More Related Content Similar to 1. health insurance orientation module Similar to 1. health insurance orientation module (20) 1. health insurance orientation module2. Introduction
ļ¼ Future Generali is an insurance joint venture between the Italy-based
Generali Group and the India-based Future Group.
ļ¼ Future Generali operates Life and Non-Life insurance businesses through āFuture
Generali India Life Insurance Co. Ltd.ā and āFuture Generali India Insurance Co. Ltd.ā
ļ¼ Future Group holds 74% each in both the companies.
ļ¼ Future Generali received license from the Insurance Regulatory Development
Authority (IRDA) in Sept 2007 and launched operations from Nov 2007.
Future Generali Health
5. How we are different:
ā¢ FutureĀ GeneraliĀ HealthĀ (FGH)Ā isĀ anĀ internalĀ unitĀ ofĀ FutureĀ GeneraliĀ IndiaĀ Insurance.
ā¢ NoĀ ThirdĀ PartyĀ AdministratorĀ (TPA)Ā involvedĀ betweenĀ theĀ insurerĀ andĀ FGH.
ā¢ NoĀ priorĀ approvalĀ requiredĀ toĀ sanctionĀ authorizationĀ forĀ cashlessĀ asĀ inĀ theĀ caseĀ ofĀ
TPAs.
ā¢ ClaimĀ settlementĀ isĀ fasterĀ dueĀ toĀ singleĀ pointĀ clearanceĀ ā noĀ exchangeĀ ofĀ claimĀ
documentsĀ betweenĀ insurerĀ andĀ TPA.
ā¢ PreferredĀ servicesĀ extendedĀ asĀ FGHĀ providesĀ serviceĀ onlyĀ toĀ clientsĀ insuredĀ byĀ
FutureĀ Generali.
Future Generali Health
6. Future Generali Health
An In-house Health Management Team of Future Generali India Insurance Co. Ltd.
Internal units of (FGH) Future Generali Health Team
Call Centre
24 X 7 Helpline to cater to customer queries
Enrolment
For card issuance and member data management
Cashless Management
24 X 7 services with 2 hours Turn Around Time (TAT)**
Claims Processing
Average TAT of 14 working days**
Provider Management
1400 hospitals and 200 diagnostic centers network
Research and Analysis
Analysis, Feedback & monitoring
Pre Policy
For retail medical underwriting
Underwriting
Centralized Group / Retail Underwriting at hubs
**All TATās subject to availability of complete documentation
Future Generali Health
8. MemberĀ EnrolmentĀ
KeyĀ Function:Ā For card issuance and member data management
ļ WithinĀ howĀ manyĀ daysĀ willĀ IĀ getĀ myĀ WellnessĀ Card?Ā Ā
ā¢ YouĀ willĀ receiveĀ healthĀ cardsĀ viaĀ courierĀ orĀ eāmailĀ withinĀ 7Ā daysĀ afterĀ yourĀ detailsĀ
areĀ receivedĀ byĀ FGHĀ fromĀ yourĀ organization.
ļ WhatĀ ifĀ thereĀ isĀ anĀ errorĀ onĀ myĀ WellnessĀ Card?Ā
ā¢ ForĀ anyĀ errorĀ inĀ cardsĀ orĀ correctionĀ required,Ā youĀ canĀ immediatelyĀ reportĀ toĀ Ā
yourĀ HR.
ļ WhatĀ isĀ theĀ useĀ ofĀ theĀ WellnessĀ Card?Ā
ā¢ YouĀ willĀ getĀ aĀ WellnessĀ CardĀ toĀ utilizeĀ theĀ CashlessĀ facilityĀ at NetworkĀ Hospitals.
ā¢ ThisĀ cardĀ helpsĀ onlyĀ inĀ yourĀ identificationĀ asĀ aĀ FutureĀ Generali HealthĀ member.
ā¢ AvailabilityĀ ofĀ CashlessĀ andĀ anyĀ otherĀ benefitĀ isĀ subjectĀ toĀ policyĀ terms.
Future Generali Health
12. CashlessĀ ProcessĀ FAQs
1. What is a Network Hospital? How do I know the hospital is on
the network?
