The Group Medical/Health Insurance is a one of the methods of paynig the healthcare financing. Others are
Out of pocket (where the patient pays from his/her own to the service provider)
Individual Health insurance
Govt. Financing
In most of the devloped countries, group healht insurance is considered to be the best way of healthcare financing for the employees and their families.
Coverage of Alfalah Group Health Insurance is Explained as.....
HOSPITALIZATION COVER
Medical Expenses will be covered/ reimbursed as per policy terms & conditions incurred up to the specified limit as in the Table of Benefits on account of the following.
1. Daily Room Charges (inclusive of meal charges wherever applicable)
2. Operation Theatre Charges
3. Surgeons/ Consultant’s fee
4. Anesthetist fee
5. Medicines and drugs
6. Diagnostic tests
7. Endoscopies, Angiography, Thallium Scan (on out-patient setting when advised by the relevant physician/surgeon).
8. Day Care Surgeries (without the condition of 24 hours in hospital) eg cataract etc.
9. Pre-admission and Post-hospitalization Benefits (expenses incurred outside the hospital provided they lead to hospitalisation, up to a limit specified (mentioned in the Table of Benefits). These expenses are payable if the hospitalization limit if not fully consumed during hospitalization. MRI and CT Scan can also be covered as pre and post hospitalization benefit.
MATERNITY COVER
Medical Expenses will be covered/ reimbursed as per policy terms & conditions incurred up to the specified limit as in the Table of Benefits on account of the following.
1. Gynaecologist’s fee
2. Labor Room/Operation theatre charges
3. Anaesthetist fee
4. Miscarriage, D&C and D&E
5. Medicines
6. Diagnostic tests
7. Baby’s Nursing Care
Maternity expense benefit limit also covers and is inclusive of:
1. Charges of baby nursing care
2. Daily Room Rent Charges set in the basic hospitalisation policy.
3. Circumcision of baby boys (Limit as mentioned in the Benefits Table)
HOW DOES THE SCHEME WORK?
1) Procedure For Admission in a Panel Hospital
1. If a qualified doctor advises hospitalisation due to a valid reason, then any of our panel hospital can be approached for treatment on credit basis against Health Card/Letter of Authority.
2. The attending hospital will retain the attested photocopy of the Health Card/Letter & National ID Card of the employee/dependent) and will extend the required hospitalisation services to the insured patient as advised by the attending doctor.
An employee can visit any of our Network Hospital according to his plan/category of benefits. The list of these hospitals changes from time to time and is available at the website (www.alfalahinsurance.com). These hospitals besides meeting our stringent quality criteria are accredited upon the credentialing of their physicians/surgeons and favourable assessment of their facilities.
2) What if an employee visits a hospital not on our panel?
We strongly urge the use of panel hospitals especially in non emergency cases. The hospitals on our panel are selected based on scientific methods and their facilities and general level of care are regularly monitored to ensure quality. Reasonable discounts have also been taken from these hospitals that are passed to the patients in the billing. If an insured wishes to utilize the services of a hospital not on our panel, then he is required to take our prior approval by sending us the history, findings & procedure to be done on the prescription paper of the attending doctor and its complete detail of charges about 3 days before the scheduled procedure. This can be faxed /emailed to Health Insurance Department. In emergency situations, an insured can go to a non-panel, but he has to inform us within 24 hours of such hospitalization. Then these claims can be submitted after filling & signing the Claim Form and a deductible will be applicable according to the policy terms & conditions and payment will be made according to the charges of our nearest panel hospital/hospital of the same standard whatever decided by the insurance company. The company reserves the right to decline the claim and to exclude the employee from the policy if a false claim is launched.
IMPORTANT NOTE:
Please ensure that before submission, your in-patient claim must be supported by documents according to the checklist provided below. Please submit your claim within 15 days of the expenses incurred along with the attested claim form.
CHECK LIST FOR REIMBURSEMENT OF CLAIM
1. Final Hospital Bill with Receipt (Original)
2. Discharge certificate / card from the Hospital indicating final diagnosis
3. Original cash memos of medicines from the Hospital / Chemist(s) supported with proper prescription
4. Receipt (Original) and Pathological / Radiogical test reports with proper prescription of the attending
Medical Practitioner / Consultant / Surgeon
5. Surgeon’s certificate stating nature of operation performed and Surgeon’s bill and receipt
6. Attending Doctor’s / Consultant’s / Specialist’s / Anesthetist’s bill and receipt (Original)
7. Medical Certificate from the attending Medical Practitioner / Consultant / Surgeon
8. Copy of Birth Certificate (In Case of Maternity)
9. Copy of Company’s Reference Letter / Health Card
10. Copy of CNIC of patient (if patient is adult)
MAIN EXCLUSIONS
Some (and not all) of the main exclusions are –
1. Mental illnesses, and any sickness or condition arising from and including drug abuse, alcoholism or a criminal act.
2. Treatment or investigation of fertility, infertility, sterilization, contraception and any complication relating thereto or hormone treatment and investigations.
3. General check-ups or rest cures or hospitalization only for evaluation and diagnostic purposes.
4. Supply or fitting of eye glasses, contact lenses or hearing aids.
5. Cost of limbs or supporting equipment for revival or correction of the function of body.
6. Dental examinations, extraction or filling unless necessitated due to an accidental injury occurring during the insured period.
7. Cost of radial keratotomy and excimer and lasik laser procedures.
8. Cosmetic surgery, unless necessitated by an accidental injury occurring during the insured period.
9. Personal comfort items such as, charges for telephone, meals for other than the patient or other non-medical items.
10. Any outpatient treatment, except that arises out of an accident.
11. In few hospitals, charges of certain treatment vary in different type of rooms i.e. private, semi private, general ward etc. individuals staying in higher than their entitlement will be responsible for payment of additional expenses for room rate plus any increase in other expenses as well.
