Mediclaim process

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Mediclaim process
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Contact Details of HR for Mediclaim Assistance
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What is Mediclaim Insurance?

• Insurance Company provides Cashless/
  reimbursement of hospitalization expenses
  incurred in India for the treatment of
  illness/diseases or injuries sustained by the
  employee and other beneficiaries during the
  period of insurance

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What is a Hospital / Nursing Home

• Any institution in India established for
  Indoor care and treatment of sickness and
  injuries and which has either been registered as
  a hospital or nursing home with the local
  authorities and is under the supervision of a
  registered and qualified medical practitioner
• OR
• Should at least have minimum of 15 beds (for
  class C cities 10) Operation Theatre etc. and
  must be run by a Registered Medical Practitioner

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Your Policy Details (1/2)
Policy Period
1st April 2013  To  31st March 2014
Sum Insured
As per policy Copy the Sum Insured
Family Floater
Family Flaoter Policy covers, Self 2 dependents
children Dependent parents
Deduction for parents coverage
1 of the total sum insured for each parent will
be deducted from the salary
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Your Policy Details - (2/2)
Maternity Benefits
Maximum upto Rs. 50,000/- or the actual
whichever is lower
Coverage for Children
2 Living Children covered
New Born Baby Coverage/ Limit
Baby covered from day one
Room Rent and Nursing Charges
Room Rent not exceeding 1 of the Sum Insured per
day or the actual amount whichever is less
ICU Nursing Charges
ICU expenses not exceeding 2 of sum insured per
day
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Important Point to be Noted

• Intimations towards admission should be given
  within 24 hours of Hospitalization / injury Claim
  Submission within15 days from discharge
• Pre Natal- Post Natal Expenses not covered unless
  admitted in Hospital/ Nursing home and treatment
  is taken there.
• No Caps on Claims

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Coverage Details

• All Pre existing diseases are covered from day
  one.
• Pre Hospitalization charges payable for the
  period of 30 days prior to Hospitalization.
• Post Hospitalization charges payable for a period
  of 60 days from the date of discharge.
• All Surcharges, service charges, admission fees,
  registration charges levied by the hospital are
  NOT payable.
• Domiciliary treatment and hospitalization limit
  (Part of Sum Insured) not covered.

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What is Covered in the policy ?

• MEDICAL expenditure such as
• Room Boarding Expenses.
• Nursing Expenses.
• Surgeon, Anaesthetist, Medical Practitioner,
  Consultants, Specialists Fees.
• Anaesthesia, Blood, Oxygen, OT charges, Surgical
  expenses.
• Medicines Pharmacy Expenses.
• Diagnostic materials and X-ray Expenses.
• Dialysis, Chemotherapy, Radiotherapy Expenses.
• Cost of pacemaker, Artificial Implants similar
  expenses.

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What is NOT covered in the policy? (1/2)

• All Non Medical Expenditure.
• Food purchased from Hotels / Hospital Canteen
• Naturopathy Treatment.
• Cost of vitamins/tonics unless forming part of
  treatment for the covered disease.
• Cosmetic Surgery, Spectacles, contact lens,
  hearing aids.
• Treatment for Infertility
• Beauty Treatment of any description.
• Plastic surgery (other than necessitated due to
  accident).

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What is NOT Covered in the policy? (2/2)

• Treatment of AIDS, HIV, VD (STD).
• Accident treatment under the influence of Alcohol
  or intoxicating drugs.
• Congenital External Disease, defects or
  anomalies.
• Out patient treatment.
• Dental treatment
• Disease or accident due to adventure sports.
• Intentional self Injury.
• The exhaustive list of not payable items are
  attached

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General Terms Conditions

• Hospitalization Period
• Minimum Hospitalization should be for the period
  of 24 Hours
• Every Individual has to give a claim intimation
  giving the details of patient name /
• phs id no./ ailment / date of admission /
  hospital name/ contact nos. etc
• Reimbursement/ Cashless Intimation should be
  mailed to
• Mr. Nitesh Padwal on nitesh.padwal_at_rpgls.com with
  a copy to
• intimation_at_ttkhealthcareservices.com
• Day Care Procedures that do not require 24 hours
  hospitalization
• Dialysis,
• Chemotherapy,
  
• Radiotherapy
• Cataract
• Eye surgery
• Lithotripsy (kidney stone removal)
• D C
• Tonsillectomy

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Format for Claim Intimation

• From xyz_at_gmail.com
• To nitesh.padwal_at_rpgls.com
• CC intimation_at_ttkhealthcareservices.com
• Subject Claim Intimation
• Please note the hospitalization intimation as per
  the details given below
• TTK ID ___________________
• Employee Name __________________
• Employee Code ______________________
• Patient Name ________________________
• Name of the Hospital ____________________
• Date of Hospitalization __________________

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• Role of TTK

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Identity Cards

• TTK will issue Identity Card to each employee
  and their dependants. No physical cards will be
  issued to any employee. Employee can take the
  printout of the e-card which is available on TTK
  website.
• IMPORTANT
• The card is issued only for identification
  purpose
• should not be construed as an Authorization
  to the
• hospitals to proceed with the treatment.

