Group Mediclaim Policy 2020-21 for ESC (H Band & Below)

Frequently Asked Questions

Vodafone India Service Pvt. Ltd. &

Vodafone Global Services Pvt. Ltd

Group Mediclaim Policy

1. What is the coverage amount under the Group Mediclaim Policy?

The sum insured limits are defined below.

PARTICULARS COVERAGES
Family Size 1+3
Family Definition E+S+2C
Employee SI = INR 2.00 lacs
Maximum Sum Insured Limit - Hospitalization Dependent SI = INR 1.00 lac
each
Policy Type Family Floater
2. What are the broad benefits under the Group Mediclaim Policy?
 Pre-Existing diseases are covered from day one without any waiting period
 Waiver of waiting period for special diseases and otherwise
 Maternity Cover for Normal or C-Section – For Single Child Delivery INR 50,000 & For Twin/Triplets
Delivery additional INR 25,000
 Newborn Child Cover from day one (Intimation to be sent about expected date of delivery or about
childbirth, within 30 days from the date of birth)
 Pre-Hospitalization expenses (30 days prior to date of Admission) & Post Hospitalization expenses (60
days postdate of Discharge) payable excluding Maternity.
 Ambulance charges covered up to INR 2000 per event basis
 Sexual Reassignment Surgery - Allowed (INR 2.00 lacs per employee limit) NO LIMITATION ON NUMBER
OF SURGERIES.
 Psychiatric / Psychosomatic Disorders (Only for Employee) - LIMITED TO INR 25,000 (IPD & OPD)
 Payment of Non-Payable Expenses in case of Death of Employee during hospitalization - Payable within
Sum Insured limit.
 Artificial Life / Limb Support (Mobility Extension) - Crutches - Rs. 1500; Wheelchairs - Rs. 5000
 Addition of 3rd Child - Allowed (with Additional Premium)
 Donor / Receiver Expenses - In case of organ transplant Surgery expenses of donor (excluding pre and
post) is covered, as per Human Transplant Act (Excluding organ cost)
 Lasik Surgery - Treatment for correction of eyesight beyond +/- 7 Covered, Including Lasik Surgery without
any sublimit
 Ayush (Homeopathic / Unani / Siddha) Treatment - Covered Sub Limited to INR 25,000 (Treatment only in
Government / NABH Accredited / QCI certified) In-Patient Treatment

3. Co Pay Under Policy,

 For Employee, Spouse & Children – 10% on all admissible claim amount except capped Ailments

4. What are the conditions for getting paid expenses incurred due to any hospitalization?
 The hospitalization must fulfill following conditions:
 Total stay in hospital should be more than 24 hours (not applicable for certain daycare procedures).
 Hospital should be registered with local authorities or should have 10 inpatient beds in those towns
having a population less than 10, 00,000 & at least 15 inpatient beds in all other places.
 Hospitalization covers various components of expenses like Stay Charges, Operation charges, and Doctor’s
fees, Nursing Charges, Investigations & Diagnostics Charges and Medicines etc.
 Hospitalizations on account of Terror attacks are also covered.

5. What are expenses covered as pre and post hospitalization expense?

 In addition to getting the expenses paid for the hospitalization, you also get reimbursement of expenses
incurred for same disease/illness 30 days prior to the Date of Admission to Hospital (Called Pre-
Hospitalization Expenses). This could be the doctor’s fees, Preliminary investigations & diagnostics and
the medicine charges.
 You also get Reimbursement of expenses incurred 60 days after the Date of Discharge from the hospital
(Called Post-Hospitalization Expenses). This could include follow-up consultations with doctors,
Medicines, & confirmatory diagnostics etc.

These benefits are subject to the limits on the policy and are not applicable for Maternity claims.

6. What are some of the important things I MUST be aware of in case I have to make a claim under the policy?
 Room rent + Nursing Charges capping amount for Normal Room - Rs. 2500/- for Pune, Rs. 4500/- for
Mumbai & Delhi/Noida, Bangalore Rs. 3000/- & Rs. 2000/- for ROI
  ICU Capping: at actual

Note: Please opt for room rent within your eligibility. In case, you opt for a room higher than your
eligibility, your entire claim amount would be deducted in proportion of the room rent availed. Please refer
the examples provided ahead in this document.

