Employee, Spouse & Children Group Mediclaim Policy 1 st April - - PowerPoint PPT Presentation

Employee Benefits Practice Almondz Insurance Brokers Private Ltd.

Employee, Spouse & Children Group Mediclaim Policy 1st April 2016 – 31st March 2017

• What is covered as part of the CIPLA Mediclaim Program?
• What are the Exclusions in CIPLA Mediclaim Program ?
• Which all forms would you require for Claims under this policy?
• What are the list of Documents required for reimbursement claims ?
• Which hospitals are empanelled for Cashless Facility ?
• How do you bring your dependents under coverage?
• What are cashless and Reimbursement procedures?
• Whom can I contact in case of claim related support ?

SUMMARY

Section I- Policy Benefits Section II- Processes Section III- Forms & Formats

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POLICY DETAILS DESCRIPTION  Policy Holder CIPLA LTD  Policy Start & End Date 1st April 2016 to 31st March 2017  Insurer The New India Assurance Co. Ltd.  Third Party Administrator (TPA) Medi Assist India TPA  Sum Insured  Covered Members Employee +Spouse + Children Employee & Spouse Covered Children Covered (as Male child up to 25 yrs and female child till age of 25 yrs

• r till she is married whichever is earlier.)

Sum Insured Eligibility Criteria Rs 1.00 lakhs Per Family Basic Salary below & up-to Rs 10,000 p.m Rs 3.00 lakhs Per Family Basic Salary Rs 10,001 - Rs 30,000 p.m Rs 5.00 lakhs Per Family Basic Salary Rs 30,001 p/m & above

GROUP MEDICLAIM PROGRAM

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Section I- Policy Benefits Section II- Processes Section III- Forms & Formats

Benefits Details

 Pre-existing Diseases Covered  Domiciliary Hospitalisation Excluded  Pre & Post Hospitalization Expenses Covered (30 days & 60 days respectively)  Room Rent 2% of Sum Insured for Normal and 4% of Sum Insured for ICU  Maternity Covered (only as reimbursement upto maximum of Rs. 30,000)  New Born Baby Cover from Day 1 Covered  Co-Payment Not Applicable  Terrorism Hospitalization due to terrorism is covered.  Ambulance Upto Rs.2000/- to be paid (To & Fro - Both way home/accident site etc)  Day Care Procedures There are 172 day care procedures covered under the policy, which do not require 24 hours hospitalization. List of all such procedures is available on Sambandh.

WHAT DOES YOUR MEDICLAIM POLICY COVER?

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Section I- Policy Benefits Section II- Processes Section III- Forms & Formats

Benefits Details

 Other Benefits Terrorism related prolonged treatment/other wise covered, Robotic surgery, Stem Cell therapy & Cyber Knife procedures/hospitalization to be covered. RMO charges, Surgery attendants charges, consultation fees for the Dr, registration charges up to Rs. 500 covered.  Additional Covers 1. Upfront payment of Rs. 25,000 on diagnosis of Critical Illness 2. Infertility treatment for employees to be covered upto Rs. 100,000 including OPD 3. Loss of pay coverage for the on duty accidental claims upto Rs. 5,000 per week ( Maximum limit upto 25 weeks) 4. OPD benefit to be extended to disabled children upto the age of 5 years Rs. 5000 5. Sleep Apnoea and pulmonary disorder to be covered for employees

• nly

6. Bariatric surgery is covered for employees with BMI > 35 7. Ayurvedic, homeopathy & unani treatments are covered if hospitalization is done in government hospitals

WHAT DOES YOUR MEDICLAIM POLICY COVER?

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Section I- Policy Benefits Section II- Processes Section III- Forms & Formats

 Natural Disasters & National Emergencies:  Cosmetics & Non Medically required procedures  Intentional self injury and use of intoxicating drugs/alcohol  Congenital external disease or defects or anomalies except life threatening  Treatment done with no active line of treatment  Cost of Spectacles, Contact Lenses, Hearing Aids  Voluntary medical termination of pregnancy during first 12 weeks from the date of conception  Naturopathy treatment  Vaccination & Inoculation  Hospitalization done for diagnostic purposes  All types of Dental treatments except arising out of an accident  Vitamins and tonics unless forming part of treatment for injury or disease as certified by the attending physician  Any Domiciliary Hospitalization / Treatment  Treatment taken outside India

Detailed file with the list of all the exclusions is available in Sambandh.

WHAT IS EXCLUDED FROM YOUR MEDICLAIM POLICY ?

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Section I- Policy Benefits Section II- Processes Section III- Forms & Formats

The Insurance cover will be extended to:

• All CIPLA employees and their Nominated Family Members as per eligibility
• Coverage will be as per the policy and guidelines presented above and any other guideline to be

issued in due course of time. Cover Expiries :

• The moment an Employee leaves the organization
• Death of the employee

 All employees will be required to provide necessary information regarding their family members to be covered under the policy, within the allowed enrolment window  This will be a one time option for all the existing employees (joined/eligible for mediclaim cover on

• r before 31st March 2016) for the policy period i.e. 1st April 2016 to 31st March 2017

 In case any employee miss to enroll the dependents during the stipulated window then he/she will not be eligible for mediclaim cover for this policy period i.e April 2016-March 2017 for his/her dependents.

