GROUP HEALTH INSURANCE POLICY for 2022-23 (Nov’22 to Oct’23)

Know Your Group Health Policy

Objective
To provide Group Hospitalization Health Insurance to all VECV employees including their family
members.
Policy Terms & Condition – Snap Shot

INSURER Oriental Insurance Co. Ltd.

POLICY PERIOD 01st November 2022 to 31st October 2023

TPA RAKSHA HEALTH INSURANCE TPA PVT. LTD.

Pre-existing Diseases Exclusion Covered

Domiciliary Hospitalization Excluded

Cashless Facility: Cashless facility is available in selected hospitals across

the country.List of networks as per GIPSA PPN.
Pre-Hospitalization and Post Hospitalization for 30 days &
Pre-Post Hospitalization:
60 days respectively are covered

Room Rent / ICU charges Room rent 1% and ICU 2 % respectively.

Employee, Spouse, 3 Dependent Children, Dependent

Parents or Parents In-laws.
Combination of set of parents is not allowed. To
illustrate, an employee cannot cover Father & Mother-
in-law or Mother & Father-in-Law in any case.
Once the a set parents and their details are added by
Family Definition:
the employees, then these can't be deleted/change from
the list for the next three years of employee’s service
with VECV. However, incase both parents are not alive
during this period, then employee has a choice to
include other set of parents.
No employee is allowed to add ONEparent when both
the parents are alive.
INR 2 Lac Automatic SI (Sum Assured) enhancement in
case any of the ailment is detected for the first time, 6 major
diseases viz. Cancer, End Stage Renal Failure, Multiple
6 Major Diseases
Sclerosis, Major Organ. Transplant, Coronary Artery
Bypass Graft/ Angioplasty (PTCA), Stroke Excluding
transient ischemia.

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 Maternity cover for Rs. 50,000/- for both Normal Delivery
Maternity Benefit: and Cesarean Section, benefit to be extended to first 2
dependent children.

COVID-19 Coverage Comprehensive coverage (including PPE kit and

consumable) for treatment of COVID-19.

Baby Day 1 Coverage: Baby covered from 1 day within family Sum Insured

Co-Payment: 10% on parents claims and 5 % on all other claims

The following additional claim amount to be deducted in

each and every claim, which is over and above co-
payment deduction as mentioned above :

Below Rs. 10,000/- - Nil

Additional Deductible Rs. 10,000/- to Rs. 24,999/- - Rs. 1,000/-
Rs. 25,000/- to Rs. 49,999/- - Rs. 2,500/-
Rs. 50,000/- to Rs. 99,999/- - Rs. 5,000/-
Rs. 100,000/- and above /- - Rs. 10,000/-

Ambulance Service: Rs. 2500/- per person and Rs. 5000/- for cardiac ambulance

Day care procedures Covered

If intimation of claims is made after 30 days, co-pay of

Claim Intimation: 10% will be applicable. This co-pay will be over and
above all other conditions of policy

Mid-term addition of Employee and Dependents will be

Mid-Term addition of employees and
Dependents;
permitted for new joiners only and not for existing
employees, Dependents of existing employees may be
added only in case of marriage of employee or in case of
childbirth. Appropriate premium to be charged as
applicable.

Applicability
1. All White-Collar employees along with their dependents (composition as mentioned in this
policy)
2. Post Graduate Trainees, Graduate Engineer Trainees & Technical Apprentice Trainees
(Diploma Holders), Functional Trainees & Management Trainees

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Who are covered under the Policy?
1. As per family definition, an employee, spouse, 3 dependent children (Unemployed son below
25 years of age; Unmarried & Unemployed daughter) are covered.
2. Employee can further choose to cover their either set of parents i.e., mother and/or father OR
mother-in-law and/or father-in-law as per VECV’s health insurance enrollment policy. The
premium for the same shall be borne by the employee. Combination of set of parents are
not allowed. To illustrate, an employee cannot cover Father & Mother-in-law or Mother
& Father-in-Law in any case.
3. Employees have the option of increasing their respective insurance coverage by paying
differential amount towards premium as mentioned in the Medi-claim table
4. The age of employee (as on record of the company) is taken for the purpose of premium
calculation and not of the dependents
5. All new joiners will be covered under the scheme from the date of joining.
6. In case of separation of the employee from the company, this policy will automatically
stand ceased immediately with effect from from his/her relieving date. In this case, any
differential amount paid by the employee towards higher insurance coverage or
coverage of parents will NOT be refunded
7. In case of separation of employee from the company on account of employee attaining age of
superannuation, the benefit will continue till the expiry of policy period.