ļ
FGHĀ hasĀ tiedĀ upĀ withĀ specificĀ hospitalsĀ andĀ nursingĀ homesĀ toĀ provideĀ preferredĀ servicesĀ
toĀ itsĀ customersĀ .Ā TheseĀ hospitalsĀ areĀ termedĀ asĀ āNetworkā hospitals.
ļ
YouĀ canĀ findĀ outĀ theĀ detailsĀ ofĀ NetworkĀ hospitalsĀ inĀ yourĀ cityĀ fromĀ ourĀ CallĀ CentreĀ onĀ
phoneĀ orĀ byĀ eāmail.Ā Ā TheĀ detailsĀ areĀ alsoĀ availableĀ inĀ theĀ HealthĀ InsuranceĀ GuideĀ sentĀ
alongĀ withĀ yourĀ WellnessĀ Card.
ļ
HospitalsĀ areĀ addedĀ andĀ removedĀ fromĀ theĀ networkĀ atĀ regularĀ intervals.Ā YouĀ areĀ
advisedĀ toĀ checkĀ withĀ ourĀ CallĀ CentreĀ Ā forĀ theĀ updatedĀ statusĀ of anyĀ hospital.
Future Generali Health
13. CashlessĀ ProcessĀ FAQs
2.How does the Hospital verify that the cardholder is genuine?
SinceĀ theĀ CardĀ issuedĀ isĀ notĀ aĀ photoĀ idĀ card,Ā youĀ areĀ requiredĀ toĀ submitĀ aĀ photoĀ idĀ toĀ
verifyĀ theĀ genuinityĀ ofĀ identityĀ atĀ theĀ AdmissionĀ DeskĀ ofĀ theĀ Hospital.Ā TheĀ photoĀ idĀ Ā canĀ
beĀ yourĀ OrganizationĀ IdentityĀ Card,Ā DrivingĀ LicenseĀ orĀ anyĀ other suchĀ cardĀ whichĀ willĀ
helpĀ theĀ hospitalĀ toĀ establishĀ theĀ genuinityĀ ofĀ theĀ patient.
3.What is a Preauthorization Request?
ThisĀ isĀ aĀ RequestĀ forĀ CashlessĀ Hospitalization.Ā TheĀ sameĀ hasĀ toĀ beĀ dulyĀ filledĀ up,Ā signedĀ
andĀ stampedĀ byĀ theĀ HospitalĀ Authorities.Ā ThereafterĀ itĀ hasĀ toĀ be sentĀ byĀ faxĀ /Ā eāmailĀ toĀ
FGH.Ā TheĀ ContactĀ detailsĀ ofĀ FGHĀ isĀ availableĀ inĀ theĀ hospital.
Future Generali Health
14. CashlessĀ ProcessĀ FAQs
4.Where do I procure the Preauthorization Request from?
TheĀ PreauthorizationĀ FormĀ templateĀ isĀ availableĀ withĀ theĀ Network HospitalsĀ orĀ alsoĀ
enclosedĀ withĀ theĀ HealthĀ InsuranceĀ Guide.Ā ItĀ canĀ alsoĀ beĀ obtainedĀ fromĀ FGHĀ CallĀ CentreĀ
onĀ phoneĀ orĀ byĀ eāmail.
5.How to fill the Preauthorization form?
ItĀ mustĀ beĀ filledĀ byĀ theĀ TreatingĀ Doctor.Ā
InformationĀ requiredĀ areĀ :Ā
IDĀ No.Ā asĀ printedĀ onĀ theĀ Card,Ā SignsĀ andĀ SymptomsĀ ofĀ theĀ present aliment,Ā durationĀ ofĀ
theĀ aliment,Ā diagnosis,Ā preĀ existingĀ conditionsĀ ifĀ any,Ā proposed lineĀ ofĀ treatment,Ā
expectedĀ dateĀ ofĀ admission,Ā durationĀ ofĀ stayĀ andĀ estimatedĀ costĀ ofĀ hospitalization.
Future Generali Health
15. CashlessĀ ProcessĀ FAQs
6.Where do I send the Preauthorization form?
TheĀ PreauthorizationĀ RequestĀ forĀ CashlessĀ HospitalizationĀ canĀ eitherĀ beĀ faxedĀ toĀ
24Ā xĀ 7Ā TollĀ FreeĀ FaxālineĀ 1800Ā 103Ā 9998Ā orĀ mailedĀ toĀ fgh@futuregenerali.in
7.What is an Authorization Letter ?
