Mol Synergy Marine Insurance Manual - Senior

7
1 INSURANCE MANUAL FOR MEDICLAIM & LIFE TERM INSURANCE POLICY SERVICES

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Insurance manual

Transcript of Mol Synergy Marine Insurance Manual - Senior

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    INSURANCEMANUALFORMEDICLAIM&LIFETERMINSURANCE

    POLICYSERVICES

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    EMPLOYEE BENEFIT PROGRAM

    TheMOLSynergyMarine(MarshallIslands)Inc.EmployeeBenefitProgramisdesignedinpartnershipwithShriissthyInsuranceandFinancialServices.Thisprogramhasbeencreatedtobetterserve,andmostimportantlymeettheneedsoftheSeafarerandtheirfamilies.

    TheEmployeeBenefitProgramcomprisestwoinsurancecoverageschemesfortheSeafarerandtheirfamilies:

    GroupFloaterMediclaimPolicy:TheMediclaimCovercanbeavailedbyanyoneoranynumberofmembersinthefamilythatarecoveredinthepolicy.TheOfficersfamilyiscoveredforafixedSumInsuredandanyoneinthefamilycanavailtheadvantagetillthelimit(SumInsured)isexhausted.

    GroupLifeTermPolicy:TheGroupLifeTermpolicyofferscompensationincaseofdeathtotheInsuredpersonsnominee,directlyandsolelyasaresultofaNormaloranAccident.

    POLICYDETAILS

    PARTICULARS

    MEDICLAIMPOLICY

    GROUPLIEFTERMPOLICY

    PolicyName

    GroupFloaterMediclaimPolicy

    (GFMP)

    GroupLifeTermInsurancePolicy

    (GLTI)

    Insurer

    TheNewIndiaAssuranceCompany

    Ltd.

    LifeInsuranceCorporationofIndia

    SumInsured

    INR.5Lakhs

    INR.30Lakhs

    PolicyNumber

    130400/34/14/04/000000009

    GINP/706000977

    PolicyPeriod

    01/09/2014TO31/09/2015

    01/09/2014TO31/09/2015

    ThirdPartyAdministrator

    HealthIndiaTPAServicesPvt.Ltd

    N/A

    THEKEYCOMPONENTSOFTHEGROUPFLOATERMEDICLAIMPOLICY

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    SumInsuredofINR.5lakhbasedontheofficersandtheirdependents Familyfloaterforself,spouseandthreechildren AvailabilityoftheThirdPartyAdministrator(TPA)facilityforClaimsettlement AvailabilityofCashlessandReimbursementfacilities

    Cashless Reimbursement

    PreHospitalization(30daysbeforeHospitalization):Doctorconsultationfees,medicalreportsandrelatedmedicationissued30dayspriortohospitalization(admission)canbeReimbursed

    PostHospitalization(60daysafterHospitalization):DoctorConsultationfees,medicalreportsandrelatedmedicationissued60daysafterhospitalization(Discharge)canbereimbursed.

    WHATISCOVERED?

    FirstyearStandardExclusions Preexistingdiseases 30dayswaitingperiod(Therefore,claimsarisingfromthefirstdayoftheinceptionof

    thepolicywillgetpaid)

    MaternityBenefituptoFirst2children Newbornchildcoveredfromday1 Ninemonthperiodwaived EyeandTeethtreatmentresultingONLYoutofanAccident CataractSurgery:TheamountpayableforCataractSurgeryislimitedtoactualora

    maximumofRs.24,000,whicheverislesseitherforCashlessorReimbursement.

    AdditionalBenefitofCyberknifeTreatmentremovalofCancerousmalignanttumor

    MEDICLAIM MANAGEMENT

    TYPESOFCLAIMS

    CASHLESS:servicewhereintheinsuredisnotrequiredtopayanymoneyatthetimeofadmissionordischargefromthehospital.ThisbenefitisprovidedonlyinthehospitalsempanelledbytheThirdPartyAdministrator.NonMedicalexpensesandServiceTaxispayablebytheInsured,forwhichaSecurityDepositisrequiredbytheHospitals

    TPANetworkofHospitals:CashlesscanbeavailedonlyattheTPA,HealthIndiasnetworkhospitals.ListisavailableonTPAwebsite:www.healthindiatpa.com

    NOTE:ShriissthyInsuranceandFinancialServicesistheCOORDINATORbetweentheClaimantandtheTPA,andisNOTtheTPA.

