Voluntary Mediclaim Policy : Parents

1
Voluntary Mediclaim Policy Parents Parents
In-law
Benefits Manual 1st April 2016 31st March 2017
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Summary
Page No
Section I- Policy Benefits
03 - 08
Section II- Processes
09-13

• What are cashless and Reimbursement procedures?
• Whom can I contact in case of claim related
  support ?

Section III- Forms Formats
15

• What are the Exclusions in the Mediclaim Program
  ?

3
Voluntary Mediclaim Policy For Parents
Comparison
Section I Policy Benefits
Section II Processes
Section III Forms Formats
4
What Is Covered Under Voluntary Parents Policy?
WHAT DOES YOUR MEDICLAIM POLICY COVER?
Section I Policy Benefits
POLICY DETAILS DESCRIPTION
Policy Holder MEDITAB SPL PVT LTD
Policy Start End Date 1st April 2016 to 31st March 2017
Insurer The New India Assurance Co. Ltd.
Third Party Administrator (TPA) Vidal Health TPA Pvt Ltd
Sum Insured (Floater) The mentioned Sum Insured is for 2 parents or single parent as per enrollment
Members Covered Employees joined before 31st March16 will be eligible to add any 2 parents or parents in law with the single floater premium deduction Employee joining after 31st March 16 will get the option to add 2 sets of parents parents in law with the payment of twice the premium
Entry Age limit Parents upto the age of 100 years can be covered under the policy
Co Payment No Co-pay on any claims
Pre Existing Diseases Covered from day 1
Section II Processes
Section III Forms Formats
5
What Is Covered Under Voluntary Parents Policy?
WHAT DOES YOUR MEDICLAIM POLICY COVER?
Section I Policy Benefits
30 Days Waiting Period for New Joiners Waived off
Cataract Eligibility
Room Rent
Pre Post Hospitalization Cover 30 days pre 60 days post hospitalization expenses covered.
Ambulance Charges Covered upto Rs. 2,000 in case of emergency only
S. No Sum Insured Eligibility
1 200,000 INR 23,000
2 300,000 INR 23,000
Section II Processes
Section III Forms Formats
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Parents Premium Chart
WHAT DOES YOUR MEDICLAIM POLICY COVER?
Section I Policy Benefits
PARENTS SUM INSURED PREMIUM (SINGLE PARENT) PREMIUM (BOTH PARENTS)
200,000 7800 8300
300,000 9,000 12900

• Note
• The premium mentioned is for 2 parents/parents-in
  law excluisve of service tax.
• If the age of parents is less than equal to 50
  yrs a discount of 5 will be there on the
  mentioned premium whereas if the age of both the
  parents is less than 50 yrs then a discount of
  10 will be given.
• Employees shall not have the option to replace
  parents with in laws or in laws with parents. An
  exception shall be for female employees who would
  be permitted to replace their parents with
  parents in law (only after marriage). But this
  option can be exercised only at the time of the
  enrolment year following the year of marriage,
  and not thereafter
• Premium will be deducted from salary in three
  equal monthly installments.
• Only one time option will be given for parents
  enrollment, employees who will miss the
  enrollment during the window period will not be
  eligible to cover the dependents in the current
  year or in the subsequent years
• New recruits can opt to cover their parents at
  the time of recruitment (during the stipulated
  window period), or at the time of enrolment year
  immediately following the year of their
  recruitment

Section II Processes
Section III Forms Formats
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Parents Policy Comparison
WHAT DOES YOUR MEDICLAIM POLICY COVER?
Our Value Proposition
Section I Policy Benefits
Retail Policy Available Outside

• Coverage for Pre-Existing Diseases from day one
  No waiting period
• No need of Pre enrollment medical check
• No ailment wise capping
• Maximum Entry Age 100 yrs
• Age limit for coverage 100 yrs
• 30 days, 1st 2nd Year exclusions Waived off

• Waiting period of 3 4 yrs for all Pre-existing
  Diseases.
• Need for Pre enrollment medical check beyond the
  age of 45 yrs
• Ailment wise capping applicable
• Maximum Entry Age for Parents 65 yrs
• Age limit for coverage 80 yrs
• 30 days, 1st 2nd Year Exclusions Applicable

Section II Processes
Section III Forms Formats
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Tax Benefit
WHAT DOES YOUR MEDICLAIM POLICY COVER?
Tax Benefits The policy offers Tax Benefit under
Sec 80 D. Tax benefit will be applicable only
towards premium paid towards coverage only of
dependent parents and not for payment made
towards coverage of Parent In Laws
Section I Policy Benefits
Section II Processes

• Will I be eligible for Tax Benefit for
  contribution made towards covering my dependent
  parents in this policy?
• The policy offers Tax Benefit under Sec 80 D of
  the IT Act for premium contributed towards
  covering your parents in this policy. No Tax
  benefit will be available for premium payment
  made towards coverage of Parent In Laws. Tax
  Benefit norms will be as per applicable
  prevailing Income Tax norms. You may seek advice
  from your tax consultant in this regards.

