Synopsis of Our Mediclaim Policy (2020-21) with particular reference to treatment of Covid-19
Like earlier years our Health Insurance Policy, popularly known as Mediclaim Policy, for the existing /retired employees and their dependents, has been renewed this year too with effect from 01.04.2020 with New India Assurance Company Ltd for one year for a total premium of Rs512,12,00,000/-(including GST).
COVERAGE
A) “NOW THIS POLICY WITNESSES that subject to the terms, conditions, exclusions and definitions contained herein or endorsed or otherwise expressed here on the Company undertakes that if during the period stated in the Schedule or during the continuance of this policy by renewal any Insured Person shall contract any Illness (herein defined) or sustain any Injury (herein defined) and if such Injury shall require any such Insured Person, upon the advice of a duly qualified Medical practitioner (herein defined) or a surgeon to incur Medical Expenses/Surgery at any Hospital / Day Care Center (herein defined) in India as an Inpatient, the Company will pay to the Insured Person the amount of such expenses as good fall under different heads mentioned below, and as are Reasonably and Customarily, and Medically Necessarily incurred thereof by or on behalf of such Insured Person.” (copied from policy Bond for future reference)
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no Description Details of benefit
1 Policy No for WZO and CO Area 12070034200400000001
Policy No for CZO Area 12070034200400000002
Policy No for NZO Area 12070034200400000003
Policy No for NCZO Area 12070034200400000004
Policy No for ECZO Area 12070034200400000005
Policy No for EZO Area 12070034200400000006
Policy No for SCZO Area 12070034200400000007
Policy No for SZO Area 12070034200400000008
2 Name of the Insured LICI, CO. YOGAKSHEMA, Mumbai-400021
3 Name of the Insurer The New India Assurance Company LTD
4 Location of the Insured Persons Anywhere in India
5 Policy period 01.04.2020-31.03.2021
6 Basic floater Sum Insured 5.0L,6.0L,10.0L
7 Optional SA on Floater Basis 6.0,8.0,10.0,12.0,15.0,20.0,25.0,30.0,40.0, and
50.0 LAKHS
8 TPA for WZO & CO
MD India Health care services (TPA) Pvt.Ltd, Web
site:www.mdindiaonline.com, email:customercare@mdindia.com,
Toll free Tel no (dedicated for LIC):18002335588
Toll free Tel nos:18002331166 & 18002334505
Fax No 020-25300003, Tele No 020-25300000
TPA for CZO Health India Insurance TPA Services Pvt Ltd
Web site: www.healthindiatpa.com
Toll free No: 1800 220 102/1800 226 970
E mail id: lic@healthindiatpa.com
For Cash less crm@healthindiatpa.com
Telephone No: Ms Sheela Pednekar 9769274124
Sheela.pednekar@healthindiatpa.com
TPA for NZO Good Health Insurance TPA Ltd
Toll free No(Dedicated for LIC) 1800 103 9919
Toll free No 1800 425 3232
1860 425 3232
Email id :LICcare@ghpltpa.com customercare@ghpltpa.com Telephone No Mr. Ajit Pratap,
Chief General Manager
+919650844011
Email id ajit.pratap@ghltpa.com
Web site: www.ghpltpa.com
TPA for NCZO Raksha TPA Pvt. Ltd.
Web site:www.rakshatpa.com email:jyotiawasthi@rakshatpa.com
Toll free Tel no (dedicated for LIC):18001039533
Toll free Tel no: 18001801444
Tel no.0129-4289999, FAX: Cashless 08881673411,
011-66173411,011-45823411
TPA for EZO Heritage Heallth TPA Pvt.Ltd.
Web site: www.heritagehealthservice.com email: lic.heritagehealth@bajoria.in
Toll free Tel no (dedicated for LIC): 18001024547
Toll free Tel no: 18003453477
Tel no:033-40334141, Fax:033-22100837
TPA for ECZO VIPUL MEDCORP INSURANCE TPA PVT LTD
Web Site: www.vipulmedcorp.com
Email id: rajeevagarwal@vipulmedcorp.com
patna@vipulmedcorp.com bihar@vipulmedcorp.com abusalim@vipulmedcorp.com arup@vipulmedcorp.com deepika@vipulmedcorp.com
Toll free No: 1800 108 7477
1800 102 7477
Telephone No: Mr Rajeev Agarwal, Branch Head
Mobile No: 9931107825
TPA for SCZO Medi Assist India TPA Pvt.Ltd.
