SBICAP VENTURES LTD

GROUP MEDICLAIM POLICY

Policy Summary

Details Policy Start Date Policy End Date

Employee Group Mediclaim Policy 4th May 2020 3rd May 2021
Benefit Details
Benefits covered
Standard Hospitalization 24 Hrs of hospitalization is required
Pre existing diseases Covered
Waiver on 1st ,2nd ,3rd & 4th exclusion. Waived
Waiver on 1st 30 days excl. Waived
Maternity benefits Normal Delivery : INR 75,000 & C-Section Delivery : INR 75,000
Baby cover from day 1 & Baby Expense during Maternity Yes- Part Of Family Floater Sum Insured Limit
Pre-Post Hospitalization Expenses (Covered up to 30 – 60 days)
Ambulance Covered up to INR 5000 per family
Room Rent 1% of sum insured for Normal Rooms & 2% of sum insured for ICU Rooms
Terrorism Covered
Co - Pay No Co - pay
Disease Wise Capping No capping on any Ailments
Congenital Internal Disease Covered
Pre-Post Natal Expenses NA
Day Care Procedure Covered
Special Condition Any Expenses towards Monitor Charges, Gloves, Pads, Mask etc will be
covered and payable under the policy
GIPSA / PPN Not applicable

Oral Chemotherapy Covered

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
•Dental treatment of any kind unless requiring hospitalization due to Accidental Injury
•HIV and AIDS
•Hospitalisation for convalescence, general disability, intentional self-injury, use of intoxicating drugs/ alcohol.
•Venereal diseases
•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
•Any cosmetic or plastic surgery except for correction of injury
•Hospitalisation for diagnostic tests only
•Vitamins and tonics unless used for treatment of injury or disease
•Voluntary termination of pregnancy during first 12 weeks (MTP)
•Intravitreal Injection (Related to Eye)
 1.3 Cashless Hospitalization

Cashless hospitalization means the Administrator may authorizes 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.

List of hospitals in the TPA’s network eligible for cashless hospitalization

Complete Hospital Network List https://www.mediassist.com/Home/ProviderNetwork.aspx

Toll free: 1800 424 9449

Medi Assist Insurance TPA Pvt Ltd Fax No. (Toll Free): 1800 425 9559

Planned Hospitalization Click Here Emergency Hospitalization Click Here

For any planned or emergency hospitalisation please call

Ms. Lekha Nair from Howden India on 91 22 66558883/ +91 8689814574
[email protected]
Planned Hospitalization

Step 2
Step 1 Admission,
Pre-Authorization Treatment &
discharge

After your hospitalisation has

All non-emergency
been pre-authorized, you Patients seeking treatment
hospitalisation instances
need to secure admission to under cashless
must be pre-authorized with
a hospital. A letter of credit hospitalization are eligible
the Help Desk, as per the
will be issued by Insurer to to make claims under pre
procedure detailed below.
the hospital. Kindly present and post hospitalization
This is done to ensure TPA
your ID card at the Hospital expenses. For all such
offers the best healthcare
admission desk. The expenses the bills and
possible, is obtained, and the
employee is not required to other required documents
patient/employee is not
pay the hospitalisation bill in needs to submitted
inconvenienced when taking
case of a network hospital. separately as part of non
admission into a Preferred
The bill will be sent directly to, cashless claims.
Network Hospital.
and settled by, Insurer .

Process Click Here Process Click Here

Pre-Authorization

Member intimates Insurer of

Claim Insurer issues letter of
the planned hospitalization Yes
Registered credit within 4 hours for
in a specified pre- by Insurer planned hospitalization to
authorization format 48 on same day
hours prior to hospitalization
the hospital

No

Pre-Authorization
Follow non
Completed
cashless process
Admission, Treatment & Discharge

Member produces medi - Member gets treated and

card with ID proof at the discharged after paying all Hospital sends complete set
network hospital and gets non entitled benefits like of claims documents for
admitted refreshments, etc. processing to the Insurer

Claims Processing by
Release of payments to the
Insurer
hospital
Emergency Hospitalization

Step 2 Step 3
Step 1
Pre-Authorization Treatment &
Get Admitted
by hospital Discharge

