group medical insurance client ashoka trust for research in ecology and the environment contents...
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Group Medical Insurance
Client ASHOKA TRUST FOR RESEARCH IN ECOLOGY AND THE ENVIRONMENT
Contents Group Medical Insurance
Prepared by
Emedlife Insurance Broking Services LtdNo. 862, 3rdFloorPrabhat Arcade, 80 Ft RoadKoramangala 8th Block Bangalore – 560 095
Tel: 080-4265000 Fax: 080-4265000
Copyright © 2012. All rights reserved. No part of this publication may be reproduced, stored in the retrieval system, or be transmitted in any form or by any means, electronic or mechanical, photocopying, recording or otherwise, without the prior written permission of the publishers.
Disclaimer:
This benefit summary will serve as a guide to the benefits provided by ASHOKA TRUST FOR RESEARCH IN ECOLOGY AND THE ENVIRONMENT. The information contained here is only a summary of the policy documents which are kept by the company. If there is a conflict in interpretation, terms & conditions of the policy will prevail.
Help Line NumbersFor all queries and assistance, please contact Emedlife Insurance
Praveen Raj S. (Sr. Executive - Client Services) – 90081 44417 (Email: [email protected])
Arjun (Escalation 1) – 90081 44456 (Email: [email protected])
Ramani (Escalation 2) - 99808 11326 (Email: [email protected])
The Insurance Third Party Administrator is Medi Assist India TPA and their contact details are:
Tel: 080- 26584811Fax: 1 800 425 9559
Toll free number: 1-800-425-9449
Email: [email protected]
Website: https://www.mediassistindia.com
Agenda
Group Medical Insurance
TPA Service Offerings
Log in Procedure
Process for Hospitalization
Escalation Matrix
Group Medical Insurance
BrokerEmedlife Insurance Broking Services Limited
Insurer National Insurance Company Ltd
TPAMedi Assist India TPA Pvt Ltd
Group Health Plan
Policy Holder ASHOKA TRUST FOR RESEARCH IN ECOLOGY AND THE ENVIRONMENT
Period of the Cover 12 months
Inception Date 21th May 2015
Expiry Date 20 th May 2016
Insurer National Insurance Company Ltd
TPA Medi Assist India TPA Pvt Ltd.
Sum Insured Limits INR 2 Lacs, 3 Lacs and 4 Lacs Sum Insured per Employee.
Members Covered Self only
Geographical Limits India (Covers treatment in India only)
Group Mediclaim Coverages Pre-existing Diseases covered
Waiver of Time exclusion for diseases (30 days/1 Year/2 Years/4 Years )
Maternity Benefit of INR 25,000 for Normal and 35,000 for C-Section.
Maternity benefit covered from day one.
New Born baby cover.
30 and 60 days Pre & Post hospitalization covered.
Ambulance Charges covered up to 1% of Sum Insured with maximum limit of INR 1,000/- per incidence .
Room rent (Including Nursing charges) charges payable up to 1% of Sum Insured for normal and 2% of Sum Insured for ICU with max limit of INR 5,000 per day.
Scope of Insurance Cover
Includes:
Only “in-patient” hospitalization expenses.
Active treatment with minimum 24 hours hospitalization.
Pre-hospitalization expenses of 30 days before admission and post hospitalization expenses for 60 days
after discharge for an eligible hospitalization
Cashless facility against Pre-Authorisation at Network hospital only
Excludes:
Non - Medical Expenses - Registration/Admission fees, hospital surcharge, food bills for attendants,
telephone charges, pharmacy charges for non-medical items etc.
Other standard exclusions
Stay in hospital without undertaking any treatment or where there is no active regular treatment
Standard exclusions to the Insurance Cover
Injury or disease directly or indirectly caused by or arising from or attributable to war or war like situations and by nuclear weapons.
Circumcision unless necessary for treatment of diseases
Congenital ailments or defects/anomalies
Hospitalization for convalescence, general debility, intentional self-injury, use of intoxicating drugs/ alcohol.
Venereal diseases, HIV and AIDS, Infertility treatment and Naturopathy
Cost of spectacles, contact lenses, hearing aids
Any cosmetic or plastic surgery except for correction of injury
Hospitalization for diagnostic tests only even if prescribed by a medical practitioner
Voluntary termination of pregnancy during first 12 weeks (MTP)
Pre and Post Natal expenses are not covered unless admitted in Hospital/Nursing Home for active line of treatment
Unproven or experimental treatment not approved by Indian Medical Council
Any Dental treatment or surgery except arising out of an accident, which requires Hospitalization for treatment
Enrollment in the program•Existing employees are covered under the policy from 21th May 2015.
•All New joiners must enroll themselves within 20 days of joining the company.
Provide required details of yourself to
the HR
Provide required details of yourself to
the HR
HR sends the data to the EMEDLIFE to
upload their system
HR sends the data to the EMEDLIFE to
upload their system
EMEDLIFE will upload this data and inform
ATREE on the activation of all facility
for employees
EMEDLIFE will upload this data and inform
ATREE on the activation of all facility
for employees
TPA will upload E cards on their Website for all
employees
TPA will upload E cards on their Website for all
employees
Employee verifies
details of the E card
on TPA website
Employee verifies
details of the E card
on TPA website
Send mail to EMEDLIFE / HR with
ID Card Nos.
