Professional Documents
Culture Documents
Benefit
Manual
2021-2022
Employee Benefits Manual – Medical Insurance
This manual has details of insurance coverage to UST employees and dependents
UST Medical for expenses related to hospitalization due to illness, disease or injury.
Insurance
The manual covers the following:
• Home care treatment package for COVID – Up to INR 5,000 per member and INR
10,000 per family.
• Room Rent eligibility for employees increased to 150% for those who avail Top Up
of 10 Lakh INR at Subsidised Premium of INR 3406 + Taxes
Policy Parameter
Siblings No
Maximum no of Members insured
1+4
in a family Note:
Others No
• New born and Newly married spouse
Employee Yes Mid Term enrollment of existing Disallowed should be added in the Medibuddy portal
Dependents within 30 days of event. Death of any
Mid Term enrollment of new joiners (New dependent should be informed within 30
Spouse Yes
days to deactivate from portal
employees +their Dependents) Allowed
Pre existing diseases Yes IPD cover of 10,000 & OPD cover of 5,000. OPD payable only if
Pre and Post Natal medically recommended by a gynecologist in a registered
Waiver on 1st year exclusion Yes hospital
Waiver on 1st 30 days excl. Yes Well Baby Expenses Within maternity limit
Normal 50k & C-Sec Room Rent Capping including boarding Normal – INR 4,000/- for Kerala and 5,000/- for rest of the states.
Maternity benefits
70K and nursing expenses, DMO/RMO ICU is INR 8,000/ per day. In case of Covid, ICU limit is INR
charges 16,000/- per day
Baby cover day 1 Yes
INR 5,000/- per event, Copay 5% Co- pay for employee ; 10% Co-pay for spouse & child on all
Ambulance Services Covid Ambulance INR claims. In case of Covid, no co-pay applicable
10,000 per family
Commencement
Commencement Date 31st May 2021 Date of joining Commencement Date Date of event
Date
Termination Date 30th May 2022 Termination Date 30th May 2022 Termination Date 30th May 2022
Coverage Details For Employee Base Policy
Treatment availed by the Insured Person at home for Covid on positive diagnosis of Covid in a Government authorized diagnostic Centre, which
Covid Home Care Treatment in normal course would require care and treatment at a hospital but is actually taken at home upto a maximum up to 14 days. Per member limit
of INR 5,000/- and family limit of INR 10,000. Applicable for all employees and dependents
NME for Covid Hospitalization NME shall be payable upto a maximum of INR 40,000/- per member
Emergency care for employee Coverage of OPD treatment/emergency care if the employee falls sick during the workplace (Annual limit of 2,000/- per employee)
Sleep Apnea Covered with 50% copay, machine cost shall not be covered
Medical Termination of pregnancy Covered upto 10k over and above maternity limit, medically certified by gynecologist
Coverage Details For Employee Base Policy
Life Threatening Cases Life threatening cases for Maternity claims coverage upto family sum insured
First Time Cancer Detection: In addition to the current benefit of INR 25,000 Employees can avail for the treatment in
Cancer Benefit the subsequent year policy for INR 25,000 , Benefit can be claimed only once in a year and maximum twice in two
years. (This extension is not given for Dependents, they are eligible for First Time Detection Cover of Rs.25000/- only)
HIV Treatment HIV Disease Covered Up to INR 100,000
Infertility Treatment Infertility coverage upto INR. 50,000 on IPD basis only
Stem Cell Treatment Stem Cell covered upto INR. 50,000 per family, Applicable on IPD basis only
Psychiatric Treatment Psychiatric & Psychosomatic disorders covered upto INR. 50,000 on IPD basis only, Applicable only for Employees
Ayurvedic Treatment INR 50,000 on registered Ayurvedic Hospitals on admission only
Coverage for Siblings Mentally physically challenged siblings are covered under the policy
Power Correction Vision correction cover +/- 7 power correction done by Lasik surgery is covered
BARIATRIC surgery for age less than 35 years is covered under the policy. Limit upto family sum insured. Only for
Bariatric Surgery
those employees whose body mass index is over 35. Not applicable to dependents.