Web site: www.mediassistindia.net-Click email: lic@mediassistindia.com; Fax:18004259559
Toll free Tel no (dedicated for LIC): 18004191154
Toll free Tel nos:18004259449,18004191160
TPA for SZO Vidal Health TPA Pvt.Ltd.
Web site: www.vidalhealthtpa.com email: lic@vidalhealthtpa.com
Toll free no/ Kerala (dedicated for LIC): 18004256268
Toll free no/ Tamilnadu (dedicated for
LIC):18004257595
Toll free no- Central (dedicated for
LIC):18004258565
Tel No: Kerala 044-28159930,
Tamil Nadu:0484-2357133
Fax No Kerala 1800-425-6262; Tamil Nadu 1800425-0112
9. List of Hospitals covered under network of TPA Available on respective TPA’s website and LIC’s intranet.
10 Procedure for availing CASHLESS facility i) Cashless hospitalization can be available only at TPA’s network of hospitals.
ii) Pre admission authorization to the Hospital/NH by TPA is essential.
iii) In case of change of residence outside Zone original TPA will provide services based on PAN India’s network hospital.
iv)
In case CASHLESS decision is declined by TPA for any reason, their decision is final.Claim for reimbursement can be made as per rules.
However, in case of treatment of covid-19 there is a instruction from IRDAI for consideration of cashless treatment vide circular
IRDAI/HLT/MISC/CIR/189/07/2020
dated 14.07.2020 to the policyholders( Copy enclosed)
11 Documents required i) E-Card of patient issued by TPA & any photo identity card such as employee ID Card, PAN, Driving License, Voter ID, Passport, Aadhar Card, School/College ID Card or any other photo ID Card by State/Central Government.
ii) In absence of TPA ID Card Certificate by respective OS Deptt will do.
12 Room Rent / Boarding Expenses limit 1.5% of total SI (Basic+ Additional) per day subject to maximum Rs7, 500/- for A Class cities; Rs 6,000/- for B Class cities; Rs4, 000/- for C class cities. (Reimbursement will be reduced proportionately in case limit exceeds). In case of Floater SA 40.L & 50.L max. Room rent is allowed
10,000/- for A class cities. However in case of
ICU/CCU there is no capping/ ceiling on ICU/ICCU Expenses. Registration / Admission charges and Service Tax / surcharges are payable.
13 Expenses relating to Diagnostics Tests without hospitalizations.
Restrictive conditions:-
1) The Maximum limit 75,000/- for the family during the Policy Year
2) MD or EQUIVALENT Doctor must advice for the same
3) In case of prescription by Govt Hospital, the above condition can be waived.
4) Allowed for only once per insured in a policy year
5) Reimbursement is restricted for the mentioned tests only. No equivalent test will be considered.
Diagnostics Tests Maximum amt payable
MRI Charges Rs8000/- each insured
CT Scan Charges Rs6000/- each insured
Sonogram Rs2000/- each insured
Biopsy Rs4000/- each insured
Tread Mill Test Rs2000/- each insured
Echo Rs2000/- each insured
Gastroscopy Rs5000/- each insured
Colonoscopy Rs7000/- each insured
EEG Rs1000/- each insured
EMG Rs2000/- each insured
Holter Monitor Rs5000/- each insured
PAP SMEAR Rs750/- each insured
PSA(Prostate Specific Rs750/- each insured Antigen)
Mammography Rs5000/- each insured
PET Scan Rs20000/- each insured.
14 ORGAN TRANSPLANT Hospitalization expenses (excluding the cost of the organ) during the course of organ transplant to the insured person. Expenses on donor and the recipient shall be limited to the insured sum.
15 LASIK LASER TREATMENT Maximum amount payable
Rs.35000/- per eye.
16. Robotic Surgery For Malignant cancer/ cancer, Brain, and Spine only are payable.
17 MATERNITY BENEFIT Maximum 65000/- for Normal
Delivery
Maximum 125000/- for Caesarean section Delivery
Lawful Medical Termination of pregnancy included.
