Reliance

1
Reliance HealthWise Policy
December 2006
2
Agenda

1. Introduction - Clinical Indian Health Industry
   and Health Insurance
2. Product Offering Reliance HealthWise Policy
3. Underwriting Overview
4. Claims Overview

3
Introduction

• Health Risks could arise from various factors
  such as
• Physical Condition
• Psychological Conditions
• Occupation
• Lifestyle Related Factors
• Growing concern over prevalence of chronic
  illnesses in India
• obesity
• heart-illnesses
• diabetes and hypertension among others
• These factors will have significant impact on the
  health-care cost.

4
Our Life Style.. A Ticking Time Bomb

• Tremendous change in our life style
• More nuclear familiesmore responsibilities
• Late working
• Extreme work pressures
• No time for self
• Not eating on timeeating out
• Eating unhealthy.junk food
• High inflation.everything getting expensive

5
Our Life Style.. A Ticking Time Bomb

• Alarming Symptoms
• Increased risk of falling sick
• More and more younger people fall sick
• One has to pay heavily for medical treatments
• Medical costs directly affect ones hard earned
  savings
• Savings which were meant for important needs is
  drained on medical expenses

6
Our Daily Solemn Promise what we should do

• Every day I promise to myself
• I will get up early and go for a walk
• I will come home early after office
• I will eat on time
• I stop drinking..Ok ..Only a little bit
• I will eat healthy, absolute NO to junk food
• Go to a gym..Take care of my health
• I will sleep early

As Promises are meant to be broken..so I break
them every day!!
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The Next Best Alternative.

• Its never too
• early to
• plan for future..
• Health Insurance

8
Need for Health Insurance

• Urban Lifestyle and Rural Infrastructure support
• Inadequate Facilities in Government Hospitals
• Privately run hospitals are expensive
• Increased cost of medication
• Diagnostic Expenses have spiraled
• Specialist Doctors come expensive
• Increasing Population with income disparity
• More nucleus family means less savings and less
  disposable income
• Changing disease profile and lack of Medical
  Information

9
Current Market Scenario

• Only 85m people in India are covered under Health
  Insurance
• Among them, only 10.8m are covered by Insurance
  Companies
• The rest are covered under government and company
  schemes
• Contributes to 9.6 of the general insurance
  market
• Intense competition among the public and private
  players
• Historically perceived as a loss making portfolio
• Lack of spread of risk
• Lack of adequate Underwriting guidelines
• Inadequate claims control
• High perceived fears of fraud and abuse
• Very little variation in product and price among
  the insurance providers
• Inadequate distribution
• Coverage of Pre-existing diseased - still a
  question

10
Healthcare Opportunity in India - Mckinsey report

• Healthcare spending in the next 10 years will
  Double
• Healthcare spending will increase to 2,00,000
  crores by 2012 (Rs.86,000 crores in 2000-01)
• Health care insurance sector is to become a
• Rs 25,000 crore industry by 2009 (Rs.1200 crores-
  in 2001-02)
• Rs 75,000 crore by 2020

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The Way Forward.

• Increased customer awareness for more spread of
  insurance
• Higher standards of customer service
• Popularisation of Floater Concept
• Reduction of Claim Ratio through efficient
  underwriting guidelines/ control / product
  offerings / spread of risk
• Value Adds and Increased Features which further
  sweetens the product
• Affordable pricing cross subsidize across age
  categories
• Increased Marketing Communication
• Increased Cashless Coverage through TPA
• Ensure Hassle-Free Policy Issuance and Claim
  Procedures
• Inclusion of Preventive elements

12
Agenda

• Introduction - Clinical Indian Health Industry
  and Health Insurance
• Product Offering Reliance HealthWise Policy
• Underwriting Overview
• Claims Overview

13
What is Reliance HealthWise Policy?

• Reliance HealthWise Policy provides for .

