TRAVELEX INDIA PVT LTD - ICICI LOMBARD GENERAL INSURANCE CO LTD. 2013.
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Group Health Insurance Policy
ICICI LOMBARD GENERAL
INSURANCE CO LTD
LTD.
TRAVELEX INDIA PVT
LTD
1ST JAN 2013 to 31st Dec
2013.
1 of 14Contents
Terminology.
Scope of coverage.
Policy terms and conditions.
Claim p
procedure and settlement p
process.
2 of 14Terminology
Hospital/ Nursing Home - Any institution in India established
for indoor care and treatment of sickness and injuries and which
Has been registered either as a Hospital or Nursing Home
with the local authorities and is under supervision of a
registered and qualified Medical Practitioner; or
Comply with minimum criteria:
Should have at least 10 inpatient beds, in those towns
having a population of less than 10,00,000 and in all
other p
places 15 in-patient
p beds
Fully equipped operation theatre of its own, wherever
surgical operations are carried out,
out qualified & round
the clock available nursing staff and doctors
3 of 14Terminology
Does not include a place of rest for the aged, de
de-addiction
addiction center
(drugs/alcohol), hotel and similar institutions.
Hospitalization - admission in a hospital upon advice of a
Medical Practitioner .
4 of 14Scope of coverage
Disease / Injury
Treated medically /surgically .
By Hospitalization of a minimum period of 24 hours (time
limit not applicable for specific treatment such as advanced
technology).
At Nursing home / hospital in India as in-patient.
in patient
The Insurer shall pay to the Insured Person expenses which are
reasonably and necessarily incurred towards Hospitalization
Amount paid will not exceed the maximum sum insured specified
for the employee for the year.
year The maximum sum insured is
determined on 1st Jan or at the time of joining for employees
joining after this date
5 of 14Scope of coverage: Compensation
Payable
Reasonable and necessarily incurred subject to 24 hours
hospitalization (23.59 hours will not be acceptable).
Room
R Expenses
E in
i Hospital/Nursing
H i l/N i H Home.
Nursing
g Expenses.
p
Medical Practitioner Fee.
Treatment cost.
Medicines
Blood / Oxygen
6 of 14Scope of coverage: Compensation
Payable
y
Operation Theatre Charges.
Charges
Surgical Appliances.
Diagnostic cost.
Dialysis, Chemotherapy, Radiotherapy.
Pre Hospitalisation and Post Hospitalisation expenses.
Pre Hospitalization - relevant medical expenses incurred during
period up to 30 days prior to hospitalization.
Post Hospitalization - relevant medical expenses incurred during
period up to 60 days after the date of discharge from Hospital
7 of 14Scope of coverage: main exclusions
General exclusions: war
war, nuclear perils
perils.
Cosmetic or aesthetic treatment, plastic surgery.
Cost of spectacles and contact lenses, hearing aids.
Dental treatment.
Intentional self injury and use of intoxicating drugs/alcohol.
Aids.
Charges incurred primarily for diagnostic, X - Ray or laboratory
examinations not consistent with treatment / presence of any
disease.
8 of 14Scope of coverage: main exclusions
Vitamins/tonic inconsistent with treatment,
treatment naturopathy
naturopathy.
Convalescence, general debility.
Sterility, veneral disease, circumcision.
Medical termination of pregnancy within 12 weeks is not
covered.
9 of 14Policy terms, conditions and Limits
Age Band- 1 day to 80 years .
Room Rent-
For 1 Lac SI- Rs-2000 per day & ICU Rs- 3000 per day.
For Others- 1.5 % of SI for Normal & 2.5% of SI for ICU.
If insured is admitted in a higher category, then insured will bear
difference of all medical expenses as in final hospital bill in same
proportion.
Maternity expenses benefit : Rs.50000/- for Normal & Rs-
50000/- for C Section. (First two children).
Baby covered from 1 day Upto the family SI.
Pre-existing diseases: Covered.
No
N waiting
iti period
i d off 1 year for
f certain
t i diseases.
di
No waiting period of 30 days.
Domiciliary hospitalization not covered.
covered
9 months waiting period waived off.
10 of 14Policy terms, conditions and Limits
Family Definition Employee,Spouse,2 Dependent Children upto
age 25 yrs and Dependent parents covered under policy.
Pre Hospitalisation and Post Hospitalisation for 30 days & 60
days respectively are covered.
Co-Payment 10% % Co-pay on all claims for parents only.
Disease wise sublimits: All forms of Arthritis including Total
Hip Replacement (THR) and Total Knee Replacement (TKR)
is restricted to 2L only.
Mid term iinclusion
l i off ddependents
d will
ill b
be possible
ibl only
l in
i case of:
f
a) spouse (on account of marriage during the policy term)
b)) children by
y Birth subject
s j to not more than 2 children beingg
covered under the Policy.
11 of 14Policy terms, conditions and Limits
Ambulance Charges limited to Rs.1000 Per Person.
Lasik Surgery, Septoplasty, Infertility & Related Ailments
incl.'Male sterility'; Treatment on trial/experimental basis; Admin /
Registration/ Service/Misc Charges; Expenses on fitting of
Prosthesis; Any device/instrument/machine contributing/replacing
the function of an organ; Holter Monitoring are outside the scope
of the policy.
Liability for FESS upto Rs.35,000; Hospitalisation arising out of
Psychiatric ailments upto Rs.30,000.
50% Co-Pay for cyberknife treatment/Stem Cell Transplantation.
Cochlear Implant treatment shall be restricted to 50% of the SI.
Claim to be filed within 20 days from the date of completion of
treatment.
The Insured to furnish the Company
p y with all original
g bills,
documents
All treatment under this policy
12 should
of 14 be taken in IndiaClaim procedure and settlement process
T
Type off Claims.
