1. health insurance orientation module

Future Generali Health

Health Insurance Orientation Module


Future Generali is an insurance joint venture between the Italy-based

Generali Group and the India-based Future Group.

Future Generali operates Life and Non-Life insurance businesses through ‘Future Generali India Life Insurance Co. Ltd.’ and ‘Future Generali India Insurance Co. Ltd.’

Future Group holds 74% each in both the companies.

Future Generali received license from the Insurance Regulatory Development Authority (IRDA) in Sept 2007 and launched operations from Nov 2007.

Introduction


Future Generali Clientele in India


Introducing


How we are different:

•• Future Generali Health (FGH) is an internal unit of Future GenerFuture Generali Health (FGH) is an internal unit of Future Generali India Insurance.ali India Insurance.

•• No Third Party Administrator (TPA) involved between the insurer No Third Party Administrator (TPA) involved between the insurer and FGH.and FGH.

•• No prior approval required to sanction authorization for cashlesNo prior approval required to sanction authorization for cashless as in the case of s as in the case of

TPAs.TPAs.

•• Claim settlement is faster due to single point clearance Claim settlement is faster due to single point clearance –– no exchange of claim no exchange of claim

documents between insurer and TPA.documents between insurer and TPA.

•• Preferred services extended as FGH provides service only to cliePreferred services extended as FGH provides service only to clients insured by nts insured by

Future Generali.Future Generali.


Call Centre 24 X 7 Helpline to cater to customer queries

Cashless Management 24 X 7 services with 2 hours Turn Around Time (TAT)**

Claims Processing Average TAT of 14 working days**

Provider Management 1400 hospitals and 200 diagnostic centers network

Research and Analysis Analysis, Feedback & monitoring

Pre Policy For retail medical underwriting

Underwriting Centralized Group / Retail Underwriting at hubs

Future Generali Health Future Generali Health An In-house Health Management Team of Future Generali India Insurance Co. Ltd.

Internal units of (FGH) Future Generali Health Team

Enrolment For card issuance and member data management

**All TAT’s subject to availability of complete documentation


Your New Wellness CardYour New Wellness Card

•• Your New card entitles you to a host of Your New card entitles you to a host of

healthcare benefits.healthcare benefits.

•• Photo identification is necessary whenever Photo identification is necessary whenever

you use this card. you use this card.

•• This card does not entitle you to avail This card does not entitle you to avail

cashless without precashless without pre‐‐authorization.authorization.

•• This is NOT a credit card.This is NOT a credit card.


Member Enrolment Key Function: For card issuance and member data management

Within how many days will I get my Wellness Card?

• You will receive health cards via courier or e‐mail within 7 days after your details

are received by FGH from your organization.

What if there is an error on my Wellness Card?

• For any error in cards or correction required, you can immediately report to

your HR.

What is the use of the Wellness Card?

• You will get a Wellness Card to utilize the Cashless facility at Network Hospitals.

• This card helps only in your identification as a Future Generali Health member.

• Availability of Cashless and any other benefit is subject to policy terms.


1.1. Carry your ID cards and authorization letter when you go to the Carry your ID cards and authorization letter when you go to the hospital for admissionhospital for admission

2.2. Get the PreGet the Pre‐‐authorization done in at least 7 days before hospitalizationauthorization done in at least 7 days before hospitalization

3.3. PrePre‐‐authorization is done to determine whether cashless facility canauthorization is done to determine whether cashless facility can be granted based on be granted based on

all medical information about your ailment and coverageall medical information about your ailment and coverage

4.4. PrePre‐‐authorization forms are available at NETWORK hospitals. You can authorization forms are available at NETWORK hospitals. You can also obtain it from also obtain it from

our call centre by eour call centre by e‐‐mail or Faxmail or Fax

5.5. Your treating doctor has to fill the form and sign itYour treating doctor has to fill the form and sign it

6.6. You will also have to sign the Pre Authorization form and providYou will also have to sign the Pre Authorization form and provide your mobile numbere your mobile number

7.7. The hospital will fax this form to our Call Centre to get an autThe hospital will fax this form to our Call Centre to get an authorizationhorization

Claim Process: Cashless

If you are going for a Planned Hospitalization:


