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Insurance Claim Manual

The Medical E-card and Reimbursement forms are available under the Medical e-card no tab. The process for filling the re-imbursement forms will be available when medical E-card no is clicked. Use google chrome to login to the ESS portal to know about the mediclaim process, e-card download, claim process etc. Please do not use internet explorer as the portal works only in google chrome.

Please click on the respective tabs to view the below details: Medical E-card and Number/ Forms To add dependent details Mediclaim process.

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Reimbursement Process Admission procedure:

In case you choose a non-network hospital, you will have to liaise directly for admission.

Intimation: In case of all reimbursement claims intimation has to be provided within 24 hrs from the date of admission

Discharge procedure:

In case of non network hospital, you will be required to clear the bill, please ensure that you collect all necessary documents

such as discharge summary, Hospital bills/receipts along with break ups, investigation reports, prescription, medicine bills

etc. for submitting your claim.

Submission of hospitalization claim:

You must submit the claim Papers within 7 days from the date of discharge from the hospital & 60 days from date of

discharge in case of claim of post hospitalization.

All queries on claim documentation received from Insurer/TPA should be satisfactorily answered within 15 days from the

date of deficiency letter.


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Standard Hospitalization Reimbursement of expenses related to

Room and boarding Expenses as incurred at the hospital/nursing home

Nursing Expenses

Surgeon anesthetist medical practitioner consultants specialists fees

Anesthesia Blood Oxygen operation theatre charges, surgical appliances

Drugs and medicines diagnostic materials consumed on the premises

x-ray dialysis, chemotherapy, radiotherapy cost of pacemaker artificial

A) The expenses shall be reimbursed provided they are incurred in India and within the policy period. Expenses will be reimbursed to the covered member depending on the level of cover that he/she is entitled to.

B) Expenses on Hospitalization for minimum period of 24 hours are admissible. However this time limit will not apply for specific treatments i.e. day care procedures like cataract, dialysis etc.

C) Hospitalization must be registered as per Nursing Act and/or must have min. 15 beds registered with relevant authorities.


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Pre & Post Hospitalization expenses

Pre-hospitalization Expenses Covered

Definition

If the Insured member is diagnosed with an Illness which results in his / her Hospitalization and for which the Insurer accepts a claim, the Insurer will also reimburse the Insured Member’s Pre-hospitalization Expenses for up to 30 days prior to his / her Hospitalization.

Covered Yes

Duration 30 Days

Post-hospitalization Expenses Covered

Definition

If the Insurer accepts a claim under Hospitalization and immediately following the Insured Member’s discharge, further medical treatment directly related to the same condition for which the Insured Member was Hospitalized is required, the Insurer will reimburse the Insured member’s Post-hospitalization Expenses for up to 60 day period.

Covered Yes

Duration 60 Days


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Customized Benefits Pre existing diseases

Definition

Any Pre-Existing Condition or related condition for which care, treatment or advice was recommended by or received from a Doctor or which was first manifested prior to the commencement date of the Insured Person’s first Health Insurance policy with the Insurer

First 30 day waiting period

Definition

Any disease contracted by the Insured Person (except for the “First Year diseases” listed below) during the first 30 days from the commencement date of the Policy is not covered. This exclusion shall not apply if in the opinion of Panel of Medical Practitioners constituted by the Company for the purpose, the Insured person could not have known of the existence of the Disease or any symptoms or complaints thereof at the timer of making the proposal for insurance to the Company.

First Year Waiting period

Definition

During the first year of the operation of the policy, the expenses on treatment of diseases such as Cataract, Benign Prostatic Hypertrophy, Hysterectomy for Menorrhagia or Fibromyoma, Hernia, Hydrocele, Congenital Internal Diseases, Fistula in anus, Piles, Sinusitis and related disorders are not payable. If these diseases are pre- existing at the time of proposal, they will not be covered even during subsequent period or renewal too.


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General Exclusions Injury or disease directly or indirectly caused by or arising from or attributable to War or War-like situations

Circumcision unless necessary for treatment of disease

Any non-medical expenses like registration fees, admission fees, charges for medical records, cafeteria

charges, telephone charges, etc

Any hospitalization to undergo permanent contraception

Dental treatment of any kind unless requiring hospitalization

HIV and AIDS

Hospitalization for convalescence, general debility, intentional self-injury, use of intoxicating drugs/ alcohol.

Venereal diseases

Injury or disease caused directly or indirectly by nuclear weapons

Naturopathy

Cost of spectacles, contact lenses, hearing aids

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

Voluntary termination of pregnancy during first 12 weeks (MTP)

Domiciliary Hospitalization


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Cashless Hospitalization Cashless hospitalization means the Administrator may authorize (upon an Insured person’s request) for direct settlement of

eligible services and the corresponding charges between a Network Hospital and the Administrator. In such case, the

Administrator will directly settle all eligible amounts with the Network Hospital and the Insured Person may not have to pay

any deposits at the commencement of the treatment or bills after the end of treatment to the extent these services are covered

under the Policy.

Step 1 Pre-Authorization

All non-emergency hospitalization instances must be pre-authorized with the Help Desk, as per the procedure detailed below. This is done to ensure that the best healthcare possible, is obtained, and the Insured Member is not inconvenienced when taking admission into a Network Hospital.

