Group Mediclaim Policy ( For Member

1
Group Mediclaim Policy ( For Members only)
2
Insurance Company United India Insurance Co.
Ltd.Name of the TPA Paramount Health
Services (TPA)Pvt Ltd.
3
Policy Cover

• Pre Post Hospitalization cover for 30 days 60
  days respectively.
• 30 days waiting period waived off.
• 1st yr waiting period waived off.
• Pre-existing diseases to be covered
• Maternity expenses- Covered for Normal for C
  Section Rs 30,000/-
• 9 months waiting period is waived off.
• Domiciliary hospitalization Deleted.
• Room rent restriction 1.5 of SI for Normal and
  2.5 of SI for ICU.
• 20 co-pay on each every claim
• Omission to Insure

4

• Ailment wise capping
• Appendectomy 25000
• Cataract/Glaucoma 20000
• Gall Bladder 31250
• Hernia 25000
• hydrocele 15000
• Hysterectomy 31000
• Joint Replacement including Vertebral joints
  150000
• Kidney Stone 40000
• Piles 18750
• Heart Related 175000
• 50 co-pay shall be applicable for cyber knife
  treatment Stem Cell Transplantation
• Diseases sublimit for kidney stone including DJ
  stent removal (for the same stone) even if at a
  later admission would be 25000.
• Coverages for hospitalization arising on account
  of or related to Psychiatric ailments would be
  limited to 30000
• Septoplasty is beyond scope of coverage, In case
  of FESS the maximum liability would be up to
  35000
• Consultation Charges / Investigation Fees and all
  other related expenses will be paid in accordance
  with the charges applicable for the authorized
  room rent limit or actual, whichever is less.

5
Day Care Procedure

• Expenses on hospitalization for minimum period of
  24 hours are admissible. However, Day Care
  procedures where 24 Hrs Hospitalization is not
  required are as follow-
• Adenoidectomy.
• Appendectomy.
• Ascitic/Pleural tapping.
• Auroplasty.
• Coronary angiography.
• Coronary angioplasty.
• Dental surgery only in case of accident.
• D C.
• Endoscopies.
• Excision of Cyst/granuloma/lump.
• Eye surgery.
• Fracture/dislocation excluding hairline fracture.
• Radiotherapy
• Lithotripsy.
• Incision and drainage of abcess.

6
Contd....

• Colonoscopy.
• Varicocelectomy.
• Wound suturing.
• FESS.
• Haemo dialysis.
• Fissurectomy/ Fistulectomy.
• Mastoidectomy.
• Hydrocele
• Hysterectomy.
• inguinal/ventral/umbillcal/femoral hernia.
• Parenteral chemotherapy.
• Polypectomy.
• Septoplasty.
• Piles/fistula.
• prostate.
• Sinusitis.
• Tonsillectomy.

7
Contd.

• Liver aspiration.
• Sclerotherapy
• Varocose Vein Ligation.
• Further if the treatment/ procedure/surgeries of
  above diseases are carried out in Day Care Centre
  which is fully equipped with advanced technology
  and specialized infrastructure where the insured
  is discharged on the same day, the requirement of
  minimum beds will be overlooked provided
  following conditions are met
• The operation theatre is fully equipped for the
  surgical operation required in respect of
  sickness/ailment/injury covered under the policy.
• Day Care nursing staff is fully qualified.
• The doctor performing the surgery or procedure as
  well as post operative attending doctors are also
  fully qualified for the specific surgery/
  procedure.
• Note Procedures/treatments usually done in out
  patient department are not payable under the
  policy even if converted as an in-patient in the
  hospital for more than 24 hours.

