actiance india private limited - fhpl · advantageously to assist actiance india private limited in...

TPA Services

For

Actiance India Private

Limited

Bangalore

Limited

By

Family Health Plan Limited

Core competence of FHPL is healthcare administration and is placed advantageously to assist Actiance India Private Limited in their pursuit of delivering quality care to its enrolled members.

� Decade old experience in Indian Health Insurance

� Licensed Third Party Administrator (TPA) by IRDA ( L.No: 013)

� First ISO Certified TPA in the country

� Largest TPA offering nation wide services to over 20 million lives

About Family Health Plan Limited (FHPL)About Family Health Plan Limited (FHPL)

� Largest TPA offering nation wide services to over 20 million lives

� Only TPA to design & implement Self Funded Schemes for Govt.

� TPA with the widest network hospital spread till district level (4577)

� Pan India presence with 19 offices across the country

Benefit Details

Policy Parameter

Insurer United India Insurance Co

TPA Family Health Plan(TPA) Limited.

Policy Start Date 3rd January 2013

Policy End Date 2nd January 2014

Coverage Type Individual Sum Insured (1+5)

Dependent Coverage Yes (Spouse, two living children & Parents)Dependent Coverage Yes (Spouse, two living children & Parents)

Benefits covered

1st 30 days waiting period exclusion • Waived off

2 year exclusion • Waived off

Scope of cover • Covered from date of joining

Co Payment 80:20% co payment for each and every claim of dependents, Maximum

Payable is INR.80000/-. However no Co - Pay clause applicable for

employees.

Maternity benefits Maternity covered upto a maximum of INR 25,000/- for Normal Delivery &

INR 35,000/-Cesarean Section , well baby expenses are covered with in

Benefit Details

INR 35,000/-Cesarean Section , well baby expenses are covered with in

maternity sub limit, for any Complication baby covered from main sum

insured

9 Month Waiting Period for Maternity

Waived for all

Special Intimation (intimation@fhpl.net) should be given within 24hrs of hospitalization to FHPL.

Claim document should be submitted with 15 days from the DOD from hosp, incase of post hospitalization claim document must be submitted with in 7day after completion of the relevant treatment

Definition of Hospital :

Any Hospital or Nursing home which is Registered with local authority and

has more than 15 Beds.has more than 15 Beds.

Definition of Hospitalization :

Minimum period of 24 hrs of admission in a hospital for a proper medical/

Surgical management.

•Adenoidectomy

•Appendectomy

•Ascitic/Pleural tapping

•Auroplasty

•Coronary angiography

•Coronary angioplasty

•Fracture/dislocation excluding hairline fracture

•Radiotherapy

•Lithotripsy

•Incision and drainage of abscess

•Colonoscopy

•Hydrocele

•Hysterectomy

•Inguinal/ventral/Umbilical/ Femoral Hernia

•Parenteral chemotherapy

•Polypectomy

Time Limit Not Applicable For Specific Treatments like

•Coronary angioplasty

•Dental surgery

•D&C

•Endoscopies

•Excision of Cyst/Granuloma/lump

•Eye surgery

•Colonoscopy

•Varicocelectomy

•Wound suturing

•FESS

•Haemo dialysis

•Fissurectomy / Fistulectomy

•Mastoidectomy

•Septoplasty

•Piles/ fistula

•Prostrate

•Sinusitis

•Tonsillectomy

•Liver aspiration

•Sclerotherapy

•Varicose Vein Ligation

Policy Exclusions - Diseases not covered

� Plastic Surgery (Cosmetic)

� Alcoholism related ailments� Alcoholism related ailments

� Sterility/Venereal Disease/Circumcision

� Intentional Self Injury

� AIDS

� Congenital Diseases (External) e.g. An operation to remove a 6th finger, Skin

Grafting, Convalescence / General Debility, Dental including root canal Treatment

Policy Exclusions: In-Patient Treatment not covered� Laboratory Expenses not consistent with treatment.

� Vitamins & Health Drinks like Horlicks, Complain etc and Tonic inconsistent with

treatment, Special diet and extra diet for patients (unless prescribed by the Doctor)

� Telephone, Fax, Barber, Photocopy, Vaccinations, Toiletries and TV charges

� External Implants e.g. An operation to remove a 6th finger, Skin Grafting, Supports

and Accessories, e.g. Crutchesand Accessories, e.g. Crutches

� Service Charges, Maintenance and Surcharges, Special Nursing, Attendant Pass

� Abortion done for voluntary reasons & before 12 weeks

� Food and Beverage for Relatives

� Diagnostic Expenses (only for out-patient)

� Damage done by the patient (accidentally). Damage charges not covered.