8.8. Our doctors will examine the form and decide on cashless availabOur doctors will examine the form and decide on cashless availability ility

9.9. If cashless is granted, we will send an Authorization Letter to If cashless is granted, we will send an Authorization Letter to the hospital. You the hospital. You

can also get a copy of the Authorization Letter from our Call Cecan also get a copy of the Authorization Letter from our Call Centre by entre by e‐‐mailmail

10.10. If cashless is denied, we will send a Denial Letter to the hospiIf cashless is denied, we will send a Denial Letter to the hospital and inform tal and inform

youyou

11.11. If cashless has been denied, you will have to pay the hospital bIf cashless has been denied, you will have to pay the hospital bill and then send ill and then send

the claim to usthe claim to us

Claim Process: Cashless Continued….

If you are going for Planned hospitalization:


Customer approaches FGH Toll Free for Cashless Treatment. Future Generali coordinates

with hospital for preauthorization

Hospital verifies customer details and sendspre‐auth by fax to FGH (Pune)

FGH verifies pre‐auth details with policy benefits and sends the response by

Fax to Hospital

Authorization Letter sent byFGH

Hospital admits the patient without any deposit and

provides cashless treatment

Query Letter sent byFGH

Denial Letter sent by FGH

Hospital admits the patient asCash Patient and patient pays the Bill

Query Denial

CashlessProcess

Network Hospital

Approved

Hospital faxes the reply for queries asked by

FGH doctors


1.1. What is a Network Hospital? How do I know the hospital is on What is a Network Hospital? How do I know the hospital is on

the network?the network?

FGH has tied up with specific hospitals and nursing homes to proFGH has tied up with specific hospitals and nursing homes to provide preferred services vide preferred services

to its customers . These hospitals are termed as to its customers . These hospitals are termed as ““NetworkNetwork”” hospitals.hospitals.

You can find out the details of Network hospitals in your city fYou can find out the details of Network hospitals in your city from our Call Centre on rom our Call Centre on

phone or by ephone or by e‐‐mail. The details are also available in the Health Insurance Gumail. The details are also available in the Health Insurance Guide sent ide sent

along with your Wellness Card.along with your Wellness Card.

Hospitals are added and removed from the network at regular inteHospitals are added and removed from the network at regular intervals. You are rvals. You are

advised to check with our Call Centre for the updated status ofadvised to check with our Call Centre for the updated status of any hospital.any hospital.

Cashless Process FAQs


2.2.How does the Hospital verify that the cardholder is genuine?How does the Hospital verify that the cardholder is genuine?

Since the Card issued is not a photo id card, you are required tSince the Card issued is not a photo id card, you are required to submit a photo id to o submit a photo id to

verify the genuinity of identity at the Admission Desk of the Hoverify the genuinity of identity at the Admission Desk of the Hospital. The photo id can spital. The photo id can

be your Organization Identity Card, Driving License or any otherbe your Organization Identity Card, Driving License or any other such card which will such card which will

help the hospital to establish the genuinity of the patient.help the hospital to establish the genuinity of the patient.

3.3.What is a Preauthorization Request? What is a Preauthorization Request?

This is a Request for Cashless Hospitalization. The same has to This is a Request for Cashless Hospitalization. The same has to be duly filled up, signed be duly filled up, signed

and stamped by the Hospital Authorities. Thereafter it has to beand stamped by the Hospital Authorities. Thereafter it has to be sent by fax / esent by fax / e‐‐mail to mail to

FGH. The Contact details of FGH is available in the hospital.FGH. The Contact details of FGH is available in the hospital.



4.4.Where do I procure the Preauthorization Request from?Where do I procure the Preauthorization Request from?

The Preauthorization Form template is available with the NetworkThe Preauthorization Form template is available with the Network Hospitals or also Hospitals or also

enclosed with the Health Insurance Guide. It can also be obtaineenclosed with the Health Insurance Guide. It can also be obtained from FGH Call Centre d from FGH Call Centre

on phone or by eon phone or by e‐‐mail.mail.

5.5.How to fill the Preauthorization form? How to fill the Preauthorization form?

It must be filled by the Treating Doctor. It must be filled by the Treating Doctor.

