Mediclaim Insurance / /
INTRODUCTION
This FAQ gives the salient features of the Health Insurance Scheme – Mediclaim Policy will reimburse reasonable expenses to the insured Tata Power, CGPL, MPL,TPJDL and TPCDT Employees, subject to certain maximum limits, which the employees have incurred on account of hospitalisation
Tata Power Employees and their families are covered under the Mediclaim Insurance Scheme for the Sum Insured as per their Grade for the Hospitalisation expenses. The Insurance policy is with New India Assurance Company (NIAC) and the claims are administered by Mediassist who are the Third Party Administrators (TPA).
The Insurance policy basically covers the Hospitalisation expenses whilst admitted as in-patient to the extent of reasonableness of the charges subject to the Individual family limit of the Sum Insured for each year of the policy.
In order to ensure that the Policy is better managed and is understood by the employees we are providing the following frequently asked questions which are covered under this write-up and will help employees to avail its facility.
For the benefit of better understanding to the Employees the FAQs are given below under 8 heads (A to H):
A)Who is covered / Limits of coverage / add and delete dependants and the I- Card / E – Card
Who all are eligible to get covered in Company‘s Group Floater Mediclaim Policy?
What are the limits for coverage?
How do we add names of new employees and dependents in the Policy?
How can I delete my dependents name from the Policy?
How can I getMediclaim I.Card/E-Card?
B)What should I do in case of Hospitalisation of Myself OR my family members?
Basic information
C)What is CASH LESS Claim / Reimbursement Claim.? / Limit Under Cash Less claim / List of Hospitals
What is Cash Less claim and Reimbursement claim
Where can I Claim Cash Less Hospitalisation / what is GIPSA Hospitals
GIPSA hospital List
If my cashless approval is partial, what I should do?
D)What expenses are payable under the Scheme / Ailments Excluded / Expenses not payable / Non Mediclaim items disallowed
What expenses are payable under the Mediclaim policy?
What expenses are not payable exclusions?
What ailments are excluded under the policy?
Additional Coverage & Restrictions to Officers
What are Non-Medical items generally disallowed? Can I get a list of it?
E)Claim Process / Procedure during Discharge at Hospital / Documents to be submitted
What is the procedure/requirement for claim submission?
What is the time limit for reimbursement claim submission?
Why are original documents required for submitting a claim? How can I get my original reports and x-ray films back?
From where I can get Claim Form
What is the cycle time for claim settlement?
How can I track my claim status / settlement letter?
How can I track my claim status?
My claim is in query stage for IR (Information required). What should I do?
My claim status is marked as denied. What should I do if I do not agree with the denial reasons?
Certain portion of my claim has been disallowed in my settlement. If I do not agree with the same, how can I claim it?
Claim vigilance / claim investigation by TPA personnel.
F)Transferred Employees Between Subsidiaries – CGPL / MPL / TPCL
I am transferred/shifted to Group Companies in Tata Power with new employee number. What is the procedure followed to avail mediclaim facility?
G)Retired Employees:
If I am retiring in the current year, what should I do for continuing my mediclaim in the Company’s Group Floater Mediclaim Policy?
I am a retired employee, what is the premium I have to pay for my coverage to continue in Tata Power Company’s Group Floater Mediclaim Policy?
I am a retired employee, wants to enhance my existing sum insured.
I have resigned from Tata Power. Whether I can continue the coverage by paying premium in the Group Mediclaim Policy. Upto what period my Mediclaim coverage remain valid?
H) Problems faced in Claim
Frequently Asked Questions
A)Who is covered / Limits of coverage / add and delete dependants and the I- Card / E – Card
1.Who all are eligible to get covered in Company‘s Group Floater Mediclaim Policy?
i)Self, Spouse, Dependent Children upto age of 25 and Dependent Parents or in-law parents
* Dependents - (1) Legally married spouse, (2) legitimate or legally adopted son/daughter, (3) parents – father, mother or father-in-law, mother-in-law who is not gainfully employed for wage or profit or in service, business or profession and to be truly a ‘dependent’ of the employee and normally reside with him.
ii)Special category
a) / In respect of dependent children who are 25 years of age and above, upon their satisfying the following conditions:i. They are not working
ii. They are not married
b) / In respect of dependent handicapped sibling, upon their satisfying the following conditions:
i. They are not working
ii.They are not married
iii. Appropriate cert of handicapped status being produced
c) In respect of siblings of Unmarried employees, upon their satisfying the following conditions:
i. They are not working
ii. The parents are deceased
For regularizing the above coverage, the employee has to make an application to Head Corporate Insurance through their concerned divisional office in the prescribed format enclosing the necessary declarationduly verified by the Divisional Head.