AuthorizationĀ LetterĀ isĀ theĀ communicationĀ ascertainingĀ theĀ AdmissibilityĀ orĀ AcceptanceĀ
ofĀ theĀ CashlessĀ Service.Ā TheĀ sameĀ isĀ issuedĀ byĀ FGHĀ subjectĀ toĀ admissibilityĀ ofĀ theĀ claimĀ
andĀ availabilityĀ ofĀ balanceĀ sumĀ insuredĀ forĀ theĀ member.
8.Is the entire amount requested by hospital authorized by
FGH?
FGHĀ wouldĀ releaseĀ aĀ partĀ orĀ theĀ entireĀ amountĀ dependingĀ onĀ theĀ ailmentĀ andĀ relatedĀ
expenses.Ā InĀ caseĀ aĀ partĀ amountĀ hasĀ beenĀ approvedĀ byĀ FGH,Ā thenĀ theĀ hospitalĀ wouldĀ
askĀ forĀ additionalĀ authorizationĀ whenĀ necessary.
Future Generali Health
16. CashlessĀ ProcessĀ FAQs
8.How do I know whether my Claim has been approved for
Cashless or not?
AuthorizationĀ LetterĀ orĀ DenialĀ LetterĀ shallĀ beĀ faxedĀ directlyĀ to theĀ HospitalĀ withĀ
intimationĀ toĀ you.
AĀ QueryĀ letterĀ shallĀ beĀ faxedĀ toĀ theĀ hospitalĀ ifĀ inĀ caseĀ FGHĀ wantsĀ someĀ additionalĀ
informationĀ toĀ decideĀ uponĀ theĀ admissibility.
Future Generali Health
17. CashlessĀ ProcessĀ FAQs
9. What are the circumstances under which a Request for
Cashless Hospitalization shall be denied?
1.
IfĀ theĀ informationĀ containedĀ inĀ theĀ RequestĀ isĀ insufficientĀ forĀ FGHĀ toĀ arriveĀ atĀ aĀ
decisionĀ andĀ furtherĀ informationĀ isĀ notĀ availableĀ forĀ whateverĀ reasons.
2.
TheĀ ailmentĀ forĀ whichĀ hospitalizationĀ isĀ soughtĀ isĀ notĀ coveredĀ underĀ theĀ
particularĀ insuranceĀ policyĀ orĀ isĀ aĀ partĀ ofĀ anĀ ExclusionĀ underĀ theĀ policyĀ
guidelines.
3.
TheĀ insuredĀ hasĀ alreadyĀ exhaustedĀ hisĀ insuranceĀ coverageĀ forĀ the year.
Future Generali Health
20. Remember
CashlessĀ facilityĀ isĀ alwaysĀ subjectĀ toĀ theĀ broaderĀ policyĀ guidelinesĀ andĀ relevantĀ
termsĀ andĀ conditions.
ImportantĀ
PleaseĀ noteĀ thatĀ declineĀ ofĀ aĀ requestĀ forĀ CashlessĀ HospitalizationĀ isĀ onlyĀ denialĀ ofĀ
CashlessĀ ServiceĀ andĀ isĀ inĀ noĀ wayĀ toĀ beĀ treatedĀ asĀ denialĀ ofĀ treatmentĀ orĀ claim.Ā TheĀ
insuredĀ retainsĀ theĀ rightĀ toĀ getĀ treatedĀ andĀ submitĀ theĀ billsĀ to FGHĀ forĀ subsequentĀ
Reimbursement.
Future Generali Health
21. PreliminaryĀ scrutinyĀ ofĀ claimĀ &
verificationĀ :
ā PolicyĀ BenefitĀ Ā Ā Ā Ā Ā Ā Ā
ā DateĀ ofĀ LossĀ Ā Ā Ā Ā Ā Ā Ā Ā Ā
ā MandatoryĀ DocumentsĀ Ā Ā Ā Ā
Deficient
(SomeĀ DocumentĀ required
ForĀ Admissibility)
Repudiated
(NotĀ fallingĀ withĀ policyĀ conditions)
ReplyĀ notĀ
received
Approved
(AdmissibleĀ underĀ policy)
RepudiationĀ letter
sentĀ toĀ client
IntimationĀ ofĀ the
DeficiencyĀ
isĀ sentĀ toĀ theĀ client
ReplyĀ receivedĀ along
withĀ allĀ
deficientĀ documents
ClaimĀ documentsĀ receivedĀ Ā fromĀ Ā
InsuredĀ member
PaymentĀ chequeĀ
sentĀ toĀ client
SubsequentĀ remindersĀ
sentĀ atĀ fixedĀ intervals
DocumentsĀ
notĀ received
ReimbursementĀ
ClaimsĀ Process
ClaimĀ closedĀ
withoutĀ payment
Future Generali Health
22. ReimbursementĀ ClaimĀ ProcessĀ ā FAQs
In case of Non Cashless Claims, what would be an appropriate plan
of action to ensure timely reimbursement of the claim?