Section III Forms Formats
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Condition Of Membership
WHAT DOES YOUR MEDICLAIM POLICY COVER?
Section I Policy Benefits
The Insurance cover will be extended to
Enrolled Parents and Parents in Law (Not
exceeding four) Definition of Parent
Biological or Legal Parents Definition of
Parents-in-law Parents of Legally Married
Spouse
Section II Processes
What if employee leaves?
In an event of separation, policy certificate
will be given to the employee. He/she will be
eligible to claim under the policy for the entire
duration of the coverage period.
Section III Forms Formats
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Group Mediclaim Policy
Network Hospitalisation - Cashless
Emergency Hospitalization
Identify Network Hospital via mobile app /
website / helpline
Visit hospital Insurance Help desk fill the
pre- authorization form
Hospital will seek approval from Vidal Health
TPA (Provided within 2 hrs)
Section I Policy Benefits
You will receive SMS confirmation
Section II Processes
Pay for Non Medical Expenses if any
At the time of discharge Hospital will send
final request to Vidal Health TPA for
approval (Provided within 2 hrs)
On successful approval admission happens
treatment starts
Section III- Forms Formats
You will receive SMS confirmation
Planned Hospitalization
In case of Planned Hospitalization, authorization
should be taken prior, which will be valid for 15
days to avoid delay /inconvenience .
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Network Hospitalisation - Cashless
Before Admission

• Check for the nearest network hospital for
  availing the Cashless hospital.
• Pre-authorization form is mandatory to be sent
  to Vidal Health TPA by network hospital.

Section I Policy Benefits
During Admission

• Inform the Vidal Health TPA call center
  immediately about the hospitalization seek pre-
• authorization.
• Vidal Health TPA will send pre-authorization
  letter for the Initial amount to the hospital.
• In case of denial, the same will be
  communicated to the Hospital with proper
  reasoning.

Section II Processes
During Discharge
Section III- Forms Formats

• The bill will be sent by Hospital to Vidal
  Health TPA
• After hospitalization has been pre-authorized
  you/your dependents can proceed with discharge by
  paying for Non Medical Expenses .

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Non Network Hospitalisation - Reimbursement
Activity done by employee
Activity done by Vidal Health TPA
Intimate Vidal Health TPA regarding claim on the
day of Hospitalization or within 7 Days from the
date of Discharge.
Submit Claim documents within 30 days from the
date of discharge.
Documents to be handed over to your Local HR who
will courier same to Vantage Mumbai office
Section I Policy Benefits
You will receive SMS confirmation
Vidal Health TPA will check for the eligibility
and admissibility of the claim as per policy
terms.
Section II Processes
Claim not permissible
Reason of Rejection will be communicated.
Is Claim payable ?
Section III- Forms Formats
No
Vidal Health TPA will ask for the
additional/missing documents
Yes
Documents incomplete
Vidal Health TPA will process the claim and send
the reimbursement by ECS, along with the
settlement letter
Reminder mails sent every 15 days
Deficiency Documents are sent
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Contact Details

• Claim intimation to be give on mediclaimsupport.is
  ervice_at_cipla.com within 7 days of
  hospitalization. Email should contain
• Corporate Name,
• Vidal Card No.
• Unique Employee ID No.
• Name of employee
• Name of patient
• Date of Admission
• Name of hospital Location
• Approximately claim amount etc.
• This intimation can be given through various
  modes like email/call centre/mobile app or may be
  via letter or any other suitable mode. For claim
  intimation you may inform Vidal Health TPA as
  below.
• CONTACT POINTS FOR CLAIMS - Vidal Health TPA
  Customer Care Details
• Email id for claim intimation
  mediclaimsupport.iservice_at_cipla.com
• 24 x 7 Help line for cashless and Reimbursement
  intimation 1800-222-878 press 4 for insurance
• ESCALATION POINT

Section I Policy Benefits
Section II Processes
Section III Forms Formats
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Helpdesk Assistance (mediclaimsupport.iservice_at_ci
pla.com)
Section I Policy Benefits
Section II Processes

• To understand Enrollment Procedure
• To understand Claim Procedure
• Assistance during cashless claims
• Assistance for Submitting Reimbursement claims
• Knowing your Claim Status

Section III Forms Formats
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Escalation Matrix
Any Assistance ? (Claim /Enrollment)
Section I Policy Benefits
Call the Toll Free No 1800-222-878 press 4 for
insurance
Query Resolved
Query Unresolved
Section II Processes
Write to mediclaimsupport.iservice_at_cipla.com
Query Unresolved
Query Resolved
Section III Forms Formats
Write to Location HR and Ms Nirzara Salvi
nirzara_at_vidalhealthtpa.com
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Forms

• Pre-Authorization Form for Cashless claim
  
• Claim Form for Reimbursement claim
• Hospital List for Cashless Hospitalizations
  
