ICICI LOMBARD GENERAL

Transcription

1 Group Health Insurance Policy ICICI LOMBARD GENERAL INSURANCE CO LTD. TRAVELEX INDIA PVT LTD 1 ST JAN 2013 to 31 st Dec of 14

2 Contents Terminology. Scope of coverage. Policy terms and conditions. Claim procedure and settlement process. 2 of 14

3 Terminology Hospital/ Nursing Home - Any institution in India established for indoor care and treatment of sickness and injuries and which Has been registered either as a Hospital or Nursing Home with the local authorities and is under supervision of a registered and qualified Medical Practitioner; or Comply with minimum criteria: Should have at least 10 inpatient beds, in those towns having a population of less than 10,00,000 and in all other places 15 in-patient beds Fully equipped operation theatre of its own, wherever surgical operations are carried out, qualified & round the clock available nursing staff and doctors 3 of 14

4 Terminology Does not include a place of rest for the aged, de-addiction center (drugs/alcohol), hotel and similar institutions. Hospitalization - admission in a hospital upon advice of a Medical Practitioner. 4 of 14

5 Scope of coverage Disease / Injury Treated medically /surgically. By Hospitalization of a minimum period of 24 hours (time limit not applicable for specific treatment such as advanced technology). At Nursing home / hospital in India as in-patient. The Insurer shall pay to the Insured Person expenses which are reasonably and necessarily incurred towards Hospitalization Amount paid will not exceed the maximum sum insured specified for the employee for the year. The maximum sum insured is determined on 1 st Jan or at the time of joining for employees joining after this date 5 of 14

6 Scope of coverage: Compensation Payable Reasonable and necessarily incurred subject to 24 hours hospitalization (23.59 hours will not be acceptable). Room Expenses in Hospital/Nursing i Home. Nursing Expenses. Medical Practitioner Fee. Treatment cost. Medicines Blood / Oxygen 6 of 14

7 Scope of coverage: Compensation Payable Operation Theatre Charges. Surgical Appliances. Diagnostic cost. Dialysis, Chemotherapy, Radiotherapy. Pre Hospitalisation and Post Hospitalisation expenses. Pre Hospitalization - relevant medical expenses incurred during period up to 30 days prior to hospitalization. Post Hospitalization - relevant medical expenses incurred during period up to 60 days after the date of discharge from Hospital 7 of 14

8 Scope of coverage: main exclusions General exclusions: war, nuclear perils. Cosmetic or aesthetic treatment, plastic surgery. Cost of spectacles and contact lenses, hearing aids. Dental treatment. Intentional self injury and use of intoxicating drugs/alcohol. Aids. Charges incurred primarily for diagnostic, X - Ray or laboratory examinations not consistent with treatment / presence of any disease. 8 of 14

9 Scope of coverage: main exclusions Vitamins/tonic inconsistent with treatment, naturopathy. Convalescence, general debility. Sterility, veneral disease, circumcision. Medical termination of pregnancy within 12 weeks is not covered. 9 of 14

10 Policy terms, conditions and Limits Age Band- 1 day to 80 years. Room Rent- For 1 Lac SI- Rs-2000 per day & ICU Rs per day. For Others- 1.5 % of SI for Normal & 2.5% of SI for ICU. If insured is admitted in a higher category, then insured will bear difference of all medical expenses as in final hospital bill in same proportion. Maternity expenses benefit : Rs.50000/- for Normal & Rs /- for C Section. (First two children). Baby covered from 1 day Upto the family SI. Pre-existing diseases: Covered. No waiting period of 1 year for certain diseases. No waiting period of 30 days. Domiciliary hospitalization not covered. 9 months waiting period waived off. 10 of 14

11 Policy terms, conditions and Limits Family Definition Employee,Spouse,2 Dependent Children upto age 25 yrs and Dependent parents covered under policy. Pre Hospitalisation and Post Hospitalisation for 30 days & 60 days respectively are covered. Co-Payment 10% Co-pay on all claims for parents only. Disease wise sublimits: All forms of Arthritis including Total Hip Replacement (THR) and Total Knee Replacement (TKR) is restricted to 2L only. Mid term inclusion i of dependents d will be possible only in case of: a) spouse (on account of marriage during the policy term) b) children by Birth subject to not more than 2 children being covered under the Policy. 11 of 14

12 Policy terms, conditions and Limits Ambulance Charges limited to Rs.1000 Per Person. Lasik Surgery, Septoplasty, Infertility & Related Ailments incl.'male sterility'; Treatment on trial/experimental basis; Admin / Registration/ Service/Misc Charges; Expenses on fitting of Prosthesis; Any device/instrument/machine contributing/replacing the function of an organ; Holter Monitoring are outside the scope of the policy. Liability for FESS upto Rs.35,000; Hospitalisation arising out of Psychiatric ailments upto Rs.30, % Co-Pay for cyberknife treatment/stem Cell Transplantation. Cochlear Implant treatment shall be restricted to 50% of the SI. Claim to be filed within 20 days from the date of completion of treatment. The Insured to furnish the Company with all original bills, documents All treatment under this policy should be taken in India 12 of 14