Further, such declaration needs to be made annually to ensure that the special status continues.
( Click here for Special categoryadditionform)
2.What are the limits for coverage?
Grade / Sum InsuredMC2 and above / 10 lakhs
MD2, MD1 / 7 lakhs
ME-2, ME1 / 5 lakhs
ME4, ME3,FDA / 4 lakhs
Staff above Basic 400 / 3.5 lakhs
Staff upto Basic 400 / 2.5 lakhs
Employees of Jojobera and Power House 5 & 6 are covered under Tata Steel medical facility. However employees are having an option to get covered under our existing Mediclaim policy for coverage of 2.5 lakhs.
3.How do we add names of new employees and dependents in the Policy?
New employees inducted through HR data get added to Mediclaim system through a process run from IT Dept.
The Employee himself has to add immediately, dependents name in Mediclaim System available in Sangam - employees portal – Mediclaim – add - dependent name.
The coverage will be regularised through monthlyaddition with Insurance Company effective from the date of addition in the Mediclaim system.
4.How can I delete my dependents name from the Policy?
Deletion of names also has to be done in Mediclaim system available in Sangam - employee’s portal.
Employee should delete the name of dependents for whom they do not want to continue the coverage due to specific reasons. i.e. marriage, employed, beyond 25 years of age, expired etc.
5.How can I get Mediclaim I.Card/E-Card?
E-card is available at employee Login id: <employee number>@tatapower(Example: 123456@tatapoweer)Password : tatapowerB)What should I do in case of Hospitalisation of Myself OR my family members?
6.Basic information
What I should do in the event of hospitalisation?
keep copy of:
i)Company ID Card,
ii)Mediassist Mediclaim E-Card/I-ICard,
iii)a list of nearby GIPSA hospitals where cashless hospitalisation facility can be availed.
iv)Contact details of few close colleagues from work place.
v)Contact details of TPA personnel and Company Insurance contact personnel.
Above basic information be kept at residence and other family members are kept informed on its utility.
Hospitalisation of Self OR Family – care that needs to be taken
When self is hospitalised ensure family members have the details of above basic informations.
C)What is CASH LESS Claim / Reimbursement Claim.? / Limit Under Cash Less claim / List of Hospitals
7.What is Cash Less claim and Reimbursement claim
What is Cash Less claim and Reimbursement claim
Cashless
i)Cashless facility is available only on GIPSA rates agreed hospitals.
ii)for cashless hospitalisation show copy of Mediassist E-Card/I-card to hospital cashless counter to facilitate them to send cashless request to TPA.
iii)in case or any problem contact TPA personnel/Corp Insurance Dept Personnel.
iv) at the time of Cashless Hospitalisation discharge it is essential to take final bill copy from Hospital.
< for more details on cashless procedure click here >
Reimbursement Mediclaim
Admitted in to a Non GIPSA hospital then settle the hospital bills and put up a reimbursement Mediclaim by filling Mediclaim form and attaching relevant original documents to Head - Corp. Insurance, B-Block, Corporate Centre, Carnac,
Care to be taken at the time of Discharge
Verify hospital for its correctness of charges, there should be detailed bills on consumables, medicines charges, diagnostic test etc. Collect original discharge card, all diagnostic test reports in original, original payment receipts for all payments made.
8.Where can I Claim Cash Less Hospitalisation / what is GIPSA Hospitals
Group of Public Sector Insurance Company has fixed certain surgical procedures cost based on hospital grades. These rates are known as GIPSA rates. Hospitals which have accepted these rates are called GIPSA Hospitals. TPC Mediclaim covered employees and dependents can avail cashless hospitalisation in GIPSA Hospitals.
