6. POLICY FEATURES
Raksha TPA Private Limited 6
Raksha TPA
Tailor Made Floater Group Mediclaim Policy
Policy No: 35020534200500000004
30-Sep-2020 to 29-Sep-2021
Insurance Co :
THE NEW INDIA ASSURANCE CO. LTD.
TPA : RAKSHA HEALTH INSURANCE TPA PVT. LTD.
7. Policy Features
Benefits/Extensions Coverage
Family Cover and size Employee
Room Rent Capping
ICU / CCU Capping
1 % of the Sum Insured
2 % of the Sum Insured
Pre existing diseases Covered
1st Year exclusion Waived Off
2nd Year exclusion Waived Off
Pre & Post Expenses 30 & 60 Days Respectively Covered
Treatment Anywhere In India
First 30 days exclusion Waived Off
Room Rent Condition Incase an employee opts for the higher room rent then his
eligibility, proportionate deduction will be applicable. Please
note proportionate deduction will not be applicable for
medicines.
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Raksha TPA
8. Raksha TPA Private Limited 8
Day Care Treatments covered under Policy
Expenses on Hospitalisation for minimum period of 24 hours are admissible. However, this time
limit is not applied to specific treatments, such as:
Appendectomy
Haemo dialysis
Coronary angiography
Hydrocele
Coronary angioplasty
Hysterectomy
Inguinal/ventral/ umbilical/femoral hernia
D&C
Parenteral chemotherapy
Eye surgery
Piles/ fistula
Fracture/ dislocation excluding hairline fracture
Sinusitis
Lithotripsy
Tonsillectomy
Incision and drainage of abcess
Liver aspiration
Colonoscopy
Sclerotherapy
Prostrate
Radiotherapy
Or any other surgeries / procedures agreed by the
TPA/ Company which require less than 24 hours
hospitalisation and for which prior approval from
TPA is mandatory.
Note: Procedures/treatments usually done in out patient department
are not payable under the policy even if converted as an in-patient in
the hospital for more than 24 hours
Raksha TPA
9. Raksha TPA Private Limited 9
Eligibility for Hospital / Nursing Home
Minimum 15 in-patient beds (in major cities) & 10 in Remote
areas.
Fully equipped OT
Fully qualified nursing staff round the clock
Fully qualified & registered doctor(s) round the clock
Raksha TPA
10. Raksha TPA Private Limited 10
General Exclusions Under the Policy
Domiciliary Hospitalization
OPD treatment
Treatment related to infertility, Voluntary Termination of
Pregnancy
External Accessories (e.g.) Walking Stick, Crepe bandage,
Spectacles, contact lens, hearing Aids etc.
Non Medical Expenses (e.g.) Telephone Charges, Food Charges,
Registration Charges, Accommodation Charges for Relatives.
Naturopathy Treatment , Homeopathic & Ayurvedic Treatment
War Like operations whether declared or not
Circumcision unless necessary for treatment of disease
Cosmetic treatment
Plastic Surgery
Raksha TPA
11. Raksha TPA Private Limited 11
General Exclusions Under the Policy
Intentional Self Injury, Intoxicating Drugs, Alcohol, Congenital External
Disease, sterility etc
Hospitalization meant for Oral Medication, primary Investigation is
non Payable
Vitamins And Tonics unless part of treatment
Hospitalization Less than 24 hrs other than day care treatments
All Expenses related to the treatment of AIDS is not covered.
Pre & Post Hospitalization charges for Maternity is Non Payable
Raksha TPA
13. Cashless Services
Raksha TPA Private Limited 13
Emergency
Identification via UHID Cards
Approach Network Hospital
Planned
Pre-authorization request to
Raksha TPA from Provider
Raksha TPA Pvt Ltd
VERIFIED BY
DOCTOR
Authorization Issued Pre – Authorization Request Denied
Queries Raised for
further Clarification
Raksha TPA
14. Communication Support…
Providing information directly from servers (www.rakshatpa.com):
- Claim Status
- Cashless Status
- ID Card Status
- Information on Network Hospitals
- Claim intimation
- Customer Care
Raksha TPA
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Raksha TPA Private Limited
15. EMERGENCY
APPROACH TO NON - NETWORK HOSPITAL
PLANNED
INTIMATE 3-4 DAYS
BEFORE ADMISSION
INTIMATE WITHIN 24 Hours from
ADMISSION
Hospitalization through Non-Network Provider
(Reimbursement Claims)
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Raksha TPA Pvt Ltd
SUBMIT DOCUMENTS IN 7 DAYS
FROM D.O.D
Raksha TPA
17. PROCESSING OF NON-NETWORKING CLAIMS
INSURED (REIMBURSEMENT with
intimation in 24 Hours
CLAIM RECEIVED BY RAKSHA
TPA PVT. LTD (within 7 days
from D.O.D.)
AUDITING
ENTRY ON LOCAL
WEBSITE
DOCTOR’S OPINION
PASSED
QUERY
NON PAYABLE
FINANCE
DEPARTMERNT
Raksha TPA
Raksha TPA Private Limited
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26. DO’S (Cashless Services)
Pre-auth form should be sent along with insured/attendant cell no. duly signed
by treating doctor/hospital.
Avail cashless treatment at Network hospitals for the covered ailments within
eligible amount under the policy.
Leave back all the original documents and signed claim form with the network
hospitals at the time of discharge.
Contact local Raksha office in case of any query.
Make payment to the network hospital for the expenditure over and above sum
insured/ specified limit for any disease, and for the expenses/treatment not
covered under the package
For current status of empanelment/de-empanelment of networking hospital,
please refer our website: www.rakshatpa.com
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Raksha TPA
27. DONT’S (Cashless Services)
Don’t insist upon admission for investigations or evaluation or health
check-ups.
Don’t carry back any original document at the time of discharge from the
hospital.
Don’t forget to sign on claim form.
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Raksha TPA
28. After discharge policy holder has to submit the following
documents to Raksha TPA within 7 days.
Original detailed discharge summary
Payment receipt in original
Copy of ID card
Original hospital bill with breakup
Package break-up (if applicable)
Original investigation reports
Pharmacy bills with prescription
Claim form duly signed
Scan copy of Cancelled Cheque
Hospital registration certificate cont……
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Raksha TPA
29. Copy of MLC and FIR in Accidental Claims.
Obstetric History in Maternity Claims.
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Raksha TPA
