Vedanta Presentation for 10-11

8/4/2019 Vedanta Presentation for 10-11

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1st

Oct 2010atJharsuguda.Odisha

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A. Room, Boarding and Nursing Expenses as provided by the Hospital/Nursing home

not exceeding 1% of the sum insured or Rs 5,000/- per day which ever is less.

B. I.C.Unit expenses not exceeding 2% of the sum insured or Rs 10,000/- per daywhich ever is less( Room stay and I.C.U stay should not exceed total number ofadmission days )

C. Surgeon, Anaesthetist, Medical Practitioner, Consultants, Specialists fees.

D. Anaesthesia, Blood,Oxygen,Operation Theatre Charges, Surgical Appliances,Medicines & Drugs, Dialysis, Chemotherapy, Radiotherapy, Artificial Limbs, Cost ofProsthetic devices implanted during surgical procedure like pacemaker, relevantLaboratory /Diagnostic tests, X-ray etc.

E. Ambulance Services 1% of the sum insured or Rs 2,000/- which ever is less shall bereimbursable in case patient has to be shifted from residence to hospital in case ofadmission in Emergency Ward / I.C.U or from one Hospital / nursing home toanother Hospital / nursing home by registered ambulance only for better medicalfacilities.

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I. HOSPITAL/NURSING HOME: Means any institution in India established for

indoor care and treatment of sickness and injuries and which either

(a) Is duly licensed and registered as Hospital/ Nursing Home with the

appropriate authorities and is under the supervision of a registered and

qualified Medical practitioner.

Or

(b) In areas where licensing and registration facilities with appropriateauthorities are not available, the institution must be one recognized in locality

as Hospital / Nursing Home and should comply with minimum criteria.

NOTE: In case of Ayurvedic / Homeopathic / Unani treatment, Hospitalization

expenses are admissible only when the treatment is taken as in-patient, in a

Govt Hospital / Medical College Hospital.

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2. SURGICAL OPERATION: Means manual and/or operative procedures for

correction of deformities/ defects and injures cure of diseases, relief of

suffering and prolongation of life.

3. HOSPITALISATION PERIOD: Expenses on Hospitalization are admissible

only if hospitalization is for a minimum period of 24 hours. However,

(A) This time limit will not apply to following specific treatments taken

in the Networked Hospital/Nursing Home where the Insured is

discharged on the same day. Such treatment will be considered to

be taken under Hospitalization Benefit:

I. Haemo Dialysis

II. Parenteral Chemotherapy.

III. Radiotherapy.IV. Eye Surgery.

V. Lithotripsy (Kidny stone removal)

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VI. Tonsillectomy.

VII. D&C

VIII. Dental Surgery.

IX. Hysterectomy.X. Coronary Angioplasty and Angiography.

XI. Surgery of Gallbladder, Pancreas and bile duct.

XII. Surgery of Hernia. Hydrocele, Prostrate

XIII. Gastrointestinal Surgery.

XIV. Genital Surgery.XV. Surgery of Nose, Throat, Appendix and Urinary System.

XVI. Treatment of fractures / Dislocation excluding hair line fracture,

Contracture releases and minor reconstructive procedures of limbs

which otherwise require hospitalization

XVII. Arthroscopic knee Surgery.

XVIII. Laparoscopic therapeutic surgery.

XIX. Any surgery under General Anesthesia.

XX. Or any such disease / procedure agreed by TPA / Company before

treatment.

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4. THIRD PARTY ADMINISTRATOR (TPA): Means any company who has

obtained license from IRDA to practice as a third party administrator and isappointed by the company.

5. NETWORK HOSPITAL: Means hospital that has agreed with the TPA to

participate for providing cashless health services to the insured persons. The

list is maintained by and available with the TPA and the same is subject to

amendment from time to time.

6. HOSPITALISATION PERIOD: The period for which an insured person is

admitted in the hospital as inpatient and stays there for the sole purpose of

receiving the necessary and reasonable treatment for the disease / ailment

contracted / injuries sustained during the period of policy. The minimum

period of stay shall be 24 hours.

7. PRE-HOSPITALISATION: Relevant medical expenses incurred during theperiod up to 30 days prior to hospitalization on disease / illness / injurysustained will be considered as part of claim.

