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This document provides information about the MORNINGSTAR INDIA PRIVATE LIMITED Hospitalization Benefit Plan. The plan covers all expenses related to hospitalization for illness or injury requiring more than 24 hours of hospital stay. It covers expenses for hospital room rent, doctors' fees, surgery, medicines and more. Insured members can avail cashless coverage at network hospitals or seek reimbursement of expenses from the Third Party Administrator. The document outlines the claims process, coverage details, and common exclusions of the policy.
This document provides information about the MORNINGSTAR INDIA PRIVATE LIMITED Hospitalization Benefit Plan. The plan covers all expenses related to hospitalization for illness or injury requiring more than 24 hours of hospital stay. It covers expenses for hospital room rent, doctors' fees, surgery, medicines and more. Insured members can avail cashless coverage at network hospitals or seek reimbursement of expenses from the Third Party Administrator. The document outlines the claims process, coverage details, and common exclusions of the policy.
This document provides information about the MORNINGSTAR INDIA PRIVATE LIMITED Hospitalization Benefit Plan. The plan covers all expenses related to hospitalization for illness or injury requiring more than 24 hours of hospital stay. It covers expenses for hospital room rent, doctors' fees, surgery, medicines and more. Insured members can avail cashless coverage at network hospitals or seek reimbursement of expenses from the Third Party Administrator. The document outlines the claims process, coverage details, and common exclusions of the policy.
1. What are the broad benefits under MORNINGSTAR INDIA PRIVATE LIMITED Hospitalization Benefit Plan?
Under MORNINGSTAR INDIA PRIVATE LIMITED Hospitalization plan, you or your eligible & insured family members would be paid all the eligible expenses incurred due to hospitalization. The hospitalization must fulfill following conditions:
Where the total stay in hospital is more than 24 hours (this condition is relaxed for certain ailments which are mentioned ahead) Where the hospitalization is for treatment of a disease or illness and the treatment given cannot not be administered on Outpatient basis. Where the hospital is more than 15 beds in Metro Cities OR is registered with the local authorities (this condition is relaxed to 10 beds for Non-Metro cities) This plan pays for various components of hospitalization expenses like Stay Charges, Operation Charges, and Doctors fees, Nursing Charges, Investigations & Diagnostics Charges, and Medicines etc. To summarize in short, it pays for all hospitalization expenses, which are Medical in nature.
2. What are the additional benefits under this Plan?
In addition to getting the expenses paid for the hospitalization, you also get reimbursement of expenses incurred for same disease/illness 30 days prior to the Date of Admission to Hospital (Called Pre-Hospitalization Expenses). This could be the doctors fees, Preliminary investigations & diagnostics and the medicine charges. You also get reimbursement of expenses incurred for same disease / illness 60 days after the Date of Discharge from the hospital (Called Post- Hospitalization Expenses). This could be follow-up consultations with doctors, Medicines, & confirmatory diagnostics etc. These benefits are subject to the limits on the policy.
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3. What is the Family Eligibility criterion for insuring the family members?
Under floater Sum Insured, you can insure up to any THREE members of your family amongst Spouse + any 2 Dependents among Children or Parents. Please note that you cannot insure your dependents like brother, sister, uncle, aunt, or your grandparents etc.
4. When does the Insurance Cover start?
The Annual Insurance Policy starts on 01st April 2013 for all existing employees who have joined on or before 01st April 2013 are already insured.
Employees who have joined post 01st April 2013, insurance cover will commence w.e.f. his/her date of joining subject to completion of his/her online enrollment into Policy
5. When does my Insurance Cover end?
Insurance policy expires on 31st March 2014 or on any of the following event, whichever occurs earlier would terminate your insurance cover.
Termination or expiration of insurance policy (in case of expiry, it would be renewed) Your separation from MORNINGSTAR INDIA PRIVATE LIMITED (Last date of employment)
As the employee insurance is extended to the dependents, the date of termination of cover for employee is also the date of termination of cover for dependents. Your dependents cover can also be terminated if the dependent is no longer eligible for such coverage.
6. I want to cover to my dependants in the policy. What are the next steps?
You will receive the mail from Medimanage for completing your online enrolment. Accordingly you can login to Medimanage portal for completing your enrolment for dependents under Group Mediclaim Policy.
7. How do I know that my dependents or I are insured?
After your enrollment, you would receive a communication from Medimanage informing the availability of e-card (Raksha TPA ID) on the website for the members insured. The process of
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generation of e-card normally takes about 4-6 weeks. Please note that each insured family member gets separate e-card therefore, if you dont get the e-card for one of your family member, chances are that the member is not insured. In such events, immediately contact our health plan coordinator, by raising tickets in my communication module on our web site www.medimanage.com.
8. How do I avail this Hospitalization benefit?
This benefit can be availed in two forms.
i. Cashless: This insurance plan is administered by an outsourced agency called Third Party Administrator (TPA). Our current TPA is M/s. RAKSHA TPA. They have a network of hospitals all over India where you or your insured dependents can get hospitalized & take the treatment without paying the eligible expenses upfront from your pocket. (Applicable for only Medical Expenses, for Non-Medical expenses, you have to make the payment as per hospitals policy.)
