Post on 25-Jul-2018
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MARSH
Medical Benefit
Coverage Details
Cashless Process
Non-Cashless
Claims Process
Claims Document List
Benefits Extensions – Definitions
Prudent Utilization of Benefit
Help desk at First American
General Exclusions
GMC Contact Details
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• Policy covers financial assistance in the event of hospitalization of covered member
• Hospitalization of member is considered in Insurance when there is treatment for
1. Diagnosed Ailment
2. Requiring Active line of treatment – treatment which can be done only in hospital not
on out patient basis. This is determined by the TPA doctor based on set medical protocols for
various ailments and procedure.
3. For at least 24 hours
• Exception to the conditions are
- Day care procedures – procedure taking less than 24 hours due to advancement in
medical technology (dialysis , cataract)
- Pre and Post hospitalization (30 & 60 days) on settlement of the main hospital bill.
• Hospitalization may be required as per treating doctor based on the presenting signs and
symptoms, but only post complete diagnosis, admissibility of treatment would be established.
• Hospitalization for Diagnosis only , where no active line of treatment or self inflicted or elective
surgery for betterment etc. are common rejections.
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Benefit Design Group Medical Plan
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Medical Benefit – GMC Coverage Details Policy Parameter
Insurer Oriental Insurance Co
TPA Good Health TPA
Policy Start Date 1st July 2016
Policy End Date 30th Jun 2017
Coverage Type Family Floater
Dependent Coverage 1 + 5 - Employee + (Spouse + 2 Dependent Children + 2 Parents / 2 Parents IL) as per company
policy conditions.
Sum Insured INR 300,000
Co – Pay 10% of Co payment applicable for all parents / parents IL claims.
Benefits / Extensions Coverage
Standard Hospitalization • Yes
TPA services • Yes
Pre existing diseases • Yes
Waiver on 1st year exclusion • Yes
Waiver on 1st 30 days excl. • Yes
Maternity benefits • Yes
Pre & Post Natal Expenses • Yes
Well Baby Expenses • Not covered
Benefits / Extensions Coverage
Baby cover day 1 • Yes
Room rent eligibility • Yes
OPD • No
Day Care • Yes
Domiciliary Hospitalization • No
Dental & Vision • Restricted (only in case
of accident)
Pre-Post Hospitalization Exp. • Yes
Ailment Capping • No*
* Except Cataract, Maternity & Dental
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Medical Benefit – Dependent Coverage
Maximum no of Members insured in a family 1 + 5
Employee Yes
Spouse Yes
Children Yes (for the first 2 living Children)
Parents Yes
Parents-in-Law Yes
Employee can choose enroll parents / parents In law
Siblings No
Others No
Please note all existing depended coverage can be done at inception of policy or 30 days from date of joining. This includes
Spouse, children and Parents / In laws
Mid Term enrollment of existing Dependents Disallowed
Mid Term enrollment of New Joinees (New employees +their
Dependents)
Allowed provided intimation to HR within 30 days from the
date of event
Mid term enrollment of new dependents (Spouse/Children) Allowed provided intimation to HR within 30 days from the
date of event
No Individual should be covered as dependent of more than one employee
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Maternity Benefits
• These benefits are admissible in case of hospitalization in India.
• Covers first two living children only. Those who already have two or more living children will not be eligible for this benefit.
• Expenses incurred in connection with voluntary medical termination of pregnancy during the first 12 weeks from the date of conception are not
covered.
•Well baby charges or cost incurred at hospital where there is no treatment was administered to the new born are not covered under the policy.
