group mediclaim policy cipla
TRANSCRIPT
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INTRODUCTION TO GROUP HEALTH INSURANCE SCHEME
Policy Details§ Definitions§ Benefit Details
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General Exclusions
Contact Details & FAQNon Network
Hospitalization
Policy Coverage
General Conditions
Cashless Hospitalization• Planned • Emergency
Health Card Issuance
Claim Documents & Forms
Procedure to Send Claim Form
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Group Mediclaimq This insurance scheme is to provide
adequate insurance coverage for the
Cipla employees and their families for
expenses related to hospitalization due
to illness, disease or injury.
POLICY DETAILS Definitions
q Our health insurance policy covers two schemes i.e. Cashless and
Reimbursement.
q Insurance company usually provides either direct payment to hospital
or reimburses the expenses associated with illnesses and injuries.
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POLICY DETAILS Definitions
Cashless Hospitalization
Cashless hospitalization is serviceprovided by an insurer whereinemployees are not required tosettle the hospitalizationexpenses at the time of dischargefrom hospital. The settlement isdone directly by the insurancecompany. However, prior approvalis required from the insurancecompany before the patient isadmitted into the hospital.Cashless facility is provided ONLYat the Network Hospitals(Preferred Provider Network-PPN) having agreement withinsurance company
Non-Network (Reimbursement)
Hospitalization
Non-network hospitals arethose who do not haveagreement / tie up withinsurance company and anypolicyholder seeking treatmentin these hospitals will have topay for the treatment and laterclaim will be reimbursed as pernormal procedure.
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Policy Parameter
Insurer Bajaj Allianz General Insurance Ltd
TPA Health Administration Team (HAT)
Policy Start Date 1st August 2012
Policy End Date 31st July 2013
Coverage Type Family Floater
Family Definition 1 + 5 (Employee + Spouse + Children + any 2 Parents) Family size should not exceed 5.
Sum Insured Rs 1.00 lakhs Per Family Basic Salary below & up-to Rs 10,000
Rs 3.00 lakhs Per Family Basic Salary Rs 10,001 – Rs 30,000
Rs 5.00 lakhs Per Family Basic Salary Rs 30,001 & above
POLICY DETAILS Benefit Details
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Benefits covered
Standard Hospitalization Yes
Pre existing diseases Yes
Baby cover day 1 Yes
Pre-Post Hospitalization ExpensesYes (upto 30 days pre-hospitalization & upto 60 days post-hospitalization)
Value Added Services OPD/IPD discounts at Network (Preferred Provider Network-PPN) Hospitals
POLICY DETAILS Benefit Details
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Applicable Members
Total No of members in one family covered 1+ 5
Employee Yes
Spouse Yes
Children Yes (Age restriction upto 25 years)
Parents (Father or Mother) or Parents in law (Father in law or Mother in law)
Any 2 (Age restriction upto 100 years)
Mid Term Changes
Any changes in Dependents’ declared should be intimated to respective HR. No claim will be settled if dependent’s details are not updated.
POLICY DETAILS Benefit Details
POLICY COVERAGE
GENERAL HOSPITALISATION EXPENSES
§In-patient hospitalisation (for a period exceeding 24 hours)
q Expenses are claimable if patient is hospitalized for minimum period of 24 hours
q However this time limit is not applicable for specific treatments i.e. Dialysis,
Chemotherapy, Radiotherapy, Eye Surgery, Lithotripsy (kidney stone removal),
tonsillectomy, D&C taken in the hospital/Nursing Home, etc.
q There are 130 day care procedures covered under the policy, which do not require
24 hours hospitalization.8
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Reimbursement of expenses related to
§Expenses reimbursed under the policy :
•Room Charges as provided by the hospital / nursing home
Ø Room rent restrictions upto 2% of Sum Insured per day in case of normal
hospitalization.
Ø Room rent restrictions upto 4% of Sum Insured per day in case of ICU.
