Target Insurance Policy-2013-14-FHPL · (kidney stone removal), ... received the same please write to insurance.helpdesk@ ... • In case you choose a non-network hospital you will

© 2013 Marsh India Insurance Brokers Pvt. Ltd.

Prepared by MARSH India Insurance brokers Pvt Ltd

Target Hospitalization Insurance Policy 131 October 2013

Medical Benefits




Medical Benefit- Employee – Coverage Details




Medical Benefit Parents– Coverage Details

Please Note: Parental cover is optional and the 20% of the premium cost has to be borne by the employee. The cost as mentioned in the following slides would be deducted from the salary of the employee in the subsequent month to the coverage.




Medical Benefit – Dependant Coverage

Maximum no of Members insured in a family 1 + 3

Employee Yes

Spouse Yes

Children Yes (for the first 2 living Children) till the age of 21

Siblings No

Others 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

No Individual should be covered as dependent of mor e than one employee in the Target India Policy (Spouse or siblings employed at Target)

Maximum no of Members insured in a family 1 + 1

Parents Optional Entry age restricted to 85 years

Parents-in-Law Optional age restricted to 85 years

Siblings No

Others No

Mid Term enrollment of existing Dependents Disallowed

Mid Term enrollment of New Joinees (Dependents) Allowed

Employee Policy

Parents Policy




Medical Benefit – Policy Period

Existing Employees + Dependents

Commencement Date 1st April 2013

Termination Date 31st March 2014

New Joinees + Dependents

Commencement Date Date of joining


New Dependents (due to Marriage / Birth)

Commencement Date Date of such event**


** Declarations for new additions in the family to be made in prescribed format within 30 days of the event . Failing which the cover would be extended in subsequent renewal post March 2014 only.

*Dependent coverage for all new joiners would be subject to the declaration made in enrolment portal. In case the one has not been enrolled the cover would be extended in subsequent renewal post March 2014 only.




Medical Benefit – Coverage Levels




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.

Covers expenses related 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 & Dental Surgery (due to accident), 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.




Post-hospitalisation Expenses

Definition

• If the Insurer accepts a claim under Hospitalization and immediately following the Insured Member’s discharge, further medical treatment directly related to the same condition for which the Insured Member was Hospitalized is required, the Insurer will reimburse the Insured member’s Post-hospitalisation Expenses for up to 60 day period.

Covered • Yes

Duration • 60 Days

Pre & Post Hospitalization Expenses

Pre-hospitalisation Expenses

Definition

• If the Insured member is diagnosed with an Illness which results in his / her Hospitalization and for which the Insurer accepts a claim, the Insurer will also reimburse the Insured Member’s Pre-hospitalisation Expenses for up to 30 days prior to his / her Hospitalization.

Covered • Yes

Duration • 30 Days




Maternity Benefits

• These benefits are admissible in case of hospitalisation in India.

• The baby is covered from Day 1 for any treatment within the family floater, subject to the intimation to the insurance company through the Insurance desk/HR within 30 days of the birth.

• The expenses incurred on account of Vaccinations, baby check up and other well baby charges will not be covered in the Policy

• Covers for first two 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.

Benefit Details

Benefit Amount• INR 50,000 for Normal Delivery

• INR 50,000 fro C section (Cesarean) Delivery

Restriction on no of children • Maximum of 2 living children

9 Months waiting period • Waived off




•Room Rent eligibility up to –1% of sum insured - INR 3000 per day for normal non ICU admission –2% of sum insured – INR 6000 per day for ICU & CCU. In event of a member opting for a higher category/ room rent – escalation cost of all other expense due to the room upgrade would be borne by the member covered.Explanation : The cost of treatment (consultation, procedure charges etc) are directly related to the category of roomExample 1- member opts for a room which is INR 6000 per day. This is two times the eligibility. The actual escalation in cost is not determined. Hence only 50% of the admissible claim would be paid Example 2- member opts for a room which is INR 7000 per day. This is two times the eligibility. The actual escalation in cost of treatment is determined and is the difference is borne by the insured Room rent to includes nursing charges

•Maternity – INR 50,000 for normal delivery – INR 50,000 for C Section (Caesarean) deliveryAny further expense have to borne by the insured / claimant.

