How To Manage Group Mediclaim Policy Effectively?

What is covered in the Group Mediclaim Insurance Policy?

A Group Mediclaim Insurance Policy covers all the following aspects-

       ·        Room and boarding
·        Doctors/Medical Practitioner fees
·        Intensive Care Unit
·        Nursing expenses (within the room rent charges)
·        Surgical fees, operating theatre, anesthesia and oxygen, and their administration
·        Drugs and medicines consumed on the premises
·        Hospital miscellaneous services (such as laboratory, x-ray, diagnostic tests)
·        Costs of prosthetic devices if implanted during a surgical procedure
·        Radiotherapy and chemotherapy

A Group Mediclaim Insurance is applicable only if the below-mentioned criteria are followed:

       ·        They occur in India and are covered by the policy’s time frame.

       ·        Hospitalization costs for a minimum of 24 hours are allowable.

       ·        If a covered member chooses a room with a higher rent category than what is allowed for him, the corresponding deductions will be made.

 

What is not covered in the Group Mediclaim Insurance Policy?

       ·        Nuclear dangers, war, and war groups

       ·        Birth control methods, hormone replacement therapy, medically assisted pregnancy termination during the first 12 weeks following conception, and treatments resulting from or linked to pregnancy. 

       ·        Circumcision unless required for a disease, illness, or injury not excluded hereunder, or as may be required as a result of an accident Vitamins and tonics unless part of treatment for a disease, illness, or injury as certified by the attending Medical Practitioner Ectopic pregnancy proven by diagnostic means and certified to be life-threatening by the attending Medical Practitioner

       ·        Routine medical, eye, and ear exams, the cost of glasses, laser eye surgery, contacts, or hearing aids, the issuance of medical certificates, and tests to determine eligibility for employment or travel

       ·        Self-medication, family member treatment, or any other kind of treatment not approved by science

       ·        Sex change or any form of treatment that arises from or is connected to sex change

       ·        Following the use of intoxicating substances and alcohol, medical treatment may be necessary. It also applies to drug abuse, solvent abuse, any addiction, or other medical conditions caused by or connected to such misuse or addiction.

       ·        Any medical care received in nursing homes, hospitals, hydrotherapy centers, natural medicine practices, or other comparable facilities

       ·        Any medical care received outside of the hospital without being admitted as a patient.

       ·         Costs associated with donor selection or care.

       ·        Treatment with naturopathy.

       ·        Treatment received from individuals who are not medical practitioners as defined by the relevant medical bodies.

       ·        Any hospital stay during which no treatments are received, or the medical practitioner is not providing active regular treatment.

       ·        Aesthetic procedures, cosmetic surgery, and plastic surgery, unless they are required as a result of an accident or as part of a condition that is not specifically prohibited.

       ·         Ionizing radiation or radioactive pollution from any type of nuclear fuel or nuclear waste that results from burning nuclear fuel.

       ·         Nuclear weapons, nuclear materials, or radioactive contamination can cause or
contribute to disease, illness, or injury either directly or indirectly.

       ·         Unproven and experimental therapies.

       ·         Expenses incurred for medications that were not prescribed by a physician.

       ·         Prosthetics, corrective equipment, and medical devices that are not necessary during surgery or for the condition, illness, or injury for which the insured or insured person was hospitalized and that are not otherwise excluded under this clause.

       ·         All illnesses, injuries, and diseases brought on by or connected to HIV, including the Acquired Immune Deficiency Syndrome (AIDS), the AIDS-related complex syndrome (ARCS), and others.

       ·        Orthodontic Care.

       ·        Treatment for obesity, general sluggishness, recuperation, ailing condition or rest cure, venereal disease or purposeful self-harm, and usage of intoxicating substances such as alcohol.

       ·        Any type of vaccination or immunization.

Process To Be Followed In Planned And Unplanned Hospitalization

In case of a planned authorization, all non-emergency hospitalization situations require prior authorization from the Help Desk. This is done to guarantee that the insured member receives the best treatment available and is not inconvenienced when seeking admission into a Network Hospital.

You must get hospital admittance after your hospitalization has been pre-authorized. Raksha TPA will give the hospital a letter of credit or a cashless approval letter. Please provide your government-issued health ID cards at the hospital entrance desk. In the event of a network hospital, the insured member does not need to pay the hospitalization bill.
The invoice will be issued to and paid for by Raksha TPA, but the employee or patient must cover any disapproved amounts. However, in case of an unplanned hospitalization, employees can get up to seven days before the entrance to request cashless approval. The cashless authorization form is accessible at the hospital’s TPA assistance desk. When visiting TPA, the employee must have a TPA Card and a valid ID. Once the hospital has given you all the necessary information, it takes no longer than three hours to approve cashless claims.