Send mail to EMEDLIFE / HR with
ID Card Nos.
Error in data on E card
Use E card/Physical card for cashless hospitalization authorization
Use E card/Physical card for cashless hospitalization authorization
E Card Ok
Medi Assist India TPA Pvt Ltd – Service Offerings
•Online access to view self details, claim status and e card download
•Cashless Hospitalization
•SMS facilities for Pre-authorizations.
•24 hour telephonic Nurse line.
•Claims Administration.
Procedure for Online AccessProcedure for Online access
Please follow the below steps to Login Log on to https//:www.mediassistindia.com . Select “Login” option present on the top Right of the screen Select “Corporate Employee”. User ID: Password:
How does the plan work ?
Hospitalization event can be:
Planned or Emergency
In a Network hospital or Out of Network
Hospitals have details of TPAs - please check with hospital helpdesk if they accept Medi Assist Insurance card to avail cashless hospitalization
For updated list of Network hospitals, seehttp://www.mediassistindia.com
Network Hospitalization (Planned)
Fill up the Pre-Authorisation form with the help of the treating Doctor and fax it to the Medi Assist Nurse
line with the assistance of the hospital staff 48 hours prior to Admission
Medical Management Team assesses the Pre-authorisation request and after it is approved,
Medi Assist Nurse line sends Credit letter to Network Hospital
All Medical Expenses including Room Rent would be covered under
Cashless
Network Hospitalization (Emergency)Call up Medi Assist Nurse line if
possible
Or else, get hospitalized into the nearest Network Hospital with
the medical E- card/Physical card
Get the Patient treated and after the patient has stabilized, complete the
Pre-authorisation process
You can also identify yourself as a member of TPA so that they can assist you with the
Pre-authorisation formality.
Possibility of Denial of Cashless - examples
• Admission for investigations/ observation / evaluation only .
• Admission beyond a certain number of days apart from the normal package stay.
• Treatment not matching with disease mentioned on pre-authorisation form.
• Any treatment which otherwise could have been taken on OPD basis.
• Any congenital external disease.
• Hospital not sending proper query reply raised by TPA on time.
• Active line of treatment not mentioned in the pre-authorisation form
Non-Network Hospitalization (Planned & Emergency)
Claim Intimation has to be provided to Emedlife/Medi Assist
Kindly make the arrangements for the admission and pay all expenses at the
hospital
Collect all original documents from the Hospital including the Hosp. & Doctor Reg-
istration No.
Claim needs to be sent to Emedlife within 20 days from the
Date of Discharge
Pre & Post Hospitalization Bills
Pre Bills: 30 days prior to Date of Admission
Post Bills: 60 days after Date of Discharge
Procedure of Discharge & Claim without Cashless facility The employee should arrange for the admission and all other payments required by the hospital. Collect and submit to Emedlife the following documents (in original) after discharge
Discharge Card/Summary Main pre-numbered Hospital Bill Signed Claim Form Pre-numbered payment Receipt Prescriptions, reports and bills for all investigations done. Prescriptions and bills for medicines consumed during hospitalization. Break-up of the medicines bills amount of Rs. 200/- or more. Sticker of lens in the case of cataract cases GPLA certificate in maternity cases Medico-legal certificate and FIR in accident cases
Hospital’s registration number is required and Mandatory
Claims will not be assessed if all the documents mentioned are not submitted.
• Claim Submission Timeline - All claims to be submitted to Emedlife within 20 days from date of discharge. NOTE : Any delayed submission beyond the timeline mentioned above will not be processed. In such cases, letter
from the employee would be required with a valid reason for delay in submission. It is at the discretion of the Insurer to provide the approval for such cases.
Claims Administration Process
• Claims Administration Team– Document handling– Registration of claim with insurer– Liaison with insurer for payment– Explanation of paid amounts and rejection
• Document Recovery Team (DR Team)– Sends reminders for the missing/required document(s). In case of non-receipt of the same,
may send the entire claim back to the employee or deduct the appropriate amount and send the balance claim for QC
• Quality Check Team (QC Team)– Re-assesses the claim to ensure that the claim is complete in all respect before sending it for
payment to the insurance company.
• Claim settlement– Approximate time to settle claim is 10 - 15 working days after receipt by TPA of complete
documentation
Some Important Do’s & Don'ts• Submit the Reimbursement claim documents to Emedlife Helpdesk within 20 days from date of
Discharge
• Always carry photo ID proof along with your medical card.
• Photo ID proof can be: Driving license / PAN Card / Passport / Voter ID.
• For Planned hospitalization: take approval before getting admitted in hospital
• For Reimbursement cases, always collect all originals from Hospital including final bill with
break up and payment receipt.
• Any issues in getting cashless approval, please contact the Account Manager (Emedlife).
• On leaving ATREE, the Insurance card is to be returned to HR Deptt.
Emedlife Medi Assist
Account Manager Praveen Raj S. Gajendra
Phone no 90081 44417 93425 33651
Mail ID [email protected]@mediassistindia.com
1st Escalation Arjun K Venkatakrishnan
Phone no 90081 44456 96861 95495
Mail ID [email protected]@mediassistindia.com
2nd Escalation Ramani
Phone no 99808 11326
Mail ID [email protected]
For any kind of clarification, please contact:
THANK YOU