Employee Benefits Manual

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Medical Benefit

Coverage Details (Employee) Claims Document List

Policy Period Benefits Extensions – Definitions

Cashless Process General Exclusions

Non-Cashless GMC Contact Details

Claims Process Prudent Utilization of Benefit

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 Medical Benefit – Coverage Details
Policy Parameter
 Insurer Oriental Insurance Company Limited
 TPA Medi Assist Insurance TPA
 Policy Start Date 21st June, 2022
 Policy End Date 20th June, 2023
 Coverage Type Family Floater

 Dependent Coverage 1 + 5 – Employee + Spouse + 2 Dependent Children + 2 Dependent Parent / Parent-in-Law

 Sum Insured Graded - INR 100,000 / INR 400,000 / INR 800,000 (as per eligibility)

Benefits / Extensions Coverage Benefits / Extensions Coverage

 Standard Hospitalization • Yes • INR 50k For Normal Delivery
 Maternity Benefit
• INR 75k For Cesarean Delivery
 Pre-existing Diseases • Yes
 Pre & Post Natal • Yes, Covered up to INR 5,000 within
 1st Year / 30 Days Exclusion Waiver • Yes Expenses Maternity Sublimit
 Pre/Post Hospitalization • 30 / 60 Days  New Born Baby • Yes, covered up to INR 2500 within
Expenses Maternity Sublimit
 Ambulance Cover. • INR 5000 Per Case
 Cataract • Covered up to INR 40,000 per eye
 Oral Chemotherapy • Covered
 AYUSH Treatment • Covered
 Room Rent For Grade “Below W” • 1% of Sum Insured
 Vision Correction / • Covered for Vision Correction Equal to or
 Room Rent For Grade “W, X, Y & Z” • Single Standard AC Room
Lasik more than Eye Power +/- 7.5
 ICU Charges • As per actuals
• Covered for COVID positive patients
• Yes, 20% for Parental
 Co-Payment  COVID-19 • In-Patient Hospitalization Treatment
Claims
• Home / Hotel Quarantine not covered
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Medical Benefit – Dependent Coverage
Maximum no of Members insured in a family 1+5

Employee Yes

Spouse Yes

Yes (maximum 2, up to 25 years of age)

Children
Children with Disability covered in the policy without Age wise Capping

Parents and Parents in laws Yes, On voluntary basis

Either set of Parent can be covered, no cross combination not allowed
Per Parent Annual Premium – INR 10,000

Siblings No

Others No

Mid Term enrollment of existing Dependents Disallowed

Mid Term enrollment of New Joinees (New employees +their

Dependents) Allowed

Mid term enrollment of new dependents (Spouse/Children) Allowed, To be enrolled within:

New Born Baby – Within 30 days from Date of Birth
Newly Married Spouse – Within 30 days from Date of Marriage

No Individual should be covered as dependent of more than one employee

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Medical Benefit – Policy Period

Existing Employees + Dependents

Commencement Date 21st June 2022

Termination Date 20th June 2023

New Joinees + Dependents On Intimation Through HR

Commencement Date Date Of Joining

Termination Date 20th June 2023

New Dependents (Due To Marriage / Birth) On Intimation Through HR

Commencement Date Date Of Such Event

Termination Date 20th June 2023

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Medical Benefit – Coverage Levels
Sum Insured Family Floater

Employee, Spouse, Dependent Children & Parents / Parent-in-Laws Graded- INR 1 Lac / INR 4 Lacs / INR 8 Lacs

Restrictions on Sum insured Not Applicable

Employee, Spouse, Dependent Children & Parents / Parent-in-Laws Not Applicable

Co-payment Not Applicable

Employee, Spouse, Dependent Children Not Applicable

Parents / Parent-in-Law 20% Co-Payment

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Medical Benefit – Standard Coverage
Covers expenses related to
• Room and boarding – As per actuals (No Capping)
• Doctors fees
• Intensive Care Unit
• Nursing expenses
• Surgical fees, operating theatre, anesthesia and oxygen and their administration
• Drugs and medicines consumed on the premises
• Hospital miscellaneous services (such as laboratory, x-ray, diagnostic tests)
• Costs of prosthetic devices if implanted during a surgical procedure
• Radiotherapy and chemotherapy

A) The expenses are payable 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.

B) Expenses on Hospitalisation 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, 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 Hospitalisation Benefit.

