Cholamandalam MS General Insurance Co. Ltd. Claims_NFL...Insurer Cholamandalam MS General Insurance...

Cholamandalam MS General Insurance Co. Ltd.

Cholamandalam MS General Insurance Co., Ltd

A JOINT VENTURE (JV) BETWEEN

MURUGAPPA GROUPAND

MITSUI SUMITOMO INSURANCE GROUP (JAPAN) (MS & AD Group)

Concept of Health Insurance

Health Insurance

is to provide

financial shelter in the event of

Medical treatment

incurred out of

Sickness or injury.

INSURANCEPROTECTION

RISK MANAGEMENT VALUE ADDITION

Policy Parameters

Policy Parameter

Insurer Cholamandalam MS General Insurance Co. Ltd.

TPA Chola MS HELP

Policy Start Date 1st Apr 2017

Policy End Date 31th Mar 2018

Coverage Type Family Floater

Dependent Coverage 1 + 1 ( Spouse)

Sum Insured As per Tender documents

Pre-existing diseases covered

30 days waiting period waived

One/two year waiting period waived

1. Room and boarding

2. Doctors fees

3. Intensive Care Unit

4. Nursing expenses

5. Surgical fees, operating theatre, anesthesia and oxygen and their administration

6. Physiotherapy

7. Drugs and medicines consumed on the premises

8. Hospital services (such as laboratory, x-ray, diagnostic tests)

9. Dressing, ordinary splints and plaster casts

10. Day care procedures like Cataract, radiotherapy, chemotherapy, dialysis etc.

Policy Benefits

Major exclusions

Injury or disease directly or indirectly caused by or arising from or attributable to

War or War-like situations

Congenital external diseases or defects/anomalies

HIV and AIDS

Hospitalization for convalescence, general debility, intentional self-injury.

Injury or disease caused directly or indirectly by nuclear weapons

Naturopathy, treatment related to obesity

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

Hospitalization for diagnostic tests only

Vitamins and tonics unless used for treatment of injury or disease

Any illness/incident caused by use of alcohol/intoxicating agents

Accidents due to breach of law

OPD, Dental and Domiciliary cover

Others as per policy.

Coverage Details

CategoryPost held at the time of leaving

Service of NFL Insurance Cover (Rs.)

A C&MD / Directors 6 Lakhs

BChief Mgr to Executive Director

(E-6 to E-9)5 Lakhs

CAsstt.officer to Sr Mgr (E-0 to E-

5)4 Lakhs

D Non- Executives (W0 to W12) 3 Lakhs

Room Rent eligibility

Delhi/NCR & all State Capitals including UTs

CategoryPost held at the time of leaving Service of

NFL Room Rent allowed

A C&MD / Directors 10000

B Chief Mgr to Executive Director (E-6 to E-9) 8500

C Asstt.officer to Sr Mgr (E-0 to E-5) 6500

D Non- Executives (W0 to W12) 4500

Excluding Delhi/NCR & all State Capitals including UTs

CategoryPost held at the time of leaving Service of

NFL Room Rent allowed

A C&MD / Directors 5000

B Chief Mgr to Executive Director (E-6 to E-9) 4250

C Asstt.officer to Sr Mgr (E-0 to E-5) 3250

D Non- Executives (W0 to W12) 2250

There is no restrictions on ICU charges

Other Benefits

Pre – Hospitalization Expenses Expenses related and incurred prior to 30 days from the date of hospitalization for which claim is admissible

Post – Hospitalization Expenses Expenses related and incurred after 60 days from the date of discharge for which claim is admissible

Co Payment NA

Disease capping NA, as per tender documents

Claim Process

Claims Process & Network

Value adds

Customer Support

Web Access & Mobile App

Awards and Recognitions

CHOLA MS HELP – Claims Process

“CHOLA MS HELP” is The brand name for the Health claims servicing team

of CHOLA MS”

• In-house Centralized processing at Chennai HO with regional co-ordinators at branches.

• Reimbursement Processing TAT of 7 Days

• Cashless issuance TAT is maintained at less than 1 hour.

• Health claims processing on a workflow (CORDYS) facilitating transparency / stage-wise status at all points.

• Auto SMS & mailers to customer & web portal updating the claim status at all the stages.

• App for claim intimation, e-card download.

Salient Feature of Chola MS HELP

Hospital Networking

13

2091

1608 1577

392169

36109 62 123 57 23 120

500

1000

1500

2000

2500

South West North East Central NE

Network Strength

No of Hospitals No Cities

0 200 400 600 800 1000 1200

ARUNACHAL PRADESH

MEGHALAYA

TRIPURA

ANDAMAN AND NICOBAR…

JAMMU AND KASHMIR

GOA

CHANDIGARH

CHATTISGARH

JHARKHAND

BIHAR

WEST BENGAL

DELHI

PUNJAB

RAJASTHAN

ANDHRA PRADESH

GUJARAT

MAHARASHTRA

States

•~5800 hospitals on Panel

•33 States & UTs covered

•Presence in more than 800 cities.

