Q: Are the doctors' fee and other charges fully covered? What is your criterion?
A: As a general rule, we will cover all of the charges as long as they are Medically Necessary, unless specifically excluded in the Policy. It also depends on which provider you use. We cover fees up to Usual and Customary Fees.
Q: How about the Prescription Drugs benefit?
A: Prescription drugs are a covered benefit under this policy pre and post Hospitalization as per the term and condition of the given policy. Prescription drugs are medications which are prescribed by a physician and which would not be available without such prescription. Certain treatments and medications, such as vitamins, herbs, aspirin, and cold remedies, medicines, experimental or Investigative drugs, or supplies even when recommended by a physician, do not qualify as prescription drugs.
Q: How about the Alternate system of Medicine like Ayurveda, Homoeopathy Unani etc?
A: In India, Alternate system of Medicine which is covered only under Government Hospital as per the T&C of the provided Policy. But there should be definite diagnosis for the disease including traditional medicine diagnosis and western medicine diagnosis as well as. The treatment of herb should be medical necessary. If it is used for adjust sub health such as fatigue it will not be covered.
Q: What Maternity costs are covered under this group health plan?
A: Generally Pregnancy and its complications are not covered under any Individual policy. Though it is covered under some Group med claim (GMP) and Tailor Made Policies.
All (medically necessary) maternity related fees can be covered up to a maximum of the limit thereafter. This includes, but is not limited to, pre-natal visits, the delivery, complications if any, and post-natal visits. There is a limit of 2 pregnancies. The newborn's expenses, such as those routine immunizations are not covered under the policy.
As a reminder, Pre-authorization is necessary for the delivery and for any special testing such as additional ultrasound or amniocentesis.
Q: If I have some kind of mental condition, will this health plan cover the treatment?
A: Mental conditions are not covered under the Standard Mediclaim Policy.
Q: Does my health plan cover an annual body checkup?
A: Yes if your policy is in 5th running year and there is no claim reported in previous years policy then only you can avail the benefit. (As per the T&C of the provided policy)
Q: What is the purpose of Pre-authorization?
A: Before undergoing certain non-emergency treatment, we wish to review your case for medical necessity and to verify your coverage for the treatment. This should be mutually beneficial; since member can also have a peace of mind knowing the upcoming treatment will be covered under their health plan.
Q: What procedures need Pre-authorization?
A: The following services comprise a complete list requiring Pre-authorization:
- All Inpatient admissions and/or treatments
- Any Surgeries requiring general anesthesia /Spinal
- Accidental Dental treatment.
- Purchase or rental of Durable Medical Equipment, including, but not limited to, *Insulin Pumps and supplies
- Organ Transplants; (Stem Cell Transplants not covered per policy exclusions)
- All Cancer treatments/therapies
- Hemodialysis for Renal Failure
- Substance Abuse treatments/therapies
- Any condition, including chronic conditions that do not meet the above criteria.
Q: How long does it take to get Pre-authorization?
A: We aim to reply within 1 hour from the time we receive the request. However, please understand that complicated cases require more time for proper review.
Q: What documents do I need to collect for a claim?
A: You need to collect the following documents for a claim:
- Complete Claim Form with signature
- Original Invoices
- Prescriptions (if any Just saying "drug / medication" is not enough. Please offer us a detailed drug list.)
- All Original Investigation reports and Radiological Films.(If Films are required for further Follow Up You can get it back after submitting the request letter along with the Doctor’s advice for the same.)
- If the treatment has been taken on basis of Package rates. Kindly submit the detail/ Itemized breakup Of the Package.
- Discharge Summary in original.
- Hospital Registration number is required only in Non Network Hospitalization Claims
- In Case Of Death Claim
- Death Certificate.
- Nomination In the proposal Form.
- Legal Heir certificate
Q: How long can I get my reimbursement?
A: eneral speaking, If all your documents are in order, it may need 5 days for the whole claim processing. For complicated or large claims, it may take a little longer.
Q: What may cause the claim to be denied?