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Pre & Post Hospitalization Expenses
Pre-hospitalization Expenses
• If the Insured member is diagnosed with an Illness which results in his / her Hospitalization
Definition and for which the Insurer accepts a claim, the Insurer will also reimburse the Insured
Member’s Pre-hospitalization Expenses for up to 30 days prior to his / her Hospitalization.
Covered • Yes
Duration • 30 Days

Post-hospitalization Expenses
• If the Insurer accepts a claim under Hospitalization and immediately following the Insured
Member’s discharge, further medical treatment directly related to the same condition for which
Definition
the Insured Member was Hospitalized is required, the Insurer will reimburse the Insured
member’s Post-hospitalization Expenses for up to 60 day period.
Covered • Yes
Duration • 60 Days

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Maternity Benefits

Benefit Details

For Normal Delivery • INR 50,000/- within the Floater Sum Insured

For C – Section / Cesarean Delivery • INR 75,000/- within the Floater Sum Insured

Restriction on no of children • Maximum of 2 Children

9 Months waiting period • Waived off

New Born Baby Expenses • Covered up to INR 2500 within Maternity Sublimit

Pre-Post Natal Expenses • Yes, Covered up to INR 5,000 within Maternity Sublimit

• These benefits are admissible in case of hospitalization in India.

• Covers first two children only. Those who already have two or more living children will not be eligible for this benefit.
• Expenses incurred in connection with voluntary medical termination of pregnancy during the first 12 weeks from the date of
conception are not covered.

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Corporate v/s Retail
Retail Cover
Product Name Corporate Cover
Leading Health Insurer

Medical Test Yes No

Ailment capping Yes No

Co-Payment Yes ranging from 20-30% ( based on ailments) Yes ( 20% for parent claims)

Cashless Facility Restricted only to PPN Available

Pre-Existing Covered Covered post 4 years of policy inception Covered from date of inception of policy

Relationship Manager No Yes

First 30 Days Waiting period Yes No Waiting Period

1st and 2nd Year Waiting Period Yes No Waiting Period

Pre and Post 30days and 60days Yes, max up to 10% sum insured Yes up to full Sum Insured

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 COVID-19

• Does my Group Mediclaim Policy cover COVID-19 Treatment?

• Yes, your Corporate Group Medical policy covers the treatment related to COVID-19.

• What benefits is covered under the Policy?

• Your policy covers in-patient treatments. Medical expenses incurred during the course of treatment including
the treatment during quarantine period shall be settled as per policy terms & conditions.

• Will charges incurred during precautionary isolation period be paid under the policy?
• A positive test is a mandatory requirement for any claim to be paid under the policy. So, any home isolation or
quarantine will not be covered under the policy.

• Can I available cashless benefit?

• Yes, Government allows COVID-19 treatment in Pvt. Hospitals and our health insurance policy will cover
treatment of COVID-19 on In-Patient Hospitalization basis along with an active line of treatment on cashless
basis.

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Medical Benefit – Cashless Process
Cashless means the Administrator may authorize upon a Policyholder’s request for direct settlement of eligible
services and it’s according charges between a Network Hospital and the Administrator. In such case the
Administrator will directly settle all eligible amounts with the Network Hospital and the Insured Person may not
have to pay any deposits at the commencement of the treatment or bills after the end of treatment to the extent
as these services are covered under the Policy.
Hospitals in the network (please refer to the website for the updated list)

https://www.medibuddy.in/networkHospitals Helpline : 1800 425 9449

Disclaimer: The Network Provider list attached above is always subject to changes, please TPA website or
check with toll free no to know the most updated list..

Emergency Hospitalization Planned Hospitalization

Note : 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 claims reimbursement.

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Emergency Hospitalization & Process
Step 1
Get Admitted
In cases of emergency, the member
should get admitted in the nearest P
network hospital by showing their ID
card. R
O
C Member gets admitted in No Non cashless
E Pre-
the hospital in case of
S emergency by showing his
authorization Hospitalization
given by TPA
Step 2 S ID Card Process
Pre-Authorization by hospital
Relatives of admitted member Yes
should inform the call centre within
24 hours about the hospitalization &
Seek pre authorization. The
preauthorization letter would be Member gets treated and
Member/Hospital applies
directly given to the hospital. In discharged after paying all
for pre-authorization to TPA
case of denial member would be non medical expenses like
within 24 hrs of admission
informed directly refreshments, etc.

