TPA Services

For

Novell Software Development

India Ltd

By

Family Health Plan (TPA) LimitedBangalore

Core competence of FHPL is healthcare administration and is placed

advantageously to assist Novell Software Development India Ltd

in their pursuit of delivering quality care to its enrolled members.

� Decade old experience in Indian Health Insurance

� Licensed Third Party Administrator (TPA) by IRDA ( L.No: 013)

� First ISO Certified TPA in the country

� Largest TPA offering nation wide services to over 7 million lives

About Family Health Plan About Family Health Plan (TPA)Limited (TPA)Limited (FHPL)(FHPL)

� Largest TPA offering nation wide services to over 7 million lives

� Only TPA to design & implement Self Funded Schemes for Govt.

� TPA with the widest network hospital spread till district level (4577)

� Pan India presence with 18 offices across the country

FHPL as the nodal agency…

United India

Insurance Co

“As Healthcare Intermediaries

our mission is to enhance

Healthcare access by blending

technology with experience and

FHPL

HOSPITALSCashless hospitalization

Novell Software Development

India Ltd

technology with experience and

expertise”

Salient Features of Policy• Coverage for a family of 6 Members(1+5) (Self, Spouse, 2 Children,

Dependent Parents)

• Sum Assured: - Rs 3 lakh per family.

• Floater policy - Sum insured can be claimed by one (OR) all the

members of the family.

• First year exclusions & 30 days waiting period clause are waived off.

• Pre-existing conditions are waived off. • Pre-existing conditions are waived off.

• Expenses related to the hospitalization, incurred preceding 30 days and

succeeding 60 days are covered.

• Maternity covered from day one upto the limit of Rs. 50,000/- for both

normal & C-Section.

• New born baby is covered from day one subject to intimation with in

15day of child birth.

Salient Features of Policy

Kindly note• Co-pay for parents of 10% on each and every claim is applicable,

max payable Rs.270000 from the basic sum assured. For buffer Co-

pay is not applicable.

• Cataract is capped at Rs.30000/ per event no Co-pay applicable.• Cataract is capped at Rs.30000/ per event no Co-pay applicable.

Definition of Hospital :

Any Hospital or Nursing home which is Registered with local authority and has more than 15 Beds.

Definition of Hospitalization :

Minimum period of 24 hrs of admission in a hospital for a proper medical/ Surgical management.

Time Limit Not Applicable For Specific Treatments like1. Adenoidectomy

Time Limit Not Applicable For Specific Treatments like�1. Adenoidectomy �2. Appendectomy �3. Ascitic/Pleural tapping �4. Auroplasty �5. Coronary angiography �6. Coronary angioplasty �7. Dental surgery �8. D&C�9. Endoscopies�10. Excision of Cyst / Granuloma/lump PTO

Time Limit Not Applicable For Specific Treatments like

�23. Hydrocele

�24. Hysterectomy

�25. Inguinal/ventral/Umbilical/ Femoral Hernia

�26. Parenteral chemotherapy

�27. Polypectomy

�28. Septoplasty

�29. Piles/ fistula

�11. Eye surgery

�12. Fracture/dislocation excluding

hairline fracture

�13. Radiotherapy

�14. Lithotripsy

�15. Incision and drainage of abcess

�29. Piles/ fistula

�30. Prostrate

�31. Sinusitis

�32. Tonsillectomy

�33. Liver aspiration

�34. Sclerotherapy

�35. Varicose Vein Ligation

�16. Colonoscopy

�17. Varicocelectomy

�18. Wound suturing

�19. FESS

�20. Haemo dialysis

�21. Fissurectomy / Fistulectomy

�22. Mastoidectomy

What is not covered under this policy

Diseases In-Patient Treatment Others

Plastic Surgery

(Cosmetic)

Laboratory Expenses not consistent with treatment.

Spectacles, Contact Lens,

Hearing Aid

Alcoholism related ailments

Vitamins Use of intoxicating drugs/ alcohol

Sterility/Venereal Disease/Circumcision

Tonic inconsistent with treatment.

Naturopathy

Intentional Self Injury Telephone,Fax,Barber,Photocopy, Vaccinations,Toiletries and

Non Medical Items- e.g. Sanitary Pads, Under pads/ Diapers, y, Vaccinations,Toiletries and

TV chargesPads, Under pads/ Diapers, Razors/Blades, Soaps, CD’s etc….

AIDS Special diet and extra diet for patients (unless prescribed by the Doctor)

Admission / Documentation / MRD Charges, Registration fees

Congenital Diseases

e.g. An operation to remove a 6th finger, Skin Grafting

External Implants

e.g. An operation to remove a 6th finger, Skin Grafting

Surcharges, Services Charges and related expenses

What is not covered under this policy

Diseases In-Patient Treatment Others

Convalescence / General Debility.

