Frequently Asked Question

 

Q: Who is the Insurer for the Policy?

A: The Policy is underwritten by United India Insurance Company Ltd. who is the lead insurer for this policy.

Q: What is Medical Expense?

A: Medical Expenses means those expenses that a member has necessarily and actually incurred for medical treatment on account of Illness or Accident on the advice of a Medical Practitioner.

Q: How can I avail of DHS TPA's services?

A: If DHS is appointed by the insurer as the authorized TPA for administration of the policy, then DHS's services can be availed. Pls. Check your Policy Copy (Name of TPA printed on the Policy Copy).

Q: What services would DHS be offering?

A: As the authorized TPA servicing the policy following services are offered:

  • A personalized Identity Card will be issued to each member and dependent's to avail of Cashless facilities in all the network hospitals of DHS.
  • Cashless service facility at network hospitals up to limit the authorized limit as per policy terms & conditions.
  • Claims processing of reimbursement of claims
  • 24hr X7 Call Center service through toll free telephone number 1800 210 0201
  • Website giving Online facility for generation of E-card, intimation, filing, upload and tracking of claims and Payment Status.
  • Help Desks at various locations across the country
  • Grievance Portal to solve all enquiries and grievance within 24 hours.
Q: In case of need for information, what are the details required for identification while contacting DHS call center?

A: Policy number, your DHS card or EMP ID number & Bank Name should be kept handy, while contacting the Call Centre.

Q: What is a Health Identity Card?

A: A Health Identity card will be given to you by your TPA. It will consist of the name of your bank , Your Employee ID, a Unique Identification Number , the Policy period and the TPA contact details. The Health card will help in availing cashless facilities in the TPA network hospitals.

Q: What is my recourse, if ID card is not given to me. ?Will I be able to avail cashless facilities without the same ?

A: Please check with your HR , if you are an enrolled member with the policy. If not kindly make provisions to enroll yourself. Once the HR sends the Information to the Insurance company the TPA will send you the ID card Kit. If you are an enrolled member please call up the TPA call centre and they shall assist you with the same. Cashless cannot be availed without the health ID card.

Q: What is the procedure of Applying for a New Health ID card in case of loss ?

A: Alongwith the ID card a welcome letter will be sent to you with your login ID and password. This will help you to go on the TPA website and download an E-card which will work similar to the Health ID card.

Q: What Is Cashless Facility ?

A: Cashless Facility is a benefit extended by the Insurance Company through a TPA wherein the insured has the option to get admitted to a Network hospital without the burden of payment of the Hospital Bill. The entire bill is settled directly by the insurance company subject to terms and conditions of the policy.

Q: Does cashless hospitalization mean getting treatment free of cost?

A: Cashless hospitalization does not mean the free of cost treatment. DHS will mediate between the hospital and the insurance company and settle the bills on behalf of the insured as per the benefits in the policy, coverage under the policy and exclusions under the policy. Any expenses that are not payable under the insurance policy will not be authorized during hospitalization and the same will have to be borne by the patient.

Q: Does cashless hospitalization cover all medical expenses?

A: Expenses like, telephone charges, diet charges, documentation charges and any other non-medical expenses included in the hospital bill are not reimbursable. All the other charges related to the treatment are covered as per the terms & conditions of the policy.

Q: What is the Procedure to be followed if we approach the Bank Claim Processing Hub?

A : The Insured can approach the Bank Processing Hub in order to avail cashless services. The Process is as Under

  • Employee Approaches the bank processing Hub with the details of his hospitalization(The Name of the Hospital , The Admission date , The Ailment and the Estimated Cost
  • The Bank Officer Guides him to the TPA Help Desk.
  • The Help Desk enters the information and prepares a letter of Authorization
  • The Help Desk give a copy of the Authorization letter to the employee and simultaneously sends a copy to the hospital.
  • The employee can get admitted to the hospital by showing the Authorization letter at TPA Help Desk
Q: How to avail Cashless? / Procedure of Cashless:

A:The Procedure mentioned below needs to follow while availing Cashless.

  •  Choose network Hospital from updated DHS network list of hospital available on the website.
  • Collect Pr-Authorization Form the TPA Counter of the hospital.
  • Fill up personal details and the rest to be filled up by the hospital treating doctor along with Contact number.
  • Pre-auth form is to be duly filled and it should be stamped & signed by the hospital authority.
  • Hospital will send the fax/ e-mail to DHS.
  • Medical and Technical scrutiny is to be done by the DHS medical team.
  • In case of requirement for more details, DHS will send the query letter to the hospital.
  • Hospital shall send the reply to DHS, and accordingly the request is to be re-processed.
  • In case of the details mentioned in the form is enough to process the cashless, and doesn't fall under any of the exclusion of the policy, DHS will send the Approval Letter to the Hospital.
  • Get admitted, take treatment and get discharge without payment of bill.
  • Please ensure Claim form is filled and duly signed and final bill is signed, before discharge.
  • Hospital Authority will submit all the bills along with claim form to DHS.
  • Payment will be made to the Hospital/Nursing Home directly by DHS.
Q: What are the documents required to avail Cashless facility ?

