Employee Benefits Guide

ThoughtWorks
Policy Period 2021-22
 Index
• Group Medi Claim Policy
• Basic Information – Page No 4
• Benefit Summary – Page No 5 to 8
• Top Up Benefits – Page No 9 to 10
• Additional Parental Cover – Page No 11

• Group Medi Claim Policy - Home Care Quarantine

• Basic Information – Page No 12
• Benefit Summary – Page No 13

• Group Medi Claim Policy

• Enrollment Procedure – Page No 14 – 15
• Claim Procedure – Page No 16 - 18
• General Exclusions – Page No 19
• Frequently Asked Questions (FAQ’s) – Page No 20 - 26

• Contact Points & Escalation Matrix - Page No 30

• Important Links - Page No 30
GROUP MEDICLAIM POLICY
The benefit of a Mediclaim Policy will offer coverage
against any Medical Contingency requiring the
member to be hospitalized. In case of hospitalization
only (i.e., hospitalization for more than 24 hours), the
Insurance Company will pay the insured person the
reasonable amount of expenses incurred towards
treatment up to the Sum Insured limits and subject
to the insurance policy guidelines.
Non-Medical expenses like Administration Charges,
Registration Charges, Telephone charges/fax
charges; food charges if not part of room rent for
patient and food charges for relatives/attendant etc.
are not payable.
09-November 2021- 08-November 2022
The New India Assurance Company Limited
Mediassist India TPA Pvt Ltd
India (Covers treatment in India only)
INR 400,000/-
Family Floater (1+6) :
Family Size under the Policy: 1+6 -Employee +
Spouse + 3 Children+ 2 Parents/Parents in laws (Only
one set of parents or one set of parents in laws
allowed, no cross selection of parents allowed) only
subject to actual declaration.
Covered
Covered
First 3 living Children till the age of 25 years
Parents/Parents in laws (Only one set of parents or
one set of parents in laws allowed, No cross
selection of parents allowed) only subject to actual
declaration.
Group Medi Claim Policy Benefits Summary
Covered Covered under Sum Insured over and above
Maternity benefit
Not Applicable
Any complications due to maternity post delivery to
Covered be covered up to sum insured over and above
maternity limit
Room Rent are linked to procedure (No capping
applicable) Sub limit of INR. 1,00,000 (Both male & female) and
can be covered above the Maternity limit *-only for
30 days pre-hospitalization and 60 days post- employees
hospitalization respectively
Day care procedures is covered under the policy and Maternity claim for the surrogate mother will be
Other day care procedures/changes As Per IRDA covered with in the Maternity limit. (Not IVF)
guideless should also be covered.
Covered
Not Applicable Covered excluding cosmetic related.

INR 50,000 for Normal & C-Section 75,000, eligible for Lasik Surgery with a minimum refraction
first three living children, for twins, the maternity limit
shall be enhanced to 125% of maternity limits
Rs.3500/-per person for interstate Rs.25000/-Air
Baby is covered from day 1 Up to the family Sum ambulance of Rs.10 lac for the entire Group
Insured.
Covered over and above the maternity limit of up to
INR. 10,000/-.
Treatment covered in all Govt Recognized hospitals
New-born baby/Newly wedded spouse within 15th of Up to 25% of the Sum Insured as IPD only
succeeding month from the date of birth/Date of
Marriage
Group Medi Claim Policy
Related to Orthopaedic or any Surgery as a part
of Rehabilitation up to INR 10,000 per member,
subject to the recommendation of the surgeon
Covered
Covered
Covered up to the Sub Limit of INR 1 Lakh per
family
Covered
Allowed, sublimated to Rs 1,00,000 per family
Dental and Vision Cover @15000, (Dental -Root
canal, Dental Caries, Filling & Tooth Extractions
per family within sum insured) (Vision (only for
employees) - Spectacle OR Lenses, Excluding
frames. Contact Lenses (E.g. Disposable) above
+/- 0.5) Suggested by licensed Ophthalmologist
& Optician along with Receipt Hospitalization
expenses
Covered
Covered with the sublimit of INR 40,000 per eye
Covered with 50% Co pay
Covered up to 50% of the Sum Insured.
Benefits Summary Contd…
Covered up to 50% of the admissible Claim
Amount subject to a Max of Rs.2,00,000.
50% of admissible amount and up to Max. of Rs
5 lakhs
No Claim Intimation is required to get the claim
processed
Covered
Covered
Covered up to INR 30,000 Per Person
Post Hospitalization expense can be submitted
up to 150 days
90 days from Date of Discharge Non-
compliance Non- compliance will result in 10%
Co-pay. However Genuine cases based of HR
approval will be considered.
With INR 10,000/- per family limit & Policy limit of
INR 5 lakhs per policy year
Covered up to Sum Insured
LGBT (Individual will be covered with all the
terms and conditions of the ThoughtWorks
policy. *Expenses other than that covered in the
policy is not Payable
Covered Upto the family Sum Insured
Genital Surgery within the Sum Insured
Group Medi Claim Policy Benefits Summary Contd…

