Siemens Group Medical Insurance Guideline 2015-16

8/19/2019 Siemens Group Medical Insurance Guideline 2015-16

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Restricted © Siemens AG 20XX All rights reserved. siemens.com/answers

Group Medical Insurance Guideline


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Insurance Company, TPA & EB Broker

Policy Company TPA

Group Medical - Employees Bajaj Allianz GIC Ltd HAT (Bajaj In-house TPA)

Group Medical - Parents Bajaj Allianz GIC Ltd HAT (Bajaj In-house TPA)

Employee Benefit Insurance Broker Marsh India Insurance Broker Pvt. Ltd

The Group Mediclaim Program provides insurance coverage to employees of Siemens Group

& their dependents for expenses relating to hospitalization due to illness, disease or injury

subject to a minimum of 24 hours hospitalization.

Program Details


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Companies Covered(Group Companies)

Siemens Ltd

STSPL

SFSPL

SPPALPL

SCCPL

SHPL

Plan Name Group Medical Policy - Employees

Policy Holder Siemens

Period of the Cover 12 months

Inception Date 1-December-2015

ExpiryDate 30-November-2016

Insurer Bajaj Allianz GIC Ltd

TPA HAT (Bajaj In-house TPA)Members Covered

2A + 2C (Self + Spouse + 2 dependent children upto 25 years)

Geographical Limits India (Covers trea tme nt in Ind ia o n ly)

Mid-Term Revision of Sum Insured No

Age-Limit 1 da y to 80 Yea rs

Mid-Term Enrollment Yes (Only for New Born Child & Newly WeddedSpouse)

Group Medical Plan – Employees (Policy Details)

Sum Insured – Graded as follows

SL STSPL

Workmen/JE-SE 2 Lac S6-P2 2 Lac

MG 1-4 3 Lac M 0-4 3 Lac

MG 5 & above 5 Lac M5 & above 5 Lac


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Group Medical – Employee (Features contd…)

Maternity Policy Features

Coverage Fornormal - INR 50,000and For C-section- INR70,000

Restriction on No. of children 2 children

9-months waiting periodWaived Off For AllEmployees

Pre-Post Natal expenses Covered up to INR 10,000within maternity limit

New born baby coveredfrom day 1

Yes

Policy benefits

Daycare Treatments Covered as per list. List in laterpart of the guideline

Medical Termination ofPregnancy

All expenses to be covered incases of Medical termination ofpregnancy under Medical adviceto save the life or prevent seriousdamage to the health of the

mother. However voluntarymedical termination ofpregnancy during the first 12weeks from the date ofconception not covered

New born babies,Genetic and Congenitaldisorders internal to becovered from day one forall types of medical

related expenses

Covered

Day care coverage (overand above the insurer'slist)

D&C, radiotherapy, Excision ofCyst/granuloma /Lump (Localand General Anesthesia) andendoscopies to be covered onOPD basis (24 hourshospitalization to be waived off)

Surgery Treatment forThalassemia

Covered

Add it ional benef its broug ht i n this year (2015-16):

•Hormone Therapy for Cancer

treatment•In case of maternity related compli cation leading tolife threatening situ ations, the maternity li mit will not

apply.

• Amb ulance cover revis ed to INR 5000 per p erso nper hospitalization

•No deduction in case of death duringhospitalization

•Coverage of dependent in case of empl oyee death

till the end of poli cy period

•Bio degradable stent up t o 1.5 Lac


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Plan Name Group Medical Policy - Parents

Policy Holder Siemens

Period of theCover

12 months

Inception Date 1-December-2015

ExpiryDate 30-November-2016

Insurer Bajaj Allianz General insurance Co ltd

TPA HAT (Bajaj In-house TPA)

MembersCovered

Natural Parents or in laws of insured employeeonly. Restricted to any 2 parents c overage only

GeographicalLimits

India (Covers trea tme nt in Ind ia o n ly)

Mid-TermRevision of SumInsured

No

Age-Limit 36 to 95 yearsLock in Period 4 years

Group Medical – Parents (Policy Details)

Flexibility Options

Coverage for any set of parents (up to 2parents only)

Option to increasethe sum insured as per

details below

Option provided between floater and nonfloater

Option once selected will be frozenfor 4years.

