Transcript cavinkare private limited

FAQ ON GROUP
MEDICLAIM POLICY
CAVINKARE PRIVATE LIMITED
What is Group Mediclaim Policy ?
GMC Policy is taken for mediclaim coverage for employees and their
families in the event of hospitalisation.
Following points are essential for coverage : •
•
Minimum Coverage of 24 hours hospitalization.
Treatment should be availed only in registered hospital / nursing
home under the supervision of a registered & qualified medical
practitioner
• Hospital should have the following:
- Minimum 20 in-patient beds (in metros) 15 in non-metros
- Fully equipped OT
- Fully qualified nursing staff round the clock
- Fully qualified & registered doctors round the clock
Who is our Insurer & TPA?
• We have our policy with National Insurance Company Limited,
Chennai
• TTK Healthcare Services, Chennai is our TPA.
• Contact Details of TTK in-charge – Ms. Anitha [email protected] / 98840 94544
TOLL FREE NOS. OF TTK
TOLL FREE FAX NOS. OF TTK
TTK HO CALL CENTER
1800 425 8885
TTK HO CALL CENTER
1800 425 7878
TTK CHENNAI CALL CENTER
1800 425 7575
TTK HO FAX NO.
1800 425 2626
TTK MUM CALL CENTER
1800 22 1717
MUMBAI FAX NO.
1800 22 1919
TTK COCHIN CALL CENTER
1800 425 6264
COCHIN FAX NO.
1800 425 6262
TTK HYD CALL CENTER
1800 345 4051
CHENNAI FAX.NO.
1800 425 7474
TTK KOL CALL CENTER
1800 345 7069
TPA stands for Third Party Agency
What is Policy period & Who are
all covered under the policy?
• CavinKare Group Mediclaim Policy period commences on
22nd August of every year, and closes by 21st August of
next year.
• Employees and their dependents are covered under the
policy.
• Dependents includes Self, Spouse, Parents & Children,
subject to max. of 6 members in a family including
employee. ( 1 + 5 coverage )
What are the features
of CK Mediclaim policy ?
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Pre-existing diseases covered
Waiver of 1st year exclusion
Waiver of 30 days waiting period
Coverage till 80 years
Inclusion of maternity benefit ( Pre & post
maternity charges not covered )
Baby coverage from Day 1
Floater made policy
Coverage for 1 + 5 dependents
Cashless scheme - network with 3500 hospitals
through out India
What is my claim eligibility ?
We have a graded coverage for our
employees –
• MN3 & Above
Rs.85,000 pa
• MN4 & MN 5
Rs.50,000 pa
• O1 & O2
Rs.40,000 pa
• O3 & O4
Rs.30,000 pa
Eligibility amount is per member in a family.
What is floater made policy ?
• Under floater scheme the sum insured for the
individual family members will be added and the total
insured amount will be treated as sum insured for
family members.
• If an employee in MN4 grade has 4 members in his
family, total SI for his family is Rs. 2.0 lacs
• 50000/- * 4 = 200000 /- Sum Insured
• Sum Insured amount can be used within the family,
and there is no restriction on the same.
What is cashless facility ?
• ID cards are provided to employees &
their dependants.
• With the use of id card, they may get
admitted in any of the network
hospitals through out India and need
not pay any cash during hospitalisation.
How does Cashless access for
Hospitalization works ?
Cashless access for Hospitalization
Hospital faxes
Pre Authorisation to
TTK on Toll Free
Number
Patient approaches
Network hospital Based on
recommendation
of physician
Request received at TTK
Pre Auth dept thru
Dedicated Fax Machines
CYCLE TIME
SAME DAY.
Claims Dept checks
for coverage and
eligibility
Authorisation
faxed to Hospital
Medical Dept checks for
Treatment & Applies
Negotiated Tariffs
Use Toll
Free Nos.
Online HelpDesk at Select Hospitals :Authorisation & Billing
Will my claim be covered under
reimbursement scheme ?
• Yes. If the hospital is not covered
under cashless scheme, employee may
get admitted to any nearest hospital.
The amount incurred by the member
towards hospitalization shall be
reimbursed.
What are the documents to be
submitted for reimbursement claim ?
• Original Discharge Summary
• Medical investigation / diagnostic test Bills must be
accompanied by photocopies of the Reports
• Medical bills and prescriptions
• Lab reports, x-ray / scan reports etc.
• Claim to be submitted to HRD.
In case of reimbursement claim
submitted by me, why full amount
doesn’t get reimbursed from TPA ?
•
Following charges / expenses incurred by member is disallowed as
per Mediclaim conditions : –
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–
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–
•
Admission fee
Registration Charges
Diet & Canteen charges
Telephone calls
Service charges
Miscellaneous Expenses
Purchase of diapers, napkins, child food like Nestum
This is applicable for both cashless & reimbursement claims.
Will maternity claim for 3rd child
be covered ?
•
Only 2 live births are covered. i.e, if the
claimant has 2 children, then the 3rd baby
delivery charges are not payable even if he/she
has not claimed for the 1st and 2nd children
•
Similarly, Medical/voluntary termination of
pregnancy – unless necessitated by medical
advice where fetal/maternal life is endangered
is not covered under Mediclaim
What are the other coverage
excluded from policy ?
•
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Domiciliary Hospitalization
Treatment for sterility / infertility.
Family planning operations
Naturopathy treatment
Admissions for evaluation / purely for
investigation
• Congenital external disease or defects
• AIDS
OTHER FREQUENTLY
RAISED QUERIES
QUERIES
REPLIES REMARKS
Will Cataract be
covered?
Yes
However, cost towards
lens shall not be
reimbursed
Will Dental treatment
be covered?
No
Dental treatment arising
out of accident shall be
covered
Will Cosmetic surgery
be covered?
No
--
Will Outpatient
treatment be covered?
No
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ADDITIONS & DELETIONS
• Employees presume that by sending their
wedding invitation to HR, their spouse shall be
covered automatically.
• Nomination form should be filled in by employee,
giving details of their nominee, DOB and duly
signed form should reach HR for adding their
dependents.
• Similarly, any deletion in the family to be
informed by giving a nomination form to HR.
Otherwise, Company will continue to pay the
premium for that member unncessarily.
Where do I get mediclaim
related forms ?
• For your convenience, forms ( claim
reimbursement & nomination form ) are
made online available in
http://my.cavinkare.com
• All you need to do is, login with your emp
id, click the DOWNLOAD FORMS link, and
can take the print out of the forms.
Whom should I contact in HR for
further information on Mediclaim ?
• You may contact Mr. Kalaiselvan,
[email protected] ( 044–24317749 )
or
• Ms. Kayal, [email protected] ( 044 –
24317751 ) for further details on Mediclaim
policy.
THANK YOU !