In cases of emergency, the Relatives of admitted After your hospitalisation has

member should get admitted member should inform the been pre-authorized the
in the nearest network Call Centre within 24 hours employee is not required to
hospital by showing their ID about the hospitalization & pay the hospitalisation bill in
card. Seek pre authorization. The case of a network hospital.
preauthorization letter would The bill will be sent directly
be directly given to the to, and settled by, Insurer.
hospital. In case of denial
member would be informed
directly

Process Click Here

Emergency Hospitalization Process

Member get admitted in the

Member/Hospital applies for TPA verifies applicability of
hospital in case of
pre-authorization to the the claim to be registered
emergency by showing his
Insurer within 24 hrs. of and issue pre-authorization
ID Card
admission within 2 hrs

Member gets treated and

Yes Pre-
Hospital sends complete set discharged after paying all
authorizatio
of claims documents for non entitled benefits like
n given by
processing to TPA. refreshments, etc. the TPA

No

Claims Processing by Release of payments to the Follow non cashless

Insurer hospital process
1.4 Non-Cashless Hospitalization

Admission procedure
In case you choose a non-network hospital you will have to liaise directly for admission.
However you are advised to follow the pre authorization procedure to ensure eligibility for reimbursement of hospitalization expenses
from the TPA.

Discharge procedure
In case of non network hospital, you will be required to clear the bill and submit a claim to TPA for reimbursement from the TPA.
Please ensure that you collect all necessary documents such as – discharge summary, investigation reports etc. for submitting your
claim.

Submission of hospitalization claim

1. After the hospitalization is complete and the patient has been discharged from the hospital, you must submit the final claim within
15-20 days from the date of discharge from the hospital. (Applicable in case of Non Network hospital)
2. Under hospitalization claims you are also permitted to claim for treatment expenses 30 days prior to hospitalization and 60 days
after the date of discharge. This is applicable for both network and non-network hospitalization. For claims related to pre-post
hospitalization expenses, submission of documents within 7 days of last event.
Non cashless Hospitalization Process

Insured admitted as per hospital Insured sends relevant documents to

norms. All payments made by designated regional office within 30 days A
member of discharge

•Insured will create the

summary of Bills (2 copies)
Is claim Is document and attach it with the bills
TPA performs medical •The envelope should
liable recd within
(coverage/a
scrutiny of the contain clearly the
30 days from
pplicability) documents discharge Employee ID & Employee
e-mail

No No
Claim Rejected

Is Yes Payment to be directly

Insurer checks Claims processing done made to Employee. The
documentation
document sufficiency complete
within 15-20 days same will be disbursed to
claimant by Controllership.

No
Send mail about deficiency
A
and document requirement
Claims Document List

Signed Claim form

Main Hospital bills in original (with bill no; signed and stamped by the
hospital) with all charges itemized and the original receipts Claims Form

Discharge Card (original) ..\..\2018 2019\Claim

Mediassist Insurance Form\SBI
Attending doctors’ bills and receipts and certificate regarding diagnosis (if TPA Pvt Ltd REIMBURSEMENT
separate from hospital bill) CLAIM FORM.pdf
Original reports or attested copies of Bills and Receipts for Medicines,
Investigations along with Doctors prescription in Original and Laboratory
Follow-up advice or letter for line of treatment after discharge from hospital,
from Doctor.

Break up with details of 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 hospitalisation, please get the hospital and doctor’s
registration number in Hospital letterhead and get the same signed and
stamped by the hospital.
FIR/MLC copy in case of accidental injury

Employee ID card copy

Patient’s photo ID proof

Cancelled cheque
 Contact & Escalation Details

Broker:
1st level Contact 2nd level Contact 3rd level Escalation Matrix

Ms. Lekha Nair Mr Sudesh Patankar Mr. Chetan Sudra

Howden Insurance
Brokers India Pvt. Ltd. 8689814574/ 022 – 6655 8883 9819174958 / 022 – 6655 8847 9820025935 / 022 – 6655 8827
6th Floor, Peninsula [email protected] [email protected] [email protected]
Chambers,
Peninsula Corporate
Park, Ganpatrao Kadam
Marg, Lower Parel,
Mumbai 400 013

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