1) What is the validity of SAIL Medi claim Scheme-2014?
Ans:-The SAIL Medi claim scheme 2014 is valid till 31st December, 2014 (2400 hrs IST).
2) What is claim intimation?
Ans:- Claim intimation is the notice of hospitalization/admission which is required to be sent to any centre of
E-Meditek in writing through letter/fax/email, 48hrs prior to planned hospitalization or within 24hrs in case of emergency hospitalization. The claim intimation should include all the relevant details like Name of Patient, age, sex, Mediclaim Index Number (MIN), contact details, diagnosis, name-address-contact details of the Nursing home/hospital, date of admission along with a copy of Admission Note of the treating doctor.
3) Where do I submit the claim document?
Ans:-You can submit the documents to the nearest E-Meditek branch (branch details has been provided in the SAIL guide book) OR
You can send the documents to E-Meditek head office at the following address, E-Meditek (TPA) Services Ltd. Plot No.- 577, Udyog Vihar, Phase - 5 Gurgaon, Haryana - 122016
4) What I have to do for availing cashless hospitalization facility?
Ans:- In case of planned hospitalization, E-Meditek should be informed 48 hrs in advance, through the duly filled-in/ Pre Authorization
form (available at E-Meditek website/in the booklet /at the TPA desk of the concerned hospital). Ensure that the Pre Authorization
Form is signed by the member and the treating doctor. Your claim would be assessed as per terms and conditions of the policy by the
insurer and a letter of authorization will be issued to the hospital authorizing treatment.
In case of emergency hospitalization/admissions, the concerned hospital is required to send the request for Authorization for
cashless hospitalization to E-Meditek with in 24 hrs of hospitalization/admission. Once E-Meditek authorizes the concerned hospital,
the cashless treatment through an Authority letter, you are not required to pay the hospital up to the amount which has been
sanctioned by the said authority letter. E-Meditek will pay your hospital bills up to the amount authorized in the Authority Letter
5) What is the time limit for claim submission for reimbursement in case of hospitalization?
Ans:-All the claim documents should be submitted within 30 days from the date of discharge from the hospital to any nearest E-Meditek Branch Office or Head Office.
6)What is the time limit for claim submission for reimbursement in case of OPD?
Ans:-OPD Claims to be submitted by the Mediclaim member to the Insurance company/ TPA when the expenses exceed Rs. 2000 per person
per policy period or within 90 days from the date of completion of the treatment, whichever is earlier. All the claim documents
should be submitted to any nearest E-Meditek Branch Office or Head Office.
7)Where can I avail cashless hospitalisation facility?
Ans:-You can avail the cashless hospitalisation facility in the Hospital mentioned in the guidebook under the head "List of empanelled
hospitals for cashless hospitalisation under TPA". The updated list of such empanelled hospitals may also be seen at the TPAs website
8)What are the documents required to be submitted for claiming reimbursement for hospitalisation?
Ans:-Kindly submit the following documents for processing your claim.
1. Duly filled-in claim form
2. Original discharge card
3. Original hospital bill
4. Original hospital bill payment receipt, and all the prescriptions.
5. Original investigation reports
6. Medicine Bills
7. ECS form duly filled-in along with the cancelled cheque incase not given earlier during renewal.
9)Whom do I contact in case of any grievance?
Ans:-In case of any grievance you may get in touch with the local branch office of E-Meditek or you can contact Head Office of E-Meditek on:
1) 24 Hrs Helpline: 0124- 4149727
2) Customer Care Help line (Toll Free No): 18001028191
3) Email ID:-email@example.com
4) Or you may Fax on: 0124-4466677
10)What do you mean by Pre-Hospitalization & Post hospitalization?
Ans:-The Pre hospitalization period is 30 days prior to Hospitalization and Post Hospitalization period is up to maximum of 60 days from the date of discharge from the Hospital.
11)What is the procedure for claiming reimbursement for Pre hospitalization as well as Post hospitalization period?
Ans:-The expenditure incurred during 30 days prior to Hospitalization (Pre hospitalization) and 60 days from the date of discharge
from the Hospital (Post Hospitalization), for the treatment of a particular disease for which Hospitalization takes place, is
considered for reimbursement under IPD/Hospitalization. This along with the claim form and prescriptions, medicine bills, investigation
reports, investigation advices should be submitted within 30 days from the date of last consultation, or 90 days from the date of
discharge, whichever is earlier.
12)My Spouse cannot sign on claim form can she give left hand thumb impression on Claim form?
Ans:-Yes, she/he can fill the claim form with left hand thumb impression on Claim form and submit the documents.
13)My OPD expenses are only 850/- can I claim for the amount?
Ans:-OPD claims may be submitted at any time by the claimant, however the claims need to be submitted necessarily before the
expenses exceed Rs 2000/- person per policy period or within 90 days from the date of completion of the treatment whichever is earlier.
14)Are only diagnostic test covered under IPD?
Ans:-Diagnostic tests which are not consistent with line of treatment are not payable at all.
However, Charges for diagnostic test consistent with or incidental to the diagnosis and IPD treatment of the positive existence or presence of any ailment, sickness or injury are payable.