IfĀ cashlessĀ facilityĀ isĀ notĀ availed,Ā preāauthorizationĀ isĀ deniedĀ orĀ treatmentĀ isĀ availedĀ atĀ aĀ nonā
networkĀ hospital,Ā theĀ insuredĀ willĀ haveĀ toĀ settleĀ theĀ billsĀ directlyĀ withĀ theĀ hospitalĀ andĀ
subsequentlyĀ claimĀ reimbursementĀ byĀ submittingĀ theĀ followingĀ documentsĀ toĀ FGH:
1. FirstĀ PrescriptionĀ /Ā consultationĀ noteĀ fromĀ theĀ Doctor
2. TheĀ ClaimĀ FormĀ dulyĀ signedĀ byĀ theĀ claimantĀ orĀ familyĀ member
3. TheĀ OriginalĀ HospitalĀ DischargeĀ CardĀ
4. TheĀ OriginalĀ HospitalĀ BillĀ givingĀ detailedĀ breakĀ upĀ ofĀ allĀ expenseĀ headsĀ mentionedĀ inĀ theĀ
bill
Future Generali Health
24. ReimbursementĀ ClaimĀ ProcessĀ ā FAQs
What are the norms for Intimation on Claims ?
PreliminaryĀ noticeĀ ofĀ claimĀ withĀ particularsĀ relatingĀ toĀ NameĀ of theĀ InsuredĀ
PersonĀ /Ā Claimant,Ā NatureĀ ofĀ illnessĀ /Ā injuryĀ andĀ NameĀ andĀ AddressĀ ofĀ theĀ
attendingĀ MedicalĀ PractitionerĀ /Ā HospitalĀ /Ā NursingĀ homeĀ shouldĀ beĀ givenĀ toĀ
FGH. IntimationĀ canĀ beĀ sentĀ byĀ eāmailĀ orĀ FaxĀ toĀ ourĀ CallĀ Centre.
FGH
Future Generali Health
25. ReimbursementĀ ClaimĀ ProcessĀ ā FAQs
Are there any norms related to the Hospital where treatment is sought
which are mandatory for admissibility of claims?
PleaseĀ ensureĀ thatĀ theĀ hospitalĀ /Ā nursingĀ homeĀ whereĀ youĀ areĀ contemplatingĀ treatmentĀ
fulfillsĀ theseĀ criteria.Ā
1.ItĀ hasĀ atĀ leastĀ 15Ā inpatientĀ beds;
2.ItĀ hasĀ aĀ DoctorĀ whoĀ isĀ inĀ attendanceĀ 24Ā hoursĀ perĀ day;
3.ItĀ maintainsĀ dailyĀ medicalĀ recordsĀ forĀ eachĀ ofĀ itsĀ patients,
4.ItĀ isĀ registeredĀ andĀ licensedĀ asĀ aĀ hospitalĀ orĀ nursingĀ homeĀ with theĀ appropriateĀ localĀ
authorities.Ā AlwaysĀ instructĀ theĀ hospitalĀ authorityĀ toĀ mentionĀ theĀ AttendingĀ DoctorāsĀ andĀ
HospitalĀ RegistrationĀ No.Ā inĀ theĀ hospitalĀ papersĀ orĀ demandĀ forĀ a separateĀ certificateĀ onĀ theĀ
same
5.TheĀ hospitalĀ providesĀ aĀ properĀ dischargeĀ summary,Ā numberedĀ billĀ andĀ receiptĀ forĀ
hospitalizationĀ expensesĀ atĀ theĀ timeĀ ofĀ discharge
Future Generali Health
26. ReimbursementĀ ClaimĀ ProcessĀ ā FAQs
Where do I send my claim documents?
