Terms and Conditions

1. Expenses for hospitalization are payable only if a 24-hour hospitalization has been taken
(except for select day care procedures, which do not require a 24-hour hospitalization) with
active line of treatment followed by the diagnosis.
2. Tests and diagnostics of all kinds with or without hospitalization for less than 24 hrs or more
than 24 hrs would not be considered as active line of treatment.
3. Claims are not admissible if the patient is admitted in hospital for observation without any
diagnosis of specific ailments or if the patient undergoes medical investigation procedures
without resulting in any diagnosis of ailments.
4. Claims which will not be admissible even if the hospitalization is for min 24 hours:
a. Viral Warts; Skin conditions where minor procedures are carried out like Keratolysis.
b. Cystoscopy: It is procedure to evaluate lining of urinary bladder where
hospitalization is not required.
c. Cervical Spondylosis: Condition where degenerative changes occur and managed by
physiotherapy & Brace application.
d. Bipolar Mood disorder: Mental illness where oral medications psychotherapy is
implemented
e. Vertigo: Condition is treated with Oral Medication with observation
5. The typical expense heads covered are the following:
a. Room/boarding expenses as provided by the hospital or nursing home
b. Nursing expenses
c. Surgeon, anesthetist, medical practitioner, consultant, specialist fees
d. Anesthesia, blood, oxygen, operation theater charges, surgical appliance, medicines
and drugs, diagnostic material and X-Ray
e. Dialysis, chemotherapy, radiotherapy, cost of pace maker, Deep Brain Stimulation
(DBS) Battery replacement artificial limbs and cost of organs and similar expenses.
6. There are two plans called as ‘Base’ and ‘Base Plus (Top-up)’. Base Medical insurance is to be
availed by the employee and immediate family (as applicable and declared) as default. It is
accounted for in deductions as a nominal monthly charge. Top-Up cover is voluntary and
charged as applicable during renewal timelines
7. Employee and dependents( spouse and children) are covered under this policy. Children
covered up to the age of 25 years.
8. Reimbursement claims will have a copay of 15% and cashless claim will have a copay of 10%.
9. Expenses 30 days prior to and 60 days after hospitalization are also covered
10. All expenses incurred in network/non-network GIPSA PPN hospitals will be paid as per GIPSA
rates in cashless & reimbursement claims.
11. Procedures/treatments usually done in outpatient department are not payable under the
policy even if converted as an in-patient in the hospital for more than 24 hours or carried out
in Day Care Centers.
12. Room, Boarding and Nursing expenses as provided by the Hospital/Nursing Home are
admissible as per sub-limits in respective policies. This also includes nursing care, RMO
charges, IV Fluids/Blood transfusion/injection administration charges and similar expenses.
13. Surgeon, Anesthetist, Medical Practitioner, Consultants, Specialists Fees is covered if it is a
part of the main hospitalization bill.
14. Anesthetic, Blood, Oxygen, Operation Theatre Charges, surgical appliances, Medicines &
Drugs, Dialysis, Chemotherapy, Radiotherapy, Cost of Artificial Limbs, Cost of prosthetic
devices implanted during surgical procedure like orthopedic implants, infra cardiac valve
replacements, vascular stents, relevant laboratory/ diagnostic tests, X Ray and other medical
expenses related to the treatment is admissible subject to sub-limits as per the policy.
15. Coverage for dependents in case of employee’s death to continue till the end of the policy.
16. No deductions in case of death during hospitalization
17. Admission less than 24 hours’ hospitalization without active line of treatment in life
threatening situations (only for employees, when at work) is admissible.
18. If an employee opts for treatment in a hospital which is in the TPA network list of hospitals,
then the payment mode opted should be cashless. We strongly advice against selecting
reimbursement in place of cashless in a network hospital as a payment mode. In an event for
any reason whatsoever, the employee has to select reimbursement mode in a network
hospital, then there may be a charge under the header of ‘hospital discount’ which will be
deducted from your final reimbursed amount. This hospital discount value covers the
difference in agreed tariffs between the hospitals and TPA for cashless and for non-cashless
payment mode. Hence, to avoid having to pay the hospital discount out of pocket, we advise
you to opt for cashless in place of reimbursement in a network hospital as a payment mode.
19. From policy year 2019-20 employees have the option to cover your same sex partner under
your mediclaim policy.
Below are the clauses applicable to same sex partner cover:
• Such relationship shall not be in contravention to any law of the land.
• The partner added during enrollment window shall be covered in the policy. No mid-term
inclusion or change of partner is permitted.
• Mid term deletion of same sex partner is only permitted in case of the unfortunate death
of the employee and upon submission of relevant proof.
• To cover same sex partner: add your partner details under myWipro > My Data >
Additional Family Details > Under Relation please choose ‘Registered Partner’ and put other
details. Once you log into the Group Insurance portal (path given below), your partner
details will be visible, post submission of self-declaration partner will be covered.
• You can cover either your spouse or same sex partner. Both cannot be covered at the
same time.
• Sexually Transmitted Diseases (STD’s) are not covered in case you cover your same sex
partner.
• Gender re-assignment is not applicable for the partner, is only applicable for employee as
per policy terms and conditions.
20. The policy covers hospitalization charges for Gender Affirmation/ Transition surgery for
employees only, up to INR.4.5 Lakh per event.
21. DOMICILIARY HOSPITALIZATIONas for a period exceeding three days and subject however
that domiciliary hospitalization benefits shall not cover:
i) Expenses incurred for pre and post hospital treatment
ii) Expenses incurred for treatment for any of the following diseases: -
1) Asthma
2) Bronchitis
3) Chronic Nephritis and Nephritic Syndrome
4) Diarrhea and all type of Dysenteries including Gastroenteritis
5) Diabetes Mellitus and Insipidus
6) Epilepsy
 7) Hypertension
8) Influenza, Cough and Cold
9) All Psychiatric or Psychosomatic Disorders
10) Pyrexia of unknown Origin for less than 10 days
11) Tonsillitis and Upper Respiratory Tract infection including Laryngitis and
pharyngitis
12) Arthritis, Gout and Rheumatism

