mol synergy marine insurance manual - senior
Post on 19-Dec-2015
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INSURANCEMANUALFORMEDICLAIM&LIFETERMINSURANCE
POLICYSERVICES
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EMPLOYEE BENEFIT PROGRAM
TheMOLSynergyMarine(MarshallIslands)Inc.EmployeeBenefitProgramisdesignedinpartnershipwithShriissthyInsuranceandFinancialServices.Thisprogramhasbeencreatedtobetterserve,andmostimportantlymeettheneedsoftheSeafarerandtheirfamilies.
TheEmployeeBenefitProgramcomprisestwoinsurancecoverageschemesfortheSeafarerandtheirfamilies:
GroupFloaterMediclaimPolicy:TheMediclaimCovercanbeavailedbyanyoneoranynumberofmembersinthefamilythatarecoveredinthepolicy.TheOfficersfamilyiscoveredforafixedSumInsuredandanyoneinthefamilycanavailtheadvantagetillthelimit(SumInsured)isexhausted.
GroupLifeTermPolicy:TheGroupLifeTermpolicyofferscompensationincaseofdeathtotheInsuredpersonsnominee,directlyandsolelyasaresultofaNormaloranAccident.
POLICYDETAILS
PARTICULARS
MEDICLAIMPOLICY
GROUPLIEFTERMPOLICY
PolicyName
GroupFloaterMediclaimPolicy
(GFMP)
GroupLifeTermInsurancePolicy
(GLTI)
Insurer
TheNewIndiaAssuranceCompany
Ltd.
LifeInsuranceCorporationofIndia
SumInsured
INR.5Lakhs
INR.30Lakhs
PolicyNumber
130400/34/14/04/000000009
GINP/706000977
PolicyPeriod
01/09/2014TO31/09/2015
01/09/2014TO31/09/2015
ThirdPartyAdministrator
HealthIndiaTPAServicesPvt.Ltd
N/A
THEKEYCOMPONENTSOFTHEGROUPFLOATERMEDICLAIMPOLICY
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SumInsuredofINR.5lakhbasedontheofficersandtheirdependents Familyfloaterforself,spouseandthreechildren AvailabilityoftheThirdPartyAdministrator(TPA)facilityforClaimsettlement AvailabilityofCashlessandReimbursementfacilities
Cashless Reimbursement
PreHospitalization(30daysbeforeHospitalization):Doctorconsultationfees,medicalreportsandrelatedmedicationissued30dayspriortohospitalization(admission)canbeReimbursed
PostHospitalization(60daysafterHospitalization):DoctorConsultationfees,medicalreportsandrelatedmedicationissued60daysafterhospitalization(Discharge)canbereimbursed.
WHATISCOVERED?
FirstyearStandardExclusions Preexistingdiseases 30dayswaitingperiod(Therefore,claimsarisingfromthefirstdayoftheinceptionof
thepolicywillgetpaid)
MaternityBenefituptoFirst2children Newbornchildcoveredfromday1 Ninemonthperiodwaived EyeandTeethtreatmentresultingONLYoutofanAccident CataractSurgery:TheamountpayableforCataractSurgeryislimitedtoactualora
maximumofRs.24,000,whicheverislesseitherforCashlessorReimbursement.
AdditionalBenefitofCyberknifeTreatmentremovalofCancerousmalignanttumor
MEDICLAIM MANAGEMENT
TYPESOFCLAIMS
CASHLESS:servicewhereintheinsuredisnotrequiredtopayanymoneyatthetimeofadmissionordischargefromthehospital.ThisbenefitisprovidedonlyinthehospitalsempanelledbytheThirdPartyAdministrator.NonMedicalexpensesandServiceTaxispayablebytheInsured,forwhichaSecurityDepositisrequiredbytheHospitals
TPANetworkofHospitals:CashlesscanbeavailedonlyattheTPA,HealthIndiasnetworkhospitals.ListisavailableonTPAwebsite:www.healthindiatpa.com
NOTE:ShriissthyInsuranceandFinancialServicesistheCOORDINATORbetweentheClaimantandtheTPA,andisNOTtheTPA.
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CashlessDenial:DenialofCashlessServiceshouldNOTbeconstruedasadenialoftreatment.InsuchacasetheinsuredisadvisedtofiletheclaimforreimbursementandtheTPAwillsettletheclaimsubjecttothepolicystermsandconditions.