a) For Male-to-Female transition, the following

procedures are covered: a) For Male-to-Female transition, the following
procedures are covered:

Genital surgery: orchiectomy, penectomy,

clitoroplasty, vaginoplasty, labiaplasty, vulvoplasty.
· Breast/chest surgery: augmentation mammoplasty
(implants/lipofilling)
Facial feminization surgery, liposuction, lipofilling, voice
surgery, thyroid cartilage reduction, gluteal
augmentation (implants/lipofilling), hair reconstruction,
and various aesthetic procedures as prescribed in
WPATH protocol.

b) For Female-to-Male transition, the following

procedures are covered: b) For Female-to-Male transition, the following
procedures are covered:
Genital surgery: hysterectomy, salpingo-
oophorectomy, vaginectomy, metoidioplasty,
scrotoplasty, urethroplasty, placement of testicular
prostheses or creation of a neophallus;
Voice surgery, liposuction, lipofilling, pectoral implants,
and various aesthetic procedure as prescribed in
· Breast/chest surgery: subcutaneous mastectomy, WPATH
creation of a male chest.
Group Medi Claim Policy Benefits Summary Contd…

a. Portability shall be granted only to the Insured Person/s who is/are presently covered and were
continuously covered without any lapses under any other similar health insurance plan with equivalent
Deductible with an Indian Non-life/Health Insurer in the past.
b. In case portability is granted by us the proviso's regarding the waiting periods specified under Exclusion
Nos 1, 2 and 3 of the Policy stands modified as under in respect of such insured persons granted with
portability.
The waiting periods shall be reduced by the number of continuous preceding years of coverage of
the Insured Person under the previous health insurance policy/Policies; AND
If the proposed Sum Insured for a proposed Insured Person is more than the Sum Insured
applicable under the previous health insurance policy, then the reduced waiting period shall apply only to the
extent of the Sum Insured under the previous health insurance policies.
the reduction in the waiting period specified above shall be only if We have received the
database and claim history from the previous Indian insurance companies. The reduction in the
waiting period specified above shall be only if We have received the database and claim history from the previous
Indian insurance company.
 GROUP MEDICLAIM POLICY - Top Up
What is Top Up policy?
A top-up health insurance policy enhances your existing health
insurance policy’s sum insured amount (Base policy sum
Insured).
The policy covers hospitalization costs but only after a
threshold limit.
The coverages & exclusions of the policy is same as base policy.
Base policy Sum Insured is the threshold limit.
09-November 2021- 08-November 2022
The New India Assurance Company Limited
Mediassist India TPA Pvt Ltd
India (Covers treatment in India only)
1L, 2L, 3L, 4L, 5L ,6 L,7L,8L,9L & 10 L
Family Floater (1+6) :
Family Size under the Policy: 1+6 -Employee +
Spouse + 3 Children+ 2 Parents/Parents in laws (Only
one set of parents or one set of parents in laws
allowed, no cross selection of parents allowed) only
subject to actual declaration.
Covered
Covered
First 3 living Children till the age of 25 years
Parents/Parents in laws (Only one set of parents or
one set of parents in laws allowed, No cross selection
of parents allowed) only subject to actual
declaration.
 Group Medi Claim Policy – TOP UP
Benefits Summary & Premium Table