Type of the Policy

The sum insured shall be a floater within a family, where any one or all the family members can avail
it up to the chosen sum insured chosen
Newborn baby is covered from day one subject to intimation to respective HR. Addition of new born
baby within specific sum insured of the member/family subject to specified family definition.

What is covered under the Policy?

 Hospitalization expenses for hospitalization for more than 24 hours for any treatment except
hospitalization or accident due consumption of alcohol or any other intoxicant.
 Pre-existing diseases are covered for all the existing employees and their dependents who
become member of the policy from beginning of the policy i.e., from November 1st, 2021.
 Pre and post hospitalization expenses for 30 and 60 days respectively are covered.
 Day care procedures are covered as per standard list. Please refer Annexure for details.

Is there any co-pay applicable on claims?

Compulsory Co-payment is applicable on all the claims –
 10 % co-pay is for claims related to parents / in-laws
 5 % co-pay on all other claims i.e., related to employee (self), spouse and children.

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What is room rent limit?
Room rent 1% and ICU 2%

Room Rent is inclusive of Nursing Charges. In cases where the claim amount exceeds this
amount and/or patient is admitted to higher category room, the entire admissible claim amount
which includes various hospital bills etc., will be reduced in the proportion which the eligible
room rent limit bears to the actual room rent.
Is there any sub-limit for treatment of specific ailments?
There are few diseases wise sub-limits in the policy including following –

Ailments Sub-limits (INR)

Cataract Up to Rs.35,000 per incidence (24 hours
hospitalization is not required)
Nasal Sinus surgeries Up to Rs.35,000
Hospitalization arising out of Psychiatric Up to Rs.30,000
ailment
Maternity Up to Rs. 50,000 for both normal and C-section
(benefits to be extended to first two dependent
children)
This a sub-package and pre/post
hospitalization and or antenatal / post natal
expenses for maternity are NOT covered
Cochlear Implant treatment Up to 50 % of Sum Insured
Cyberknife treatment/Stem Cell 50 % copay is applicable
Transplantation

Does Maternity benefit cover any hospitalization/complication prior and post-delivery due to
causes related to childbirth?
Yes, Medical treatment expenses traceable to childbirth (including complicated deliveries and
caesarean sections incurred during hospitalization). Expenses towards lawful medical termination of
pregnancy during the policy period are covered.
Does Maternity benefit cover Miscarriage?
Yes, it is covered within maternity sub-limit as per policy terms and conditions.
Does Maternity benefit cover Treatment arising from or traceable to pregnancy, childbirth
including caesarean section?
Yes, it is covered within maternity sub-limit

Is there any provision for ambulance charges?

Ambulance charges are maximum up to Rs. 2500/- and Rs. 5000/- for cardiac ambulance.
Is mid-term inclusion possible?

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Midterm inclusion of dependents will be possible only in case of a) spouse (on account of marriage
during the policy term) b) children (childbirth during the policy term subject to not more than 3 children
being covered under the Policy.
Incase an employee fails to enroll their dependent members during the time of enrollment, such
dependents will not be covered during mid-term except above. Further, the sum insured opted
by an employee cannot be changed (increased or decreased effect) mid-term.
Once the a set parents and their details are added by the employees, then these can't be
deleted/change from the list for the next three years of employee’s service with VECV.
However, incase both parents are not alive during this period, then employee has a choice to
include other set of parents
No employee is allowed to add only ONE parent when both the parents are alive.

What are the restrictions under the policy?

1. For the cataract operation, the upper limit is fixed at Rs 35,000/- (each incidence). For cataract
operation 24 hrs. hospitalizations is not required
2. Day care procedures are covered for kidney stone, Hysterectomy, Cataract surgery,
Parenteral Chemotherapy, Sinusitis, Inguinal/Ventral/Umbilical/ Femoral Hernia.
3. Psychiatric ailment covered up to Rs. 30,000/- arising of hospitalization only.
4. Congenital internal diseases are covered if is not known.
5. Baby cover from day one under floater policy. Information is to be provided by HR partner to
service provider.
6. Treatment of the functional endoscopy sinus surgery up to Rs. 35,000. Nasal Sinus Surgeries
up to 'Rs. 35,000/-

Are there any non-payable items/services in cashless or reimbursement claims?