• Nursing expenses
• Surgeon, Anaesthetist, Medical Practitioner, Consultants, Specialists fees
POLICY COVERAGE
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POLICY COVERAGE ….. Continued
Reimbursement of expenses related to
• Anaesthesia, Blood, Oxygen, Operation Theatre Charges, Surgical
Appliances, Medicines & Drugs, Diagnostics Materials & X-ray,
Dialysis, Chemotherapy, Radiotherapy, Cost of Pacemaker, Artificial
Limbs & Cost of organs & similar expenses
• Non medical expenses which are not payable under the policy are
as outlined in this link.
GENERAL EXCLUSIONS
Dental treatment of any kind unless requiring hospitalization
Congenital external diseases or defects/anomalies
Hospitalization for convalescence, general debility, intentional self-
injury, injury arising out of intoxicating drugs/ alcohol.
Venereal diseases
Naturopathy
Any non-medical expenses like cafeteria charges, telephone charges, etc
Cost of spectacles, contact lenses, hearing aids11
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GENERAL EXCLUSIONS
Any cosmetic or plastic surgery except for correction of injury
Hospitalization for diagnostic tests only
Vitamins and tonics unless used for treatment of injury or disease
Infertility treatment
Under Maternity, expenses pertaining to caesarian or normal delivery
Any type of MTP (Voluntary termination of pregnancy) excluding those
requiring both medical reasons and surgical intervention
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CASHLESS HOSPITALIZATION
§ Employee shall avail Cashless hospitalization benefits upon receipt ofapproval from Administrator (Insurance company)
§ Insurance company will directly settle all eligible amounts with theNetwork Hospital
§ Insured Person may have to pay a nominal deposits (normally as a deposittowards non medical expenses and room rent capping) at thecommencement of the treatment
Planned Hospitalization
Emergency Hospitalization
Cashless Hospitalization
CASHLESS HOSPITALIZATION
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Planned Hospitalization
Step 1Pre-Authorization
All non-emergency/ plannedhospitalization instancesmust be pre-authorized withthe help desk of hospital , asper the procedure detailed asfollow. This is done to ensurethat the best healthcarepossible, is obtained, and thepatient/employee is notinconvenienced when takingadmission into a NetworkHospital.
Pre-Authorization Process
Member has to intimate insurance
company in a specified pre-
authorization format preferably 72 hours
prior to hospitalization
same day
Claim Registered
by the Insurance
Co. on same day
Insurance company issues approval
letter to Hospital
Pre-Authorization Completed &
treatment starts
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Step 2Admission, Treatment
& discharge
After your hospitalization hasbeen pre-authorized, you need tosecure admission to a hospital.Approval letter will be issued byInsurance Company to thehospital. You have to presentHealth card and photo ID at theHospital admission desk. Theemployee is not required to paythe hospitalization bill in case ofa network hospital. The bill willbe sent directly to, and settled by,Insurance Company. In case ofdenial, member shall seek helpfrom Cipla.
Process - Admission, Treatment & Discharge
CASHLESS HOSPITALIZATION Planned Hospitalization
Member produces Health card and photo
ID at the network hospital and gets
admitted
Member gets treated and discharged after
paying all non entitled benefits like
refreshments, etc.
Hospital sends complete set of claims
documents for processing to
Insurance Company
Claims Processing by Insurance Company
Release of payments to the hospital by
Insurance Company
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Step 1Get Admitted
Step 2Pre-
Authorization by hospital
Step 3Treatment &
Discharge
Member/ relative shouldinform the call centreimmediately about thehospitalization & Seekpre-authorization.Preauthorization form ismandatory to be sent toInsurance Company bynetwork hospital. Inreturn InsuranceCompany will sendpreauthorization letterto the hospital. In case ofdenial member would beinformed directly.
After hospitalization hasbeen pre-authorized theemployee is not required topay the hospitalization billin case of a networkhospital. The bill will be sentdirectly to, and settled by,Insurance Company.
Process
In cases of emergency,the member should getadmitted in the nearestnetwork hospital byshowing his healthcard & photo ID proof.If possible, Membershall inform his HODabout the incidence.