REIMBURSEMENT:WhenyoudonotgotooneofthehospitalsthatsnotempanelledwiththeTPA,youwouldusuallyenduppayinghospitalbillsyourself.Butyoucanproducethebillslaterandgetthemreimbursed.
CLAIMINTIMATIONREQUIREMENTS
Shriissthymustbeintimatedattheearliestforbothplannedandemergencyhospitalizations.ForClaimIntimation,1stIntimationforReimbursementorCashlessshouldbesenttoShriissthyInsuranceandFinancialServicesviaemailat:patrashefale@gmail.com;shefale1757@yahoo.com;shaikhsalim554@yahoo.com;salimsk09@gmail.com;vignesh.k@synergyship.comwiththefollowinginformation:
CompanysName CrewName CompanyCrewIDandRank NameofthePatient,AgeandRelationship NatureorIllness/Accident HospitalDetails,DoctorsName,HospitalAdmissionandDischargedate PersonalContactinformation(AddressandNumber) Commencementdateofsymptomofthediseaseincaseofanillness AccidentCase:Dateandtime,locationofaccident,FIRReport,andSelfDeclaration
REIMBURSEMENTCLAIMPROCEDURE:IMPORTANTNOTES
ClaimIntimationshouldbemadewithin7workingdaysafterdischargefromhospital.
Onclaimintimation,ShriissthywillemailalistofOriginalReimbursementDocumentstobecompletedandcourieredtouswithin25daysofdischargefromthehospitalforclaimsettlement
ClaimpaymentsarenowbeingmadethroughNEFT/RTGS,thereforeacopyofacancelledchequeofyourresidentbankaccount(notNRE)iscompulsoryalongwiththesubmissionoftheclaimdocuments.SendShriissthyanacknowledgementonreceiptofpayment
Pleaseretainacopyofallclaimrelateddocumentssubmittedincasequeriesareraisedregardingtheclaimorasabackupincasedocumentsaremisplacedetc.
Claimsettlementtakesaminimumof1monthtoprocess,howeverifdeficienciesindocumentsubmissionsarisethenthesettlementcanbedelayed
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DoctorsFeespaidincashshouldnotexceedthelimitofRs.10000.AspertherulesoftheinsurancecompanycashpaidaboveRs.10000isnotpayable.
Prehospitalization:AlltheOriginalClaimdocuments,billsandreportsofPrehospitalizationmustbecourieredtoShriissthywithin25daysofdischargeforreimbursement
Posthospitalization:Allbillsaccrued60daysPosthospitalizationmustbecourieredtoShriissthywithin90daysofdischargeforreimbursement
CASHLESSCLAIMPROCEDURE:IMPORTANTNOTES
ClaimIntimation:IntimateShriissthyandpatient/relativemustproceedtotheTPAdeskattherespectivehospitalwithIDProof&ecard(accesstodownloadecardisprovided)
PreauthorizationProcedure:
CollectpreauthorizationformfromtheTPAdeskandproceedtothetreatingdoctortobefilledandthenreturntotheTPAdesk
TheTPAdeskwillfaxtheformandrelevantdocumentstoHealthIndiaTPA(EnsurethattheTPAdeskfaxes/emailsthedocumentsandpatient/relativemustinformShriissthyviaphoneoremail.Shriissthywillhelpfacilitateasmoothercashlessauthorization)
HealthIndiaspanelofDoctorswillscrutinizethedocumentstoauthorizethecashless(IncaseofanydocumentdeficienciesHealthIndiawillinformtheHospitalsTPADesk.Itisimportantthatthepatient/relativeconstantlymonitorthedevelopmentsbetweentheTPAandHospital)
OnCashlessauthorizationtheTPAwillsanctionaninitialamounttothehospitalbeforeadmission(Pleasenoteitwillnotbethefullamount)
SecurityDeposit:Thepatientwillbechargedasecuritydepositbythehospital.Thisdepositismaintainedintheeventthatcashlessisdeniedornonpayableitemswhicharenotpayablebytheinsurancecompanywillbededucted.
