Why Insure

Why choose health insurance for your company?

Globalization of the economy, employee mobility, high cost of employee replacement, and the need to retain valuable employees, have posed new challenges for companies. At the same time cost of medical treatment is escalating at an alarming rate. Healthcare episodes range from high frequency low-cost conditions, through to major surgical events requiring intensive care costing Rs. 200,000 or more. Today, employees demand and choose to work for companies that offer medical benefits.

Some companies have offered medical benefits to their employees by maintaining an accounts ledger of medical expenses and reimbursing claims. They have not only experienced steadily rising costs but also sudden peaks in expenses caused by major medical events. Managing health care requires a combination of clinical knowledge, contractual

administration, tracking systems and healthcare management expertise. As their primary focus is to make a profit in their core business they neither have the time nor the resources to undertake healthcare management on their own and then there is also the risk associated with major medical events.

The answer is to out-source your medical benefits to a healthcare specialist. The healthcare specialist for a growing number of leading businesses in Pakistan is Allianz EFU.

Benefits

Benefits At A Glance
Comprehensive Care, Convenience, Choice, all at the same time!

Allianz EFU takes pride in offering high quality insurance plans for your staff. With Allianz EFU taking care of their health, you can enjoy extra peace of mind.

We cover healthcare through our network of hospitals, where your staff and their dependent family members will receive the most appropriate treatment. And we even have the systems in place to make the process simple and transparent.

We offer you choice and flexibility to choose amongst the following six different plans.

Benefit Description A B C D E F
Suggested Eligibility Criteria

Hospital Care

Pays for expenses incurred during hospital stay up to the Per Annum Per Insured Limit
CEO & Directors Departmental Heads Middle Management Clerical Staff Non-Clerical Support staff
• Overall Maximum Annual Limit Per Person 150,000
100,000
75,000
50,000
35,000 25,000
• Daily Room & Board Sub-Limit 16,360
6,720
4,810
2,500
1,500 1,000
• Intensive Care
• Surgeon’s Fees
• Anaesthetist's Fee
• Operating Theatre Charges
• Prescribed Medicines Used During Hospital Stay
• Blood and Oxygen Supplies
• Ventilators and Allied Services
• Kidney Dialysis & Cancer Treatment
• Daycare Surgeries / Procedures (including Endoscopy, Angiography, Dialysis etc.)
• Diagnostic Investigations conducted during hospital stay
• MRI, CT Scan , Thallium Scan, PET Scan (specialized investigations covered as OPD)
• Organ Transplant
• In-Hospital Consultation
• Fractures and Lacerated Wounds
• Local Ambulance (in Emergency from home to hospital within the same city on reimbursement)
• Pre & Post Hospitalization
(OP Expenses covering Consultations, Medicines and Diagnostic Tests 30 days before and after hospital confinement)
OPTIONAL BENEFITS
Major Medical Care
Additional Annual Limit Per Insured (Enhances the annual limit of Hospital Care for each insured) 450,000 300,000 250,000 200,000 150,000 125,000
Maternity Care
Pays for medical expenses related to Pregnancy and Childbirth. All Maternity related expenses are payable from Maternity Limit
Normal Delivery 128,000 80,000 53,500 30,000 20,000 15,000
Caesarean Section /Multiple Births / Assisted Deliveries 222,500 158,500 123,000 60,000 40,000 30,000
Outpatient Care
Annual Limit Per Family 25,000 20,000 15,000 10,000 7,500 5,000


Notes:

• You can elect to offer different plans to employees based on seniority and Management Grade
• Customized plans are available for large Groups
• Figures given above are in Pakistani Rupees

Exclusions

The following Treatments, events, conditions, activities and their related or consequential expenses are excluded from the Policy, unless specifically agreed upon in writing by the Company:

