Group Mediclaim Policy for the Financial Year 2015 – 16

 

Policy No: 12070034150400000008

 

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The cashless facility has been introduced for the year 2015 – 16 through TPA M/s  Vidal Health TPA Pvt. Ltd.

 

The contact numbers of TPA are:

 

Particulars	Tamilnadu	Kerala
Toll Free No	1800-425-7595	1800-425-6268
Toll Free No (Both Kerala and Tamilnadu)	1800-425-8565
Call Centre	044 – 28159930	0484 - 2357133
Co-ordinator (Both Kerala and Tamilnadu)	Sri Murugan – 8939891109
Website	www.vidalhealthtpa.com

 

​Division-wise co-ordinators:

 

Division	Name	Mobile
Chennai Region	K Sivaganesh	8939821205
Vellore and Puducherry	K  Manikandan	8939821206
Coimbatore and Salem	Saravana Kumar.S	8939821207
Thanjavur	Gomar Canaz R	8939821209
Madurai and Tirunelveli	T G Sivanath	8939821208
Trivandrum	Prasanth	09847985444
Ernakulum	Jagadish	09895700851
Kottayam	Gincemon	09947865544
Kozhikode	Abilash	09847264488
Thrissur	Abilash/Gincemon	09847264488/09947865544

 

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Procedure for availing Cashless:

 

Cashless facility can be availed only at TPA network of hospitals.

 

The employee / retired employee should produce the E-cardof the patient issued by TPA along with some photo ID card (LIC ID, PAN, DL, Passport, Aadhar, School ID, and College ID)

 

In case E-card of the TPA is not available, cashless request will be processed based on the letter issued by the OS department.

 

Cashless is subject to pre-admission authorization. The TPA will verify if the person is eligible to claim under the policy and give the pre-authorization

 

Updated list of network hospitals and the claim forms are available in the above mentioned website of TPA. The network hospitals have Preauthorisation request form and the same has to be filled in by the employee/retiree/beneficiary claimant and the treating doctor.  All details have to be filled in completely to ensure speedy processing of CASHLESS Request.  This form has to be faxed / mailed to TPA and the TPA will process the cashless request.  The medical team at TPA will determine whether the condition requiring admission and the treatment plan are covered by the Group Mediclaim Policy.

 

The hospital will ask the claimant to pay for all the Non-medical expenses in the bill. This payment will have to be made before discharge and the same can be claimed as reimbursement.

 

In case pre-authorization for cashless is not approved, a letter denying cashless will be sent to the hospital and the claimant will have to settle the full bill and claim for reimbursement.

 

Cashless facility is only a mode of claim payment and cannot be demanded in every claim. If TPA has doubts regarding admissibility of claim at the initial stage, which cannot be decided without further verification of treatment records, request for Cashless may be declined. Such decision by TPA regarding cashless shall be final.

 

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Diagnostic Tests reimbursable without hospitalization:

 

Diagnostic Tests	Maximum Charges Payable
MRI Charges	8000/- each insured
CT Scan Charges	5000/- each insured
Sonography Charges (Excluding Maternity Related)	2000/- each insured
Biopsy	3000/- each insured
Tread Mill Test	1200/- each insured
Echo Test	1500/- each insured
Gastroscopy	4000/- each insured
Colonoscopy	6000/- each insured
EEG (Electroencephalogram)	1000/- each insured
EMG (Electromyogram)	2000/- each insured
Holter Monitor Test	5000/- each insured
PAPSMEAR	750/- each insured
PSA (Prostrate Specific Antigen)	750/- each insured
Mammography	5000/- each insured

 

The amount reimbursable under this benefit shall be Rs.65,000/- for the family during the policy year. For claiming reimbursement under this, the test should be recommended by a MD doctor or a doctor with equivalent qualification.

 

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Cataract Surgery: Claim relating to Cataract is limited to actuals OR maximum of 60,000/- for each eye, whichever is less.

 

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Ayush: Expenses incurred for Ayurvedic / Homeopathic / Unani Treatment are admissible provided the treatment is taken in a Government Hospital or in any institute recognized by the Government and / or accredited by Quality Council of India / National Accreditation Board.