8. POST-HOSPITALISATION: Relevant medical expenses incurred during the

period of60 days after hospitalization on disease / illness / injury sustained will

be considered as part of claim.

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9. IN-PATIENT: An insured person who is admitted to hospital and stays for at

least 24 hours for the sole purpose of receiving the treatment for sufferedailment / illness / disease / injury / accident during the currency of the policy

10. CASHLESS FACILITY: Means the TPA may authorize upon the insureds

request for direct settlement of admissible claim as per agreed charges

between Network Hospitals & the TPA In such cases the TPA will directly settle

all eligible amounts with the Network Hospitals and the Insured person may

not have to pay any bills after the end of the treatment at Hospital to the

extent the claim is covered under the policy.

11. E.CARD: Means the card issued to the insured person by the TPA to avail

Cashless facility in the Network Hospital.

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Those insured persons who are already having two or more living

children will not be eligible for this benefit.

Claim in respect of only first two children and / or operation associated

therewith will be considered. The Maximum benefit allowable under this clause will be Rs 50,000/- and

would fall under different heads .The sum insured under above benefit

shall be a part of basic sum insured.

These benefits are admissible only if the expenses are incurred in

hospital / nursing home as in-patient in India. Expenses incurred in connection with voluntary medical termination of

pregnancy during the first 12 weeks from the date of conception are not

covered.

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Pre-natal and Post-natal expenses are not covered unless admitted inHospital/Nursing Home and treatment is taken there.

Pre Hospitalization and Post Hospitalization benefits are not available

under this section.

New born child shall be covered from day one up to the age of3 months

and expenses incurred for treatment taken in hospital as in-patient shall

only be payable within the specified sum insured of Rs 50,000/- under

Maternity benefit Extension. Congenital diseases of new born child shall

be excluded.

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Injury or disease directly or indirectly caused by or arising from or attributable towar,invasion, Act Of foreign Enemy, war like operation 9Whether war be declared

or not) or by nuclear weapons / materials.

Circumcision, vaccination, inoculation or change of life or cosmetic or of aesthetic

treatment of any description, plastic surgery other than as may be necessitated

due to an accident or as a part of any illness.

Cosmetic surgery for correction of eye sight, cost of spectacles, contact lenses,

hearing aids etc..

Convalescence, general debility, run down condition or rest cure, congenital

external diseases or defects or defects or anomalies, sterility, any fertility, sub-

fertility or assisted conception procedure, venereal diseases, intentional self-

injury / suicide, accident due to and or use misuse of drugs / alcohol or use ofintoxicating substances or such abuse or addiction etc.

Any dental treatment or surgery which is corrective, cosmetic or of aesthetic

procedure, filling of cavity, root canal including wear and tear etc unless arising

from disease or injury and which requires hospitalization for treatment.

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All expenses arising out of any condition directly or indirectly caused by, or

associated with Human T-Cell Lymphotropie Virus Type III (HTLD-III) orLymohadinopathy Associated Virus (LAV) or the Mutants Derivative or VariationsDeficiency Syndrome or any Syndrome or condition of similar kind commonlyreferred to s AIDS, HIV and its complications including sexually transmitteddiseases.

Expenses incurred at Hospital or Nursing Home primarily for evaluation /diagnostic purposes which is not followed by active treatment fro the ailmentduring the hospitalised period.

Any treatment arising from or traceable to pregnancy, child birth, miscarriage,caesarean section.

Naturopathy treatment, unproven procedure or treatment, experimental or

alternative medicine and related treatment including acupressure, acupuncture,magnetic and such other therapies etc.

Expenses incurred fro investigation or treatment irrelevant to the diseasesdiagnosed during hospitalisation or primary reasons for admission. Privatenursing charges, Referral fee to family doctors, Outstation consultants/ Surgeonsfees etc.

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Expenses on vitamins and tonics etc unless forming part of treatment for injury

or disease as certified by the attending physician.

External and / or durable medical / Non-Medical equipment of any kind used fordiagnosis i.e walker, crutches, Belts etc

All non medical expenses including personal comfort and convenience items orservices such as telephone, television , cosmetics, napkins etc,

Change of treatment from one pathy to other pathy unless being agreed /allowed and recommended by the consultant under whom the treatment istaken.

Any stay in the Hospital for any domestic reason or where no active regulartreatment is given by the specialist.

