GROUP MEDICLAIM INSURANCE POLICY
Our Insurance Provider for this year is The United India Insurance company Ltd., our TPA is
FHPL Pvt. Ltd and our Insurance Broker is Pioneer Insurance & Reinsurance Brokers Pvt Ltd.
Our broker will assist you in understanding the benefits of the Insurance Policies, addition of
Family Members, Query Handling, Claim Settlement, Distribution of Cashless Cards, and any
other issues that you might have.
As part of the Hospitalization Insurance benefit, you and your dependants whose names have
been declared, are eligible for Medical Insurance cover. The major features of the Policy
Benefits are as under:
Family Floater Policy (1+5)
Family Members Eligible for coverage - Employee + Spouse + 2 Dependent Children + 2
Parents (up to a maximum of 5 members)
o Note: Only those dependents whose names have been declared are covered
under the Policy.
Sum Insured- Based on your eligibility.
Hospitalization – Minimum 24 hrs.
Pre and Post hospitalization for 30 & 60 days respectively.
Pre Existing Disease Covered.
Waiver of time exclusion for diseases (30 days / 1 year/2 year/4 year)
Maternity Expenses Covered. Sub Limit of Rs. 25,000 for Normal and Rs. 35,000 for
Caesarean Delivery.
9 months waiting period for maternity is applicable only for new joinees
Baby Cover from Day One (New born baby has to be enrolled in the policy within 90
days from date of birth)
20% Co-Pay applicable only for Parents.
Room Rent is capped at Rs.2000/-for S.I Rs.75,000,Rs.1 Lakhs & Rs.1.5 Lakhs &
Rs.4000/-for S.I &2.5 LAC,3 LAC,4 LAC,6LAC (For ICU - No Capping)
Cashless Facility available.
The above coverages are subject to the overall policy conditions and exclusions. A power point
presentation is also attached to enable you to understand the salient features of this policy.
Mediclaim cards are issued to each employee and his/her named dependant. This ID card will
enable admission into network hospitals and will provide access to credit (cashless) facilities at
those Hospitals around the country. Please note that ID card is non-transferable.
We have endeavored to make our Insurance Program quite comprehensive and offer flexibility
to you, so that you may make the most of it.
While we cannot control most of the elements, we can definitely control the costs by being
vigilant about the charges and services being applied by Hospitals. For example - We can make
effort to take up reasonable facilities and spend more on the actual aspects of treatment rather
than on higher category of room rents. We can also be careful about the unnecessary packages
pushed by the health care providers. Such responsible health care claims will help the program
remain under manageable proportions.
S.No Process for availing Cashless Hospitalisation Facility
1 Cashless facility can be availed only in hospitals that are in the TPA's Network. (Refer Network Hospital List)
Produce the ID Card issued by the TPA at the Insurance / Hospital Help Desk – along with any other ID Proof
2 (compulsory) like DL/ Voter’s ID/ Passport etc in respect of THE PATIENT.
Obtain the Pre-authorisation Form from the Hospital Help Desk, complete the Patient Information and resubmit to the
3 Hospital Help Desk.
4 Please indicate the Mediclaim ID Card's Number without fail. Please also furnish the Employee Number.
Please intimate our claims Coordinator Ms.Mohansundari @ +91 9710925153 after submitting the form to the
5 Insurance desk at the hospital for us to coordinate with the Hospital & TPA to arrange the cashless approval at the
earliest.
On submission, The Treating Doctor at the hospital will complete the hospitalisation/ treatment information and the
6 hospital will fill up expected cost of treatment and the form would be sent to the TPA through mail or Fax.
TPA will process the request and approve the cashless according to the terms of the policy if all the documents are
7 adequate or call for additional documents/ clarifications if the information furnished is inadequate.
Process for Claims Reimbursement
Applicable when the Patient gets admitted in a Non Network hospital or getting admitted in Emergency when Hospitalization is not
planned.
The following Documents need to submit within 10 days from the Date of Discharge for us to go through the same and check if
they are in order or call for the additional required documents and then submit it to the TPA for reimbursement process.
S.No Documents to be submitted for Reimbursement
1 Original Claim form duly filled and signed by the employee.
2 Original medical certificate duly filled and signed by the treating consultant / Surgeon
Original detailed Discharge summary from the hospital including Hospital Registration number and
3
No of beds (should be in hospital's letter head with seal and sign)
All Bills including Hospital bills (with detailed break up), Prescriptions, Pharmacy bills, Payment
4 receipts, Laboratory Bills, Scans, X-ray and all Reports to be submitted in Originals duly attested by
the hospital.
Pioneer would coordinate with the TPA for the reimbursement cheque to be dispatched at the
5
earliest.
In the event that you have any queries or face any difficulty, please contact the Pioneer Brokers
representatives given below
Contact Details
Contact Point Of Vantage
Contact
Location Contact Person Mobile No Mail Id
Level
First
Ms.Mohanasundari 09710925153 mohana.sundari@pincinsure.com
Level
Chennai
Second
Mr.Santhosh 09944068990 santhosh.g@pincinsure.com
Level