21. Expenses on Hospitalization upon written advice of a Medical Practitioner, for minimum period
of 24 consecutive hours are admissible. However, this time limit is not applied to specific treatments
, you may refer to the Group Mediclaim Policy in myWipro- Mypolicies to know more.

22. This condition will also not apply in case of stay in hospital of less than 24 hours provided

a. The treatment is undertaken under General or Local Anesthesia in a hospital/day care

center in less than 24 hours because of technological advancement and

b. Which would have otherwise required a hospitalization of more than 24 hours.

23. For Ayurvedic Treatment, hospitalization expenses are admissible only when the treatment has
undergone in a Government Hospital or in any Institute recognized by the Government and/or
accredited by Quality Council of India/National Accreditation Board of Health.

24. The Policy covers critical Illness for a Sum Insured of INR 2,00,000 only for Employees.

a. The Benefit under this clause is in addition to the Floater Sum Insured applicable to the
Employee.

b. The cover is not applicable to the Employee’s Spouse or Children.

The insured must survive at least three months after commencement date of insurance and
30 days after the diagnosis of the ailment for the cover to be become payable by the insurer.

Please refer to policy for the listed ailments under critical illness cover.

25. New incumbents -spouse and child details need to be added within the 30 days of date of
marriage or date of birth, respectively.

26. The adopted child can be covered from the date of adoption and the claims will be honored with
effect from the adoption date. However, the adopted child should be enrolled through myWipro >
My Data within 30 days from the date of adoption to be eligible for any claim reimbursement.

27. RCT (Root Canal Treatment) Flap surgery/Surgical Extraction should be claimed under insurance
in the first instance. Once insurance is settled, unpaid value can be claimed under MAS by producing
the insurance settlement letter. Co-pay amount will not be payable through MAS.

a. The limit for Dental treatment is up to INR 10,000 for surgical treatment per family.