7. What is a floater cover and who can be covered as family?

 A floater cover is a common insurance coverage for a set of people. In your case, this common
coverage is offered for you and your family members. Family members would include.
 Spouse
 2 dependent children up to the age of 24 years

Thus, it means that any member from the family unit can use the cover up to the total limit as shown
above.

Family will not include dependents like Brother, Sister, Uncle, Parents/In Laws, Aunt or your Grand-
Parents, etc.

8. Do I need to intimate about enrollment of new family members like in case of marriage or childbirth? Will I
need to pay any premium?
Yes, to get the insurance cover for your new dependents from day one of the incidence i.e. marriage date or
child’s birth date, you MUST enroll them within 30 days from the date of marriage / birth.

You can enroll your new dependents with HR team. You do not have to pay any extra premium (up to 2 living
children).

9. Can I add any of my dependents mid-year during the policy period?

No. Mid-year inclusions are allowed only in case of marriage or childbirth. Enrollments otherwise need to be
completed at the time of policy renewal or as per the date of joining in case of new joinees.

10. What happens if any of the details like DOB, Name etc. furnished by me while enrolling are incorrect?
At the onset, it is important that you carefully provide information that is correct while enrolling your
dependents. In case of a discrepancy in data available with TPA & the actual data furnished by you in case of a
cashless hospitalization or reimbursement, the claim may get rejected.

Please immediately intimate the HR team.

11. How will I get the Mediclaim ID Card?

After completing the enrollment process, an E-Card will be generated by the TPA and made available on the
portal for all members covered in the policy.

In the event an E-card is not generated for any member covered by you, immediately contact your HR

Also notify your HR team immediately if you find any details mentioned on your e-card to be incorrect to
avoid any last minute hassles during hospitalization. For e.g. DOB, name, relation.

12. Both my spouse and me, are working for _VOIS. Can we add our children and parents as our dependents
respectively?
No, as per the Policy guidelines, same dependent cannot be insured twice in the same policy. Thus, either you
or your spouse can cover your children and parents.
13. How do I avail Hospitalization benefit?
Hospitalization benefit can be availed of either through a Cashless Hospitalization or Reimbursement of
expenses incurred due to hospitalization

Cashless
The Cashless facility is administered by the Third-Party Administrator (TPA) Medi Assist. through a list of
network hospitals all over India. As per this facility, your insured dependents can get hospitalized & take the
treatment without paying the eligible expenses upfront from the pocket. Cashless hospitalization is allowed
only in hospitals that are part of the TPA network list.

(Note: Applicable for Medical Expenses only. For Non-Medical expenses, you have to make the payment as
per hospital’s policy).

Reimbursement
In case your dependent is hospitalized in a non-network hospital or you have made the payment for the
hospitalization expenses, you can get the same reimbursed from Medi Assist TPA.

Reimbursement claim documents should be submitted within 30 days from date of discharge. You have to
collect all original documents & submit it to location-based Claim Collection Helpdesk within 30 days from the
date of discharge.

14. What is the process to avail cashless facility?

 Identify whether the hospital is part of the TPA Network List
 If Yes, Obtain Cashless Request Form from the Insurance Desk at the Hospital.
 Fill up the form with details like your name, Employee No, TPA ID No, Relationship, Contact No etc.
 Hospital will fill up details like Date Of Admission & Discharge, Ailment, Treatment Plan, Estimated
Expenses & send the Fax to the TPA
 TPA will scrutinize the Request & send the Approval / Rejection / Query Request to Hospital
 At this stage, If you need any support, please get in touch with the Medi Assist TPA Coordinators (Contact
Points mentioned in communication matrix below)
 If actual bill is more than approved amount, additional approval is required
 Ask hospital to fax the Discharge card & Final Bill at least 4 hours before the discharge & get the
additional approval from TPA
 On discharge, Sign bill & Claim Form, Pay non-medical charges etc.

Note: Employee (or dependents attending the patient), after the hospital has faxed the Pre-authorization
request, can call the Cashless Coordination Helpline of Medi Assist TPA & inform about the request.

The Cashless desk of Medi Assist TPA will then process the form and identify queries, if any. The queries
raised will be resolved basis interaction with the member at the hospital or hospital staff to ensure smooth &
timely approval of request.

15. How do I claim the amount if the hospitalization is a Non-network hospital?

You have to collect all original documents and submit the original documents as per the document checklist
with Medi Assist TPA. The claim documents have to submit to the claim collection desk, within 30 days from
the date of discharge.

