Mediclaim InsuranceMediclaim

Claims Management


Process for Planned hospitalization - eCashless & Cashless

eCashless

Click the eCashless tile on your MediBuddy mobile app or online portal.

Enter details of your impending hospitalization, send intimation at least 48 hours ahead of admission.

You receive a secure passcode confirming your provisional preauthorization.

On the day of admission, present your secured pass-code, MA e-card and photo ID card at the hospital.

Cashless

Click the Network Hospital tile on your MediBuddy for a GPS map-based search to locate the nearest network hospital.

Visit ecard.medibuddy.in to download your card instantly

At the hospital, display your ecard at the Insurance Desk.

Complete and submit the pre-authorization form. Your hospital will send the form to Medi Assist for approval.

eCashless/Cashless hospitalization is available only at network hospitals. Visit ecard.medibuddy.in to download your card instantly.

During the course of the hospitalization, Medi Assist may request your hospital for additional information to process interim claims and final bill before discharge.

Track your claim in real-time.
MediBuddy: Click the Claims tile
SMS: CLAIM (CLAIM NUMBER) to +919664172929
Visit track.medibuddy.in


Process for Planned hospitalization


Step 1 | Pre-Authorization

All non-emergency hospitalisation instances must be pre-authorized with the TPA, as per the procedure detailed below.

This is done to ensure that the best healthcare possible, is obtained, and the patient/ employee is not inconvenienced when taking admission into a Network Hospital.

Member intimates TPA of the planned hospitalization in a specified pre- authorization format at-least 48 hours in advance

Claim Registered by the TPA on same day

Follow non cashless process

TPA authorizes cashless as per SLA for planned hospitalization to the hospital

Pre-Authorization Completed




Step 2 | Admission, Treatment & discharge

After your hospitalisation has been pre- authorized, you need to secure admission to a hospital. A letter of credit will be issued by TPA to the hospital. Kindly present your ID card at the Hospital admission desk. The employee is not required to pay the hospitalisation bill in case of a network hospital. The bill will be sent directly to, and settled by TPA

Member produces ID card at the network hospital and gets admitted

Member gets treated and discharged after paying all non entitled benefits like refreshments, etc.

Hospital sends complete set of claims documents for processing to TPA

Claims Processing & Settlement by TPA & Insurer



Process for Emergency Hospitalization


Step 1 | Get Admitted

In cases of emergency, the member should get admitted in the nearest network hospital by showing their ID card.



Step 2 | Pre-Authorization by hospital

Relatives of admitted member should inform the call centre within 24 hours about the hospitalization & Seek pre authorization. The preauthorization letter would be directly given to the hospital. In case of denial member would be informed directly



Step 3 | Treatment & Discharge

After your hospitalisation has been pre- authorized the employee is not required to pay the hospitalisation bill in case of a network hospital. The bill will be sent directly to, and settled by TPA

Member gets admitted in the hospital in case of emergency by showing his ID Card

Member/Hospital applies for pre- authorization to the TPA within 24 hrs of admission

TPA verifies applicability of the claim to be registered and issue pre-authorization

Pre-authorization given by the TPA

Member gets treated and discharged after paying all non medical expenses like refreshments, etc.

Hospital sends complete set of claims documents for processing to the TPA

Reimbursement process



Reimbursement process for hospitalization at a non-network hospital

Click the Reimbursement tile on your MediBuddy to give us prior intimation about your impending claim before discharge from the hospital.

Click the Submit Claims tile on your MediBuddy online portal to scan and upload your hospitalization bills.

Submit all hard copies of bills in original to your servicing Medi Assist branch or your HR SPOC.

Track your claim in real-time.
MediBuddy: Click the Claims tile
SMS: CLAIM (CLAIM NUMBER) to +919664172929
Visit track.medibuddy.in


Reimbursement claims process


Insured admitted as per hospital norms. All payments made by member

Insured sends relevant documents to TPA office within 30 days of discharge

A

Is document received within 30 days from discharge

Claim Rejected

TPA performs medical scrutiny of the documents

Is claim payable?