8
Policy Does not Covers

• Injury/disease directly or indirectly caused by
  or arising from or attributable to War, invasion,
  Act of Foreign enemy, War like operations
  (whether war be declared or not)
• Cost of spectacles and contact lenses, hearing
  aids.
• Dental treatments except arising out of an
  accident and requiring hospitalization.
• Convalescence, general debility, Run-down
  condition or rest cure, obesity treatment and its
  complications including morbid obesity,
  Congenital diseases/defects or Anomalies,
  treatment relating to all psychiatric and
  psychosomatic disorders, infertility, sterility,
  venereal disease, Intentional self-injury and use
  of intoxicating drugs/alcohol.
• All expenses arising out of any condition
  directly or indirectly caused to or associated
  with Human T- Cell Lymphotropic Virus Type III
  (HTLB III) or Lymphadinopathy 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.
• Charges incurred at Hospital or Nursing Home
  primarily for diagnosis x-ray or Laboratory
  examinations or other diagnostic studies not
  consistent with or incidental to the diagnosis
  and treatment of positive existence or presence
  of any ailment, sickness or injury, for which
  confinement is required at a Hospital/ Nursing
  Home.

9
Contd.

• Expenses on vitamins and tonics unless forming
  part of treatment for injury or diseases as
  certified by the attending physician.
• Injury or Disease directly or indirectly caused
  by or contributed to by nuclear weapon/
  materials.
• Naturopathy Treatment, acupressure, acupuncture,
  magnetic therapies, experimental and unproven
  treatments/therapies.
• Genetic disorders and stem cell
  implantation/surgery.
• Change of treatment from one system of medicine
  to another unless recommended by the
  consultant/hospital under whom the treatment is
  taken.
• Treatment for Age Related Macular Degeneration
  (ARMD), treatments such Rotational Field Quantum
  Magnetic Resonance (RFQMR), Enhanced External
  Counter Pulsation (EECP), etc.
• All non medical expenses including convenience
  items for personal comfort such as charges for
  telephone, television, ayah, private
  nursing/barber or beauty services, diet charges,
  baby food, cosmetics, tissue paper, diapers,
  sanitary pads, toiletry items and similar
  incidental expenses.
• Any kind of services charges, surcharges,
  admission fees/registration charges, luxury tax
  and similar charges levied by the hospital.

10
Claim Procedure

• Claim notice to be given immediately to TPA/
  Insurer within 48 hours of Hospitalization
• Claim to be filed within 7 days of discharge from
  hospital
• All documents in original viz. bills, receipts,
  Test Reports, discharge Card etc. to be provided
• Any Medical Practitioner appointed by the Insurer
  will be allowed to examine the insured person
• Maximum of 24 hours hospitalization is must
  except in respect of certain Day-care treatment.
  It is always advisable to check with TPA for
  hospitalization of less than 24 hours (Day-care)
  to avoid rejection of claim.

11
Type of Claims

• Cashless
• Reimbursement
• Post Hospitalization expenses can be claimed
  separately hence no need to wait till post
  hospitalization treatment is over.

12
(No Transcript)
13
Claim Procedure - Cashless

• Cashless in Network hospitals Only
• For Planned Hospitalization, intimate TPA 7 days
  in advance.
• For Immediate Hospitalization, contact TPA by
  completing form faxing cashless request to TPA.
• TPA authorizes the treatment.
• Hospital extends credit based on TPAs
  authorization
• Hospital sends bills to TPA for settlement.
• Member gets discharged from Hospital and signs
  claim form and final bill
• Member has to make full payment for the treatment
  before discharge for the uncovered services
  (excluded from the scope of cover)

14
Claim Procedure-Reimbursement

• In Non-Network Hospitals
• Member gets discharged from Hospital after
  treatment and submits duly completed claim form
  with following documents
• Discharge Card
• Main Hospital Bill with Receipt for payment
• All Investigation Reports
• Prescription for all investigation reports.
• Prescription for medicines
• Bills for medicines and investigations
• Break-up of medicines charged in Hospital Bill
• Xerox copy of ID Card
• Hospital and Doctors Registration number is a
  must
• TPA Settles the claim

15
Thank You