b. Out of this, the sublimit for Root Canal treatment is INR 5,000 per tooth inclusive of cost
of the crown. (Cosmetic treatment like filling, capping, polishing, dentures, scaling, cleaning
and treatment of similar nature are not payable. Detailed prescription, nature of treatment,
procedures done, pre-numbered receipts are a must for dental treatment claims. In
addition, Post RCT X-ray film is mandatory for justification of admissibility of claim.).
28. For reimbursement claims documents must be submitted within 30 days of completion of
hospitalization. Any late submission shall not be considered.
29. Please find below the policy benefits and coverage.
Benefits
Standard Hospitalization
Pre & Post Hospitalization expenses
Pre-existing diseases (including internal and external
congenital diseases)
Waiting periods (First 30-days,
First Year and First Four Years)
Ambulance services (Shifting patient to hospital only)
Maternity
Maternity Related complications
Surrogacy (Legal surrogacy)
New born baby cover from day 1
Day care procedures
Dental
Base & (Top Up) Base plus plan Benefits
Covered as per hospitalization benefits
Relevant expenses Covered (30 days & 60
days respectively) Refer maternity benefit for
maternity related pre and post-natal limits
Covered as per hospitalization benefits
Waived off
Waived off
Up to INR 2,000 per claim
Normal & Caesarian Delivery (first 2 instances
of live birth for the mother): INR 40,000. Pre-
& Post Natal, OPD expenses up to INR 5,000
within the maternity limit.
Not covered
Covered up to Maternity Limit
Within the maternity limit for normal new
born baby expenses. Complications which
require an admission can be processed under
the balance floater sum insured provided
baby declaration is done in My Wipro within
30 days from date of birth.
Covered (Only selected procedures like
dialysis, chemotherapy, radiotherapy and
other such specified treatments taken in the
hospital / nursing home where the insured
member is discharged on the same day. (Refer
policy terms and conditions for details.)
Up to INR 10,000 for surgical treatment per
family. Out of this, the sublimit for Root Canal
treatment is INR 5,000 per tooth inclusive of
cost of the crown. (Cosmetic treatment like
filling, capping, polishing, dentures, scaling,
cleaning and treatment of similar nature are
not payable. Detailed prescription, nature of
treatment, procedures done, pre-numbered
receipts are a must for dental treatment
claims. In addition, Post RCT X-ray film is
mandatory for justification of admissibility of
claim.)
In-vitro fertilization- Intrauterine Insemination are covered
(on day care and OPD basis, no coverage of pre and post).
However, Treatment related to infertility like
Hysterolaparscopy, Ovarian drilling, Endometriosis,
Chocolate Cyst and diagnostic D&C are not covered.
Emergency Air Ambulance
Mobility Extension
Lasik Treatment Covered only basic surgical procedures
are covered (Smile, Femto, ICL & etc will be restricted to
basic Lasik treatment cost)
Morbid obesity treatment
Ayurveda
Mental Ailment
Genetic Disorder
Congenital External Diseases
Oral chemotherapy – restricted to cancer treatment only
Hormone therapy / Immunotherapy covered/ targeted
therapy/adjuvant therapy / immune modulators / AMRD –
restricted to cancer treatment
HIV
Stem cell and cyber knife treatment
Up to INR 40,000
Covered for a maximum of first 10 cases
throughout the year with a limit of INR
100,000 per case in absence of multi-specialty
hospital in a radius of 50 kms for named
ailments only (subject to approval of insurer).
Covered up to INR 5,000 per employee.
Expenses related to external aids used for
mobility (like walker, crutches) upon the
prescription of the treating doctor and
admissibility of the main claim.
Covered, if required for correction of power of
+/- 6.0 or above. Only spherical power is
admissible.
Covered only if it is life threatening and not
for cosmetic purposes
Ayurvedic hospitalization is covered for
treatment taken in taken in a Government
Hospital or in any Institute recognized by the
Government and/or accredited by Quality
Council of India/National Accreditation Board
on Health. (Refer section 4.4 for details)
The Policy covers inpatient treatment for
Psychiatric or Mental Illness where the illness
is an established non-genetic disease like BPD,
Schizophrenia or such similar disease.
Covered
Covered
Up to 20% of Sum Insured subject to a
maximum of Rs.2 Lacs per policy period for
claims involving Oral Chemotherapy
Covered as per MTMT Table
Covered up to base sum insured for
employee, spouse and children, as per the
employee grade
Covered up to 50% of the sum insured
 Limited up to the default sum insured as per
the employee grade, top-up sum insured
cannot be utilized for this purpose
Cochlear implant surgery
All expenses shall be covered upto the total
sum insured (base + top-up) that the
employee is eligible for. All expenses shall be
honored only if the employee is the recipient
Donor medical expenses is a member in the policy
Keratoconus treatment Not covered
Pace Maker battery, DBS battery replacement Covered
Room rent/ICU charge limit across all cities per day (No
Limit for Band E employees) INR 3,500. ICU – No limit
Nursing charges (to be billed separately) 25% of room rent limit

