CIRCULAR
Members will be aware that the Central Office had recently introduced some changes/improvements in the Group Mediclaim Scheme. Since some members have sought the details, we furnish below the salient features of the relevant Central Office circular.
- Cashless facility has been extended for specified treatment/surgeries as follows:- Cancer, Renal Failure & Accident Trauma Cases (Treatment/Medical management/Surgery) and Cardiac disease & Neuro Ailments (surgery).
- Waiting period of one year in case of claim settlement for optionally increased sum assured to take care of a particular disease or for a planned surgery has been removed.
- Treatment for fracture/dislocation (excluding hairline fracture). Coronary Angiography/Angioplasty requiring hospitalization less than 24 hours has been allowed under Hospitalization Benefit.
- Unemployed children age upto 25 years, whether he/she is pursuing whole time studies in recognized educational instituion or not, will be considered as dependent children.
- Present limit of refractive error (-7) has been reduced to (-2) for providing mediclaim cover for Lasik Laser treatment to get rid of spectacles and/or contact lenses.
- Waiting period of nine months for the reimbursement of Maternity Expenses has been removed.
- In case of Caesarian Section Delivery, limit for the reimbursement of maternity expenses has been increased from present limit of Rs.50,000/- to 1,00,000.
- Expenses in respect of new born child, during the delivery confinement period in the hospitalization has been allowed to be reimbursed upto the mother's sum assured instead of present limit of Rs.50,000/-.
- The amount reimbursable against expenses relating to Diagnostic Tests without hospitalization has been increased from Rs.15,000/- to Rs.20,450/- per insured.
- Grievances redressal cell or Appeal mechanism, has been specifically built for insured who feels that the claim is wrongly repudiated by the insurer's claim servicing office. To read more, please click below.
Procedure for availing Cashless Access Service
Claims in respect of Cashless Access Services will be through the agreed list of network of Hospital/Nursing Home and is subject to pre-admission, authorization. The TPA shall, upon getting the related medical information from the insured person/network provider, verify that the person is eligible to claim under the policy and after satisfying itself will issue a pre-authorization letter/guarantee of payment letter to the Hospital/Nursing Home mentioning the sum guaranteed as payable and also the ailment for which the person is seeking to be admitted as a patient. The TPA reserves the right to deny pre-authorisation in case the insured person is unable to provide the relevant medical details as required by the TPA. The TPA will make it clear to the insured person that denial of Cashless Access is in no way construed to be denial of treatment. The insured person may obtain the treatment as per his/her treating Doctors advice and later on submit the full claim papers to our policy servicing office for reimbursement.
Members are advised to contact their respective servicing offices for any further clarification on the above.
GN SRIDHARAN, GENERAL SECRETARY