Supports and Accessories, e.g. Crutches

Admission fee

Dental including root canal Treatment

Service Charges, Maintenance and Surcharges

Food & Beverages

Special Nursing, Attendant Pass Telephone/Fax

Health Drinks:

e.g. Horlicks, Complan etc

Medical records/ Stationary

Xerox or Certifying charges

Abortion done for voluntary reasons & before 12 weeks

Attendant’s Charges

Food and Beverage for Relatives Special Nursing charges

Diagnostic Expenses (only for out-patient)

Extra Bed/ Bed retaining charges

Damage done by the patient (accidentally). Damage charges not covered.

TV/ Laundry

�

Pre-authorization Process for Cashless

Hospital sends Intimation to

FHPL

Out of Pocket

Member approaches Hospitals with FHPL ID Card

Eligibility

Covered

Not

Covered

Authorization asper eligibility

Out of Pocket payment

� TAT : less than 2hrs for routine cases

� Regularization within 24 Hrs

� Process of cashless authorisation is

decentralized Cashless treatmentat NWH

Member avails treatment at any hospital and makes upfront payment�

Member submits bills to FHPL within15 days of discharge

Protocol for Availing Treatment in Non Network Hospital

FHPL processes claimsSettle the Claim in 21 working days

FHPL verifies the documents submitted

In case of incomplete documents recovery of documents for scrutiny

Procedure for Reimbursement(Non Network Hospitals)

Pay and settle the bills & collect the following dockets from the hospital for :

1. UIIC claim form, duly filled & signed by the claimant.

2. Discharge Summary - Original.

3. Final Bill with breakup

4. Receipts for the payment made.

5. All Laboratory investigation Request & Repots

6. Incase of surgical packages – detail breakup of the package.6. Incase of surgical packages – detail breakup of the package.

7. Medicine bills with prescriptions.

30 Days pre & 60 Days Post hospitalization.

1. UIIC claim form, duly filled & signed by the claimant.

2. Original investigation reports along with bills & receipts.

3. Consultation receipts.

4. Medicine bills with prescriptions.

Hospitalization Guidelines

• Recommend you to obtain pre-authorizations at least in advance of 24

hours for all elective cases and get treated in a Network Hospital of FHPL

Advantages:

- Availing cashless facility

- Simple Documentation – Sign off on discharge (Non-Medical expenses

will be borne by the member) , documents processed by FHPL directly.

• Non – Network Hospitals can be used based on needs & urgency.

Call Center

Dedicated member helpline 24 x 7

Nationwide Toll free 1800 – 425 - 4033

24 X 7days accessible

Electronically supported systems

Managed by professionally skilled manpower

Assistance in information on

� Network hospitals

� Enrollment status

� Support services in an Emergency

� Coverage eligibility

� Claims- documentation support, query handling

� General information on health plan

Contact – FHPL, BangaloreQuery onQuery on PersonPerson MobileMobile EmailEmail

Account ManagerAccount Manager Mr. Suresh P Mr. Suresh P 09243479820 sureshp@fhpl.netsureshp@fhpl.net

Claims & General Claims & General Queries Queries

Ms.Ms. Cynthia Cynthia KavirajKaviraj 080-22356251 / 52 cynthiakavirajcynthiakaviraj@fhpl.net@fhpl.net

Network Hospital / Network Hospital / Cashless ServiceCashless Service Dr.ManusharmaDr.Manusharma 92434 79824 manu.sharma@fhpl.netmanu.sharma@fhpl.net

PrePre--authorizationsauthorizations Dr. Kiran / Mr. RaviDr. Kiran / Mr. Ravi 080-22356251 / 52 preauthblr@fhpl.netpreauthblr@fhpl.netPrePre--authorizationsauthorizations Dr. Kiran / Mr. RaviDr. Kiran / Mr. Ravi 080-22356251 / 52 preauthblr@fhpl.netpreauthblr@fhpl.net

Any Escalations on Any Escalations on the abovethe above

11stst Level : Ms. Aliva Level : Ms. Aliva DasDas

22ndnd Level : Mr. Rama Level : Mr. Rama LingaReddyLingaReddy

92434 79825

92434 79822

aliva.dasaliva.das@fhpl.net@fhpl.net

ramalinga@fhpl.netramalinga@fhpl.net

FHPL Contacts

Office Address: BangaloreFamily Health Plan (TPA) Ltd

# 11 2nd Floor, E Block NITON Palace Road

Head Office: HyderabadFamily Health Plan (TPA) Ltd

Srinilaya – Cyber Spazio, suit # 101,102,109&110 Palace Road

Bangalore. – 560 052Ph: 080 – 22356256 / 57Fax: 080 – 22356255

suit # 101,102,109&110 ground floor, Road #:2,Banjara Hills, Hyderabad. –500 034Ph: 040 – 2355-6464Fax: 040 – 2354-1400

Our commitment to serve You …….

……. Is absolute