Group Mediclaim Policy

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Group Mediclaim Policy
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Insurance Company United India Insurance Co.
Ltd.Name of the TPA Paramount Health
Services (TPA) Pvt. Ltd.
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Scope of the Policy

• General Hospitalization Expenses
• Room, Boarding and Nursing expenses as provided
  by the Hospital/Nursing Home not exceeding 1 of
  the Sum Insured per day or the actual amount
  whichever is less. This also includes nursing
  care, RMO charges, IV Fluids/Blood
  transfusion/injection administration charges and
  similar expenses.
• I.C.U. expenses not exceeding 2 of the Sum
  Insured per day or Actual amount whichever is
  less.
• Pre and Post hospitalization expenses payable in
  respect of each hospitalization shall be the
  actual expenses incurred subject to a maximum of
  10 of the sum insured whichever is less.
• For Ayurvedic /Homeopathic/ Unani treatment,
  hospitalisation expenses are admissible only when
  the treatment is taken as in patient in a
  Government Hospital/ Medical College hospital.

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Coverage
Category Sum Insured
Upto Senior Executive 1.00 Lakh
Assistant Manager Manager 2.00 Lakhs
Senior Manager Assistant Vice President 3.00 Lakhs
Vice President Above 4.00 Lakhs
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Policy Cover

• Pre Post Hospitalization cover for 30 days 60
  days respectively.
• 30 days waiting period waived off.
• 1st year waiting period waived off.
• Pre-existing diseases to be covered
• Maternity expenses- Covered - with 15,000 for
  Normal 25,000 for C Section.
• 9 months waiting period is waived off.
• Domiciliary hospitalization Deleted.
• Room rent restriction 1 of SI max of Rs.
  5,000/- for normal hospitalization and 2 of Sum
  Insured maximum of Rs. 8,000/- for ICU.
• 20 co-pay on each every claim.

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• Ailment wise capping
• Appendectomy Rs. 25,000
• Cataract/Glaucoma Rs. 20,000
• Gall Bladder Rs. 31,250
• Hernia Rs. 25,000
• Hydrocele Rs. 15,000
• Hysterectomy Rs. 31,000
• Joint Replacement including Vertebral joints
  Rs. 150,000
• Kidney Stone Rs. 40,000
• Piles Rs. 18,750
• Heart Related Rs. 175,000
• 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 Rs. 25,000.
• Coverages for hospitalization arising on account
  of or related to Psychiatric ailments would be
  limited to Rs. 30,000

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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.

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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.

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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.

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Other Details
Network Hospitalization means the hospital /
nursing home or such other medical aid provider
that has agreed with the TPA to provide cashless
access services to policy holders. The list of
Network Hospitals is maintained by and available
with the TPA and the same is subject to amendment
from time to time. Cashless Facility means
facility whereby the TPA agrees on the insureds
request to settle the admissible claim directly
to the network hospital. E -ID Card means the
identity card issued to the insured person by the
TPA to avail cashless facility in network
hospitals. Day Care Procedure means the course
of medical treatment/ surgical procedure in
specialized day care centre which enables the
insured to be discharged on the same day.
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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.

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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.

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Claim Procedure

• Claim notice to be given immediately to TPA/
  Insurer within 48 hours of Hospitalization on the
  email id amitabh.naidu_at_paramounttpa.com CC to
  pranali.hanjankar_at_spagroupindia.com,
  b.priyadarshini_at_centrum.co.in
• 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.

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Type of Claims

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

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(No Transcript)
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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)

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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

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• Insured has to arrange for the Admission Request
  Note to be sent across from respective network
  hospital to Paramount. Admission request note is
  available on admission counter of network
  hospitals.
• Send the Admission request note to PHS 24 x 7
  Help Desk (022 66620808) Fax [phone] /
  543 / 784 / 489.
• On receipt of the completely filled request
  letter, claim will be registered a unique claim
  number (FIR / CCN) will be generated.
• In case there is a deficiency, it will be raised
  in the form of an additional information letter
  faxed to respective Hospital. The query claim
  status can be obtained from Hospital itself or
  Call Centre or on the website.
• On receipt of deficient documents claim will be
  reviewed processed further on as per
  admissibility.
• If the coverage is not established, Intimation
  (Denial) will be sent to the hospital.

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Contact Details
Insurer
TPA
UNITED INDIA INSURANCE CO. LTD Address Chembur
Div Office, Natraj Cinema Bldg, 1st flr, N G
Acharya Marg, Chembur (East), Mumbai-400071. Con
tact No [phone]/25/26
PARAMOUNT HEALTH SERVICES (TPA) PVT.
LTD Address Elite Auto House, 2nd Flr, 54-A, M
Vasanji Road, Andheri (East) Mumbai-400093. Cont
act No [phone] Website
www.paramounttpa.com
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Thank You