Cashless hospitalization not allowed only in Preferred Provider Network (PPN) hospitals.
ii. Reimbursement: In this traditional form, after your/or your insured dependents hospitalization is complete; you need to make the payment for these expenses & then get the eligible amount reimbursed from the TPA.
Note: 1. Claim intimation is mandatory in case of planned hospitalization; you should provide intimation of claim at least 3 days before the hospitalization and if it is emergency hospitalization, then provides intimation of claim within 48 hours of getting hospitalization. Please intimate about the hospitalization on. 2. Reimbursement claim documents should be submitted within 15 days from date of discharge.
9. What is the process to avail cashless facility?
Please follow the steps mentioned herein:
Identify the hospital where you wish to undergo treatment & confirm whether the same is part of Network Hospital list of Raksha TPA. You can do so by referring to the hospital list available with your HR. You can also contact Medimanage OR get in touch with their voice contacts as mentioned at the end of this document. (As this hospital list gets
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constantly updated, its recommended that you check on the RAKSHA TPA empanelment with the hospital prior to admission)
Fill up the Cashless Request Form & the network hospital will fax the duly filled request to RAKSHA TPA. The cashless formalities need to be done a week prior or at least two days prior to the date of hospitalization in order to ensure timely approval from RAKSHA TPA. In cases, RAKSHA TPA requests for submission of additional documents, please do furnish the same. In case, you do not comply with this, your cashless request would be rejected. In such cases, please call Medimanage voice contacts to help you solve the problem if any. Upon scrutiny of this form, RAKSHA TPA would accept the request & send the authorization letter to hospital stating the amount approved. This is the amount, up to which your expenses would be paid for directly by the TPA. RAKSHA TPA could also reject the request subject to policy terms and conditions. In such events, please call Medimanage to understand the reason for the same. For payment of Non-Medical expenses, you may have to pay Security Deposit to hospital. In case, the hospitalization expenses exceed the Authorized Limit (AL), which is initially sanctioned by Raksha TPA, the hospital sends request for additional authorization or the final bills, in case of discharge and the claim is further approved as per the eligible limits. In case employee does not want to wait for the final approval and wants to be discharged, he / she can pay the balance amount and later get the balance eligible amount reimbursed from Raksha TPA.
10. What happens if I have to be hospitalized in emergency or in case of accident?
In case of such emergency events
Please take the patient to the hospital & start the treatment. Let the patient stabilize Follow the standard procedure for Cashless Authorization in case of network hospital and Reimbursement in case of non-network hospital.
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11. How do I claim the amount if the hospitalization is in Non-network hospital?
You have to collect all the documents (As per the document checklist enclosed on Medimanage portal) & submit it to your HR along with your e-mail details. You should get the settlement within 21 working days from the date of submission of your claim or the date of fulfilling all the additional documents, whichever is later. Additional documents (Deficiency documents) need to be submitted within 45 days from the date of first intimation of the additional required documents. Please note that you have to submit claim documents within 15 days from Date of Discharge from hospital. In case you delay submitting the claim, the same may not be paid for.
12. What are the exclusions of this policy?
HIV and AIDS Intentional Self-Injury, Use of intoxicating drugs/alcohol Venereal Diseases, Naturopathy, unproven procedure/treatment, experimental or alternative medicine/treatment including acupuncture, acupressure, magneto-therapy etc All psychiatric & psychosomatic disorders Injury or Disease caused directly or indirectly by nuclear weapons Naturopathy Expenses on Vitamins/Tonics unless forming part of treatment Cost of Spectacles or Contact Lenses, Correction of eyesight, Hearing Aid etc. Any cosmetic or plastic surgery except for correction of injury War, Invasion, Act of foreign enemy, War like operations, Nuclear weapons, Ionising Radiation, contamination by Radioactive material nuclear fuel or nuclear waste Any hospitalization for Diagnostic tests only Infertility treatment Any hospitalization less than 24 hours except for specific treatments like Dialysis, Chemotherapy, Radiotherapy, Cataract Surgery, Lithotripsy, Tonsillectomy etc. Any Non Medical Expenses like Registration Fees, Admission Fees, and Charges for Medical Records, Cafeteria Charges, Telephone Charges, and Service Charges etc. Any dental treatment or surgery, which is corrective filling of cavity, root canal etc. Expenses incurred for investigation or treatment or irrelevant to the diagnosed during hospitalization, private nursing charges, referral fee to family physician, outstation Doctor/Surgeon/ consultants fees etc. Vaccination & Inoculation