Financial Assistance for you and your family
against Hospitalisation Expenses towards disease
/ illness / injury in India along with host of
value additions / options
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Reliance HealthWise Policy

1. Basic Features
2. Value Added Features
3. Policy Features
4. Exclusions
5. Plan Details
6. Our Advantage

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1. Basic Features

1. Hospitalisation Expenses
2. Daycare Treatment
3. Domiciliary Hospitalisation
4. Pre and Post Hospitalisation
5. Coverage of Pre-Existing Diseases
6. Critical Illness Cover
7. Donor Expenses

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1.a. Hospitalisation

• Covers hospitalisation expenses incurred as an
  in-patient in a Hospital which will include
• Room, Boarding and Operation Theatre charges
• Fees of Surgeon, Anesthetist, Nurses, Specialists
  
• The cost of diagnostic tests, medicines, blood,
  oxygen, appliances like pacemaker, artificial
  limbs and organs etc
• Hospitalisation for a minimum period of 24 hours
  is a must

The cover provided is to a maximum of the Sum
Insured as selected by the Customer
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1.b. Day Care Treatment

• Hospitalisation less than 24 hrs
• Due to advancement of technology, hospitalisation
  expenses for certain treatments / diseases like
  the following are also covered, even though the
  hospitalisation is for less than 24 hours

• Cardiac Catheterization
• Cataract
• Chemotherapy
• Coronary Angiography
• Coronary Angioplasty
• Dialysis

• Dilation Curettage
• Eye Surgery
• Hernia Repair Surgery
• Hydrocele Surgery
• Lithotripsy (Kidney stone removal)
• Radiotherapy
• Tonsillectomy

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1.c. Domiciliary Hospitalisation

• Medical Treatment at your Home
• Medical Treatment for a period exceeding three
  days, which in the normal course, would require
  hospitalisation, but treatment is actually taken
  at home, under any of the following
  circumstances -
• the condition of the patient does not permit
  him/her to be removed to Hospital or
• the patient cannot be admitted to Hospital for
  lack of accommodation therein
• This benefit also covers expenses on employment
  of a qualified nurse, as recommended by the
  attending Doctor.

The cover provided is to a maximum of 10 of the
Sum Insured as selected by the customer
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1.d. Pre and Post Hospitalisation

• Extended Pre and Post Hospitalisation
• Policy also covers relevant medical expenses
  incurred during a specified period, before
  after hospitalisation (for which a claim is
  payable)

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1.e. Coverage of Pre-Existing Diseases

• Pre-Existing Diseases Coverage
• Hospitalisation expenses incurred on treatment
  towards Pre-existing diseases / condition can be
  covered
• Gold Plan after completion of 2 consecutive
  years of the policy period
• Silver Plan after completion of 2 consecutive
  years of the policy period
• Standard Plan after completion of 4 consecutive
  years of the policy period

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1.f. Critical Illness Cover

• Double Sum Insured Benefit
• If Insured contracts any of the following nine
  Critical Illnesses, the Sum Insured under the
  Policy (chosen by the Insured), is doubled
  towards hospitalisation expenses incurred for
  treatment of such Critical illness.
• Cancer
• Coronary Artery Bypass Surgery
• First Heart Attack
• Kidney Failure
• Multiple Sclerosis
• Major Organ Transplant
• Stroke
• Aorta Graft Surgery
• Paralysis
• Primary Pulmonary Arterial Hypertension

This feature is available only in Gold Plan
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1.g. Donor Expenses

• Major Organ Transplant
• Covers hospitalisation expenses towards donor in
  case of major organ transplant.

This feature is available to customers of Gold
and Silver Plans
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2. Value Added Features
Value added benefits are payable up to the Sum
Insured for the plan opted.

