INTRODUCTION TO GROUP HEALTH INSURANCE SCHEME

Policy Details
Definitions Benefit Details

General Conditions Health Card Issuance Claim Documents & Forms Procedure to Send Claim Form Contact Details & FAQ
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Policy Coverage General Exclusions Cashless Hospitalization

Planned Emergency

Non Network Hospitalization

POLICY DETAILS
Group Mediclaim

Definitions

q This insurance scheme is to provide adequate insurance coverage for the Cipla employees and their families for expenses related to hospitalization due to illness, disease or injury. q Our health insurance policy covers two schemes i.e. Cashless and Reimbursement. q Insurance company usually provides either direct payment to hospital or reimburses the expenses associated with illnesses and injuries.
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POLICY DETAILS
Cashless Hospitalization
Cashless hospitalization is service provided by an insurer wherein employees are not required to settle the hospitalization expenses at the time of discharge from hospital. The settlement is done directly by the insurance company. However, prior approval is required from the insurance company before the patient is admitted into the hospital. Cashless facility is provided ONLY at the Network Hospitals (Preferred Provider NetworkPPN) having agreement with insurance company

Definitions
Non-Network (Reimbursement) Hospitalization
Non-network hospitals are those who do not have agreement / tie up with insurance company and any policyholder seeking treatment in these hospitals will have to pay for the treatment and later claim will be reimbursed as per normal procedure.

POLICY DETAILS
Policy Parameter Insurer TPA Policy Start Date Policy End Date Coverage Type Family Definition Sum Insured

Benefit Details

Bajaj Allianz General Insurance Ltd Health Administration Team (HAT) 1st August 2012 31st July 2013 Family Floater 1 + 5 (Employee + Spouse + Children + any 2 Parents) Family size should not exceed 5. Rs 1.00 lakhs Per Family Rs 3.00 lakhs Per Family Rs 5.00 lakhs Per Family Basic Salary below & up-to Rs 10,000 Basic Salary Rs 10,001 Rs 30,000 Basic Salary Rs 30,001 & above
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POLICY DETAILS

Benefit Details

Benefits covered Standard Hospitalization Pre existing diseases Baby cover day 1 Yes Yes Yes Yes (upto 30 days pre-hospitalization & upto 60 days post-hospitalization) OPD/IPD discounts at Network (Preferred Provider Network-PPN) Hospitals
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Pre-Post Hospitalization Expenses

Value Added Services

POLICY DETAILS
Applicable Members Total No of members in one family covered Employee Spouse Children

Benefit Details

1+ 5 Yes Yes Yes (Age restriction upto 25 years)

Parents (Father or Mother) or Parents in law (Father in law or Mother in law) Mid Term Changes

Any 2 (Age restriction upto 100 years)

Any changes in Dependents declared should be intimated to respective HR. No claim will be settled if dependents details are not updated.
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POLICY COVERAGE

GENERAL HOSPITALISATION EXPENSES In-patient hospitalisation (for a period exceeding 24 hours) q Expenses are claimable if patient is hospitalized for minimum period of 24 hours

q However this time limit is not applicable for specific treatments i.e. Dialysis, Chemotherapy, Radiotherapy, Eye Surgery, Lithotripsy (kidney stone removal), tonsillectomy, D&C taken in the hospital/Nursing Home, etc.

q There are 130 day care procedures covered under the policy, which do not require 24 hours hospitalization.
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POLICY COVERAGE
Reimbursement of expenses related to
Expenses reimbursed under the policy : Room Charges as provided by the hospital / nursing home
Room rent restrictions upto 2% of Sum Insured per day in case of normal hospitalization. Room rent restrictions upto 4% of Sum Insured per day in case of ICU.