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Cashless Facility
To avail the cashless facility from the TTK
network hospital, policyholder/employee/person
accompanying the patient need to provide TTK card
details to hospital, hospital in turn will send
the details to TTK Mumbai Following details to
be provided to hospital on admission/ before
admission TTK ID Card Number of patient (not
mandatory, employee number will do) Mobile
Number, Corporate Name, valid ID proof of
patient Hospital will fill the following details
and send it to TTK Mumbai (mumpreauth_at_ttkhealthcar
eservices.com) - Nature of illness/ disease/
injury. - The remarks of the recommending
physician or the treating physicians name,
address contact no
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Cashless Facility
- The hospital where the policyholder intends to
take treatment - The estimated cost etc. The
preauthorization request should be sent atleast
48 hours before admission. TIPS TO MAKE CASHLESS
HASLE FREE Give Mobile number on the Pre
authorization form Valid photo ID proof of
patient at the time of admission Prior
investigation reports, based on which
hospitalization recommended
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Pre-authorization Form
Part I- Has to be filled by the employee/ the
person accompanying the patient
Part II- Has to be filled by the hospital
authorities
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Authorization
Upon receipt of cashless request from hospital to
TTK Mumbai, our team of Drs, review the details
and decide on admissibility (shortfall, Approval,
Denial) 1 shortfall Any further document
required to process claim further, to be
submitted by hospital 2 Approval If all
documents are in line to take decision, then
initial approval given to hospital (this is
initial, and not final approval), upon receipt of
final bill and discharge summary, final decision
will be taken 3 Denial Based on policy T C if
the said ailment is not covered, the denial
letter with reason will be intimated to
fax Authorization is given by our medical team
subject to policy terms conditions such as
extension of coverage for the ailment, balance
sum insured etc. Authorization is rarely denied
unless the policy disallows it specifically or
sum insured balance is unavailable.
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Claim Settlement Cashless

• Please ensure that the bills are signed either by
  the
• Claimant / employee at the time of discharge
• Please note
• Cashless Hospitalization facility is available
  only at Network
• Hospitals listed by TTK

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Reimbursement Process (1/4)

• Please fill up the claim form of United Insurance
  Company Limited and attach the following
  documents in original for reimbursement claims
• Original bills, receipts and discharge
  certificate / card from the hospital.
• Medical history of the patient recorded by the
  Hospital.
• Original Cash-memo from the hospital (s) /
  chemist (s) supported by proper prescription.
• Original receipt, pathological and other test
  reports from a pathologist / radiologist
  including film etc supported by the note from
  attending medical practitioner / surgeon
  demanding such tests.
• Attending Consultants / Anesthetists / Specialist
  certificates regarding diagnosis and bill /
  receipts etc.
• Surgeons original certificate stating diagnosis
  and nature of operation performed along with
  bills / receipts etc.
• Any other information required by TPA / Insurance
  Company.

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Reimbursement Process (2/4)
All the original bills / reports along with the
filled up claim form has to be sent to respective
HR Partners for processing
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Reimbursement Process (4/4)

• Important Note
• The claim has to be sent within 7 days from the
  date of discharge
• After initial scrutiny of the claim, the TTK may
  ask for additional documents, if required in the
  form of Deficiency Letter
• On receipt of Deficiency Letter, the employee can
  send the necessary documents to respective HR
  Partner within 7 days of date of receipt of
  letter. In case of non-submission of additional
  documents asked by TTK, the claim may be
  rejected.
• Please attach the deficiency letter also while
  sending the deficiency documents.

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WHAT TO DO IN AN EMERGENCY ?

• In an accidental case or in medical
  emergency you are advised to approach nearest
  Network / Non Network Hospital with your ID Card.
  If the admittance is in network hospital you or
  your relatives or the hospital will send the
  preauthorization note to TTK (Helpdesk is open
  24 hrs a day). TTK 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.

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Access to http//ttkhealthcareservices.com

• View to E card
• Check claim status
• Updated Hospital Network List

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Steps to login to TTK Website
Go to, http//ttkhealthcareservices.com Click
yes if system prompts any security information
alert.
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Select Login
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Please turn off Pop-up blocker in tools bar Go
to, Please select login Select Employee login
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Self Access
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Please enter the below details Group ID
R0403 Policy No 121200/48/13/41/00000130 System
would ask for change password once you login to
the site.
User ID Employee number Password Employee
number
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Click here for Policy number
Please type your Group Code
Please type your password
Please type your Employee Number
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Click here to Download E-Card
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Click here for claim status and select the name
in respect of whom claim is made
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Click here to view Shortfall
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• THANK YOU