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| Frequently
Asked Questions (for Policy Holders) |
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Help
Desk |
| At
Sri Gokulam TPA, we believe that customer
satisfaction comes FIRST. In order to
provide the same, Sri Gokulam TPA has
a dedicated CALLCENTRE (No.1800-425-2868)
This number lands at a help desk that
is equipped to handle the customer queries. |
| The
help desk analysts are available to
help customers to : |
- Provide the status of the claims
on phone, fax or e-mail.
- Provide Cheque details and Cheque
dispatch information.
- General questions regarding Sri
Gokulam TPA and our operations
- Provide information related to
Network Providers and their contact
information
- Queries related to Sri Gokulam
TPA membership
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| Q1
: Provide the different benefits in the Mediclaim
insurance policy under hospitalization. |
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| Q2
: Explain how to determine whether a disease
is a pre-existing one or not. |
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| Q3
: Explain the procedure to apply for cover
under an Overseas Mediclaim policy. |
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| Q4
: What is the process of availing cashless
facility in the hospital ? |
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| Q5
: What are the formalities that need to be
done at the time of discharge in case of a
cashless facility ? |
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| Q6
: After availing cashless treatment facility
for my hospitalisation, how shall I claim
for my post Hospitalisation expenses ? |
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| Q7
: Where shall I file my claim after availing
treatment in a non-network hospital ? |
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| Q8
: What is a thirty-day exclusion ? |
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| Q9
: What is a one-year exclusion ? |
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| Q10
: Is dental treatment covered ? |
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| Q11
: Is pregnancy or child-birth covered ? |
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| Q12
: Whether treatment for AIDS is covered ? |
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| Q13
: Whether charges for diagnostic test etc.
are also covered ? |
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| Q1
: Provide the different benefits in the Mediclaim
insurance policy under hospitalization. |
| Under
hospitalization, the following are the segments
under which benefits are drawn: |
- Boarding expenses in a hospital / nursing
home
- Nursing expenses
- Professional fees of Surgeon, anesthetist,
medical practitioner, consultants and
any specialist
- Charges such as anesthesia, blood, oxygen,
operation charge, surgical appliances,
medicines and drugs, diagnostic material
and x-rays, dialysis and chemotherapy,
radiotherapy, pacemaker, artificial limbs
and cost of organs and similar expenses
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| Q2
: Explain how to determine whether a disease
is a pre-existing one or not. |
| At
the time of insurance, you should declare
whether you suffer any disease or undergoing
any treatment. Such health issues are referred
to their medical panel to differentiate between
pre-existing and newly contracted illnesses.
The proposal form for insurance given by you
provides details of the illnesses you have
suffered during your lifetime. Such disclosures
are essential for the insurance company to
determine the rate and conditions at which
you can be covered. For false details or non-disclosure
if discovered at a later stage over a claim
you could end up losing out. |
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| Q3
: Explain the procedure to apply for cover
under an Overseas Mediclaim policy. |
| To
acquire cover under an Overseas Mediclaim
policy, the traveler must submit his |
- Passport details
- Country of visit
- Details of Visa and its validity
- Details of employment / studies and
its duration & Name and address of
the sponsor
- Income certificate of the sponsor in
case of student
- Period of cover required
- Medical examination certificate as per
the prescribed guideline
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| Q4
: What is the process of availing cashless
facility in the hospital ? |
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For a planned hospitalisation: Please inform
us two to three days in advance by faxing
us the pre-authorisation form (form on website)
signed by the treating doctor.
Based on the policy issued to you, a letter
of authorisaion will be issued to the hospital
for necessary treatment. For emergency cases,
the hospital will inform us for obtaining
the pre-authorisation letter from our end.
Based on the Authorisation Letter to the
hospital you can avail the treatment at
the respective hospital.. We will pay your
hospital bills up to the amount authorized
as per our Authorisation Letter.
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| Q5
: What are the formalities that need to be
done at the time of discharge in case of a
cashless facility ? |
| Please
sign your bills, fill up the claim form with
signature, leave all your investigation /
diagnostic reports and X-ray/ultrasound films,
etc. The hospital will send us the documents
for assessment and payment. |
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| Q6
: After availing cashless treatment facility
for my hospitalisation, how shall I claim
for my post Hospitalisation expenses ? |
| You
can file a claim for reimbursement of your
Pre & Post hospitalisation expenses (30
days before date of admission and 60 days
after the date of discharge) with your "Gokulam
TPA". |
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| Q7
: Where shall I file my claim after availing
treatment in a non-network hospital ? |
| You
can lodge your claim at any of our offices
nearest to your location. If your claim is
found admissible it shall be paid within 7
days of receipt at our end. |
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Q8 : What is
a thirty-day exclusion ? |
| As
per an exclusion clause of the policy, any
disease contracted by the insured person within
the first thirty days from the commencement
date of policy, is not payable unless proved
by a panel of doctors that the insured could
not have known of the disease before the commencement
of the policy. |
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Q9 : What is
a one-year exclusion ? |
| In
a standard mediclaim policy certain diseases
are not payable in the first one or two years
or so, of insurance cover. These diseases
are payable after a 12 month or such exclusion
period of continuous cover, if they were not
contracted before the commencement of the
policy. Diseases such as Cataract, Benign
Prostatic hypertrophy, Hysterectomy for menorrhegia
or fibromioma, hernia, hydrocele, congenital
internal diseases, fishula in anus, piles,
sinusitis and such related disorders are excluded. |
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| Q10
: Is dental treatment covered ? |
| No,
dental treatment of any kind is not covered
unless requiring hospitalisation |
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| Q11
: Is pregnancy or child-birth covered ? |
| No,
treatment arising from or traceable to pregnancy
or childbirth including cesarean section is
not covered in a standard individual Mediclaim
policy. |
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| Q12
: Whether treatment for AIDS is covered ? |
| No,
expense arising out of any condition directly
or indirectly attributable to any syndrome
or condition commonly called AIDS are not
covered. |
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| Q13
: Whether charges for diagnostic test etc.
are also covered ? |
| Charges
for diagnostic test consistent with or incidental
to the diagnosis and treatment of the positive
existence or presence of any ailment, sickness
or injury are payable. |
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