Terms & Conditions Same as the Base Policy

1 lakh ₹ 6,973 • Same set of dependent can avail the top Up Policy benefits
2 Lakhs ₹ 8,743 who are covered under
3 Lakhs ₹ 10,513 •Additional Member can not be added in Top Up Policy.
4 Lakhs ₹ 12,283 •Top-up Policy cover triggers after the exhaustion of the
5 Lakhs ₹ 14,053 Corporate offered
6 Lakhs ₹ 15,823 •Avail Tax benefit under section 80D* as per the Guideline
7 Lakhs ₹ 17,593
•Easy Premium payment mode
8 Lakhs ₹ 19,363
9 Lakhs ₹ 21,133
10 Lakhs ₹ 22,903
 GROUP MEDICLAIM POLICY - Additional Parental Cover
09-November 2021- 08-November 2022

The New India Assurance Company Limited

Mediassist India TPA Pvt Ltd

India (Covers treatment in India only)

What is Additional Parental policy?
The policy covers hospitalization costs for one set of Parents or INR 4,00,000/-
In laws who are not covered under base policy
Family Floater (1+1) :
Parents or In laws who are not covered under
2 Parents/Parents in laws who are not covered
base policy can only be covered under this policy under base policy (Only one set of parents or
one set of parents in laws allowed, no cross
The coverages & exclusions that are covered for parents or In
selection of parents allowed) only subject to
Laws in the base policy is covered. All the Ailment capping actual declaration.
applicable in Base Policy is also applicable under this policy.
Covered
Non-Medical expenses like Administration Charges,
Registration Charges, Telephone charges/fax charges; food 4 Lakhs
charges if not part of room rent for patient and food charges for Single Parent / In Laws ₹ 15,340
relatives/attendant etc. are not payable.
Both Parent / In Laws ₹ 21,240

•Avail Tax benefit under section 80D* as per the Guideline & Easy Premium payment mode
 GROUP MEDICLAIM POLICY – Home Quarantine
Treatment availed by the insured person at Home when tested
positive for Covid-19 in a Govt Authorized Diagnostic Centre
which in normal course would require care & treatment at
hospital but is taken at Home.
Non-Medical expenses like Administration Charges,
Registration Charges, Telephone charges/fax charges; food
charges if not part of room rent for patient and food charges for
relatives/attendant etc. are not payable.
09-November 2021- 08-November 2022
The New India Assurance Company Limited
Mediassist India TPA Pvt Ltd
India (Covers treatment in India only)
INR 12,000/- Per Person (Individual SI)
Family Size under the Policy: 1+6 -Employee + Spouse
+ 3 Children+ 2 Parents/Parents in laws (Only one set
of parents or one set of parents in laws allowed, no
cross selection of parents allowed) only subject to
actual declaration.
Covered
Covered
First 3 living Children till the age of 25 years
Parents/Parents in laws (Only one set of parents or
one set of parents in laws allowed, No cross selection
of parents allowed) only subject to actual
declaration. (Additional Parents are not covered
under this policy)
Group Medi Claim Policy – Home Quarantine
Benefits Summary

Same Treatment availed by the insured person at Home when tested positive for Covid-19 in a Govt
Authorized Diagnostic Centre which in normal course would require care & treatment at hospital but is
actually taken at Home . This can be for a maximum of 14 days per incidence.

a) The Medical Practitioner advises the insured person to undergo treatment at home .
b) Insured shall be permitted to avail the services as prescribed by the medical practitioner.
Terms & Conditions
c) Covers diagnostic Tests undergone at home or Govt authorized diagnostic Centre.
d). Medicine prescribed in writing.
e). Consultation charges related to medical Practitioner .
f). Nursing charges related to medical Staff.
g). Medical procedures limited to Parental administration of medicines.
h).cost of Pulse Oximeter, Oxygen cylinder and Nebulizer as the Base Policy
 GROUP MEDICLAIM POLICY
ENROLLMENT PROCEDURE
Upload your Dependent details in
Joining to Ensure adequate coverage within the policy
Dependents details are shared by HR as per employee's declaration in
Workday at the time of inception.
All New Joinees are requested to declare their dependents along with their
own declaration at the time of joining ThoughtWorks.
All New Joinees must ensure that their Date of Birth (DOB) are declared at
on the date of the time of joining as without the same Insurance Enrolment is not
processed.
Note : * There will be no mid year enrolment allowed during the year except :
provided there is scope available
to cover the dependent.
• Intimation should be provided to Insurance Company within 30 days
from the date of marriage and 7 days from the date of birth incase of
newborn child.
All the Employees will receive login credentials from TPA to opt for Voluntary
policies such as Top Up & Additional Parental Cover.
GROUP MEDICLAIM POLICY