1. Expenses on accompanying person at the Hospital
2. Local Road Ambulance Services
3. Recovery Benefit
4. Cost of Health Check up
5. Nursing Allowance
6. Hospital Daily Allowance

These features become applicable once a valid
claim is admitted under the basic hospitalisation
expenses cover of the Policy
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2.a. Expenses on Accompanying Person

• Payment towards expenses incurred by an
  accompanying person at the hospital while Insured
  is hospitalised for a minimum period of 5 days.
• Gold Plan Rs. 300/- per day for a maximum of 5
  days
• Silver Plan Rs. 250/- per day for a maximum of
  5 days
• Standard Plan Rs. 200/- per day for a maximum
  of 5 days

This is a common feature available to all
Policyholders
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2.b. Local Road Ambulance Services

• Reimbursement of Expenses incurred for necessary
  transportation of the insured to the Hospital in
  an ambulance for hospital admission and requiring
  immediate treatment.
• Maximum limit
• Gold Plan Rs. 1000/-
• Silver Plan Rs. 750/-
• Standard Plan Rs. 500/-

This is a common feature available to all
Policyholders
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2.c. Recovery Benefit

• In an unfortunate event, if the Insured is
  hospitalised for more than 10 consecutive days, a
  lump sum benefit of Rs. 10,000 will be payable as
  Recovery Benefit.
• Basic Hospitalisation claim is enough. No need to
  provide for bills as this is a benefit payment.
• This benefit is applicable for
• All the members of the floater separately
• Irrespective of the number of occurrence during
  the policy period

This feature is available only to customers of
Gold Plan
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2.d. Cost of Health Check up

• This benefit provides for reimbursement of cost /
  charges incurred for medical check up.
• Applicable once at the end of a block of 4
  claim free years.
• Reimbursement is limited to 1.25 of the
  average sum insured.

This is a common feature available to all
Policyholders
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2.e. Nursing Allowance

• Payment of Nursing Allowance for expenses towards
  employment of registered nurse at the residence
  of Insured or at the Hospital provided such
  services are
• Confirmed as being necessary by the treating
  Physician
• Relate directly to a disease / illness / injury
  for which the Insured has been hospitalised.
• This is applicable irrespective of the number of
  times of occurrence
• Allowance is payable for 5 days. In case of
  Critical Illness under Gold Plan this is payable
  for 10 days.
• Gold Plan Rs 300/- per day
• Silver Plan Rs. 250/- per day

This feature is available to customers of Gold
and Silver Plans
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2.f. Hospital Daily Allowance

• Daily Hospital Allowance of Rs. 250 per day up to
  7 days will be paid to Insured, provided he/she
  is hospitalised for more than 3 days.
• It is irrespective of the number of
  occurrences
• If case two people of the same floater are
  hospitalised, concurrently, each one of them
  will be eligible for hospital daily allowance
  separately

This feature is available only for Gold Plan
customers
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3. Policy Features

1. Income Tax Benefit
2. Family Floater
3. Sum Insured
4. Pre-insurance Health Check up
5. Option in Policy Duration
6. Renewal Discount
7. Cashless Facility (Through Third Party
   Administrators - TPA)
8. Age Slabs

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3.a. Income Tax Benefit

• Premium paid for Reliance HealthWise Policy is
  eligible for tax deduction under section 80 D of
  the Income Tax Act, subject to the condition that
  the premium amount is paid by cheque/DD by the
  customer from his bank account.
• Rs. 10,000/- for self, spouse, kids and parents
• Rs. 15,000/- if the policy includes senior
  citizens whose ages is above 65 yrs

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3.b. Family Floater

• Policy can be issued on a Floater basis covering
  the family members of the Insured comprising the
  Insured, spouse and two dependant children (upto
  the age limit of 21 years).
• What is floater, how does it benefit?
• All members of the family (Self, Spouse, 2 Kids)
  can be covered under one single policy
• Single premium payable for the entire family
• The amount of Sum Insured floats over the
  entire family
• No need to insure individual members separately
• No hassles of tracking renewals for different
  members

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3.b. Family Floater - Illustration

• Family Mr. Ashish Sethi, Mrs. Sethi their kid
  Nikki
• Scenario 1
• They take an insurance policy with a SI of Rs.1
  Lakh each
• Mr. Sethi unfortunately needs to undergo
  angioplasty
• The total bill amount Rs. 1.4 lakhs
• Insurance company pays only Rs. 1 Lakh as he is
  covered for only 1 Lakh. He cannot adjust the
  rest in the unused coverage amount of his wife
  and daughter
• Mr. Sethi needs to bear the reminder of the cost
  i.e. Rs, 40,000!!