Nursing expenses Surgeon, Anaesthetist, Medical Practitioner, Consultants, Specialists fees

POLICY COVERAGE
Reimbursement of expenses related to

.. Continued

Anaesthesia, Blood, Oxygen, Operation Theatre Charges, Surgical Appliances, Medicines & Drugs, Diagnostics Materials & X-ray, Dialysis, Chemotherapy, Radiotherapy, Cost of Pacemaker, Artificial Limbs & Cost of organs & similar expenses Non medical expenses which are not payable under the policy are as outlined in this link.

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GENERAL EXCLUSIONS
Dental treatment of any kind unless requiring hospitalization Congenital external diseases or defects/anomalies Hospitalization for convalescence, general debility, intentional selfinjury, injury arising out of intoxicating drugs/ alcohol. Venereal diseases Naturopathy Any non-medical expenses like cafeteria charges, telephone charges, etc Cost of spectacles, contact lenses, hearing aids
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GENERAL EXCLUSIONS
Any cosmetic or plastic surgery except for correction of injury Hospitalization for diagnostic tests only Vitamins and tonics unless used for treatment of injury or disease Infertility treatment Under Maternity, expenses pertaining to caesarian or normal delivery Any type of MTP (Voluntary termination of pregnancy) excluding those requiring both medical reasons and surgical intervention

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CASHLESS HOSPITALIZATION
Employee shall avail Cashless hospitalization benefits upon receipt of approval from Administrator (Insurance company) Insurance company will directly settle all eligible amounts with the Network Hospital Insured Person may have to pay a nominal deposits (normally as a deposit towards non medical expenses and room rent capping) at the commencement of the treatment
Planned Hospitalization

Cashless Hospitalization
Emergency Hospitalization
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CASHLESS HOSPITALIZATION Planned Hospitalization

Step 1 Pre-Authorization
All non-emergency/ planned hospitalization instances must be pre-authorized with the help desk of hospital , as per the procedure detailed as follow. 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.

Pre-Authorization Process
Member has to intimate insurance company in a specified preauthorization format preferably 72 hours prior to hospitalization Claim Registered by the Insurance Co. on same day

Pre-Authorization Completed & treatment starts

Insurance company issues approval letter to Hospital

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CASHLESS HOSPITALIZATION Planned Hospitalization

Step 2 Admission, Treatment & discharge
After your hospitalization has been pre-authorized, you need to secure admission to a hospital. Approval letter will be issued by Insurance Company to the hospital. You have to present Health card and photo ID at the Hospital admission desk. The employee is not required to pay the hospitalization bill in case of a network hospital. The bill will be sent directly to, and settled by, Insurance Company. In case of denial, member shall seek help from Cipla.

Process - Admission, Treatment & Discharge

Member produces Health card and photo ID at the network hospital and gets admitted Member gets treated and discharged after paying all non entitled benefits like refreshments, etc.

Hospital sends complete set of claims documents for processing to Insurance Company Release of payments to the hospital by Insurance Company

Claims Processing by Insurance Company

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CASHLESS HOSPITALIZATION Emergency Hospitalization

Step 1 Get Admitted
Step 2 PreAuthorization by hospital Member/ relative should inform the call centre immediately about the hospitalization & Seek pre-authorization. Preauthorization form is mandatory to be sent to Insurance Company by network hospital. In return Insurance Company will send preauthorization letter to the hospital. In case of denial member would be informed directly. Step 3 Treatment & Discharge

In cases of emergency, the member should get admitted in the nearest network hospital by showing his health card & photo ID proof. If possible, Member shall inform his HOD about the incidence.

After hospitalization has been pre-authorized the employee is not required to pay the hospitalization bill in case of a network hospital. The bill will be sent directly to, and settled by, Insurance Company.

Process

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EMERGENCY HOSPITALIZATION PROCESS

Member get admitted in the hospital in case of emergency by showing his Health Card and photo ID Member through hospital applies for pre-authorization to the Insurance Company immediately Insurance Company verifies applicability of the claim to be registered and issue pre-authorization letter to hospital

Hospital sends complete set of claim documents for processing to the Insurance Company

Member gets treated and discharged after paying all non entitled benefits like refreshments, etc.