Step 3 TPA verifies applicability of Hospital sends complete set

Treatment & Discharge the claim to be registered of claims documents for
and issue pre-authorization processing to TPA
After your hospitalisation has been
pre-authorized the employee is not
required to pay the hospitalisation
bill in case of a network hospital.
The bill will be sent directly to, and
settled by TPA

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Planned Hospitalization
Step 1 Member intimates TPA of the Claim
Yes TPA authorizes cashless as
Pre-Authorization planned hospitalization in a Registered by per SLA for planned
specified pre-authorization format TPA on same hospitalization to the
at-least 48 hours in advance day hospital

All non-emergency hospitalisation No

instances must be pre-authorized
with TPA, as per the procedure
detailed below. This is done to
ensure that the best healthcare Follow non cashless Pre-Authorization
possible, is obtained, and the process Completed
patient/employee is not
inconvenienced when taking
admission into a Network Hospital.

Step 2
Member produces ID card Member gets treated and
Admission, Treatment & Hospital sends complete
at the network hospital discharged after paying
discharge set of claims documents
and gets admitted all non entitled benefits
for processing to TPA
like refreshments, etc.

After your hospitalisation has been

pre-authorized, you need to secure
admission to a hospital. A letter of
credit will be issued by TPA to the
hospital. Kindly present your ID
card at the Hospital admission Claims Processing &
desk. The employee is not required Settlement by TPA &
to pay the hospitalisation bill in case Insurer
of a network hospital. The bill will be
sent directly to, and settled by TPA

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Non-Cashless
Admission procedure
• In case you choose a non-network hospital you will have to liaise directly with the hospital for admission.
• However you are advised to follow the pre authorization procedure to ensure eligibility for reimbursement of
hospitalisation expenses from the insurer.

Discharge procedure
• In case of non network hospital, you will be required to clear the bills and submit the claim to TPA for
reimbursement from the insurer. Please ensure that you collect all necessary documents such as – discharge
summary, investigation reports etc. for submitting your claim.

Submission of hospitalisation claim

• You must submit the final claim with all relevant documents within 30 days from the date of discharge from the
hospital.

Claims Process Claim Docs

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 Non-Cashless Claims Process
Member intimates TPA before Insured admitted as per hospital Insured Submits relevant
Claim registered by TPA after
or as soon as hospitalization norms. All payments made by documents to the TPA within 30 A
receipt of claim intimation
occurs member days of discharge

Is document
received
Is claim TPA performs medical scrutiny of
within 30 days •Insured will create the
payable? the documents
Yes from summary of Bills (2 copies)
Yes discharge and attach it with the
No No original bills.
•The envelope should
contain clearly the
Employee ID & Employee e-
Claim Rejected
mail.

Is
TPA checks document documentatio Claims processing done as per ECS Payment will be done directly
sufficiency n complete SLA to the Employee bank a/c.
Yes
as required

No

Receives mail about deficiency

A
and document requirement

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Claims Document List
Completed Claim form with Signature- Mandatory *Please retain photocopies of all documents
submitted
Hospital bills in original (with bill no; signed and stamped by the hospital) with all •Disclaimer: IPD papers can be requested on the
charges itemized and the original receipts-Mandatory later stage after initial
•Scrutiny of aforesaid papers which purely depends
Discharge Report (original)-Mandatory upon case to case.

Attending doctors’ bills and receipts and certificate regarding diagnosis (if separate from
hospital bill)

Original reports or attested copies of Bills and Receipts for Medicines, Investigations
along with Doctors prescription in Original and Laboratory

Follow-up advice or letter for line of treatment after discharge from hospital, from
Doctor.

Provide Break up details including Pharmacy items, Materials, Investigations even

though it is there in the main bill

In case the hospital is not registered, please get a letter on the Hospital letterhead
mentioning the number of beds and availability of doctors and nurses round the clock.

In non- network hospital, you may have to get the hospital and doctor’s registration
number in Hospital letterhead and get the same signed and stamped by the hospital, if
required.

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 Prudent Utilization of Benefit
 Health Insurance is a benefit for the employee and their dependents. One has to utilize the benefit with utmost
caution and prudence.
 The ever increasing cost for the benefits require a proactive involvement from all of us.
 The following steps are recommended, ensuring the benefits is prudently utilized by the employee and dependents
covered

Please ensure to cross check the final bill sent to the TPA for the following:

You are Billed only for the services utilized for e.g. category of room, diagnostics undergone , medicines consumed
Total of the bill
In case of any planned hospitalization, approach the hospital in advance(48 hrs) and request pre
authorization- this enables TPA to further negotiate the rates

To approach hospitals with caution – most expensive is not necessarily the best.

To cross check the tariff with the Bench Mark Rates provided- the benchmark rates would give an idea the general spend
for the treatment or procedure.