ļ¼ClaimĀ documentsĀ willĀ beĀ forwardedĀ toĀ theĀ FutureĀ GeneraliĀ HealthĀ TeamĀ inĀ PuneĀ byĀ theĀ
memberĀ /Ā corporate.Ā AllĀ claimsĀ willĀ beĀ managedĀ byĀ theĀ ClaimsĀ TeamĀ locatedĀ inĀ Pune.Ā
Claims Team
Future Generali Health
2nd Floor, Kant Helix Tower, Bhoir Colony, Opp Tata Motors, Chinchwad,
Pune ā 411033 (Maharashtra)
ļ¼AllĀ claimĀ paymentsĀ adviceĀ shallĀ beĀ madeĀ withinĀ 14Ā workingĀ daysĀ fromĀ theĀ dateĀ ofĀ receiptĀ ofĀ
COMPLETEĀ documents.
ļ¼FGHĀ mayĀ askĀ forĀ theĀ additionalĀ documentsĀ fromĀ theĀ claimantĀ ifĀ theĀ submittedĀ documentsĀ
areĀ notĀ sufficientĀ toĀ decideĀ theĀ admissibilityĀ ofĀ theĀ claim.
Future Generali Health
27. ReimbursementĀ ClaimĀ ProcessĀ ā FAQs
What does FGH do with my claim documents?
ļ¼YourĀ claimĀ isĀ assessedĀ byĀ ourĀ expertĀ teamĀ andĀ doctorsĀ whoĀ verify theĀ documentsĀ andĀ bills
ļ¼IfĀ allĀ requirementsĀ areĀ completeĀ andĀ theĀ claimĀ isĀ admissible,Ā theĀ claimĀ isĀ approvedĀ andĀ theĀ Ā
chequeĀ isĀ sentĀ toĀ youĀ orĀ yourĀ corporate
ļ¼IfĀ theĀ claimĀ isĀ notĀ admissible,Ā thenĀ aĀ RepudiationĀ LetterĀ isĀ sentĀ toĀ youĀ /Ā corporateĀ byĀ eāmailĀ
/Ā courier
ļ¼IfĀ ourĀ teamĀ requiresĀ additionalĀ documentsĀ toĀ processĀ theĀ claim,Ā thenĀ aĀ DocumentĀ RecoveryĀ
letterĀ willĀ beĀ sentĀ toĀ youĀ /Ā corporateĀ byĀ eāmailĀ /Ā courier
ļ FGHĀ willĀ sendĀ oneĀ intimationĀ andĀ twoĀ remindersĀ atĀ intervalsĀ ofĀ 15Ā days
ļ IfĀ additionalĀ documentsĀ areĀ notĀ receivedĀ afterĀ theĀ secondĀ reminderĀ fromĀ FGH,Ā theĀ
claimĀ isĀ assessedĀ withĀ theĀ availableĀ documents.Ā ThisĀ couldĀ leadĀ toĀ partĀ paymentĀ orĀ
noĀ paymentĀ atĀ all.
Future Generali Health
28. YourĀ ContactĀ Points
ForĀ anyĀ claimĀ relatedĀ query,Ā hospitalĀ information,Ā grievance,Ā feedbackĀ orĀ
appreciation,Ā pleaseĀ contactĀ usĀ onĀ theĀ following:
Toll Free Phone No
1800 103 8889
Toll Free Fax No
1800 103 9998
Email
fgh@futuregenerali.in
InĀ caseĀ youĀ doĀ notĀ receiveĀ aĀ responseĀ fromĀ theĀ above,Ā thenĀ youĀ canĀ escalateĀ yourĀ
issueĀ toĀ theĀ following:Ā Ā
*1st Escalation:Ā VinayakĀ PankhadeĀ at palanivel.a@futuregenerali.in
*2nd Escalation:Ā AshishĀ SaxenaĀ atĀ ashish1.saxena@futuregenerali.in
*3rd Escalation:Ā BishwajitĀ NayakĀ atĀ bishwajit.nayak@futuregenerali.in
Future Generali Health
29. Future Generali Health Insurance
2nd Floor, Kant Helix Tower, Bhoir Colony, Opp Tata Motors, Chinchwad,
Pune ā 411033 (Maharashtra)
Future Generali Health