•Will have more than 6000 hospital by Mar,17 end covering ~900 cities

Value Adds

• Apollo Pharmacy :- 10% discount on medicines and 15% discount on Apollo

labeled products and 5% discount on FMCG.

• Thyrocare :- upto 50% discount on blood investigations and free sample

collection at home.

• Health camps/Health Talks

• Discounted Specialty consultations at selected hospitals

• Vaccination camps as required at discounted rates

• Master Health check up discount vouchers

• Any special requirement as per need.

Types of Claims

1. Cashless – Through Network Hospitals

2. Reimbursement – From Any Hospital as per IRDAI guidelines

3. Pre & Post hospitalization claim

4. Daycare procedures Claims

Claim Processing

Claim Intimation

In case of emergency, please intimate us to Chola MS HELP within 24 hours of hospitalisation.If planned hospitalisation, intimate us 48 hours prior to your admission.

CashlessRequest for Pre-Authorisation

Re-imbursementClaim Form Submission

Complete the pre-authorisation form available at the hospital's insurance/TPA Desk and send us through email/fax.

This form can also be downloaded from Website

Submission of claim form along with required documents, as per the policy terms & conditions. The form can be

downloaded from website.

Approved letter sent by the claim management team

Hospital/Insurance to respond to any query raised by the claim management team

You may initiate the treatment and file for reimbursement claim

Approved letter sent by the claim management team

Hospital/Insurance to respond to any query raised by the claim management team

You may initiate the treatment and file for reimbursement claim

Toll free 1800-200-5544 Fax 1800-425-2200

customercare@cholams.murugappa.com

E-Mail

Mandatory documents for claim:

• Claim form duly filled and signed.• Hospital final bill along with payment receipt.• Detailed discharge summary• Medical bills along with supporting prescriptions.• All investigation reports along with bills.• Invoice or sticker for implants used in surgery.• Copy of policy certificate / health card.• Medico Legal Certificate (MLC) / FIR in case of road traffic accidents (RTA)

Note: Bills and receipts has to be submitted in originalCont...

Online E-Cards and claims status on www.cholainsurance.com.

To access the E-cards and claims status follow the below mentioned Steps.

•Step 1 - Go To e-card•Step 2 - Click on individual Login Icon•Step 3 - Enter Policy Certificate Number as Login ID•Step 4 - Enter Policy Certificate Number as Password

Promise of complete transparency with necessary details available on Web

Web Access

1)Download Procedure:

Log on to http://eezeeapps.cholainsurance.com/chola/ website or from play store

Please click on Chola MS Wellness on the go app for downloading (down arrow) in to your mobile.

Once you click on the app for downloading, it will ask you to enter your name and mobile number to download.

Once the app is downloaded, Install the same in your mobile

Note: This app has to be downloaded from the above mentioned URL only and it is not available in play store (Android app store).

Cont…

Mobile App ( Wellness on the Go)- Health Claims

2)Registration:

After downloading and installation of the app, you have to register the same to login in to the app.

Please enter the policy number followed by employee ID.

Then it will prompt you to login through face book, google or with your own PIN opted.

If you wish to login to through own PIN, you have to chose 6 digit PIN of your own choice, and alternatively you can login using your face book or google account.

Note: You need to have GPRS facility in your mobile in order to access the above facilities except for My policy details, health card, storage of medical documents & BMI which works offline also.

Cont…

Mobile App ( Wellness on the Go)- Health Claims

Salient features of the app are as followed:

•Health Card on mobile•Nearest Network hospitals details on google map•Nearest Ambulance services details on google map•Store Medical files and Pill reminder•Value added services•Nearest Services (Labs, Pharmacy and scan centre)•BMI calculator•Pedometer•BP/Sugar reading /Trend•My contact•Contact Chola MS Care•Policy details•Cover Benefits•Claim intimation

Mobile App ( Wellness on the Go)- Health Claims

2222

Customer Support

• Chola MS HELP line customer support operates 24/7 basis.

• Toll Free Phone No: 1800-200-5544

• Toll Free FAX No: 1800-425-2200

•Mail: customercare@cholams.murugappa.comClaim can be submitted to Chola MS HO atChola MS General Insurance, Claims Processing Centre, New # 319, Old # 154, Shaw Wallace Building, 2nd Floor, Tambu Chetty Street, ParrysCorner, Chennai – 600001

Or To the nearest regional offices.

