Policy no /12001/2011/A Policy period 22-Apr-2012 to 21-Apr-2013 Insurer Apollo MUNICH Health Insurance Co Ltd TPA Family Health Plan Limited
Policy details Coverage Details Persons CoveredEmployee, Spouse, and 2 children Pre/Post Hospitalizations30 days/ 60 days Sub- Limit for Maternity TypeSublimits NormalRs.35000/- CaesarianRs.50000/- Pre/Post natal expenses a)OPD basis Rs.2500/- upto the maternity sub-limit - b) Inpatient- Upto maternity limit b) New Born is cover from day one. Expenses on New Born Baby Prior to discharge from Hospital is covered upto Rs of the Maternity sublimit Local Ambulance Charges 1% of SI subject to a maximum of Rs.2000/- per person per policy whichever is less Special Condition Daily room rent restricted to 1% of the in-patient Sum Insured, if admitted to regular room Daily room rent restricted to 2% of the in-patient Sum Insured, if admitted to ICU Family FloaterFamily floater of Rs. 2 Lacs, Rs.5 Lacs and 10 Lacs
Policy details Existing Employees Dependents of Existing Employees Future Employees Dependent of Future Employees Pre Existing Exclusions Waived 1st Year Exclusions Waived 30 days waiting period Waived 9 Months waiting period Waived
Issuance of member ID card Physical card will be issued to each and every member and their dependents enrolled in the policy Corporate Login id will be provided to HR for access of the policy details.
Cashless Claim Procedure (Network Hospitals) Fill in the pre – authorization form – available at TPA desk of network hospitals Fax the form to: 022 – Authorization for cashless facility will be issued at Network Hospitals only, subject to the policy conditions Contact points from FHPL - Ms. Bijal Kansara TAT for Pre-authorization: 4 hours from receipt of pre-authorization request from hospital, subject to complete information. Authorization latter will be approved for a particular amount, as per policy terms & conditions, and faxed back to the hospital.
Reimbursement Claim Procedure (Non-network Hospitals) Claim documents will be sent to the TPA – Family Health Plan Ltd. A copy of all original documents sent should be maintained with the dealers to enable tracking of documents if required. TAT for processing 7days TAT for releasing claim payment 15 days from submission of all the documents, Documents mentioned in check list to be submitted in originals Claims will not be processed with deficiency of documents Checklist of Enclosures for Submission of Claim (MRC ) – Duly Filled claim form – Discharge Summary – Final bill and complete bill break up – Payment receipt – First consultation letter and subsequent Prescriptions – Original Bills, original payment receipts and reports for Investigations – Original Medicine bills and receipts with corresponding Prescriptions – Original invoice/bills for implants with original payment receipts
Reimbursement Claim Procedure (Non-network Hospitals) In the Case of Road Traffic Accident( in addition to above documents) – Copy of the First Information Report from police department / Copy of Medico legal certificate. – Treating doctors certificate giving details of injuries( How, when and where injury sustained) In Accidental Death cases ( in addition to above documents) – Copy of Post Mortem Report and Death Certificate. All above documents should be in original
Reimbursement Claim Procedure (Non-network Hospitals) Intimation of hospitalisation should be given to FHPL within 48 hrs of the admission in the hospital. Documents should be submitted in original at the following address within 30 days from the date of discharge. Ms. Bijal Kansara Family Health Plan Ltd. Gala no. 24, Adhyaru Industrial Estate Sun Mills Compound, Lower Parel (W) Mumbai
Exclusions No Claims shall be payable in respect of any Insured Person directly or indirectly for, caused by, arising from or in any way attributable to any of the following. Caused by or attributable to War Any Insured Person committing or attempting to commit a criminal or illegal act, or intentional self injury or attempted suicide while sane or insane. Any Insured Person ’ s participation or involvement in naval, military or air force operation, racing, diving, aviation, scuba diving, parachuting, hang-gliding, rock or mountain climbing.
Exclusions Drugs consumption Psychiatric or mental disorders AIDS Dental Treatment Plastic/Cosmetic surgery Any non-allopathic treatment. * For complete exclusion list please refer group health policy wordings
Toll Free no/Customer ID Toll Free NoCustomer ID Apollo Munich Health
Escalation matrix Level -1Level - 2 FHPLMs. Bijal Kansara Mr. Abhishek Yadav Apollo Munich Mr. Jitender Kumar Mr. Padmesh Nair