Employee Grade BandNew plan design

(Non-floater )

New Plan design for(Floater)

up to P2/SE grade 1 Lac/ 2 Lac/3 Lac/ 4 Lac/ 5 Lac/6 Lac 2 Lac/3 Lac/4 Lac/6 Lac

M0/MG1 – M4/MG4 grade 3 Lac/4 Lac/5 Lac/6 Lac/8 Lac 3 Lac/4 Lac/6 Lac/8 Lac

M5/MG5 & above 3 Lac/4 Lac/5 Lac/6 Lac/8 Lac 3 Lac/4 Lac/6 Lac/8 Lac


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Group Medical – Parents Additional Benefits this year

Addi tional benefi ts brought in this year (2015-16):

Hormone therapy for cancer treatment

Oral Chemotherapy for all types ofcancer

Ambulance cover revised to INR 5000 per person per

hospitalization

Age-Limit covered 36 to 95 years


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Policy Features Acceptabi li ty

Standard Hospitalization Yes

Pre & Post HospitalizationExpenses

Yes (30 days-60 days)

Pre-existing Diseases Yes (waived)

First 30-days Waiting Period Yes (waived)

First Year Waiting Period Yes (waived)

Policy Features Acceptabil ity

Domiciliary Hospitalization No

Day CareCovered as per theInsuranc e company's list

OPD Expenses No

Health Check Up Not covered

Room Rent Capping No Restriction

Co-Pay No

Ayurvedic Treatment Not covered

Septoplasty and stem celltreatment Not covered

Hormone therapy for cancertreatment Covered

• There will be 4 years lock-in period for parents policy. This means once the parents are declared youcannot change the same till 4 years are completed. Only incase of death of any parent/death ofemployee/ resignation/retirement, the parents declaration can be stopped.• This Lock-In period will benefit employee to take policy on a retail mode in the event ofretirement/resignation benefits at par as per the corporate policy (portability option)• The applicable waiting periods in normal retail policies are waived off in the portability option post thecompletion of this 4 years lock in period . e.g. 30 days waiting period, pre-existing diseases, 1st and 2nd years

exclusions are waived off. However, premium would be at discretion of the insurance c ompany

Group Medical – Parents (Features)

Lock in Period - Features

Refractive error or sight

correction (+-) 7

Covered on OPD or IPD basis (lasik

or any injection given on OPD basis

are covered)

Dental and Vision only incase

of accidentsCovered

Internal congenital,

Pandemic, Oral

Chemotherapy

Covered


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Standard Hospitalization

Reimbursement of expenses related to

• Room and boardingcharges

• Doctors/Consulting fees

• Intensive Care Unit

• Surgical fees, operating theatre, anesthesia and oxygen and their administration

• Drugs ,medicines and consumables consumed on the premises.

• Hospital miscellaneous services (such as laboratory, x-ray, diagnostic tests)

• Diagnostic procedures such as Laboratory, X ray and other diagnostic tests

• Costs of prosthetic devices if implanted during a surgical procedure

• Radiotherapy and chemotherapy

• Organ transplantation includingthe treatment costs of the donor but excluding the costs of the organ

Note:

A) The expenses shall be reimbursed provided they are incurred in India and within the policy period. Expenses will be

reimbursed to the covered member depending on the level of cover that he/she is entitled to.

B) Expenses on Hospitalization for minimum period of 24 hours are admissible. However this time limit will not apply

for specific treatments i.e. Dialysis, Chemotherapy, Radiotherapy, Eye surgery, Dental Surgery, Lithotripsy (kidney

stone removal), Tonsillectomy, D & C taken in the Hospital/Nursing home and the insured is discharged on the same

day of the treatment will be considered to be taken under Hospitalization Benefit.

C) A security deposit of a minimum of INR 10,000 or more may be collected from the empanelled hospitals which may

be reimbursed fully or partially post deduction of non admissible expenses and once cashless settlement is done by

the Third Party ClaimsAdministrator (TPA)


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Pre & Post Hospitalization expenses

Pre-hospitalization Expenses

Definition

If the Insured member is diagnosed with an il lness

which results in his / her Hospital izat ion and for which

the Insurer accepts a claim, the Insurer will also

reimburse the Insured Member’s Pre-hospital izat ion

Expenses incurred towards that illness for which

hosp itali zation is done for up t o 30 days p rio r to hi s /

her Hospitalization.