Escalation Matrix

Reimbursement ClaimsEscalation Name Contact Number E-Mail

Level 1 Sathish G R044 - 39910759 /

8939834685 sathishGR@cholams.murugappa.com

Level 2 Dr Rajesh Kanna P044 - 39910758/

9962987794 rajeshkannap@cholams.murugappa.com

Level 3 Dr Bharathi S044 -39910749 /

9176053753 bharathis@cholams.murugappa.com

Level 4 Dr Basant Kumar044 - 39910615 /

7338990225 basantkumar1@cholams.murugappa.com

Cashless ApprovalsEscalation Name Contact Number E-Mail

Level 1FAX Health / Dr.

Sreenivasulu044 - 39910745 /

39910743faxhealth@cholams.murugappa.com /

sreenivasuluk@cholams.murugappa.com

Level 2 Dr Bharathi S044 - 39910749 /

9176053753 bharathis@cholams.murugappa.com

Level 3 Dr Basant Kumar044 - 39910615 /

9381873027 basantkumar1@cholams.murugappa.com

For any issue related to claim NFL team can get in touch with Dr Manish Batra @ manishbatra@cholams.murugappa.com # 9910591595 or business team.If not resolved , case can be escalated as per below matrix.

Claim process in the beginning of the Policy

Membership card not available :-

For cashless :- Insured can approach network hospital with employee ID card and to inform them that they have policy with CHOLA MS. Hospital will do rest of the process related to approval.

If insured details are not available with CHOLA MS then mail will be triggered to NFL HR for confirmation of coverage at:-

– Ms. Vaishali Tayade, Asstt. Manager (HRD) – 8882568339 - vaishali.tayade@nfl.co.in

– Mrs. Promila Goyal, Sr. Manager (Coord), NFL, – 9818221412 – promilagoyal@nfl.co.in;

– Mr. D.R. Choudhary, Chief Manager (HR) – 9425131293 – drchoudhary@nfl.co.in;

Post confirmation of coverage ,cashless will be processed as per policy T&C.

In absence of coverage , denial letter will be send .

For Reimbursement :- Insured can file claim for reimbursement with employment details .Post confirmation from NFL HR , claim will be processed .

Chola MS business team will be kept in loop in all above communications.

Awards and Recognitions

Health Claims process at Chola MS HELP is now ISO 9001:2008

certified

“Health Insurer Claims Team of the Year for the year 2013”

Thank You

Annx.

Cashless Claim

1) Fresh pre authorization request:

• Cashless access is possible only at Chola MS HELP network hospitals (Approximately 5800 in number). Please refer our website www.cholainsurance.com for updated list of network hospitals.

• Insured should approach the hospital insurance desk, with the health card issued by Chola MS HELP along with a valid photo ID proof.

•Insured can avail advance pre-authorisation ( 7 days ) in case of Planned hospitalisation .

• Hospital will send filled pre authorization request, copy of health card, valid photo ID proof and all necessary medical records (prior consultations, lab reports) through toll free FAX (1800-425-2200) to Chola MS HELP.

• Cashless approval will be provided by Chola MS HELP with in 2 hours, if the claim is admissible under policy terms & conditions.

Cont..

2) Query Process :

• In case of any deficiency of necessary documents, Chola MS HELP will raise a query to the hospital, within 2 hour of receipt of the cashless request.

• On receipt of the query response from the hospital, the same will be processed within 1 hour.

3) Enhancement Process:

• If the expenses of treatment exceeds the initial cashless approval, hospital will send enhancement request to Chola MS HELP along with the necessary documents (Bills and treatment summary)

• Enhancement request will be processed within 1 hour from the time of receipt of the necessary documents from the hospital

Reimbursement Claim

All reimbursement claims should be intimated to Chola MS HELP immediately or before discharge from the hospital, through toll free number 1800-200-5544 or E-mail at customercare@cholams.murugappa.com

Reimbursement claim should be submitted with in 30 days from the date of discharge at any regional office of Chola MS or HO.

Claims submitted at regional offices will be registered on the same day and forwarded to Chola MS head office for adjudication.

Chola MS HELP team will scrutinize the claim and it will be processed within 30 days of receipt of the documents, if the claim documents are complete and claim is payable as per the policy terms and conditions.

Cont..

Query Process:

In case of any deficiency of necessary documents, Chola MS HELP will raise a query to the insured / corporate, within 3 working days of receipt of the claim at HO.

Query follow up will be done as mentioned below:

• 1st Query letter – Day 1

• Reminder letter – 15th day after 1st query

• Final reminder cum closure letter – 30th day after 1st query

• Claim will be closed on 45th day in the absence of query response from the insured.

Pre & Post Claim:

Pre & post hospitalization bills should be submitted within 30 days from the time of completion of the treatment or post hospitalization period defined in the policy, which ever is earlier.

Claims is payable, if the main claim is admissible under the policy subject SI availability

Daycare Procedures:

No need for 24 hrs hospitalization for these procedures.

Prior intimation and approval from Chola MS HELP is mandatory.

Procedures defined under the policy only payable.

Pre & Post and Day Care Procedures