Heritage Health Insurance TPA Pvt. Ltd.

IRDAI license No 008     CIN U85195WB1998PTC088562     An ISO 9001:2015 Company


on revised Group Medi-claim Policies of GIPSA employees

Section A: About the scheme:

Q.A1: What is the name of the scheme?

Ans: Revised Group Mediclaim Policy (for employees & retired employees).

Q.A2: What is period of Policy?

Ans: 1st February 2014 to 31st January 2015, to be renewed on annual basis.

Q.A3: Which insurers this scheme applies to?

Ans: This covers the employees of New India Assurance Co. Ltd., National Insurance Co.Ltd., United India Insurance Co. Ltd. and Oriental Insurance Co. Ltd.

Q.A4: What is Floater basis?

Ans: This policy operates on floater basis, i.e. the applicable Sum Insured floats over the covered family members and full sum insured may be consumed for the treatment of any of the single member or collectively by entire family in a given policy period.

Q.A5: Does this scheme apply to the dependents?

Ans: Yes, as per GIPSA guidelines dependents are covered among spouse, dependent children & dependent parents.

Q.A6: What is the cut-off date for exercising options for employees?

Ans: For existing/serving employees---31st January 2014 For retired employees--- 31st March 2014

Q.A7: Who is the TPA allocated for my Zone?

  • EAST Zone – Heritage Health TPA Pvt. Ltd.
  • WEST Zone – MDIndia TPA
  • SOUTH Zone – Mediasssit TPA
  • NORTH Zone – Raksha TPA

Q.A8: What is the premium payable & option of Sum Insured etc?

Ans: The choice of Sum Insured is 3 Lacs to 20 Lacs. For details on eligible & opted Sum Insured, applicable premium etc. employees may contact their respective office.

Section B: Enrolment & ID Cards:

Q.B1: What is Option Form/Enrolment Form?

Ans: Each employee has to submit an Option Form (Enrolment Form) clearly mentioning the opted sum insured and details of dependents. Photographs of the employee & each dependent should be provided along with the option form.

Q.B2: To whom the option form & photograph be submitted?

Ans: Duly filled in Option form shall be submitted to the nodal officer (designated person) at respective regional office. This may be through respective divisional office/branch office but eventually it should reach the nodal officer at R.O. who will be responsible for collection of enrolment forms & photo for all offices falling under their jurisdiction.

Q.B3: How the Option Form will reach TPA?

Ans: The TPA representatives will co-ordinate with the designated person at respective R.O. for collecting enrolment forms with photo of all serving / retired employees & their dependents at scheduled intervals.

Q.B4: What is ID card and who will issue the same?

Ans: The TPA will issue an Identification (ID) card to each insured for identification purpose. The ID card has a unique number which will be helpful in communication with the TPA and this number should be quoted in all communications with the TPA.

Q.B5: Is photo ID card necessary?

Ans: The ID cards will be mainly useful in availing cashless. As per the instructions of the insurers, “No photo no cashless”, hence, photo ID card is necessary for availing cashless facility.

Q.B6: How will I get my ID card?

Ans: Once all details & photo of the insured is made available to the TPA, the Photo ID card will be sent to the respective office of the insurer.

Q.B7: What documents do I get along with ID cards?

Ans: A Guide Book for the insured containing general information and important tips related to claim procedures, List of Network Hospitals/Nursing Homes throughout India; specimen of Pre-authorization Request Form for cashless hospitalisation purpose.

Section C: Claims:

Q.: What is Cashless claims?

Ans: Cashless Claim service is the service where patient need not to pay any amount either as a deposit at the time of admission or for the admissible treatment cost as per hospital bills subject to policy terms & condition. This facility is available only at network providers. To avail the “Cashless Service” patient need to get an authorization from Heritage for hospitalization in the network.

Q. Can I get Cashless benefit in non Network Hospital?

Ans: The insured should preferably take treatment in Network Hospitals of Heritage. In case treatment is taken at a Hospital which is not in the Network, Heritage will try to arrange for Cashless facility up to 75% of the cost of treatment provided the non-network hospital agrees for such arrangement.

Q.: Is there any time limit for cashless?

Ans: For Planned hospitalisation TPA should be informed at least 3 working days in advance, prior to admission, by completed pre-authorization request as per format annexed in Guide Book. In case of Emergency hospitalisation insured may submit the copy of ID within 24 hours of admission.

Q.: What is Reimbursement claims?

Ans: Claim for which cashless benefit not extended/availed, such claim is referred as “Reimbursement” claim. In other words, expenses incurred by insured for hospitalisation treatment upfront and subsequently request placed for reimbursement.

Q.: What is intimation?

Ans: Intimation is preliminary notice of claim with particulars relating to insured & hospitalisation. It is required to record claim on reimbursement basis. Intimation of claim to Heritage Health TPA can be submitted at- heritage.gipsainfo@bajoria.in Alternatively the same can be submitted at any of our offices.

Q.: Is there any format for submitting intimation?

Ans: The format can be collected from any of our offices. It is also available at our website. It includes following details:
  • Name of insured person in respect of whom claim is to be made,
  • ID Card Number as provided by Heritage,
  • Name of employee & Employee S.R. Number as provided by respective insurer,
  • Nature of illness/injury
  • Name and address of Hospital/Nursing Home
  • Name of treating Doctor
  • Date of admission

Q.: Is there any time limit for intimation?