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Genetical disorders & stem cell implantation / surgery Change of treatment from one pathy to other pathy unless recommended by consultant Treatment for obesity or condition arising there from (including morbid obesity) and any other weight control program/services/supplies Any treatment required arising from insureds participation in any hazardous activity Any stay in the hospital for any domestic reason or no active regular treatment is given Massages, Steam bathing, Shirodhara & alike treatment under Ayurveda All expenses arising out of any condition directly or indirectly caused to or associated with Human T-Cell Lymphotrophic Virus Type III (HTLB-III) or Lymphadinopathy Associated Virus (LAV) or the Mutants Derivative or variations Deficiency Syndrome or any Syndrome or condition or a similar kind commonly referred to as AIDS, complications of AIDs and other sexually transmitted diseases (STD) Treatment which is continued before & after hospitalization for an ailment / disease / injury different from one for which hospitalization was necessary Voluntary Termination of Pregnancy during first 12 weeks from the date of conception. Treatment arising from or traceable to pregnancy/ childbirth including caesarean section, miscarriage, abortion or complications thereof including changes in chronic conditions arising out of pregnancy Out patient Diagnostic, Medical or Surgical procedures or treatments, non-prescribed drugs & Hormone replacement Therapy, Sex Change Any treatment received in convalescent home, convalescent hospital, health hydro, nature care clinic Doctors home visit charges, Attendant/Nursing Charges during pre & post Hospitalization External/ durable medical/Non-medical equipments of any kind used for diagnosis/treatment including CPAP, CAPD, infusion Pump etc., ambulatory devices like walker/ crutches/ belts/ collars/caps/ splints/ slings/ braces/ stockings/ diabetic foot- wear/ glucometer/ thermometer & similar related items & any medical equipment which could be used at home subsequently. Non-medical expenses including personal comfort/ convenience items/ services such as telephone/ television/ aya/ barber/ beauty services/ diet charges/ baby food/ cosmetics/napkins/ toiletries/ guest services etc. Treatment, which the insured was on before hospitalization and required to be on after discharge for the ailment/disease/injury different from the one for which hospitalization was necessary.
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13. I am a female employee & married recently. My name is changed after the marriage. Is my insurance cover still valid with my new name?
Your insurance cover is still valid but getting the name change process completed is important. As in near future, you may go for a claim, which will be lodged, under your Post-Marital name and the claim may not be honoured due to difference in names. Please submit a requisition for change of name along with a photocopy of your marriage certificate.
14. What happens if the details like DOB, furnished by me is incorrect.
It is important that you provide correct information. In case of discrepancy in data available with TPA & the actual data furnished (you may have mentioned in the form your wifes age as 35 years and the claim form & hospital records have mentioned it as 45 years), your claim may get rejected. Please get in touch with our executive about this & get the necessary & timely changes made in the insurance records.
15. I am an existing Employee & during the enrollment exercise (i.e. before April 19 2013); I have covered my Spouse & 1 Child. I need hospitalization for my other child later in the month of October 2013; can I cover my child then?
All the dependent enrollments have to be done on or before 19 th April 2013 for existing Employees (& within fifteen days of joining the company for New Joiners). These Enrollments cannot be amended (except for additions like Marriage & child-birth) till expiry of this policy i.e. Up to 31 st March 2014.
16. I have insured my spouse under the policy. Do I have to intimate insurer when my first child is born?
Yes, New Born Child Cover from Day One. Intimation of the new born baby should be within 1 month from DOB. You add his/her details in My Members Section on www.medimanage.com within 1 month from the date of birth of new born. You also have to intimate us and your HR about this addition.
17. Are there any specific restrictions on my hospital expenditure?
To rationalize the expenses paid under Mediclaim, insurance company has issued sub limits, which are as follows:
Room Rent Capping - 1% of Sum Insured
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ICU Rent Capping - 2 % of Sum Insured Maternity - INR 50,000 for Normal and Caesarean OPD - Rs. 5,000/- per Employee Co-payments for dependents - 10% of Admissible claim amount OPD claims in respect to each insured can be lodged only once during the policy period. OPD claims would be admissible only after 90 days from inception.
18. I have insured my Spouse under the policy. My spouse was hospitalized and the total hospital bill was 100,950. The non-medical expenses (like food, telephone bill & registration charges etc. are INR 950. The room rent per day was Rs. 3000 only. Now, how much money I will get once the claim is settled? First, the admissible claim amount would be identified. As the non-medical charges are INR 950, the total admissible claim value would be INR 100,000 (i.e. Total Bill of INR 100,950 Non- medical charges of INR 950). Raksha will issue a cheque amounting to INR 100,000.
19. In case of any query regarding this Benefit Plan, whom should I get in touch with?
You can raise a ticket in My Communication Section by logging on to www.medimanage.com for all issues regarding this Health Plan. You can get in touch with Medimanage for any of the following issues.
Checking whether enrollment is done or not Getting the TPA ID. How to get cashless hospitalization done In case of delay or problems in getting the Cashless Changes in the enrollment information Any other query regarding this Health Plan
20. Where do I check my claim status? You can check your claim status on Medimanage Portal under My Claims section. You can also register your claim online through this section and get regular updates on the claims which you have already submitted. Log-on to https://www.medimanage.com
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Homepage on Medimanage portal will be displayed Reach the Dashboard on the homepage Click on My Claims 21. Do I need to intimate about the hospitalization? Claim intimation is mandatory in case of planned hospitalization; you should provide intimation of claim at least 3 days before the hospitalization and if it is emergency hospitalization, then provides intimation of claim within 48 hours of getting hospitalization. Please intimate about the hospitalization on claimintimation@medimanage.com