ࡱ> e_ 0pbjbj:: 4dX{9\X{9\gQ NNNNNbbb8vb"j6#L#L#L#$ *F,$nJN-$$--NNL#L#4ĥ"H5H5H5-~NL#NL#H5-H5H5`L#ld*/\u<"Kh0,&N٠&-:-H5H- T-X&-&-&-38&-&-&-"----&-&-&-&-&-&-&-&-&- > : @INTRODUCTION This FAQ gives the salient features of the Health Insurance Scheme Mediclaim Policy will reimburse reasonable expenses to the insured Tata Power, CGPL, MPL, TPJDL and TPCDT Employees, subject to certain maximum limits, which the employees have incurred on account of hospitalisation Tata Power Employees and their families are covered under the Mediclaim Insurance Scheme for the Sum Insured as per their Grade for the Hospitalisation expenses. The Insurance policy is with New India Assurance Company (NIAC) and the claims are administered by Mediassist who are the Third Party Administrators (TPA). The Insurance policy basically covers the Hospitalisation expenses whilst admitted as in-patient to the extent of reasonableness of the charges subject to the Individual family limit of the Sum Insured for each year of the policy. In order to ensure that the Policy is better managed and is understood by the employees we are providing the following frequently asked questions which are covered under this write-up and will help employees to avail its facility. For the benefit of better understanding to the Employees the FAQs are given below under 8 heads (A to H): Who is covered / Limits of coverage / add and delete dependants and the I- Card / E Card  TOC \o "1-3" \h \z \u  HYPERLINK \l "_Toc395802815" Who all are eligible to get covered in Companys Group Floater Mediclaim Policy?  PAGEREF _Toc395802815 \h 4  HYPERLINK \l "_Toc395802816" What are the limits for coverage?  PAGEREF _Toc395802816 \h 4  HYPERLINK \l "_Toc395802817" How do we add names of new employees and dependents in the Policy?  PAGEREF _Toc395802817 \h 5  HYPERLINK \l "_Toc395802818" How can I delete my dependents name from the Policy?  PAGEREF _Toc395802818 \h 5  HYPERLINK \l "_Toc395802819" How can I get Mediclaim I.Card/E-Card?  PAGEREF _Toc395802819 \h 5 What should I do in case of Hospitalisation of Myself OR my family members?  HYPERLINK \l "_Toc395802821" Basic information  PAGEREF _Toc395802821 \h 5 What is CASH LESS Claim / Reimbursement Claim.? / Limit Under Cash Less claim / List of Hospitals  HYPERLINK \l "_Toc395802824" What is Cash Less claim and Reimbursement claim  PAGEREF _Toc395802824 \h 6  HYPERLINK \l "_Toc395802825" Where can I Claim Cash Less Hospitalisation / what is GIPSA Hospitals  PAGEREF _Toc395802825 \h 6  HYPERLINK \l "_Toc395802826" GIPSA hospital List  PAGEREF _Toc395802826 \h 7  HYPERLINK \l "_Toc395802827" If my cashless approval is partial, what I should do?  PAGEREF _Toc395802827 \h 7 What expenses are payable under the Scheme / Ailments Excluded / Expenses not payable / Non Mediclaim items disallowed  HYPERLINK \l "_Toc395802828" What expenses are payable under the Mediclaim policy?  PAGEREF _Toc395802828 \h 8  HYPERLINK \l "_Toc395802829" What expenses are not payable exclusions?  PAGEREF _Toc395802829 \h 8  HYPERLINK \l "_Toc395802830" What ailments are excluded under the policy?  PAGEREF _Toc395802830 \h 8  HYPERLINK \l "_Toc395802831" Additional Coverage & Restrictions to Officers  PAGEREF _Toc395802831 \h 8  HYPERLINK \l "_Toc395802832" What are Non-Medical items generally disallowed? Can I get a list of it?  PAGEREF _Toc395802832 \h 9 Claim Process / Procedure during Discharge at Hospital / Documents to be submitted  HYPERLINK \l "_Toc395802833" What is the procedure/requirement for claim submission?  PAGEREF _Toc395802833 \h 9  HYPERLINK \l "_Toc395802834" What is the time limit for reimbursement claim submission?  PAGEREF _Toc395802834 \h 9  HYPERLINK \l "_Toc395802835" Why are original documents required for submitting a claim? How can I get my original reports and x-ray films back?  PAGEREF _Toc395802835 \h 9  HYPERLINK \l "_Toc395802836" From where I can get Claim Form  PAGEREF _Toc395802836 \h 9  HYPERLINK \l "_Toc395802837" What is the cycle time for claim settlement?  PAGEREF _Toc395802837 \h 10 How can I track my claim status / settlement letter?  HYPERLINK \l "_Toc395802839" How can I track my claim status?  PAGEREF _Toc395802839 \h 10  HYPERLINK \l "_Toc395802840" My claim is in query stage for IR (Information required). What should I do?  