1. health insurance orientation module

Health Insurance Orientation
Module

Future Generali Health

Introduction

 Future Generali is an insurance joint venture between the Italy-based
Generali Group and the India-based Future Group.

 Future Generali operates Life and Non-Life insurance businesses through ‘Future
Generali India Life Insurance Co. Ltd.’ and ‘Future Generali India Insurance Co. Ltd.’

 Future Group holds 74% each in both the companies.
 Future Generali received license from the Insurance Regulatory Development
Authority (IRDA) in Sept 2007 and launched operations from Nov 2007.


Future Generali Clientele in India


Introducing


How we are different:
• Future Generali Health (FGH) is an internal unit of Future Generali India Insurance.
• No Third Party Administrator (TPA) involved between the insurer and FGH.
• No prior approval required to sanction authorization for cashless as in the case of
TPAs.
• Claim settlement is faster due to single point clearance – no exchange of claim
documents between insurer and TPA.
• Preferred services extended as FGH provides service only to clients insured by
Future Generali.

An In-house Health Management Team of Future Generali India Insurance Co. Ltd.

Internal units of (FGH) Future Generali Health Team
Call Centre

24 X 7 Helpline to cater to customer queries

Enrolment

For card issuance and member data management

Cashless Management

24 X 7 services with 2 hours Turn Around Time (TAT)**

Claims Processing

Average TAT of 14 working days**

Provider Management

1400 hospitals and 200 diagnostic centers network

Research and Analysis

Analysis, Feedback & monitoring

Pre Policy

For retail medical underwriting

Underwriting

Centralized Group / Retail Underwriting at hubs

**All TAT’s subject to availability of complete documentation


Your New Wellness Card
• Your New card entitles you to a host of
healthcare benefits.
• Photo identification is necessary whenever
you use this card.
• This card does not entitle you to avail
cashless without pre‐authorization.
• This is NOT a credit card.


Member Enrolment
Key Function: For card issuance and member data management
 Within how many days will I get my Wellness Card?
• You will receive health cards via courier or e‐mail within 7 days after your details
are received by FGH from your organization.
 What if there is an error on my Wellness Card?
• For any error in cards or correction required, you can immediately report to
your HR.
 What is the use of the Wellness Card?
• You will get a Wellness Card to utilize the Cashless facility at Network Hospitals.
• This card helps only in your identification as a Future Generali Health member.
• Availability of Cashless and any other benefit is subject to policy terms.

Claim Process: Cashless
If you are going for a Planned Hospitalization:
1. Carry your ID cards and authorization letter when you go to the hospital for admission
2. Get the Pre‐authorization done in at least 7 days before hospitalization
3. Pre‐authorization is done to determine whether cashless facility can be granted based on
all medical information about your ailment and coverage
4. Pre‐authorization forms are available at NETWORK hospitals. You can also obtain it from
our call centre by e‐mail or Fax
5. Your treating doctor has to fill the form and sign it
6. You will also have to sign the Pre Authorization form and provide your mobile number
7. The hospital will fax this form to our Call Centre to get an authorization

Claim Process: Cashless Continued….
If you are going for Planned hospitalization:
8.

Our doctors will examine the form and decide on cashless availability

9.

If cashless is granted, we will send an Authorization Letter to the hospital. You
can also get a copy of the Authorization Letter from our Call Centre by e‐mail

10. If cashless is denied, we will send a Denial Letter to the hospital and inform
you
11. If cashless has been denied, you will have to pay the hospital bill and then send
the claim to us


Cashless
Process

Customer approaches FGH Toll Free
for Cashless Treatment. Future Generali coordinates
with hospital for preauthorization

Hospital verifies customer details and sends
pre‐auth by fax to FGH (Pune)

FGH verifies pre‐auth details with
policy benefits and sends the response by
Fax to Hospital

Network Hospital

Approved
Authorization Letter sent by
FGH

Hospital admits the patient
without any deposit and
provides cashless treatment

Query

Denial

Query Letter sent by
FGH

Denial Letter sent by
FGH

Hospital faxes the reply for
queries asked by
FGH doctors

Hospital admits the patient as
Cash Patient and patient pays the Bill


Cashless Process FAQs
1. What is a Network Hospital? How do I know the hospital is on
the network?