Oral Chemotherapy Oral Chemo Covered upto INR 50,000 including Hormonal Therapy. Applicable only for Employees
External Congenital 10% of the sum insured i.e. Rs.40,000/- per family for a maximum of 50 families per policy period
Congenital External
(over and above the sum insured)
Maternity Benefits For Employee Base Policy
Benefit Details
Benefit Amount INR 50k For Normal & INR 70k For C-section
• The sum insured is INR 1 Lac, 2 Lacs, 3 Lacs, 6 Lacs, 10 Lacs, 15 Lacs & 20 Lacs for Employee, Spouse & Children
• The top up plan is placed with the same insurer and TPA who underwrites the Group Medical Policy for operational efficiency
• Nomination for top up policy is done once a year & not in between the policy period except for the new joiners
• When the main medical plan sum insured is exhausted, only then the top up plan pays for the claim (amount over and above it).
• The top up sum insured could be utilized for ailments, except for Maternity
Kindly note that the room rent limit shall be enhanced by 0.5% of your base policy limit if you opt for 10 lac, 15 lac or 20 lac cover
Voluntary Parental Plan
•Co-Pay reduction by 5%
•Home care treatment package for COVID – Up to INR 5,000 per member
•Non-Medical Expense (NME) coverage for COVID hospitalisation up to INR 7,500 per parent
•Ambulance services enhanced: INR 5,000/ event; COVID-19 ambulance up to 10,000 per family
Coverage Details For Parents Base Policy
Policy Parameter
Sum Insured 31-35 35-40 41-45 46-50 51-55 56-60 61-65 66 & Above
INR 2,00,000 3,712 3,712 4,638 6,525 7,521 8,530 9,713 10,754
INR 3,00,000 5,180 5,180 6,465 9,288 10,749 12,226 14,004 15,705
INR 4,00,000 6,459 6,459 8,799 11,840 14,989 15,654 17,978 19,971
Coverage Details For Parents Base Policy
Room Rent Capping Room rent of 1.5 % for normal subject to minimum of INR Waiver on 1st year exclusion Yes
including boarding and 3,000 and maximum of INR 5,000 and 2.0% for ICU in Kerala
nursing expenses, duty and 1.75% normal subject to minimum of INR 3,000 and
medical officer/resident maximum of INR 5,000 and 2.0% ICU for rest of the states with Waiver on 1st 30 days excl. Yes
medical officer charges proportionate clause applicability
Cataract Limit 24,000/- per eye
Scenario Claim Type Total Claimed Deduction after non Total Admissible Ailment Copay Payable Amount after Parents covered last
Amount medical expenses amount Copay (in INR) year
1 Hospitalization 1,00,000 90,000 90,000 Accident 13,500 76,500 Yes then 15% Applied
2 Hospitalization 1,00,000 90,000 90,000 Accident 18,000 72,000 Yes then 20% Applied
Room rent will have an upper limit of 1.5% of the SUM INSURED and ICU rentals to 2.5% of the SUM INSURED and applicability of proportionate clause if higher room rents are opted.
(eg: if 2 lac sum insured is opted, 1.5% of 2 lac is INR 3000. So room rent per day will be INR 3000 inclusive of nursing and DMO charge). If some hospitals charges, nursing and duty medical officer charges
(DMO) separately, this will be summated with room rent and considered as room rent. Eg: Room rent alone is INR 3000, nursing charge INR 500 and DMO charge INR 250, the room rent will be considered as
INR 3000 + 500 +250 =INR 3750. Kindly note, so proportionate clause will be applicable as it exceed the room rent eligibility as per terms and conditions as mentioned above.
Basic sum insured of 3 lacs (1.5%), room rent is INR 4500/day.
Basic sum insured of 4 lacs (1.5%), room rent is INR 6000/day, but maximum capping INR 5000/day only.
