Heritage Health Insurance TPA Pvt. Ltd.

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


Group Mediclaim Insurance Policy Life Insurance Corporation of India (for employees)(Eastern Region)

Section A: About the scheme:

Q.A1: What is the scheme?

Ans: Tailor Made Floater Group Mediclaim Policy for employees & retired employees of Life Insurance Corporation of India including their dependents.

Q.A2: What is period of Policy?

Ans: 1st April, 2015 to 31st March, 2016, to be renewed on annual basis.

Q.A3: Who are the persons deemed to be covered in this scheme?

Ans: This covers the employees / Retired employees of Life Insurance Corporation of India, residing anywhere in India.

Q.A4: Does this scheme apply to the dependents?

Ans: Yes, as per guidelines issued by LICI - dependents are covered among spouse, dependent children & dependent parents/in-laws, once the premium is received by LICI.

Q.A5: 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.A6: Who is the TPA allocated for my Zone?

  • · EAST Zone – Heritage Health Insurance TPA Pvt. Ltd.
  • · EAST Central Zone – Heritage Health Insurance TPA Pvt. Ltd.

Q.A7: What is the premium payable & option of Sum Insured?

Ans: The choice of Sum Insured (Floater) is
  • a) 3 Lacs
  • b) 4 Lacs
  • c) 6 Lacs
Also, option is available for Additional Sum Insured (i.e. Top up). For details on eligible & opted Sum Insured, applicable premium etc. employees may contact their respective office.

Q.A8: What is the scope of coverage under this Policy?

Ans: During the currency of the policy If any insured person shall contract any illness or sustain any injury, and insured is required to be hospitalized at any Hospital / Day Care Centre upon the advice of a Medical Practitioner for treatment / surgery, then this policy will pay to the insured the reasonable and necessary expenses incurred by the insured under different head i.e. Room, boarding, Nursing, Doctor/Surgeon Fees, Medicines, Blood, Oxygen, Operation Theatre etc. as defined in the policy up to the limit mentioned therein.

Q.A9: Is there any restrictions in Room Rent?

Ans: Yes, Room, Boarding Expenses as provided by the hospital including Nursing Charges not exceeding 1.5% of Sum Insured, per day, subject to maximum amount of:
  • (1) Rs.7500/-per day (for Class A Cities)
  • (2) Rs.5000/- per day (for Class B Cities)
  • (3) Rs.4000/-per day (for other Cities)
[Classification of Cities as per list available with LICI]

Q.A10: Any Restrictions for Intensive Care Unit (ICU) and Intensive Cardiac Care Unit (ICCU)?

Ans: Admission in ICU/ICCU will be on actual basis.

Q.A11: What if I opt for higher room rent over my per day eligibility?

Ans: In case of admission to a Room exceeding the per day eligibility limit, the reimbursement/payment of all other expenses incurred at the Hospital, with the exception of cost of medicines and implants, shall be effected in the same proportion as the admissible rate per day bears to the actual rate per day for Room Rent (including but not limited to boarding and nursing expenses).

Q.A12: Any restrictions for Surgeon, Anaesthtist Fees?

Ans: In case above charges are included in hospital Bill then policy will pay reasonable and customary charges as per limit of the Policy. But, no amount under above head would be paid/reimbursed, other than part of the hospital Bill. However,
  • 2 (a) In case of Cheque payment – Maximum 25% of SI, provided the Surgeon / Anaesthetist provides the numbered Bill. Bill given on letter-head of the Surgeon, Anaesthetist will not be entertained.
  • 2 (b) Fees paid in cash will be reimbursed up to a limit of Rs.10,000/- only, provided the Surgeon/Anaesthetist provides a numbered bill.

Q.A13: Apart from above whether other charges may be available in full?

Ans: Expenses apart from Room rent and Doctor fees is payable as per limit of Sum Insured after deductions for non medical items, expenses which are specifically excluded in the policy, subject to reasonably, customarily incurred.

Q.A14: Any Add on Cover available under the scheme?

