25% to 40%. The details of various packages would be uploaded on Vipul Wellness package A: You can book your Executive Health check /MedHealth Check from Vipul Portal, which is being offered to you on a discount of 25 to 40% on the market rates. You can avail of First Medical Opinion ( FMO), Doctor on Chat, Electronic Medical Recors Management (EMRM) on a FOC basis The room category option will depend on your Sum Insured. SI upto 1.5 lakhs can opt for Ward and those between 1.5 to 3 lakhs can opt for Semi Private/Twin Share room and those with SI > 3 lakhs can opt for Single room Q57: Since when Vipul ID Card is applicable? Will I get cards for my dependents too? Q58: Do I have to provide photographs for all of my dependents? A: Vipul ID Cards is applicable from , from the policy inception date, and Vipul shall prov ide ID cards for all your dependents as per the policy A: Yes, as per your policy, you need to prov ide us the photographs to us for issuing the Vipul ID Cards. Q59: Can Enrollment of the dependents be done any time in the policy year? Q60: In Self care portal is password change mandatory? Q61: Can I change the sum insured during the course of the policy? A: Enrollment can be done only once in a policy year, also it is restricted to a time period as specif ied by your HR. Newly married spouse, new born baby can be added during the policy year, subject to free slot availability. Please get in touch with your HR SPOC for such additions A: Yes, for security purpose of your data, we have made it mandatory to change the password. A: No, you cannot change the sum insured during the policy period. you may get in touch with the HR SPOC for such a requirement Q62: What is a TPA Desk in the hospital? A: TPA Desk is a help desk provided by the network hospital in their premises to facilitate communication with the TPA for availing cashless benefit in the hospital. Q63: Is there any time frame for submitting A: Yes, it is advisable that claim documents are submitted within

6 the documents? Q64: Do I get to know about my ROOM rent eligibility? Q65: What is theme based event in health camps? Q66: How to confirm discount for diagnostic centers and pharmacy? 21 days of discharge and for Post hospitalization claims, within 21 days of completion of treatment or 60 days, which ever is a early period. A: Yes through self care portal you may raise a querry or your room rent eligibility or for that matter on any other matters relating to your policy A: Theme based events relate to the health camps / events organised making base as the theme which may be woman s day, world cancer day, etc. A: One can confirm the discounts through Vipul Wellness portal. Coverage: Family & eligible members: Salient features of NIIT Policy coverage All members including new joinees are covered from day one subject to inclusion in the policy or by way of endorsement and payment of premium. The term Family can be defined as Employee + 3 dependants i.e. (1+3). Family members Eligible for coverage: a) Spouse b) Children, c) Parents/Parents in law d) Brother e) Sister f) Grandparents / and any dependent relative. Addition/Deletion & Substitution/Swapping: Employee may cover their extra Dependants (other than employee + 3 dependents) with additional sum insured on individual basis as per indiv idual medicla im policy which shall attract additional premium. Maximum entry age is 80 years. (Persons above the age of 50 years will have to submit the report of Blood Sugar, ECG, KFT,LFT, TMT & Lipid profile) Any Addition/Deletion & Substitution/Swapping of dependents allowed only in case of new child birth, marriage, divorce and death, subject to availability of slot. Fresh midterm inclusion of parents not allowed in the policy. Other then the above mentioned no midterm add ition would be accepted and premium will be charged on pro-rata basis. Special Coverage: Pre Existing disease (Clause 4.1): PED is covered only for employee, Spouse and Children only. Parents are not covered for any Pre existing ailment until 3 years from the date of joining subject to continuous coverage. For Employee, spouse and Children all pres existing ailments are covered irrespective of a 3 year waiting period, while for Parents, pre existing disease are not payable in the first 3 years of their joining in the scheme. IN case they continue in the scheme for 3 yrs, then in the 4 th year, the claims arising out of their pre existing ailments would be payable 1 st 30 days Coverage (Clause 4.2): Waived Off. This means that all admissions within the f irst 30 days of the fresh coverage ( New joinees ) is also admissible 1 st Year Exclusion: The treatment of disease such as Cataract, Benign Prostatic Hypertrophy, Hysterectomy for Menorrhagia or Fibromyoma, Hernia, Hydrocele, Congenital internal disease, fistula in anus, piles, Sinusitis and related disorders, Gall Bladder Stone removal, Gout & Rheumatism, Calculus Diseases are not covered during first year of insurance however this exclusion is waived off for self/employee, spouse & child only. Maternity Benefit : Maternity Covered from Day 1. INR 35,000 for Normal Delivery & INR 50,000 for Cesarean. Baby coverage: Baby covers from day one, if free slot is available. Declaration for enrolment in the policy from employee should be within 60 days of birth.

7 Room Rent Capping: Room Rent is restricted to 2% of the various Sum Insured Limits or Rs.2000/- whichever is higher. Other Increases expenses due to higher room rent need to be borne by employee. ICU charges will be paid as per actual. Co Pay : 10% co-pay ment on all claims will apply on each and every claim; except claims for Self, Spouse and Children. Disease Capping: Cataract INR 30,000 per eye, Stone, Hernia (bilateral and unilateral) INR 75,000, Hysterectomy -INR 1,00,000/-