Chola MS HELP – Health Claims Presentation

M/s VA Tech Wabag Group Health Cover

2009-2010

When does your cover start?

– You and your dependents are covered from the time you join the company and send in the MIS form.

– In case of a new dependent addition (Spouse by marriage and newborn by birth) - please enroll within 30 days of the event.

When does your cover end?– Termination of Insurance Policy– Separation from the company

Group Mediclaim Cover

Hospitalization Insurance Cover

Includes:

– Only “in-patient” hospital expenses.

– Listed “day care” procedures ( 141 ailments) (pre-authorization is required for availing treatment in non-network hospitals)

Excludes:– Non - Medical Expenses.

– Out Patient (OPD) treatment

– Other standard exclusions

VA TECH COVERAGES

• Individual Sum Insured of Rs 1 Lac - Rs 5 Lac –Plz contact HR for your SI

• Employee+5 dependants covered in the policy• Pre existing diseases covered• 30 days and 1st year exclusion covered

Pre and post hospitalization covered for 30 and 60 days respectively.

• Rs 1000 payable for expenses incurred towards Ambulance, per person per policy year

VA TECH COVERAGES cont….

Maternity Benefits• Day 1 Maternity Cover

– Sub limit • Rs.50000 for normal • Rs.50000 for caesarian

Pre and Post Natal OPD Expenses eligible up to 5% of caesarian limit or rs 1000 whichever is more

Pre and Post Natal Expenses on in-patient basis up to the maternity limit

Baby expenses payable up to 5% of caesarian limit or rs 1000 whichever is more

STANDARD EXCLUSIONS OF THE POLICY

• Hospitalization for diagnostic / investigation purpose only• Domiciliary hospitalization• Circumcision unless necessary for treatment of diseases• Dental treatment of any kind• Congenital internal & external diseases, defects or anomalies• Hospitalization for convalescence, general debility, intentional self-injury,

use of intoxicating drugs/ alcohol.• Injury or disease caused directly or indirectly by nuclear weapons• Costs incurred on all method of medical treatment except allopathic • Cost of spectacles, contact lenses, hearing aids• Any cosmetic or plastic surgery except for correction of injury• Vitamins and tonics unless used for treatment of injury or diseases• Vaccinations and inoculations• Infertility treatment• HIV / AIDS and Venereal diseases

Enrolment TAT ENROLMENT

• In house card printing monitored by Enrolment Dept• Issuance of cards within 72 hours

What the ID card would contain;

•Name of the insured •Unique alpha-numeric ID no•Date of Birth•Age•Gender•Policy No.•Valid from date•Help Line & Toll Free No•Address of the claims office

CLAIMS

Cashless Claims

• Till date 2173 hospitals networked

• Additional hospitals have been identified and to be empanelled on priority

• Total hospitals spread across 300 cities / towns

Availing Cashless facility from Chola MS Help:

Planned Hospitalization• Identify the network hospital from the list provided by Chola HELP.• Approach the hospital at least 48 hrs prior admission and flash the ID

card in the billing dept.• Hospital will capture the information of the patient in a Pre-auth

request, provided by us, and will fax the same to our toll free fax• On receipt of the request our panel of doctors will scrutinize the same

as per policy terms and conditions and fax the approval back to the hospital.

• TAT 6 hours• On receipt of the approval the hospital will extend cashless

hospitalization• Certain non medical expenses like registration fee, admission fee, diet

etc has to be born by the claimant.• After discharge, the hospital send the bills to Chola HELP and gets it

reimbursed.

Availing Cashless facility from Chola MS Help Contd….

Emergency Hospitalization

Patient get admitted as per the hospital procedure• Attendant flashes ID card in the billing dept• Hospital will capture the information of the patient in a Pre-auth request,

provided by us, and will fax the same to our toll free fax• On receipt of the request our panel of doctors will scrutinize the same as

per policy terms and conditions and fax the approval back to the hospital.• TAT 6 hours• On receipt of the approval the hospital will extend cashless

hospitalization• Certain non medical expenses like registration fee, admission fee, diet

etc has to be born by the claimant.• After discharge, the hospital send the bills to Chola HELP and gets it

reimbursed.• Please note that unless the ID flashed, the hospital will not know that the

patient is covered under mediclaim and may ask for a advance.

CLAIMS Cont…

REIMBURSEMENT CLAIMS

• Reimbursement claim documents can be submitted to any of our regional/branch offices

• Supported by experienced domain knowledge and medical team

• Settlement of reimbursement claims would be made within 15 working days

• Electronic Fund Transfers to Corporate

REIMBURSEMENT CLAIM PROCESS

• Reimbursement claim can be submitted when hospitalization is to a non network hospital or when cashless is not availed from a network hospital.

• The claims documents have to be submitted to Chola HELP within 30 days from date of discharge

• The detailed list of documents required for reimbursement claims are provided in a separate word format along with this presentation, however following is the gist of the same

– Claim form duly filled and signed (Soft copy provided with this presentation)

– Original detailed Discharge Summary, Original main bill, all original lab reports with bills, all original pharmacy bills with prescriptions.

• Any documentation required further will be communicated to the claimant in writing

• TAT 15 working days for settlement of claims

CRM Cell

• Chola MS HELP LINE will operate 24/7 basis. CRM team will be available between 7AM to 9PM. After 9 PM, calls will be forwarded to a pre-designated mobile

• The customer care number is All India Toll Free no ( 1800-200-5544) and is also supported by Toll free fax (1800-425-2200).

THANK YOU