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3.b. Family Floater - Illustration

• Family Mr. Ashish Sethi, Mrs. Sethi their kid
  Nikki
• Scenario 2
• They take a Reliance Healthwise Policy with a SI
  of Rs. 3 Lakh for the family
• Mr. Sethi unfortunately needs to undergo
  angioplasty
• The total bill amount Rs. 1.4 lakhs
• The entire amount is paid for by Reliance
  HealthWise Policy
• Mr. Sethi does not need shell out any money out
  of his own picket

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3.b. Your Choice!

• OR

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3.b. Advantage Floater!

• Chance of all in the Sethi family falling ill in
  one year is low as compared to one member falling
  severely ill Theory of probability

Individual Floater
Single cover for each member Common cover for all members
No flexibility to transfer the unutilized limit for other members The limit can be used by any member of the family for any number of times
Separate policy (separate document) for family members Single document, single premium, single date to track
Premium payment annual in nature For the 2 year option, premium payment once in 2 years (at the beginning)
Currently, all plans annual in nature Floater plan available for one/two years..so assured zero hassle renewal next year
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3.b. Fits all in the Family

• Family covered under floater policy
• Choice to cover
• Individual
• Couple
• Couple One kid
• Couple Two kids
• Choice of cover amount
• Rs. 1 to 5 Lakh per family depending on the plan
  selected

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3.c. Sum Insured

• Wide range of Sum Insured option depending upon
  his medical requirement
• Gold Plan 1 lac, 2 lac, 3 lac, 4 lac, 5 lac
• Silver Plan 1 lac, 2 lac, 3 lac, 4 lac, 5 lac
• Standard Plan 1 lac, 2 lac, 3 lac, 4 lac, 5 lac

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3.d. Two Year Policy Option

• The Reliance HealthWise Policy offers to the
  Insured an option of
• 1 year Policy
• 2 years Policy
• If two year policy option is taken.
• No worries for the insured members regarding
• Any price increase
• Remembering to renewing the policy again next
  year
• Premium to be paid for 2 years at the beginning
  itself

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3.e. Pre-insurance health Check up

• No medical tests required at enrollment stage for
  family members under the age of 45 and the Policy
  is issued immediately based on proposal form and
  declaration
• Applicants above 45 yrs will be covered only
  after completion of medical tests, submission of
  reports and the approval of Underwriting team

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3.f. Renewal Discounts

• A renewal discount of 5 on the renewal premium
  will be allowed, in case no claim is made during
  the expiring policy period
• This renewal discount can be accumulated upto a
  maximum of 50

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3.g. Cashless Facility (Through TPA)

• Each Policy holder will get a Health Card
• Using Health Card the Insured can avail of
  Cashless Hospitalisation facility through
  contacting the TPA
• Cashless facility is available in over 3000
  networked hospitals across the country
• TPA provides assistance in
• Cashless hospitalisation
• Information on Claims status
• Information on Hospitals
• 24 hour helpline

(TPA - Third Party Administrators)
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3.h. Age Slabs Applicability

• Anyone between the age of 3 months to 65 yrs can
  be covered under the various plans
• No fresh policy to be issued after 55 yrs in case
  of Gold Plan 60 yrs incase of Silver Plan 65
  yrs incase of Standard Plan
• 3 months - 45 yrs can be covered without
  Pre-insurance medical tests
• 46 yrs above Mandatory medical test necessary
  approval from the UW

Age band Coverage
3 months to 5 yrs Covered only along with either of the parents without any medical examination
6 years to 45 yrs Covered without any medical examination.
46-65 yrs Covered subject to satisfactory medical examination
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4. Exclusions

• First year Exclusions
• There are certain ailments which are not covered
  for the First year of inception of health
  insurance cover, but are covered subsequently
• Cataract
• Benign Prostatic Hypertrophy
• Myomectomy, Hysterectomy or menorrhagia or
  fibromyoma unless because of malignancy
• Dilation and curettage
• Hernia, hydrocele, congenital internal disease,
  fistula in anus, sinusitis
• Skin and all internal tumors/ cysts/nodules/
  polyps of any kind including breast lumps unless
  malignant /adenoids and hemorrhoids
• Dialysis required for chronic renal failure
• Gastric and Duodenal ulcers