Try to negotiate

Ask WHY & WHAT is billed to you ( as a consumer , we have the right to know)

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Medical Benefit – General Exclusions
• 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
• Hospitalization for convalescence, general debility, intentional self-injury, use of intoxicating drugs/ alcohol.
• Venereal diseases
• Injury or disease caused directly or indirectly by nuclear weapons
• Naturopathy
• Any non-medical expenses like registration fees, admission fees, Hospital surcharge, charges for medical records, cafeteria
charges, telephone charges etc
• Any cosmetic or plastic surgery except for correction of injury
• Hospitalization for diagnostic tests only
• Vitamins and tonics unless used for treatment of injury or disease
• Infertility treatment
• Voluntary termination of pregnancy during first 12 weeks (MTP)
• OPD Claims
• Claims (of high value) submitted without prescriptions/diagnosis
• Health foods
• Costs incurred as a part of membership/subscription to a clinic or health centre
• Cost of appliances, spectacles, contact lenses, hearing aids

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Group Personal Accident Policy

Benefit Details

Enrollment in the program

Document Checklist

GPA Contact Information

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GPA – Benefit Details
This insurance provides compensation/payment up to a financial limit as assigned by the company, to the insured person or his legal
personal representative, if the insured person suffers death or disablement due to an accident. The cover is worldwide but payment
of claim can only be made in India and in Indian Rupees.

Policy Parameter
Insurer Oriental Insuraance Company

Policy Start Date 21st June, 2022

Policy End Date 20th June, 2023

Coverage Employees Only
Sum Insured Graded

Coverage Details
Accidental Death • Covered

Permanent Total Disability • Yes (100% of Sum Insured)

Permanent Partial Disability • Yes (100% of Sum Insured)

Temporary Total Disability • Yes (INR 15,000 per week maximum up to 104 weeks)

Accidental Medical Expenses • Yes (Covered up to 10% of Sum Insured or 40% of Admissible amount under the basic cover or actual whichever is lower)

Hospital Daily Cash Allowance • Yes (INR 1,500 Covered during hospitalization due to accident for minimum of 30 days with 3 days deductible)

Broken Bones • Yes (INR 15,000 Covered due to accidental injury where surgery is required and will be on indemnity basis)

Repatriation of Mortal Remains • Yes (1% of Sum Insured or Rs. 2500 or actual expenses, whichever is less)

Funeral Expense • Yes (1% of Sum Insured or Rs. 5000 or actual expenses, whichever is less)

Educational Grant • Yes (In case of Death or PTD of the insured, for one dependent child below 23 years of age, INR 10000 and in case of two
dependent children below the age of 23 years, INR 20000)

Terrorism • Yes

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GPA – Details for PPD

* Indicative list, Please refer to policy document

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GPA – Enrollment
All existing employees are covered under the policy from 21st June, 2022. The policy ends on 20th June, 2023

For new employees, enrollment data must reach the Insurer within 30 days of your joining.
Please contact your HR.

The policy ends on 20th June, 2023 or Date of Leaving the Organization whichever is earlier

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GPA – Claims Document Checklist
Dismemberment/ Disablement
Weekly Benefit Claims Death Claims
Claims
1. Completed Claim form 1. Completed claim form 1. Completed claim form
2. Doctor's Report 2. Attending Doctor's report 2. Doctor's Report
3. Disability Certificate from the 3. Death Certificate 3. Disability Certificate from the
Doctor, if any 4. Post Mortem/ Coroner's report Doctor
4. Investigation/ Lab reports (x-ray 5. FIR ( First Information Report) 4. Investigation/ Lab reports (x-ray
etc.) 6. Police Inquest report, wherever etc.)
5. Original Admission/discharge applicable 5. Original Admission/ discharge
card, if hospitalized card, if hospitalized.
6. Employers Leave Certificate & 6. Police Inquest report, wherever
Details of salary applicable

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GPA – General Exclusions
1. Service on duty with any armed force
2. Insanity
3. Venereal disease
4. AIDS
5. Influence of intoxicating drink or drugs
6. Aviation other than as a passenger (fare paying or otherwise) in any duly licensed standard type of
aircraft any where in the world
7. Nuclear radiation or nuclear weapons material
8. Any consequence of war, invasion, act of foreign enemy, hostilities (whether war be declared or
not), civil war, rebellion, revolution, insurrection, mutiny, military, or usurped power, seizure,
capture, arrest,, restraint, detainment’s of all kings, princes, and people of whatever nation,
conditions and qualities so ever
9. Childbirth, pregnancy or other physical causes peculiar to the female sex
10. While committing any breach of law with criminal intent

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