FAQs

Download as pdf or txt
Download as pdf or txt
You are on page 1of 5

FAQ Answer

Q1: What are the services available to me from the


TPA? A: You can avail of the following services :
ENROLLMNT e-Card against your policy, which would give you access to our TPA
services.
Cashless service facilitation at networl hospital upto limit authorized by
Mediclaim / Hospitalization Insurance
Claim processing and Reimbursement for non network hospitals
24hr access to our Call Center through our Toll Free line and IVR and location
spoc.

Online Assiaitance during hospitalization and filing claim form documents.


documents
Other services as defined by Employer/ Insurer.

A: Please mention your Vipul e-Card Number to the Call Center Executive, IVR,
locat ion SPOC. The executive may verify other details like your Date of Birth,
Q2: When I call Vipul MedCorp TPA's Call Employer Details etc. On establishing your ident ity, we will be happy to answer
Center/IVR/Office, how will you identify me? your quer ies.
Q3: What if I don’t remember my Card Yes you can use the employee ID along
Number and my Policy Number and I am in with your company name
an emergency situation? Can I use my
employee ID no.?
Q4: How do I avail of Cash Less Facility? Cash Less facility is available only in network hospitals
To avail cashless facility, the member has to visit any of the
network hospital (network hospital list available on Vipul MedCorp
website)
Insured has to produce his TPA card at the recept ion/TPA desk.