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    CashlessDenial:DenialofCashlessServiceshouldNOTbeconstruedasadenialoftreatment.InsuchacasetheinsuredisadvisedtofiletheclaimforreimbursementandtheTPAwillsettletheclaimsubjecttothepolicystermsandconditions.

    REIMBURSEMENT:WhenyoudonotgotooneofthehospitalsthatsnotempanelledwiththeTPA,youwouldusuallyenduppayinghospitalbillsyourself.Butyoucanproducethebillslaterandgetthemreimbursed.

    CLAIMINTIMATIONREQUIREMENTS

    Shriissthymustbeintimatedattheearliestforbothplannedandemergencyhospitalizations.ForClaimIntimation,1stIntimationforReimbursementorCashlessshouldbesenttoShriissthyInsuranceandFinancialServicesviaemailat:[email protected];[email protected];[email protected];[email protected];[email protected]:

    CompanysName CrewName CompanyCrewIDandRank NameofthePatient,AgeandRelationship NatureorIllness/Accident HospitalDetails,DoctorsName,HospitalAdmissionandDischargedate PersonalContactinformation(AddressandNumber) Commencementdateofsymptomofthediseaseincaseofanillness AccidentCase:Dateandtime,locationofaccident,FIRReport,andSelfDeclaration

    REIMBURSEMENTCLAIMPROCEDURE:IMPORTANTNOTES

    ClaimIntimationshouldbemadewithin7workingdaysafterdischargefromhospital.

    Onclaimintimation,ShriissthywillemailalistofOriginalReimbursementDocumentstobecompletedandcourieredtouswithin25daysofdischargefromthehospitalforclaimsettlement

    ClaimpaymentsarenowbeingmadethroughNEFT/RTGS,thereforeacopyofacancelledchequeofyourresidentbankaccount(notNRE)iscompulsoryalongwiththesubmissionoftheclaimdocuments.SendShriissthyanacknowledgementonreceiptofpayment

    Pleaseretainacopyofallclaimrelateddocumentssubmittedincasequeriesareraisedregardingtheclaimorasabackupincasedocumentsaremisplacedetc.

    Claimsettlementtakesaminimumof1monthtoprocess,howeverifdeficienciesindocumentsubmissionsarisethenthesettlementcanbedelayed

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    DoctorsFeespaidincashshouldnotexceedthelimitofRs.10000.AspertherulesoftheinsurancecompanycashpaidaboveRs.10000isnotpayable.

    Prehospitalization:AlltheOriginalClaimdocuments,billsandreportsofPrehospitalizationmustbecourieredtoShriissthywithin25daysofdischargeforreimbursement

    Posthospitalization:Allbillsaccrued60daysPosthospitalizationmustbecourieredtoShriissthywithin90daysofdischargeforreimbursement

    CASHLESSCLAIMPROCEDURE:IMPORTANTNOTES

    ClaimIntimation:IntimateShriissthyandpatient/relativemustproceedtotheTPAdeskattherespectivehospitalwithIDProof&ecard(accesstodownloadecardisprovided)

    PreauthorizationProcedure:

    CollectpreauthorizationformfromtheTPAdeskandproceedtothetreatingdoctortobefilledandthenreturntotheTPAdesk

    TheTPAdeskwillfaxtheformandrelevantdocumentstoHealthIndiaTPA(EnsurethattheTPAdeskfaxes/emailsthedocumentsandpatient/relativemustinformShriissthyviaphoneoremail.Shriissthywillhelpfacilitateasmoothercashlessauthorization)

    HealthIndiaspanelofDoctorswillscrutinizethedocumentstoauthorizethecashless(IncaseofanydocumentdeficienciesHealthIndiawillinformtheHospitalsTPADesk.Itisimportantthatthepatient/relativeconstantlymonitorthedevelopmentsbetweentheTPAandHospital)

    OnCashlessauthorizationtheTPAwillsanctionaninitialamounttothehospitalbeforeadmission(Pleasenoteitwillnotbethefullamount)

    SecurityDeposit:Thepatientwillbechargedasecuritydepositbythehospital.Thisdepositismaintainedintheeventthatcashlessisdeniedornonpayableitemswhicharenotpayablebytheinsurancecompanywillbededucted.

