THE ADVOCATES’ MUTUALLY AIDED CO-OP. SOCIETY LTD., HYDERABAD MEDICLAIM POLICY TERMS & CONDITIONS
The present Policy No. 62030034190400000014 - From 02-02-2020 to 01-02-2021
The Members of The Advocates’ Mutually Aided Co-op. Society Ltd., Hyderabad., are requested to note the following Policy Conditions before availing Medi claim facility.
Policy has the following conditions:
- Room Rent / Boarding/ Nursing Expenses as provided by the Hospital/nursing home not exceeding 1.0 % of sum insured per day or actual amount whichever is less
- Intensive care unit (ICU) / Intensive Cardiac Care Unit (ICCU) expenses not exceeding 2% of Sum Insured per day or actual amount whichever is less.
- Pre-Hospitalization medical charges up to 30 days period immediately before the Insured’s admission to hospital for that illness or injury.
- Post -Hospitalization mediclaim charges up to 60 days period immediately after the Insured’s discharge from the hospital for that illness or injury.
The amounts payable under Surgeon ,Medical Practitioner, Consultants Specialist fees, Anesthesia, Blood, Oxygen, Operation Theatre Charges, surgical appliances, Medicines & Drugs, Diagnostic Materials and X-ray, Dialysis, Chemotherapy, Radiotherapy, Artificial Limbs, cost of prosthetic devices implanted during surgical procedure like Pacemaker, relevant laboratory /diagnostic tests, X-Ray and other medical expenses related to the treatment shall be at the rate applicable to the entitled room category. Policy has the following caps for all categories of Members opted with a Floater Sum Insured of Rs.1.50 lac under the policy NO. 62030034190400000014 - From 02-02-2020 to 01-02-2021
REIMBURSEMENT CHECK LIST
- Copy of the Intimation Letter
- Duly Filled & signed IRDA Claim Form (part-A & part-B by the hospital)
- Original Discharge Card / Summary with sign & stamp of the hospital.
- Original Final Bill of the Hospital with sign & stamp of the hospital.
- Original Bill Paid Receipt with sign & stamp of the hospital.
- Original Investigation Reports signed by MD.Pathologist as per IRDA guidelines.
- All Imaging Films along with reports sign & stamp, ECG Strips, Doppler / Angiogram CD etc.
- Original Prescriptions and corresponding Medicine bills,
- Hospital Registration Certificate.(if required query will be raised)
- Any other original documents related to the claim.
- MLC/FIR in case of Accident cases.
- Patient photo id proof name should match with the name provided in the policy .
- The copy of the cancelled cheque with printed name (or) front page of Bank passbook of the policy holder should be clear & need to submit along with the claim documents. PLS NOTE ITS MANDATORY.
- Required IPD Papers Xerox with sign & stamp.
NOTE: AFTER MEDICAL SCURTINY 2ND LEVEL QUERIES MAY BE MAY NOT BE RAISED BASED ON CASE STUDY….
Address : HEALTH INDIA INSURANCE TPA SERVICES PVT.LTD..
H.NO:7-1-28/9 A,1st Floor, Sai Towers,DK Road,
Ameer pet ,Hyderabad – 500016
Office Contact No’s :7207022632 & 8019022617
Mr B.SRinath Sr.CRM Cell No:- 8247650675
Mr.Santosh kumar manthri Cell No:- 7400037518
1. Maternity Claims, Normal and Caesarian is restricted to RS.25,000/
2. Cataract Claims restricted to Rs.15,000/
3. Fever Rs.30,000/-
4. Septo Plastic Rs.35,000/-
5. Six chemos are allowed in one year.
6. Hysterectomy cap is Rs.35,000/-
7.Lap surgeries Rs.40,000/-
8. Lasix Surgery excluded from the scope
9. Knee replacement Rs. 1,00,000/-
10. Disease for kidney stone including DJ strength remover for the same stone would be Rs.45,000/
11. In case Insured opts for a room with rent higher than the entitled category as under , the charges payable under above shall be limited to the charges
applicable to the entitled category.
No payment shall be made to Surgeon, Anaesthetist, Medical practitioner etc other than part of hospitalization bill.
Note : However, bills raised by Surgeon, Anaesthetist directly and not included in the hospitalization bill may be reimbursed in the following manner:
a) The reasonable, customary and necessary Surgeon fee and Anaesthetist fee would be reimbursed, limited to the max 25% of SI. The payment shall be
reimbursed provided the insured pays such fee(s) through cheque and the Surgeon / Anaesthetist provides a numbered bill. Bills given on letter-head of
the Surgeon, Anaesthetist would not be entertained.
b) Fees paid in cash will be reimbursed up to a limit of Rs. 10,000/- only, provided the Surgeon/Anesthetist provides a numbered bill.
c) Age Related Muscular Degeneration(ARMD) and/or Choroidal Neo Vascular Membrane done by administration of Lucentis / Avantis / Macugen/Avastin
and other related drugs as intra-vitreal injection, Rotational Field Quantum Magnetic Resonance(RFQMR), External counter Pulsation (ECP) and
Hyperberic Oxygen Therapy. Not payable
- Pre Hospitalization: 30 days, Post hospitalization : 60 days
- Claim Intimation : 24-48 hrs from the date of hospitalization
- Claim Submission: 7 days from the date of discharge at local Vidal office.
Any delay in claim submission should be supported by reason for delay and same will be forwarded to Insurance Company for confirmation based on their concurrence further claim will be processed.
NOTE : The TPA shall be informed before getting admitted in Hospital or availing the benefits under the policy.