1. Things to Remember:
The Group Medilclaim policy is divided into two. Carnival Films Pvt Ltd - North and Carnival Films Pvt Ltd – South (As per the Geographical area in which employee is located). All employee’s of north region are covered under Carnival films Pvt Ltd North and all employee’s of the south region covered under the Carnival Films Pvt Ltd South.
Employee need to keep the E cards/TPA no. and TPA toll free no. handy and saved on his/her hand phone
In case employee loses / misplace their E card, they need to download from the cards themself through the below link of Health India Insurance TPA Services Pvt Ltd.
Claim intimation is mandatory and to be made within 7 days from date of admission failing to do so will result in Claim rejection
Employee Login Link –
For North Policy
For South Policy
(Employee to login with User ID & Password)
User Name – EMPLOYEE
User Name – EMPLOYEE
Password – DOB
(eg. DOB is 1st Jan 1980 – password will be )
Please find below the screenshot to download the Health India's app (mobile app of Healthindia)
The policy details are also available on the mobile app.
Mobile App link as below –
For Google Play Store –
For App Store –
For login to App please follow steps below – 
Click on Login, -- Click on Corporate Employee --- Click on Group Code
Enter Group Code – CFPL (For North)
Enter Group Code – CFPS (For South)
Enter Employee Code Click on Proceed

2. Group Mediclaim Policy - Carnival Films Pvt Ltd
Policy Period: 06th June th June 2019
Edelweiss Insurance Brokers Ltd.

3. Agenda Coverage Details Benefits Exclusions Claim Process
Steps to Access Website
Frequently Asked Questions (FAQs)
Contact Points

4. Coverage Details Particulars Details Policy Name & No.
Carnival Films Pvt Ltd – North
Policy Name & No
Carnival Films Pvt Ltd – South
Policy Period
6th June 2018 to 5th June 2019
Insurer
The New India Assurance Co. Ltd
TPA
HEALTH INDIA INSURANCE TPA SERVICES PVT. LTD
Broker
Edelweiss Insurance Broking Ltd.
Sum Insured
Rs. 2 Lakhs per family
Family Definition
Employee + Spouse + 2 Dependent Children
Hospital Criteria
Registered 15 bedded hospital

5. Benefits Features Applicability Pre existing diseases
Yes. Covered from Day One
Waiting Periods
Not Applicable
Coverage
Inpatient hospitalisation- Active treatment with minimum 24 hours hospitalization with exception of certain Day care expenses.
Pre-Post Hospitalisation Expenses
Yes. Pre- 30 days, Post- 60 days (Excluding Maternity)
Pre-Post Natal Expenses
Covered up to Rs.5000 within maternity limit
Maternity benefits
Covered. Normal delivery for Rs.35,000/- and C-section for Rs.50,000/-. When maternity claim is made under two different policies, the spill over amount will be restricted to Rs. 25,000 only
Domiciliary Hospitalization
Not Covered
Baby cover from Day one
Yes
Room rent eligibility
Room rent is capped at 2% of sum insured or Rs.5000 whichever is less for Normal and ICU
Aliment Wise capping
Cataract capped at 24,000 per eye. In case of multi focal lens implants will be paid up to 20% of the lens cost only within the cataract limit
Co Payment
45% co payment on All Dependents claims
Ambulance Charges
Rs 1000 per hospitalization
Ayurvedic Treatment
Ayurvedic Treatment taken at Govt. Hospitals
Mid Term Addition
Only for New Employees, Child Birth, Newly Married Couple. To be informed to respective HR within 30 days