He will have to fill a pre-authorization request form The preauthorizat


ion form will be duly signed by the treat ing doctor and
will be faxed/emailed to Vipul by the hospital
Vipul doctor will process the documents based on eligibility/policy
condition and send a final authorization to hospital. There may be
some deduct ions of non-payable items like registration fees,
personal items etc. for which the hospital may insist on a
refundable nominal deposit.
On the date of discharge, hospital will fax/email the f inal bill and
discharge summary to TPA and patient/dependents of patient
needs to sign all original documents, which will be retained by the
hospital for onward submission to TPA. Pat ient should retain
Xerox of all documents for future reference.
Q5: What documents do I need to send for A: Following documents are required for processing your claims
processing claims if the treatment has been on reimbursement basis:
done in a non-network hospital / In a a. Online Claim Form to be filled thru Self Care Portal.
network hospital where cash less facility b. Discharge Summary from the hospital(in case of
was not granted / availed ? hospitalisation)
c. All original documents pertaining to the illness
d. Main Hospital Bill.
e. Payment Receipt.
f. Relevant reports/films of diagnost ics tests.
Q5A . Where do I submit my claims A A: you can submit the claims to the Vipul Help Desk Execut ive
along with print out of the online claim form
Q6: When will my claim be reimbursed? A: The claim will be reimbursed within - 15 days after receipt of
complete documentation from the client / Corp HR.
Q7: What documents should we obtain A: All bills in original and a discharge cert ificate are to be left with
before discharge from the hospital in case of the hospital prov iding cashless treatment. The pat ient has to
cash less facility availed? countersign all bills and fill the claim form and also leave the
same with the hospital at the time of discharge.
A copy of the bills & Discharge Summary can be carried by the
patient for his records and for submission along with Pre & Post
Hospitalization bills.
Q8: Is there any exclusion in the policy A: Yes. As per policy T & Cs
Q9: Can I get the salient features of our A: The salient features of the policy can be viewed by visit ing the
Policy coverage Vipul MedCorp website
(http://www.vipulmedcorp.com/niit/Index.aspx)
Q10: Can Vipul MedCorp TPA reject my A: Yes, the TPA can reject / deny your claim based on their
claim? Do I have any remedy? evaluation / analysis on justif iable grounds. The reject ion letter
will cover the reasons for rejection of the claim.
Remedy :- In case you are not satisfied by the reasons for
rejection, you can represent to the insurer/TPA within 15 days of
such denial.
Q11: How do I get a list of network A: The list of hospitals is available on the Vipul MedCorp website
hospitals of Vipul MedCorp TPA Pvt. Ltd.? under the "Hospital Network" sect ion
Q12: Can I lodge more than one claim for A: Yes, your mediclaim policy covers 30 days Pre-hospitalizat ion
the same disease? expense reimbursement and 60 days Post-hospitalization
expenses. You may lodge your Pre-hospitalization claim along
with hospitalization claim. The Post-hospitalizat ion claim may be
lodged after 60 days of the hospitalization. However, please
quote your Vipul ID Number for easy referral and sort ing.
Q13: How will you keep track of my claim? A: You may lodge your claim online with us and submit the claim
through our Helpdesk and it should be mapped with the checklist
and the claim status can be v iewed online through self care
portal.
Q14: In case I require my original medical A: Please carry a complete set of photocopied documents when
papers back for future reference, what you lodge your claim. The relevant original documents will be
should I do ? returned to you after verification. We will however stamp the
original documents [Vipul MedCorp TPA - Claim Processed on
Xeroxed copy ]. Please note that normally, the original doctor
prescription, medicine bills and discharge summary along with the
hospital bills will be retained by us. Only X-ray films, ECG, other
medical records will be returned to you as a special case after
verification / approval of our medical team.
Q15: During the course of my treatment, A: Yes it is possible to shift to another hospital for reasons of
can I change the hospitals? requirement of better medical procedure. However, this will be
evaluated on the mer its of the case and as per policy terms and
conditions.
Q16: Can I get outpatient treatment using A: No. The TPA Card is issued to you against your mediclaim
my TPA Card? policy which only covers hospitalization expenses. The outpat ient
expenses pertaining to the treatment of disease which is the
cause of hospitalization is however covered in Pre & Post
Hospitalization benefits.
Q17: I have received my e-Card but there A: For any changes, please contact your HR Team.
are mistakes. What should I do?
Q18: I am not happy with the services of A: You can access our online Query module through self care and
Vipul MedCorp TPA or if I have a query. we shall resolve your quer ies within 48 hours. In case you face
What should I do? any service issues , please escalate to your HR SPOC or to Vipul
SPOC/Escalation Matrix contacts.
Q19: I went to one of your network A: You may immediately call our location spoc, giving details of
hospitals and they did not entertain me. such hospitals/medical providers. Our network department will
How should I proceed? immediately contact the concerned medical provider and sort out
the matter.
Q20: I am not keen to avail of Cash Less A: Yes. Under the Mediclaim Policy, you can opt for Cash Less as
facility. Can I go in for reimbursement? well as Reimbursement. We would advise that in case you are
taking treatment from a network hospital, then you should avail
of the Cash Less facility. This will give you the financial
advantage of not paying for your hospital treatment and also
gives you more cushion to meet your post-hospitalization
expenses, as we have package/discounted rates with the network
hospitals.
Q21: In case the child after birth suffers A: The new born is covered from day 1 in case of hospitalization
from any disease is the expense covered. If and justified treatment is administered. In case of cashless,
yes, how will the enrolment be done when the hospital needs to prepare bills and send cashless request in the
the child has not been named? name of “B/o <mother’s name>” for processing.
For re imbursement, the child has to be enrolled with Vipul first
in order to process the claim through our enrollment module.
Congenital ailments are not covered.
Q22: If the member suffers from any A: The complications arising out of maternity are covered under
complication due to her maternity, is it the maternity benefits and upto the limit of the maternity sum
covered and up to what limit? insured.
Q23: How do I access the A: Please refer to the Self care module to view the Relationship
relationship/escalation matrix? matr ix.
Q24: If a network hospital does not cooperate A: Employees are advised to contact the Vipul representatives in
with me, what recourse do I have? case the hospital does not co-operate.
Q25: What do you mean by pre-existing A: Any disease exist ing pr ior to the inception of policy
coverage?
Q26: What is floater cover? Sum Insured can collectively be utilized by any member in the
family.
Q27: What do you mean with the term A: The durat ion of indoor stay in the hospital should be more
hospitalization? than 24 Hrs. However, this time limit will not apply for specific
treatments i.e. dialysis, chemotherapy, radiotherapy, eye surgery,
lithotr ipsy, tonsillectomy, D&C, etc.
Q28: Can I go to any hospital or clinic for A: Yes, but please ensure that the hospital is well equipped to
taking treatment? handle medical emergencies.
Q29: What is called maternity benefits? A: Any expense related to maternity expenses related to
hospitalizat ion only. These expenses are payable only if insured
has less than 2 living children. Postnatal & prenatal expenses are
not covered.
Q31: Will I get the entire amount of the A: The insurance company will pay the entire amount of the claim
