1. Employee Insurance Guide
Client
Supreme Universal
Remark
Benefit Manual

2. ABOUT
GENERAL ALLIANCE

3. About General Alliance
Risk Advisory Services
We provide international quality risk advisory services including insurance audits, insurance portfolio analyses and risk
assessment studies. As your partners in managing risk we help you understand where risk lies and how to address them. We
also help in negotiation for customized coverage and pricing negotiations on behalf of our clients.
Faster Documentation and Training.
We provide the checklist of documents to be submitted for claims processing well in advance, we also brief and train employees
on the health policy covered ensuring the employees are educated on what is covered and do’s and don’t in case of insurance
claim.
Claims Servicing & Dedicated Relationship Manager
We bring superior claims servicing team. We have a dedicated Relationship Manager for servicing your account who also looks
after the renewal and retention vertical, he/she will be in charge of Monthly Additions/Deletions and Claims management in
assistance with the Health Administration team.

4. Supreme Universal
Policy Details
GHI

5. Policy Details Group Health Insurance Floater Policy
Family Definition: Self + Spouse + 2 Dep. Kids
Sum Insured: Grade - wise
Underwriting Co.: ICICI Lombard
TPA: I Health

6. Medical Compensation
Payable for

7. Compensation Payable Reasonable and necessarily incurred
Room Expenses in Hospital/Nursing Home
Nursing Expenses
Medical Practitioner Fee
Treatment cost
Medicines
Blood / Oxygen
Cost of Pacemaker / Artificial Limbs
Operation Theatre Charges
Surgical Appliances
Diagnostic cost
Dialysis, Chemotherapy, Radiotherapy
Pre Hospitalisation (30 days) and Post Hospitalisation (60 days) expenses
Max of SI
Minimum 24 hrs of hospitalization compulsory

8. Important Extension Pre existing disease covered
First year exclusion waived off
30 Days waiting period waived off

9. Important Cappings Co-pay of 10% in each & every reimbursement
Room rent capping restricted to 1% of SI max Rs 3000/- & for ICU 2% of SI max Rs 5000/-

10. EXCLUSIONS

11. EXCLUSIONS
Injury or disease directly or indirectly caused by or arising from or attributable to War or War-like situations
Circumcision unless necessary for treatment of disease
Dental treatment of any kind unless requiring hospitalisation
Congenital external diseases or defects/anomalies
HIV and AIDS
Hospitalisation for convalescence, general debility, intentional self-injury, use of intoxicating drugs/ alcohol.
Venereal diseases
Injury or disease caused directly or indirectly by nuclear weapons

12. EXCLUSIONS Naturopathy
Any non-medical expenses like registration fees, admission fees, charges for medical records, cafeteria charges, telephone charges, Surcharge etc
Cost of spectacles, contact lenses, hearing aids
Any cosmetic or plastic surgery except for correction of injury
Hospitalization for diagnostic tests only
Vitamins and tonics unless used for treatment of injury or disease
Infertility treatment
Voluntary termination of pregnancy during first 12 weeks (MTP)

13. Claim Process

14. Claim Settlement & Process
Planned Network Hospitalization (Cashless)
Emergency Network Hospitalization (Cashless)
Non Network Hospitalization ( Re-imbursement)

15. Planned Network Hospitalization
Claim Registered by I Health on same day
Member intimates I Health of the planned hospitalization in a specified pre-authorization format 48 hours prior to hospitalization
I Health issues letter of credit within 12 hours for planned hospitalization to the hospital
Yes No
Pre-Authorization Completed
Pre – Authorization Form
AT web
Healthtpa.com
Follow non cashless process

16. Emergency Hospitalization Process
Member get admitted in the hospital in case of emergency by showing his ID Card
Member/Hospital applies for pre-authorization to the I Health within 24 hrs of admission
I Health verifies applicability of the claim to be registered and issue pre-authorization
Pre-authorization given by the I Health
Hospital sends complete set of claims documents for processing to the I Health
Member gets treated and discharged after paying all non entitled benefits like refreshments, etc. No
Claims Processing by I Health & Insurer
Release of payments to the hospital
Follow non cashless process

17. Non cashless Hospitalization Process
Member intimates I Health before or as soon as hospitalization occurs
Claim registered by I Health after receipt of claim intimation
Insured admitted as per hospital norms. All payments made by member
Insured sends relevant documents to I Health office in Mumbai within 20 days of discharge
Insured will create the summary of Bills (2 copies) and attach it with the bills
The envelope should contain clearly the Employee ID & Employee
Is claim liable (coverage/applicability)
Is document received within 20 days from discharge
I Health performs medical scrutiny of the documents
Yes
Claim Rejected No No
Yes
Is documentation complete as required
I Health checks document sufficiency
Claims processing done within days
Payment to be directly made to Employees Bank Account. The discharge voucher and copy of payment receipt to be sent to Controllership.
Yes
Send mail about deficiency and document requirement A No
Back

18. Re-imbursement Claim Documentation
Signed Claim form
Main Hospital bills in original (with bill no; signed and stamped by the hospital) with all charges itemized and the original receipts
Discharge Card (original)
Attending doctors’ bills and receipts and certificate regarding diagnosis (if separate from hospital bill)
Original reports or attested copies of Bills and Receipts for Medicines, Investigations along with Doctors prescription in Original and Laboratory
Follow-up advice or letter for line of treatment after discharge from hospital, from Doctor.
Break up with details of Pharmacy items, Materials, Investigations even though it is there in the main bill
In case the hospital is not registered, please get a letter on the Hospital letterhead mentioning the number of beds and availability of doctors and nurses round the clock.
In non- network hospitalisation, please get the hospital and doctor’s registration number on Hospital’s letterhead and get the same signed and stamped by the hospital.
Claims Form
AT web

19. Important Web Links
Cashless Hospital Link:
Healthtpa.com/ProviderNetwork/ProviderNetwork.aspx
Claim Form Link:
Healthtpa.com/DownloadForms/downloadforms.aspx
Pre Authorization Claim Form:
Pre Authorization E-cards download:
Healthtpa.com/CardStatus/CardStatus.aspx