MUTHOOTTU MINI

HRD DEPARTMENT CORPORATE OFFICE COCHIN KNOWLEDGE SERIES - 8 QUESTION ANSWERS ON MEDICLAIM INSURANCE POLICY WITH ORIENTAL INSURANCE COMPANY
1) Briefly explain the salient features of the Mediclaim Health Insurance policy?

The policy is valid after 30 days of commencement date. (Date when the first premium is paid) 2. If have any accidental cases, policy is valid from Policy issuing date. 3. Inpatient hospitalization is compulsory for a minimum period of 24 hours 4. Cash less facility is available at hospitals through TPA (Third Party Administrators).
1. 2) What are the various types of Mediclaim policies offered by Oriental Insurance

Company?

1. Medi Claim policy (Individual)

2. Happy Family floater policy

3) What are the Eligibility criteria for each of the scheme?

1. Individual-Mediclaim policy is available to any individual between the age of 18-80 years. 2. In Family floater policy Family means Self, Spouse, Children of age 3months 21 years,

dependent parents and parents in-law. ( Brother ,sisters are not included in family)
3. Self declaration will do for the family relations.

4) What are salient features of the HAPPY FAMILY FLOATER POLICY?

There are two kinds of Policies under this scheme. SILVER Plan Policy and GOLD Plan Policy Under Silver Policy, the sum assured is from 1lakh to 5 lakhs Under Gold Policy, the sum assured is from 6 lakhs to 10 lakhs

5) What is the difference between Silver Plan and Gold Plan policies?

a) In Silver plan policy 10% co pay system exists. (ie, the policy holder has to pay 10% of the Bills from his side for each hospitalization) b) In Gold plan scheme Daily hospital Cash allowance as follows is available

0.1 % of the sum insured per day per illness subject to a maximum compensation for 10 days illness. The overall liability of the company during the policy period will be limited to 1.5 % of the sum insured (Eg Mr A has taken Gold plan for Sum of 6.00 lakhs he is eligible for the daily cash allowance of Rs 600 per day for 10 days per illness. During the policy period total amount eligible is Rs 9000/)

c) Attendant allowance -At the rate of 500 per day of hospitalization for a child below 10 years to a maximum compensation for 0 days illness. The overall liability of the company during the period is limited up to 1.5 % of the policy.

d) Domiciliary Hospitalization in exceptional cases is allowed (eg. The hospital is far away from village where patient is residing or some diseases like chicken pox patient could not be hospitalized. Certificate from Doctor is needed In silver plan, 10% of sum insured Max 25000 during the policy period. In Gold plan, Maximum 50,000 during the policy period.

e) Whether registration charges are reimbursed? No-Registration Charges (at the hospital are not reimbursable in both Silver & Gold policies).

ADD ON COVERS (OPTIONAL- SUBJECT To EXTRA PREMIUM)

1) Personal Accident Cover -- In Silver Plan sum insured in multiples of 1,00,000 and up to 5.00lacs per person aged 18 years and above ( 50% 0f the limit for persons below 18 years )

2) In Gold plan sum insured in multiples of 2.00lacs and up to 10.00lacs per person aged 18 years and above 50% of the limit for persons below 18 years

Life Hardship Survival benefit (Only for Gold Plan holders) If

this benefit is opted for and if a claim for specified diseases listed hereunder is admitted survival benefits are paid as under

Diseases covered --- Cancer metastasis (Stage -4) End stage Renal Disease (ESRD)

Stroke leading to Paralysis paraplegia Under Plan A - 15 % of Sum insured ( 5 % of amount payable on survival of 180 days and above from date of discharge and 10 % of the sum insured on survival of 270 days and above from date of discharge Under Plan B ---- 25 % of the sum insured (10% of sum insured on survival of 180days and 15 % of sum insured on survival of 270 days from date of discharge from hospital.

6) Is there any Pre-insurance medical checkup in Family floater plan?

The insured, (or family members), above age of 60 has to undergo pre-insurance health checkup through the companys authorized diagnostic centre and cost of such expenses are to be borne by him/them.

7) Is there any Pre-insurance medical checkup in Medi Classic Individual? Age 45 and above.

8) What is the eligibility for the Room rent in hospitals?

Eligibility for room rent is 1 % of sum insured. Subject to a, maximum of Rs 5000 per day. I C Unit expenses not exceeding 2% of sum insured or 10,000 per day whichever is less.

9) What other benefits are available after hospitalization? Nursing expenses. Surgeons fees, Consultants fees, Anaesthetitsand Specialists fees.

Cost of medicines and drugs. /Relevant laboratory diagnostic test, X-rays etc.

10) Whether pre hospitalization expenses are permitted? In all types of policies Pre hospitalization expenses incurred up to 30 days prior to the date of hospitalization are payable . 11) How post hospitalization expenses are reimbursed?
In all the above policies Post hospitalization expenses incurred for a period of 60 days hospitalization on disease/ illness sustained will be considered as a part of claim. after

12) Whether Ambulance Charges are payable under the policies?