A: Your claim may be denied for the following situations:
- Late Intimation of Hospitalization. Intimation of any Hospitalization must be within 24 Hrs of Hospitalization.
- Treatment not covered by the policy.
- Treatment not medically necessary or OPD treatment
Q: What is status of the claim?
A: Appropriate status is given according to the stage under which the claim is in viz; under process; pending for information from member/insurance; processing completed and read for dispatch or rejected.
Q: The hospital is refusing to provide the requested documents in original, what is the alternative?
A: In such a case the hospital needs to mention the same on its letterhead along-with the seal and signatures of the treating doctor and the medical administrator. Attested photocopies are also accepted by the TPA in such a case bearing the seal and the signatures of the treating doctor and the medical administrator.
Q: How does one file intimation?
A: The intimation needs to contain details like policy number UHID#, name of the hospital, date of the admission and the medical condition of the patient. This information can be faxed or sent by post to TPA.
Where can one obtain the claim form?
The claim form can be obtained in any office of the Insurance Company or with the TPA
What is status of the claim?
Appropriate status is given according to the stage under which the claim is in viz; under process; pending for information from member/insurance; processing completed and readt for dispatch or rejected.
The hospital is refusing to provide the requested documents in original, what is the alternative?
In such a case the hospital needs to mention the same on its leeterhead along-with the seal and signatures of the treating doctor and the medical administrator. Attested photocopies are also accepted by the TPA in such a case bearing the seal and the signatures of the treating doctor and the medical administrator.
Can the cheque be sent to another address, if the member sends a letter?
No, this is not allowed as per the guidelines from the Insurance Company. An endorsement is required from the insurance stating the same.
If the claim is partially settled, can we claim for the balance by producing the required documents?
Yes, this can be done by producing the required documents to Safeway TPA Pvt Ltd.
If the cheque is prepared,what is the reason for delay in cheque dispatch and will the TPA/Insurance pay for interest charges on on the same?
The cheque will be dispatched as soon as possible (we do not have an answer in such a case as, we are not supposed to reveal the insufficiency of float funds received and also, we have no answer for the payment of interest charges).
If the claim is rejected and the insurance has been informed about the same, how long does it take for the insurance to approve the rejection?
The insurance company is supposed to send a reply within 15 days from the date of rejection intimation letter.
If the insurance Co. does not respond on the rejection of claim, what would be state of claim?
Safeway waits for response from insurance Co. for 15 days from the date of rejection intimation letter. If no reply is received, then Safeway takes a decision on rejection and intimates the member accordingly.
If the member feels that the rejection is not appropriate, to who can be member appeal i.e. TPA/Insurance and if yes, what is the procedure for the same?
The member can be appeal to the TPA Cell appointed by Insurance companies at their Respective Regional Offices.
Can I get my claim papers back, if the claim is rejected by Safeway as I have other source for getting the claim reimbursed?
Yes. The claim can be returned and considered as No Claim.
How does an employee of a corporate benefit from Safeway TPA ?
Assurance of Qualitative Healthcare delivery
- No necessity to pay any advance at the time of admission nor to settle bills at the time of discharge.
- Comfort extended to the patient/employee/family at the time of crisis due to medical emergency.
- Additional comfort that second opinion is always at hand, where necessary.
What are the criteria for a Healthcare Provider to be included in the Safeway network?
Emphasis is on qualitative healthcare delivery to the members of the Safeway. The range of facilities at the provider are analysed at various levels of healthcare viz. Primary, Secondary and Tertiary. Medical capabilities w.r.t. emergencies and trauma conditions are evaluated. Bed strength, Medical Equipments, Eminent consultants, skilled medical professionals. Intensive Care facilities, Ambulance, Lab facilities, Technicians, Geographical spread, Population coverage, Chain of hospitals, Tariff, Medical performance, etc., are the other factors that determine the inclusion of a healthcare provider into the Safeway Network.
Q: What Charges will not be payable in respect of claim?
A:The Following Charges are generally disallowed in Standard Individual Mediclaim Policy;
- Registration Charges/ Admission Charges.
- Record/ Documentation Charges.