•Ailment capping – – No Ailment caps

Limits & Eligibility – Employee Policy

Please note: The detail are indicative. For further details on the restrictions, limits and eligibility , please refer to the policy document




•Room Rent eligibility up to – 1.5 % of sum insured – INR 3000 per day for normal Non ICU admission – 3% of sum insured- INR 6000 per day for ICU & CCUIn event of a member opting for a higher category/ room rent – escalation cost of all other expense due to the room upgrade would be borne by the insured / member covered.

Explanation : The cost of treatment (consultation, procedure charges etc) are directly related to the category of roomExample 1- member opts for a room which is INR 6000 per day. This is two times the eligibility. The actual escalation in cost is not determined. Hence only 50% of the admissible claim would be paid Example 2- member opts for a room which is INR 6000 per day. This is two times the eligibility. The actual escalation in cost is determined and is the difference is borne by the insured Room rent to includes nursing charges

Ailment capping – Cataract : INR 27, 000 per eye including cost of lens

Limits & Eligibility – Parents Policy

Please note: The detail are indicative. For further details on the restrictions, limits and eligibility , please refer to the policy document




Medical Benefit – Enrollment of Parents

Parental coverage is optional. Employee can choose to cover parents on agreement to share premium cost with Target India in proportion of 20:80. where employee pays 20% of the annual premium and Target India shares 80% of the premium.

•For new joiners only pro-rata premium i.e. premium for the remaining number of days in the policy would be changed.

• There will be no refund of premium for terminated team members.

Annual Premium per parent family

Target’s Contribution Employee’s contribution

INR 17,240 INR 13,792 INR 3,448




• Log on to FHPL website https://www.fhpl.net

• Click on the Logins -> E-Card Tag

• Key in the Corporate ID – 840

• Key in the Login ID and the Password **

• Click on Login

• Click on the Member Details

• Click on E-Card option to view / print the card

** Unique User id and password for each team member has been sent by mail. In case you have not received the same please write to [email protected]

Medical Benefit – E Cards




Medical Benefit – Cashless Process

Cashless means the Administrator may authorize upon a Policyholder’s request for direct settlement of eligible

services and it’s according charges between a Network Hospital and the Administrator. In such case the

Administrator will directly settle all eligible amounts with the Network Hospital and the Insured Person may not

have to pay any deposits at the commencement of the treatment or bills after the end of treatment to the extent

as these services are covered under the Policy.

List of hospitals in the FHPL network eligible for cashless process

Please refer to the updated list from the TPA website by following the link https://www.fhpl.net/NetworkHospitals/NWHospitals.aspx

Contact Customer Service Line :

Toll Free No:1-800-425-4033

Note : Patients seeking treatment under cashless hospitalization are eligible to make claims under pre and post hospitalization expenses. For all such expenses the bills and other required documents needs to submitted separately as part of the claims reimbursement.




Step 1Pre-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.

Planned Hospitalization




Emergency Hospitalization & Process




Non-Cashless

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

hospitalisation expenses from the insurer.

Discharge procedure

• In case of non network hospital, you will be required to clear the bills and submit the claim to TPA for

reimbursement from the insurer. Please ensure that you collect all necessary documents such as – discharge

summary, investigation reports etc. for submitting your claim.

Submission of hospitalisation claim

• You must submit the final claim with all relevant documents within 30 days from the date of discharge from

the hospital. Post 30 days the reimbursement claims will not be considered.




Non-Cashless Claims Process

Member intimates TPA before or as soon as hospitalization

occurs

Insured admitted as per hospital norms. All payments made by

member

Claim registered by TPA after receipt of claim intimation

Insured sends relevant documents to TPA office within

30 days of discharge

Is document received

within 30 days from

discharge

Claim Rejected

No

TPA performs medical scrutiny of the documents

Is claim payable?

Yes

TPA checks document sufficiency

No

Yes

Is documentation complete

as required

Claims processing done as per SLA

Send mail about deficiency and document requirement

A

A

Payment to be made to Insurance Help Desk . The

discharge voucher and copy of payment receipt to be sent to

Insurance Help Desk .Yes

No

•Members will create the summary of Bills (2 copies) and attach it with the bills

•The envelope should contain clearly the Employee ID & Employee e-mail




Claims Document ListCompleted 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.

