GROUP HEALTH INSURANCE BENEFITS OYO & GROUP COMPANIES

HOSPITALIZATION WHAT IS COVERED ?

1
•Room and Boarding
2
•Doctor’s Fees
3
•Intensive Care Unit
4
•Nursing expenses
5
•Surgical Fees, Operating Theatre, Anesthesia, Oxygen, and
their administration.
6
•Drugs and medicines consumed on the premises.
7
•Hospital allied services (such as Laboratory, X-Ray,
Diagnostic Tests).
8
•Dressing, Ordinary Splints and Plaster Casts.
9
•Cost of Prosthetic devices if implanted during surgical
procedure.
10
•Radiotherapy and Chemotherapy.
11
•Expenses on vitamins and tonics forming part of treatment
as certified by the attending Medical Practitioner.
12
•Organ Transplantation including the treatment costs of the
donor but excluding the cost of the organ.
The expenses shall be reimbursed provided they are incurred in India and within the policy period. Expenses will be reimbursed to the covered member depending on the level of cover that he/she is entitled to.

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 BENEFIT DETAILS
Policy Start Date Pre-Post Natal Expenses
01 12
• 27- January- 2021
• Pre-Post natal expenses up to Rs2500/- is covered within
Policy End Date maternity limit
02
• 26-January- 2022
Ambulance Charge
03 Insurance Company 13
•The New India Assurance Company Limited • 1% of Sum Insured subject to maximum of Rs. 2000/- Per
person per policy
04 Third Party Administrator (TPA)
• Good Health Insurance TPA Limited
14 Pre Hospitalization
05 Policy Number
•Under Process • 30 Days

Family Size 15 Post Hospitalization

06
•Self+ Spouse + Two Dependent Children up to 25 years
• 60 Days
Sum Insured
07
• 5 Lakhs per family 16
Psychiatric Ailments
Pre Existing and 30 Days Exclusion
08 • Waived off • Psychiatric ailments / treatment is covered under the policy
up to Rs.25,000/- per family on IPD &OPD basis
1st Year Exclusion
17
• Waived off Claim Intimation
09
Room Rent
•Customer.care@ghpltpa.com within 24 hours
10 •Single Standard A/C room, maximum 4% of Sum Insured for
ICU
18 Claim Submission
Maternity Expenses
• 75K for C-sec and Normal Delivery • Claim must be filed within 30 days from the date of
11
discharge

**All terms, conditions and exclusions as per standard Policy Wordings.

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 BENEFIT DETAILS

Premium for Top Up Plan

Premium for Top Up Plan is to be borne by the Employee

Home Quarantine for COVID

Detailed Coverage Plan for COVID is at Slide number 8

Co Payment
5% on all admissible Claims, applicable to all members

- Within 30 days

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 BENEFIT DEFINITIONS HOSPITALIZATION PERIOD

MINIMUM DURATION OF HOSPITALIZATION

Definition

•Expenses on hospitalization are admissible only if

hospitalization is for a minimum period of 24 hours with
active line of treatment, except in cases of specialized
treatment as detailed here below (commonly known as Day
Care Procedures)
•Dialysis
•Chemotherapy
•Radiotherapy
•Cataract ( Eye surgery)
•Dental Surgery
•Lithotripsy (Kidney Stone Removal)
•Tonsillectomy

The condition of 24 hours hospitalization will

not be applicable if

•The treatment is such that it necessitates hospitalization

and the procedure involves specialized infrastructural
facilities available only in hospitalization.

•Due to technological advances hospitalization is required

for less than 24 hours.

NOTE: Procedures / treatments usually done in Out Patient Department (OPD) are not payable under the policy even if converted to day care surgery / procedure or as in patient in the hospital for more than 24 hours.

