Client Name: Spectrum consultants (I) P Ltd

Insurer: United India Insurance Co Ltd

TPA: Vidal health TPA (P) Ltd
Insurance Brokers: RMS ARC Insurance Brokers (P) Ltd
Policy Number: 0120002819P112362493
Policy Period: 00:00 Hrs on 30/11/2019 To Midnight on 29/11/2020

Group Mediclaim Policy :

All Medical 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.

Expenses on Hospitalization for minimum period of 24 hours are admissible. However this time limit will
not apply for specific treatments i.e. Dialysis, Chemotherapy, Radiotherapy, Eye surgery, Dental
Surgery(Due to accident), Lithotripsy (kidney stone removal), Tonsillectomy, D & C taken in the
Hospital/Nursing home and the insured is discharged on the same day of the treatment will be considered to
be taken under Hospitalization Benefit

Only Treatment taken in registered hospital /Nursing home with local authority are considered under the
policy

(A Hospital means any institution established for in-patient care and day care treatment of illness and/or
injuries and Which has been registered as a Hospital with the local authorities under the Clinical
establishments (Registration and Regulation) Act, 2010 or under the enactments specified under the
Schedule of Section 56(1) of the said Act OR complies With all minimum criteria as under

- Has qualified nursing staff under its employment round the clock.
- Has at least 10 in-patient beds in towns having a population of less than 10 lacs and at least 15 in-patient
beds in all Other places;
- Has qualified medical practitioner(s) in charge round the clock;
- Has a fully equipped Operation Theatre of its own where surgical procedures are carried out
- Maintains daily records of patients and makes these accessible to the insurance company's authorized
personnel.)

Policy Conditions :

• Floater sum Insured per family (1+3/Self ,spouse ,children & Parents )

• Pre Existing diseases are covered – Meaning of Pre existing disease: Any Pre-Existing ailments
such as diabetes, hypertension, etc or related ailments for which care, treatment or advice was
recommended by or received from a Doctor or which was first manifested prior to the
commencement date of policy

• 30 Days Waiting Period waived off - Meaning of 30 Days Waiting Period: Any Illness diagnosed
or diagnosable within 30 days of the effective date of the Policy Period

• First/second Year Waiting period waived off - Meaning of First/second Year Waiting period :
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.
 • Maternity Covered from Day 1 within the limit of Rs 50,000
• Child Day one cover
• 30 days Pre & 60 days post Hospitalization expenses covered
• 10% Co-Pay on each & every claim
• Parental sum insured restricted to 50% of total family Sum insured

This benefit can be availed in two ways.

1, Cashless Hospitalization – This facility available if the employee is getting admitted to any of the
hospital listed with Vidal Health TPA

2,Claim Reimbursement – Incase employee is getting admitted to any of the hospital which is not listed
with Vidal Health TPA or in case where he has already made payment directly to Hospital

CASHLESS HOSPITALISATION

To avail cashless hospitalization treatment at network hospitals -

A, The employee has to get the pre authorization request form filled by the treating Doctor which will
contain details like Vidal Health TPA Card No. , estimated cost, Ailment, course in hospital, duration
of the stay, etc and to be sent by mail to Vidal Health TPA.

B, Once Vidal Health TPA receives the request by mail they will scrutinize the same and will
approve/Reject based on the policy terms & conditions.

C, Incase the employee receives the approval, he gets treated & on discharge sign on all relevant bills
/pay the non medical expenses to hospital.

D, Vidal Health TPA pays the bills to the hospital

Incase of planned hospitalization employee can get the pre authorization form filled from hospital and
mail it to Vidal Health TPA 3-4 days in advance.

Note: VIDAL HEALTH TPA can also reject the authorization in the following conditions

1. Incomplete information
2. Improper support of documentation
In such events, please pay the hospital and submit the claim for reimbursement.

CLAIM REIMBURSEMENT

Incase of reimbursement employee has to directly pay to the hospital & collect all the documents
from hospital in original as submit to us.

Checklist of document to be submitted:

1, Discharge Summary
2, Hospital Main Bill with breakup
3, Payment receipt
4, All Investigation Report
5, Duly filled claim form
6, Pharmacy bills followed by prescriptions
7, Alcohol report/FIR/MLC in case of accident claim
8, Implant Stickers/Invoice

Note: All reimbursement Claim has to be submitted to Spectrum consultants within 7 days from
the date of Discharge from hospital.

General Exclusions: (Though the policy is with all covers there are certain general exclusions
which cannot be covered as mentioned below)

▪ Injury or disease directly or indirectly caused by or arising from or attributable to

War or War-like situations
▪ Circumcision unless necessary for treatment of disease
▪ Congenital external diseases or defects/anomalies
▪ HIV, AIDS and related conditions
▪ Preventive Medical Expenses like Vaccination, Inoculation etc.
▪ Hospitalization for convalescence, general debility, intentional self-injury, use of
intoxicating drugs/ alcohol.
▪ Genetic Disorders
▪ Stem Cell Treatment
▪ Injuries sustained whilst being engaged in a Hazardous Activity or Hazardous Sports,
Injury or disease caused directly or indirectly by nuclear weapons
▪ Venereal diseases
▪ Naturopathy
▪ Any non-medical expenses like registration fees, admission fees, charges for medical
records, cafeteria charges, telephone charges, etc
▪ Surgery for correction of eye sight, cost of contact lens, spectacles, hearing aids,
CPAP and other durable medical equipments
▪ Cosmetic, aesthetic treatment
▪ Plastic surgery unless due to accident or part of treatment of an ailment
▪ Hospitalization primarily for Diagnostic/evaluation purposes without active line of
treatment during hospitalization
▪ Medical Expenses for illness or injuries which are treated on an Out Patient basis.
▪ Mere Hospitalization of 24 hours or more does not guarantee admissibility of the
claim. Any treatment or procedure usually done in OPD ,even if converted to Day
care Surgery procedure or as inpatient in Hospital for more than 24 hours, will not be
payable.
▪ Medical Expenses incurred in a Hospital or Nursing Home not meeting the criteria as
defined will be outside the scope of cover
▪ Vitamins and tonics unless used for treatment of injury or disease
▪ Treatment for Sterility, Infertility, Assisted Conception
▪ Intentional self injury, Suicide, Psychiatric/Psychosomatic Disorders, Alcohol or
drug misuse or abuse.
▪ Dental treatment unless arising out of an accident and unless the treatment requires
inpatient admission
▪ Voluntary termination of pregnancy.
Hospital List – update list can be viewed online at -
https://www.vidalhealthtpa.com/home/Network-Services/Network-Hospital-List

SPOC:

For any Assistance related to policy conditions/cashless/claim settlement

Mr.Binu Gopinath – 9900921380 – binu@rmsarc.com

Assuring best of services.