Академический Документы
Профессиональный Документы
Культура Документы
Client
Remark
Benefit Manual
Document No
TTIBI/EB/01
Proceed
Disclaimer:
This benefit summary will serve as a guide to the benefits provided by United India Insurance Co Ltd. The
information contained here is only a summary of the policy documents which are kept by the company. If there is
a conflict in interpretation, terms & conditions of the policy will prevail.
Copyright 2005. All rights reserved. No part of this publication may be reproduced, stored in the retrieval
system, or be transmitted in any form or by any means, electronic or mechanical, photocopying, recording
or otherwise, without the prior written permission of the publishers.
Proceed
2
Main Menu
A. Program Details
Exit
1. Group Medical
Coverage Type
Family Floater
Dependent Coverage
Sum Insured
Benefits covered
Benefits covered
Standard Hospitalization
Yes
Yes
Waived
Waived
Maternity benefits
Yes
Yes
Yes
Ambulance Cost
Yes
Yes
Yes
Co-Payment
Room Rent
General Exclusions
Back
Applicable Members
Employee
Yes
Spouse
Yes
Children
Parents
Disallowed
Back
6
Policy Period
Existing Employees + Dependents
Commencement Date
Termination Date
Date of joining
Termination Date
Termination Date
Back
7
Coverage Levels
Individual Sum Insured
Limits (INR)
Employee
Family Floater
Dependents
Back
8
Standard Hospitalization
Reimbursement of expenses related to
Doctors fees
Nursing expenses
Surgical fees, operating theatre, anesthesia and oxygen and their administration
Physical therapy
A) The expenses shall be reimbursed 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.
Back
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 surgery, Dental Surgery, 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.
Maternity Benefits
Reimbursement of expenses related to maternity as per
The maximum benefit allowable will be INR 25,000 for normal delivery and INR 40,000 for C-section within the Sum
Insured limit, max up to 2 children. There are special conditions applicable to the Maternity Expenses Benefits as below:
These benefits are admissible only if the expenses are incurred in Hospital/Nursing Home as in-patients in India.
Claim in respect of delivery for only first two children and/or operations associated therewith will be considered in
respect of any one Insured Person covered under the Policy or any renewal thereof. Those Insured Persons 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.
Pre-natal and post natal Covered over & above maternity with restriction of INR 2,500
Benefit Details
Maximum Benefit allowable
Restriction on no of children
Maximum of 2 children
Waived off
Covered
Back
Applicable
10
Customized Benefits
Pre existing diseases
Definition
Covered
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
Waived Off
Waived Off
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
Covered
Back
11
Ambulance Cost
Applicable
Ambulance Services
Definition
The Insurer will pay for Emergency ambulance and other road transportation by a
licensed ambulance service to the nearest Hospital where Emergency Health
Services can be rendered. Coverage is only provided in the event of an
Emergency.
Amount restriction
Back
12
Customized Benefits
Restricted
Applicable
Day Care
Definition
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.
Back
13
Applicable
Pre-hospitalisation Expenses
Definition
Applicable
Yes
Duration
30 Days
Post-hospitalisation Expenses
Definition
Applicable
Yes
Duration
60 Days
Back
14
General Exclusions
Injury or disease directly or indirectly caused by or arising from or attributable to War or War-like situations
Injury or disease caused directly or indirectly by nuclear weapons
Back
15
HR provides data to
insurer
Insurer passes
adequate
endorsement
Contact PHM
Healthcare Customer
service
Endorsement copy
forwarded by insurer
to client / TPA
Error in data
printed on
card
Employe
e verifies
details
on the E
- card
Card Ok
Use card for cashless
hospitalization
Back
16
http://www.paramounttpa.com/providernetwork/providernetwork.
aspx
Planned Hospitalization
Back
Emergency Hospitalization
17
Planned Hospitalization
Step 1
Pre-Authorization
Step 2
Admission, Treatment
& discharge
All non-emergency
hospitalisation instances
must be pre-authorized with
the insurer, 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.
Process
Process
Back
18
Pre-Authorization
Pre Authorization
form
Claim
Registered
by insurer
on same
day
Yes
No
Follow non cashless
process
Pre-Authorization Completed
Back
19
Back
20
Emergency Hospitalization
Step 1
Get Admitted
Step 2
Pre-Authorization by
hospital
Relatives of admitted
member should inform the
insurer / HR 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
Back
Step 3
Treatment &
Discharge
Process
21
Preauthorizatio
n given by
the insurer
No
Claims Processing by insurer
Non cashless
Hospitalization
Process
Back
22
Back
Claims Process
Claim Docs
23
Claims Process
Member intimates insurer
before or as soon as
hospitalization occurs
Claim registered by
insurer after receipt of
claim intimation
Is claim
liable
(coverage/
applicabilit
y)
Yes
No
No
Yes
Is
document
received
within 21
days from
discharge
Claim Rejected
Back
Is
documenta
tion
complete
as
required
Yes
No
24
Standard Claims
Guide
Claims Guide
Claims Status
For claims status log on to:
www.paramounttpa.com
Back
25
Contact Details
Group Mediclaim
Escalation Point
Mr. T Srinivas
Mobile: + 91 97111 33621
t.srinivas@ttibi.co.in
Proceed
26
Contact Details
Group Mediclaim
Escalation Point
Shamita Paul
Group Head Corporate relations
Email- shamita.paul@paramounttpa.com
Office 033- 2356 7005/08
M 093309 17499
Fax 033-2356 7037
Back
27
http://www.irdaindia.org
Back
28