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Most commonly asked questions and their answers

Hospital coverage

Hospitalisation limit is the per person per year limit that covers all in-patient and related medical expenses for the year which includes the room/board expenses as well. Admission is only covered when a person is admitted for a minimum 24 hours.

Note: This limit covers all medical treatments in case of admission other than Maternity.

It varies from insurance company to company, but yes there is usually an increase of the hospitalisation limit in case of an accident. (For further information on this, please confirm the enhancement from SmartBenefits support.)

Note: Accidental enhancement is only given when there is an admission.

Accidental benefits cover any unforeseen situation which results in injury of any kind. This could occur anywhere whether at home, outdoors or at work.

This is based on the room limit mentioned on your medical card. For example your room limit is Rs. 10,000 and the semi private room offered by the hospital cost Rs. 8,000, in that case you can avail this room. However if you want to avail a private room which costs Rs. 15,000, in that case the difference will be paid as applicable.

It will be covered depending upon the condition for 24 hours only.

  • To answer this, we need to know more. Please reply with option number
    • 1 It is an accidental emergency?

Yes it will be covered within 48 hours completely even if you need treatment for minor injury. This expense will be reimbursed from the insurance company. However medicines prescribed by doctor aren’t covered for home use. 

  • 2 It is a non-accidental (medical) emergency? 

Yes it will be covered if your treatment requires IV Fluids/Drip, for instance you have high fever or diarrhoea. This expense will be reimbursed from the insurance company. However medicines prescribed by doctor aren’t covered for home use. 

Following are some of the diseases that are covered under your insurance plan

  • Covid -19
  • Cancer 
  • Heart diseases
  • Kidney failure
  • Hypertension
  • Cataract 
  • Birth defects (depending upon coverage)
  • Critical illness

Note: Any disease that you already have are called Pre-existing conditions and may not be covered under your plan. (Link to pre-existing diseases list article/Show list of pre-existing diseases list)

Day Care Surgeries

Due to advancement in medical sciences, certain surgeries can be performed in a few hours and do not require prolonged aftercare hence you are released by doctor without admission. Such surgeries are known as Day Care surgeries 

It differs from insurance company to company.

(Link to daycare surgeries list article/Show the list of daycare surgeries)

For Panel Hospital, the process is fairly simple. The employee or the covered person just has to visit the corporate admission department of the hospital along with doctor’s prescription and your insurance card to get pre-approval of the surgery. You must initiate this process 24 hours before the scheduled surgery.

For Non-Panel Hospital, the employee will have to pay from his or her own pocket and get reimbursed from the respective insurance company by filling the claim form along with all original payment slips with discharge summary and itemized billing.

Accordion Content

Lab investigations covered

No, only specialised investigations as per provided list are covered.
Please check the list of covered SIT by following the steps on the app:
Guides > Special Investigation Tests

No, it is an OPD test hence not covered (only certain conditions apply as below)

  1. It is only covered if an employee or his/her family had a positive result and is admitted due to that, if he or she is quarantined at home, then it will not be covered.
  2. If you are admitted to the hospital for any procedure which is covered by insurance, however before the procedure could start, COVID test is mandatory. In such case, the test would be covered on reimbursement basis 

Follow the steps to check the list of discount labs.
Guides > Discount Labs

Maternity

If you have maternity coverage in your policy, it should be mentioned on your medical card. Check your physical medical card or virtual card on your mobile app to know your maternity limits. 

Maternity benefit covers all the expenses incurred from conception till the delivery including circumcision. These expenses include doctor visits, ultrasound and medicines.

Yes, the complicated delivery limit is mentioned separately on your medical card. Check your physical medical card or virtual card on your mobile app to know your limits. 

For Network hospital, you must visit the Corporate admission department of the hospital along with the doctor’s prescription and health insurance card to get prior approval. You would be issued an approval letter which you must keep safe. It is required to be presented at the reception when you visit the hospital for admission.

For Non Network hospitals, you will be required to pay all the expenses out of your pocket and later fill the claim form and provide all original documents to begin the claim process. The required documents list is attached.

Yes, these are covered. Some insurance companies have a seperate limit for Legal abortions, DNE or multiple births while other companies cover it from normal delivery limit.

Claims Assistance

In the case of a Panel Hospital, the process is all cashless as long as you are admitted for more than 24 hours. 

In case of a Non Panel Hospital, the employee has to pay from his or her own pocket and begin the claim process by filling the claim form along with all required original documents

It takes up to 14 working days to get your claim settled. This begins from the day you submit all the original documents along with claim form to the insurance company

 Following are the items which are not paid out by insurance company

  • Non medical or personal items such as telephone bill, food and etc
  • Benefit that has a sub-limit and not fully covered under hospitalisation such as Pre-existing condition
  • Expenses which go above your assigned hospital limit
  • There maybe deductions of upto 20% of your total bill if medical treatment is carried out at non-network hospital 
  • R&C (reasonable and customary charges)

Following are the reasons insurance company may reject your claim

  • Incomplete documents
  • Photocopies of bills
  • Benefits that are not part of the policy or exclusions.
  • On hold by the insurance company due to non-payment of premium

Only those Medicine, lab tests expenses which are incurred 30 days before or after hospitalisation can be claimed on reimbursement basis. 

Doctor consultation fees or medicine expenses which does not lead to hospitalisation are not covered.