Covered Yes

Duration 30 Days

Post-hospitalization Expenses

Definition

If the Insurer accepts a claim under Hospitalization andimmediately following the Insured Member’s discharge,

fur ther medical t reatment direct ly related to the same

condition for which the Insured Member was

Hospitalized is required, the Insurer will reimburse the

Insured member’s Post-hospitalization Expenses for up

to 60 day per iod.

Covered Yes

Duration 60 Days

Covered


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Maternity Benefits

The maximum benefit allowable is INR 50,000 for Normal and INR 70,000 for C-section per delivery within the policy Sum

Insured, max up to 2 children.

There are special conditions applicable to the Maternity Expenses Benefits as below:

• These benefits are admissible only if the expenses are incurred in Hospital/Nursing Home as in-patients in India.

• Claim in respect of delivery for only first two children and/or operations associated therewith will be considered in

respect of any one Insured Person covered under the Policy or any renewal thereof. Those Insured Persons who

already have two or more living children will not be eligible for this benefit.

• Expenses incurred in connection with voluntary medical termination of pregnancy during the first 12 weeks from the

date of conception are not covered

• Sterilization expenses are not covered

Reimbursement of expenses related to maternity as per policy

Benefit Details

Maximum Benefit allowable For normal - INR 50,000 and For C-section- INR 70,000

Restriction on no. of children Maximum of 2 children

9 Months waiting period Waived off

Pre-Post Natal Expenses on IPD and

OPD basis

Covered upto INR 10,000 within maternity limit

IMPORTANT:

For maternity reimbursements and employees on subsequent maternity leave , please do not wait ti ll you return back to office

to submit a claim as it will cross the claim submission timeframes and claim may be denied. please also immediately inform

HR about the new baby coverage as your dependent as subsequent complication may be a possibility and intimation is

mandatory prior to coverage.


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Pre existing diseases

Definition

Any Pre-Existing Condition or related condition for which care, treatment or

advice was recommended by or received from a Doctor or which was first

manifested prior to the commencement date of the Insured Person’s first Health

Insurance policy with the Insurer

First 30 day waiting period

Definition

Any disease contracted by the Insured Person during the first 30 days from the

commencementdate of the Policy is also covered.

First Year Waiting period

Definition

During the first year/second year of the operation of the policy, the expenses on

treatment of diseases such as Cataract, Benign Prostatic Hypertrophy,

Hysterectomy for Menorrhagia or Fibromyoma, Hernia, Hydrocele, Congenital

Internal Diseases, Fistula in anus, Piles, Sinusitis and related disorders are also

payable.

Covered

Baby Cover Day 1

Definition

Extension to cover the new born child of an employee covered under the Policy

from the time of birth. Not withstanding this extension, the Insured shall be

required to cover the newly born children immediately as additional member. Covered

Customized Benefits

Covered

Covered


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Customized Benefits contd..

Day Care

Definition Day Care Procedure means the course of medical treatment or a

surgical procedure listed in the policy schedule which is undertaken

under general or local anesthesia in a Hospital by a Doctor in not less

than 2 hours and not more than 24 hours.

Restriction List of day care procedures as named in the Policy schedule

Vision & Hearing aid

Defini tion The cost of spectacles and contact lenses, hearing aids

R Restricted

X Not Payable

R Restricted

R Restricted

Dental Treatment

Defini tion Any dental treatment or surgery of a corrective, cosmetic or aesthetic

nature unless it requires Hospitalisation; is carried out under general

anesthesia and is necessitatedby Illness or Accidental Bodily Injury.

Restriction Expenses arising only by way of an accident are payable.

Diagnostics Expenses

Definition Charges incurred at Hospital or Nursing Home primarily for diagnostic,

X-Ray or laboratory examinations or other diagnostic studies

consistent with or incidental to the diagnosis and treatment of the

positive existence of any ailment, sickness or injury for which

confinement is required at a Hospital/Nursing Home are admissible.

However diagnostics on standalone basis are not payable.


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General Exclusions

• Injury or disease directly or indirectly caused by or arising from or attributable to War, Invasion, Act of Foreign Enemy,

War like operations (whether war be declared or not) or by nuclear weapons / materials.

• Circumcision (unless necessary for treatment of a disease not excluded hereunder or as may be necessitated due to any

accident), vaccination, inoculation or change of life or cosmetic or of aesthetic treatment of any description, plastic

surgery other than as may be necessitated due to an accident or as a part of any illness.