Yes, there are non-payable items and services as per IRDA (Insurance Regulatory and Development
Authority) and policy terms and conditions, which are given under list of non-payables. It includes
expenses as – registration charges, file charges, TPA service charges, telephone charges, luxury tax,
surcharge, service charge, washing charges consumables – such as gloves, syringe, hand sanitizers,
sanitary napkins/pad, diapers, crepe bandage, tissue paper, bottle, brush, hand wash, towel etc. and
Bed pan, slippers etc. List of Non-payables is attached as Annexure.

Is there any exclusion in the policy?

Apart from the non-payables there are exclusions of certain types of treatment in the policy such as
 OPD expenses are not covered. Further 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 consecutive twenty-four consecutive hours.
 Dental treatment like root canal, capping and other cosmetic treatments are not covered
 Other procedures such as Lasik Surgery, Septoplasty, Infertility & Related Ailments including
Male sterility; Treatment on trial/experimental basis; Admin/Registration/Service/Misc.
Charges; Expenses on fitting of Prosthesis; Any device/instrument/machine
contributing/replacing the function of an organ; Holter Monitoring are outside the scope of the
policy.

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  Hospitalization only for the purpose of diagnosis is not covered (however diagnosis
followed by hospitalization and active line of treatment is covered subject to policy
terms).

STANDARD EXCLUSIONS
The company shall not be liable to make any payment under this policy in connection with or in
respect of any expenses whatsoever incurred by any insured person in connection with or in
respect of:
1. Diseases, illness, accident, or injuries 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).
2. Circumcision whether necessitated by vaccination or inoculation or change of life or
cosmetic or aesthetic treatment of any description, plastic surgery unless necessary for
treatment of a disease not excluded by terms of the policy or as may be necessitated due
to treatment of an accident.
3. The cost of spectacles, contact lenses and hearing aids.
4. Dental treatment or surgery of any kind unless requiring hospitalization
5. Convalescence, general debility, run-down condition or rest cure, congenital external
disease or defects or anomalies, sterility, venereal disease, intentional self-injury (whether
arising from an attempt to suicide or otherwise) and use of intoxicating drugs and/or
alcohol.
6. Expenses related to any admission primarily for diagnostics and evaluation purposes and
any diagnostic expenses which are not related or not incidental to the current diagnosis
and treatment
7. Treatment for, Alcoholism, drug or substance abuse or any addictive condition and
consequences thereof.
8. All expenses arising out of any condition directly or indirectly caused to or associated with
Acquired Immune Deficiency Syndrome (AIDS) or Lymphadenopathy Associated Virus
(LAV) or the Mutants Derivative or Variations Deficiency Syndrome or any other Syndrome
or condition of a similar kind
9. Charges incurred at Hospital or Nursing home primarily for diagnostic, X-Ray or laboratory
examinations or other diagnostic studies not consistent with or incidental to the diagnosis
and treatment of the positive existence or presence of any diseases, illness or injury
whether or not requiring Hospitalization.
10. Expenses on vitamins and tonics unless forming part of treatment for injury or disease as
certified by the attending Medical Practitioner
11. Diseases, illness, accident, or injuries directly or indirectly caused by or contributed to by
nuclear weapons / materials or contributed to buy 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.
12. Voluntary medical termination of pregnancy during the conception
13. All non-medical expenses including convenience items for personal comfort such as
telephone, television, Aya, Private Nursing / barber or beauty services, diet charges, baby
food, cosmetics, tissue paper, diapers, sanitary pads, toiletry items and similar incidental
expenses

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 14. Service charges or any other charges levied by hospital
15. Naturopathy / Homeopathy / Ayurvedic treatment

How to avail cashless facility under Policy

Cashless facility is available in selected hospitals across the country. The individual & the covered
family members will be issued a soft copy identity card to avail the same.
List of network hospitals can be accessed from
https://www.rakshatpa.com/WebPortal/Form/search_PN
The below documents need to be carried while visiting the network hospital: -
a) Raksha Mediclaim Card
b) Employee I Card
c) Valid Photo Id Proof of the patient

1) Approach the TPA counter at the hospital and provide your Raksha Card
2) There will be “Request for Authorization Form” provided to be filled and signed.
3) The hospital will enter the treatment and other details and send the documents to Raksha
TPA
On receipt of request, Raksha TPA will have the cashless request processed and will revert to hospital
with the outcome. Generally, the revert is sent within 4 hours from receipt of all required documents.
Approvals are provided on the basis of T&C of the policy and MOU of the TPA with the network hospital
Is claim intimation must for reimbursement claims?
Claim intimation for reimbursement claims is must prior to hospitalization in case of planned
hospitalization and within 24 hours after hospitalization for other cases. As per the policy conditions,
all Reimbursement Claims must be intimated to Raksha TPA within 24 hours of Admission;
In case of non-intimation/Delayed intimation beyond 24 hours of admission, 10% additional Co-pay
would be applicable except for Accidental claims.