Step 2 Admission, Treatment & discharge

After your hospitalization has been pre-authorized, you need to secure admission to a hospital. A letter of credit will be issued by TPA to the hospital. Kindly present your E- card at the Hospital admission desk. The Insured Member is not required to pay the hospitalization bill in case of a network hospital. The bill will be sent directly to, and settled by, Insurer

Note: - Patients seeking treatment under cashless hospitalization are eligible to make claims under pre and post hospitalization expenses. For all such expenses, the bills and other required documents need to be submitted separately as part of non-cashless claims.


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Pre-Authorization

Member intimates Hospital of the planned hospitalization in a specified pre-authorization format (available at hospital desk) 48 hours prior to hospitalization

Claim Registered by the TPA on same day

Follow non cashless process

No

TPA issues letter of credit within 12 hours for planned hospitalization to the hospital

Yes Process Complete


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Admission, Treatment & Discharge

Member produces E-card at the network hospital and gets admitted

Member gets treated and hospital sends complete diagnosis & bills to TPA for approval, on receipt of authorization from TPA members gets discharge .

Claims Processing by Insurer

Release of payments to the Hospital


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Emergency Hospitalization

Step 1 Get Admitted

Step 2 Pre-Authorization by hospital

Step 3 Treatment & Discharge

In cases of emergency, the member should get admitted in the nearest network hospital.

Relatives of admitted member should show ID card and start pre authorization procedure within 24 hours of hospitalization. The pre authorization letter would be directly given to the hospital by TPA, In case of any further documents or queries TPA will contact to hospital asking the same.

On completion of treatment and at time of discharge hospital sends final diagnosis and final bill to TPA for approval .on receipt of final authorization the employee is not required to pay the hospitalization bill.

Link for List of Hospitals Mediassist - https://tpa.mediassistindia.com/network.htm ICICI Lombard - https://www.icicilombard.com/Content/ilom-en/Hospital_list/search.asp

https://tpa.mediassistindia.com/network.htm


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Claims Document List No. Document Required

1 Duly Completed Claim form.

2 Main hospital bills in original (with bill no; signed and stamped by the hospital) with all charges itemized and the original receipts .

3 Discharge card (original).

4 Attending doctors’ bills and receipts and certificate regarding diagnosis (if separate from hospital bill).

5 Original reports or attested copies of bills and receipts for medicines, investigations along with doctors prescription in original and laboratory .

6 Follow-up advice or letter for line of treatment after discharge from hospital, from doctor.

7 Break up with details of pharmacy items, materials, investigations even though it is there in the main bill.

8 In case the hospital is not registered, please get a letter on the hospital letterhead mentioning the number of beds and availability of doctors and nurses round the clock.

9 In case of non- network hospitalization, please get the hospital and doctor’s registration number in hospital letterhead and get the same signed and stamped by the hospital.

10.

The procedure for lodging the claim shall be as under: Upon the happening of any event giving rise or likely to give rise to a claim under this policy : a) The Insured shall give immediate notice thereof in writing to the Company. b) The Insured shall deliver to the Company, within 30 days from the date of completion of treatment, a detailed statement in writing as per the claim form together with bills, vouchers and any other material particular, relevant to the making of such claim. c) The Insured shall tender to the Company all reasonable information, assistance and proofs in connection with any claim hereunder.


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Group Personal Accident – Benefit Details

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Policy Benefit Coverage's

Permanent Total Disablement Covered

Permanent Partial Disablement Covered

Temporary Total Disablement (Weekly Benefit) Covered

Accidental Temporary Total Disablement Means disablement caused due to an accident which temporarily and totally prevents the Insured Person from attending to the duties of his usual business or occupation and shall be payable during such disablement from the date on which the Insured person first became disabled. Accidental Permanent Total Disablement Means disablement caused due to an accident which entirely prevents an Insured Person from attending to any Business or Occupation of any and every kind and which lasts 12 months and at the expiry of that period is beyond hope of improvement. Accidental Permanent Partial Disablement Doctor certified total and continuous loss or impairment of a body part or sensory organ caused due to an accident , to the extent specified in the chart on the next slide.


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Group Personal Accident – Key Exclusions

Suicide, attempted suicide (whether sane or insane) or intentionally self-inflicted Injury or illness, or sexually transmitted conditions, mental or nervous disorder, anxiety, stress or depression, Acquired Immune Deficiency Syndrome (AIDS), Human Immune-deficiency Virus (HIV) infection; or

Being under the influence of drugs, alcohol, or other intoxicants or hallucinogens unless properly prescribed by a Physician and taken as prescribed; or

Participation in an actual or attempted felony, riot, crime, misdemeanor, (excluding traffic violations) or civil commotion; or

Operating or learning to operate any aircraft, or performing duties as a member of the crew on any aircraft; or Scheduled Aircraft.; or

Self exposure to needless peril (except in an attempt to save human life);

Loss due to child birth or pregnancy.


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Group Personal Accident – Document Check List

Weekly Benefit / Temporary Disability Claims

Disablement Claims

Document Details

1 Completed Claim form

2 Doctor's Report

3 Disability Certificate from the Doctor, if any

4 Investigation/ Lab reports (x-ray etc.)

5 Original Admission / discharge card, if hospitalized

6 Employers Leave Certificate & Details of salary

Document Details

1 Completed Claim form

2 Doctor's Report

3 Disability Certificate from the Doctor, if any

4 Investigation / Lab reports (x-ray etc.)

5 Original Admission / discharge card, if hospitalized

6 Police Inquest report, wherever applicable

This is an indicative list of documents and there may be additional documents required by the insurer. It is mandatory to provide the details for nomination of beneficiary.


Thank You

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