This exclusion will not apply for roll over cases
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4. Exclusions

• Permanent Exclusion
• Disease/ Injury existing before inception of
  health insurance policy being pre-existing
  disease (however, these will be covered after 2nd
  year, depending on the choice of plan)
• Any disease contacted during the first 30 days of
  inception of policy accidents excluded and roll
  over cases excluded
• Naturopathy or other forms of local medication
• Pregnancy childbirth related diseases
• Intentional self-injury / injury under influence
  of alcohol, drugs
• Diseases such as HIV or AIDS
• Diseases existing from the time of birth
  (Congenital diseases)

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4. Exclusions contd..

• Cost of spectacles, contact lenses and hearing
  aids
• Dental treatment or surgery of any kind unless
  requiring hospitalization
• Charges incurred at Hospital or Nursing Home
  primarily for diagnostic without any treatment
• Expenses on vitamins and tonics unless forming
  part of treatment for disease or injury as
  certified by the medical practitioner
• Cosmetic, aesthetic, treatment unless arising out
  of accident
• Treatment related to obesity
• War, riot, strike, terrorism, nuclear weapons
  induced hospitalisation
• Routine medical, eye and ear examinations
• Treatment of mental illness

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Plan Comparison Basic Features
5. Plan Details
48
Plan Comparison Value added Benefits
5. Plan Details
49
Plan Comparison Policy Features
5. Plan Details
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6. Our 17 points Advantage!

1. Family Floater Option
2. Coverage of Pre-Existing Diseases after 2nd year
   of renewal
3. Automatic Double Sum Insured under Critical
   Illness cover
4. Policy duration for 2 years
5. Extended Pre and Post-hospitalisation
6. Wider Sum Insured options
7. Hospital Daily Allowance
8. Nursing Allowance
9. Recovery Benefit
10. Reimbursement of Cost of Health Check up after 4
    years
11. Local Road Ambulance Services
12. Expenses on Accompanying Person
13. Cashless Facility
14. Policy without Medical test till 45 yrs
15. Renewal Reward - No Claim Bonus
16. Income Tax Benefits

And you tell me the Last Advantage. The 17
advantage
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6. Our 17 points Advantage!

1. Instant Policy Issuance

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6. Reliance Healthwise Vs. Other Cos.
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6. Reliance Healthwise Vs. Other Cos.
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6. Reliance Healthwise Vs. Other Cos.
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Agenda

• Introduction - Clinical Indian Health Industry
  and Health Insurance
• Product Offering Reliance HealthWise Policy
• Underwriting Overview
• Claims Overview

56
Product Code

• Reliance HealthWise Policy
• Product Code - 28-25

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Proposal acceptance authority fresh proposal
Type of Proposal Age Band Acceptance Authority Acceptance Authority Acceptance Authority Medical Test
Type of Proposal Age Band Branch Office Regional Office Corporate Office Medical Test
Fresh Proposals 3 Mths - 45 Front Line Office can accept business based on clear proposal form where there is no pre-existing disease. Where proposal form states pre-existing disease, proposal form as to be referred to Regional Office Proposal referred to by the Front line office with pre-existing disease may be considered for acceptance based on underwriting. N A No Medical Required
Fresh Proposals 46 -55 RO can accept the proposal subject to medical examination. Only such medically cleared proposals are to be underwritten by the RO for this age group . Any deviation refer to CO CO may consider acceptance depending on merits of each case Medical Required
Fresh Proposals 56-65 (Applicable to Standard Silver Plans Only RO can accept the proposal subject to medical examination. Only such medically cleared proposals are to be underwritten by the RO for this age group . Any deviation refer to CO CO may consider acceptance depending on merits of each case Medical Required
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Proposal acceptance authority renewal /
rollover proposals
Type of Proposal Age Band Acceptance Authority Acceptance Authority Acceptance Authority Medical Test
Type of Proposal Age Band Branch Office Regional Office Corporate Office Medical Test
Renewals or Rollovers 3 Mths - 45 Proposal/Renewal with No Claim maybe accepted Proposal/Renewal with claim history may be consider based on underwriting No Medical Required
Renewals or Rollovers 46yrs -55 yrs Proposal/Renewal maybe accepted where there is "No Claim" Proposal/Renewal with claim history may be consider based on underwriting No Medical Required
Renewals or Rollovers 56 yrs 65yrs (Applicable to Standard Silver Plans Only Proposal/Renewal maybe accepted where there is "No Claim" Proposal/Renewal with claim history may be consider based on underwriting No Medical Required
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Endorsements - Non premium bearing endorsements