15)What do I need to do at the time of discharge in case of a cashless facility?
Ans:-You need to sign your bills, fill up a claim form and sign the same, leave all your investigation/diagnostic reports
and X-ray/ultrasound films etc. with the Hospital. The hospital authorities will send the documents to E-Meditek for assessment
16)What is room restriction?
Ans:-• For metro cities (Hyderabad, NCR, Bangalore, Mumbai, Chennai, Kolkata) Ceiling of 2% of the sum insured per member , i.e Rs. 4000, or a single AC Non Deluxe room per day, whichever is lower .
• For Non- Metro cities which are state capitals –Ceiling of 1.5% of the sum insured per member, i.e Rs. 3000, or a single AC non- deluxe room per day, whichever is lower ,
• For rest of country – ceiling of 1% of the sum insured per member, i.e Rs. 2000 or a single AC non –deluxe room per day, whichever is lower.
17)Are there any limits on IOL (implant used in Cataract Surgery)?
Ans:-Ceiling rates for different types of lntra Lens (IOL) implants to be as per actual or Rs 10,000/- whichever is lower and
shall be reimbursable in addition to the package rates for cataract surgery procedure. It is mandatory to attach the empty IOL
sticker bearing the signature and stamp of the operating surgeon on it along with the bill in support of the type of IOL used
containing its batch number at the time of claim submission.
18)Are there any limits on Stents (used in Angioplasty)?
Ans:Yes, ceiling rates for different types of Coronary Stents to be as per the actual or the rates mentioned below, whichever is lower
||Name of the Drug
||Rs. 95000 +VAT
||Rs. 67300 +VAT
||Rs. 95000 +VAT
||Rs. 85000 +VAT
||Xience V EECSS
||Rs. 95000 +VAT
||Rs. 55000+ VAT
||Rs. 50000 +VAT
||Rs. 55000 +VAT
||Bare Metal Stent
||Rs. 45000 (All inclusive)
Ceiling rates for Coronary Stents other than the Stents mentioned above, to be as per actuals or Rs. 95000/- plus VAT, whichever is lower.
In case of reimbursement claimant has to submit the Outer part of the Stent Packet along with the Sticker on it, on which the details of the stent are printed.
19)Are there any treatment –wise capping/ceilings in the policy?
Ans:-In addition to the capping on Stents/ implants, the following capping on procedures/ packages as given below, shall also be applicable:
The above cappings/ ceilings are applicable on ‘per Hospitalization’ basis and only for cases where there are no complications/multiple diseases. Moreover, Pre-Hospitalization & Post-Hospitalization claims pertaining to the above treatments do not come under the purview of the aforementioned cappings.
20)What are the details on ECS Payments?
Ans:-Electronic clearance system is process where the amount is directly transferred to claimant's account. Claimant needs to
fill in the ECS form available on the E-meditek website (www.emeditek.com) or avail it from its branches. Once duly filled
they can send the document to the branch or Head office along with a cancelled cheque.
21)Will the company claim reimbursement for treatment/ medicines disbursed to the members through its Hospitals & Health Centres?
Ans:-Yes, SAIL will claim reimbursement against the treatment (OPD/ IPD) provided through its Hospital & Health Centres including
SAIL dispensaries and the same will be adjusted against the available Sum Insured for OPD/ IPD of the concerned member, as the case
22)Please specify the procedure for Renewal of Membership
Ans:-Following are the procedure for renewal of membership:
• The scheme is operational for a period of one year and the expiry of the scheme will be 31st December of the year.
• The member is required to deposit the renewal fee for joining the scheme in the next calendar year by 31st December of the current year. A grace period of 30 days would be provided for renewal.
• Though the concerned plant/unit would be informing the member of the renewal amount it will be the liability of the member to ensure his/her renewal every year, as the concerned plant/unit will not be responsible for any delay in the communication reaching the member.
• Various renewal payment procedures have been introduced for the benefit of the members. For details please visit the SAIL Website (www.sail.co.in).
Note: Any change of address must be immediately intimated to the concerned Plant/Unit and Insurance Company giving the Mediclaim Index No. (MIN).
23)When is my membership activated/ renewed?
• You have paid your premium fees through the various payment procedures as informed.
• You have sent your receipt of payment along with the renewal application form (complete in all aspects) to your concerned plant/ unit for activation/ renewal of your membership.
• Renewal will not be complete till payment receipt is sent to concerned plant/ unit along with application form.
24)Is Robotic surgery payable?
Ans:-No, robotic surgery or robotic assisted surgery is not payable under this policy.
25)Can I Claim hospitalization expenses of Ayurvedic/Homeopathic/Unani treatment of any hospital?
Ans:-Hospitalization expenses of of Ayurvedic/Homeopathic/Unani treatment are admissible only when the treatment is taken in
Government Hospital/Medical College Hospital
26)Can I claim the expenses of Rejuvenation therapy/Massage/Panchkarma?
Ans:-These are not payable under this Policy.
27)Can I Claim hospitalization expenses for Stem cell Transplantation?
Ans:-Stem cell Transplantation is not covered in this policy except Haemopoetic Stem Cell Transplant/ Bone Marrow Transplant.