• Surgery for correction of eye sight, cost of spectacles, contact lenses, hearing aids etc.

• Any dental treatment or surgery which is corrective, cosmetic or of aesthetic procedure, filling of cavity, root canalincluding wear and tear etc. unless arising from disease or injury and which requires hospitalization for treatment.

• Convalescence, general debility, “run down” condition or rest cure, congenital external diseases or defects or anomalies,

sterility, any fertility, sub-fertility or assisted conception procedure, venereal diseases, intentional self-injury/suicide, all

psychiatric and psychosomatic disorders and diseases / accident due to and or use, misuse or abuse of drugs / alcohol or

use of intoxicating substances or such abuse or addiction etc.

• All expenses arising out of any condition directly or indirectly caused by, or associated with Human T-cell Lymphotropic

Virus Type III (HTLD - III) or Lymohadinopathy Associated Virus (LAV) or the Mutants Derivative or Variations Deficiency

Syndrome or any Syndrome or condition of similar kind commonly referred to as AIDS, HIV and its complications

including sexually transmitted diseases.

• Expenses incurred at Hospital or Nursing Home primarily for evaluation / diagnostic purposes which is not followed byactive treatment for the ailment during the hospitalised period.

• Expenses on vitamins and tonics etc. unless forming part of treatment for injury or disease as certified by the attending

physician.

• Any Treatment arising from or traceable to pregnancy, miscarriage, abortion or complications of any of these including

changes in chronic condition as a result of pregnancy except where covered under the maternity section of benefits

• Naturopathy treatment, unproven procedure or treatment, experimental or alternative medicine and related treatment

including acupressure, acupuncture, magnetic and such other therapies etc.


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General Exclusions contd..

• Expenses incurred for investigation or treatment irrelevant to the diseases diagnosed during hospitalisation or primary

reasons for admission. Private nursing charges, Referral fee to family doctors, Out station consultants / Surgeons fees

etc,.

• Genetical disorders and stem cell implantation / surgery.

• External and or durable Medical / Non medical equipment of any kind used for diagnosis and or treatment including CPAP,

CAPD, Infusion pump etc., Ambulatory devices i.e. walker , Crutches, Belts ,Collars ,Caps , splints, slings, braces

,Stockings etc of any kind, Diabetic foot wear, Glucometer / Thermometer and similar related items etc and also any

medical equipment which is subsequently used at home etc..

• All non medical expenses including Personal comfort and convenience items or services such as telephone, television, Aya / barber or beauty services, diet charges, baby food, cosmetics, napkins , toiletry items etc, guest services and similar

incidental expenses or services etc..

• Change of treatment from one path to other path unless being agreed / allowed and recommended by the consultant

under whom the treatment is taken.

• Treatment of obesity or condition arising therefrom (including morbid obesity) and any other weight control programme,

services or supplies etc..

• Any treatment required arising from Insured’s participation in any hazardous activity including but not limited to scuba

diving, motor racing, parachuting, hang gliding, rock or mountain climbing etc unless specifically agreed by the Insurance

Company.

• Any treatment received in convalescent home, convalescent hospital, health hydro, nature care clinic or similar

establishments.

• Any stay in the hospital for any domestic reason or where no active regular treatment is given by the specialist.

• Out patient Diagnostic, Medical or Surgical procedures or treatments, non-prescribed drugs and medical supplies,

Hormone replacement therapy, Sex change or treatment which results from or is in any way related to sex change.

• Massages, Steam bathing, Shirodhara and alike treatment under Ayurvedic treatment.

• Doctor’s home visit charges, Attendant / Nursing charges during pre and post hospitalisation period.

• Treatment which is continued before hospitalization and continued even after discharge for an ailment / disease / injury

different from the one for which hospitalization was necessary.

• The above are only indicative and not exhaustive.


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Non Payable Expenses under Mediclaim Policy

•Admission charges or Kit / Registration/Token/Supplementary /service charges/Pre – post Consultants homevisit charges

•Any kind of Service charges, Surcharges, Admission fees / Registration charges etc levied by the hospital.

•Transportation/Ambulance/Local conveyance charges where ambulance is not required medically and as per the policy conditions.

•Administrative/Charges of Identification Band/Identification card

•Attendee or attendance staff /cleaner charges•Amenity of the hospital/water ,electricity, luxurious utility charges/establishment charges/ charges related tolinen/laundry/washing charges/establishment charges/any sort of overhead/lodging charges.