Benefit Details
For Normal Delivery • INR 30,000/- within the Floater Sum Insured
For C – Section / Cesarean Delivery • INR 50,000/- within the Floater Sum Insured
Restriction on no of children • Maximum of 2 Children
9 Months waiting period • Waived off
Baby wellness charges • Not covered
Pre-Post Natal Expenses • Not covered
Baby Day One Cover
All new born babies are eligible to be covered form date of birth. In unfortunate event of baby requiring inpatient
hospital care , the policy extends the coverage
• Subject to declaration to HR / Insurer with in 30 days from the date of the event
• the baby gets covered within the available family floater sum insured for the policy year
•Well baby charges are not covered – the charges / treatment cost spent towards baby check up , vaccination,
inoculations etc
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Medical Benefit – Standard Coverage
• Room and boarding
• Doctors fees
• Intensive Care Unit
• Nursing expenses
• Surgical fees, operating theatre, anesthesia and oxygen and their administration
• Physical therapy
• 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 Hospitalization for minimum period of 24 hours are admissible. However this time limit will not apply for
specific treatments i.e. Dialysis, Chemotherapy, Radiotherapy, 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 Hospitalization Benefit, however under pre authorization (cashless) only.
C) Anesthesia, Blood, oxygen, OT charges, Surgical appliances, Medicines, drugs, Diagnostic Material & X-ray, Dialysis,
Chemotherapy, Radiotherapy, cost of pacemaker, artificial limbs and cost of stent and implant.
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Benefits For
FAI Definition
Pre existing diseases
Covered Any Pre-Existing ailments such as diabetes, hypertension, etc or related ailments for which care, treatment or advice
was recommended by or received from a Doctor or which was first manifested prior to the commencement date of the
Insured Person’s first Health Insurance policy with the Insurer
First 30 day waiting
period
Not
Applicable
Any Illness diagnosed or diagnosable within 30 days of the effective date of the Policy Period if this is the first Health
Policy taken by the Policyholder with the Insurer. If the Policyholder renews the Health Policy with the Insurer and
increases the Limit of Indemnity, then this exclusion shall apply in relation to the amount by which the Limit of Indemnity
has been increased
First Year Waiting
period
Not
Applicable During the first year of the operation of the policy the expenses on treatment of diseases such as Cataract, Benign
Prostatic Hypertrophy, Hysterectomy for Menorrhagia or Fibromyoma, Hernia, Hydrocele, Congenital Internal Diseases,
Fistula in anus, Piles, Sinusitis and related disorders are not payable. If these diseases are pre- existing at the time of
proposal they will not be covered even during subsequent period or renewal too
Baby Cover Day 1
Covered This policy is extended to cover the new born child of an employee covered under the Policy from the time of birth till 90
days. Not withstanding this extension, the Insured shall be required to cover the newly born children after 90 days as
additional member as mentioned elsewhere under this Policy.
Ambulance
Covered The Insurer will pay Rs.2000/- for Emergency ambulance and other road transportation by a licensed ambulance
service to the nearest Hospital where Emergency Health Services can be rendered. Coverage is only provided in the
event of an Emergency.
Dental & Vision
Treatment
Not
Applicable Treatment cost for root canal, tooth fillings, scaling of teeth and Optical care cost of eye glasses besides cosmetic
treatment, frames, contact lenses & hearing aid cost would not be paid / covered/
Day Care
Covered Day Care Procedure means the course of medical treatment or a surgical procedure listed in the Schedule which is
undertaken under general or local anesthesia in a Hospital by a Doctor in not less than 2 hours and not more than 24
hours. Generally 8 aliments (i.e. Dialysis, Chemotherapy, Radiotherapy, Cataract surgery, Lithotripsy (kidney stone
removal), Tonsillectomy, D & C)
Benefit Extensions – Definitions
X
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X
X
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Once in 15 days
FAI would share New Joiners and Deletions with Oriental,
Marsh
In 2 working days
Marsh would compute the premium send it to OIC for endorsement
issuance
In 4 working days
OIC would issue endorsement and confirm to Good Health
TPA / Marsh / FAI
In 2 working days
Good Health TPA upload e cards and Welcome mailers
would be shared with all employees
1. Employee Joining
2. Employee to enroll his / her
dependents with HR with in
30 days of Joining.
