Presentation on theme: "Policy no Policy period Insurer TPA"— Presentation transcript:
1Presentation on Employee Benefits Shobiz Experiential Communications Pvt Ltd
2Policy no Policy period Insurer TPA Policy no160900/12001/2011/APolicy period22-Apr-2012 to 21-Apr-2013InsurerApollo MUNICH Health Insurance Co LtdTPAFamily Health Plan Limited
3Policy details Coverage Details Persons CoveredEmployee, Spouse, and 2 childrenPre/Post Hospitalizations30 days/ 60 daysSub- Limit for MaternityTypeSublimitsNormalRs.35000/-CaesarianRs.50000/-Pre/Post natal expensesa)OPD basis Rs.2500/- upto the maternity sub-limit - b) Inpatient- Upto maternity limitb) New Born is cover from day one . Expenses on New Born Baby Prior to discharge from Hospital is covered upto Rs of the Maternity sublimitLocal Ambulance Charges1% of SI subject to a maximum of Rs.2000/- per person per policy whichever is lessSpecial ConditionDaily room rent restricted to 1% of the in-patient Sum Insured, if admitted to regular roomDaily room rent restricted to 2% of the in-patient Sum Insured, if admitted to ICUFamily FloaterFamily floater of Rs. 2 Lacs, Rs.5 Lacs and 10 Lacs
4Dependents of Existing Employees Dependent of Future Employees Policy detailsExisting EmployeesDependents of Existing EmployeesFuture EmployeesDependent of Future EmployeesPre Existing ExclusionsWaived1st Year Exclusions30 days waiting period9 Months waiting period
5Issuance of member ID card Physical card will be issued to each and every member and their dependents enrolled in the policyCorporate Login id will be provided to HR for access of the policy details.
6Cashless Claim Procedure (Network Hospitals) Fill in the pre – authorization form – available at TPA desk of network hospitalsFax the form to: 022 –Authorization for cashless facility will be issued at Network Hospitals only, subject to the policy conditionsContact points from FHPL - Ms. Bijal KansaraTAT 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.
7Reimbursement 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 7daysTAT for releasing claim payment 15 days from submission of all the documents,Documents mentioned in check list to be submitted in originalsClaims will not be processed with deficiency of documentsChecklist of Enclosures for Submission of Claim (MRC )Duly Filled claim formDischarge SummaryFinal bill and complete bill break upPayment receiptFirst consultation letter and subsequent PrescriptionsOriginal Bills, original payment receipts and reports for InvestigationsOriginal Medicine bills and receipts with corresponding PrescriptionsOriginal invoice/bills for implants with original payment receipts
8Reimbursement 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
9Reimbursement 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 KansaraFamily Health Plan Ltd.Gala no. 24, Adhyaru Industrial EstateSun Mills Compound,Lower Parel (W)Mumbai
10ExclusionsNo Claims shall be payable in respect of any Insured Person directly orindirectly for, caused by, arising from or in any way attributable to any of thefollowing.Caused by or attributable to WarAny 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.
11Exclusions Drugs consumption Psychiatric or mental disorders AIDS Dental TreatmentPlastic/Cosmetic surgeryAny non-allopathic treatment.* For complete exclusion list please refer group health policy wordings
12Toll Free no/Customer ID Apollo Munich HealthFHPL