- Attendant/ Visitor Pass Charges.
- Extra Bed Charges for attendant etc.
- Ambulance Charges(Allowed in some cases as per T&C).
- Special Nurses charges.
- Vitamins, tonic if not forming a part of treatment.
- Service Charges.
- Sanitary Items.
- Bed Retaining Charges
- Charges for TV, Laundry, radio etc.
- Food and Beverages for attendant and visitors.
- Toiletries etc.
- Purchased of medicines not related to treatment.
- Stationery, Xerox or certifying charges.
- Expenses on newborn babies for vaccinations nutrition, tonic etc.
- Out patient treatment.
- Personal Conveyance.
- Attendant Diet.
- Cost of spectacles, contact lenses, Hearing Aid.
- Dental Treatment or Surgery.
- Baby Care during maternity like inoculation nutrition and tonic.
- Tubectomy/ Sterlization.
- General Debilty.
- Pre Hospitalization beyond 30 Days.
- Post Hospitalization beyond 60 Days.
- War or War like Operations.
- Circumcision unless necessary for treatment of disease or accident.
- Cosmetic Surgery or aesthetic treatment.
- Venereal diseases.
- Intentional self Injury
- Use of intoxicating Drugs/alcohol, immolation or suicide.
- Diseases due to nuclear weapon.
- Naturopathy Treatment
- Voluntary termination of pregnancy
- Any Other expenses not directly connected with treatment and miscellaneous expenses unless and until specifically covered under the policy
- External Instruments or devices such as crutches , Glucometer, CPAP Machine etc
- No Prescriptions with the bills
- Drugs and consumable not in line with the treatment
- Pharmacy items bills for the management of Pre existing Disease, though admission is for an Acute Ailment.
Q: What may cause your claim reimbursement to be delayed?
A: Your claim reimbursement may be delayed for the following situations:
- Claim Form incomplete or not signed
- Doctor's description incomplete or unclear
- Lack of medical report (for hospitalization)
- Claims of Rs.100000.00 or more require more time for processing
Q: How can I get my reimbursement?
A: After approving your Claim we will Provide you Discharge Voucher (DV), which carry details of the settled amount. You need to sign and provide your bank detail so we can issue an account Payee Cheque in your Favor.
Q: As a Insured, how many days do I need to wait to get my insurance card after Safeway TPA Pvt Ltd receives the enrollment information?
A: After we receive the enrollment information, your insurance card(s) will be sent out to you/Your Human Resource Dept. within 3 days. Afterwards, your HR Dept. will forward the insurance card(s) to you.
Q: How do I add my newborn infant into?
A: To enroll your newborn, please contact Your Insurance Company or your HR department of our office. Please provide your baby's full name, gender and date of birth.
Q: If I resign from company, is my group health plan coverage still effective?
A: I No. If you resign from your company, your last day of health coverage will be your last day at work. Please return your insurance card to your HR department. Thank you for cooperating.
Q: The name /address on the ID card is incorrect, what is the procedure to correct the same?
A: Safeway TPA Pvt Ltd enters the data as per the information what is given on the policy paper. If the policy paper contains the name/address incorrectly then, an endorsement from the Insurance Company is required in order to make the changes.
Q: What does Cashless service mean?
A: It means that you can use your insurance card there and the hospital will send the bill directly to us. You only need pay co-pay if your have policy co-pay or if you obtain treatment that is not covered under the Policy during your visit. We are always updating our Network Hospitals List at regular intervals. The most updated List should be available on our website.
Q: I often travel on business. Can I use the cashless service all over India?
A: Yes, you may use any of the Network Hospital across the India. The procedure is the same. Just bring your Insurance Card and a Photo ID.
Q: I visited the ABC Hospital and was fairly happy with their medical services. However, this hospital is not on your Network Hospital. Could your company look into working with this hospital?
A: SWe can ask our Medical Executives to look into the hospital. We continuously make efforts to add quality health care providers to our Network. Sometimes though, even if we are willing to work with the hospital, the hospital might not be open to cooperating with insurance companies.