Discharge: TakethedischargedocumentstothehospitalsTPADesk,whowillsenditacross
totheTPA.Again,ensurethattheHospitalsTPAdesksendsthedocumentstotheTPAandinformthesametoShriissthyviaphoneoremail
OnreceiptofthedocumentstheTPAwilltakefewhourstoverifythedocuments.IncaseofanydocumentdeficienciesHealthIndiawillinformtheHospitalsTPADesk.Itisimportantthatthepatient/relativeconstantlymonitorsthedevelopmentsbetweentheTPAandHospital
Afterclearanceofdeficiencies(ifany)theFinalbillamountwillbesanctionedtothehospitalafterdeductionsofnonpayableitems.
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SecurityDeposit:ThedepositwillnotbereimburseduntilthehospitalreceivestheclaimsettlementchequefromtheInsuranceCompany(Thisproceduremaytakeamonthstime)
NOTE:THROUGHEVERYSTEPOFCASHLESSPROCEDUREINTIMATESHRIISSTHYVIAPHONE/EMAILTOFACILITATESMOOTHCOORDINATIONWITHTHETPA.
MANDATORYDOCUMENTS
Whilesubmittingtheclaims(ReimbursementandCashless)forthebelowlistedAilments,thecorrespondingmandatorydocumentsmustbesubmittedalongwithotheressentialclaimrelevantdocuments:
CataractSurgery:A'Scanreport&IOLSticker(IflensisaboveRs.10,000thenapurchaseinvoiceisrequired)
Fractures:Xrayreportswithplates(IncludingHip&KneeReplacement) Accidents:MLC/FIR/Selfdeclarationfrompatient Angiography:FinalReportwiththeDiagram ImplantsinBones/HerniaMesh:IfitisaboveRs.10,000thenapurchaseinvoiceis
required EarSurgery:Audiometryreport Pneumonia:XrayChestreport PreexistingDisease:DetailedHistorywithdurationofAilmentslikeDiabetes,
Hypertension,Asthma,Fits/Epilepsy,HeartDiseases,KidneyStones,Arthritis,TB Paralysis:CTscan/MRIReport
GROUPLIFETERMPOLICY:CLAIMSETTLEMENTPROCEDURE
ClaimIntimation:ShouldbesenttoShriissthywithin48hoursaftertheofficersdeath,sothatShriissthycanguidethedeceased'sfamilyforthebeststepsforward.Aformallettershouldalsobesentfromthecompany'sendprovidingtherelevantinformation ThesameintimationissenttotheclaimhuboftheInsurancecompany
Requirements: PostMortemReportismandatory DeathCertificateismandatory F.I.Rifapplicable Latestsalaryslip(sentbythecompany) Claimformdulyfilledbythedeceasedsfamilymember Declarationbyafamilymemberstatingthecaseofdeath
Iftheclaimispayable,thentheclaimamountforLifeTermpolicywillberaisedinthenameofthecompany,andnotthedeceasedsfamilydirectly
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ONLINE:ECARDOFFAMILYMEDICLAIM
TheinsuredcanaccesstheECardorClaimStatuswiththefollowing:
Logontohttps://www.healthindiatpa.com/DownloadEcard.aspx SelectCorporate EnterEMPID ClickonECardandPrint Pleaseensuretocheckforcorrectdetailsenteredontheecardandrevertincaseyou
noticeanydiscrepancies.Pleaseemailusatourgivenids. Mostimportantly,pleaseintimateyourcompanyforanyadditionssuchasmarriageand
childbirthsothatthenewfamilymemberscanbeincludedunderthepolicy.
TPASNETWORKHOSPITALS
TheTPAHealthIndiashospitalsinitsnetworkcanbeaccessedwiththefollowing:
Logontowww.healthindiatpa.com ClickonHospitalontheRighthandsideofthewebpage SelectState,City,Location
SHRIISSTHYINSURANCEANDFINANCIALSERVICESCONTACTINFORMATION
Primacycontact:Mrs.ShefalePatraManagingDirector Email:shefale@shriissthy.com,shefale1757@yahoo.com Phone:+919892009036/+919820103003
SecondaryContact:Mr.SalimShaikhOperationsManager Email:salim.shaikh@shriissthy.com,salimsk09@gmail.com
Phone:+919987206258/Landline:+912226334291 WorkingHours:(MonFri)(10am6pm)Sat(10am2pm)
Address:207/C,Vriddhi,KalyanComplex,YariRoad,Versova,AndheriWest,Mumbai400061
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