New born child is covered from day one within the family floater limit if the child is declared for insurance and the premium in respect of the child is received by LIC.
18 Limitation of 24Hrs. hospitalization. Not applicable for certain surgeries, procedures and eye surgeries. (189 such surgeries/operations have been given in page 45-51 of the original Policy Bond) Annexure- III
19 Pre and post hospitalization expenses. 30 days and 60 days respectively. The above limitations may be waived in cases of renal failure and/or organ transplantation.
Cost of Physiotherapy, as a part of Pre and Post hospitalization period will be reimbursed up to Rs.40000/- per person per year, if it is taken at a physiotherapy clinic or at specialized
physiotherapy treatment centre. Other conditions are also applicable. Please see page no 22 , F(xxiv) under head Exclusions, of Policy Bond for details.
20 Surgeon/Anesthetists Payment Restricted to 25% of SI. Payment must be paid by cheque and numbered bill (not receipt on letter head) is required. However fees paid by cash may be reimbursed up to following limit provided numbered bill is obtained.
Surgeon Rs 30,000/-
Assistant Surgeon Rs12,000/- Anesthetists Rs20,000/-
21 Limit for payment on cataract Rs60, 000/- for each eye (all inclusive) or actual cost, whichever is less.
22 Ambulance charges Limited to maximum Rs5, 000/- per trip per hospitalization. However, in case of Cardiac Cases, if cardiac equipped Ambulance is required the amount may be allowed up to Rs10, 000/- while going to hospital only.
23. Dental treatment Not allowed, except arising out of accident.
24 Dependent children Insurance cover is restricted to in-service, Retired employee, spouse, dependent parents/parents-inlaws of in service employees/Retired employees, dependent male children up to 25 years of age, dependent female children ( unmarried, widow and divorcee), residing with the insured parents and having income less than Rs10,530/- per month. Independent female children residing with the Retired employee can continue to be covered till marriage. However after the marriage of unmarried female children or remarriage of widowed/divorced female children, the cover shall remain valid for 3 months or policy expiry date whichever is earlier.
Please see C.O Circular CO/PER/ER-A/164/2017 dated 23.09.2017 for further clarification.
25 Submission of claim Must be submitted within 20days from discharge of the Hospital.
26 Settlement of claim The Insurer must settle the claim, including rejection within 30 days from receipt of the last document. Once claim is settled by TPA fund will be transferred to LICI within seven working days.
27 Claim intimation forms Claim form, Doctor/consultant’s prescription, Discharge Summary/Discharge card, Bills cash memo and money receipts, pathological test reports, Surgeon’s certificate, attending Doctor’s bill and receipt and claimant’ s details
28 Exclusions: A) Cost of Non-medical items during hospitalization.
B) Cosmetic or aesthetic surgery.
C) Treatment taken outside India
Treatment of Covid-19 patient:-
Reproduced, here in below, two circulars issued by IRDAI, which shows Covid-19 positive patients are covered under Health Insurance policy and also cashless facility is to be provided to them. Circulars are self explanatory.
If we consider, the condition mentioned under head COVERAGE at the beginning at A, IRDAI circular dated 04.03.2020 and 14.07.2020 there is no doubt that claims under Corona Virus are covered under our Group Medical Policy. Regarding settlement of claim, matter may be taken up with concerned TPA, Insurer i.e The New India Assurance Company Ltd and also with Life Insurance Corporation of India for further clarification. Since several hospitals have come out with corona virus treatment package, either from home or through Hospital admission, it is suggested to obtain clarification from TPA or Insurer regarding their acceptability on case to case basis.
By this time most members are aware of precautionary measures to be taken to prevent infection through corona virus. Hence repetition of the same is avoided here. It is always suggested to visit website of Government, World Health Organization and to act as per advice of Doctors to fight Corona Virus.
Let us hope that, this pandemic be over at the earliest and we can lead happy, healthy and peaceful life.
NB. In case of any doubt/dispute, please refer the original Policy Bond and related circular for clarification
Enclo:1) IRDAI Circular dated 04.03.2020 Compiled by Partha Chatterjee
2) IRDAI Circular dated 14.07.2020 pchatterjee52@gmail.com
Mobile No:-9068634932
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