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Out patient Diagnostic, Medical and Surgical procedures or treatments, non-prescribed drugs and medical supplies, Hormone replacement therapy, SexChange .

Messages, Steam bathing, Shirodhara and alike treatment under Ayurvedictreatment.

Any kind of service charges, Surcharges, Admission Fees/ Registration Charges

etc. Levied by the hospital. Doctors home visit charges, Attendant/Nursing charges during pre and post

hospitalisation period.

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Please visit our website www.heritagehealthservice.com/corp

Then go to E-card option.

Then select the corporate Code i.e VEDANTA178

Then put your employee ID No along with the password same as employee ID.

After submit all the data then you will receive your e-card instantly.

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Claim in respect of cashless access services will be through the TPA provided

admission is in a listed hospital in the agreed list of the Networked hospital issubject to pre admission authorisation. The TPA shall upon getting the related

medical details/ relevant information from the insured person/ network hospital,verify that the person is eligible to claim under the policy and after satisfying itself will issue a pre-authorisation letter to the hospital mentioning the sumguaranteed as payable, also the ailment for which the person is seeking to beadmitted as in-patient.

TPA reserves the right to deny pre-authorisation in case the hospital insured

person is unable to provide the relevant information medical details as requiredby the TPA.

Should any information be available to the TPA which makes the claiminadmissible or doubtful requiring investigations, the authorisation of cashlessfacility may be withdrawn. However this shall be done by the TPA before thepatient is discharged from the Hospital.

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Please intimate us through Fax (033-22100837,22310287) by sending

completed pre-authorisation request through Hospital/Nurshing Home.

In every network hospital there is a corporate or TPA help desk corner is

available so you may please show your e-cards and coordinate with the

hospital people to provide us all the relevant information.

Then please sign the Pre Authorization Form which is provided by

the network hospitals.

FOR MORE INFORMATION AND F&Qs PLEASE VISIT OUR WEBSITE

www.heritagehealthservice.com

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Following documents are to be submitted in case of Cash less Claim:

a) First Prescription with Provisional Diagnosis & Medical history.

b) Completed Pre-Authorisation Form sign with Patient/Relative.

c) All relevant positive radiological & pathological reports.

d) Advice for hospitalization by a registered Medical practitioner.

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Following documents are to be submitted in case of Reimbursement Claim:

Photocopy of E- Card .

Claim Form duly signed and completed by the claimant/proposer & breakup in

summary sheet of all expenses.

Advice for Hospitalization and first consultation papers of each doctor who has

treated the insured in Original.

Advice for investigation from the treating doctor in Original.

Original consolidated hospital bill & money receipt signed by patient /relative

/insured. (Bill breaks up & package break up to be given in all cases.

Cash memos of chemist(s)/ hospital supported by prescription note from the

attending doctor demanding such test. (Including X-ray plate, USG plate, CT Scan plate,MRI plate etc.)

Attending Doctors / Consultations/ specialist/ Anesthetists bill, receipt.

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Following documents are to be submitted in case of Reimbursement Claim:

Obstetric Details from treating doctor (In the Maternity benefit case)in original Discharge Certificate / Summary / Card with proper seal - in original. MLC (Medical Legal Certificate) with proper seal from nearest police station (InRoad Traffic Accident Case) IOL sticker ( In case of Cataract Operation ) Fitness Certificate from the attending doctor. Any other documents having any relation to the treatment & claims.

For Reimbursement Please send all the Original Documents on the followingaddress.

Heritage Health TPA Pvt LtdPlot No- 31/A, Unit-III,

Kharvela Nagar, BhubaneswarOdisha. Pin-751001Phone No- 0674 2393107

NOTE: PLEAE KEEP A PHOTO COPY OF EVERY DOCUMENTS BEFORE SEND TO TPA.

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Branch

Office

Corporate

Office

Heritage Health TPA Pvt LtdPlot No- 31/A, Unit-III,

Kharvela Nagar, BhubaneswarPhone No- 0674 2393107

Nicco House, 5th Floor, 2 Hare Street, Kolkata 700 001 Phone (033) 2248 6430/2784,

Fax: (033) 2210 0837National Toll Free No.18003453477 (24 hrs)

Email:[email protected]

Website: www.heritagehealthservice.com

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