CONDITION OF MEMBERSHIP

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Section I- Policy Benefits Section II- Processes Section III- Forms & Formats

Steps to Login

Please use the following link and login your MediBuddy portal Link: https://cipla.medibuddy.in Login Details: Username: EmployeeCode@cipla.com Password: your date of birth in DDMMYYYY format (this password is only applicable for employees who are logging in for the first time, others have to login using their changed password) For Example if your employee ID is 1234 and date of birth is 01 June 1980 than your user ID and password will be as follow Username: 01234@cipla.com Password : 01061980 Refer to the detailed visual guide available in Sambandh for enrolment of spouse & children. In case of newly married employee, name of spouse needs to be enrolled within 30 days from the date of marriage In case of new born child, enrolment needs to be done within 30 days from the date of birth

PROCESS TO GENERATE E-CARD

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Section I- Policy Benefits Section III- Forms & Formats

PROCESS TO GENERATE E-CARD- STEP 1

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Click here for login

Section I- Policy Benefits Section III- Forms & Formats

PROCESS TO GENERATE E-CARD- STEP 2

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Username: EmployeeCode@cipla.com Password: your date of birth in DDMMYYYY format

Section I- Policy Benefits Section III- Forms & Formats

PROCESS TO GENERATE E-CARD- STEP 3

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Click here to download E cards

Section I- Policy Benefits Section III- Forms & Formats

PROCESS TO GENERATE E-CARD - STEP 4

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E-Cards generated in .pdf format Section I- Policy Benefits Section III- Forms & Formats

Group Mediclaim Policy

NETWORK HOSPITALISATION - CASHLESS

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Identify Network Hospital via mobile app/ website /helpline Pay for Non Medical Expenses if any At the time of discharge Hospital will send final request to Medi Assist for approval (Provided within 2 hrs) On successful approval admission happens & treatment starts Visit hospital Insurance Help desk & fill the pre- authorization form Hospital will seek approval from Medi Assist (Provided within 2 hrs)

Emergency Hospitalization Planned Hospitalization

In case of Planned Hospitalization, authorization should be taken prior, which will be valid for 15 days to avoid delay /inconvenience at the time of hospitalization. You will receive SMS confirmation You will receive SMS confirmation

Section I- Policy Benefits Section III- Forms & Formats

NETWORK HOSPITALISATION – CASHLESS

• Check for the nearest network hospital for availing the Cashless hospital.
• Pre-authorization form is mandatory to be sent to Medi Assist by network hospital
• Inform the Medi Assist call center immediately about the hospitalization & seek pre-

authorization.

• Medi Assist will send pre-authorization letter for the minimum amount of expected

expenses to the hospital

• In case of denial, the same will be communicated to the Hospital with proper reasoning
• The bill will be sent by Hospital to Medi Assist
• Upon final approval on cashless by Medi Assit to hospital you/patient can proceed

with discharge by paying for Non Medical Expenses.

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Before Admission : During Admission : During Discharge :

Section I- Policy Benefits Section III- Forms & Formats

NON NETWORK HOSPITALIZATION - REIMBURSEMENT

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Intimate Medi Assist regarding claim on the day of hospitalization or within 7 Days from the date of admission Medi Assist will process the claim and send the reimbursement by ECS, along with the settlement letter Deficiency Documents are sent Reason of Rejection will be communicated Documents can be submitted at the drop box of each location or handed

• ver to Help Desk

Medi Assist will ask for the additional/missing documents Medi Assist will check for the eligibility and admissibility of the claim as per policy terms

Is claim payable ?

No Yes Submit Claim documents within 30 days from the date of discharge

You will receive SMS confirmation for document receipt You will receive SMS confirmation You will receive SMS confirmation You will receive SMS confirmation 14 Documents incomplete Claim not permissible

3 Reminder mails sent every 15 days Activity done by employee Activity done by Medi Assist

Section I- Policy Benefits Section III- Forms & Formats

• 1. Claim intimation to be give on claimsupport@mediassistindia.com within 7 days of admission. Email

should contain : I. Company Name, II. Policy No. III. Mediclaim ID no: IV. Employee code: V. Name of employee VI. Name of patient

• VII. Date of Admission
• VIII. Name of hospital

IX. Approximate claim amount etc. This intimation can be given through various modes like email/helpline/MediBuddy portal. Against this intimation you will receive intimation no for your claim. Which you can use while submitting claim documents.