A: Cash Less facility is available only in network hospitals. The following documents will be required before issuing cashless Authorization Letter.

  1. Duly filled, Signed & Stamped Pre Authorization Form from the hospital.
  2. Investigation Reports & Previous Consultation Papers (if any).
  3. Photo Id Proof
  4. DHS Id Number / Policy Number / Employee Number (Pls. mention on the form / provide a copy).
Q: How to avail Reimbursement of claim? / Procedure of Reimbursement Claim.

A: The process is listed below:

  • Claim Intimation to be sent (Telephonically/ e-mail/ fax/ online intimation) prior to the Hospitalization or in case of emergencies immediately upon hospitalization but prior to discharge).
  • Insured gets admitted to the hospital, take treatment and pay the bill after collecting all the original documents from the hospital.
  • Insured can get admitted in any hospital (Network / Non Network).
  • Claim documents to be submitted to Help Desk , Bank Claim Processing Office or nearest DHS office as per the convenience of the employee
  • Unique claim number for all the individual hospitalization / insured will be auto-generated in DHS System after intimating the details in system.
  • Medical / technical Scrutiny is to be done.
  • The claim is processed on the basis of the terms and conditions laid down in the policy, and NEFT will be done directly to the employee.
  • In case, the claim does not fall within the terms & conditions of the Policy after medical / technical scrutiny, the claim will be recommended for repudiation in front of the committee appointed by the bank and Insurance Company . The Committee will be the final authority for repudiation and the ltter of denial will then be sent by the insurance company.
Q: Is there any scope of Repudiation of Claim ?

A: If the Ailment is not covered in the terms and conditions of the policy, the claim may be repudiated. (For details of the policy terms and condition, Kindly log into the TPA website). In case of Repudiation , the claim will be first put up before the committee and then repudiated.

Q: What documents are needed for processing claims that have to be reimbursed?

A: Following documents are required for processing reimbursement claims:

  • Claim Form duly filled and signed by the claimant.
  • Final Bill & Discharge Card from the hospital.
  • All documents pertaining to the onset from the date it was first detected.
  • All relevant bills and receipts in originals
  • Medicine / Chemist Bills supported by prescriptions in originals
  • Original Receipt and diagnostic test reports to be supported by a letter from the consulting doctor prescribing such tests.
  • In case of surgery a certificate issued by the operating surgeon (OT Note) detailing the nature & Grade of the operation performed and attached along with relevant bill and receipt is required in original with Bifurcations.
  • Certificate from the attending medical practitioner / surgeon that the patient is fully cured.
  • DAMA / Transfer Certificates in case the patient has been shifted from one hospital to another.
  • Bank Details with copy of Cancelled Cheque (Only For Individual Policy Holder).

Apart from the documents listed above - Disease specific documents: *For any accidental / fracture case: MLC Copy and letter from hospital / treating doctor stating details of accident, alcohol or any intoxicating drugs history. *Complete obstetric history (anti natal card) with GPLA status in case of pregnancy / delivery / maternity. If it is LSCS then necessity for the same is required to be mentioned on discharge card along with the indication of LSCS. *IOL sticker showing serial number in case of cataract operation. *Serial Number sticker in case of insertion of "stent" for Heart operation. *Invoice for any of the implant surgery.

Q: Whether treatment is allowed in any of the hospitals or nursing homes?

A: A Hospital means any institution established for in-patient care and day care treatment of illness and/or injuries and which has been registered as a Hospital with the local authorities under the Clinical establishments (Registration and Regulation) Act, 2010 or under the enactments specified under the Schedule of Section 56(1) of the said Act OR complies with all minimum criteria as under

  • Has qualified nursing staff under its employment round the clock.
  • Has at least 10 in-patient beds in towns having a population of less than 10 lacs and at least 15 in-patient beds in all other places;
  • Has qualified medical practitioner(s) in charge round the clock;
  • Has a fully equipped Operation Theatre of its own where surgical procedures are carried out;
  • Maintains daily records of patients and makes these accessible to the insurance company's authorized personnel.

The term "Hospital / Nursing Home" shall not include an establishment which is a place of rest, a place for the aged, a place for drug-addicts or place for alcoholics, a hotel or a similar place. This clause will however be relaxed in areas where it is difficult to find such hospitals.

Q: What is pre-post hospitalization & how much amount / limit / number of days are covered for the same?

A: Pre- Hospitalization: Pre-Hospitalization means relevant medical expenses incurred during a period up to 30 days prior to Date of Admission for an illness or bodily injury sustained and considered a part of claim admissible under the policy.

Post-Hospitalization: Post-Hospitalization means relevant medical expenses incurred during a period up to 60 days after the Date of Discharge for an illness or bodily injury sustained and considered a part of claim admissible under the policy.

Q: What is Pre-Existing disease? Is it covered in my policy?