6. Exclusions
Injury / disease directly or indirectly caused by or arising from or attributable to War, invasion, Act of Foreign enemy, War like operations (whether war be declared or not)
Circumcision unless necessary for treatment of a disease not excluded hereunder or as may be necessitated due to an accident
Vaccination or inoculation change of life or cosmetic or aesthetic treatment of any description, such as correction of eye sight plastic surgery other than as may be necessitated due to an accident or as apart of any illness
Cost of spectacles and contact lenses, hearing aids.
Dental treatment or surgery of any kind unless requiring hospitalization.
Convalescence, general debility; run-down condition or rest cure, obesity treatment and its complications including morbid obesity, Congenital external / Congenital internal diseases or defects or anomalies, treatment relating to all psychiatric and psychosomatic disorders, thalassamia, Sterility, Venereal disease, intentional self injury and use of intoxication drugs / alcohol.
All expenses arising out of any condition directly or indirectly caused to or associated with Human T-Cell Lymphotropic Virus Type III (HTLB - III) or lymphadinopathy Associated Virus (LAV) or the Mutants Derivative or Variation Deficiency Syndrome or any syndrome or condition of a similar kind commonly referred to as AIDS.
Charges incurred at Hospital or Nursing Home primarily for diagnosis x-ray or Laboratory examinations or other diagnostic studies not consistent with or incidental to the diagnosis and treatment of positive existence of presence of any ailment, sickness or injury, for which confinement is required at a Hospital / Nursing Home or at home under domiciliary hospitalisation as defined.
Expenses on vitamins and tonics unless forming part of treatment for injury or diseases as certified by the attending physician
Injury or Disease directly or indirectly caused by or contributed to by nuclear weapon or materials

7. Exclusions
Naturopathy Treatment, acupressure, acupuncture, magnetic therapies, experimental and unproven treatment / therapies.
External and or durable Medical / Non-medical equipment of any kind used for diagnosis and or treatment including CPAP, CAPD, Infusion pump etc. Ambulatory devices i.e., walker, crutches, Belts, Collars, Caps, Splints, Slings, Braces, Stockings, etc., of any kind. Diabetic foot wear, Glucometer / Thermometer and similar related items etc., and also any medical equipment, which subsequently used at home etc.
Genetic disorders and Stem Cell Implantation/ surgery.
Change of treatment from one system of medicine to another unless recommended by the consultant / hospital under whom the treatment is taken.
Treatment for Age Related Macular Degeneration ( ARMD ), treatment such as Rotational Field Quantum Magnetic Resonance (RFQMR ), Enhanced External Counter Pulsation ( EECP )
All non medical expenses including convenience items for personal comfort such as charges for telephone, television, ayah, private nursing / barber or beauty services, diet charges, baby food, cosmetic, tissue paper, diapers, sanitary pads. Toiletry items and similar incidental expenses in excess of Rs. 10,000/- per claim
Any kind of Service charges, Surcharges, Admission Fees/Registration Charges levied by the hospital.

8. Cashless Reimbursement Claim Process
Cashless facility can be availed or granted when the hospital is registered as Network hospital of TPA
To check the list of Cashless hopsitals, login to TPAs website or contact Hospital desk
Reimbursement facility is generally availed if the hospital is not in network list of TPA or due to unclear requests cashless is not granted by TPA or if the insured voluntarily does not opt for Cashless facility

9. Claim Process- Cashless
Cashless facility is only applicable if the member goes to a network hospital
Employees should carry their TPA E-card along with a photo id proof to the hospital. If TPA e-card is not available then show your employee card
Initiate at the TPA Desk/Reception. This would require pre-author cashlessisation form to be filled by hospital and signed by doctor and faxed/ ed to TPA. Normally Hospital would do this activity but at-times it may require your intervention
Decision of TPA in form of Initial approval/additional documents requirement/ rejection will take around 7-8 hours
If the final bill is more than initial sanctioned amount then at the time of discharge follow the above process again. Additional limit will be granted if things are in order
There are few hospitals which may ask for certain deposit amount at the time of admission which will be refunded to you once the hospital gets it payment from the TPA
Approach TPA hospital with patient’s TPA e-card for approval
Hospital sends Cashless papers to TPA and reply to TPA’s query(if any)
TPA scrutinizes the request. Issues Initial Approval Letter/ Query letter/ Denial Letter as per requirement and coverage
On receipt of Query letter, Hospital to reply accordingly and co-ordinate with TPA for initial approval
At the time of Discharge, the above process to be repeated for Final approval
Employee to pay non-admissible expenses and take discharge. To claim pre-post expenses subsequently on reimbursement
Incase of planned hospitalization intimation at least 2-3 days before date of admission and incase of emergency within 24 of admission
TPA takes around 7-8 hours to process the claim, so initiate final approval accordingly
The denial of authorization for cashless access does not mean denial of treatment and does not in any way prevent you from seeking necessary medical attention or hospitalization