FGH has tied up with specific hospitals and nursing homes to provide preferred services
to its customers . These hospitals are termed as “Network” hospitals.



You can find out the details of Network hospitals in your city from our Call Centre on
phone or by e‐mail. The details are also available in the Health Insurance Guide sent
along with your Wellness Card.



Hospitals are added and removed from the network at regular intervals. You are
advised to check with our Call Centre for the updated status of any hospital.

2.How does the Hospital verify that the cardholder is genuine?
Since the Card issued is not a photo id card, you are required to submit a photo id to
verify the genuinity of identity at the Admission Desk of the Hospital. The photo id can
be your Organization Identity Card, Driving License or any other such card which will
help the hospital to establish the genuinity of the patient.
3.What is a Preauthorization Request?
This is a Request for Cashless Hospitalization. The same has to be duly filled up, signed
and stamped by the Hospital Authorities. Thereafter it has to be sent by fax / e‐mail to
FGH. The Contact details of FGH is available in the hospital.


4.Where do I procure the Preauthorization Request from?
The Preauthorization Form template is available with the Network Hospitals or also
enclosed with the Health Insurance Guide. It can also be obtained from FGH Call Centre
on phone or by e‐mail.

5.How to fill the Preauthorization form?
It must be filled by the Treating Doctor.
Information required are :
ID No. as printed on the Card, Signs and Symptoms of the present aliment, duration of
the aliment, diagnosis, pre existing conditions if any, proposed line of treatment,
expected date of admission, duration of stay and estimated cost of hospitalization.

6.Where do I send the Preauthorization form?
The Preauthorization Request for Cashless Hospitalization can either be faxed to
24 x 7 Toll Free Fax‐line 1800 103 9998 or mailed to fgh@futuregenerali.in
7.What is an Authorization Letter ?
Authorization Letter is the communication ascertaining the Admissibility or Acceptance
of the Cashless Service. The same is issued by FGH subject to admissibility of the claim
and availability of balance sum insured for the member.
8.Is the entire amount requested by hospital authorized by
FGH?
FGH would release a part or the entire amount depending on the ailment and related
expenses. In case a part amount has been approved by FGH, then the hospital would
ask for additional authorization when necessary.

8.How do I know whether my Claim has been approved for
Cashless or not?
Authorization Letter or Denial Letter shall be faxed directly to the Hospital with
intimation to you.
A Query letter shall be faxed to the hospital if in case FGH wants some additional
information to decide upon the admissibility.


9. What are the circumstances under which a Request for
Cashless Hospitalization shall be denied?
1.

If the information contained in the Request is insufficient for FGH to arrive at a
decision and further information is not available for whatever reasons.

2.

The ailment for which hospitalization is sought is not covered under the
particular insurance policy or is a part of an Exclusion under the policy
guidelines.

3.

The insured has already exhausted his insurance coverage for the year.


Claim Process
If there is an EMERGENCY
• Contact our call centre and inform them about the nature of emergency
• If possible, always go to a network hospital
• If not, then go to the nearest hospital
• In a network hospital, the patient can be admitted by showing the FGH Wellness
Card only
• After admission, the pre authorization has to be done


Claim Process
If there is an EMERGENCY

• Our doctors will inform you and the hospital if cashless can be given
• The hospital will ask you for a deposit if we deny cashless
• If you have gone to a non – network hospital, keep our call centre informed


Remember
Cashless facility is always subject to the broader policy guidelines and relevant
terms and conditions.
Important
Please note that decline of a request for Cashless Hospitalization is only denial of
Cashless Service and is in no way to be treated as denial of treatment or claim. The
insured retains the right to get treated and submit the bills to FGH for subsequent
Reimbursement.