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 CUSTOMIZED BENEFITS
01
PRE-HOSPITALIZATION EXPENSES COVERED
DEFINITION
•If the Insured Person is diagnosed with an Illness which
results in his Hospitalization and for which the Insurer
accepts a claim, then the Insurer will reimburse the Insured
Person’s Pre-hospitalization Expenses for up to 30 days
prior to his Hospitalization as long as the 30-day period
commences and ends within the Policy Period. Not
applicable for maternity claim.
APLICABLE
•Yes
DURATION
•30 Days
04
FIRST 30 DAY WAITING PERIOD WAIVED
DEFINITION
•Any Illness diagnosed or diagnosable within 30 days of the
effective date of the Policy Period if this is the first Health
Policy taken by the Policyholder with the Insurer, except in
claims arising due to accidents. If the Policyholder renews
the Health Policy with the Insurer and increases the Limit of
Indemnity, then this exclusion shall apply in relation to the
amount by which the Limit of Indemnity has been increased
ADD-ON FEATURES
02
POST-HOSPITALIZATION EXPENSES COVERED
DEFINITION
•If the Insurer accepts a claim and, immediately following
the Insured Person’s discharge, he requires further medical
treatment directly related to the same condition for which
the Insured Person was Hospitalized, the Insurer will
reimburse the Insured Person’s Post-hospitalization
Expenses. Not applicable for maternity claim.
APLICABLE
•Yes
Duration
•60 Days from Date of Discharge
05
FIRST YEAR WAITING PERIOD WAIVED
DEFINITION
•During the first year of the operation of the policy the
expenses on treatment of diseases such as Cataract, Benign
Prostatic Hypertrophy, Hysterectomy for Menorrhagia or
Fibromyoma, Hernia, Hydrocele, Congenital Internal
Diseases, Fistula in anus, Piles, Sinusitis and related
disorders are not payable. If these diseases are pre- existing
at the time of proposal, they will not be covered even
during subsequent period or renewal too.
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03
PRE-EXISTING DISEASE COVERED
DEFINITION
•Any Pre-Existing Condition or related condition for which
care, treatment or advice was recommended by or received
from a Doctor within 48 months prior to the
commencement date of the Insured Person’s first Health
Insurance policy with the Insurer
06
DAY CARE COVERED
DEFINITION
•Day Care Procedure means the course of medical treatment
or a surgical procedure listed in the Schedule which is
undertaken under general or local anesthesia in a Hospital
by a Doctor for not less than 2 hours and not more than 24
hours. These are the treatments which take less than 24
hours due to medical advancements.
6
 CUSTOMIZED BENEFITS ADD-ON FEATURES

07 08 09

DENTAL TREATMENT RESTRICTED VISION & HEARING RESTRICTED DIAGNOSTIC EXPENSES RESTRICTED

DEFINITION
DEFINITION
•Charges incurred at Hospital or Nursing Home primarily for
•Any dental treatment or surgery of a corrective, cosmetic diagnostic, X-Ray or laboratory examinations or other
or aesthetic nature unless it requires Hospitalization; is diagnostic studies only if incidental to the diagnosis and
carried out under general anesthesia and is arising only out treatment of the positive existence/presence of any
of Accidental Bodily Injury. ailment, sickness or injury for which confinement is
required at a Hospital/Nursing Home.
DEFINITION
•Charges incurred at Hospital or Nursing Home primarily for
diagnostic, X-Ray or laboratory examinations or other
diagnostic studies only if incidental to the diagnosis and
treatment of the positive existence/presence of any
ailment, sickness or injury for which confinement is
required at a Hospital/Nursing Home.

10 11
CO - PAY APPLICABLE ROOM RENT EXPENSES RESTRICTED

DEFINITION
DEFINITION
•Co-pay again is a special cost containment measure, wherein •Per Day Rent for Room/ICCU are generally capped and so is
claimant has to pay a certain % of the claim amount limit applicable.
mentioned in the policy. For example if the policy say a co
payment of 5% on all claims by employee means claims
made by employee has to have a co-payment of 5% of the STATUS UNDER THIS POLICY
amount claimed from the employee or claimant.
•Single Standard A/C Room available
CO – PAY AMOUNT

•5% Co-pay on all admissible claims

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 COVID COVERAGE
BENEFITS

•Home care / Home Quarantine expenses of COVID 19 Positive Cases ( for mild and asymptomatic cases ) if referred by GOVT/
Authorized Hospitals subject to following conditions.
•If the Home care / Home Quarantine exceeds 3 consecutive days, then expenses from Day 1 is covered subject to Maximum of
25000/- per Member during the policy period.
•Ayush treatment can also be covered if referred by GOVT/ Authorized Hospitals subject to Maximum of 25000/- per Member
during the policy period. Total per person limit remain Rs.25000/- ( including under the head Ayush).
•All expenses to be Claimed are on valid GST bills.
•Teleconsultation to a max of 3 consults @1000/- each; Overall Doctors Fees limited to 6000/-
•RT PCR ( Real time reverse transcription polymerase chain reaction) tests as per ICMR rates & Guidelines and usually the test is
not required to be repeated.
•Any other test to be done under a cover of INR 1000/-
•Pulse-oximeter & Thermal Scanner - once only for the family during the Policy period.
•In cases where the person is required to be isolated but is staying alone and cannot take care of oneself, a daily nurse@500/- per
day upto 3000 may be allowed
•Oxygen charges @2000/- per case.
•Drugs as prescribed including immunity boosters, however, have to be FDA certified
•Masks and Gloves to be capped at INR 1000/- for the policy for home stay
•PPE Kit to be capped at INR 2000/- per case

EXCLUSIONS

• Self Medication
• Self Quarantine for suspected COVID-19
• Diagnosed with COVID-19 prior to commencement of Policy
**All terms, conditions and exclusions as per standard Policy Wordings.

