Reimbursement Claim

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Reimbursement Claim
ITTI Pvt. Ltd.,
MEDICLAIM INSURANCE
• Insurance Co Name – United India Insurance Co Ltd.,
Mission Rd Branch, Bangalore.
• Broker Name – Mahindra insurance Brokers, Bangalore.
• TPA – Mediassist India TPA Pvt Ltd., Bangalore.
• Cover Start Date 02-11-2013 and end date 01-11-2014
Salient Features Of Mediclaim Policy

Mediclaim Policy covers in-patient hospitalization expenses
provided the hospital stay is for minimum period of 24 hrs.

However this time limit is not applied to specific treatments like
Dialysis, Chemotherapy, Radiotherapy, Eye Surgery, etc. where
the insured is discharged on the same day.



Employee + Spouse + 2 kids + 2 Dependent Parents only
Sum Insure – Rs. 2 Lac family Floater
10 % co pay for each and every claim.
Add on Covers
Pre-existing disease cover is an extension wherein the policy
covers any disease or ailment existing prior to the inception of the
policy.
30-days exclusion waiver is an extension wherein any medical
expenses incurred during the first 30 days of inception of the policy is
covered.
1st year exclusion waiver is an extension wherein few diseases not
covered under normal circumstances during first year of the inception
of the policy will be covered.
Pre & Post Hosptalization - The policy will cover all medical
expenses incurred for 30 days prior to hospitalization as well as
expenses incurred for 60 days post hospitalization.
Add On Covers....Contd
Maternity Cover under which maternity expenses for employee and spouse
are covered up to a specified limits for both Normal – Rs.
25,000 & Cesarian Delivery – Rs. 35,000.
Waiver of 9 month waiting period for Maternity coverage.
New Born Baby Cover under which new born baby is covered from birth
i.e. day 1 with in the SI.
Ambulance Charges up to Rs. 1000 in case of emergency.
Room rent and other charges – Normal 1% SI and ICU 2% of SI
Cataract - Up to 10% of SI per eye.
Day care treatments – Covered up to SI
Exclusions

Injury or diseases caused by invasion, war, act of foreign enemies, etc.

Circumcision unless necessary for treatment of a disease covered.

Cosmetic treatment or plastic surgeries other than those necessitated
by an accident or any illness.

Cost of spectacles, contact lens or hearing aids.

Dental treatment or surgery unless requiring hospitalization in case of an
accident.

Convalescence, general debility, run down condition, congenital
external disease or defects, venereal disease etc. kindly see the link.
www.mediassist.com. Please go to the section mentioned exclusions.
Exclusions…Contd

Any medical treatment undergone because of intentional self injury or
consumption of intoxicating drugs or alcohol.
 AIDS
or any of its variant.

Expenses on vitamins and tonics unless forming part of treatment for injury
or disease as certified by the attending physician.

Hospitalisation solely for the purpose of testing not covered.

Injury or disease directly or indirectly caused by or contributed to or by any
nuclear weapon or materials.

Naturopathy Treatment
DEFINITIONS OF HOSPITALS
• An institution established India for indoor care and
treatment of sickness.
• Registered with local authorities
• Under supervision of a registered and qualified medical
authorities
• Minimum of 15 inpatient beds(incase of smaller cities
and towns the bed count is a minimum of 10)
• Fully equipped operation theatre
• Fully qualified nursing staff available 24/7
• Fully qualified doctors available 24/7
MIBL as the nodal agency…
“As an Intermediary our mission is to
ensure best possible services to our
INSURED
(Members)
ultimate customers by blending
technology with experience and
expertise”
MIBL
TPA’s
INSURANCE CO.
Value Added Services
- Handling all policy related queries
- Assist in Admissions / Discharge in Network hospitals*
- Assist in case of Emergency
-Conduct Employee Orientation on Policy related issues
-Collection of claims forms
-Verification of documentation / Checklist
Enhance
Employees’ Morale
-Follow-up for deficient documents
-Handing over payment of settled claims.
Claims Management
Third Party Administrators, the Company that administers the plan on behalf
of Insurance Company, will handle the claims.
If Non-TPA approved hospital is used the employee will first pay the bill and
forward the documents to MIBL to facilitate faster claims settlement.
In emergency one can
first get admitted and
then get approval
Claims Management

Member Reimbursement
Claim (MRC)
Network Hospital Claim
At MIBL/TPA – Document verification
Complete
Documents
At TPA Claims
Processing / Medical scrutiny
Incomplete
Documents
Receipt of missing document
Settlement / Rejection / Disallowance
PRE-AUTHORIZATION PROCESS FOR CASHLESS

Employee
approaches
TPA / MIBL /
Hospital with
Mediclaim
Card
Employer / MIBL / Hospital
Sends intimation to
TPA
Eligibility
Not
Covered
Out of Pocket
payment
Covered
Authorization as
per eligibility
Cashless treatment
at NWH
Protocol for Availing Treatment in Non Network Hospital
(Reimbursement Claim)

Member avails treatment at any hospital and makes
upfront payment
Member submits bills to
MIBL / TPA Help desk
MIBL / TPA representative verifies the documents submitted
In case of incomplete documents
recovery of documents for
scrutiny
MIBL sends papers to TPA who
process the claim and provides the
cheque
Standard Claim documents
 Duly filled Claim form.
 Detail Hospital final Bills with break ups.
 Payment Receipts for above bills
 Hospital Discharge Card / Discharge Summary.
 Cash Memos of the chemists supported by Doctors prescription.
 Pathological & Medical Investigation reports.
 Bills and receipts for above tests etc
 Claim Bill / Statement of total expenses incurred.
 All the originals should be submitted, keep a copy of the same.
Additional documents as may be required case to case basis.
For any kind of further information please also log onto www.mediassist.com
Escalation Matrix: M/s. Mediassist India TPA Pvt. Ltd.,
•
•
•
•
•
•
•
•
1st point of contact
Prathibha, Corporate Relations
9379424435 / 080 26537870
[email protected]
2nd Level of contact
Mr. S. Venkatakrishnan, Corp Service Manager
9686195495
[email protected]
Contact Details - MIBL
 Mr. Rohit Mehrotra – Business Head – Commercial
Mobile No - 9967714700
[email protected]
Level 4
 Mr. K. Sai Prasad - Area Manager –Commercial
Mobile No - 9900977229
[email protected]
Level 3
 Mr. Swapnandu Das – Territory Manager Commercial
Mobile No- 09886894199
[email protected]
Level 2
 Mr. Rebanta Sanyal
Mobile No- 9739947245
[email protected]
Level 1
Thank you for your attention!!

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