• Change in the following
• Correction in Name of the Insured and/or
  dependants (only spelling)
• Correction in Gender
• Correction/Change in Address
• Correction on Date of Birth provided no impact on
  the premium
• Correction in Relationship of the dependants
• Change in Nominee
• Cancellation of Policy due to dishonor of Cheque

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Endorsements - Premium bearing endorsements

• Endorsements resulting in Refund
• Cancellation
• at the request of the Insured (short period rate)
  subject to no claim policy.
• at the instance of the Insurance Company (pro
  rata basis)
• Deletion of Insured Members
• only in case of legal separation and/or demise of
  Spouse or demise of child
• premium to be refunded subject to no claim paid
• Change in Date of Birth of the oldest member of
  the family
• resulting in charging a lower premium due to
  reduction in age shall be done on receipt of
  written request from the Insured and proof of
  Date of Birth. (Proof of DOB can be Birth
  certificate, copy of Passport, Pan Card, driving
  license and the like)
• premium will be refunded pro rata basis

All the above are subject to UW approval
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Endorsements - Premium bearing endorsements

• Reduction in Period of Insurance
• No reduction on Period of Insurance is allowed
• Degradation of Plan
• No mid term degradation of plan to be allowed
• Decrease in Sum Insured
• No mid term decrease in Sum Insured to be allowed
• All the above are subject to UW approval

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Endorsements - Premium bearing endorsements

• Endorsements resulting in collection of
  additional premium
• Inclusion of dependants
• Mid term addition is allowed only in the
  following cases
• New Born Child ( to be intimated within 4 months
  of birth)
• Newly married Spouse, ( to be intimated within 2
  months of marriage)
• Premium in case of the above scenario to be
  collected on pro rata basis
• Under no other circumstances addition of family
  members is allowed
• 2) Change in Date of Birth of the oldest member
  of the family
• Resulting in charging a higher premium due to
  increase in age shall be done on receipt of
  written request from the Insured and proof of
  Date of Birth. (Proof of DOB can be Birth
  certificate, copy of Passport, Pan Card, driving
  license and the like)
• Premium will be colleted on pro rata basis

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Endorsements - Premium bearing endorsements

• 3) Increase in Period of Insurance
• No mid term increase in Period of Insurance is
  allowed
• 4) Upgradation of Plan
• No mid term upgradation of plan to be allowed
• 5) Increase in Sum Insured
• No mid term increase in Sum Insured to be allowed
• All the above are subject to UW approval

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Agenda

• Introduction - Clinical Indian Health Industry
  and Health Insurance
• Product Offering Reliance HealthWise Policy
• Underwriting Overview
• Claims Overview

65
Types of claims - Hospitalisation

• Claims can be broadly of two types
• Reimbursement claims
• Cashless claims
• This further can be broken into
• Planned - Where the customer is aware of the
  hospitalisation atleast 72 hours in advance
• Emergency - Where the customer meets with an
  accident or suffers from bout of illness that
  requires immediate admission to the hospital
• Claims are serviced at both network as well as
  non-network hospitals
• Network hospitals Hospitals which are on the
  tied up list (more than 3000 hospitals covered) -
  Where our service provider has a relationship
• Non-network hospitals which do not form part of
  the list