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 EXCLUSIONS WHAT IS NOT COVERED ?
10
1
•Acquired Immune Deficiency Syndrome- and sexually transmitted
•Any kind of Service charges, Surcharges, Admission fees / diseases.
Registration charges, etc. levied by the hospital. So at the time of
admission you may check the % of these expenses on total bill, to 11
make necessary financial arrangement. •Expenses on vitamins and tonics etc. unless forming part of
2 treatment for injury or disease as certified by the attending
physician.
•Outdoor Patient Treatment(OPD) expenses are not covered
3 12
•Pre-natal and post-natal expenses are not covered unless •Naturopathy treatment, unproven procedure or treatment,
admitted in Hospital/nursing home and treatment is taken there. experimental or alternative medicine and related treatment
4 including acupressure, acupuncture, magnetic and such other
therapies etc.
•Expenses incurred on Diagnosis, X-Ray, or Laboratory
examinations not followed by Hospitalization to cure a sickness or 13
an injury
•Any Expenses under Domiciliary Hospitalization.
5
•Circumcision, Vaccination or Inoculation or change of life or 14
cosmetic or aesthetic treatment of any description, plastic surgery •Genetic disorders and stem cell implantation / surgery.
except for relating to treatment of injury or illness.
6 15

•Cosmetic surgery for correction of eye sight, cost of spectacles,
contact lenses, hearing aids, etc.
7 Belts, Collars, Caps, splints, slings, braces, Stockings etc. of any
•All non medical expenses including Personal comfort and
convenience items or services such as telephone, television, aaya
/ barber or beauty services, diet charges, baby food, cosmetics,
napkins, toiletry items etc., guest services and similar incidental
expenses or services etc.
8
•Dental treatment or surgery of any kind unless requiring
hospitalization on account of accident cases
9
•Convalescence, General Debility, Run down condition or rest cure,
sterility, venereal disease, intentional self injury and use of
Intoxicating drugs/alcohols.
•External and or durable Medical / Nonmedical equipment of any
kind used for diagnosis and or treatment including CPAP, CAPD,
Infusion pump etc., Ambulatory devices i.e. walker, Crutches,
kind, Diabetic footwear, Glucometer / Thermometer and similar
related items etc. and also any medical equipment which is
subsequently used at home etc.
16
•Change of treatment from one pathy to other pathy unless being
agreed / allowed and recommended by the consultant under
whom the treatment is taken.
17
•Treatment of obesity or condition arising from weight control
program, services or supplies etc.

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 EXCLUSIONS WHAT IS NOT COVERED ?
26
18
•Infertility Treatment and related treatments (PCOD)
•Any treatment required arising from Insured’s participation in any
hazardous activity including but not limited to scuba diving, motor
27
racing, parachuting, hang gliding, rock or mountain climbing etc.
•Voluntary termination of pregnancy during first 12 weeks (MTP).
19
•Any treatment received in convalescent home, convalescent 28
hospital, health hydro, nature care clinic or similar establishments • Intravitreal injections are excluded from the scope of policy
20
•Any stay in the hospital for any domestic reason or where no
active regular treatment is given by the specialist.

21
•Outpatient Diagnostic, Medical and Surgical procedures or
treatments, non prescribed drugs and medical supplies, Hormone
replacement therapy, Sex change or treatment which results from
or is in any way related to sex change.

22
•Massages, Steam bathing, Shirodhara and alike treatment under
Ayurvedic treatment.

23
•Doctor’s home visit charges, Attendant / Nursing charges during
pre- and post-hospitalization period.

24
•Treatment which is continued before hospitalization and
continued during and after discharge for an ailment / disease /
injury different from the one for which hospitalization was
necessary.

25
•Expenses incurred for investigation or treatment irrelevant to the
diseases diagnosed during hospitalization or primary reasons for
admission. Private nursing charges, Referral fee to family doctors,
Out station consultants / Surgeons' fees etc.
NOTE: For complete list, kindly refer the standard policy copy.

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 CLAIM PROCESS !