Cl i
Cashless Claim.
Reimbursement Claim.
In Cashless health insurance Service, when you get hospitalized
with a network hospital, you do not have to settle the bill with the
hospital. The Insurance Company represented by the TPA, co-
ordinates with the hospital
p and settles the bill.
In Reimbursement claim you may pay the expenses and claim
reimbursement
i b t as per policy
li terms
t & conditions.
diti
13 of 14Claim procedure and settlement process
ABOUT YOUR HEALTH ID CARD
It is not a Credit or Cashless Card, but an Identity Card which
will identify you as the beneficiary of ICICI LOMBARD and
will
ill give
i him
hi access to
t our Network
N t k Hospitals
H it l
It bears Name of the Insured, Policy No., DOB, Gender, ID No.,
Policy Validity etc.
For any correspondence and queries Insured should quote
unique ICICI Health ID no. as mentioned on ID card.
As ID card carries all crucial information related to an insured
so while enrolling all these details should be taken with due care.
14 of 14Claim procedure and settlement process
HOSPITALIZATION PROCEDURE
Pre authorization in case of admission in Network Hospital
and intimation incase of Non Network hospital is mandatory.
WHAT TO DO WHEN YOU FALL ILL?
When you fall ill, generally you contact your family physician,who
treats you
and when necessary, refers to the consultant/Hospital.
WHAT TO DO IF YOUR DOCTOR TELLS YOU TO GET
HOSPITALISED?
Your Health Policy Provides for Cashless Hospitalization at ICICI
Health Group Network Hospitals
Selection of Hospital and doctor is your prerogative
If you chose to get admitted network hospital then, please obtain a
Dr.'s reference letter in the prescribed format available in the
hospital
15 of 14Claim procedure and settlement process
HOW TO ASK FOR PRE-AUTHORISATION
PRE AUTHORISATION
Send the pre Auth form to ICICI Health care 24 hrs. Help Desk
or Telephone
T l h att Helpline
H l li 18002098888
On receipt of the above form, on duty doctor will verify your
coverage vis-à-vis your insurance policy and if covered a
authorization
h i i letter
l (AL) will
ill be
b sent to your hospital
h i l and
d copy to
you if you so desire.
If the coverage is not established, Intimation (Denial) will be
sent to your hospital
h i l and
d to you.
The denial of authorization for cashless access does not mean
denial of treatment and does not in any way prevent you from
seeking necessary medical attention or hospitalization
The above procedure will take approx. 4 hrs. after you send the
Doctor’s Reference letter with full details.
16 of 14Claim procedure and settlement process
CASHLESS MEDICLAIM: WHAT TO DO IN AN
EMERGENCY ?
In an accidental case or in medical emergency you are advised to
approach
pp nearest Network / Non Network Hospital p with y
your
ID Card. If the admittance is in network hospital you or your
relatives or the hospital will call up ICICI Healthcare
(Helpdesk is open 24 hrs a day). They will verify the coverage
and if covered issue the authority letter to network hospital. If
you are in non network hospital you may pay the expenses and
claim reimbursement based on the coverage.
17 of 14Claim procedure and settlement process
IN THE HOSPITAL
If you are required to buy medicine or investigation done outside
the hospital, kindly obtain proper Cash Memo/Receipt for
payment made by you.
Certain charges such as (Telephone/Fax,Food & Beverages for
relatives, Barber, Ambulance etc.) are not covered in your
insurance policy, if you have obtained such services from the
hospital please pay for the same directly to the hospital.
18 of 14Claim procedure and settlement process
AT THE TIME OF DISCHARGE
The hospital will discharge you without payment of the bills on
the basis of A/L issued to them. If the bill amount exceeds the
authorized amount, you will have to pay such amount to hospital.
The Network hospital generally will not give you the Original
Bill, Discharge Card, Investigation Reports, etc. (as they have to
send these to TPA) you may ask for copies of the same.
19 of 14Claim procedure and settlement process
Reimbursement
R i b – Mediclaim
M di l i
Planned / Emergency treatment in non-network
non network hospital
Notice to TPA & approved
Documents required
q for claim
Duly completed claim form
Bills, receipts and discharge certificate/card from the
H
Hospital
it l
Bills from Chemists supported by proper prescription.
Test reports and payment receipts.
Any Other documents as queried by TPA.
Settlement within 21 days on complete submission
20 of 14Claim procedure and settlement process
WHAT HAPPENS WHEN SUBMITTED DOCUMENTS ARE
NOT COMPLETE
When you submit your claim along with all relevant documents as
explained above to TPA, the same will be scrutinized by a team of
medical doctors and claim processors and if found in order,
order TPA will
issue a reimbursement cheque for the amount paid by you.
If there are discrepancies or deficiencies in the documents TPA will
issue a letter listing the deficiencies and ask you to submit deficient
documents within 15 days of receipt of the letter.
21 of 14Claim procedure and settlement process
HOW MUCH TIME DOES IT TAKE TO SETTLE A CLAIM
If the claim file is complete in all respect TPA will settle the
claim within 21 working days from the date of receipt of
complete documents. Sometime TPA may settle the claim
deducting
g the amount pertaining
p g to deficient document.
When the deficient documents are submitted TPA will reopen
the file and pay for the same if they are payable under the policy.
22 of 14.
WHAT ABOUT POST HOSPITALIZATION EXPENSES
If you have incurred post hospitalization expenses which are
permissible under the policy you may submit a supplementary
claim along with the relevant documents immediately after the
permitted p
p post hospitalization
p p
period.
TPA will scrutinize the same reopening the original claim and
settle the same.
23 of 14.
Helpline
H l li Services
S i
TEL NO - 1800 209 8888
8888..
FAX NO - 1800 209 8880
8880..
THANK YOU
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