Policy Exclusions: Other Expenses not covered

� Spectacles, Contact Lens, Hearing Aid

� Use of intoxicating drugs/ alcohol

� Naturopathy

� Non Medical Items- e.g. Sanitary Pads, Diapers, Razors, Soaps, CD’s etc� Non Medical Items- e.g. Sanitary Pads, Diapers, Razors, Soaps, CD’s etc

� Admission , Documentation and MRD Charges, Registration fees, Surcharges, Services

Charges and related expenses

� Food & Beverages

� Telephone/Fax, Xerox or Certifying charges, Medical records/ Stationary expenses

� Attendant’s & Special Nursing charges, Extra Bed/ Bed retaining charges, TV/

Laundry

�

Pre-authorization Process for Cashless

Hospital sends Intimation to

FHPL

Out of Pocket

Member

approaches

Hospitals with

FHPL ID Card

Eligibility

Covered

Not

Covered

Authorization asper eligibility

Out of Pocket payment

� TAT : less than 2 hrs for routine cases

� Regularization within 24 Hrs

� Process of cashless authorisation is

decentralized

Cashless treatmentat NWH

Member avails treatment at any hospital and makes upfront payment

Member submits bills to FHPL within15 days of discharge

Protocol for Availing Treatment in Non Network Hospital

FHPL processes claimsSettle the Claim in 21 days

FHPL verifies the documents submitted

In case of incomplete documents recovery of documents for scrutiny

Procedure for Reimbursement (Non Network Hospitals)

Pay and settle the bills & collect the following documents from the hospital.

Submit the same to FHPL representative within 15 days of discharge :

1. UIIC claim form, duly filled & signed by the claimant.

2. Discharge Summary - Original.

3. Final Bill with breakup

4. Receipts for the payment made.

5. All Laboratory investigation Reports

6. In case of surgical packages – detail breakup of the package.

7. Medicine bills with prescriptions.

8. In case of maternity Gravida status to be mentioned in discharge summary.

9.In case of road accidents member needs to submit FIR copy/MLC copy

30 Days pre & 60 Days Post hospitalization.

1. UIIC claim form, duly filled & signed by the claimant.

2. Original investigation reports along with bills & receipts.

3. Consultation receipts.

4. Medicine bills with prescriptions.

Hospitalization Guidelines & Advantages

Guidelines:

Recommend you to obtain pre-authorizations at least in advance of 24 hours for all elective cases and get treated in a N etwork Hospital of FHPLFHPL

Advantages:

Simple Documentation – Sign off on discharge (Non-Me dical expenses will be borne by the member) , documents processed by FHPL directly.

Non – Network Hospitals can be used based on needs & urgency.

Call Center

� Dedicated member helpline 24 x 7

� Nationwide Toll free 1800 – 425 - 4033

� 24 X 7days accessible

� Electronically supported systems

� Managed by professionally skilled manpower� Managed by professionally skilled manpower

� Assistance in information on

� Network hospitals

� Enrollment status

� Support services in an Emergency

� Coverage eligibility

� Claims- documentation support, query handling

� General information on health plan

Query onQuery on PersonPerson MobileMobile EmailEmail

Account ManagerAccount Manager Mr. L Chandra ShekarMr. L Chandra Shekar 09243700289 l.chandrashekar@fhpl.netl.chandrashekar@fhpl.net

Claims & General Claims & General Queries Queries

Ms.Ms. Cynthia KavirajCynthia Kaviraj 080-22356251 / 52 cynthiakaviraj@fhpl.netcynthiakaviraj@fhpl.net

Network Hospital Network Hospital manu.sharma@fhpl.netmanu.sharma@fhpl.net

Contact – FHPL, Bangalore

Network Hospital Network Hospital Dr. Manu SharmaDr. Manu Sharma 92434 79824

manu.sharma@fhpl.netmanu.sharma@fhpl.net

PrePre--authorizationsauthorizations Dr. Kiran / Mr. RaviDr. Kiran / Mr. Ravi 080-22356251 / 52 preauthblr@fhpl.netpreauthblr@fhpl.net

Any Escalations on Any Escalations on the abovethe above

Mr. Ramalinga ReddyMr. Ramalinga Reddy 092434 79822ramalinga@fhpl.netramalinga@fhpl.net

FHPL Address

Family Health Plan (TPA) Ltd

No.11,2nd Floor E Block No.11,2nd Floor E Block

NITON Palace Road

Bangalore. – 560 052

Ph: 080 – 22356256 / 57

Fax: 080 – 22356255

THANK YOU THANK YOU