Employee not availing Cashless facility and paid hospitalisation expenses, he has to put up a Reimbursement Mediclaim attaching all original documents for getting reimbursement.
9.GIPSA hospital List
i) GIPSA hospital list is available in our Mediclaim System front page – Cashless facility.
ii) Latest cashless hospital list available at mediassistindia.com
Click here to get GIPSA Hospitallist
10.Cashless initial approval is partial.
In certain cases TPA gives an initial approval which is lesser than the estimated amount requested by the hospital. The remaining amount can get cleared at the time of discharge by sending final hospitalisation bill, discharge card copy and a fresh request form duly filled and signed by the hospital
In case of any problems TPA responsible persons on Tata Power Mediclaim Policy can be contacted on following numbers:
Ms Tejeshree Gujar : 7718813070
Ms Smita Khedekar : 8451050893
D)What expenses are payable under the Scheme / Ailments Excluded / Expenses not payable / Non Mediclaim items disallowed
11.What expenses are payable under the Mediclaim policy?
Expenses Payable:
- Room Charges, RMO charges, Nursing Charges, ICU Charges.
- Surgeon fee, Anaesthetist fee, Consultants fee, Medical Practitioner fee, Specialist fees, Anaesthesia., OT charges
- Medicines & drugs,
- Cost of Implants, Devices like pacemaker
- Relevant Diagnostic tests charges
- Expenses towards pre and post hospitalisation for a period of 30 and 60 days respectively
12.What expenses are not payable exclusions?
Expenses Not Payable:
- Health Check up charges without effective Hospitalisation
- Admission/Registration, Telephone charges, Attendants charges, Special Nurses.
- Non Medical Expenses generally disallowed. < click here view non medical expenses list
- Expenses beyond pre 30 and post 60 days.
- Experimental & unproven treatment.
- Treatment taken outside India.
13. What ailments are excluded under the policy?
General Policy Exclusions:
Circumcision, Vaccination, Inoculation, Cosmetic treatment, Plastic surgery
Spectacles, Contact lenses, Hearing Aids
Dental Treatment Congenital disease, Sterility, Venereal disease, Alcohol use, Self injury.
Vitamins and Tonics not prescribed post hospitalisation & unrelated to treatment
Naturopathy treatment
Treatment for Infertility
Beauty Treatment of any description.
Plastic surgery (other than necessitated due to accident)
Sexually transmitted diseases, any condition directly or indirectly associated with Human T cell lymphotropic virus Type-III or condition of similar kind commonly referred to as AIDS.
14. Additional Coverage & Restrictions to Officers
Maternity coverage / normal delivery procedure Rs 30,000 and caesarean delivery procedure Rs 50,000Room Rent (per day) / Shall not exceed 1% of sum insured subject to maximum of
Rs 5,000 per day.
ICU (per day) / Shall not exceed 2.5% of sum insured subject to maximum of
Rs 10,000 per day.
GIPSA rates / Applicable for cashless as well as reimbursement claims.
Cataract Operation / Limited to Rs 45,000 per eye.
Parents /In-law parents / Employees can include either parents or in-law parents
Click here to view Circular
13.What are Non-Medical items generally disallowed? Can I get a list of it?
Click here to view Non-Medical items generally disallowed
E)Claim Process / Procedure during Discharge at Hospital / Documents to be submitted
14.What is the procedure/requirement for claim submission?
i) / Make an intimation entry in the mediclaim system available at Sangam-employee portal and get the claim number.ii) / Fill up the Mediclaim form and sign it. Mention the claim intimation number
iii) / Attach following original documents:
a) / Duly filled claim form
b) / Discharge card
c) / Detailed Final Hospital bills
d) / Payment receipts
e) / All diagnostic test reports with advice note.
f) / Medicine cash memo with prescription.
g) / X-ray reports and films.
15.What is the time limit for reimbursement claim submission?
For Hospitalisation claim submission, initial claim should be submittedimmediately after the discharge i.e. within 10 days from the date of discharge This will enable speedy recovery of major portion of the claim amount and any query on claim processing can be resolved by getting required documents from hospital without much trouble.
Follow-up claim can be submitted as subsequent claim once follow-up on hospitalised treatment gets over, subject to maximum 60 days post hospitalisation period.
