FAQ - Membership

Q1: What is a family floater plan? Will I be eligible for it even if I am insured by my employer?
Ans : A Family Floater is a single and comprehensive policy for an entire family. It not only covers medical expenses during sudden illness, surgeries and accidents but also hospitalization costs.  You can buy a family floater policy even if you are insured by your employer. It will supplement your existing medical cover if the cost of medical treatment is a little high to be covered by your existing cover level. Also, the insurance cover by your employer will remain in effect till you are in the service.

Q2: Do I need to get a medical checkup done? If yes, how often that should be done?
Ans : No Medical checkup is required.

Q3: Is it possible to add my family members to my existing policy?
Ans : Yes, A newly-born baby or a newly-married spouse can be added immediately, in the middle of a policy. However you can add other members only after renewing an Individual Policy or Floater Policy and following the necessary procedure to get an approval from the insurer.

Q4: Can I increase my insurance cover?
Ans : No, you can not increase the sum insured at the time of renewal of your insurance policy.

Q5. What is a Third Party Administrators (TPA) & what is its function?
Ans : Third Party Administrators (TPA ) is an important link between Insurance companies policyholders & healthcare providers (Hospitals and nursing homes).TPA’s role is to provide administrative support to the insurance companies for servicing their insurance policies.

Q6. Who is our TPA?
Ans : Our TPA is Alankit Healthcare Ltd. For any assistance from TPA, you can either call/write to us or call +91-11-42541265 & speak to Mr. Trivedi for all cashless requests who is dedicatedly working to assist our members in resolving their queries.

Q7. What are the services offered by TPA?
Ans : TPA can be approached for following assistance:
1 Cashless Hospitalization: Each policyholder is provided with a list of empanelled hospitals where in he/she can avail cashless hospitalization. (Refer attached booklet issued by Alankit for more information)

2. ID Card: TPA provides ID cards to their entire policy holder in order to validate their Identity at the time of admission.

3. Claims Management: On behalf of insurance companies TPA administers & settle claims
for hospitals & policyholders.

4. 24 hours customers support services: TPA provides assistance through its 24 hrs call
center information regarding policyholder’s data, provider network, claim status, benefits
available with existing cardholder, etc is furnished on request.

Q8: Who will bear the cost of medicines used for treatment during hospitalization?
Ans : Cost of medicines used for treatment during hospitalization will be borne by insurance company.

Q9: What do the network hospitals mean?
Ans :Network Hospitals are hospitals all over India to which you can go for treatment which number over 2500+ hospitals.

Q10: Does it cover basic illness like flu/ cold etc.? Are they only covered if you go to one of the hospitals mentioned?
Ans : It shall cover only in case followed by hospitalization on doctor’s recommendation. Your nominated beneficiary can avail cashless facility in our network hospitals and Non-cashless/ reimbursement for non-network hospital.

Q11: Does it cover medicine in hospitalization?
Ans : Medicines are covered in hospitalization except expenses on vitamins, tonics if not directly related with the treatment.

Q12: Pre existing diseases exclusion: would like to know if all the diseases are covered under the policy e.g. Cancer, Heart disease, dialysis and diabetes etc?
Ans : Pre-Existing diseases are covered after 6 months.

Q13: 30 days waiting period exclusion: If the disease mention above is included then will these be covered from day one of the Policy being taken?
Ans : This waiting period reduced to 10 days provided the photographs of the beneficiaries are made available to Sahara Care House.

Q14: If there are any diseases which are not covered in the Policy?
Ans : Some of the diseases excluded are Circumcision, vaccination, inoculation, cosmetic or aesthetic treatment, plastic surgery, cost of spectacles, contact lenses, hearing aids, dental treatment/surgery unless requiring hospitalization, convalescene, general debility, rundown condition or rest cure, congenital external disease or defects or anamolies, sterility, veneral diseases, intentional self injury, use of intoxicating drugs/ alcohol expenses arising out of any condition directly or indirectly caused to or associated with Human T- cell Lymphotropic Virus Type III.

Q15: Expenses covered under the policy?
Ans : Policy covers expenses incurred in treatment under following heads.

Medicines and Drugs, Diagnostic Material and X-ray, Dialysis, Chemotherapy, Radiotherapy, Cost of pacemaker, Artificial Limbs and cost of organ and similar expenses.

Q16: Does it cover existing heart condition?
Ans : No. However Hypertension shall only be covered in case followed by hospitalization on doctor’s recommendation.

Q17: Expenses not covered under medical policy?
Ans : The expenses not covered includes following:

Q18: What is the process of availing cashless facility in the hospital?
Ans : Cashless Hospitalization facility is available only at Network Hospitals. Cashless Hospitalization facility enables the Insured to obtain admission at designated hospitals after obtaining an Authority Letter from the service provider. This certificate will authorize the hospital to deliver treatment up to the limits. This shall be organized by the network hospital. In such cases, service provider settles the hospital bills directly on your behalf.
In case of a planned hospitalization you need to inform us two to three days in advance by faxing the pre-authorization form signed by the treating doctor to TPA Alankit. Your claim would be assessed in the light of the policy issued to you by your insurance company and a letter of authorization will be issued to the hospital authorizing treatment. In case of an emergency the hospital will fax the pre-authorization letter. Once the Authority letter has been sent to the hospital you need not pay at the hospital. Alankit will pay your hospital bills up to the amount authorized in the Authority Letter.