Information required are : Information required are :

ID No. as printed on the Card, Signs and Symptoms of the presentID No. as printed on the Card, Signs and Symptoms of the present aliment, duration of aliment, duration of

the aliment, diagnosis, pre existing conditions if any, proposedthe aliment, diagnosis, pre existing conditions if any, proposed line of treatment, line of treatment,

expected date of admission, duration of stay and estimated cost expected date of admission, duration of stay and estimated cost of hospitalization.of hospitalization.



6.6.Where do I send the Preauthorization form?Where do I send the Preauthorization form?

The Preauthorization Request for Cashless Hospitalization can eiThe Preauthorization Request for Cashless Hospitalization can either be faxed to ther be faxed to

24 x 7 Toll Free Fax24 x 7 Toll Free Fax‐‐line 1800 103 9998 line 1800 103 9998 or mailed to or mailed to [email protected]@futuregenerali.in

7.7.What is an Authorization Letter ?What is an Authorization Letter ?

Authorization Letter is the communication ascertaining the AdmisAuthorization Letter is the communication ascertaining the Admissibility or Acceptance sibility or Acceptance

of the Cashless Service. The same is issued by FGH subject to adof the Cashless Service. The same is issued by FGH subject to admissibility of the claim missibility of the claim

and availability of balance sum insured for the member.and availability of balance sum insured for the member.

8.8.Is the entire amount requested by hospital authorized by Is the entire amount requested by hospital authorized by

FGH?FGH?

FGH would release a part or the entire amount depending on the aFGH would release a part or the entire amount depending on the ailment and related ilment and related

expenses. In case a part amount has been approved by FGH, then texpenses. In case a part amount has been approved by FGH, then the hospital would he hospital would

ask for additional authorization when necessary.ask for additional authorization when necessary.



8.8.How do I know whether my Claim has been approved for How do I know whether my Claim has been approved for

Cashless or not? Cashless or not?

Authorization Letter or Denial Letter shall be faxed directly toAuthorization Letter or Denial Letter shall be faxed directly to the Hospital with the Hospital with

intimation to you.intimation to you.

A Query letter shall be faxed to the hospital if in case FGH wanA Query letter shall be faxed to the hospital if in case FGH wants some additional ts some additional

information to decide upon the admissibility.information to decide upon the admissibility.



9.9. What are the circumstances under which a Request for What are the circumstances under which a Request for

Cashless Hospitalization shall be denied?Cashless Hospitalization shall be denied?

1.1. If the information contained in the Request is insufficient for If the information contained in the Request is insufficient for FGH to arrive at a FGH to arrive at a

decision and further information is not available for whatever rdecision and further information is not available for whatever reasons.easons.

2.2. The ailment for which hospitalization is sought is not covered uThe ailment for which hospitalization is sought is not covered under the nder the

particular insurance policy or is a part of an Exclusion under tparticular insurance policy or is a part of an Exclusion under the policy he policy

guidelines.guidelines.

3.3. The insured has already exhausted his insurance coverage for theThe insured has already exhausted his insurance coverage for the year.year.



•• Contact our call centre and inform them about the nature of emerContact our call centre and inform them about the nature of emergencygency

•• If possible, always go to a network hospitalIf possible, always go to a network hospital

•• If not, then go to the nearest hospitalIf not, then go to the nearest hospital

•• In a network hospital, the patient can be admitted by showing thIn a network hospital, the patient can be admitted by showing the FGH Wellness e FGH Wellness

Card onlyCard only

•• After admission, the pre authorization has to be doneAfter admission, the pre authorization has to be done

Claim Process

If there is an If there is an EMERGENCYEMERGENCY


•• Our doctors will inform you and the hospital if cashless can be Our doctors will inform you and the hospital if cashless can be givengiven

•• The hospital will ask you for a deposit if we deny cashlessThe hospital will ask you for a deposit if we deny cashless

•• If you have gone to a non If you have gone to a non –– network hospital, keep our call centre informednetwork hospital, keep our call centre informed

Claim Process

If there is an If there is an EMERGENCYEMERGENCY


Cashless facility is always subject to the broader policy guidelCashless facility is always subject to the broader policy guidelines and relevant ines and relevant

terms and conditions.terms and conditions.