PAGEREF _Toc395802840 \h 10  HYPERLINK \l "_Toc395802841" My claim status is marked as denied. What should I do if I do not agree with the denial reasons?  PAGEREF _Toc395802841 \h 10  HYPERLINK \l "_Toc395802842" Certain portion of my claim has been disallowed in my settlement. If I do not agree with the same, how can I claim it?  PAGEREF _Toc395802842 \h 10  HYPERLINK \l "_Toc395802843" Claim vigilance / claim investigation by TPA personnel.  PAGEREF _Toc395802843 \h 10 Transferred Employees Between Subsidiaries CGPL / MPL / TPCL  HYPERLINK \l "_Toc395802844" I am transferred/shifted to Group Companies in Tata Power with new employee number. What is the procedure followed to avail mediclaim facility?  PAGEREF _Toc395802844 \h 11 Retired Employees:  HYPERLINK \l "_Toc395802845" If I am retiring in the current year, what should I do for continuing my mediclaim in the Companys Group Floater Mediclaim Policy?  PAGEREF _Toc395802845 \h 12  HYPERLINK \l "_Toc395802846" I am a retired employee, what is the premium I have to pay for my coverage to continue in Tata Power Companys Group Floater Mediclaim Policy?  PAGEREF _Toc395802846 \h 12  HYPERLINK \l "_Toc395802847" I am a retired employee, wants to enhance my existing sum insured.  PAGEREF _Toc395802847 \h 12  HYPERLINK \l "_Toc395802848" I have resigned from Tata Power. Whether I can continue the coverage by paying premium in the Group Mediclaim Policy. Upto what period my Mediclaim coverage remain valid?  PAGEREF _Toc395802848 \h 12  Problems faced in Claim Frequently Asked Questions Who is covered / Limits of coverage / add and delete dependants and the I- Card / E Card Who all are eligible to get covered in Companys Group Floater Mediclaim Policy? Self, Spouse, Dependent Children upto age of 25 and Dependent Parents or in-law parents * Dependents - (1) Legally married spouse, (2) legitimate or legally adopted son/daughter, (3) parents father, mother or father-in-law, mother-in-law who is not gainfully employed for wage or profit or in service, business or profession and to be truly a dependent of the employee and normally reside with him. Special category a)In respect of dependent children who are 25 years of age and above, upon their satisfying the following conditions: i. They are not working ii. They are not married b)In respect of dependent handicapped sibling, upon their satisfying the following conditions: i. They are not working ii. They are not married iii. Appropriate cert of handicapped status being produced c) In respect of siblings of Unmarried employees, upon their satisfying the following conditions: i. They are not working ii. The parents are deceased For regularizing the above coverage, the employee has to make an application to Head Corporate Insurance through their concerned divisional office in the prescribed format enclosing the necessary declarationduly verified by the Divisional Head. Further, such declaration needs to be made annually to ensure that the special status continues. ( HYPERLINK "https://webapplnapp.tatapower.com/mediclaim/Special_category_addition_form.pdf"Click here for Special category addition form) What are the limits for coverage? GradeSum InsuredMC2 and above10 lakhsMD2, MD17 lakhsME-2, ME15 lakhsME4, ME3,FDA4 lakhsStaff above Basic 4003.5 lakhsStaff upto Basic 4002.5 lakhs Employees of Jojobera and Power House 5 & 6 are covered under Tata Steel medical facility. However employees are having an option to get covered under our existing Mediclaim policy for coverage of 2.5 lakhs. How do we add names of new employees and dependents in the Policy? New employees inducted through HR data get added to Mediclaim system through a process run from IT Dept. The Employee himself has to add immediately, dependents name in Mediclaim System available in Sangam - employees portal Mediclaim add - dependent name. The coverage will be regularised through monthly addition with Insurance Company effective from the date of addition in the Mediclaim system. How can I delete my dependents name from the Policy? Deletion of names also has to be done in Mediclaim system available in Sangam - employees portal. Employee should delete the name of dependents for whom they do not want to continue the coverage due to specific reasons. i.e. marriage, employed, beyond 25 years