3. Employee gets e cards and
welcome mailers by latest 35th
day from joining
Employee Experience
Group Medical Plan Enrollment Process and Time lines
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Group Medical Plan Enrollment Process and Time lines
Insurance Policy Allows enrollment of members
• New Joiners and their eligible dependents – within 30 days from the date of
• Existing Employees
• New additions in family like new born child or newly wedded spouse
• Declarations to be made within 30 days from date of event (birth /
marriage)
• Names not required for New born babies (can be enrolled as baby of
member)
• Any delay in intimation would decline coverage regardless of the eligibility
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Member approaches TPA
Network Hospital for Cashless Treatment
Hospital verifies member details and send
pre-authorization by fax to TPA
Good Health TPA verifies pre-authorization details with
policy benefits and send response the
Fax to Hospital (TAT - 4 hrs)
Approved letter send by
Good Health TPA
Hospital admits patient
and Provide Cashless
treatment
Query letter send to
Good Health TPA
Hospital fax the reply for
Queries Asked by
UHC doctors
Denial letter send by
Good Health TPA
Query Denial
Hospital
Approved
Member can apply for
reconsideration through
reimbursement
Group Medical Plan Cashless Claim Process
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Group Medical Plan Cashless Claim Process ..2
Admission procedure
• Identify the hospital form the updated list of Network hospitals on Good Health Plan TPA Website for
cashless.
• The network hospital are not preferential hospitals , Cashless Network is a market arrangement for member’s
convenience. As a consumer, member is liable to get , procure & share requisite data with TPA .
• The hospital would share a pre-authorization form, which must be partly filled by the member and partly by
hospital and treating doctor
• This form highlights the initial diagnosis , line of treatment and estimated length of stay and cost of treatment
• This form is faxed / sent online to GHPL . (Please insist the form is sent to Bangalore for priority clearing)
• The requisite / Industry accepted / agreed TAT is 4 hrs to revert form the time of receipt of documents.
• TPA may ask for more documents if the line of treatment or admissibility in policy is not clear or other wise
documents are not in order. Approval TAT starts all over again on receipt of the documents from hospital.
• The initial approval is generally granted for fraction of the requested amount
• As initial request has diagnosis, line of treatment and price estimate which is tentative , pre-
authorization approval is also tentative
• This allows TPA to negotiate with the hospital at discharge.
• If a claim is rejected on initial approval, members are required to apply for reimbursement for second opinion
on the same. Cashless process is usually fast track process and reconsiderations are possible.
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Interim Enhancement
• For claims which are of higher cost and require longer stay, hospital would from time to time raise interim
enhancement during the stay at Hospital
• Hospital shares the exact treatment details over fax/ online for enhancement of initial approval
Discharge procedure
• Upon clearance / discharge advise from the doctor , the hospital shares the complete set of documents
including discharge summary , final bill , reports etc
• This process to share the details with TPA takes 3-4 hrs after the doctor’s discharge advise.
• TPA’s TAT would start post receipt of documents
• The requisite / Industry accepted / agreed TAT is 4 hrs to revert from the time of receipt of documents.
• TPA may ask for more documents if the line of treatment or admissibility in policy is not clear or other wise
documents are not in order. Approval TAT starts all over again on receipt of the documents from hospital.
How do I know what is the status
1. Good Health shares SMS (mobile) and emails for the registered number and email id at every step on real
time basis e.g. on receipt of request , shortfall of documents , approval etc
Its important that all members updated their active mobile numbers. This would give timely updates &
reduce heartburns
2. IWP / Website : individual login is updated real-time
3. Mobile App / Mobile internet : updates can be viewed real-time.
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Group Medical Plan Cashless Claim Process ..3
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Admission procedure
• In case of a non-network hospital member will have to liaise directly with the hospital for treatment and
insurance claim documents
• Member should intimate Good Health TPA within 24 Hrs of admission and request for intimation number and
seek claim registration number.
• Member will pay and clear the bills before discharge from the hospital
• Member will collect all necessary documents such as discharge summary, detailed investigation reports, final bill
with detailed break-up of expenses, stamped paid receipts etc. for reference
• To obtain reimbursement of the expenses, member should submit the final claim with all relevant documents
within 30 days from the date of discharge from the hospital along with the intimation number
Group Medical Plan Reimbursement Process
Note: Members are advised to register the claim with Good Health TPA (via call or mail) on or
before the date of admission
Note: Onus to procure and submit requisite documents from hospital is on the member. TPA
would not be able to support / consider aberrations.