Following are mandatory documents required to process claims 

  1. Use a separate claim form for each claim or course of treatment
  2. Part A of a claim form: To be completed by patient
  3. Part B- To be completed by treating doctor
  4. Diagnostic /Investigation reports / Medical Reports
  5. Original Bills / Prescriptions / Reports
  6. Hospital Discharge Report / Discharge Slip
  7. Medical Emergency report in case of Accidental or Medical Emergencies.
  8. Birth certificate in case of delivery.

Note: Non-original / Photocopy bills are not acceptable

A cashless claim facility is where the insured person does not have to pay anything if the individual visits a panel hospital. 

No, there isn’t any limit on the number of claims during a year. However, the hospitalization limit is the maximum limit that can be claimed for in a year.

In such case, the insurance company will only settle the claim for the amount available in your hospital limit while the remaining has to be paid out of pocket.

For instance, if you have an available limit of Rs. 500,000 and your final bill is Rs. 550,000, the insurance company will only settle Rs. 500,000 while Rs. 50,000 has to be paid by you.

Accidental and medical emergencies are covered on reimbursement basis and paid as per benchmarking with local (Pakistan) hospitals. No elective or planned admission is covered.

Panel Hospital

A network hospital or also known as panel hospital is where the facility of cashless claim can be availed by the insured person.

It is advised that the insured person should get treatment at panel hospitals due to the facility of cashless claims being provided by the insurance provider

Those hospitals which are part of the network hospital list of your insurance provider. In that case the admission is done on a cashless basis, so there is no need to pay anything. 

(Link to Article of network hospitals/Take to network hospital search screen)

A non-network hospital or also known as a non-panel hospital is where the facility of cashless claim cannot be availed by the insured person. The individual has to bear all the expenses first and then file for a claim when being treated at a non-network hospital.

If you get treated at a non-panel hospital you will first have to bear the expenses from your own pocket then file for a claim with all the necessary documents attached and the claim form. 

A: Panel & reimbursement facility is available in GB and Azad Kashmir. (Link to panel hospitals search screen/ Link to Intercom article for panel hospital list)

Following are the reasons insurance company may reject your claim

  • Incomplete documents
  • Photocopies of bills
  • Benefits that are not part of the policy or exclusions.
  • On hold by the insurance company due to non-payment of premium

Only those Medicine, lab tests expenses which are incurred 30 days before or after hospitalisation can be claimed on reimbursement basis. 

Doctor consultation fees or medicine expenses which does not lead to hospitalisation are not covered.

Following are mandatory documents required to process claims 

  1. Use a separate claim form for each claim or course of treatment
  2. Part A of a claim form: To be completed by patient
  3. Part B- To be completed by treating doctor
  4. Diagnostic /Investigation reports / Medical Reports
  5. Original Bills / Prescriptions / Reports
  6. Hospital Discharge Report / Discharge Slip
  7. Medical Emergency report in case of Accidental or Medical Emergencies.
  8. Birth certificate in case of delivery.

Note: Non-original / Photocopy bills are not acceptable

A cashless claim facility is where the insured person does not have to pay anything if the individual visits a panel hospital. 

No, there isn’t any limit on the number of claims during a year. However, the hospitalization limit is the maximum limit that can be claimed for in a year.

In such case, the insurance company will only settle the claim for the amount available in your hospital limit while the remaining has to be paid out of pocket.

For instance, if you have an available limit of Rs. 500,000 and your final bill is Rs. 550,000, the insurance company will only settle Rs. 500,000 while Rs. 50,000 has to be paid by you.

Accidental and medical emergencies are covered on reimbursement basis and paid as per benchmarking with local (Pakistan) hospitals. No elective or planned admission is covered.

Exclusions

  • Cosmetic or plastic surgery unless it is reconstructive surgery necessitated by an injury
  • Test or treatment relating to fertility, infertility contraception or sterilisation
  • Sleeping disorders, psychiatric, mental or any nervous disorder
  • Self-inflicted injuries including attempt to commit suicide.
  • Eye glasses, contact lenses, hearing aids, artificial limbs etc.
  • Professional sports injury.

Doctor Consultation or OPD is usually not covered unless it is part of pre and post hospitalisation after the admission and discharge process is completed. (For further details, Please consult you HR)

Such condition is called a pre-existing condition and in most cases there is a sub-limit which is less than the hospitalisation limit. (Ask insurance company name and link to respective intercom article for list of pre-existing condition)

No, these items are not covered under any policy.

No mental health treatments will not be covered under any policy.

Dental treatments are not covered but if the insured person is involved in an accident then it is covered only to relieve pain. 

Congenital defects will vary according to the policy. (Show list of congenital defects in an intercom article)

Hospital coverage Jubilee (111-111-554)

  1. Adamjee (0300-2018246)
  2. IGI (111-111-711)
  3. EFU allianz (0300-8207000 for Karachi) (0300-848318 for Lahore) (0300-8508550 for Islamabad)
  4. Pak Qatar (111-825-238)
  5. TPL (0307-2222953)

 

Daycare surgeries

Lab Investigations

Maternity 

Claims Assistance 

Panel Hospitals 

Exclusions 

Health Card

The health card has all your details in one place and it can be used to get cashless claims at panel hospitals.

Your health cards will be dispatched once you are onboarded. SmartBenefits offers virtual health cards also to make the process faster.

Note: For now the virtual health card is only available for TPL and Jubilee insurance.

1) Use SmartBenefits mobile app to access your Virtual health card.

2) Ask your HR to request SmartBenefits for a replacement card.

Your health insurance has coverage all over Pakistan in the network hospitals of the respective insurance companies.