of age, expired etc. How can I get Mediclaim I.Card/E-Card? E-card is available at  HYPERLINK "https://www.mediassistindia.net/IWP/Account/LogOn" https://www.mediassistindia.net/IWP/Account/LogOn employee Login id: <>@tatapower (Example: 123456@tatapoweer) Password : tatapower What should I do in case of Hospitalisation of Myself OR my family members? Basic information What I should do in the event of hospitalisation? keep copy of: i) Company ID Card, ii) Mediassist Mediclaim E-Card/I-ICard, iii) a list of nearby GIPSA hospitals where cashless hospitalisation facility can be availed. iv) Contact details of few close colleagues from work place. v) Contact details of TPA personnel and Company Insurance contact personnel. Above basic information be kept at residence and other family members are kept informed on its utility. Hospitalisation of Self OR Family care that needs to be taken When self is hospitalised ensure family members have the details of above basic informations. What is CASH LESS Claim / Reimbursement Claim.? / Limit Under Cash Less claim / List of Hospitals What is Cash Less claim and Reimbursement claim What is Cash Less claim and Reimbursement claim Cashless i) Cashless facility is available only on GIPSA rates agreed hospitals. ii) for cashless hospitalisation show copy of Mediassist E-Card/I-card to hospital cashless counter to facilitate them to send cashless request to TPA. iii) in case or any problem contact TPA personnel/Corp Insurance Dept Personnel. iv) at the time of Cashless Hospitalisation discharge it is essential to take final bill copy from Hospital. < for more details on cashless procedure click here > Reimbursement Mediclaim Admitted in to a Non GIPSA hospital then settle the hospital bills and put up a reimbursement Mediclaim by filling Mediclaim form and attaching relevant original documents to Head - Corp. Insurance, B-Block, Corporate Centre, Carnac, Care to be taken at the time of Discharge Verify hospital for its correctness of charges, there should be detailed bills on consumables, medicines charges, diagnostic test etc. Collect original discharge card, all diagnostic test reports in original, original payment receipts for all payments made. Where can I Claim Cash Less Hospitalisation / what is GIPSA Hospitals Group of Public Sector Insurance Company has fixed certain surgical procedures cost based on hospital grades. These rates are known as GIPSA rates. Hospitals which have accepted these rates are called GIPSA Hospitals. TPC Mediclaim covered employees and dependents can avail cashless hospitalisation in GIPSA Hospitals. Employee not availing Cashless facility and paid hospitalisation expenses, he has to put up a Reimbursement Mediclaim attaching all original documents for getting reimbursement. GIPSA hospital List i) GIPSA hospital list is available in our Mediclaim System front page Cashless facility. ii) Latest cashless hospital list available at mediassistindia.com <HYPERLINK "https://webapplnapp.tatapower.com/mediclaim/Gipsa_Hospital_List1.xls"Click here to get GIPSA Hospital list> Cashless initial approval is partial. In certain cases TPA gives an initial approval which is lesser than the estimated amount requested by the hospital. The remaining amount can get cleared at the time of discharge by sending final hospitalisation bill, discharge card copy and a fresh request form duly filled and signed by the hospital In case of any problems TPA responsible persons on Tata Power Mediclaim Policy can be contacted on following numbers: Ms Tejeshree Gujar : 7718813070 Ms Smita Khedekar : 8451050893 What expenses are payable under the Scheme / Ailments Excluded / Expenses not payable / Non Mediclaim items disallowed What expenses are payable under the Mediclaim policy? Expenses Payable: Room Charges, RMO charges, Nursing Charges, ICU Charges. Surgeon fee, Anaesthetist fee, Consultants fee, Medical Practitioner fee, Specialist fees, Anaesthesia., OT charges Medicines & drugs, Cost of Implants, Devices like pacemaker Relevant Diagnostic tests charges Expenses towards pre and post hospitalisation for a period of 30 and 60 days respectively What expenses are not payable exclusions? Expenses Not Payable: Health Check up charges without effective Hospitalisation Admission/Registration, Telephone charges, Attendants charges, Special Nurses. Non Medical Expenses generally disallowed. < click here view non medical expenses list > Expenses beyond pre 30 and post 60 days. Experimental & unproven treatment. Treatment taken outside India. 