Are there any preliminary medical check-ups required?
No, there are no medical check ups required. Depending on the terms and conditions in the policy, in a few instances, 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:
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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EFU Health is Pakistan’s First Specialized Health Insurance Company. Our financial stability and experience in serving all of our clients’ insurance needs form the basis of our customer oriented philosophy. Our structure and products are designed around our customers.