Group Medi claim Policy Presentation North Shore Technologies … · 2020. 6. 12. · Medical Benefits –Policy Details for Employee Policy Insurer TPA Medi Assist Insurance TPA

Group Medi claim Policy PresentationNorth Shore Technologies Pvt Ltd

Medi Assist Insurance TPA Pvt Ltd| Private & Confidential | Not for Circulation

Medical Benefits – Policy Details for Employee Policy

Insurer

TPA Medi Assist Insurance TPA Pvt Ltd.,

Name of Insured North Shore Technologies Pvt Ltd

Policy Tenure for Employee 26-Apr-2020 To 25-Apr-2021

Policy Number

Coverage Type Family Floater

Dependent CoverageFAMILY :1+5 ( Self + Spouse + 2 Dependent Children , Father ,Mother

SBI General Insurance Company Limited

4101190500000049-01

Benefits / Extensions Coverage – In Patient

Standard Hospitalization Minimum 24 hrs justified hospitalization

Pre existing diseases Covered Yes

Waiver of 4.1,4.2 & 4.3 Yes

Waiver on 30 days waitingperiod.

Yes

Maternity BenefitRs.35,000 for normal delivery and Rs.50,000 forLSCS without waiting period.9 months waitingperiod waived off.

New Born Baby Cover From Day 1 Within SI

Sum Insured 300000 Base

Cataract Limit 30000 Per eye

Room Rent Eligibility

Employee Policy :: Room rent + Nursing+ RMO charges eligibility per day is

up to Rs 6000/-Normal and ICU Rs 10000

If a person opts for a Higher Category Room+ Nursing+ RMO, the related

expenses would be proportionately be reduced.

Note: ROOM RENT INCLUDES NURSING CHARGES, RESIDENT

MEDICAL OFFICER, IV FLUIDS AND OTHER ADMINSTRATION CHARGES

NOTE:

Prorate will be calculated on all the charges expect medicines.

Pre & Post Hospitalization Expenses

Post-hospitalization Expenses

Definition

If the Insured member is diagnosed with an Illness which results in his / herHospitalization and for which the Insurer accepts a claim, the Insurer will alsoreimburse the Insured Member’s Post-hospitalization Expenses for up to 60 daysprior to his / her Hospitalization.

Covered Yes

Duration 60 Days

Pre-hospitalization Expenses

Definition

If the Insured member is diagnosed with an Illness which results in his/herHospitalization and for which the Insurer accepts a claim, the Insurer will alsoReimburse the Insured Member’s Pre-hospitalization Expenses for up to 30 daysPrior to his/her Hospitalization.

Covered Yes

Duration 30 Days

Medi Assist India TPA Private Limited | Private & Confidential | Not for Circulation


Hospital Definition

Medical Benefit – Standard Coverage –In Patient

➢ Room / boarding, Nursing expenses

➢ Doctors fees

➢ Intensive Care Unit

➢ Surgical fees, operating theatre, anesthesia and oxygen and their administration

➢ Physio therapy followed by Inpatient treatment

➢ Drugs and medicines consumed on the premises

➢ Hospital miscellaneous services (such as laboratory, x-ray, diagnostic tests)

➢ Dressing, ordinary splints and plaster casts

➢ Costs of prosthetic devices if implanted during a surgical procedure

➢ Radiotherapy and chemotherapy

A) The expenses are payable provided they are incurred in India and within the policy period. Expenses will be

reimbursed to the covered member depending on the level of cover that he/she is entitled to.

B) Expenses on Hospitalisation for minimum period of 24 hours are admissible. However this time limit will not

apply for specific treatments i.e. Dialysis, Chemotherapy, Radiotherapy, Eye surgery, Dental Surgery, Lithotripsy

(kidney stone removal), Tonsillectomy, D & C taken in the Hospital/Nursing home and the insured is discharged on

the same day of the treatment will be considered to be taken under Hospitalisation Benefit.