claim always? if it is related with the medical treatment and is supported by
proper documentations and within the limits. However, all the
claims should stand testimony to medical professional jurisdiction.
Failing this only that part of the claim that is justified will be
payable. There is 20% co-pay applicable on all claims of parents and
10% on claims of Self, Spouse & Kids. Non payable item list can be
referred through self care module.
Q32: If I have not utilized my permissible A: The amount will not be carr ied forward to subsequent periods
eligibility amount in a particular policy
period will I get any benefits like carry
forward for the next period if I renew the
policy?
Q33: In case of employee transfer to another A: Change of location , within India does not affect the coverage
location in there any procedure involved to as your policy coverage is PAN India and Vipul MedCorp provides
continue the scheme? cashless facility on PAN India basis
Q34: Will the change in names in between A: Yes. According to insurance company the claim will not be
policy period matters? settled (unless prior intimation to TPA and the Insurance
company) if there is any alterations in the name and in
bills/reports (documents) submitted by member/hospital
Q35: Can I change or add my dependents A: It is not allowed however you may get in touch with
name in between the policy period? your HR spoc for such a facility.
Q36: In case of part settlement of claims, A: Yes. But only eligible amount as per the terms and conditions
can the member claim for the balance by of the policy shall be paid. Original settlement letter and attested
producing the required documents? copies of the claim document from the other Service provider is
required as per policy norms.
Q37: What about dental treatment? A: All expenses related to dental treatment shall not be covered
under the group hospitalization policy unless it is an accidental
case.
Q38: What about termination of pregnancy? A: This will be covered under the hospitalization limits. But only if
done on the advice of a qualified doctor and on account of
medical reasons. Expenses arising out of voluntary termination of
pregnancy are not covered. However, medical expenses arising
out of terminat ion of pregnancy (commonly termed as
miscarriage) will be covered, within normal maternity sum insured.
Q39: What happens when a newborn child A: Expenses of newborn child is covered under the policy in case
has to undergo treatment in the nursery? a justified hospitalization has been administered. A separate bill
and discharge summary would be issued for the baby by the
hospital and stay in the hospital should be as per the policy terms
and conditions.
Q40: What happens when I have to undergo A: When treatment such as dialysis, chemotherapy, and
a treatment like dialysis when I an radiotherapy etc. is taken in the hospital/nursing home and the
discharged on the same day? insured person-patient is discharged on the same day, the
treatment will be considered to be taken under hospitalization
benefit
Q41: Do we require any photo ID Proof in A: Vipul will issue a E-card to all the covered members along with which
cashless facility? What is the purpose of , we need a valid photo such Pan Card, Driving License etc.
photo ID proof? It is to validate the identity of the patient
Q42: In case of non availability of Ecard A: You can contact Vipul SPOC in your area and give your
what should we do? Also, please Employee ID or Inform the Hospital that you are covered under
advise on children if they get hospitalized? Vipul service and they can mention the Employee ID and Vipul
SPOC will provide the Vipul ID no .
For children, school ID proof is admissible or Parents ID is also
admissible
Q43: What if my bill exceeds the covered A: Vipul shall authorise the cashless / reimbursement claim upto
amount / sum insured? the sum insured and deductions would be made as per policy
sublimits /co payment clause/Non payable items. Amount
exceeding the settled amount/Sum Insured , has to be be borne
by the employee.
Q44: In how many hospitals Vipul has A: Vipul has package rates with 1000+ hospitals and the hospital
packages and where can I see the list of list can be viewed as PPN LIST on www.vipulmedcorp.com
such hospitals?
Q45: Will Vipul Packages with hospitals A: The quality of treatment / implants will not be affected due to
affect the quality of the treatment/ packages.
implants?
Q46: If the employee does not opt for A: We would always advise to go for packages as this will help
packages , will he get the cashless / you in gett ing more benefits in your future claims for pre & post
reimbursement on open billing amount? hospitalization, however you are free to go in for open billing
also.
Q47: Do we have provision of discounts in We have discounts in Stand alone pharmacy and diagnostic
pharmacy of hospitals or open pharmacy / centers as available in the wellness portal, which is updated by
diagnostic centers? us on real time basis.
Some of the hospitals do give discounts in their in house
pharmacy /OPD and the list would be viewed from the Vipul
Wellness portal
Q48: What if any new joinee who is not yet A: After validation through location HR, Vipul shall authorise
enrolled needs a cashless, how will he avail cashless, out of system to the hospital for the new joinee as per
the cashless benefit? policy terms and conditions in network hospital. If such a
situation arises , please get in touch with Vipul SPOC
Q49: Will the resigned employees get the A: If they take the policy from the current Insurer , then they
continuity benefit of the policy? can get a continuity benefit subject to the agreement with the
Insurance Co . In such a case the existing Corporate GMC card
would be cancelled and Vipul will issue a new cards , on receipt
of the new policy
Q50: Will the family members of employees A: If the employees are listed in your policy and he /she is on
travelling or working overseas get the oversees posting , and their family members are residing in
medical benefit? India, then the family members can avail the benefit of the
policy. If the entire family along with the employee are residing
overseas then they may be covered in a separate Overseas
Mediclaim Policy.
Q51: Can the employee view the claim A: Yes, the employee can view the scan documents through self
documents on vipul portal? care portal
Q52: What are the services, we can get A: You can book your Executive Health check /MedHealth Check
from Vipul Wellness portal . Will it be on from Vipul Portal , which is being offered to you on a discount of
FOC basis? 25 to 40% on the market rates. You can avail of First Medical
Opinion ( FMO) , Doctor on Chat, Electronic Medical Records
Management (EMRM) on a FOC basis
Q53: Since when Vipul ID Card is applicable? A: Vipul ID Cards is applicable from 01.15.2015, from the policy
Will I get cards for my dependents too? inception date, and Vipul shall provide Ecards for all your
dependents as per the policy
Q54: Can Enrollment of the dependents be A: Enrollment can be done only once in a policy year, also it is
done any time in the policy year? restricted to a time period as specified by your HR. Newly married
spouse, new born baby can be added during the policy year ,
Please get in touch with your HR for the same.
Q55: Can I change the sum insured during A: No, you cannot change the sum insured dur ing the policy
the course of the policy? period.
Q56: What is a TPA Desk in the hospital? A: TPA Desk is a help desk provided by the network hospital in
their premises to facilitate communication with the TPA for
availing cashless benefit in the hospital.
Q56: Is there any time frame for submitting A: Yes, it is advisable that claim documents are submitted within
the documents? 30 days of discharge and for Post hospitalization claims , within
07 days of completion of treatment or 60 days , which ever is a
early period .
Q57: Do I get to know about my ROOM rent A: Yes through self care portal you may raise a querry or your
and other eligibility? room rent eligibility or for that matter on any other matters
relating to your policy

You might also like