What is the time limit for submission of claims?

All claims must be filed within 30 days from the date of completion of treatment.

What is claim process for reimbursement claims?

 Pease send the intimation as per below format at following email- id:
claimintimation@rakshatpa.com;

mohit.solanki@rakshatpa.com

NOTE : that claim intimation within 24 hours of admission is necessary to avoid additional co-
pay of 10 %.

Hospital Name :
Hospital Address :
Name of Patient :
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 Name of the Employee :
Employee ID Number :
Raksha ID Number :
Policy No :
Diagnosis :
Date of Admission :
Name of Treating Doctor :
Approximate Expenses :
Any other Relevant Information :
Contact No. :

 Please mention claim intimation date and time on the claim form and also attach claim intimation
and confirmation mail received after intimation with claim form. Also enclose signed copy of
consent letter attached with the document with claim form.
 Submit claim documents within 15 days from the date of discharge from the hospital for
timely reimbursement of claims. In case one also wishes to claim for post hospitalization
expenses then the claim should reach Raksha TPA within 30 days from the date of
discharge.
Indicative Documents Required for Reimbursement Claim*
 Duly filled & signed Claim form by the employee
 Photocopy of Raksha TPA card.
 Original Discharge card / Discharge summary.
 Original Hospital bill with the seal & signature of the Hospital.
 Detailed Hospital bill break-up for the expenses.
 All original prescriptions & consultation papers of the Doctor.
 All original Medical bills with the name of the Patient duly endorsed by the treating Doctor.
 All original cash paid receipts supporting the bills in the name of patient.
 All original Medical reports certified by the Doctor (Pathology, X-Ray, CT-Scan, ECG, MRI,
etc.)
 Summary of all Expenses.
 Medico Legal Certificate (MLC) / FIR in case of accident cases.
 Medico Legal Certificate (MLC) & FIR both are mandatory in case of road traffic accident.
 All Indoor Case Papers (ICP).
 Copy of Hospital Registration certificate in case of private non-empanelled hospitals.
 Implant sticker / invoice, if used (E.g. lens details in cataract case, stent details in angioplasty)
 Any other related documents
Please note all documents should be in Original
This is not an exhaustive list; any other document could be required on case to case basis. For
Queried claims, it is mandatory to submit the required documents within 30 days from the date
of query intimation. Non receipt of query response within the mentioned timelines will lead to
rejection of the claim, as per the IRDA guidelines
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*Kindly Keep photocopies of all the documents before sending for process
You can send complete claim form and documents to any of the office of Nearby Raksha TPA office
can be search at - https://www.rakshatpa.com/WebPortal/Login/Branches , Mobile App:
https://goo.gl/3L1jpO or via What’s app Application: 9029070051 through registered mobile
number (4U Video attached) or you can send directly at -
Raksha Health Insurance TPA Pvt. Ltd.
5TH Floor, Commerce house
7 Race Course Road, Near Janjirwala Square
Indore – 452 001 (Madhya Pradesh)
Phone : 0731 4967535

How much it takes in settlement of reimbursement claims?

The reimbursement claims are settled within 30 days from the receipt of final claim documents at
Raksha Health Insurance TPA Private Limited
How I can get my Raksha / Health Card?
Raksha numbers are sent by Raksha TPA along with welcome SMS and final E-health cards are sent
with welcome mail to every employee. Raksha details are also available with the respective HR BP
 Employees can download e-health card through Raksha Mobile App -
https://goo.gl/3L1jpO
 Employee can also get e-health cards through miss Whats app call from registered mobile
number at 9029070051
Whom to contact for problem solving?
In case of any unresolved issue related to claims / settlement / coverage, employees can contact to
concern HR SPOC/ HRBP.
For any assistance and query one can contact to following –

RAKSHA TPA Level Name E-Mail ID Phone

rishi.jain@rakshatpa.com 9109972901
First Contact Rishi Jain
V 0731 4967535

Upendra Singh
Escalation upendra@rakshatpa.com 9303247002
Chouhan
Deshraj Dogra
Alliance Broker First Level deshraj@allianceinsurance.in 9205584672