•Any charges named as Sundry/Stationary/File/Folder/Documentation/ xerox charges/medico legal charges/charges of birth or medical certificate or related to any certificate issuance.

•Telephone charges/TV charges/Video charges/Cable charges/internet charges/AC charges/cost of cassette/CD charges in case of endoscopy, color doppler etc/camera and related charges

•Mess/ Food charges/Diet charges/Nutrition and nutrition planning charges/Diabetic charges/cost related tomineral water

•Input & Output charges/Daily pass charges,/relative stay/extra bed charges/companion stay or relatedcharges/donor screening/organ harvesting charges/,private nursing charges during hospitalisation.

•Biomedical Waste charges/waste maintenance charges

•The above are only indicative and not exhaustive. Refer policy terms and conditions. Link for list of nonadmissible expenses https://www.bajajallianz.com/Corp/content/claim/nonadmissibleexpenses.pdf


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Voluntary Top Up pol icy

A Top-up policy supplements your existing mediclaim policy, insuring

you for a larger sum insured limit at lower cost

A Top-up cover is initiated when the full sum assured of your base

policy is exhausted (i.e. Threshold limit is reached) it excludes maternity

and maternity related issues.

Sum insured available 2lacs, 3lacs and 5 lacs

Advantages

Customizable “top-up” cover for each corporate customer

Terms and conditions to be in sync with the base policy

Option with the employee to enroll for the cover

“Group Leaver Benefit” – Employee can continue the same benefits even after he/she quits the

company.

Benefits under section 80D of Income Tax Act.

FAQ

Top up

policy


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Employee must enroll in order to obtain coverage for yourselves and your eligible dependents. Employee will

receive a link for Benefit me portal of Marsh where employee can provide relevant enrollment data on the portal

which will be open for 15 days. Post which the data will be shared with Insurer and endorsed and be used for

policy period 2015-16

In case of life events i.e. each time you acquire a new dependent like when your family status changes because ofmarriage, birth or adoption of a child. The acquisition of a new spouse and new born must be declared within 30

days of the marriage or child-birth.

If you fail to enroll within the defined timelines, the next enrollment can be done only at next renewal.

The UHID will be uploaded on the portal as well will be shared on email to all employees along with welcome

mailers.

On receipt of e cards employee should verify the details of self & Dependents notify HR & Marsh, post which samewill be rectified with endorsement with insurer and new details will be shared with employee.

Enrollment in the program


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Cashless Hospitalization

Cashless hospitalization means the Administrator may authorize (upon an Insured person’s request) for direct settlement of

eligible services and the corresponding charges between a Network Hospital and the Administrator. In such case, the

Administrator will directly settle all eligible amounts with the Network Hospital and the Insured Person may not have to pay

any deposits at the commencement of the treatment or bills after the end of treatment to the extent these services are

covered under the Policy. However, in spite of the above benefits, some hospitals may demand a deposit before admission

and refund of deposit shall be as per hospital policies.

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

Customer Care Center /Toll free no:

Toll Free No -1800 22 5858, 1800 102 5858

+91 9731407546

List of network hospitals

Note: The network hospital is subject to change, hence please

reconfirm with TPA before admission into any hospital or you

may log on to for an updated list


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Planned Hospitalization

Step 1Pre-Authorization

Step 2 Admission,

Treatment &

discharge

All non-emergency

hospitalization instancesmust be pre-authorized with

the TPA, as per the

procedure detailed below.

This is done to ensure that

the best healthcare

possible, is obtained, and

the Insured Member is not

inconvenienced when taking

admission into a Network

Hospital.

After your hospitalization has

been pre-authorized, you

need to secure admission toa hospital. A letter of credit

will be issued by TPA to the

hospital. Kindly present your

Mediclaim card at the

Hospital admission desk. The

Insured Member is not

required to pay the

hospitalization bill in case of

a network hospital. The bill

will be sent directly to, andsettled by, TPA.

Patients seeking treatment

under cashlesshospitalization are eligible to

make claims under pre and

post hospitalization

expenses. For all such

expenses, the bills and

other required documents

need to be submitted

separately as part of non-

cashless claims.