ENROLLMENT PROCEDURE

FLOW CHART
 Group Medi Claim Policy Claim Procedure
Contact Mediassist & inform
PLANNED HOSPITALIZATION about the nature of emergency
PROCEDURE & your ID No. on Toll Free
Nurse line :

Get the Admission

Request Note form filled,

Cashless – TPA :
and Network hospital will
email the Request to

Planned Hospitalization Medi Assist India Insurance TPA Pvt Ltd

signed by the treating
doctor/hospital and
Website : https://www.medibuddy.in/ signed by insured, done in
Call Center Toll Free – 1800-425-4033 advance.

Authorization Letter (AL) / Denial

Mediassist doctors will examine the Pre- Letter / Addition Requirement
Authorization Request form & decide on Letter issued depending on plan,
cashless availability, as per the policy benefit & balance sum available to
guidelines. the hospital.

Patients seeking treatment under cashless hospitalization are eligible to make claims
under pre- and post-hospitalization expenses. For all such expenses the bills and
other required documents needs to submitted separately as part of the claim's
reimbursement.
 Group Medi Claim Policy Claim Procedure
Member gets Member /
admitted in the Hospital applies
hospital in case of for pre-
TPA verifies
emergency by authorization to
applicability of the
showing his ID the TPA within
claim to be registered
Card. Treatment 24 hours of
and issue
starts. admission
pre-authorization
Cashless – Hospital sends Member gets
Emergency Hospitalization complete set of
claims
treated and
discharged after
documents for paying all non Yes
processing to entitled benefits like Pre-
the TPA refreshments, etc. authorization
given by the
TPA

Claims Processing by TPA

No
& Insurer

Release of payments to Member pays and takes

the hospital discharge.
 Group Medi Claim Policy Claim Procedure
Employee intimates about Employee submits all
the hospitalization by the original
mentioning Employee ID documents along
with the cancelled TPA will check for
Patient’s Name, Med ID the eligibility and
Hospital Name, Date of cheque to the TPA
admissibility of the
Admission and Ailment name within 15 days of claim as per policy
on within 24hrs from the time discharge from the terms
of admission. hospital

Reimbursement
Insurance Company sends
denial letter to the
employee. No

Is Claim
TPA will process the claim payable?
and sends the Yes
reimbursement cheque, TPA will check
along with the settlement whether all
letter the
documents
are in order

Employee submits the

shortfall documents to
TPA within 7 working days TPA will ask for the
from the receipt of additional/missing
intimation documents
 GROUP MEDICLAIM POLICY –
GENERAL EXCLUSIONS
1. Injury or disease directly or indirectly caused by or arising from or attributable to War or War-like situations
2. Circumcision unless necessary for treatment of disease
3. Congenital external diseases or defects/anomalies for Cosmetic Purpose
4. Hospitalization for convalescence, general debility, intentional self-injury, use of intoxicating drugs/ alcohol.
5. Venereal diseases
6. Injury or disease caused directly or indirectly by nuclear weapons
7. Any non-medical expenses like registration fees, admission fees, charges for medical records, cafeteria charges, telephone charges, etc.
8. Hospitalization for diagnostic tests only
9. Vitamins and tonics unless used for treatment of injury or disease
10. Voluntary termination of pregnancy during first 12 weeks (MTP)
11. OPD Claims
12. Claims (of high value) submitted without prescriptions/diagnosis
13. Health foods
14. Costs incurred as a part of membership/subscription to a clinic or health center
15. Naturopathy & Unani treatments on OPD
 FAQ’s
Group Mediclaim Policy
• What is Pre-Existing Disease Coverage?

Pre-Existing disease coverage is offered to all members without any waiting period. This helps the
member get a complete coverage for all medical emergencies, including ailments that may have been there
before the start of this policy.

• What is Waiver of 1 Year Waiting Period for nine specified disease?

Policy there is No one year waiting period for the nine specified aliments - Cataract, Benign Prostatic
Hypertrophy, Hysterectomy for Menorrhagia or Fibromyoma Hernia, Hydrocele, Congenital Internal disease,
Fistula in anus, Piles, Sinusitis and related disorders.