Medical Benefit – Cashless Process

Cashless means the Administrator (TPA) may authorize upon a Policy holder’s request fordirect settlement of eligible services and it’s according charges between a Network Hospitaland the Administrator. In such case the Administrator will directly settle all eligible amountswith the Network Hospital and the Insured Person may not have to pay any deposits at thecommencement of the treatment or bills after the end of treatment to the extent as theseservices are covered under the Policy.

Copies of documents to given for cashless :

Employee ID card Employee PAN / Aadhar cardPatient photo ID proofMedi Assist Card No. / copy of e-cardEmployee contact No. to be mentioned in claim form


Reimbursement:

Admission procedure

➢ In case you choose a non-network hospital you will have to liaise directly with the hospital for admission.

➢ However you are advised to follow the pre authorization procedure to ensure eligibility for reimbursement of hospitalization expenses from the insurer.

➢ Please ensure you take your health card along with a valid photo ID proof like- driving license / ration card / passport, etc. for admission in the hospital.

Discharge procedure

➢ In case of non-network hospital, you will be required to clear the bills and submit theclaim to TPA for reimbursement from the insurer. Please ensure that you collect allnecessary documents such as – discharge summary, investigation reports etc. Forsubmitting your claim.

Submission of hospitalization claim

➢ You must submit the final claim with all relevant documents within 30 days from the dateof discharge from the hospital.


Documents check list➢ The following are the documents that you would have to submit while claiming a reimbursement:

➢ Original hospital final bill

➢ Original numbered receipts for payments made to the hospital

➢ Complete breakup of the hospital bill

➢ Original discharge summary

➢ All original investigation reports along with prescriptions

➢ All original medicine bills with relevant prescriptions

➢ Original signed claim form

➢ Copy of the Medi Assist ID card

➢ Mention of complete address, contact numbers and email address (if available) in the Claim form.

➢ Cancellation cheque for NEFT purpose for the first time reimbursement during policy period. (Advised to give the bank details in the Medi buddy portal for quick tracking and future use too).


Medical Benefit – General Exclusions

➢ Injury or disease directly or indirectly caused by or arising from or attributable to War or War-like situations➢ Circumcision unless necessary for treatment of disease.➢ Congenital external diseases or defects/anomalies.➢ HIV and AIDS.➢ Hospitalization for convalescence, general debility, intentional self-injury, use of intoxicating drugs/ alcohol.➢ Venereal diseases.➢ Injury or disease caused directly or indirectly by nuclear weapons.➢ Naturopathy, Homeopathy, Ayurvedic treatments.➢ Any non-medical expenses like registration fees, admission fees, charges for medical records, cafeteria charges &

telephone charges.➢ Cost of spectacles, contact lenses, hearing aids.➢ Any cosmetic or plastic surgery except for correction of injury.➢ Hospitalization for diagnostic tests only.➢ Vitamins and tonics unless used for treatment of injury or disease.➢ Voluntary termination of pregnancy during first 12 weeks (MTP).➢ Others: Example- Service Tax, Luxury Tax, barber or attendant charges etc.


ADDRESS FOR CORRESPONDENCE

Medi Assist Insurance TPA Pvt Ltd8 B, TEJ Building , 2nd floor, Bahadur Shah Zafar Marg,Next to Times of India, Delhi – 110 002Website: www.medibuddy.in

http://www.mediassistindia.com/

1st Level:-

Name : Surya Prakash Email ID : [email protected]

2nd Level : • Name:-Manish Kumar

Email ID : [email protected]

Name-Subodh Kumar Jha

[email protected]

3rd Level:

• Name:-Manoj Kumar

Email ID:[email protected]

CUSTOMER SERVICE CONTACTS MEDI ASSIST

mailto:[email protected]:[email protected]

Wish You & Your Family A Healthy & Happy Future

Medi Assist Insurance TPA Pvt Ltd| Private & Confidential | Not for Circulation