ATT3KATO .pdf

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Group Medical Insurance Policy - Ready Reckoner

Policy No: 4016/80110607/00/000
Policy Period: 01/05/2013 to 30/04/2014
Insurance Company: ICICI Lombard General Insurance.
Broker: Aditya Birla Insurance Brokers Ltd.
TPA: ICICI Lombard I health Care

A) COVERAGE
B) CASHLESS HOSPITALIZATION PROCESS
C) CLAIM INTIMATION
D) REIMBURSEMENT CLAIM PROCESS
E) REIMBURSEMENT CLAIM DOCUMENTS LIST
F) ESCALATION MATRIX & CONTACT DETAILS

A)Coverage:


Hospitalization Expenses due to illness/accident



Group Mediclaim policy which includes Floater (Self + Spouse +
Children up to 25 Years)



30/60 days pre and post Hospitalization expenses



Maternity benefit- 9 months waiting period waived off Rs.30,000/- for Normal and
Rs.30,000/- for Caesarian



Sum Insured is grade wise



Pre-existing disease covered



Waiver of for 1st 30 Days,



Waiver of 1st year exclusion



Ambulance charges payable up to 1000/-



Day care surgeries will be payable as mentioned in policy



Baby covered from Day 1 within family floater Sum Insured.

Dependent

The policy does not cover:
1) Intentional self-injury (Suicide)
2) Cosmetic Surgery
3) AIDS
4) Naturopathy Treatments
5) Domiciliary hospitalization expenses
6) Expenses on fitting of Prosthesis
7) Any devise/Instrument / Machine / that does not become part of Human anatomy
/ Body but would contribute / replace the function of an organ is not covered
8) Treatment on trial / Experimental basis (Investigation purpose)
9) Lasik Treatment
10) Infertility and related ailment , Male sterility
11) Administration, registration, service charge, & Miscellaneous charges Etc.
12) External medical equipment used as post hospitalization care not covered
13) General debility, use of drugs or alcohol, intentional self injury, sterility, venereal
disease not covered
14) Any device/instrument/machine that does not become part of the human

anatomy/body but would contribute/replace the function of an organ is not
covered

Add on Coverages:
 Coverage of hospitalization due to psychiatric illness and related conditions
restricted to Rs.30000/- maximum, as well as treatment of Functional Endoscopic
Sinus Surgery (FESS) within a limit of Rs. 35,000.
 50% copay for cyber knife treatment & stem cell transplantation. Cochlear
Implant treatment shall be restricted to 50% of the SI.
 FESS could be covered with maximum liability of Rs.35000/-.
 Kidney Stone- Rs 25,000 incl DJ stent removal (for the same stone) even if
at a later admission)

Some Hospitals take
Deposit for Admission

B) Cashless Hospitalization Process:
Employee to contact TPA/Insurance Help Desk at
Hospital with Patient’s ID Card & Photo Identity
proof.
Hospital will send Form by Fax/mail to TPA for
Cashless Processing

TPA Shall process request within 4-6 Hours

TPA raising Query for
Details

Hospital sends Queried
documents

Cashless Approved

Treatment converted in
Cashless
Hospitalization

Cashless Denied

Employee sends Claim
for Reimbursement

On discharge, the billing counter will advise on the non
– medical expenses which will be paid by the Employee.
(Some Hospitals have a practice of taking Security
deposit which will be returned to Employee after TPA
settles Hospital claim)

Employee to check
Hospital bill & obtain
copy of the same at
time of Discharge

C) Claim Intimation:
Claim intimation is mandatory within 24 Hrs from date of
admission.
Mandatory details for Intimation
 Policy No.
 Corp Name
 Emp code
 Emp Name
 Claimant Name
 Date of Admission
 Hospital Name & Address
 Diagnosis
Intimation can be forwarded through mail on. ihealthcare@icicilombard.com
Mark

cc

to

kirti.shivalkar@adityabirla.com;
nitin.rsharma@adityabirla.com & hrd@mindcraft.in

siddhi.warang@adityabirla.com

Incase of non availability of Email facility, Intimation can be given on below mentioned no
18002098888

D) Reimbursement Claims Process:
Employee pays to Hospital directly. Original
Documents as per List to be submitted for
Reimbursement within stipulated time

Fill up Claim form completely and Submit along
with supporting documents

TPA shall process claim within stipulated time

TPA raising Query for
Details

Claim approved

Claim Repudiated

Employee
sends
queried Documents

Claim payment will
be done to
Employee/Corporate

Repudiation Letter will
be sent to Employee
Hospitalization

E) Reimbursement Claims Documents List:
 Claim submission should be within 15 days from the date of Discharge.
 Post claim should be submitted within 7 days from completion of post
60 days limit/completion of treatment whichever is earlier.
 Signed Claim Form of the Insurance Company
 Original Final Hospital Bill along with Payment Receipt
 Original Discharge Summary /Card.
 Death Certificate /Death Summary in case of Death
 All Investigation Reports in original
 Original Bills & Receipts for investigations done outside hospital
 Doctors Prescription, Pre & Post Hospitalization bills (in original)
 Original Bills of medicines and surgical appliances if purchased
 Cancelled cheque for reimbursement through NEFT
 COPY OF SET OF ALL SUBMITTED DOCUMENTS INCLUDING BILLS SHOULD
BE KEPT WITH EMPLOYEE

 Note: Claims submitted after stipulated time shall not be considered for
the claim processing in any condition

F) Contact details & Escalation Matrix:

First point of contact
Ms Kirti Shivalkar:
Email ID:

kirti.shivalkar@adityabirla.com

Mobile No.: 9594470220

Escalation Point 1
Ms Siddhi M Warang:
Email ID:

siddhi.warang@adityabirla.com

Mobile No.: 9975709244

Escalation Point 2
Mr Nitin Sharma:
Email ID:

nitin.rsharma@adityabirla.com

Mobile No.: 9594688765


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