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Member intimates Good Health
TPA before or as soon as
hospitalization occurs
Member avails treatment from the
hospital and clears the payment
Document
received within
30 days from
discharge
Claim Rejected
No
TPA Does Medical scrutiny of the
claim documents
Document
sufficiency
check
Yes
No
Claims processing done in 15
working day
Member receives mail about
document deficiency in 7
working days
A
A
Claim settled and amount
paid to FAI in total of 21
working days
Yes
No
Yes
Claim payable?
Important Points
• All documents are required to be submitted in originals only. Member are advised to retain copies of all originals submitted to TPA
• Medical help desk can only do physical verification of documents . Document shortfall may be raised on medical scrutiny by TPA.
• Multiple queries / shortfall for claim are not allowed by TPA. GHP can only ask query on shortfall document.
• If shortfall documents are not submitted within 30 days from date of intimation, the claim is closed in the system.
Group Medical Plan Reimbursement Process
Member submits claim
documents at FAI helpdesk
within 30days of discharge
Help desk scrutinized
physical document
sufficiency
Yes
No
FAI re-credit the amount in
23 working day
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*Please retain photocopies of all documents
submitted
• Download claim form from your FAI
Intranet Portal
• All documents are indicative additional
documents will be called by the TPA
doctor.
Completed Claim form with Signature
Hospital bills in original (with bill no; signed and stamped by the hospital)
with all charges itemized and the original receipts
Discharge Report (original)
Attending doctors’ bills and receipts and certificate regarding diagnosis (if
separate from hospital bill)
Original reports or attested copies of Bills and Receipts for Medicines,
Investigations along with Doctors prescription in Original and Laboratory,
Stickers in case of Implants E.g.: Lens ( Cataract), Stents ( Heart Surgery)
etc.
Follow-up advice or letter for line of treatment after discharge from hospital,
from Doctor.
Provide Break up details including Pharmacy items, Materials,
Investigations even though it is there in the main bill
In case the hospital is not registered, please get a letter on the Hospital
letterhead mentioning the number of beds and availability of doctors and
nurses round the clock.
In non- network hospital, you may have to get the hospital and doctor’s
registration number in Hospital letterhead and get the same signed and
stamped by the hospital, if required
All claims must be intimated to
the TPA within 24 hrs of
Hospitalization and claim
registration no. must be
obtained
Group Medical Plan Claims Document List
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• Intentional self injury , suicide, all psychiatric and psychosomatic disorder and diseases / accident due to and or use ,
miss use or abuse of drugs/ alcohol or use of intoxicating substances or such abuse or addiction etc.
• Expenses incurred at hospital and nursing home primarily for evaluation / diagnostic purposes which is not followed by
active treatment for the ailment during the hospitalized period
• Expenses incurred for investigation or treatment irrelevant to the disease diagnosed during hospitalization or primary
reason for admission reason. Private nursing charges , referral fee to family doctor, outstation consultants / surgeons fee
etc
• Genetical Disorder and Stem cell implantation / surgery
• External and or durable medical / non medical equipment of any kind used for diagnosis and or treatment including CPAP,
CAPD, infusion pump etc ambulatory devises that is walker , crutches , belts, collars , caps , splints, slings , braces,
stocking etc of any kind , diabetic footwear, glucometer / thermo meter and similar related items etc and also any medical
equipment which is subsequently used at home etc.
• Treatment of obesity or condition arising there from (including morbid obesity) and any other weight control program,
services or supplies etc
• Any treatment required arising from insured’s participation in any hazardous activity including but not limited to scuba
diving , motor racing , parachuting , hand gliding , rock or mountain climbing etc
• Spill over claims from other insurance policies for capped ailment like maternity and cataract.