• What is Waiver of 30 days waiting period for non accidental claims?

In this policy there is No 30 days waiting period for enrolled members for filing any claim due to illness.

• Is Maternity Benefit Covered under the Policy ?

Yes, it is covered. INR 50,000 for Normal & C-Section 75,000, eligible for first three living children, for twin
Born’s, the maternity limit shall be enhanced to 125% of maternity limits

• Newborn Baby Covered in the policy ?

Baby is covered from day 1 Upto the family Sum Insured.

 FAQ’s
Group Mediclaim Policy
• What is Pre & Post Hospitalization Benefit ?

Relevant medical expenses incurred during a period up to 30 days prior to 60 days after hospitalization will be
considered as part of claim and therefore settled as per policy guidelines.

• What expenditures will generally be covered under the Pre-Hospitalization Clause?

Medical expenses incurred for Laboratory Test, Pathological Test and such similar overheads are usually
incurred prior to hospitalization and will be covered under the Pre - Hospitalization Clause.

• What expenditures will generally be covered under the Post Hospitalization Clause ?

Medical expenses incurred for recommended health check up subsequent to discharge from hospitalization
and other such similar overheads usually incurred post hospitalization will be covered under the Post
Hospitalization Clause.

• How do you define dependency and in whose case is it applicable?

Dependency means a person is financially dependent on the primary insured i.e., they are not engaged in any
kind of profession of earning their livelihood or are gainfully employed. They should be dependent on the
Employee. Dependency is only applicable in the case of Children, parents.

• Is dependency relevant in case of Spouse also?

No, dependency for spouse is not relevant under Health Insurance.

 FAQ’s
Group Mediclaim Policy
• What happens if my family status changes during the policy?

If the family status changes (by reason of marriage or birth), the employee needs to enroll the details of the new
dependent within 15 days from date of marriage or date of birth as may be applicable.

• Will location of dependent family members matter?

No. Further, as the policy provides the coverage for treatment taken within India, employee and dependent
family member can avail benefit at any registered hospital in India.

• What happens if I and my spouse are working in the same organization?

An individual can be covered in the policy only once. In such a case, you are advised not to declare each other
under the definition of family, and may cover your children, if any, only once under any of the two families.

• What expenditures will generally be covered under the Pre-Hospitalization Clause?

Medical expenses incurred for Laboratory Test, Pathological Test and such similar overheads are usually
incurred prior to hospitalization and will be covered under the prehospitalization clause. Pre-Hospitalization
expenses are payable only if it is followed by at least 24 hrs. hospitalization within 30 days of expense and there
should be an active line of treatment given based on the investigation and should be related to the
treatment/diagnosis
 FAQ’s
Group Mediclaim Policy
• What expenditures will generally be covered under the Post Hospitalization Clause?

Medical expenses incurred for the treatment subsequent to release from hospitalization and other such similar
overheads will be covered under the post hospitalization clause. Post Hospitalization expenses are covered up
to 60 days from the date of discharge and should be related to the treatment/diagnosis.

• Is there any limit for reimbursement of expenses incurred in a laboratory or a diagnostic center as part of hospitalization?

No. If the expenses form part of the hospitalization process and if the amount is approved and payable as per
the terms and conditions of the policy, then they are reimbursable up to the sum insured amount.

• Does pre-existing disease cover mean that all diseases and medical procedures are covered?

Pre-existing disease benefit helps the member get a complete coverage for all medical emergencies, including
ailments that may have been there before the start of this policy. However, it does not cover congenital
external disease / illness / defect.

• Is the 24 hours rule applicable for all ailments?

Yes, the 24 hours hospitalization is a must. However, this time limit is not applied to specific treatments which
do not necessarily require 24 hours due to technological advancement in treatment. Some of these
treatments include Dialysis, Chemotherapy, Radiotherapy, Cataract, Tonsillectomy taken in the
Hospital/Nursing Home.
 FAQ’s
Group Mediclaim Policy
• Are there any special criteria for seeking admission/ treatment in the hospitals/ nursing homes?

It is generally recommended that you choose a Hospital on the TPA Network. However, you do have the right to
choose any other hospital also, subject to the Hospital meeting one of the following minimum criteria as under:

It should have at least 15 inpatient beds.