  • Any expenses directly or indirectly incurred for the treatment of any Pre-existing Medical Conditions.
  • Any charges in respect of the donor for organ transplant Claims.
  • Services or Treatment in any spa, hydro clinic, sanatorium, nursing home or long term-care facility that is not a Hospital.
  • Routine medical examinations or check-ups including charges arising out of any Hospital confinement or admission primarily for diagnostic purposes unless specifically authorised by the Company, routine eye or ear examinations, vaccinations (except WHO recommended EPI vaccinations for Children), medical certificates, examination for employment or travel, spectacles, contact lenses, hearing aids. Cost of correction of refractive errors of the eye and procedures such as Radial Keratotomy and Excimer Laser.
  • All dental Treatment or oral surgery apart from Emergency Accidental Dental Treatment.
  • Any Out-Patient Treatment, except Emergency Accidental Out-Patient Treatment within forty eight hours of the Accident.
  • Cosmetic or plastic surgery, unless it is re-constructive surgery necessitated by an Injury that occurred during the period whilst the Insured Member was covered under this Policy and subject to the limits and sub-limits stated in the Benefits Table.
  • Pregnancy and complications thereof, childbirth (including surgical delivery), miscarriage, abortion and/or any related prenatal or postnatal care unless covered by a separate rider under this Policy.
  • Tests or Treatment relating to fertility, infertility, contraception or sterilisation.
  • Birth defects or congenital Illness.
  • Prostheses, corrective devices and medical appliances which are not surgically required.
  • Psychotic, mental or nervous disorders (including any neuroses and their physiological or psychosomatic manifestations) or sexual reassignment (whether or not for psychological reasons).
  • Experimental or unproven Treatment.
  • Self-inflicted Injury, attempted suicide, abuse of alcohol or drug addiction.
  • Participation in or training for any dangerous or hazardous sport, pastime or competition or riding or driving in any form of race or competition or any professional sport.
  • Aviation other than as a fare-paying passenger of a recognized airline or charter service.
  • Treatment received in a location other than the Insured Member’s Geographical Area of Coverage.
  • Injury or Treatment resulting from war, riots, invasion, act of foreign enemies, hostilities or warlike operations (whether war be declared or not), civil war, mutiny, civil commotion assuming the proportions of or amounting to a popular uprising, military uprising, insurrection, rebellion, military or usurped power or any act of any person acting on or on behalf of or in connection with any organization actively directed towards the overthrow or to the influencing of any government or ruling body by force, terrorism or violence.
  • Injuries as a result of an illegal act other than a minor misdemeanour or minor delinquency by the Insured Member.
  • Ionising radiation or contamination by radioactivity from any nuclear fuel or nuclear waste, from the process of nuclear fission or from any nuclear weapons material.
  • Any increase in the expenses incurred for Treatment on account of the Insured Member being admitted to a more expensive room than allowed by his Daily Room and Board Limit.
  • The cost of non-medically necessary goods or services including such items as telephone, television, newspapers or accommodation for the insured person’s family members.
  • Weight management services and treatment related to weight reduction programs including treatment of obesity.
  • Natural catastrophes, epidemic, including, but not limited to, flood, earthquake, avalanche and cyclone.
  • Any Disability directly or indirectly related to or resulting from HIV, AIDS or any other sexually transmitted disease.
  • Air ambulance or evacuation or repatriation expenses.

Value Added

How Allianz EFU helps improve your health?

Allianz EFU is the only company in Pakistan with the resources to deliver an effective integrated health care programme that is sufficiently flexible to develop and grow as needs change.

Integrated healthcare
Integrated Health Care system that improves the quality of care while reducing / containing the cost.

Allianz EFU uses a state-of-the-art computerized system that enables us to track medical events, benchmark practice and analyze clinical practice in detail. All this activity is aimed at ensuring that patients receive the most appropriate care. If the patients need extensive treatment, Allianz EFU staff doctors will work closely with the hospital to ensure that the best approach to treatment is being arranged.

An integrated HealthCare system consists of the following main components.

  • Selection of only those hospitals that meet stringent quality criteria. Facility Assessment through internal grading system.
  • Credentialing of network hospital's physician and surgeons.
  • Case Management for admitted patients in network hospitals

Health Card
To provide that extra peace of mind, we will issue a personalized health card to each employee. In case of medical emergency, this card serves to identify you to a network hospital. It features your insurance coverage details, emergency phone numbers and family details.

24 Hours Medical Hotline
In case of a medical emergency, our team of doctors is accessible 24 hours a day through our medical hotlines. These doctors will guide and help you in seeking treatment and admission if needed in a network facility.

Call Center
The company has established a specialized Call Center that ensures timely response to all customer enquiries. The Call Center is available during office hours. Our dedicated and trained Call Center representatives ensures that our valued customers are at complete ease and comfort by providing them the accurate information to all their enquiries.

Dedicated Customer Service Hotline
The company also has a dedicated customer service hotline, available after office hours, to cater to the needs of the customers.

Network Hospitals
Allianz EFU has developed close business relationships with a network of medical service providers. Today, the company enjoys strong professional association with a network of over 170 carefully selected hospitals spread throughout the country. These hospitals are accredited based upon the credentialing of their physicians /surgeons and favorable assessment of their facilities. In addition to better quality care, you get the following benefits:

  • No cash payment required, we reimburse hospitals directly.
  • No claims form and no waiting time for reimbursement cheques.
  • Less administrative work.

Discount Centers To add greater value to our services, Allianz EFU Health Insurance Ltd has entered into a contract with some reputable providers whereby our insured members can avail discounts on Out Patient Consultation and Investigations upon presenting their Health Cards (even where outpatient treatment is not covered under the policy).

Web portal
We provide a secure web based portal service* to our corporate clients. This facility enables our corporate customers to track the claim detail and status of their insured employees any time without needing to contact Allianz EFU Customer service representative.
* Conditions apply

FAQ

Are there any preliminary medical check-ups required?
No, there are no medical check ups required. However, all employees have to disclose complete medical history of the persons to be insured under the health plan.