13. What ailments are excluded under the policy? General Policy Exclusions: Circumcision, Vaccination, Inoculation, Cosmetic treatment, Plastic surgery Spectacles, Contact lenses, Hearing Aids Dental Treatment Congenital disease, Sterility, Venereal disease, Alcohol use, Self injury. Vitamins and Tonics not prescribed post hospitalisation & unrelated to treatment Naturopathy treatment Treatment for Infertility Beauty Treatment of any description. Plastic surgery (other than necessitated due to accident) Sexually transmitted diseases, any condition directly or indirectly associated with Human T cell lymphotropic virus Type-III or condition of similar kind commonly referred to as AIDS. 14. Additional Coverage & Restrictions to Officers Maternity coveragenormal delivery procedure Rs 30,000 and caesarean delivery procedure Rs 50,000Room Rent (per day)Shall not exceed 1% of sum insured subject to maximum of Rs 5,000 per day.ICU (per day)Shall not exceed 2.5% of sum insured subject to maximum of Rs 10,000 per day.GIPSA rates Applicable for cashless as well as reimbursement claims.Cataract OperationLimited to Rs 45,000 per eye.Parents /In-law parentsEmployees can include either parents or in-law parents < HYPERLINK "https://webapplnapp.tatapower.com/mediclaim/Tata%20Power%20Officers%20Group%20Mediclaim%20policy%20FY15.pdf"Click here to view Circular > What are Non-Medical items generally disallowed? Can I get a list of it? < HYPERLINK "https://webapplnapp.tatapower.com/mediclaim/Non%20Medical%20Expenses.xls"Click here to view Non-Medical items generally disallowed > Claim Process / Procedure during Discharge at Hospital / Documents to be submitted What is the procedure/requirement for claim submission? i)Make an intimation entry in the mediclaim system available at Sangam-employee portal and get the claim number.ii)Fill up the Mediclaim form and sign it. Mention the claim intimation number iii)Attach following original documents:a)Duly filled claim formb)Discharge cardc)Detailed Final Hospital billsd)Payment receiptse)All diagnostic test reports with advice note.f)Medicine cash memo with prescription.g)X-ray reports and films. What is the time limit for reimbursement claim submission? For Hospitalisation claim submission, initial claim should be submittedimmediately after the discharge i.e. within 10 days from the date of discharge This will enable speedy recovery of major portion of the claim amount and any query on claim processing can be resolved by getting required documents from hospital without much trouble. Follow-up claim can be submitted as subsequent claim once follow-up on hospitalised treatment gets over, subject to maximum 60 days post hospitalisation period. Why are original documents required for submitting a claim? How can I get my original reports and x-ray films back? Original documents are required for Insurance companys audit compliance.Where the employee wants his original reports for future treatment, kindly submit a letter along with the original & duplicate reports. TPA will verify the same & return the original reports. From where I can get Claim Form < HYPERLINK "https://webapplnapp.tatapower.com/mediclaim/Mediclaim_form.pdf"Click here to view Claim Form > What is the cycle time for claim settlement? 15 working days from the date the claim is submitted to Insurance Company, subject to availability of complete documents and information required to settle the claim by TPA. How I get my Mediclaim settlement payment? Mediclaim settlement payment received from Insurance Company will get credited to employees bank account through NEFT from Tata Power. For subsidiaries / JVs NEFT transfer will be done to the concerned Company, who in turn will disburse the amount to its employees. How can I track my claim status / settlement letter?  