Ans: Yes. Add on Covers:
  • 1. Maternity Expenses Benefit
  • 2. New Born Child at Birth is covered under Mother’s Sum Insured.
  • 3. Children are covered for additional sum insured once the premium is received by LIC
  • 4. All pre existing diseases are covered as per clause
  • 5. Payment for Diagnostic Test without hospitalisation as per clause
  • 6. Payment of Ambulance charges – 1.0% of the sum insured or actual, whichever is less, subject to maximum of Rs.2500/- in case patient has to be shifted from residence to hospital for admission in
Emergency Ward or ICU or from one hospital to another hospital by fully equipped ambulance for better medical facilities.

Q.A15: Is there any scope for receiving medical expenses incurred for Diagnostic Purpose without hospitalization under this Policy?

Ans: Yes, Following expenses relating to Diagnostic Tests without hospitalization would be reimbursed subject to terms and conditions of the policy:
  • · MRI – 8000/
  • · CT SCAN – 5000/
  • · SONOGRAPHY (Excluding Maternity) – 2000/ [Each insured]
  • · BIOPSY (Internal ) – 2000/ [Each insured]
  • · BIOPSY (External) – 750/ [Each insured]
  • · TREAD MILL TEST – 200/ [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]
Reimbursement of expenses is allowed only for the above tests and no equivalent diagnostic test will be considered for this purpose. The Amount reimbursable under this benefit shall be maximum Rs.33,450/- per insured subject to Rs.66,900/- for the family, during the policy year. The above amounts shall be within the overall sum Insured limit. For Claiming reimbursement under this, the tests should be recommended by an MD Doctor or A DOCTOR with EQUIVALENT QUALIFICATION and supported by documents and certification evidencing present complaints necessitating the tests to be carried out. Only expenses for the Diagnostic tests are payable. Pre post expenses are not payable. Any hospitalization expenses relating to the tests without active treatment in the hospital are also not payable.

Q.A16: Whether Policy will cover AYUSH treatment?

Ans: Expenses for Ayurvedic/Homeopathic/Unani are admissible, if treatment is taken as in-patient in Govt. Hospital or any Institute recognized by Govt. subject to terms and conditions of the policy and not exceeding 25% of Sum Insured.

Q.A17: Whether Policy will cover expenses during Pre-hospitalisation and Post-hospitalisation?

Ans: Yes, Pre-Hospitalisation : up to 30 days prior to Date of Admission and, Post-Hospitalisation: up to 60 days from Date of Discharge.

Section B: Enrolment & ID Cards:

Q.B1: What is ID card (TPA Health Card) and who will issue the same?

Ans: The TPA will issue an Identification (ID) card (i.e. TPA Health 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.B2: Is photo ID card necessary for availing Cashless facility?

Ans: The ID cards issued by TPA (TPA Health Card) will be mainly useful in availing cashless. This will be issued without photograph. For availing cashless facility, this TPA card should be accompanied by a photo ID card issued by appropriate authority, including the Photo Identity Card issued by LICI or any other Photo ID Cards such as PAN, Driving License, Voter ID Card, Passport, Adhar Card etc. issued by central or state govt.

Q.B3: How will I get my ID card?

Ans: Once all details of the insured are made available to the TPA, the ID card will be issued and facility of e-card will be available on the TPA website which can be downloaded by the employee. The same will also be available on LIC Portal and NIA website. Also, a Guide Book for the insured containing general information and important tips related to claim procedures, List of Network Hospitals/Nursing Homes, specimen of Pre-authorization Request Form for cashless hospitalisation purpose and FAQs will available on the TPA/LIC/NIA websites.

Section C: Claims:

Q.C1: 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.C2: Can I get Cashless benefit in non Network Hospital?

Ans: Cashless will be provided only in Network Hospitals.

Q.C3: 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 and in case of Emergency hospitalisation, within 24 hours of admission.

Q.C4: 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 of expenses.

Q.C5: What is intimation?

Ans: Intimation is preliminary notice of claim with particulars relating to policy number, name of insured person in respect of whom claim is to be made, his / her ID Card Number &/or Employee S.r. Number; nature of illness/injury and name and address of attending medical practitioner/Hospital/Nursing Home to the TPA. It is required to record claim on reimbursement basis. Intimation of claim to Heritage Health TPA can be submitted to following Email ID:

Q.C6: Is there any time limit for intimation?