Q19: What are the formalities that need to be done at the time of discharge in case of a cashless facility?
Ans: You need to sign your bills, fill up a claim form and sign the same, leave all your investigation/diagnostic reports and X-ray/ultrasound films etc. The hospital authorities will courier the documents to us for assessment and payment.

Q20: Conditions where the cashless request may be denied?
Ans : The cashless facility may be denied in the following circumstances:
(a) Where sufficient medical/past insurance information is not available to TPA.
(b) Where the reported symptoms/available inputs are inadequate in the opinion of TPA medical team as regard to determine the liability under the policy.
(c) Where the intimation of claim has not been given in time.
(d) Where any information has been concealed or misrepresented in the proposal form available on record.
(e) Where the reported ailment/treatment is excluded under the policy.

Q21: Cashless emergency conditions which do not require hospitalization?
Ans : Expenses on Hospitalization for minimum period of 24 hours are admissible. However this limit will not apply for specific treatment i.e. Dialysis, Chemotherapy, Radiotherapy Eye surgery, Dental Surgery etc taken in Hospital/Nursing Home and Patient is discharged on the same day, the treatment will be considered to be taken under Hospitalization benefit.

Q22: If I avail cashless facility for my hospitalization, how will I claim for my post Hospitalization expenses?
Ans: You can file a claim for reimbursement of your Pre & Post hospitalization expenses (30 days before date of admission and 60 days after the date of discharge)

Q23: Where do you lodge your claim if you get treated in a non-network hospital?
Ans: You can lodge your claim at our office at  Client Relationship Manager, Sahara Care House, Infinity Tower 'A', 2nd Floor, DLF City-II, Gurgaon-122001. If your claim is found admissible it shall be paid within 30-45 days of receipt at our end.

Q24: What services are spend first claimed later?  
Ans : When hospitalization is in a non- network hospital. Please note non-network hospital should be a recognized hospital and a have at least 15 inpatient beds or 10 beds for Class “C” town. Claim must be filed within 30 days from date of discharge from the hospital with required documents.

Q25: What documents are required for reimbursement of expenses for taking treatment in Non-Network hospitals or in non-Cashless situation?
Ans : If cashless facility is not availed/or pre-authorization is denied or treatment is availed at a non-network hospital, the insured will have to settle the bills directly with the hospital and subsequently claim reimbursement from service provider by submitting the following documents in original :

1. Bill, Receipt and Discharge certificate / card from the Hospital.
2. Cash Memos from the Hospitals (s) / Chemists (s), supported by proper prescriptions.
3. Receipt and Pathological test reports from Pathologist supported by the note from the attending Medical Practitioner / Surgeon recommending such Pathological tests.
4. Surgeons certificate stating nature of operation performed and Surgeons’ bill and receipt.
5. Attending Doctor's/ Consultant's/ Specialist's / Anesthetist's bill and receipt, and certificate regarding diagnosis.
6. In case of Domicillary Hospitalisation, receipt from a qualified nurse who attended the patient at his/her residence duly supported by a certificate from attending Medical Practitioner.
7. Certificate from attending Medical Practitioner giving reasons for allowing treatment at home.
8. Certificate from attending Medical Practitioner / Surgeon that the patient is fully cured
9. Photocopy of TPA-Alankit health card.
10. Dully filled in Claim-Reimbursement Form.

Do’s and Don’ts of availing cashless services from Third Party Administrators (TPA)

Do’s
1. Obtain pre – authorization form from Insurance Helpdesk 3 – 4 days prior to the admission for planned hospitalization.
2. Pre – authorization form is to be filled in by treating doctor.
3. Check about the pre – authorization approval at the Insurance helpdesk within next 24hrs.
4. You can avail cashless treatment at the hospital after receipt of written authorization from TPA for the covered.
5. Leave back all the original documents and signed claim form with the hospital at the time of discharge.
6. Make payment to the hospital for the expenditure over and above the TPA approved limit and for the treatment not covered under the package.

Don’ts
1. Don’t insist upon admission at the hospital merely for investigation, evaluation or Health
check – up as these are not approved by TPAs.
2. Don’t insist on admission on cashless basis at the Hospital without obtaining the pre –
Authorization approval from TPA.
3. Don’t carry back any original documents at the time of discharge from the hospital, if your cashless is approved by the TPA.
4. Don’t forget to sign the claim form.

Q26: What is the age limit?
Ans : Maximum age limit is 80 years for beneficiaries of members covered under our Mediclaim cover.

Q27:What is the available amount of insurance at the time of renewal this year?
Ans: The available Mediclaim Cover for your beneficiaries in India (max. of four blood relations- dependent parents, spouse, 2 dependent children below 21 yrs residing in India) is Rs. 2,00,000.