CASHLESS HOSPITALIZATION Emergency Hospitalization
Member get admitted in
photo ID
Member get admitted in the hospital in case of
emergency by showing his Health Card and
photo ID
Member through hospital applies for
pre-authorization to the Insurance
Company immediately
Insurance Company verifies applicability of
the claim to be registered and issue
pre-authorization letter to hospital
Member gets treated and discharged after
paying all non entitled benefits like
refreshments, etc.
Hospital sends complete set of claim
documents for processing to the
Insurance Company
Claims Processing by Insurance Company
Release of payments to the hospital
Company
Pre-authorization given by the Insurance Company
EMERGENCY HOSPITALIZATION PROCESS
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Admission procedureq In case an employee chooses a non-network hospital, he will have to liaise
directly for admission.
Discharge procedure
q Employee will be required to clear the bill and submit the claim to insurancecompany after discharge.
Claim Submission Procedure
q An intimation has to be given to insurance company immediately after thehospitalization or at least within 7 days from date of discharge by dialing theirhelpline no or via mail to [email protected].
q However if Employee intimates Insurance company via mail, he should sendClaim intimation form which is available on ESS Hospitalisation Policy page
q Employee must submit the final documents within 25 days from date of discharge
NON-NETWORK HOSPITALIZATION (Reimbursement)
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NON-NETWORK HOSPITALIZATION
Hospitalization of patient
After treatmentinsured memberpays all the bills ofthe hospital
Member has to fillthe Claim form ofthe InsuranceCompany
Member has to submit the claim form along
with all the necessary original documents as
per the procedure stated in Slide No. 27
Insurance Company performs medical
scrutiny of the documents
If claim is , payment is If claim is approved, payment is released to member through NEFT to the member’s salary account or as per the details
provided by member (NEFT form and cancelled cheque to be
submitted) 19
If additional documents required , intimation about deficiency is sent to
member. Member has to submit additional documents Within 7 days Upon receipt of required documents
payment would be made through NEFT.
If claim is rejected,
repudiation letter is sent to
member
Reimbursement Process
Member should intimate
helpline no.
Member should intimateInsurance companyimmediately or within 7 daysfrom the date of discharge byeither mail or using Bajaj’shelpline no.
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GENERAL CONDITIONS
q Under hospitalization claims, employees are also permitted to claim separately forexpenses incurred 30 days pre and 60 days post hospitalization.
q Separate Claim for post hospitalization can be intimated within 75 days from dateof discharge (Hospitalization Claim no. to be mentioned). This is applicable forboth network and non-network hospitalization.
q It is advisable that member shall approach Network (PPN) hospitals to availcashless benefits
q Under Cashless Hospitalization, Pre-auth Form should be obtained from ourEmployee Self Service System or alternatively from “Bajaj Allianz” websitehttp://www.bajajallianz.com/Corp/claims/general-insurance-claim-forms.jsp
q Under Non Network hospitalization, Claim form should be obtained from ourEmployee Self Service System or alternatively from “Bajaj Allianz” websitehttp://www.bajajallianz.com/Corp/content/claim/HG_Claim_Form.pdf(along with NEFT form and cancel cheque)
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GENERAL CONDITIONS
q Only employees bank details should be provided in NEFT Form.
q In case of admissible Cashless claim, the first amount approved is the interimpayment of the estimate provided. However final amount is settled as per policyterms and conditions
q Hospitals get empanelled and de-empanelled on regular basis and list ofNetwork Hospital is updated on Bajaj’s Website. Hence to see updated list kindlyclick on the link provided below:https://general.bajajallianz.com/BagicNxt/hm/hmSearchState.do
q Also to see the updated list of Diagnostic Centres, please click on below link:https://general.bajajallianz.com/BagicNxt/ihg/getStateList.do?p_flag=D
HEALTH CARD ISSUANCE
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q Each Employee will be provided with
Unique Identity Code which will be stored
in “Personal Details” as well as
“Hospitalization Policy” Page in Employee
Self Service Portal.
q A link will be provided with the Unique
Identity Code
q This Unique Identity code is the access code
(password)
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Employee can log in and download Health Cards by clicking on any one of
the below link followed by the instructions :
Link 1https://general.bajajallianz.com/BagicNxt/ecards/ecards_login.jspand enter access code or
Link 2https://general.bajajallianz.com/BagicCorp/qlogin.jsp and enter the User ID - [email protected] and access code in Login Area.