Ans: Intimation of claims should be made within 7 days from time of admission or before time of discharge whichever is earlier.

Q.C7: 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.C8: What is non- Network Hospital?

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

Q.C9: Where do I get list of Network Hospital?

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

Q.C10: 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 TPA e-card, Photo ID card, Doctor’s advice for hospitalization, prescription/consultation, all investigation reports etc. preferably 3 days in advance from the planned date of admission. The network hospital would arrange to forward to TPA duly filled in pre-authorization request form seeking cashless authorization of the insured.

Q.C11: 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, the intimation should be given to the TPA.

Q.C12: What documents are required for availing cashless?

Ans: TPA ID (Health) card accompanied by Photo ID card (as above) Doctor’s advice for hospitalization, Prescription/consultation, All investigation reports etc to be submitted to the Cashless (Insurance/TPA) Desk of the network hospital who will arrange for completed pre-authorization request form.

Q.C13: 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 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 LICI (OS Dept), indicating employee ID No., Sum Insured etc.

Q.C14: 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.C15: 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.C16: Whether non-medical expenses are payable?

Ans: The hospital will ask claimant to pay for all the Non-Medical Expenses in the bill. The claimant has to make this payment before discharge.

Q.C17: When can a request for Cash less be denied?

Ans: Cash less may be denied if found non-payable as per the Policy Terms, conditions & exclusions. Further, It is worth noting that Cash Less facility is extended either, before or during the course of treatment. Decision for claim payment is made on the basis of only few available documents. Given the nature of a particular case, the Cash Less may also be rejected in the absence of relevant information required for arriving at clear decision. Also, the cash less request may be rejected in doubtful cases. Please, note that the denial of Cash Less access does not mean denial of treatment and does not in any way prevent the patient from seeking necessary medical attention or hospitalization. It also does not prevent the patient to submit his claim for Reimbursement. The insured person may obtain the treatment as per his/her treating doctors advice and later on submit the full claim papers to the policy servicing office for reimbursement.

Q.C18: 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.C19: What is the process of getting reimbursement claim?

Ans: In case of submission of request seeking reimbursement of treatment cost, insured should submit following documents in original: Claim form duly completed showing his/her total monetary claim by enclosing original prescription, bill/receipt and Discharge Certificate /Card from the Hospital Cash Memos from Hospitals (s) / Chemists (s), supported by proper Prescriptions Receipt and Pathological Test reports from Pathologist supported by the note from the attending Medical Practitioner/Surgeon recommending such Pathological Test related to hospitalization treatment. Certificate, if any, from attending Medical Practitioner / Surgeon that the patient is fully cured.

Q.C20: Is there any time limit for submission of claim documents?

Ans: For hospitalisation and pre-hospitalization expenses, claim should be made within 20 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.C21: What is Claim Form and where can I get it?

Ans: Claim Form is a prescribed form, which is required to be submitted when Claim is lodged for Reimbursement payment. It is designed to elicit all the relevant information about the hospitalisation. It is a compulsory document and should be placed on the top of claim documents. A Claim Form can be downloaded from our Website.

Q.C22: 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 LICI through NEFT/RTGS. The employee will get the claim amount form LICI.

Q.C23: Whom do I contact for my queries/question related to claims?

Ans: To the office of TPA at their Dedicated set up –
  • Toll Free No.  : – 1800 102 4547
  • Help Line No. : – 033-40334141

Q.C24: Is there any Time limits for settlement of Hospitalization Claims?

Ans: The TPAs are required to comply with the following TATs in respect of Hospitalization Claims :-
  • · Authorization of Cashless facility – within 2 working hours from receipt of complete documents
  • · Settlement of Reimbursement Claims –wWithin 7 working days from receipt of complete documents

Q.C25: Is there any Grievance Redressal mechanism?

Ans: In case of any grievance, the employee may contact TPA at - Finally, disputes arising out of decision TPA, if any, would be resolved by constitution of Regional redressal committee constituted at each Zone, as per administrative guideline issued.