* Indicative list, Please refer to policy document
Group Medical Plan General Exclusions
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• Circumcision unless necessary for treatment of disease
• Congenital external diseases or defects/anomalies
• Treatments/ procedures attributing Fertility, sterilization. HIV and AIDS, Venereal diseases
• Hospitalization for convalescence, general debility, intentional self-injury, use of intoxicating drugs/ alcohol, obesity
• Naturopathy, chiropractic medicine, herbalism, traditional Chinese medicine, Ayurveda, meditation, yoga, biofeedback,
hypnosis, homeopathy, acupuncture, and nutritional-based therapies. Any experimental or unproven procedure / treatment
• Any non-medical expenses like registration fees, admission fees, charges for medical records, cafeteria charges,
telephone charges, hospital surcharges etc
• Surgery for correction of eye sight, Cost of spectacles, contact lenses, Lasik Surgery , hearing aids, cost of appliances,
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
• Infertility treatment sub fertility or assisted conception , Voluntary termination of pregnancy during first 12 weeks (MTP),
• Vaccinations & inoculation, OPD Claims, Claims submitted without prescriptions/diagnosis/ original bills ,
• Costs incurred as a part of membership/ subscription to a clinic or health center, Health foods, Dietary supplements
Cosmetic or aesthetic treatment of any description, plastic surgery other than necessitated due to an accident or illness.
• Any dental treatment or surgery
• Injury or disease directly or indirectly caused by or arising from or attributable to War or War-like situations, nuclear
weapons
….. Cont * Indicative list, Please refer to policy document
Group Medical Plan General Exclusions
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1) ADMINISTRATIVE EXPENSES
• Admission charges
• Registration charges
• Medico-legal charges
• Attendant stay charges
• Relative stay charges
• Additional stay
• Gate pass/Attendant pass
• Conveyance charges
• Booking charges
• Overhead charges
• Establishment charges
• Tax/Luxury charges
• Surcharge/Service charges
• Incidental charges
• Waste disposal charges
2) DOCUMENTATION EXPENSES
• Documentation charges
• Discharge summary
• Medical records charges
• Birth certificate
• Death certificate
• Medical certificate
• TPA charges
3) CONSUMABLES
• Antiseptic/ disinfectant solutions
• Soap
• Powder (talc)
• Oil
• Cream
• Sanitary pads/Diapers
• Toiletries & stationeries & cosmetic expenses
• Cassette/CD/Film charges
• Oxygen cylinder
• ECG electrode charges
• Mortuary/coffin charges
• Housekeeping charges
• Preparation charges
• DONOR charges
• Vaccination charges
• Outstation consultants / surgeons
• Referral charges
• HIV Charges
• RMO/ duty doctor charges
• Assistant charges for minor cases
• Expenses towards sterilization
4) SERVICES
• Private nurse charges
• Telephone charges
• Fax charges
• Food/beverages
• Diet & dietician charges
• Electricity charges
• Water charges
• T.V / Internet charges
• Newspaper/magazine
• A/C charges
• Stationary charges
• Lines/Laundry charges The list is indicative, actual deduction would vary
Group Medical Plan Deduction / Non payable expenses
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Health Insurance is a benefit for the employee and their dependents. One has to utilize the benefit with utmost
caution and prudence.
The ever increasing cost for the benefits require a proactive involvement from all of us.
The following steps are recommended, ensuring the benefits is prudently utilized by the employee and dependents
covered
Cashless is generally found to be expensive, explore reimbursement if possible –
---“Act with prudence/ discretion on your choice of hospital/service provider”
Please ensure to crosscheck the final bill sent to the TPA for the following:
You are Billed only for the services utilized for e.g. category of room, diagnostics undergone , medicines
consumed
Total of the bill
In case of any planned hospitalization, approach the hospital in advance(48 hrs) and request pre
__authorization. This enables TPA to further negotiate the rates with the hospital
To approach hospitals with caution – most expensive is not necessarily the best. .
Try to negotiate
Ask WHY & WHAT is billed to you ( as a consumer , we have the right to know)
Group Medical Plan Prudent Utilization of Benefit
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