Important Important

Please note that decline of a request for Cashless HospitalizatiPlease note that decline of a request for Cashless Hospitalization is only denial of on is only denial of

Cashless Service and is in no way to be treated as denial of treCashless Service and is in no way to be treated as denial of treatment or claim. The atment or claim. The

insured retains the right to get treated and submit the bills toinsured retains the right to get treated and submit the bills to FGH for subsequent FGH for subsequent

ReimbursementReimbursement..

Remember


Repudiation lettersent to client

Repudiated(Not falling with policy conditions)

Reimbursement Claims Process

Preliminary scrutiny of claim &verification :

‐ Policy Benefit ‐ Date of Loss ‐Mandatory Documents

Deficient(Some Document required

For Admissibility)

Approved(Admissible under policy)

Subsequent reminders sent at fixed intervals

Reply received alongwith all

deficient documents

Reply not received

Documents not received

Intimation of theDeficiency

is sent to the client

Claim closed without payment

Payment cheque sent to client

Claim documents received from Insured member


In case of Non Cashless Claims, what would be an appropriate plaIn case of Non Cashless Claims, what would be an appropriate plan n

of action to ensure timely reimbursement of the claim?of action to ensure timely reimbursement of the claim?

If cashless facility is not availed, preIf cashless facility is not availed, pre‐‐authorization is denied or treatment is availed at a nonauthorization is denied or treatment is availed at a non‐‐

network hospital, the insured will have to settle the bills direnetwork hospital, the insured will have to settle the bills directly with the hospital and ctly with the hospital and

subsequently claim reimbursement by submitting the following docsubsequently claim reimbursement by submitting the following documents to FGH:uments to FGH:

1.1. First Prescription / consultation note from the DoctorFirst Prescription / consultation note from the Doctor

2.2. The Claim Form duly signed by the claimant or family memberThe Claim Form duly signed by the claimant or family member

3.3. The Original Hospital Discharge Card The Original Hospital Discharge Card

4.4. The Original Hospital Bill giving detailed break up of all expenThe Original Hospital Bill giving detailed break up of all expense heads mentioned in the se heads mentioned in the

billbill

Reimbursement Claim Process Reimbursement Claim Process ‐‐ FAQsFAQs


5.5. The Money Receipt duly signed with a Revenue Stamp. The Money Receipt duly signed with a Revenue Stamp.

6.6. All Original Laboratory & Diagnostic Test Reports. E.g. XAll Original Laboratory & Diagnostic Test Reports. E.g. X‐‐Ray, E.C.G, USG, MRI Scan, Ray, E.C.G, USG, MRI Scan,

HaemogramHaemogram etcetc

7.7. If you have purchased medicines in cash and if this has not beenIf you have purchased medicines in cash and if this has not been reflected in the reflected in the

hospital bill, please enclose a prescription from the doctor andhospital bill, please enclose a prescription from the doctor and the supporting the supporting

medicine bill from the Chemistmedicine bill from the Chemist

8.8. If you have paid cash for Diagnostic or Radiology tests and it hIf you have paid cash for Diagnostic or Radiology tests and it has not been reflected as not been reflected

in the hospital bill, please enclose a prescription from the docin the hospital bill, please enclose a prescription from the doctor advising the tests, tor advising the tests,

the actual test reports and the bill from the diagnostic centre the actual test reports and the bill from the diagnostic centre for the tests. for the tests.



What are the norms for Intimation on Claims ?What are the norms for Intimation on Claims ?

Preliminary notice of claim with particulars relating to Name ofPreliminary notice of claim with particulars relating to Name of the Insured the Insured

Person / Claimant, Nature of illness / injury and Name and AddrePerson / Claimant, Nature of illness / injury and Name and Address of the ss of the

attending Medical Practitioner / Hospital / Nursing home should attending Medical Practitioner / Hospital / Nursing home should be given to be given to

FGHFGH. Intimation can be sent by eIntimation can be sent by e‐‐mail or Fax to our Call Centre.mail or Fax to our Call Centre.



Are there any norms related to the Hospital where treatment is sAre there any norms related to the Hospital where treatment is sought ought

which are mandatory for admissibility of claims?which are mandatory for admissibility of claims?

Please ensure that the hospital / nursing home where you are conPlease ensure that the hospital / nursing home where you are contemplating treatment templating treatment

fulfills these criteria. fulfills these criteria.