HYPERLINK "https://www.mediassistindia.net/IWP/Account/LogOn" https://www.mediassistindia.net/IWP/Account/LogOn Login id : employee number@tatapower Password : tatapower (here employee can get coverage details, e-card, claim status, settlement details) My claim is in query stage for IR (Information required). What should I do? Employee has to submit the information/documents required by the TPA. Attach the documents with IR intimation mail received and send the documents to The Tata Power Company Limited Corporate Centre B-Block, 5th floor, 34 Sant Tukaram Road, Carnac Bunder Mumbai 400 009 Tel. 67171536 Attn: Mr Abdul Razak L KhanMy claim status is marked as denied. What should I do if I do not agree with the denial reasons? Employee has to submit the reason with supporting documents to TPA directly or forward it to Corp. Insurance Dept., Carnac. Mumbai. Certain portion of my claim has been disallowed in my settlement. If I do not agree with the same, how can I claim it? Employee has to submit the supporting documents for the disallowed portion of the claim along with settlement copy to TPA directly or forward it to Corp. Insurance Dept.,34, Sant Tukaram Road, Carnac Bunder, Mumbai 400 009 Claim vigilance / claim investigation by TPA personnel. As a part of claim containment measures TPA investigator may visit the hospital to confirm the authenticity of the patient, check theemployees entitlement and facility provided by the hospital, ailment and treatment plan, billing pattern matching with agreed GIPSA rates. The TPA investigator may visit patient/relative in this regard. Employees are requested to co-operate with this procedures to enable us to keep a proper control and claim containmentin this regard. Transferred Employees Between Subsidiaries CGPL / MPL / TPCL I am transferred/shifted to Group Companies in Tata Power with new employee number. What is the procedure followed to avail mediclaim facility? i) Transfer to from Tata Power to CGPL / CGPL to Tata Power and Transfer to from Tata Power to MPL / MPL to Tata Power with new employee number: Current coverage continues upto 31st March of the change year. Any claim during the year can be claimed under old employee number. On induction through new employee number employee name will get added in Mediclaim system directly from HR induction process. Employee has to add dependents name for regularising their coverage for renewal. ii) Transfer from Jojobera to other locations, how Mediclaim coverage get regularised? (a) If the employee is already covered in Contributory Jojobera Special Coverage for 2.5 lakhs Sum Insured, then he has to intimate Insurance Dept. to change the category of his insurance from JSP coverage to regular coverage as per his grade. Insurance Dept will change the coverage category as per his grade and regularise it. Employee has to verify and confirm his eligible coverage regularised by viewing his coverage data available and accessible to him in Sangam-Employees portal-mediclaim-view/edit family data. (b) If the employee is not covered under Mediclaim then he has to intimate Insurance Dept. to add his name in Mediclaim System. Insurance Dept will add employee name in Mediclaim System. Employee has to add his dependents in Mediclaim system available in Sangam-Employees portal-Mediclaim-Add Dependents Name. iii) Transferred to Jojobera (a) Existing coverage will continue till expiry of the policy period. On renewal name get deleted. Employee can opt for Jojobera Contributory Special Coverage for 2.5 lakhs. iv) Shifting from Tata Power to Overseas Assignment and employee wants to continue his and family coverage in Tata Powers Group Floater Mediclaim Policy. Employees are permitted to continue their coverage by paying full premium. These category employees are kept in a separate group and premium will be collected during March month of every renewal Retired Employees: If I am retiring in the current year, what should I do for continuing my mediclaim in the Companys Group Floater Mediclaim Policy? Mediclaim policy coverage period is 1st April to 31st March. Retiring employee does not have to pay the premium upto the end of the Financial year in which he retires. Thereafter, for continuing the mediclaim coverage in Tata Power Group Mediclaim policy, retired employee has to pay the premium on every renewal. i.e. during the month of March of every year. Renewal intimation will be sent to the retired employee at the residential address available in mediclaim system.Retiring employee has to update his post retirement