Then follow the instructions mentioned below.ü Click on “Self”
ü Click on the check box against each dependent member relation to view
the details of your dependent.
ü Click on Generate Health card
HEALTH CARD ISSUANCE
q Bajaj Allianz claim form duly signed.
q Bill detail sheet
q Copy of Health Card
q Photo ID Proof (Pan card, Driving License, Voter’s ID, etc)
q First Consultation Letter
q Original Discharge Summary
q Original Final Hospital Bill giving detailed break up of all expense
heads mentioned in the bill.24
CLAIM DOCUMENTS & FORMS
CHECKLIST FOR REIMBURSEMENT CLAIMS
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CLAIM DOCUMENTS & FORMS
q Stamped receipt for final hospital bill
q Pharmacy cash receipts/ cash bills along with supporting prescription
q Reports of Investigation, Pathology/ Radiology/ Cardiology
q Original paid receipt towards the investigation charges
q In case of a Cataract Operation, the IOL (Intra Ocular Lens) Sticker,
receipt / invoice / box
q NEFT Form and cancelled cheque of the employee in case of different
account number. (i.e. Other than salary account no.)
CHECKLIST FOR REIMBURSEMENT CLAIMS ……..continued
q Bajaj Allianz claim form duly signed
q Claim settlement letter
q Pharmacy cash receipts/ cash bills along with supporting prescription
q Reports of investigations done, Pathology/ Radiology/ Cardiology
q Original paid receipt towards the investigation charges
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CLAIM DOCUMENTS & FORMS
CHECKLIST FOR PRE-POST ( CASHLESS SCHEME)
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PROCEDURE TO SEND CLAIM FORM
In case of FIELD Employee
In case of NON-FIELD Employee
Field employee should courierthe Claim Form along with allrequired documents to thefollowing address:
HR DepartmentRajplazaLBS RoadVikhroli WestMumbai 400083
The envelop should be markedas HOSPITALIZATION CLAIM
Non field employee has to put claim form along with all required documents in drop box provided at HR department of respective Unit. Further Unit HR will forward the same to HR department at Rajplaza, Vikhroli.
Claim forms will be collected by themember of the Insurance companyon every Tuesday & Friday fromRajplaza Vikhroli
24 X 7 Helpline
1800 22 5858 (Toll free MTNL / BSNL)
1800 102 5858 (Toll free Airtel / Bharti)
1800 209 5858 (Toll free Any Landline /
Mobile)
020 30305858 (STD)
Claim Tracker: https://general.bajajallianz.com/BagicNxt/b2c/cus
tomer/claim_enquiry_new.jsp
CONTACT DETAILS
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HEALTH ADMINISTRATION TEAM(BAJAJ ALLIANZ) CIPLA HELP DESK
Mr J V [email protected]
Ms Pratiksha Bhosale9870386478(022)-23025848 [email protected]
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FAQs
What is a Health Card? What are its benefits?
A health card is a card that comes along with the Policy. It is similar to an
Identity card. This card would entitle you to avail cashless hospitalization
facility at any of our network hospitals. All members are eligible for the health
card
What are Network hospitals?
The hospitals which have a tie up with your insurer would come under the
category of network hospital. The network hospital provides cashless
facilities to the insured on approval by the insurer. The insured while getting
admitted shall provide health card to the hospital administration. The
hospital will seek approval for treatment on your behalf. If approved, the
payments will be settled by insurer subject to the cover taken by the insured.
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What are non-network hospitals?
The hospitals which have no tie-up with the insurer are called non-network
hospitals. If the insured seeks treatment in any of the non-network
hospitals, the bills have to be settled by the insured himself. However the
hospitalization expenses are reimbursed by submitting claim forms along
with other documents to the insurer.
Why prefer network hospitals over non-network hospitals?
If you are admitted to a non-network hospital you need to settle the hospital
bills yourself and then submit the hospitalization documents along with the
claim form for reimbursement of hospitalization expenses.
FAQs
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We aim to Secure Your & Your Family’s Health with the Right Insurance…