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Reimbursement - Steps to follow during
hospitalisation

• A) Emergency hospitalisation
• Step 1. Take admission into the hospital.
• Step 2. As soon as possible, inform TPA about the
  hospitalisation.
• Step 3. At the time of discharge, to settle the
  hospital bills in full and collect all the
  original bills, documents and reports.
• Step 4. Lodge the claim with TPA for processing
  and reimbursement by duly filling in the
  claim form enclosing all original
  bills/vouchers/receipts
• B) Planned hospitalisation
• Step 1. Inform TPA about the planned
  hospitalisation.
• Step 2. Get admitted into the hospital as
  planned.
• Step 3. At the time of discharge, to settle the
  hospital bills in full and collect all the
  bills, documents and reports.
• Step 4. Lodge the claim with TPA for processing
  and reimbursement by duly filling in the
  claim form enclosing all original
  bills/vouchers/receipts

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Reimbursement Claims - Claim procedure

• As soon as hospitalised, to intimate the TPA
  (Help line/Toll free number mentioned in the
  Health Card)
• Following information needs to be furnished while
  intimating a claim
• Contact Numbers
• Policy Number (as reflecting on the Health Card)
• Name of Insured person who is Sick or Injured
• Nature of Sickness/Accident
• Date Time in case of accident, commencement
  date of symptom of disease in case of sickness
• Location of accident

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Cashless Claims Procedure (Approval)

• Cashless Service is the service wherein the
  Insured need not pay any money at the time of
  admission or discharge.
• This facility is available only at our Network
  Hospitals
• To avail the Cashless Service
• Cashless Request Form available in network
  hospital (and in the H Kit) is to be filled up
  and sent to TPA for getting authorisation from
  TPA. The Hospital will coordinate for this.
• This authorisation along with a copy of the
  Health Card has to be given to the Network
  Provider at the time of admission
• Please also keep a copy of any photo ID card, it
  may be required by the Hospital.
• TPA will authorize Cashless Service at the
  Network Hospitals for all cases which are
  covered under the policy.

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Cashless Claims - Procedures (Denial)

• Cashless Service may be denied in following
  situations
• In case of any doubt in the coverage of treatment
  of present ailment under the Policy
• If the information sent to TPA is insufficient to
  confirm coverage
• The ailment/condition etc. not being covered
  under the policy
• If the request for pre-authorisation is not
  received by TPA in time
• Denial of Cashless Service is not denial of
  treatment. The Insured can continue with the
  treatment, pay for the treatment to the hospital
  and after discharge send the claim to TPA for
  processing.

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Cashless Claims - Procedures for emergency
hospitalisation

• Rush to hospital and get admitted.
• Obtain the Pre-Authorisation Form from the
  hospital (if it network).
• Get the same filled in signed by the attending
  doctor with required details.
• Fax the pre-authorization form along with
  necessary medical details to TPA at the number
  mentioned in health card. The Hospital will
  coordinate for this.

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Cashless Claims - Procedures for emergency
hospitalisation

• If pre-authorisation is received from the TPA for
  Cashless Service
• At the time of discharge.
• Verify the bills and sign on all the bills at the
  Hospital.
• Pay only for those items that are not
  reimbursable under the Policy (Hospital / TPA
  will guide in this).
• Leave the original discharge summary other
  investigations reports with the hospital. Retain
  a Xerox copy for records.

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Cashless Claims - Procedures for Planned
hospitalisation

• Coordinate with hospital send in all the
  details along with the Pre-Authorisation Form at
  least 2 days prior to the hospitalisation
  including the plan of treatment, cost estimates
  etc. to TPA.
• If Cashless Service is authorised by TPA
• At the time of admission, handover in the
  authorisation letter of TPA for cashless service
  a photocopy of ID card to the hospital.
• At the time of discharge
• Verify the bills and sign on all the bills.
• Pay only for those items that are not
  reimbursable under the Policy.
• Leave the original discharge summary, other
  reports with the hospital. Retain a Xerox copy
  for records.

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fast forward better living
74
Thank you
December 2006