What is per annum limit?
Per annum limit is the maximum amount of eligible benefits payable for incurred medical expenses in a single policy year.

How to avail Credit facilities at the Network hospitals?
In order to avail credit facilities at the network hospital, you should first obtain PRE-AUTHORIZATION. Pre-authorization is the process used to review the proposed plan of medical treatment prior to medical admission. This is done to assure that the Insured member’s medical needs are met in the most efficient and effective manner.

In a non-emergency case involving a scheduled Hospitalization, you shall notify the admissions office of the Network Hospital at least three (3) working days prior to the scheduled admission, giving the reason for admission, the name of the admitting Physician and the information contained on your Health Card. Alternatively you may provide all of the above information at least three (3) working days prior to the scheduled admission, directly to us on our Preauthorization Form. The Company shall review the request for admission and approve Treatment that it believes is Medically Necessary and satisfies the terms and conditions of the Policy.

Some of the benefits of pre-authorization are:

  • You do not have to pay cash, we settle the bills related to the covered treatment directly to the network hospitals, as per your entitlement.
  • There is no need to complete lengthy documentation and to file a claim
  • You don’t have to wait for 15 working days to get the reimbursement
  • If the hospital is not properly equipped for the recommended treatment, you are advised and an alternate is suggested
  • You are informed in advance about the insurance limits available and any shortage, enabling you to make prior arrangements for any out-of-pocket expenses that you may have to incur

Pre-authorization is NOT RECOMMENDED in an ‘Emergency Medical Condition’ * since a delay can be detrimental to the patient’s health.

* An ‘Emergency Medical Condition’ refers to a medical condition resulting from sickness or accident and requiring emergency hospital admission for which delay in treatment could reasonably be expected to result in significant and permanent impairment of the Insured’s health and/or bodily functions.

What happens if I take a room that is more expensive than my Daily Room & Board sub-limit?
Premium rates for health insurance are based on several factors. One of those factors is the room entitlement. Hospitals charge a higher rate for the same procedure performed for a Private room patient than for a General Ward patient. Therefore, you should select a room that is within your insurance policy’s Daily Room and Board sub-limit. If you elect to stay in a room that is more expensive than your Daily Room and Board sub-limit, then you will not only have to pay the difference in room cost but will also have to pay the extra charges for ancillary services.

What happens if my hospital bill exceeds my maximum hospitalization limit?
Ours sales team performs a consultative role and guides employers in selecting appropriate maximum limits. However, due to costs and other considerations, it is not always possible for employers to offer high maximum limits that covers all hospitalization expenses. Therefore, there are occasions when your maximum limit will be insufficient to cover all hospitalization expenses. In such cases, you will incur out-of-pocket expenses and will be required to pay the hospital that amount exceeding your maximum hospitalization limit.

What happens if I go to the non-network hospital in an emergency situation?
We have carefully selected our network hospitals to ensure geographical dispersion and we strongly recommend our insured members to visit the nearest network hospital. Still if you are unable to find a network hospital you can visit a non network hospital in case of emergency but you will have to settle the entire bill yourself, complete all claims procedure and documents and wait to receive reimbursement cheque. If you are unaware of a network hospital near you, call us at 021-111-4357-00 (during office hours) or our Medical and Customer service hotline numbers after office hours.

If an employee leaves six months after the commencement of the policy, does he continue to remain covered until the end of the year?
No. He will remain covered only as long as he remains employed with the company that has taken the health policy.

What is the role of your Case Managers?
Our case managers are qualified doctors assigned to visit our insured members admitted in hospitals. Their primary responsibility is to ensure that patients are treated by credentialed and qualified physicians and surgeons at the hospitals in conformity with Internationally Accepted Best Practice medical guidelines and that patients have no problem during stay.

Do you cover treatment in Hospital Emergency Room where the patient is treated for high fever, diarrhea etc. and discharged from the Emergency Room within 3-4 hours?
No. Hospital Care and Major Medical Care products are priced to cover the cost of treatment after the patient is admitted in the hospital. Expenses incurred on Hospital Emergency Room treatment are covered under our optional Outpatient Care product. However, Hospital Emergency Room treatment necessitated due to an accident is covered under Hospital Care.

Do you cover pre and post hospitalization consultations, investigations and medicines?
All consultations, investigations and medications related to a hospitalization would be covered for a period of 30 days prior to and after that hospitalization. These expenses are claimable on reimbursement only.

Are Day Care Procedures covered?
Yes. Apart from In-patient hospitalization, the policy also covers Day Care procedures. Day care procedures are medically necessary treatment/surgical procedures that require the patient to occupy a hospital bed but do not require an overnight stay, such as, Angiography, Endoscopies, Dialysis, etc.

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