CASHLESS FACILITY REIMBURSEMENT FACILITY

CASHLESS FACILITY CAN BE AVAILED OR REIMBURSEMENT FACILITY IS

GRANTED WHEN THE HOSPITAL IS GENERALLY AVAILED IF THE HOSPITAL
REGISTERED AS NETWORK HOSPITAL IS NOT IN NETWORK LIST OF TPA OR
OF TPA. DUE TO UNCLEAR REQUESTS
CASHLESS IS NOT GRANTED BY TPA
OR IF THE INSURED VOLUNTARILY
UNPLANNED/
PLANNED DOES NOT OPT FOR CASHLESS
EMERGENCY
HOSPITALIZATION FACILITY.
HOSPITALIZATION
________________
________________
______
______
WHEN THE
WHEN THE
CASHLESS REQUEST
REQUEST FOR
PROCESS IF
CASHLESS IS MADE
COMPLETED IN
AT THE TIME OF
ADVANCE.
ADMISSION ONLY.

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 EMERGENCY ?
CASHLESS PROCESS
•Approach the nearest empaneled Network Hospital with your
employee ID card / Mediclaim e-card, if you want to avail the
cashless facility. If there is no empaneled institutions close by,
go to a non empaneled hospital and the claim can be
reimbursed later.
•In case of an empaneled hospital, your hospital can follow up
with the TPA Helpdesk which is open 24 hrs. a day for the
cashless facility with the TPA.
•Network Hospital List Link- https://bit.ly/39lDXyQ (Select the
Insurer as The New India Assurance Co. Limited)
ASSISTANCE
•Please get in touch for any assistance
Assist@plancover.com
CLAIM INTIMATION
•Claim Intimation - For planned treatments: 48 hours prior to
hospitalization and for emergency Treatment: 24 hours within
hospitalization. This is applicable for both cashless &
reimbursement claims. Please send the intimation to
Customer.care@ghpltpa.com / Assist@plancover.com
KNOW YOUR POLICY !
CLAIM PROCESS – PLANNED / UNPLANED REQUEST
Cashless facility is only applicable if the member goes to a
network hospital
Employees should carry their mediclaim cards or mediclaim
ids along with a photo id proof to the hospital, you can
download ecards by March 2021. If a need for hospitalization
arises before you receive your ecard, please carry your
personal Id proof and corporate Id proof
Once in the hospital, go to the Help desk/TPA Desk/Reception,
and inform that you are covered under Group Mediclaim
Insurance Policy serviced by TPA, the TPA (pls. do not mention
for Insurance / Brokers)
Ask for the preauthorization form and get it filled from the
doctor you or your dependent is being treated by. Get the
at filled form faxed to the TPA at Customer.care@ghpltpa.com
If everything is ok, within 12 hours (generally 2-4 hours) the
TPA will sanction the amount.
If TPA requires more clarification, it will re-fax the letter of
requirement/clarification. The query needs to be answered
satisfactorily via fax. If the query is resolved, then TPA will
sanction the cashless.
The cashless may be rejected if TPA is of the view that ailment/
hospitalization is not covered under the policy
If the final bill is more than initial sanctioned amount, then at
the time of discharge follow the above process again.
Additional limit will be granted if things are in order.
There are few hospitals which may ask for certain deposit
amount at the time of admission which will be refunded to you
once the hospital gets it payment from the TPA
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 EMERGENCY ? KNOW YOUR POLICY !
REIMBURSEMENT PROCEDURE CONDITIONS FOR REIMBURSEMENT

In case of non-network hospital patient has to bear the Reimbursement under the scheme is provided for expenses
hospitalization expenses and can get them reimbursed from the incurred for medical treatment on or after the date of joining of
Insurer after Discharge. However insured needs to intimate the the employee anywhere in India on or after the effective date of
TPA about the hospitalization coverage for the following conditions:

Please send intimation mail to Customer.care@ghpltpa.com i.e.
emp code, corporate name, patient name, date of admission,
hospital name and city
Please ensure that you collect all necessary documents such as –
discharge summary, investigation reports etc. for submitting your
claim.
After the hospitalization is complete and the patient has been
discharged from the hospital, you must submit the final claim
within 30 days from the date of discharge from the hospital.
(Applicable in case of Non-Network hospital), & 15 days for pre-
post hospitalization claim after completion of the treatment.
There has to be a 24-hour hospitalization to claim medical
expenses.
The treating hospital should be a registered one with the local
authorities having at least 15 beds.
No investigation expenses are covered in case an ailment is not
coming out of the investigations.
Reimbursement claims should reach the Insurer for processing
within 15 days from the discharge date of the patient from
hospital.