In all the above policies Emergency ambulance charges to a sum of Rs. 1000/- per hospitalization and limited to a maximum 1% of the sum insured or Rs. 3000 /whichever is less per policy period. (For Silver Card holders).

For Gold Plan Card holders 2000 per illness and limited to maximum of 2% of the sum insured or Rs 6000 whichever is less for entire policy period.

13) What all diseases are excluded in the First Year? Benign ENT disorders, Tonsillectomy, Mastoidectomy Timpanoplasty, Adenoidectomy Polycystic ovarian diseases etc. 14) What are diseases excluded for two years? Surgery of Hernia, Benign Prostate hypertrophy Surgery of Hydrocele, Cogenital internal disease/defect, Fistula in anus, Piles, Sinusitis and related disorders treatment for gall stone sand renal stone, Cataract, Hysterectomy for menorrhagia or fibromyoma, Varicose veins and varicose ulcers , Diabetes , hypertension , Gout and Rheumatism .

15) What are other Exclusions? ( Not eligible ) 1. Naturopathy treatment, unproven procedure or treatment, alternative medicine and treatment including acupuncture, acupressure, magnetic therapies etc. 2. Treatment which are irrelevant to the disease diagnosed , during hospitalization or primary reasons for admission , referral fee to family doctors , outstation surgeons fee etc, 3. Treatment arising from or traceable to pregnancy childbirth miscarriage, caesarean section abortion or complications of any of these conditions as a cause of pregnancy. 4. Treatment of obesity or condition arising thereon( including morbid obesity ) any other weight control programme services or supplies et.c 5. Expenses on vitamins and tonics unless forming part of treatment for injury or diseases as certified by the attending physician 6. Genetical disorders and stem cell implantation . 16) Whether preexisting diseases are covered under the policies? Pre-existing diseases are covered after 48 months of continuous Insurance.

17) What are the Income tax benefits available for the policy holder?

* As per IT act exemptions under 80 (D) are available for MEDICLAIM policies as under General Public ----- Rs 15,000 Senior Citizens ------Rs 20,000 18) Is there any No Claim Discount, if so what are the details? Insured persons are eligible for No clam discounts as follows: A discount of 5 % on the premium in respect of each claim free year subject to a maximum of 20 % shall be allowed provided the policy is renewed with the company without any break In case any claim is admitted under the policy the entire no claim discount earned shall be forfeited in the next renewal of the policy However the no claim discount shall continue to accrue afresh from the next claim free year. 19)

Whether any grace period is allowable for renewal of policy?

Payment of premium for renewal should be sent before the due date. However delay up to 7 days can be condoned by Insurance authorities depending on the merits

20)

Current rate of Service Tax?

12.36%

21)

Criteria to opt a Hospital?

Hospital, Nursing Home means any institution In India established for indoor and treatment of sickness and injuries and which

Either

It has been registered with the local authorities and is under the supervision of a registered and

qualified Medical practitioner.

OR

Should comply with minimum criteria as under

a. It should have at least 15 inpatient beds (10 in Class C Towns). b. Fully equipped operation theatre of its own wherever surgical operation is carried out. c. Fully qualified nursing staff under its employment round the clock. d. Fully qualified Doctor (S) should be in charge round the clock.

22)

CLAIM PROCEDURE-IMPORTANT INFORMATION:

In the event of a Hospitalization, Kindly produce the ID card at the Hospital.

Intimate the hospitalization within 48 hours of admission or before discharge from hospital.

23) Information to be given while intimating a Claim: a) Policy Number/Customer ID Number b) Name of the person who got admitted c) Name/Location and Contact number of the hospital d) Illness/disease for which admitted e) Name and contact number of the person intimating the Claim f) Contact number of the patient

24) CLAIM PROCEDURE In the case of Network Hospitals:

Claim in respect of cash less services will be through the TPA ( Third Party Agency ) provided the admission is in a listed hospital in the agreed list of the net work hospital s The TPA after getting the related medical details from the insured person or from the network hospital verify whether the person is eligible to claim under the policy and will issue a pre authorization letter/ guarantee of payment letter to the hospital mentioning the sum guaranteed payable

The TPA reserves the right to deny the preauthorization in case of relevant information as required by the TPA. In such cases the denial of Cashless Access should in no way be construed as denial of the claim The insured person may get the treatment as per the Doctors advice and later on submit the full claim papers to the TPA for reimbursement within 7 days of discharge from the hospital

Proposal form and Documents needed

The proposer has to complete the proposal form and enrolment form in duplicate and submit the details of the person/ each member to be enrolled under the scheme. The proposer has to affix a coloured stamp size photographs of each of the members to be insured on the enrollment form. These photographs will be used by the TPA for preparing the ID card for each of the members insured

MEDICLAIM WITH OMP In case where a person covered under a Mediclaim policy goes abroad by taking Orientals Overses Mediclaim Policy his /her Individual /Family floater policy becomes suspended for the period he/she is abroad

Discount on OMP --- A discount of 15% on overseas Mediclaim policy will be allowed when even a single family member covered under Family floater policy takes the OMP policy from the company, provided the policy is valid on the date of taking the OMP Policy.

28/7/12