16. In how many days a reimbursement claim get settled?

 You should get the settlement within 10 working days from the date of submission of your claim provided all
documentary requirements are fulfilled or within 15 days from the date of fulfilling all the additional
documents called for.

Note: Additional documents (Deficiency documents), if any, need to be submitted within 15 days from the
date of first intimation of the additional required documents.

17. What is the Claim collection helpdesk Schedule for reimbursement claim document submission?

_VOIS Facilities Days Timing

EON, Pune Monday / Wednesday / Friday 11.00-17.00 hours
Mantri, Pune Tuesday / Thursday 11.00-17.00 hours
Ahmedabad Monday / Wednesday / Friday 11.00-17.00 hours
Maple Tree, Bangalore Monday / Wednesday / Friday 11.00-17.00 hours

18. What is the list of mandatory documents required for registering a reimbursement claim?
Following is the detailed list of documents. Please note that all reimbursements documents should be
ORIGINAL.

1. Claim Form duly filled and signed by employees.

 All details in the claim form must be filled in and the same should be signed by the EMPLOYEE only

2. Discharge Card
 It contains details like Date of Admission and discharge, patient’s condition while getting hospitalized,
brief diagnosis and treatment administered at hospital and doctor’s advice on discharge.

3. Letter of 1st Consultation and advice for hospitalization

 This is the document vide which your Doctor advises you to get hospitalized for medical treatment of
disease or a Surgical Procedure.
 It should be on the letterhead of the Doctor and should clearly mention the date.

4. Proper Hospital Bills with Receipts Duly Stamped and Signed.

 This is the most important document & in absence of it, no payment can be made.
 The bill should be detailed.
 Also insist that the Registration No. of the hospital is mentioned on the bill.
 The receipt for the payments made should be Pre-numbered and preferably Pre-printed.

5. Medicine Bills with Doctor’s prescriptions for the same

 Each medicine bill must have the date on it and should bear the patient’s name too.

6. Investigation Reports, Bill Receipts & Treating doctor’s advice letter for all the tests performed.
 For all the tests conducted, the same MUST be advised by the doctor. A receipt of payment should be
produced and the report should be submitted.
 Please do not send any X-Ray films. Only report by competent doctor is good enough. In case of X-ray
film required, same will be communicated separately.
 7. Consultation Papers & Receipts
 This is the proof of payment made to doctor for consultations. As these payments are small in
denominations, we often forget to get these receipts & lose on the payments. Please insist on receipt
every time you visit the doctor for consultation.

8. Photo ID proof & address proof of claimant (patient)

 For reimbursement claims, which are above 1 Lakh, please attach Photo ID proof & address proof of
patient.

9. Cancelled Cheque
 You need to submit a cancelled cheque for your bank account with account holder name, IFSC code.
The reimbursement amount will be credited this account.

Disclaimer: At the time of claim processing, TPA officials may require additional documents in case
submitted documents are not sufficient for claim processing.

19. How do I get my reimbursement claim status?

TPA will share the real time status on your contact details & mail ID mentioned on the claim form. In case of
further assistance on the claims, you can contact the Primary Contact from Medi Assist TPA on the contact
numbers mentioned at the end of this document.

20. My husband, & me both of us work with _VOIS & reside in Pune. My delivery is due in couple of months.
How much maternity benefit I can avail for Delivery? Will it be INR 100,000 i.e. INR 50,000 thru my
husband’s coverage & INR 50,000 thru my own coverage?
No, it would be INR 50,000 only as that’s the maximum benefit under the policy.

21. Can I claim for expenses incurred in Hospitalization for Miscarriage/Abortion?

Yes, you can. Miscarriage/Abortion claims can be filed & will be paid as per the Normal delivery Maternity
limit. However, please note that Voluntary Termination of pregnancy is not payable.