• (The hospital list is dynamic will be updated on
  monthly basis also available on our website

Section I Policy Benefits
Section II Processes
This form is filled by the Hospital Authorities.
The Employee/ members accompanying the patient
has to sign the Authorization letter.
Section III Forms Formats
Please note that all the forms are also available
with the Local HR.
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Hospital List for Cashless Hospitalisation
For the updated list of hospitals please visit on
www.vidalhealthtpa.com and click on the link
titled Mediassist Network of Hospitals
Section I Policy Benefits
https//www.vidalhealthtpa.com/home/Network-Servic
es/Network-Hospitals
Section II Processes
While the soft copy version of this list is also
available with the Local HR, it is recommended
you use the online link to check for your
preferred hospital since it would be the most
updated.
Section III Forms Formats
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What is excluded from your policy ?
Natural Disasters National Emergencies

• Injury or disease directly or indirectly caused
  by or arising from or attributable to War,
• Invasion, Act of Foreign Enemy, Warlike operation
  (whether war be declared or not)
• Injury or disease directly or indirectly caused
  by or contributed to by nuclear
  weapons/materials
• Expenses incurred for disease declared as an
  Epidemic by Health Authorities

Section I Policy Benefits
Section II Processes
Cosmetics Non Medically required procedures

• Maternity is not covered
• Cost of Spectacles, Contact Lenses, Hearing Aids
• Treatment done with no active line of treatment
• Dental Treatment or surgery of any kind unless
  requiring hospitalization on account of
  accidental cases.
• Vitamins and nutritional supplements
• Cosmetic or aesthetic treatment of any
  description, plastic surgery other than as may be
  necessitated due to an accident or as a
  part of any illness.
• Convalescence, general debility Run-down'
  condition or test cure
• Intentional self injury and use of intoxicating
  drugs/alcohol
• Sterility (infertility), venereal disease
• Congenital external disease or defects or
  anomalies

Section III Exclusions
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What is excluded from your policy ?
Other policy Exclusions

• Naturopathy treatment
• Medical Expenses for Organ Donor
• Vaccination Inoculation.
• Cost of braces, equipment or external prosthetic
  devices, non-durable implants, eyeglasses, Cost
  of spectacles and contact lenses, hearing aids
  including cochlear implants and durable medical
  equipment's
• All types of Dental treatments except arising out
  of an accident
• Convalescence, general debility, Run-down
  condition or rest cure, obesity treatment and its
  complications, congenital external
  disease/defects or anomalies, treatment relating
  to all psychiatric and psychosomatic disorders,
  infertility, sterility, use of intoxicating
  drugs/alcohol, use of tobacco leading to cancer
• Bodily injury or sickness due to wilful or
  deliberate exposure to danger (except in an
  attempt to save a human life), intentional
  self-inflicted injury attempted suicide and
  arising out of non-adherence to any medical
  advice
• Treatment of any Bodily injury sustained whilst
  or as a result of active participation in
  hazardous sports of any kind
• Treatment of any bodily injury sustained whilst
  or as a result of participating in any criminal
  act
• Sexually transmitted diseases, any condition
  directly or indirectly caused due to or
  associated with Human T-Cell Lymphotropic Virus
  Type III (HTLB-III) or Lymphotropathy Associated
  Virus (LAV) or the Mutants Derivative or
  Variation Deficiency syndrome or any syndrome or
  condition of a similar kind commonly referred to
  as AIDS.

Section I Policy Benefits
Section II Processes
Section III Exclusions
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What is excluded from your policy ?
Other policy Exclusions

• Diagnostic, X-Ray or Laboratory examination not
  consistent with or incidental to the diagnosis of
  positive existence and treatment of any ailment,
  sickness or injury, for which confinement is
  required at a Hospital/Nursing Home.
• Vitamins and tonics unless forming part of
  treatment for injury or disease as certified by
  the attending physician.
• Instrument used in treatment of Sleep Apnoea
  Syndrome (C.P.A.P.) and Continuous Peritoneal
  Ambulatory Dialysis (C.P.A.D.) and Oxygen
  Concentrator for Bronchial Asthmatic condition
• Genetical disorders and stem cell implantation /
  surgery.
• Any Domiciliary Hospitalization / Treatment.
• Treatment taken outside India.
• Experimental and unproven treatment (not
  recognized by Indian Medical Council)
• Change of treatment from one system of medicine
  to another unless recommended by the Consultant /
  Hospital under whom the treatment is taken
• All non-medical expenses including convenience
  items for personal comfort such as telephone,
  television, Aya, Private Nursing / Barber or
  beauty services, diet charges, baby food,
  cosmetics, tissue paper, diapers, sanitary pads,
  toiletry items and similar incidental expenses
• Service charges or any other charges levied by
  hospital, except registration/admission charges

Section I Policy Benefits
Section II Processes
Section III Exclusions
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• Thank You