13 Claim procedure and settlement process Type of Claims. Cashless Claim. Reimbursement Claim. In Cashless health insurance Service, when you get hospitalized with a network hospital, you do not have to settle the bill with the hospital. The Insurance Company represented by the TPA, coordinates with the hospital and settles the bill. In Reimbursement claim you may pay the expenses and claim reimbursement as per policy terms & conditions. 13 of 14

14 Claim procedure and settlement process ABOUT YOUR HEALTH ID CARD It is not a Credit or Cashless Card, but an Identity Card which will identify you as the beneficiary of ICICI LOMBARD and will give him access toour Network Hospitals It bears Name of the Insured, Policy No., DOB, Gender, ID No., Policy Validity etc. For any correspondence and queries Insured should quote unique ICICI Health ID no. as mentioned on ID card. As ID card carries all crucial information related to an insured so while enrolling all these details should be taken with due care. 14 of 14

15 Claim procedure and settlement process HOSPITALIZATION PROCEDURE Pre authorization in case of admission in Network Hospital and intimation incase of Non Network hospital is mandatory. WHAT TO DO WHEN YOU FALL ILL? When you fall ill, generally you contact your family physician,who treats you and when necessary, refers to the consultant/hospital. WHAT TO DO IF YOUR DOCTOR TELLS YOU TO GET HOSPITALISED? Your Health Policy Provides for Cashless Hospitalization at ICICI Health Group Network Hospitals Selection of Hospital and doctor is your prerogative If you chose to get admitted network hospital then, please obtain a Dr.'s reference letter in the prescribed format available in the hospital 15 of 14

16 Claim procedure and settlement process HOW TO ASK FOR PRE-AUTHORISATION Send the pre Auth form to ICICI Health care 24 hrs. Help Desk or Telephone at Helpline li On receipt of the above form, on duty doctor will verify your coverage vis-à-vis your insurance policy and if covered a authorization i letter (AL) will besenttoyour hospital and copy to you if you so desire. If the coverage is not established, Intimation (Denial) will be sent to your hospital and to you. The denial of authorization for cashless access does not mean denial of treatment and does not in any way prevent you from seeking necessary medical attention or hospitalization The above procedure will take approx. 4 hrs. after you send the Doctor s Reference letter with full details. 16 of 14

17 Claim procedure and settlement process CASHLESS MEDICLAIM: WHAT TO DO IN AN EMERGENCY? In an accidental case or in medical emergency you are advised to approach nearest Network / Non Network Hospital with your ID Card. If the admittance is in network hospital you or your relatives or the hospital will call up ICICI Healthcare (Helpdesk is open 24 hrs a day). They will verify the coverage and if covered issue the authority letter to network hospital. If you are in non network hospital you may pay the expenses and claim reimbursement based on the coverage. 17 of 14

18 Claim procedure and settlement process IN THE HOSPITAL If you are required to buy medicine or investigation done outside the hospital, kindly obtain proper Cash Memo/Receipt for payment made by you. Certain chargessuchas(telephone/fax,food & Beverages for relatives, Barber, Ambulance etc.) are not covered in your insurance policy, if you have obtained such services from the hospital please pay for the same directly to the hospital. 18 of 14

19 Claim procedure and settlement process AT THE TIME OF DISCHARGE The hospital will discharge you without payment of the bills on the basis of A/L issued to them. If the bill amount exceeds the authorized amount, you will have to pay such amount to hospital. The Network hospital generally will not give you the Original Bill, Discharge Card, Investigation Reports, etc. (as they have to send these to TPA) you may ask for copies of the same. 19 of 14

20 Claim procedure and settlement process Reimbursement Mediclaim i Planned / Emergency treatment in non-network network hospital Notice to TPA & approved Documents required for claim Duly completed claim form Bills, receipts and discharge certificate/card from the Hospital Bills from Chemists supported by proper prescription. Test reports and payment receipts. Any Other documents as queried by TPA. Settlement within 21 days on complete submission 20 of 14

21 Claim procedure and settlement process WHAT HAPPENS WHEN SUBMITTED DOCUMENTS ARE NOT COMPLETE When you submit your claim along with all relevant documents as explained above to TPA, the same will be scrutinized by a team of medical doctors and claim processors and if found in order, TPA will issue a reimbursement cheque for the amount paid by you. If there are discrepancies or deficiencies in the documents TPA will issue a letter listing the deficiencies and ask you to submit deficient documents within 15 days of receipt of the letter. 21 of 14

22 Claim procedure and settlement process HOW MUCH TIME DOES IT TAKE TO SETTLE A CLAIM If the claim file is complete in all respect TPA will settle the claim within 21 working days from the date of receipt of complete documents. Sometime TPA may settle the claim deducting the amount pertaining to deficient document. When the deficient documents are submitted TPA will reopen the file and pay for the same if they are payable under the policy. 22 of 14

23 . WHAT ABOUT POST HOSPITALIZATION EXPENSES If you have incurred post hospitalization expenses which are permissible under the policy you may submit a supplementary claim along with the relevant documents immediately after the permitted post hospitalization period. TPA will scrutinize the same reopening the original claim and settle the same. 23 of 14

24 . Helpline l li Services TEL NO FAX NO THANK YOU 24 of 14