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Pre-Authorization

Member approaches TPA

counter of the Hospital with

planned hospitalization

details filled in a specified

pre-authorization format 48

hours prior to hospitalization

Hospital in turn

intimates the TPA

& Claim is

Registered by the

TPA on same day

Follow non

cashless process

No

TPA issues letter of credit

within 12 hours for planned

hospitalization to the

hospital

Yes

Pre-Authorization

Completed

For Pre-Authorization Claim Form please find the link

https://www.bajajallianz.com/Corp/content/health/health_claim_forms/cashless_request_form.pdf


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Admission, Treatment & Discharge

Member produces E-card 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 the TPA

Claims Processing by TPA

(with approval by Insurer)

Release of payments to the

hospital

Note: Employee /Insured is requested to check details of the Final Bill for its correctness before signing the

same


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Emergency Hospitalization

Step 1Get Admitted

Step 2Pre-Authorization by

hospital

Step 3Treatment &

Discharge

In cases of emergency, the

member should get

admitted in the nearest

network hospital by showing

their E-card. The treatment

should not be put on hold

irrespective of the time of

receipt of pre-authorization.

Relatives of admitted

member should inform the

call center /TPA Helpdesk

within 24 hours of

hospitalization & seek pre

authorization. The letter of

credit would be directly

given to the hospital. In

case of denial, relative

/member would be informed

directly by TPA.

After your hospitalization

has been pre-authorized,

the employee is not required

to pay the hospitalization bill

(except for the non-

medical/non-payable

expenses) in case of a

network hospital. The bill

will be sent directly to and

settled by TPA to the

hospital


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Member gets admitted in the

hospital in case of

emergency by showing his

E-card. Treatment starts

Member / Hospital applies

for pre-authorization to the

TPA within 24 hrs of

admission

TPA verifies applicability of

the claim to be registered

and issue pre-authorization

Pre-

authorizatio

n given by

the TPA

Follow non

cashless process

No

Member gets treated and

discharged after paying all

non entitled benefits like

refreshments, etc.

Hospital sends complete set

of claims documents for

processing to the TPA

Claims Processing by TPA &

Insurer

Release of payments to the

hospital

Emergency Hospitalization Process


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Non cashless Hospitalization Process

Member intimates TPA

before or as soon as

hospitalization occurs

Insured admitted as per

hospital norms. All

payments made by

member

Claim registered by TPA

after receipt of claim

intimation

Insured sends relevant

documents to TPA office

within 30 days of

discharge

•Insured will create the summary of Bills

(2 copies) and attach it with the bills

•The envelope should contain clearly

the Employee Name, Employee Code

& Employee e-mail & contact

Is

documentreceived

within 30

days from

discharge

Claim RejectedNo

TPA performs medical

scrutiny of the

documents

Is claim

admissible?

(coverage /

applicability

)

Yes

TPA checks document

sufficiency

NoYes

Is

document-

ation

complete

as required

Claims processing done

within 10 working days

Send mail about deficiency

and document requirement A

A

NEFT payment to the

employee shall be made. An

auto mailer will be sent to

your email id the following

day after NEFT is done

Yes

No


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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

Discharge Card (original)

Attending doctors’ bills and receipts and certificate

regarding diagnosis (if separate from hospital bill)

Original reports or attested copies of Bills and Receipts forMedicines, 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 andavailability 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.

Cancelled copy of cheque or NEFT details

Note: Please attach the completed document check-

list along with claim form and claim documents and

submit the same to TPA within the timeline specified.

Member needs to retain a photocopy of all thedocuments he is submitting for future reference

To download claim Form click on the links below

https://www.bajajallianz.com/Corp/content/health/health_claim_forms/ReimbursementFormA+B2013.pdf


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Prudent Utilization of Benefit

Health Insurance is a benefit for the employee and their dependents. One has to utilize the benefit with utmost

caution and prudence.

The ever increasing cost for the benefits require a proactive involvement from all of us.

The following steps are recommended, ensuring the benefits is prudently utilized by the employee and

dependents covered

Please ensure to crosscheck the final bill sent to the TPA for the following:

You are Billed only for the services util ized for e.g. category of room, diagnostics undergone ,

medicines consumed

Total of the bill

In case of any planned hospitalization, approach the hospital in advance(48 hours) and request pre

authorization- this enables TPA to further negotiate the rates

To approach hospitals with caution – most expensive is not necessarily the best.

To cross check the tariff with the Bench Mark Rates provided- the benchmark rates would give an

idea the general spend for the treatment or procedure.