Preliminary scrutiny of claim &
verification :
‐ Policy Benefit
‐ Date of Loss
‐ Mandatory Documents

Deficient
(Some Document required
For Admissibility)

Repudiated
(Not falling with policy conditions)

Reply not
received

Approved
(Admissible under policy)

Repudiation letter
sent to client

Intimation of the
Deficiency
is sent to the client

Reply received along
with all
deficient documents

Claim documents received  from
Insured member

Payment cheque
sent to client

Subsequent reminders
sent at fixed intervals

Documents
not received

Reimbursement
Claims Process

Claim closed
without payment


Reimbursement Claim Process ‐ FAQs
In case of Non Cashless Claims, what would be an appropriate plan
of action to ensure timely reimbursement of the claim?
If cashless facility is not availed, pre‐authorization is denied or treatment is availed at a non‐
network hospital, the insured will have to settle the bills directly with the hospital and
subsequently claim reimbursement by submitting the following documents to FGH:
1. First Prescription / consultation note from the Doctor
2. The Claim Form duly signed by the claimant or family member
3. The Original Hospital Discharge Card
4. The Original Hospital Bill giving detailed break up of all expense heads mentioned in the
bill


5.

The Money Receipt duly signed with a Revenue Stamp.

6.

All Original Laboratory & Diagnostic Test Reports. E.g. X‐Ray, E.C.G, USG, MRI Scan,
Haemogram etc

7.

If you have purchased medicines in cash and if this has not been reflected in the
hospital bill, please enclose a prescription from the doctor and the supporting
medicine bill from the Chemist

8.

If you have paid cash for Diagnostic or Radiology tests and it has not been reflected
in the hospital bill, please enclose a prescription from the doctor advising the tests,
the actual test reports and the bill from the diagnostic centre for the tests.



What are the norms for Intimation on Claims ?

Preliminary notice of claim with particulars relating to Name of the Insured
Person / Claimant, Nature of illness / injury and Name and Address of the
attending Medical Practitioner / Hospital / Nursing home should be given to
FGH. Intimation can be sent by e‐mail or Fax to our Call Centre.
FGH


Are there any norms related to the Hospital where treatment is sought
which are mandatory for admissibility of claims?

Please ensure that the hospital / nursing home where you are contemplating treatment
fulfills these criteria.
1.It has at least 15 inpatient beds;
2.It has a Doctor who is in attendance 24 hours per day;
3.It maintains daily medical records for each of its patients,
4.It is registered and licensed as a hospital or nursing home with the appropriate local
authorities. Always instruct the hospital authority to mention the Attending Doctor’s and
Hospital Registration No. in the hospital papers or demand for a separate certificate on the
same
5.The hospital provides a proper discharge summary, numbered bill and receipt for
hospitalization expenses at the time of discharge

Where do I send my claim documents?
Claim documents will be forwarded to the Future Generali Health Team in Pune by the
member / corporate. All claims will be managed by the Claims Team located in Pune.
Claims Team
2nd Floor, Kant Helix Tower, Bhoir Colony, Opp Tata Motors, Chinchwad,
Pune – 411033 (Maharashtra)
All claim payments advice shall be made within 14 working days from the date of receipt of

COMPLETE documents.
FGH may ask for the additional documents from the claimant if the submitted documents
are not sufficient to decide the admissibility of the claim.


What does FGH do with my claim documents?
Your claim is assessed by our expert team and doctors who verify the documents and bills
If all requirements are complete and the claim is admissible, the claim is approved and the
cheque is sent to you or your corporate
If the claim is not admissible, then a Repudiation Letter is sent to you / corporate by e‐mail
/ courier
If our team requires additional documents to process the claim, then a Document Recovery
letter will be sent to you / corporate by e‐mail / courier
 FGH will send one intimation and two reminders at intervals of 15 days
 If additional documents are not received after the second reminder from FGH, the
claim is assessed with the available documents. This could lead to part payment or
no payment at all.

Your Contact Points
For any claim related query, hospital information, grievance, feedback or
appreciation, please contact us on the following:
Toll Free Phone No

1800 103 8889

Toll Free Fax No

1800 103 9998

Email

fgh@futuregenerali.in

In case you do not receive a response from the above, then you can escalate your
issue to the following:
*1st Escalation: Vinayak Pankhade at palanivel.a@futuregenerali.in
*2nd Escalation: Ashish Saxena at ashish1.saxena@futuregenerali.in
*3rd Escalation: Bishwajit Nayak at bishwajit.nayak@futuregenerali.in

Future Generali Health Insurance
2nd Floor, Kant Helix Tower, Bhoir Colony, Opp Tata Motors, Chinchwad,
Pune – 411033 (Maharashtra)


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