22. What are the Standard exclusions of this policy?

Any medical expenses incurred for or arising out of:
1. War invasion, Act of foreign enemy, War like operations, Nuclear weapons, ionizing radiation,
contamination by radio activity, by any nuclear fuel or nuclear waste or from the combustion of nuclear
fuel.
2. Circumcision, Preputio Plasty, Frenuloplasty, cosmetic or aesthetic treatment, plastic surgery unless
required to treat injury or illness, Change of sex, all treatment for erectile dysfunctions.
3. Inoculation or Vaccination ( except for post bite treatment and for medical treatment other for
prevention of disease )
4. Cost of braces, equipment or external prosthetic devices, non-durable implants, eyeglasses, Cost of
spectacles and contact lenses, hearing aids including cochlear implants, durable medical equipment,
continuous ambulatory peritoneal dialysis, infusion pump.
5. Convalescence, general debility, ‘Run-down’ condition or rest cure, Weight control, obesity treatment and
its complications, congenital external disease/defects or anomalies, treatment relating to all psychiatric,
genetic and endocrine disorders. And psychosomatic disorders, infertility, sterility, use of intoxicating
drugs/alcohol, use of tobacco leading to cancer.
6. Bodily injury or sickness due to willful or deliberate exposure to danger (except in an attempt to save
human life), intentional self-inflicted injury, attempted suicide, arising out of non-adherence to medical
advice.
7. Treatment of any Bodily injury sustained whilst or as a result of active participation in any hazardous
sports of any kind.
8. Treatment of any bodily injury sustained whilst or as a result of participating in any criminal act.
9. Sexually transmitted diseases, any condition directly or indirectly caused due to or associated with Human
T-Cell Lymphotropic Virus Type III (HTLB-III) or lymphotropathy Associated Virus (LAV) or the Mutants
Derivative or Variation Deficiency syndrome or any syndrome or condition of a similar kind commonly
referred to as AIDS.
10. Diagnosis, X-Ray or Laboratory examination not consistent with or incidental to the diagnosis of positive
existence and treatment of any ailment, sickness or injury, for which confinement is required at a
Hospital/Nursing Home.
11. Vitamins and tonics unless forming part of treatment for injury or disease as certified by the attending
Medical Practitioner.
12. Lasik Laser or refractive error correction and its complications all treatment for disorders of eye requiring
intra vitreal injections and related procedures.
13. Naturopathy Treatment, unconventional, untested, unproven, experimental therapies.
14. Instrument used in treatment of Sleep Apnea Syndrome (C.P.A.P.) and continuous Peritoneal Ambulatory
dialysis (C.P.A.D.) and Oxygen Concentrator for Bronchial Asthmatic condition.
15. Genetic disorders and stem cell implantation / surgery, Chndrocyte Implantation, Immunotherapy
without proper indication.
16. Treatment taken outside India.
17. Unproven / Experimental Treatment.
18. Change of treatment from one system to another unless recommended by the consultant / Hospital
under whom the treatment is taken.
19. Service charges or any other charges levied by hospital, registration/admission charges.
20. Treatment for Age Related Macular Degeneration (ARMD), treatments such as Rotational Field Quantum
Magnetic Resonance (RFQMR), External Counter Pulsation (ECP), Enhanced External Counter Pulsation
(EECP), Hyperbaric Oxygen Therapy, injection Lucentis, injection Avastin.
21. Expenses incurred on high intensity focused ultra sound, Uterine embolization, Ballon, Sinoplasty,
enhanced external counter pulsation therapy and related therapies, chelation therapy, deep brain
stimulation, hyperbaric oxygen therapy, rotational field quantum magnetic resonance therapy, VAX-D low
level laser therapy, photodynamic therapy.
22. Other standard exclusions specific to the insurance company

GMC Contact Points & Escalation Matrix

Primary Contact Escalation-1 Escalation-2

CRM Contact Centre - Voice
Karishma Dixit Kiran Hudge
MA 24*7
08067714650 7028971086 8600666465
vodafone@mediassist.in vodafone@mediassist.in Kiran.hudge@mediassist.in
 COMMUNICATION MATRIX
  Facilities
FOR EMPLOYEES

CRM Contact Centre - Employees can call on this number for any mediclaim
08067714650
Voice 24*7 policy related queries

CRM Contact Centre - Employees can communicate for Mediclaim policy

vodafone@mediassist.in
Non Voice related assistance

Employee can give missed call to this toll free number

to get link on his smart phone to avail hassle free e-
e-Cashless Facility 180030101696 cashless facility in case of planned hospitalisation.
More Info - https://www.youtube.com/watch?
v=3dgifO8QpWE

Employee can send SMS – INTIMATION to this number

SMS Alerts Facility (No
919664172929 & Employee will receive a call from MediAssist Team
calls)
for Claim Intimation.