16.Why are original documents required for submitting a claim? How can I get my original reports and x-ray films back?
Original documents are required for Insurance company’s audit compliance.Where the employee wants his original reports for future treatment, kindly submit a letter along with the original & duplicate reports. TPA will verify the same & return the original reports.
17.From where I can get Claim Form
Click here to view ClaimForm
18.What is the cycle time for claim settlement?
15 working days from the date the claim is submitted to Insurance Company, subject to availability of complete documents and information required to settle the claim by TPA.
19.How I get my Mediclaim settlement payment?
Mediclaim settlement payment received from Insurance Company will get credited to employee’s bank account through NEFT from Tata Power. For subsidiaries / JVs NEFT transfer will be done to the concerned Company, who in turn will disburse the amount to its employees.
20.How can I track my claim status / settlement letter?
Login id : employee number@tatapower
Password : tatapower
(here employee can get coverage details, e-card, claim status, settlement details)
21.My claim is in query stage for IR (Information required). What should I do?
Employee has to submit the information/documents required by the TPA.Attach the documents with IR intimation mail received andsend the documents to
The Tata Power Company LimitedCorporate Centre B-Block, 5th floor,
34 Sant Tukaram Road, Carnac Bunder
Mumbai 400 009
Tel. 67171536 Attn: Mr Abdul Razak L Khan
22.My claim status is marked as denied. What should I do if I do not agree with the denial reasons?
Employee has to submit the reason with supporting documents to TPA directly or forward it to Corp. Insurance Dept., Carnac. Mumbai.
23.Certain portion of my claim has been disallowed in my settlement. If I do not agree with the same, how can I claim it?
Employee has to submit the supporting documents for the disallowed portion of the claim along with settlement copy to TPA directly or forward it to Corp. Insurance Dept.,34, Sant Tukaram Road, Carnac Bunder, Mumbai – 400 009
24.Claim vigilance / claim investigation by TPA personnel.
As a part of claim containment measures TPA investigator may visit the hospital to confirm the authenticity of the patient, check theemployee’s entitlement and facility provided by the hospital, ailment and treatment plan, billing pattern matching with agreed GIPSA rates. The TPA investigator may visit patient/relative in this regard. Employees are requested to co-operate with this procedures to enable us to keep a proper control and claim containmentin this regard.
F)Transferred Employees Between Subsidiaries – CGPL / MPL / TPCL
25.I am transferred/shifted to Group Companies in Tata Power with new employee number. What is the procedure followed to avail mediclaim facility?
i) Transfer to from Tata Power to CGPL / CGPL to Tata Power and Transfer to from Tata Power to MPL / MPL to Tata Power with new employee number:
Current coverage continues upto 31st March of the change year. Any claim during the year can be claimed under old employee number. On induction through new employee number employee name will get added in Mediclaim system directly from HR induction process. Employee has to add dependents name for regularising their coverage for renewal.
ii) Transfer from Jojobera to other locations, how Mediclaim coverage get regularised?
(a) If the employee is already covered in Contributory Jojobera Special Coverage for 2.5 lakhs Sum Insured, then he has to intimate Insurance Dept. to change the category of his insurance from JSP coverage to regular coverage as per his grade. Insurance Dept will change the coverage category as per his grade and regularise it. Employee has to verify and confirm his eligible coverage regularised by viewing his coverage data available and accessible to him in Sangam-Employees portal-mediclaim-view/edit family data.
(b) If the employee is not covered under Mediclaim then he has to intimate Insurance Dept. to add his name in Mediclaim System. Insurance Dept will add employee name in Mediclaim System. Employee has to add his dependents in Mediclaim system available in Sangam-Employees portal-Mediclaim-Add Dependents Name.
iii) Transferred to Jojobera
(a) Existing coverage will continue till expiry of the policy period. On renewal name get deleted. Employee can opt for Jojobera Contributory Special Coverage for 2.5 lakhs.
iv) Shifting from Tata Power to Overseas Assignment and employee wants to continue his and family coverage in Tata Powers Group Floater Mediclaim Policy.
Employees are permitted to continue their coverage by paying full premium. These category employees are kept in a separate group and premium will be collected during March month of every renewal