Mediclaim Insurance &

Hospitalisation Scheme

(11 Sep 2013 to 10 Sep 2014)

Entities Involved

Insurer :

Policy Period :

Universal Sompo General Insurance Co. Ltd

11 Sep 2013 to 10 Sep 2014

TPA : Family Health Plan Ltd. ( FHPL)

Mediclaim pays for treating an ailment and Mediclaim pays for treating an ailment and

not for diagnosing an ailmentnot for diagnosing an ailment

Sum Insured

PDPMIIITDM College has opted cover of

Sum Insured Rs. 50,000/-

1). Pre-Existing:- Covered.2). 30 Days waiting: - Applicable. 3). 1, 2 years Exclusions: - 1 Year Exclusions are Applicable. 4). Co Payments: - No Copayment. 5). Pre & Post Hospitalization: - 30 / 60 Days. 6). Domiciliary Hospitalization Charges: - Not Covered. 7). Dental & Spectacles & Hearing aids: - Not Covered. 8). Health Check-up: - Not Covered. 9). Special Conditions 1: - Claim Submission for MRC should be within 60 Days from the DOD from Hospital, Post 60 Days TPA should raise the deficiency for the submission delay reason from the insured. Claim submission for Hospitals (PP Claims) should be within 30 Days from DOD from Hospital, Post 30 Days TPA can reject the claim with concurrence of USGI Claims Team. 10). Special Conditions 2:- All other terms & conditions shall be as

per Standard GMP. 11). Room Notes: - As per GMP conditions..

Policy Terms & Conditions

Definition of Hospital :

Any hospital which is tied up by FHPL and any Nursing home or hospital

which is Registered and has more than 15 Beds.

Definition of Hospitalization:

Minimum period of 24 hrs of admission in a hospital for a proper medical

management.

Time Limit Not Applicable For Specific Treatments Like

• Dialysis

• Chemotherapy

• Eye surgery

What is not covered under this policyDiseases In-Patient Treatment Others

Plastic Surgery (Cosmetic) Laboratory Expenses not consistent with treatment.

Spectacles,Contact Lens,

Hearing Aid

Orthodontics Treatment Vitamins Use of intoxicating drugs/ alcohol

Sterility/Venereal Disease/Circumcision

Tonic inconsistent with treatment.

Naturopathy

Intentional Self Injury Telephone,Fax,Barber,Photocopy, Vaccinations,Toiletries and TV charges

Aids Special diet and extra diet for patients (unless prescribed by the Doctor)

Congenital Diseases (External)

e.g. An operation to remove a 6th finger, Skin Graphting

External Implants

e.g. An operation to remove a 6th finger, Skin Graphting

Registration fees

What is not covered under this policyDiseases In-Patient Treatment Others

Convalescence / General Debility.

Supports and Accessories, e.g. Crutches

Admission fees

Service,Maintenance and Surcharges

Food & Beverages

Special Nursing, Attendant Pass Telephone/Fax

Health Drinks:

e.g. Horlicks, Complan etc

Medical records/ Stationary

Xerox or Certifying charges

Abortion done for voluntary reasons & before 12 weeks

Attendants Charges

Food and Beverage for Relatives Special Nursing charges

Diagnostic Expenses (only for out-patient)

Extra Bed/ Bed retaining charges

Damage done by the patient (accidentally). Damage charges not covered.

TV/ Laundry

Do’s

1. Carry your ID card (IDEA)/ E Card (FHPL) at the time of admission at

network hospitals

2. Incase of emergency admission kindly contact FHPL within 24 hrs of

Hospitalisation

3. Incase of emergency kindly refer your companies name and your Emp

No at the time of admission

4. Take a pre approval from FHPL for all the elective cases

5. Sign on the final bill at the time of discharge from the hospital

6. For any other assistance call the account manager

Eligibility

Covered

Not

Covered

Hospital sends Intimation to

FHPL

Authorization as per eligibility

Out of Pocket payment

TAT : less than 2 hr for routine cases

Emergency : No authorization required

Regularization within 24 Hrs

Member approaches with Network Hospitals with ID

Cashless treatment at NWH

How to avail benefits under your policy

Member approaches Any other Hospital

Avails treatment, makes upfront payment

Submits bills to FHPL for reimbursement

Documents required for reimbursement

1. Original detailed discharge summary

2. Original investigation reports along with bill

3. Original Hospital Bill-consolidated and with detail breakup of every component of the bill with the patients signature on it.

4. Incase of surgical packages – detail breakup of the package

5. Medicine bills with prescriptions.

6. Claim Form – ( available on FHPL website )

7. MLC Certificate from the hospital in the case of Road traffic accident. Or a certificate from the treating doctor mentioning that the patient was not under the influence of alcohol at the time of Accident.

8. Payment receipt for the payment done to the hospital.

*30 Days pre & 60 Days Post hospitalization Original investigation reports along with bills & receipts

1. Consultation receipts.

2. Medicine bills with prescriptions

Our commitment to serve You …….

……. Is absolute