Preauthorization given by the Insurance Company

Claims Processing by Insurance Company

Release of payments to the hospital

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NON-NETWORK HOSPITALIZATION (Reimbursement)

Admission procedure
q In case an employee chooses a non-network hospital, he will have to liaise directly for admission.

Discharge procedure
q Employee will be required to clear the bill and submit the claim to insurance company after discharge.

Claim Submission Procedure

q An intimation has to be given to insurance company immediately after the hospitalization or at least within 7 days from date of discharge by dialing their helpline no or via mail to hat@bajajalliaz.co.in. q However if Employee intimates Insurance company via mail, he should send Claim intimation form which is available on ESS Hospitalisation Policy page q Employee must submit the final documents within 25 days from date of discharge 18

NON-NETWORK HOSPITALIZATION
Hospitalization of patient After treatment insured member pays all the bills of the hospital

Reimbursement Process

Member should intimate Insurance company immediately or within 7 days from the date of discharge by either mail or using Bajajs helpline no.

Insurance Company performs medical scrutiny of the documents

Member has to submit the claim form along with all the necessary original documents as per the procedure stated in Slide No. 27

Member has to fill the Claim form of the Insurance Company

If claim is approved, payment is released to member through NEFT to the members salary account or as per the details provided by member (NEFT form and cancelled cheque to be submitted)

If additional documents required , intimation about deficiency is sent to member. Member has to submit additional documents Within 7 days Upon receipt of required documents payment would be made through NEFT.

If claim is rejected, repudiation letter is sent to member

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GENERAL CONDITIONS
q Under hospitalization claims, employees are also permitted to claim separately for expenses incurred 30 days pre and 60 days post hospitalization. q Separate Claim for post hospitalization can be intimated within 75 days from date of discharge (Hospitalization Claim no. to be mentioned). This is applicable for both network and non-network hospitalization. q It is advisable that member shall approach Network (PPN) hospitals to avail cashless benefits q Under Cashless Hospitalization, Pre-auth Form should be obtained from our Employee Self Service System or alternatively from Bajaj Allianz website http://www.bajajallianz.com/Corp/claims/general-insurance-claim-forms.jsp q Under Non Network hospitalization, Claim form should be obtained from our Employee Self Service System or alternatively from Bajaj Allianz website http://www.bajajallianz.com/Corp/content/claim/HG_Claim_Form.pdf (along with NEFT form and cancel cheque)
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GENERAL CONDITIONS
q Only employees bank details should be provided in NEFT Form. q In case of admissible Cashless claim, the first amount approved is the interim payment of the estimate provided. However final amount is settled as per policy terms and conditions q Hospitals get empanelled and de-empanelled on regular basis and list of Network Hospital is updated on Bajajs Website. Hence to see updated list kindly click on the link provided below: https://general.bajajallianz.com/BagicNxt/hm/hmSearchState.do q Also to see the updated list of Diagnostic Centres, please click on below link: https://general.bajajallianz.com/BagicNxt/ihg/getStateList.do?p_flag=D

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HEALTH CARD ISSUANCE

q Each Employee will be provided with Unique Identity Code which will be stored in Personal Details as well as Hospitalization Policy Page in Employee Self Service Portal. q A link will be provided with the Unique Identity Code q This Unique Identity code is the access code (password)
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HEALTH CARD ISSUANCE

Employee can log in and download Health Cards by clicking on any one of the below link followed by the instructions : Link 1 https://general.bajajallianz.com/BagicNxt/ecards/ecards_login.jsp and enter access code or Link 2 https://general.bajajallianz.com/BagicCorp/qlogin.jsp and enter the User ID - cpl@cipla.com and access code in Login Area. Then follow the instructions mentioned below. Click on Self Click on the check box against each dependent member relation to view the details of your dependent. Click on Generate Health card
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CLAIM DOCUMENTS & FORMS

