1. Universal Sompo General Insurance Company Ltd
In House Claims Management- Overview

2. Over View In- house Claims setup
Started In House Health Claim Management in the year 2015
Operation – Centralized
Location – Noida
Support – 365 days (9 AM to 9 PM)
Cashless Management
Claim Reimbursement
Card Issuance
Claim Payment- In house Claims
Dedicated Team available from 9 AM to 9 PM 365 days
Medical team for Cashless and Reimbursement claims
Customer Care & Grievance Management
Enrollment & Cards
Investigation & Audit
Dedicated Toll free Help line No – 24X days
Robust Application for Health Policy Administration- HPAS

3. Demographic Pan India Presence- Network Hospitals - 3827
North Zone
1044
South Zone
1584
East Zone
336
West Zone
863

4. State wise- Network Hospitals
No of Hospitals
ANDHRA PRADESH
194
ASSAM 24
BIHAR 35
CHANDIGARH 13
CHHATTISGARH
DELHI
179
GOA 6
GUJARAT
199
HARYANA
177
HIMACHAL PRADESH 7
JAMMU AND KASHMIR 3
JHARKHAND 26
KARNATAKA
448
KERALA
161
State
No of Hospitals
MADHYA PRADESH
106
MAHARASHTRA
528
MANIPUR 1
ODISHA 55
PONDICHERRY 8
PUNJAB
144
RAJASTHAN
153
TAMIL NADU
502
TELANGANA
271
TRIPURA 2
UTTAR PRADESH
329
UTTARAKHAND 39
WEST BENGAL
193

5. Service Overview Member Enrollment & Card Issuance Cashless Management
Reimbursement Claims
Customer Support Services
Grievance Management
Claims Payment
Claims Audit & Investigation
Provider Management
MIS

6. Cashless Process Receive Fax document & Segregrate
Attach Card No /Claim No
Intimate Claim
Update Cashless Request Form
Cashless Process by doctor and recommened to Coommittee
Committee takes final decision on case
Issue Authrization Letter /Rejection letter /raise Query
Inform Hospital thru Fax &
Cashless case Close
Hospital sends Original Claim dcoument for Payment

7. Claim Reimbursement Process
Receipt of Claim Document from Insured and Hospital
Capture Information in Inward Module and Segregate and tag document tpe
Intimate the Claim and update claim form information
Scanning of Documents
Enter Hospital bills details
Claim Process by Doctors and recommend for approval
Claim approved /reject /raised query by committee
Payment advice note send to accounts
Amount paid to Insured /hoispital thru NEFT
NEFT details updated in the system and mark claim as paid claim
Claim file sent to Store for Storage.

8. Application Overview- HPAS
In built Document Digitization module
Fax Server/ Mail Server
Inward & Outward Management
Document Management System
Integrated Alert Management for real time update
Integrated with SMS
Auto mailer
Hospital Management through Application
Tariff & Discount Update
Facilities update
Hospital Empanelment Process
Integrated Policy Administration System
Insured Policy enrollment and card issuance
Addition and deletion of members
Policy benefit Management

9. Application Overview- HPAS Contd..
Cashless & Claim Management
Request through Fax/Mail / Inward & Outward Module
Update through SMS & to Insured for claims update
Integrated with Policy Benefits & Hospital Tariff
Online Cashless & Claim document view
Claim Payment
Electronic Fund transfer for Claim payment
Bank interface for claim payment
Inward & Outward
Document collection though Inward module
Acknowledgement of Claim documents
Dispatch of Claim documents through Outward Module

10. Support Services 24X7 365 Days
Toll free Health Helpline Number :
Toll Free Fax Number :
Health Direct No :
Single ID support for all queries related to Health Claims & Cards
Single ID Support :
Auto mailer & SMS update at each stage to Insured
Hospital Address details through SMS
Real time update through SMS with link to download letter

11. Web Portal – Health Portal
Web Portal for Real time access for - Claim Tracking & E-Card
Employee
Corporate HR
Member Login
Bank Partners
Broker /Agents/Web Aggregator through IMD login
USGI Branch Office
Sales Manager

12. Claim Document Submission
Universal Sompo General Insurance Co Ltd
Health Department
5th Floor Assotech One,
C-20/1 A, Block- C,
Sector-62, Noida,
Uttar Pradesh

13. Web Login Access Login Option User Type User ID Broker /Agent
Broker HO
IMD CODE
Broker Branch Office
SUB -IMD CODE
Individual Agents
Web Aggregators
Bank Partners
Bank HO
Bank Branch Office
Bank Branch Code
Sales Manager
Banca Assurance Executive
Primary Manager Code
USGIC Office
USGICL Branch Office
USGI Branch Code
Member
Individual Insured
Health Serve Card Number
Corporate Employee
Employee
Employee Code/Health Card No.
Corporate
Corporate HR
Corporate Code

14. Features of Web Portal View & Download E-Card Track Claims Status
View & Download Communication letters
Claim Intimation Letter
Cashless Authorization Letter
Claims Query Letter
Claims Settlement Letter
Search Network Provider
Download Forms
Claim Form
Cashless Request Form
Electronic Fund transfer Form
Reimbursement Claim Form
Feed back form
Cashless & Reimbursement Claims Process
Contact Details

15. Service Standards Claims Settlement TAT 7 days Card Issuance
Physical Card Issuance 7 days
E Cards hrs
Customer Query response hrs
Claim Payment hrs
Cashless Authorization Response Time
Fresh cashless request mins
Query reply cases mins
Discharge cases mins

16. Value Added Services Fortnightly Claims MIS to Corporate
Real time Web portal access to Corporate
Single ID support for employees & HR for prompt response.
Discounted Coupons for Employees
Outbound call support to employees for Query Cases
E -Card on SMS
Corporate Guide Book
Web portal Manuals for Employees & HR

17. Discounted Diagnostic Centre Network for USGI Cardholders
Provider Name
No Centers
Discount offered
SRL Limited 18
20% discount on routine Pathology & Radiology test
Apollo Health& Lifestyle 56
• 10% discount on In House Diagnostics
• 15% discount on Standard Health Check ups
Express Clinic
30% discount on routine Pathology Tests
Thyrocare
PAN India
Discounted Packages for USGICL Policy Holders

18. Key Differentiators
Direct Connect with Insured’s- Reduce response time
Faster Claim Settlement to Insured & Hospitals
Direct payment to hospitals – better hospital discounts
Robust Health Claims Application-minimize cost of operation & Improve Processing TAT
100% Digitization of claims documents
Real time update on claims tracking through SMS and Auto mailer
Link on SMS to download E-card & Communication letter
Quality network of hospitals and diagnostic centers
100% electronic fund transfer for all payments

19. Thank You