10. Claim Process- Reimbursement
Intimate claim within 7 days of admission- Online/ /Phone
At the time of Discharge- Collect all Original documents
Submit the claim form duly filled and all original documents to TPA/Broker within 30 days of discharge (For hospitalization and Pre 30 and Post 60 days)
Decision- Claims Approved / Additional Documents Required/ Claim Denied
TPA will convey the decision through
Claim Settled and Funds Transferred
Untimely intimation may result in claim rejection
Ensure all documents are collected including copy of indoor case papers
Send all documents in original including medical reports
Incase of any dissatisfaction/delay get in touch with Edelweiss RM
Any Original documents submitted will won’t be returned as the same required by TPA for Audit
Original hospital final bill
Original pre-numbered receipts for payments made
Complete breakup of the hospital bill
Original Discharge Card/Summary
All original investigation reports
All original medicine bills with relevant prescriptions
Original signed claim form
Govt. approved Photo ID card copy of claimant
TPA Card copy
Intimation mail copy/ Claim Registration no.
Paginated copy of Indoor Case papers
FIR/MLC copy incase of Road accidents. If MLC is not applicable then written confirmation from Doctor/Hospital that the patient was not under influence of alcohol or drugs
Cancelled Cheque of a/c of Employee
Documents Required for Reimbursement Claims

11. Steps to access Website
To Print e-Cards 
Go to
To print e-cards, click on the ID-card status link
Click on the “Print ID card” for each member and print the card.
You are allowed to print each ID card only thrice. Please ensure that you save the ID cards
Log off once the e-card is printed
To Locate a Network Hospital
Login to
Click on Tools & Resources
Select Current Network
Input your Username, password or Common Login Credentials to log-in
Select insurance company as The New India Assurance Co. Ltd.
Select City
Click on Search –will display list of hospitals in the selected city

12. Frequently Asked Questions (FAQs)
Q. Will I receive physical card? Where do I find TPA card?
No, however employee can download the e-cards Cards from link
Q. Will my previous year’s claim affect current sum
insured? No
Q. Is sum insured restricted for any ailment?
No. The policy sum insured is the limit except for Maternity
Q. Can I change my dependent details mid-term?
No. Except due to marriage or child birth. If there’s any error in Name, Age, Gender of dependents then it is to be brought to notice of HR for rectification
Q. Are all pre-existing diseases covered?
Yes
Q. Are all documents required to be submitted in original? Will photocopy do?
All documents are required in original. You are requested to retain photocopy of all documents
Q. What is reimbursement settlement TAT?
Generally within 45 working days post receipt of all requisite documents.
Q. Will my intimation suffice for cashless treatment?
No. On the contrary you need not send intimation if you are opting for cashless. For cashless you need to visit TPA desk at hospital and need to arrange for documents to be faxed to TPA. The TPA desk is not Health India team but it is hospital’s team
Q. How can I get cashless claim approval in case of emergency. If the admission is at odd-hours
In case of emergency, employee has to pay deposit money. To apply for cashless, at the hospital and call TPA help desk Toll Free no working 24*7. In case hospital desk is closed.
Q. Incase of urgent assistance/query whom do I call?
A. Toll Free no

13. Contact Points Level 2 – Level 3 - Health India Insurance TPA
24*7 toll free no / ,
Contact persons at Health India Insurance TPA services Pvt. Ltd.
The following can be contacted in case of claim status inquiry
Level 2 –
Ms Akshata Sawant
Contact Details /
Level 3 -
Ms. Reshma Pawar Id
Phone : / Mob
In case of Third Level escalation mark mail to with cc to
s will be responded within 2 working days
In case you are do not get any response within turnaround time mentioned, Kindly mark mail to below mentioned mail id
Id:   
              Note: - Landlines are available on weekdays i.e. Monday to Saturday from 10:00 AM to 6:00 PM
Employees shall send the claim documents to the below mentioned address:
Mr. Abhay Sawant/ Mr. Vijay Jha
Edelweiss Insurance Brokers Ltd.,
Unit No & 1202, 12Th floor,
C- wing, Godrej Coliseum,
Everard Nagar, SION, Mumbai Board:

14. Thank you