residential address, Telephone No./Mobile No, e-mail id in the mediclaim system available in Sangam-employees portal before retirement. I am a retired employee, what is the premium I have to pay for my coverage to continue in Tata Power Companys Group Floater Mediclaim Policy? There are three options available; employee can choose any one during retiring year. (i) There is a special coverage for Retired employees for Sum insured Rs.2.00 lakhs. Premium for this coverage is Rs 6000/- + service tax for self and 10% addition for dependent. i.e for coverage of self and spouse Rs 6600/- + service tax. (ii) There is a special coverage for Retired employees for Sum insured Rs.4.00 lakhs. Premium for this coverage is Rs 10000/- + service tax for self and 10% addition for dependent. i.e for coverage of self and spouse Rs 11000/- + service tax. (iii) For employees opting for the existing coverage to continue, the premium will be calculated on prevailing rates and intimated to them during the month of February/March for making payment of the premium during the month of March I am a retired employee, wants to enhance my existing sum insured. Enhancement of sum insured is not permitted. Reduction from higher sum insured category to lower sum insured category is permitted I have resigned from Tata Power. Whether I can continue the coverage by paying premium in the Group Mediclaim Policy. Upto what period my Mediclaim coverage remain valid? Mediclaim claim insurance is renewed every year based on employees who are in service as on 1st April. Policy is valid upto 31st March of the financial year. Recovery of Mediclaim premium is done from resigned employees final settlement for unexpired periods coverage i.e. Separation date to 31st March of the financial year Problems faced in Claim Clarification on Mediclaim related issues. Sr. NoAreas of Frequent Disallowment in MediclaimSolution/Remarks1Cashless hospitalisation request denied by TPA for want of information on admissibilityEmployee can put up a reimbursement claim clarifying the information needed by TPA along with supporting documents.2Surcharge/Service charges are payable in current years Mediclaim Policy. Hospital collected surcharge charges from employee.Put up reimbursement mediclaim attaching payment receipt of surcharge amount.3Diagnostic test expenses disallowed for want of original reports.Put up a Grievance Claim attaching original test report with settlement letter copy.4Medicine charges disallowed for want of bifurcated/detailed bills.Get the detailed medicine charges from hospital and put up a Grievance Claim attaching it with settlement letter copy.5Expenses beyond agreed GIPSA rates for cashless cataract operationExpenses beyond cashless GIPSA rates approval on Cataract Operation cannot be claimed through reimbursement Mediclaim.6In emergency cashless request E-Card not availablePut Emp. No. on cashless request form and send the request to TPA from Hospital. In case of any problem take the help of TPA contact persons/Company Insurance contact persons.7TPA will give immediate initial approval on cashless request and final approval on receipt of final bill and discharge summary.Ensure from the hospital, the final bill and discharge summary has been send to TPA well in advance before discharge.8Line of treatment is not clear on cashless request TPA may raise queries on information required. Upon satisfying the query by Hospital TPA clear the cashless request.All developments on cashless approval is marked to employee e-mail id/mobile. Ensure queries if any have been replied by hospital in time.9Cashless facility is only available in GIPSA hospitals.Cashless facility is not available in NIA network hospitals who are not agreed GIPSA rates.10Cashless claims settlement payment to hospitals will be paid within 30 days and employee get mail from TPA in this regard. Employee get copy of mail on cashless Settlement advice to hospital. Deposit refund can be collected accordingly.11Cashless hospitals collect nominal deposit amount from employee to cover up non medical expenses on cashless hospitalisation. Employee get mail on cashless settlement advise to hospital. Deposit refund can be collected accordingly.     THE TATA POWER CO. 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