A: Pre Existing Disease is any condition, ailment or injury or related condition(s) for which you had signs or symptoms, and/or were diagnosed, and/or received medical advice/treatment, prior to the first policy issued by the insurer. Pre-existing diseases are covered in the policy

Q: How can one know more about terms and conditions of the Mediclaim policy?

A: Information about terms of specific policy is available in the member page on the website. Alternative one can call up on the toll free number and seek the necessary information.

Q: In the event of loss of DHS Mediclaim card, what is the procedure to get a duplicate card issued?

A: A request can be put up on our website, at the help desk or on the exclusive email id provided for duplicate ID card, mentioning DHS ID number , or Employee number and name of the bank. A duplicate card will be issued at no cost within 48 hours

Q: What if original medical documents are required by the patient/insured for future medical follow ups?

A: Original documents are required to settle any claims. However Original Investigation reports can be returned back after verification with the stamp originals verified. All original bills and discharge card will be retained by us

Q: Can outpatient treatment be availed under the Mediclaim policy?

A: Medical expenses incurred in case of the following diseases which need Domiciliary Hospitalization /domiciliary treatment as may be certified by the attending medical practitioner and / or bank's 'medical officer shall be deemed as hospitalization expenses and reimbursed to the extent of 100% Cancer , Leukemia, Thalassemia, Tuberculosis, Paralysis, Cardiac Ailments , Pleurisy , Leprosy, Kidney Ailment , All Seizure disorders, Parkinson's diseases, Psychiatric disorder including schizophrenia and psychotherapy , Diabetes and its complications, hypertension, Hepatitis-B , Hepatitis-C, Hemophilia, Myasthenia gravis, Wilson's disease, Ulcerative Colitis , Epidermolysis bullosa, Venous Thrombosis(not caused by smoking) Aplastic Anaemia, Psoriasis, Third Degree burns, Arthritis , Hypothyroidism , Hyperthyroidism expenses incurred on radiotherapy and chemotherapy in the treatment of cancer and leukemia, Glaucoma, Tumor, Diptheria, Malaria, Non-Alcoholic Cirrhosis of Liver, Purpura, Typhoid, Accidents of Serious Nature , Cerebral Palsy, Polio, All Strokes Leading to Paralysis, Haemorrhages caused by accidents, All animal/reptile/insect bite or sting , chronic pancreatitis, Immuno suppressants, multiple sclerosis / motorneuron disease, status asthamaticus, sequalea of meningitis, osteoporosis, muscular dystrophies, sleep apnea syndrome(not related to obesity), any organ related (chronic) condition, sickle cell disease, systemic lupus erythematous (SLE), any connective tissue disorder, varicose veins, thrombo embolism venous thrombosis/venous thrombo embolism (VTE)], growth disorders, Graves' disease, Chronic obstructive Pulmonary Disease, Chronic Bronchitis, Asthma, Physiotherapy and swine flu shall be considered for reimbursement under domiciliary treatment. The cost of Medicines, Investigations, and consultations, etc.in respect of domiciliary treatment shall be reimbursed for the period stated by the specialist and / or the attending doctor and / or the bank's medical officer, in Prescription. If no period stated, the prescription for the purpose of reimbursement shall be valid for a period not exceeding 90 days.

Q: What is critical illness cover under the policy ?

A: Critical Illness cover is provided to the employee only subject to a sum insured of Rs. 1,00,000/- . Cover starts on inception of the policy. In case an employee contracts a Critical Illness as listed below, the total sum insured of Rs.1,00,000/- is paid, as a benefit. This benefit is provided on first detection/diagnosis of the Critical Illness.

  • Cancer including Leukemia
  • Stroke
  • Paralysis
  • By Pass Surgery
  • Major Organ Transplant
  • End Stage Liver Disease
  • Heart Attack
  • Kidney Failure
  • Heart Valve Replacement Surgery

Hospitalization is not required to claim this benefit. Further the Employee can claim the cost of hospitalization on the same from the Group Mediclaim Policy as cashless / reimbursement of expenses for the treatment taken by him.

Q: What action needs to be taken if a network hospital denies admission?

A: Please make a call to the DHS call center, providing details of the hospital. The concerned department at DHS will immediately contact the medical provider and resolve the issue.

Q: Can Mediclaim benefits be availed across India?

A: DHS TPA services are offered all over India. For detailed list of network hospitals , please check the Hospital Network list on the website or contact the call centre.

Q: What is the time limit for submission of documents in case of reimbursement claims ?

A: All the documents need to be submitted within 30 days of Discharge. For the Post Hospitalization - 90 days from Date of Discharge.

Q: What is Day Care Treatment?

A: Day care Treatment refers to medical treatment and or surgical procedure which is

  • undertaken under general or local anesthesia in a hospital/day care Centre in less than a day because of technological advancement, and
  • Which would have otherwise required a hospitalization of more than a day?

Treatment normally taken on an out-patient basis is not included in the scope of this definition.

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