No Proportionate deduction on opting for higher room Yes (only difference in room charges need to
rent. be borne by the employee)
10% from the employee for admissible claim
amount on claims. 5% additional in case of
Co-pay on all claims reimbursement claims.
10% from the employee for admissible claim
amount. 5% additional in case of
Co-pay on day care procedures reimbursement claims.
10% from the employee for admissible claim
amount. 5% additional in case of
Co-pay on maternity claims reimbursement claims.
Co-pay for employees dies in harness No co-pay to be levied
PPE Kit, Gloves, Mask and such other similar
Non-Medical Expenses (NME’s) expenditure - 15,000 per person
Rehabilitation expenses following a major
illness / injury (Employees only). Sub limit of
INR 50,000. Up to 90 days beyond post
Rehabilitation Expenses hospitalization period
Peritoneal Dialysis Not Covered

30. Please refer to the Group Mediclaim insurance policy in myWipro-myPolicies for Modern
Treatment Methods & Advancement in Technology and the limits per surgery.

Exclusions under Mediclaim

The company shall not be liable to make any payment under this policy in respect of any expenses
whatsoever incurred by any Insured Person regarding or in respect of:

a) Injury / disease directly or indirectly caused by or arising from or attributable to War, invasion, Act
of Foreign enemy, War like operations (whether war be declared or not).

b) Circumcision unless necessary for treatment of a disease not excluded hereunder or as may be
necessitated due to an accident.
c) Vaccination and inoculation of any kind unless it is post animal bite.

d) Change of life or cosmetic or aesthetic treatment of any description such as correction of

eyesight, etc.

e) Cost of spectacles and contact lenses, hearing aids. Internal to Wipro

f) Dental treatment or surgery of any kind unless necessitated by accident and requiring
hospitalization.

g) Convalescence, general debility; run-down condition or rest cure, obesity treatment and its
complications including morbid obesity, Congenital external disease/ defects or anomalies is not
covered until it is life threatening or impacting regular life, treatment relating to all psychiatric and
psychosomatic disorders, infertility, sterility, Venereal disease, intentional self-injury and use of
intoxication drugs / alcohol/tobacco (Gutka)

h) All expenses arising out of any condition directly or indirectly caused to or associated with Human
TCell Lymph Tropic Virus Type III (HTLB -III) or lymphadenopathy 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.

i) Charges incurred at Hospital or Nursing Home primarily for diagnosis x-ray or Laboratory
examinations or other diagnostic studies not consistent with or incidental to the diagnosis and
treatment of positive existence or presence of any ailment, sickness or injury, for which confinement
is required at a Hospital / Nursing Home.

j) Expenses on vitamins and tonics unless forming part of treatment for injury or diseases as
certified by the attending physician.

k) Injury or disease directly or indirectly caused by or contributed to by nuclear weapon / materials

or contributed to/by or arising from ionizing radiation or contamination by radioactivity by any
nuclear fuel or from any nuclear waste or from the combustion of nuclear fuel.

l) Treatment arising from or traceable to pregnancy, childbirth, miscarriage, abortion or

complications of any of these including caesarean section, except abdominal operations for extra
uterine pregnancy (Ectopic Pregnancy) which is provided by submission of Ultra Sonographic report
and certification by Gynecologist that it is life threatening one, if left untreated.

m) Naturopathy Treatment, acupressure, acupuncture, magnetic therapies, experimental and

unproven treatments/ therapies. Treatment related like Hysterolaparscopy, ovarian drilling,
endometriosis, chocolate cyst, diagnostic d and C, experimental and unproven treatments/ therapies
are not covered. Treatment including drug experimental therapy, which is not based on established
medical practice in India, is treatment experimental or unproven.

n) Treatment for Age Related Macular Degeneration (ARMD), treatments such as Rotational Field
Quantum Magnetic Resonance (RFQMR), Enhanced External Counter Pulsation (EECP), etc.

o) Family planning surgeries are not covered.

p) Change of treatment from one system of medicine to another unless recommended by the
consultant/ hospital under whom the treatment is taken.
q) All non-medical expenses including convenience items for personal comfort such as charges for
telephone, television, ayah, private nursing/ barber or beauty services, diet charges, baby food,
cosmetics, tissue paper, diapers, sanitary pads, toiletry items and similar incidental expenses.

r) Any kind of Service charges, Surcharges, Admission Fees/ Registration Charges, Luxury Tax and
similar charges levied by the hospital.

s) All non-medical expenses. The list of non-medical expenses is available in the FAQs on the Vidal
health portal accessible from mywipro >> myMedicalclaim.