Please courier you documents to- Employee should intimate the TPA within 24 hours of
hospitalization in case of unplanned treatment and before 48
Good Health Insurance TPA Ltd.
hours of hospitalization in case of planned treatments
S-2, 2nd Floor, Near SBI Bank,
Okhla Industrial Area, Phase-II,
New Delhi - 110020

Please write a mail to Assit@plancover.com for dispatch details

i.e. date of sent, courier name and consignment no

Once insurer will receive the docs from your courier company,
employee will get an auto mailer with in 1-2 working days with
confirmation of receipt.

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 REIMBURSEMENT CLAIM PROCESS
REIMBURSEMENT CLAIM PROCES IN NON-MEDICO LEGAL CASES

CHECKLIST OF DOCUMENTS FOR GMC

IN ACCIDENTAL DEATH CASES

GENERAL DOCUMENTS – (APPLICABLE TO ALL •Treating Doctor’s certificate giving details of injuries (How, when and where
TYPES OF CLAIMS) injury sustained) and whether the claimant was under the influence of any
intoxicating substance.
•Duly filed and signed Claim form.
•Photocopy of ID card / Photocopy of current year policy.
FOR DEATH CASES (IN ADDITION TO IN-PATIENT TREATMENT
SPECIFIC DOCUMENTS – BENEFIT WISE DOCUMENTS)

•Copy of Post-mortem examination report and death certificate.

IN-PATIENT TREATMENT / DAYCARE PROCEDURE /
AYUSH BENEFIT
•Original detailed discharge summary / daycare summary from the PRE AND POST – HOSPITALIZATION EXPENSES
hospital.
•Original consolidated hospital bill with break-up of each item, duly •Original Death summary from the hospital.
signed by the insured.
•Copy of death certificate from treating doctor or the hospital authority.
•Original payment receipt of the hospital bill.
•Copy of legal heir certificate, if the claim is for the death of the principle insured.
•First consultation letter and subsequent prescriptions.
•Viscera report for death due to poisoning or Snake Bite.
•Original bills, original payment receipts and reports for
investigation.
•Original medicine bills and receipts with corresponding AMBULANCE BENEFIT
prescriptions.
•Original invoice / bills for implants (viz. stents/ PHS Mesh/ IOL
etc.) with original payment receipts. •Original medicine bills, original payment receipt with prescriptions.
•Original investigation bills, original payment receipts with prescription and
ROAD TRAFFIC ACCIDENT (IN ADDITION TO THE IN- report.
PATIENT TREATMENT DOCUMENTS) •Original consultation bills, original payment receipt with prescriptions.
•Copy of discharge summary of the main claim.
•Copy of First Information Report from Police Department / copy
of the medico – legal certificate •Original bill with original payment receipt.
•Treating doctor’s consultation prescription indicating emergency
hospitalization.

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 OUR SERVICES

ABOUT HIBS INDUSTRY LEADERS

HII Insurance Broking Services Pvt. Ltd. (HIBS) has been appointed as
the Broker for your GMC policy this year. HIBS will be the single point
of contact for your employees for all queries / coordination and
consultancy related to insurance benefits.
Explain policy benefits & Terms and Conditions to employees
Manage the SLAs and ensure claim settlement as per the policy
features

Assistance on cashless facility across the country

SERVICES OFFERED BY HIBS
Claim and query handling through dedicated call centre
Major responsibilities of HIBS are to ensure the following;
Health insurance consultation by industry specialists / health benefits
Manage the employee experience. Help in documentation, query experts.
resolution and emergency assistance.

Guaranteed Claim settlement as per the policy

Assist in the painful process of cashless & reimbursements

Provide an integrated portal for enrollment, claim status, policy

details and all other information related to health insurance benefits

Monitor the policy performance and challenge genuine but denied

claims including partial settlements.

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 CONTACT DETAILS

Queries Regarding Data and Other Issues

Level Name Email Contact Numbers
Level 1 Ms. Vidhya Rani Assist@plancover.com 9873925551

Level 2 Ms. Geeta Gulati Assist@plancover.com 9971730455/56 Ext. - 39

Queries Regarding Hospitalization or Claims

Level Name Email Contact Numbers

Level 1 Mr. Avneesh Kumar Assist@plancover.com 9100065478

Level 2 Ms. Vidhya Rani Assist@plancover.com 9873925551

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THANK FOR YOUR
YOU VALUABLE TIME !

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