Ans: Intimation of claims should be made within 48 hours from time of admission or before time of discharge whichever is earlier.

Q.: What is Network Hospital?

Ans: Hospital/Nursing Home having agreement with TPA for providing cashless facility to the insured members of the concerned TPA

Q.: What is non- Network Hospital?

Ans: Any Hospital / Nursing Home not enlisted in the Network of the TPA for providing cashless facility.

Q.: Where do I get list of Network Hospital?

Ans: An updated list of Network Hospitals is available on our website i.e. www.heritagehealthservice.com and/or with our call centre/help line. The list is also available in the Guidebook issued by us along with ID card which is subject to change.

Q.: I want cashless facility for my planned treatment, please, guide me.

Ans: For planned hospitalisation, insured to approach network hospital of his/her choice along with Photo ID card, Doctor’s advice for hospitalization, prescription/consultation, all investigation reports etc. The network hospital would arrange to forward to TPA duly filled in pre-authorization request form seeking cashless authorization of the insured.

Q.: What will I need to do in case of an Emergency admission?

Ans: In case of emergency admission to Network hospital, ID card and other treatment details to be made available to the hospital within 24 hours from the time of emergency admission. Hospital will arrange to forward documents along with completed pre-authorization request form to TPA for cashless authorization. In case of non network hospital, concerned employee must coordinate with the TPA with full details

At Toll Free No. : 1800 102 4547

Help Line No. : 033-40334141

Q.: What documents are required for availing cashless?

Ans: Duly filled in Pre-auth from is required with following documents:
  • Copy of Photo ID card (issued by Heritage),
  • Doctor’s advice for hospitalization,
  • Relevant prescription/consultation,
  • All relevant investigation reports etc
Above documents to be submitted to the Cashless Desk of the network hospital who will arrange for completed pre-authorization request form to be sent to us.

Q.: I have not yet received ID card, what should I do to avail cashless?

Ans: Cashless facility will not be available in the absence of Photo ID card duly issued by the TPA. However, during the transition period, the same can be considered on timely receipt of: - Copy of employee’s identity card bearing employee ID with photo, - Email from concerned nodal officer of the RO indicating employee ID No., Sum Insured etc.

Q.: What documents shall I get on discharge from hospital in cashless case?

Ans: The hospital will submit all original documents directly to TPA for payment in cashless cases. The copy of Discharge Summary with advice of follow up treatment, copy of final bill etc may be collected by the patient party. However, original money receipt against payment by patient party will be made available.

Q.: What is the process of bills settlement of the hospital in cashless?

Ans: The patient must sign the final bill before leaving the hospital. Hospital will submit all original documents to TPA seeking payment against authorization. Payment to Hospital would be directly made by TPA after due verification.

Q.: Can I claim for the expenses incurred during pre-hospitalisation & post-hospitalisation?

Ans: Yes, as per the policy term and condition, the expenses of 30 days prior to & related to the disease for which insured have been hospitalized and 60 days after discharge can be claimed on production of original bills, cash memos, prescription, reports etc.

Q.: What are the documents needed to be submitted for getting reimbursement claim?

Ans: In case of submission of request seeking reimbursement of treatment cost, insured should submit Claim form duly completed showing his/her total monetary claim by enclosing following original documents:
  • Hospital Bill, Receipt and Discharge Certificate /Card
  • Advice for hospitalisation & all prescriptions
  • Cash Memos from Hospitals (s) / Chemists (s), supported by proper Prescriptions
  • Receipt and Investigation reports supported by the note from the treating doctor
  • Certificate, if any, from attending Medical Practitioner / Surgeon that the patient is fully cured.

Q.: Is there any time limit for submission of claim documents?

Ans: For hospitalisation and pre-hospitalization expenses, claim should be made within 30 days from the date of discharge from hospital. For Post hospitalization, claims should be submitted to the TPA within 90 days from the date of discharge from the hospital

Q.: How payment will be made in reimbursement of my expenses?

Ans: Reimbursement claim settlement would be made by directly transferring the amount of settlement to the bank account of the employee through NEFT/RTGS

Q.: Whom do I contact for my queries/question related to claims?

Ans: We have set up a dedicated set up for efficient servicing to this GIPSA – GMC policy with following numbers:

Toll Free No. : 1800 102 4547

Help Line No. : 033-40334141

For further details, you may contact our website www.heritagehealthservice.com

Q. Is there any Time limits for settlement of Hospitalization Claims ?

Ans: Heritage will ensure to comply with the following TATs in respect of Hospitalization Claims, on receipt of all relevant details/documents:-
  • Authorization of Cashless facility - 2 hours
  • Discharge from Hospital - 3 Hours
  • Settlement of Reimbursement Claims - 7 working days

Q.: What is the Grievance Redressal mechanism ?

Ans: In case of any grievance insured may contact TPA at:
  • Email ID for grievance : heritage.complaint@bajoria.in
  • Toll Free No. : 1800 102 4547
  • Help Line No. : 033-40334141
Heritage has also provided a page on our website, where any complaints can be lodged. Finally, disputes arising out of decision of the TPA, if any, would be resolved by constitution of Regional redressal committee constituted at each R.O. of the respective insurers.