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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
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: [email protected] 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 [email protected]
Level 2 Dr Rajesh Kanna P044 - 39910758/
9962987794 [email protected]
Level 3 Dr Bharathi S044 -39910749 /
9176053753 [email protected]
Level 4 Dr Basant Kumar044 - 39910615 /
7338990225 [email protected]
Cashless ApprovalsEscalation Name Contact Number E-Mail
Level 1FAX Health / Dr.
Sreenivasulu044 - 39910745 /
Level 2 Dr Bharathi S044 - 39910749 /
9176053753 [email protected]
Level 3 Dr Basant Kumar044 - 39910615 /
9381873027 [email protected]
For any issue related to claim NFL team can get in touch with Dr Manish Batra @ [email protected] # 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 - [email protected]
– Mrs. Promila Goyal, Sr. Manager (Coord), NFL, – 9818221412 – [email protected];
– Mr. D.R. Choudhary, Chief Manager (HR) – 9425131293 – [email protected];
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 [email protected]
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