Claim Rejected

TPA checks document sufficiency

Is documentation complete as required

Send mail about deficiency and document requirement to the employee

Claims processing done

Payment to be made to Employee. The discharge voucher and copy of payment receipt to be sent to employee through Mediassist Helpdesk.

A



* Insured will create the summary of Bills and attach it with the bills
* The envelope should contain clearly the Employee ID & Employee e-mail


Claims Document List

Completed Claim form , ECS form , Cancel cheque 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

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.

Your Group Medical Health Policy and Benefits

Details on your Health Insurance Policy: Your insurer: United India Insurance Co. Ltd., Your TPA: Medi Assist


Your Policy in a Nutshell

EMPLOYEE POLICY(1+3) TOP UP POLICY
Policy Period 1st July 2017 – 30th June 2018 1st July 2017 – 30th June 2018
Beneficiaries Self + Spouse + 2 dependent children
+ Parents + Parent in-laws 		As per what employee has opted
Coverage Type Family floater As per what employee has opted
Sum insured Grade wise Sum Insured Grade wise Sum Insured
Room rent As per actuals As per actuals
Inclusions Hospitalization expenses covered upto 30 days for pre-hospitalization and upto 60
days for post-hospitalization

Maternity Benefits

STANDARD PLAN
Benefit Upto the Family sum insured under the policy
Pre/ Post Natal expenses Covered if warrants IP admission
Maternity expenses Benefits admissible in case of hospitalization in India
9 months waiting period is waived off
Maternity expenses payable only for the first two living children
Pre and Post Hospitalization benefits not extended to Maternity related Expenses
Baby Cover from Day one to be included under family sum insured

Policy Period and Dependent Coverage details

POLICY PERIOD
Beneficiaries Commencement Date Termination Date
Existing Employees + Dependents 1st July 2017 30th June 2018
New Joinees + Dependents Date of joining 30th June 2018
New Dependents due to Marriage/Birth Marriage – Date of intimation (To be intimated
within 30 days) to insurer Birth – Date of
birth(To be intimated within 30 days)		 30th June 2018

DEPENDENT COVERAGE DETAILS
Maximum no of Members insured in a family (Employee Policy) Self + Spouse + 2 dependent children + Parents + Parent in-laws
Employee Yes
Spouse Yes
Children Yes (for the first 2 living Children up to Maximum age 24 Years)
Parents + Parent in-laws Yes
Siblings No
Mid Term enrollment of existing Dependents Disallowed
Mid Term enrollment of New Joinees (New employees + their Dependents) Allowed
Mid term enrollment of new dependents (Spouse/Children) Allowed

Standard Coverage Details

Room rent paid at actuals

Professional charges at actuals

Intensive Care Unit charges at actuals

Other Charges paid (Excluding Non Medicals Expenses)

Immunization / Immuno Therapy for Cancer Cases Covered : 50% of the SI or actual amount whichever is less Per Year Per Family

Cyber knife / Robotic Surgeries Covered: 50% of the SI or actual amount whichever is less Per Year Per Family

AYUSH as per policy terms and conditions

Unmarried and unemployed girls ,disabled children without income and dependent upto the primary insured, the above age limit will not apply

Diagnostic expenses covered upto Rs 10,000/- per family (Insured must be presented with complaints / symptoms of disease and referred by a qualified physician / surgeon for further investigation as per medical protocol)

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.

24 Hours hospitalization not required on the below
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, Eye surgery, Dental Surgery ( Due to Accident ) , Lithotripsy (kidney stone removal), Tonsillectomy, Colonoscopy , Hydrocele, Hysterectomy, Prostate, Piles/fistula, Lithotripsy , Colonoscopy ,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.


Definitions of Negotiated Benefits

Benefits Definition
Pre existing diseases 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 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 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 In consideration of additional premium, 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.

Note: When treatment such as Dialysis, Chemotherapy, Radiotherapy is taken in the Hospital/Nursing Home/Clinic and the insured is discharged the same day, the treatment will be considered to be taken under Hospitalization Benefit section and thus covered.

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