*Please retain photocopies of all documents submitte d


Benefit Extensions – Definitions




Benefit Extensions – Definitions

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 Hospitalisation Benefit section and thus covered.

Benefits For Target Definition

Day Care

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, Lithotripsy (kidney stone removal), Tonsillectomy, D & C)

Domiciliary Hospitalization

DOMICILIARY HOSPITALISATION BENEFIT means Medical treatment for a period exceeding three days for such illness/disease/injury which in the normal course would require care and treatment at a hospital/ nursing home but actually taken whilst confined at home in India under any of the following circumstances, namely:

– The condition of the patient is such that he/she cannot be removed to the hospital/nursing home or– The patient cannot be removed to the hospital/nursing home for lack of accommodation therein

Benefits not covered

•Expenses incurred for pre and post hospital treatment, and

• Expenses incurred for the treatment for any of the following diseases:– Asthma– Bronchitis– Chronic Nephritis and Nephritic Syndrome– Diarrhea and all types of dysentries including Gastroenteritis– Diabetes Mellitus and Insipidus– Epilepsy– Hypertension– Influenza, Cough, and Cold– All Psychiatric or Psychosomatic disorders– Pyrexia of unknown origin for less than 10 days– Tonsillitis and upper respiratory tract infection including Laryngitis and Pharyngitis– Arthritis, Gout and Rheumatism


22

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 , Venereal diseases

•Hospitalisation for convalescence, general debility, intentional self-injury, use of intoxicating drugs/ alcohol.

•Injury or disease caused directly or indirectly by nuclear weapons

•Naturopathy, Any non-medical expenses like registration fees, admission fees, charges for medical records, cafeteria charges, telephone charges, etc

•Cost of spectacles, contact lenses, hearing aids and various other external prosthetic devices like cochlear implants, crutches, wheel chairs etc.

•Any cosmetic or plastic surgery except for correction of injury due to accident

•Hospitalisation for diagnostic tests only, well baby charges, no active line of treatment, no diagnosed ailment, less than 24 hrs of Hospitalization (except day care procedure listed in the policy)

•Psychiatric treatment

•Vitamins and tonics unless used for treatment of injury or disease

•Infertility treatment , Sterility and related treatments.

•Voluntary termination of pregnancy during first 12 weeks (MTP)

•Immunization, Vaccinations, Inoculations.

•OPD Claims, Health foods , Costs incurred as a part of membership/subscription to a clinic or health centre or stay at rehabilitation center for alcoholics, drug or narcotics




Medical Benefit – Contact Details

Insurance Help Desk

Email & Communicator : [email protected]

Name

Contact Details

Name: Vignesh

Email ID : [email protected]

Mob: +91 95354 58903

Direct : +91 80 4223 5057

Name

Contact Details

Name: Praveen

Email: [email protected]

Mob: +91 99860 16536

Escalation Point

Name

Contact Details

Name: Rahul


Mob: +91 92434 68395

Escalation Point

Name

Contact Details

Nakul Bhatia


Mob: +91 97422 01638

Please Note :

• Help desks are available between 10.00 am to 5.30 pm all working days at GWS - Manyata Tech Park Campus

• The help desk to provide assistance on Information on policy, claim procedure & claim status.

• Claim / Shortfall Documents to be submitted at the Insurance Help Desk

• Claims document can be sent using shuttle services from EGL office to insurance desk.

• Claim would be settled using ECS , no Cheques wou ld be issued.

© 2013 Marsh India Insurance Brokers Pvt. Ltd.Target Hospitalization Insurance Policy 2431 October 2013

� The following steps are recommended, ensuring the benefits extended are adequately utilized by the employee and dependents covered

Please ensure to crosscheck the final bill sent to the TPA for the following:

�Billed only for the services utilized for e.g. category of room, diagnostics undergone

�Total of the bill

In case of any planned hospitalization, approach the hospital in advance(48hrs) and request pre

authorization- this enables TPA to further negotiate the rates

To approach hospitals with caution – most expensive is not necessarily the best. One can explore

Preferred Partner Hospitals for special discounts

Try to negotiate ( you as a consumer have the right to negotiate)

Ask WHY and WHAT




FAQs & Common Definitions