INTIMATION FOR REIMBURSEMENT CLAIM

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Section I- Policy Benefits Section III- Forms & Formats

SUPPORT

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CONTACT POINTS FOR CLAIMS - Medi Assist TPA – Customer Care Details I. Email id for claim intimation – claimsupport@mediassistindia.com

• II. 24 x 7 Help line for cashless and Reimbursement intimation – 1800-425-7476
• Below are the details of ‘Helpdesk’ which are located at respective location. These helpdesk will be

available between 10am to 6pm on all working day of respective location: HELPDESK : Manufacturing Unit of INDORE Name : Mr. Salik Ahmed Phone No : +91-9165414100 Email ID : Medihelpindore@Cipla.com HO HELPDESK MUMBAI Name – Ms. Suvarna Khandagle Phone No : 022-24814786 Email ID – HealthHelpdesk@Cipla.com HELPDESK :Manufacturing Unit BANGALORE Name : Mr. Sowdahmed Anwar Phone No : +91-9148566494 Email ID : sowdahamad.anwar@mediassistindia.com HELPDESK : DELHI CP office –Field Staff Name – Mr. Anuj Sharma Phone No : +91-9599385420 Email ID – anuj.sharma@mediassistindia.com HELPDESK : Manufacturing Unit of Goa Name : Mr. John Rodrigues Phone No : 0832-2889896 Email ID : Goa.Healthhelpdesk@Cipla.com HELPDESK : KOLKATA Depot – Field Staff Name : Ms. Rimpa Paul Phone No : +91-842099160 Email ID : rimpa.paul@mediassistindia.com

Section I- Policy Benefits Section III- Forms & Formats

All the employees (field/non-field) can handover their claim documents to the helpdesk as per their reach and

• convenience. The local helpdesk setup is as follows:

1. Helpdesk at Head office, Lower Parel, Mumbai. 2. Indore Manufacturing Unit 3. Goa Manufacturing Unit 4. Bangalore Manufacturing Unit 5. Delhi CP Regional Office 6. Kolkata Depot Employees who cannot submit their reimbursement claim documents to the helpdesk can send the documents to HO address with below mentioned mandatory details : Superscibe the envelope with (Hospitalization Claim)

To, HR –Mediclaim Team Cipla Ltd. Peninsula Business Park, Tower- A, 1st Floor, Lower Parel, Ganpatrao Kadam Marg, Mumbai - 400013”

WHERE DO I SUBMIT CLAIM DOCUMENTS?

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Section I- Policy Benefits Section III- Forms & Formats

From, Your name, Employee Code, Contact number, Current address Pin code.

HELP DESK ASSISTANCE

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 To understand Enrollment Procedure  To understand Claim Procedure  Assistance during cashless claims  Assistance for Submitting Reimbursement claims  Submission of claim Documents  Knowing your Claim Status

Section I- Policy Benefits Section III- Forms & Formats

ESCALATION MATRIX

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Any Assistance? (Claim /Enrollment)

Call the Toll free no. 1800-425-7476 Speak to Local Help Desk Representative

Query Resolved Query Unresolved Query Resolved Query Unresolved

Write : claimsupport@mediassistindia.com

Query Resolved Query Unresolved

Write : sunil.shinde@almondz.com Section I- Policy Benefits Section III- Forms & Formats

 Cashless claim form : This form is filled by the Hospital Authorities. The Employee/ members accompanying the patient has to sign the Authorization letter.  Reimbursement claim form: Refer to the detailed presentation on the process of filling the claim form separately uploaded on Sambandh  Network Hospital for Cashless Hospitalizations: Refer to the detailed Hospital list on Sambandh for the listing of Hospitals in various categories.

CASHLESS/REIMBURSEMENT CLAIM FORM

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Section I- Policy Benefits

 Claim form duly signed and properly filled in  Main Hospital bills in original (with bill no; signed and stamped by the hospital) with all charges itemized and the original receipts  Original Payment Receipt  Original Discharge Summary  Attending doctors’ bills and receipts and certificate regarding diagnosis (if separate from hospital bill)  Original reports, Bills and Receipts for Medicines, Investigations along with Doctors prescription in Original  Consultation letter, Follow-up advice or letter for line of treatment after discharge from hospital, from Doctor.  Break up with details of Pharmacy items, Materials, Investigations even though it is there in the main bill  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.  In non- network hospitalization, you may have to get the hospital and doctor’s registration number in Hospital letterhead and get the same signed and stamped by the hospital, if required.  Cancel copy of cheque & NEFT details of the employee. Note the above list is indicative and TPA may ask for any additional document on case to case basis. In case of pre & post hospitalization all the bills, test reports, consultation letter coming under the window(30 days before discharge for pre & 60 days after discharge for post) needs to attached along with the reimbursement claim form, with the accurate claim number.

DOCUMENTS REQUIRED FOR REIMBURSEMENT

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COMPLETE ASSISTANCE

Assistance on:  Generating E- Cards  Know the Network of Hospital  Enroll Dependents  Check for the Claim Status CONTACT POINTS FOR CLAIMS: 24 x 7 Help line for cashless and Reimbursement intimation – 1800-425-7476 GENERAL QUERIES: claimsupport@mediassistindia.com

SAMBANDH MEDI ASSIST WEBSITE CENTRAL HELP DESK A detailed presentation on :

 Mediclaim Coverage's  Exclusions in Policy  Enrollment Process  Cashless Process  Reimbursement Process  List of Network Hospitals  172 Day Care Procedures  FAQ’s  Guidelines to fill the claim forms

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THANKS & STAY HEALTHY