Fully qualified doctor(s) should be in charge round the clock.

Should be registered with the relevant governmental and regulatory authorities. The registration
number should be printed on discharge summary and / or receipt of the Hospital.

Further, it necessarily should not be blacklisted with the TPA.

• Will I get my claim papers back?

No, you will not get the claim papers back even after settlement / rejection of the claim. You are expected,
to keep a photocopy of the same for your future reference, before submitting the papers.

• Are naturopathy and Ayurvedic expenses covered?

Naturopathy and Ayurvedic expenses are not covered under the policy, irrespective of whether they were
incurred in a network hospital or otherwise.
 FAQ’s
Group Mediclaim Policy
• What is an Authorization Letter?

Authorization Letter is the communication authorizing extension of cashless hospitalization to the Insured.
The same is issued by The TPA subject to admissibility of the claim and availability of balance sum insured for
the member.

• How do I know whether my Claim has been admitted for Cashless Reimbursement or not?
Authorization Letter or Denial Letter shall be faxed directly to the Hospital and the Hospital will intimate you
about the same.
• Do I need to carry my cashless card when I go to the hospital?
Ideally, you should always carry the cashless card with yourself, when getting admitted to the hospital. But, in
case if you do not have the cashless card, you can mention your employee id and corporate name on the
cashless request form.
However, it is advisable to carry a valid photo identity proof (Employee ID Card, Driving license, Election card
or any card which is approved by Government of India), irrespective of whether you are carrying the cashless
card or not.
• Can I file more than one claim in a year?
You can claim as many time you are hospitalized during the period of Insurance but the insurance company's
liability in respect of all claims put together shall not exceed the Sum Insured.
 FAQ’s
Group Mediclaim Policy
• What if I have not got your cashless card yet? Am I covered? What do I need to do to get cashless treatment?
The claims would be settled without the cards provided if the claimant (the employee or the dependent) is
endorsed in the policy. You would be entitled to cashless treatment but in such case, you are requested to get in
touch with Howden, before the hospitalization.
• If I avail cashless facility, will the Insurer pay the entire amount, or will I be required to bear part of the bill at the hospital?
All expenses that are covered under the Insurance Policy will be paid for by the Insurer. However, you will be
required to pay for non admissible expenses, if any, such as Registration charges, charges incurred on account of
person accompanying you, etc. Further, you will also bear the amount deducted on account of any restriction in
the policy like room rent, co-pay, proportion deductible etc.
• If I apply reimbursement facility, will the Insurer pay the entire amount, or will I be required to bear part of the bill at the hospital?
All expenses that are covered under the Insurance Policy will be paid for by the Insurer. However, you will be
required to pay for non admissible expenses, if any, such as Registration charges, charges incurred on account of
person accompanying you, etc. Further, you will also bear the amount deducted on account of any restriction in
the policy like room rent, co-pay, proportion deductible etc.
 CONTACTS

venu.gopal@mediassist.in

mohan.hr@mediassist.in

patricia.joseph@howdeindia.com +

remith@howdenindia.com +

Reimbursement Claim Form & Documents Checklist : https://www.medibuddy.in/assets/claimForms/reimbursement-claim-form.pdf

Cashless Request Form : https://www.medibuddy.in/assets/claimForms/cashless-claim-form.pdf

Hospital Network List : https://www.medibuddy.in/networkHospitals

This manual is intended to be general summary of the benefits offered by your company & should be
regarded as guide only. While Howden shall make every reasonable effort to ensure the accuracy and
validity of the information provided here in this document. Howden accepts no liability or
responsibility for any errors or omissions in the content or for any loss or damages arising out of your
reliance on information provided here. If there is a conflict in interpretation or benefit applicability,
then the terms & conditions of the policy will prevail

No part of this publication may be reproduced, stored in the retrieval system, or be transmitted in any form or by any
means, electronic or mechanical, photocopying, recording or otherwise, without the prior written permission of
HOWDEN.
 Thank You

This document or any portion of the information it contains may not be copied or reproduced in any
form without the permission of Howden.
Howden Broking Group Limited is registered in England & Wales under company registration
number 6249799. Registered address: One Creechurch Place, London EC3A 5AF

Copyright © 2020