Individual / Standard Mediclaim Policy Holder.. (changes as per corporate queries)

What are the services offered by FHPL to its beneficiaries?

FHPL is the service provider for required Health care service to its members through activities like -

Cashless services at over 7000 Network hospitals, reimbursement facility for Non-network hospitals, personalized client servicing, enrollment of members for issuance of E-card, 24/7 call centre and claims administration.

How different is FHPL from Health Insurance Company?

FHPL is a Third Party Administrator (TPA) in health Insurance Sector servicing all four public sector insurers and many Private Insurance Companies. FHPL is an intermediary between insurance company and policy holder.

What does an Insurance Policy cover? Is maternity covered under Insurance Policy?

‘Healthcare Packages' of Insurance is standard Mediclaim Policy for individual members. Majority of policies do not cover maternity. A few policies cover maternity with waiting period.

What are the exclusions in the policy?

Exclusion in the policy varies from insurer to insurer. Generally hospitalization during first 30 days from inception of policy is excluded subject to exceptions. There are specific exclusions during first one, two, three and four years of policy. Policy schedule and wording need to be referred to know the conditions applicable.

Whether Out Patient services are covered under the insurance policy?

Out Patient services is not covered under any Insurance policy.

Where can the member avail the required services?

The cashless facility can be availed at all our Network Hospitals, and at any other hospital in India that satisfies the definition as given the policy, the member has to pay the amount first and submit the bills along with complete documents for re-imbursement.

Will location of dependent family matter in availing services under FHPL?

No, Location does not affect the operational activities, main member or the dependant Network of hospitals is spread across the country. FHPL has accredited over 7000 healthcare providers so far and expands and updates the network in deference to the requirements of its users.

Will the change in names in between policy period matters?

Yes, the change need to be endorsed by the insurance company.

What are the documents required to lodge under the medical reimbursement scheme.

• Duly filled in claim form of respective insurance company
• Copy of Member ID card with the member’s details.
• Copy of the policy schedule.
• Original detailed discharge summary.
• Original investigation reports
• Original Hospital Bill-consolidated and with detail breakup with the patients signature on it.
• Incase of surgical packages – detail breakup of the package.
• Pharmacy bills and breakup.
• Prescriptions if any.
• In case of hospitalization due to accident, copy of MLC

Note: member needs to retain a photocopy of all the documents he is submitting for future reference.

What are KYC documents and when do I have to submit ?

As per ‘’AML/CFT guidelines for General insurance companies“ issued by IRDA, beneficiary need to submit KYC documents where the amount payable is equal to or above Rs.1 lakh. If it is cashless hospitalization, the documents need to be submitted to our network hospital at the time of sending cashless request to us, hospital will in turn submit the KYC to us along the claim documents. In case of reimbursement claim, KYC documents need to be submitted to us directly along with other claim documents being submitted for reimbursement.

What are the list of documents allowed by IRDA as KYC (ID & Address Proof).

Individual claims where cashless request approved is more than 1 lakh, hospital has to collect KYC documents mentioned below.

Should the claim be submitted with the insurance company or with FHPL?

Preferably at FHPL only.

In case of rejected claims, where should they be appealed?

TPA cell at the respective insurance company

In case of payments, can the member or the member's representative collect the same?

Only member is eligible to receive the payment

In case of part settlement of claims, can the member claim for the balance by producing the required documents?

Yes, but only eligible amount as per the terms and condition of the policy shall be paid. The member has to quote the claim number & UHID for such resettlement

In case of change of residence, can the cheque be sent to the new address?

No, unless an endorsement from the policy issuing office of such change of address is produced.

Are there chances of 'claim rejection'?

Yes, claim will be settled as per the terms and conditions of policy issued.

In case of non-receipt of ID Card, can one avail cashless treatment? What is the procedure?

A member can start availing the cashless treatment if the member is already enrolled with a UHID No: but it is mandatory to prove the identity at the time of discharge hence the member is advised to provide a photo along with the proof of identity before discharge.

Are there any charges by the hospital, which are not reimbursable and hence have to be paid by me even after “Cashless Service” has been authorized for treatment in the network hospitals?
Yes. There are quite a few charges, which are not reimbursable and have to be paid by you even though you have been authorized for “Cashless Service” at the Network Hospitals. The list as per IRDA is enclosed