    Discharge: TakethedischargedocumentstothehospitalsTPADesk,whowillsenditacross

    totheTPA.Again,ensurethattheHospitalsTPAdesksendsthedocumentstotheTPAandinformthesametoShriissthyviaphoneoremail

    OnreceiptofthedocumentstheTPAwilltakefewhourstoverifythedocuments.IncaseofanydocumentdeficienciesHealthIndiawillinformtheHospitalsTPADesk.Itisimportantthatthepatient/relativeconstantlymonitorsthedevelopmentsbetweentheTPAandHospital

    Afterclearanceofdeficiencies(ifany)theFinalbillamountwillbesanctionedtothehospitalafterdeductionsofnonpayableitems.

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    SecurityDeposit:ThedepositwillnotbereimburseduntilthehospitalreceivestheclaimsettlementchequefromtheInsuranceCompany(Thisproceduremaytakeamonthstime)

    NOTE:THROUGHEVERYSTEPOFCASHLESSPROCEDUREINTIMATESHRIISSTHYVIAPHONE/EMAILTOFACILITATESMOOTHCOORDINATIONWITHTHETPA.

    MANDATORYDOCUMENTS

    Whilesubmittingtheclaims(ReimbursementandCashless)forthebelowlistedAilments,thecorrespondingmandatorydocumentsmustbesubmittedalongwithotheressentialclaimrelevantdocuments:

    CataractSurgery:A'Scanreport&IOLSticker(IflensisaboveRs.10,000thenapurchaseinvoiceisrequired)

    Fractures:Xrayreportswithplates(IncludingHip&KneeReplacement) Accidents:MLC/FIR/Selfdeclarationfrompatient Angiography:FinalReportwiththeDiagram ImplantsinBones/HerniaMesh:IfitisaboveRs.10,000thenapurchaseinvoiceis

    required EarSurgery:Audiometryreport Pneumonia:XrayChestreport PreexistingDisease:DetailedHistorywithdurationofAilmentslikeDiabetes,

    Hypertension,Asthma,Fits/Epilepsy,HeartDiseases,KidneyStones,Arthritis,TB Paralysis:CTscan/MRIReport

    GROUPLIFETERMPOLICY:CLAIMSETTLEMENTPROCEDURE

    ClaimIntimation:ShouldbesenttoShriissthywithin48hoursaftertheofficersdeath,sothatShriissthycanguidethedeceased'sfamilyforthebeststepsforward.Aformallettershouldalsobesentfromthecompany'sendprovidingtherelevantinformation ThesameintimationissenttotheclaimhuboftheInsurancecompany

    Requirements: PostMortemReportismandatory DeathCertificateismandatory F.I.Rifapplicable Latestsalaryslip(sentbythecompany) Claimformdulyfilledbythedeceasedsfamilymember Declarationbyafamilymemberstatingthecaseofdeath

    Iftheclaimispayable,thentheclaimamountforLifeTermpolicywillberaisedinthenameofthecompany,andnotthedeceasedsfamilydirectly

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    ONLINE:ECARDOFFAMILYMEDICLAIM

    TheinsuredcanaccesstheECardorClaimStatuswiththefollowing:

    Logontohttps://www.healthindiatpa.com/DownloadEcard.aspx SelectCorporate EnterEMPID ClickonECardandPrint Pleaseensuretocheckforcorrectdetailsenteredontheecardandrevertincaseyou

    noticeanydiscrepancies.Pleaseemailusatourgivenids. Mostimportantly,pleaseintimateyourcompanyforanyadditionssuchasmarriageand

    childbirthsothatthenewfamilymemberscanbeincludedunderthepolicy.

    TPASNETWORKHOSPITALS

    TheTPAHealthIndiashospitalsinitsnetworkcanbeaccessedwiththefollowing:

    Logontowww.healthindiatpa.com ClickonHospitalontheRighthandsideofthewebpage SelectState,City,Location

    SHRIISSTHYINSURANCEANDFINANCIALSERVICESCONTACTINFORMATION

    Primacycontact:Mrs.ShefalePatraManagingDirector Email:[email protected],[email protected] Phone:+919892009036/+919820103003

    SecondaryContact:Mr.SalimShaikhOperationsManager Email:[email protected],[email protected]

    Phone:+919987206258/Landline:+912226334291 WorkingHours:(MonFri)(10am6pm)Sat(10am2pm)

    Address:207/C,Vriddhi,KalyanComplex,YariRoad,Versova,AndheriWest,Mumbai400061


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