 

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Ambulance Charges: Actual subject to maximum of 5000/- in case patient has to be shifted from residence to hospital or from one hospital to another hospital by fully equipped ambulance for better medical facilities. Ambulance charges from hospital to residence are also covered.

 

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Organ Transplant: Hospitalization expenses (excluding cost of organ) incurred on the donor during the course of organ transplant to the insured person. The liability towards expenses incurred on the donor and the recipient shall not exceed the sum insured of the insured person receiving the organ.

 

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Lasik Treatment: Lasik Laser treatment performed to get rid of spectacles or contact lenses is not covered unless the treatment is for Keratomy of Insured having more than (-4) refractive error and for therapeutic reasons like recurrent corneal erosions, nebular opacities and non-healing ulcers. The maximum amount payable under this section is 35,000/- per eye.

 

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Maternity Expenses: The maximum benefit allowable will be 65,000/- for normal delivery and 1,25,000/- for CaesarianSection Delivery. A waiting period of nine months is not necessary for payment of claim.  Pre-natal / Post-natal expenses are not covered for maternity related claims.

 

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General:

 

Room rent/Boarding Expenses as provided by the hospital including Nursing Charges, is restricted to 1.5 % of Sum Insured( Basic + Additional) per day, subject to a maximum of Rs 7,500/- per day ( for class A Cities), Rs. 5000/- per day (for class B Cities) and Rs.4000/- per day (for Class C cities).  

 

If the room rent exceeds the  aforesaid limits, the reimbursement/payment of all other expenses incurred at the hospital, with the exception of cost of medicines, drugs and implants shall be effected as per eligible room category(reduced proportionately) in the hospital.

 

Bills raised by Surgeons, Anesthetist directly and not included in the hospital bill may be reimbursed in the following manner:

 

(a)

The reasonable fee would be reimbursed limited to 25 % of Total Sum Insured. The payment shall be made provided the insured pays such fees by cheque only and the Surgeon / Anesthetist gives a numbered receipt. Bills given in letter head are not entertained.

 

(b)

Fees paid in cash will be reimbursed to the following limit provided the Doctor provides a numbered receipt:

 

(a)

Surgeon​​:​30,000/-

(b)

Assistant Surgeon​:​12,000/-

(c)

Anesthetist​:​20,000/-

 

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The Claim papers in case of reimbursement of mediclaim must be accompanied by the following:

 

(a)

Claim Form mentioning the SR No (claim form can alsobe downloaded from the websitewww.vidalhealthtpa.com)

(b)

Doctor / Consultation Prescriptions (original )

(c)

Discharge Summary / Discharge Card (original)

(d)

Bills / Cash Memo & Money Receipts (original)

(e)

Diagnostic Test / Pathological Test Reports (original or verified Xerox copies by Class I Officer of LIC)

(f)

Surgeon's certificate stating nature of operation performed and surgeon's bill and receipt

(g)

Attending Doctor's / Consultant's / Specialist's / Anesthetist's Bill and receipt and certificate regarding diagnosis

(h)

Contact number, e-mail id and Correspondence address of the Claimant

 

Source: LIC Group Mediclaim Policy issued by New India for the year 2015 – 16

 

Process for E-card generation & View Enrolment/preauth/claims status

 

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Login to www.vidalhealthtpa.com

 

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Click on Login à Employee Login

 

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Group ID: Group ID is L0291 for Tamilnadu Divisions and L0292 for Kerala Divisions (L followed by zero two nine one / zero two nine two)

 

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Policy Number: Policy number can be selected from the drop down option (Policy number is 120700/34/15/04/00000008 for Compulsory Floater Sum Assured and 120700/34/15/04/00000008 /TOP-UP for top-up sum assured)

 

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User id and Password: SR No is the user id and the first time password is also the SR No. The user will be prompted to change the password immediately. After the password is changed successfully, the user will have to re-login with the new password.

 

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E-card and family details: After logging in the user can generate e-card from the site. The enrolment tab will furnish the details of family members covered under the policy.

 

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Pre-authorisation and Claim Status: If the user has opted for cashless facility the status of the pre-authorisation can be viewed. Similarly the status of the claims submitted by any of the members can also be viewed.

 

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Network Hospitals: The user can confirm if any hospital in any city is covered under the TPA network (for cashlessfacility) thru the option Network Providers à Vidal Health TPA Network