Second Level Jayant Singh jayant@allianceinsurance.in 92055 84673

Whatsapp Give miss call on no. 9029070051 and automatically on what’s app assistance message will be receive.
assistance
Escalation Respective HR SPOC / HRBPs

Direct Link Of website

Claim intimation https://www.rakshatpa.com/WebPortal/Login/ClaimIntimation
Network Hospital https://www.rakshatpa.com/WebPortal/Login/search_PPN
Bank detail upload https://www.rakshatpa.com/WebPortal/Login/UploadBankDetail
E-card https://www.rakshatpa.com/WebPortal/Login/Anonymous/ECard

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 Claim form A https://www.rakshatpa.com/WebPortal/document/Annexure01(Part%20A).pdf
Claim form B https://www.rakshatpa.com/WebPortal/document/Annexure01(Part%20B).pdf

Is the differential premium paid for the whole year reimbursable in case of separation with the
company?
No, the differential premium paid by the employees for the whole year is not reimbursable.
Does employee get income tax benefit on the differential premium paid by him/her?
Yes, the employee can claim income tax benefit as per IT provisions on the differential premium only if it
has been paid for biological mother/father.
This benefit will not be valid for any premium paid for mother in law/father in law.
The insurer would not be issuing any separate rebate certificate, however, the employee can produce the
premium approval on evolve as the proof for payment towards medical insurance.
Are trainees (MTs, PGETs, GETs, GTs, DET/TAT covered under this policy)? Is it applicable for
interns?
Trainees falling under the category of the employees as per definition (company policy) are covered in the
group health policy. Interns are not covered under the policy.
What is the meaning of from the date of completion of treatment? How is it different from date of
discharge from hospital?
The policy is covering hospitalization expenses (admission in a Hospital for a minimum period of 24 In
Patient Care consecutive hours except for specified Procedures/Treatments, where such admission could
be for a period of less than 24 consecutive hours and 30 and 60 days pre and post hospitalization
expenses respectively.
Date of discharge is date of discharge from the hospitalization and in certain cases treatment may be
continue after discharge from the hospital. In such cases date of treatment completion differ from date of
discharge from the hospital. For the purpose of cashless claims, expenses related to hospitalization are
settled through cashless settlement process subjected to policy terms and conditions and pre and post
hospitalization expenses, if applicable, can be claimed through submission of claim forms with required
details and original bills and documents.

No Claim Bonus is eligible, in case and employee has not claimed during the previous policy
year?
No. This is a Group Mediclaim Policy and hence the NCB is not eligible.
Which are network hospitals of this policy?
Cashless facility is available in selected hospitals across the country. The individual & the covered family
members will be issued a soft copy identity card to avail the same. Cashless facility means a facility
whereby the New India Assurance / Raksha TPA agree to settle the admissible claim directly to the
network hospital. Any expense in excess of the admissible claim amount will be borne by the insured
himself
List of network hospitals can be accessed from https://www.rakshatpa.com/WebPortal/Form/search_PN
Is Hospitalization for Diagnostic or Check-up payable under the policy?
This is not payable.
What to do if I am admitted in a non-network hospital?
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In an emergency situation, you might be admitted in a non-network hospital and knowing the
claim protocol at that time is imperative. Please notr that treatment in a non-network hospital
would be on a reimbursement basis only, i.e, you would first have to bear all the medical expenses
and then you can get the amounts reimbursed from your insurer. Please also note that claim
intimation within 24 hours of hospitalization is must to avoid any additional 10% co-pay.
The employees who are retiring during the policy period can extend the coverage till 31st October
2022.
Yes, this facility is available. It may however, be noted that this facility is extended only to those
employees who are attaining age of superannuation during the policy period. Employees who are
separating otherwise from the organization cannot avail this facility.
Pre-existing deceases are covered under the policy?
Pre-exiting deceases other than Standard exclusions are covered from the date of joining.
What is the maximum number of claims allowed in policy year?
There is no limit for number of claims during the policy period. However, the sum insured is the maximum
limit under the policy.
It is a Family Floater Policy?
Yes. The sum insured shall be a floater within a family, where any one or all the family members can avail
it up to the chosen sum insured.
IVF is covered under the policy?
No. IVF is not covered under this Policy.
Ayurvedic treatment covered in the policy?
In-patient hospitalization expenses for Ayurvedic treatment is covered as per policy terms and conditions.
___________________

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