Try to negotiate

Ask WHY & WHAT is billed to you ( as a consumer , we have the right to know)


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Timelines for submission of documents

Type of document

Intimation of reimbursement claims-

Documents of hospitalisation and pre-hospitalisation

Documents of post-hospitalisation

Timeline for submission

No Intimation required

Within 45 days from the date ofdischarge

Maximum within15 days from the date

of completion of 60 days from

discharge or completion of treatment

whichever is earlier


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FAQ contd..

• Is pre authorization necessary?

Yes. This will help you in the following ways:

1) You will be informed in advance regarding your coverage for the treatment and whether it is covered under your

medical plan or not . This will help you know in advance if your claim may get rejected at a later stage and you do not end

up paying out of pocket.

2) It will help you ensure that the treatment cost is appropriate and not inflated. as the TPA will be able to cross check

costs with the hospital in question. This will also help TPA in planning your hospitalization expenditure such that you donot run out of the cover that you are entitled to.

3) It will help TPA in registering the impending claim with the insurer.

• What are the key points I must remember when using benefits under this pol icy

• Please ensure that all your dependents are covered and have a valid card at the outset itself as it will not be possible

to add dependents at a later stage

• Submit your reimbursement claims within timelines from the hospital. Please do not postpone this till later as it may

mean that your claim gets rejected due to late submission .

• Please check that your documents are submitted completely at the first instance itself and originals are submitted

wherever requested for . Do note that incomplete submissions will not be considered as exceptions by the insurers

and will only delay the process further for you and a delay may lead to the claim getting closed.

• Please retain a copy of all claim documents submitted to the insurer

• Please do a pre-authorization for all claims including a proposed reimbursement as it will clarify issues regarding

coverage for you well in advance of an expense being undertaken.


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FAQ contd..

• What are the key reasons why a claim under the medical policy could be completely rejected under the plan?

The following are some common reasons for rejection although these are NOT the only reasons why a claim could be

rejected :

1) Treatment taken after leaving the organization. (If you have been transferred from one business to another please

confirm with your HR that you have been included for coverage under your new entity)

2) Treatment that should have been taken on an outpatient basis (unnecessary inpatient admission and / or no active

line of treatment.) or where hospitalization has been done primarily from a preventive perspective. Please remember thaton occasion your personal doctor may recommend hospital admission for observation purposes however such

admissions are not covered under your medical plan

3) Treatment taken is not covered as per policy conditions or excluded, under the policy. Please go through the list of

standard exclusions listed earlier. (for e.g. : Ailment is a because of alcohol abuse is a standard exclusion, similarly

cosmetic treatments or treatments for external conditions like squint correction etc are not covered) . Hospitalization taken

in a hospital which is not covered as per policy conditions (Ex. less than 10 bed hospitals), Admission is before/after the

policy period or details of the member are not updated on the insurer’s list of covered members . Additionally in case

original documents are not submitted as per the claim submission protocol,

• What are the key reasons why a claim under the medical poli cy could be reduced v/s sum insured ?

The following are some common reasons for rejection although these are NOT the only reasons why a claim could be

reduced : (1) Limits for the specific ailment exceed the reasonable cap on ailments listed in the manual,

(2) Claim amount exceeds the permissible limit under the policy for you ( denied to the extent of the excess),

(3) Some expense items are non payable for e.g. toiletries , food charges for visitors etc.


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Contact Details

TPA Contact Details

Insurer

Bajaj Allianz General Insurance

Co Ltd.

Insurer Website:

https://www.bajajallianz.com

Bajaj Allianz General InsuranceCo ltd Health Care TPA Address

for sending reimbursement

claim documents:

Health Claim DeptBajaj Allianz General Ins Co Ltd

Rustomjee Aspire, 3rd Floor, EveradNagar-2 ,Near APEX Honda,

Priyadarshini Circle,

Off Eastern Express Highway,Chunabhatti – Sion,Mumbai-400022

Marsh India Insurance Broker Pvt Ltd

Relationship Manager

Name: Ajay Shetty

Email: [email protected]

Phone no-7507606228

Escalation poin t

Name: Beena Nair


1st Level Contact

Toll Free Nos

1800 22 5858

1800 102 5858

Fax Number of Cashless Dept: 020-30512224/6/7

Pre Auth Mail Id: [email protected].

Relationship manager Bajaj Alli anz :Shwetambari Rane


Phone no:+917738367194

Vikhyat Rai