1.1.It has at least 15 inpatient beds;It has at least 15 inpatient beds;

2.2.It has a Doctor who is in attendance 24 hours per day;It has a Doctor who is in attendance 24 hours per day;

3.3.It maintains daily medical records for each of its patients,It maintains daily medical records for each of its patients,

4.4.It is registered and licensed as a hospital or nursing home withIt is registered and licensed as a hospital or nursing home with the appropriate local the appropriate local

authorities. Always instruct the hospital authority to mention tauthorities. Always instruct the hospital authority to mention the Attending Doctorhe Attending Doctor’’s and s and

Hospital Registration No. in the hospital papers or demand for aHospital Registration No. in the hospital papers or demand for a separate certificate on the separate certificate on the

samesame

5.5.The hospital provides a proper discharge summary, numbered bill The hospital provides a proper discharge summary, numbered bill and receipt for and receipt for

hospitalization expenses at the time of dischargehospitalization expenses at the time of discharge



Where do I send my claim documents? Where do I send my claim documents?

Claim documents will be forwarded to the Future Generali Health Claim documents will be forwarded to the Future Generali Health Team in Pune by the Team in Pune by the

member / corporate. All claims will be managed by the Claims Teamember / corporate. All claims will be managed by the Claims Team located in Pune. m located in Pune.

Claims Team


2nd Floor, Kant Helix Tower, Bhoir Colony, Opp Tata Motors, Chinchwad,

Pune – 411033 (Maharashtra)

All claim payments advice shall be made within All claim payments advice shall be made within 14 working days 14 working days from the date of receipt of from the date of receipt of

COMPLETE COMPLETE documents.documents.

FGH may ask for the additional documents from the claimant if thFGH may ask for the additional documents from the claimant if the submitted documents e submitted documents

are not sufficient to decide the admissibility of the claim.are not sufficient to decide the admissibility of the claim.



What does FGH do with my claim documents? What does FGH do with my claim documents?

Your claim is assessed by our expert team and doctors who verifyYour claim is assessed by our expert team and doctors who verify the documents and billsthe documents and bills

If all requirements are complete and the claim is admissible, thIf all requirements are complete and the claim is admissible, the claim is approved and the e claim is approved and the

cheque is sent to you or your corporatecheque is sent to you or your corporate

If the claim is not admissible, then a Repudiation Letter is senIf the claim is not admissible, then a Repudiation Letter is sent to you / corporate by et to you / corporate by e‐‐mail mail

/ courier/ courier

If our team requires additional documents to process the claim, If our team requires additional documents to process the claim, then a Document Recovery then a Document Recovery

letter will be sent to you / corporate by eletter will be sent to you / corporate by e‐‐mail / couriermail / courier

FGH will send one intimation and two reminders at intervals of 1FGH will send one intimation and two reminders at intervals of 15 days5 days

If additional documents are not received after the second remindIf additional documents are not received after the second reminder from FGH, the er from FGH, the

claim is assessed with the available documents. This could lead claim is assessed with the available documents. This could lead to part payment or to part payment or

no payment at all.no payment at all.



For any claim related query, hospital information, grievance, feFor any claim related query, hospital information, grievance, feedback or edback or appreciation, please contact us on the following:appreciation, please contact us on the following:

In case you do not receive a response from the above, then you cIn case you do not receive a response from the above, then you can escalate your an escalate your issue to the following: issue to the following:

**11stst Escalation: Vinayak Pankhade atEscalation: Vinayak Pankhade at [email protected]@futuregenerali.in

**22ndnd Escalation: Ashish Saxena at Escalation: Ashish Saxena at [email protected]@futuregenerali.in

**33rdrd Escalation: Bishwajit Nayak at Escalation: Bishwajit Nayak at [email protected]@futuregenerali.in

Your Contact PointsYour Contact Points

Toll Free Phone NoToll Free Phone No 1800 103 88891800 103 8889

Toll Free Fax NoToll Free Fax No 1800 103 99981800 103 9998

EmailEmail [email protected]@futuregenerali.in


Future Generali Health Insurance2nd Floor, Kant Helix Tower, Bhoir Colony, Opp Tata Motors, Chinchwad,

Pune – 411033 (Maharashtra)

Economy & Finance

1. health insurance orientation module