Top-up if opted, will be utilized if the basic sum insured is exhausted. (will not be a part of room rent calculation)
Associates opting for a higher category of room shall have to bear the room rent difference as well as the proportionate expenses. This shall apply to cashless and reimbursement claims.
• The sum insured is INR 1 Lac, 2 Lacs & 3 Lacs for Parents
• The top up plan is placed with the same insurer and TPA who underwrites the Group Medical Policy for operational efficiency
• Nomination for top up policy is done once a year & not in between the policy period except for the new joiners
• When the main medical plan sum insured is exhausted, only then the top up plan pays for the claim (amount over and above it).
Kindly note that the room rent limit (including boarding and nursing expenses, duty medical officer/resident medical officer charges) shall be restricted as
per your base policy and top up amount shall not enhance your room rent eligiblity
Details of your
Insurance Policy
Hospitalization Coverage Expenses
Room and Boarding including boarding and nursing expenses, duty medical officer/resident medical officer charges Please Note:
A) The expenses are payable
Doctors/Medical Practitioner fees provided they are incurred in India
and within the policy period.
Expenses will be reimbursed to the
Intensive Care Unit covered member depending on the
level of cover that he/she is entitled
Nursing expenses to.
Any hospitalization claim shall be admissible only if there is an active line of treatment during the course of hospitalization i.e. any investigations or
treatment consistent and incidental to the diagnosis of positive existence and treatment of any ailment, sickness or injury, for which confinement is
Hospitalized and administered only with oral medication/injections, even if prescribed by a doctor
Treatment which would be done as out patient and admission not required
Covered • Yes
Duration • 30 Days
Covered • Yes
Duration • 60 Days
Cashless Process
https://network.medibuddy.in/
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.
Emergency Hospitalization
YES
Step 2: Pre-Authorization by hospital
Relatives of admitted member should inform the call Member/Hospital applies for Member gets treated and
centre within 24 hours about the hospitalization & pre- authorization to the discharged
PROCESS
Seek pre authorization. The preauthorization letter Administrator within 24 hrs of after paying all non medical
would be directly given to the hospital. In case of admission expenses like refreshments,
denial member would be informed directly etc..
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 hospitalization 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 Mediassist for reimbursement from the insurer. Please ensure that you
collect all necessary documents such as – discharge summary, investigation reports etc. for submitting your claim.
• You must submit the final claim with all relevant documents within 60 days from the date of discharge from the hospital.
Non Cashless Process
Member intimates Mediassist Claim registered by Insured admitted as per Insured Submits relevant
before or as soon as Mediassist after receipt of hospital norms. All payments documents the Help desk A
hospitalization occurs claim intimation made by member within 60 days of discharge
Yes Is document
Is claim Mediassist performs medical •Insured will create the
received summary of Bills (2 copies) and
payable? scrutiny of the documents
within 30 attach it with the original bills
Yes
days from
•The envelope should contain
discharge
clearly the Employee ID &
No Employee e-mail
No
Claim Rejected
Is
documentation Yes
Mediassist checks document complete Claims processing done as Payment to be done to
sufficiency as required per SLA Employee account
No
Receives mail about
deficiency and document A
requirement
Claim Document Checklist
Hospital bills in original (with bill no; signed and stamped by the hospital) with all
charges itemized and the original receipts
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.
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.
Standard 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
•Congenital external diseases or defects/anomalies
•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 and AYUSH
•Any non-medical expenses like registration fees, admission fees, charges for medical records, cafeteria
charges, telephone charges, etc
•Cost of spectacles, contact lenses, hearing aids
•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
•Voluntary termination of pregnancy during first 12 weeks (MTP)
• OPD Claims not payable under the base Group Mediclaim Policy
• Claims (of high value) submitted without prescriptions/diagnosis
• Health foods
• Costs incurred as a part of membership/subscription to a clinic or health centre
• Naturopathy
• Cost of appliances, spectacles, contact lenses, hearing aids
• Non-medical expenses like Hospital surcharge, telephone bills, cafeteria bills
Contact Details
Escalation Matrix