CHECKLIST FOR REIMBURSEMENT CLAIMS

q Bajaj Allianz claim form duly signed. q Bill detail sheet q Copy of Health Card q Photo ID Proof (Pan card, Driving License, Voters ID, etc) q First Consultation Letter q Original Discharge Summary q Original Final Hospital Bill giving detailed break up of all expense heads mentioned in the bill.
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CLAIM DOCUMENTS & FORMS

CHECKLIST FOR REIMBURSEMENT CLAIMS ..continued

q Stamped receipt for final hospital bill q Pharmacy cash receipts/ cash bills along with supporting prescription q Reports of Investigation, Pathology/ Radiology/ Cardiology q Original paid receipt towards the investigation charges q In case of a Cataract Operation, the IOL (Intra Ocular Lens) Sticker, receipt / invoice / box q NEFT Form and cancelled cheque of the employee in case of different account number. (i.e. Other than salary account no.)

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CLAIM DOCUMENTS & FORMS

CHECKLIST FOR PRE-POST ( CASHLESS SCHEME)

q Bajaj Allianz claim form duly signed q Claim settlement letter q Pharmacy cash receipts/ cash bills along with supporting prescription q Reports of investigations done, Pathology/ Radiology/ Cardiology q Original paid receipt towards the investigation charges

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PROCEDURE TO SEND CLAIM FORM

In case of FIELD Employee
Field employee should courier the Claim Form along with all required documents to the following address: HR Department Rajplaza LBS Road Vikhroli West Mumbai 400083 The envelop should be marked as HOSPITALIZATION CLAIM

In case of NON-FIELD Employee

Non field employee has to put claim form along with all required documents in drop box provided at HR department of respective Unit. Further Unit HR will forward the same to HR department at Rajplaza, Vikhroli. Claim forms will be collected by the member of the Insurance company on every Tuesday & Friday from Rajplaza Vikhroli
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CONTACT DETAILS
HEALTH ADMINISTRATION TEAM (BAJAJ ALLIANZ) 24 X 7 Helpline 1800 22 5858 (Toll free MTNL / BSNL) 1800 102 5858 (Toll free Airtel / Bharti) 1800 209 5858 (Toll free Any Landline / Mobile) 020 30305858 (STD) hat.helpline@bajajallianz.co.in hat@bajajallianz.co.in Claim Tracker:
https://general.bajajallianz.com/BagicNxt/b2c/cus tomer/claim_enquiry_new.jsp
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CIPLA HELP DESK

Mr J V Pillai 09820130056 Jvpillai@cipla.com Ms Pratiksha Bhosale 9870386478 (022)-23025848 Pratiksha.bhosale@cipla.com

FAQs
What is a Health Card? What are its benefits? A health card is a card that comes along with the Policy. It is similar to an Identity card. This card would entitle you to avail cashless hospitalization facility at any of our network hospitals. All members are eligible for the health card What are Network hospitals? The hospitals which have a tie up with your insurer would come under the category of network hospital. The network hospital provides cashless facilities to the insured on approval by the insurer. The insured while getting admitted shall provide health card to the hospital administration. The hospital will seek approval for treatment on your behalf. If approved, the payments will be settled by insurer subject to the cover taken by the insured . 29

FAQs
What are non-network hospitals? The hospitals which have no tie-up with the insurer are called non-network hospitals. If the insured seeks treatment in any of the non-network hospitals, the bills have to be settled by the insured himself. However the hospitalization expenses are reimbursed by submitting claim forms along with other documents to the insurer. Why prefer network hospitals over non-network hospitals?

If you are admitted to a non-network hospital you need to settle the hospital bills yourself and then submit the hospitalization documents along with the claim form for reimbursement of hospitalization expenses.
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We aim to Secure Your & Your Familys Health with the Right Insurance
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