Employee Group Mediclaim Policy

Policy Period : 1st April 2023 To 31st March 2024

This is the sole and exclusive property of HDFC Life. April 3, 2023
Index
Topics Page No. Topics Page No.

Base Policy Overview 3 Group Health Shield Features and Benefits 16

Emergency Contact Details 4 Premium Chart For Group Health Shield 17

Policy Coverage 5 Policy Disclaimer 18

Maternity Coverage 6 Claim Process 20

Ailment Capping 7 Cashless Claim Process 21

Co-payment Deduction 8 Pre-authorization (Cashless) 22

Room Rent Conditions and Inclusions 9 Dos and Don’ts for Cashless Facility 23

Major Exclusions 10 Reimbursement (Non Cashless) Process 24

Member – Addition & Deletion 11 List of Documents For Reimbursement Claim Submission 25

Top-Up on Base Policy 13 Additional Services from Medibuddy (TPA) 26

Add-On Policy For Dependents 14 Frequently Asked Questions on Mediclaim Policy 27

Premium Chart For Voluntary Add-on Policy 15

Base Policy Overview

Coverage Type TPA

Group Mediclaim Policy - MediAssist India
Family Floater

Insurer Broker
Future Generali India Gallagher Insurance Brokers Private
Insurance Company Limited
Limited

Policy Period Dependent Coverage*

1st April 2023 To 31st March Select any 3 from the following
2024 Dependents:
• Spouse: Defined as any legally
wedded “Partner” or any
Band wise Sum Insured Cover Cohabiting partner of any
Sum Insured can be seen on gender, legally wedded or
MConnect > Mediclaim > otherwise
Policy • Dependent Children: up to the
age of 23 years
• Set of Dependent Parents of
age 58 years and above
Note:
• Pre-existing diseases are not covered in Cancer , Cardiac and Personal Accident Policy of Group Health Shield
• As one time exception during enrollment window, dependent parents under base policy can be replaced with
Spouse/Children however, replacing Spouse/Children with Parents is not allowed.
Emergency Contact Details
Please follow below specified escalation matrix in case of any query:

1st 2nd 3rd 4th

Level Level Level Level
Escala Escala Escala Escalat
tion tion tion ion

CRM SPOC ACCOUNT LEAD GALLAGHER INSURANCE BROKERS SPOC HDFC LIFE
Farzana Shaikh Dhiraj Medhekar Rajprasad Mahapatra Minal Parte
.
Mobile: Mobile: Mobile: Mobile:
7045456681 7718813050 9082839766 9028137503
Email: Email: Email: Email:
farzana.altaf@mediassist.in dhiraj.bhagwan@mediassist.in Rajprasad_Mahapatra@ajg.com pminal@hdfclife.com

1st level support

Dedicated Email ID: Sachin Tathare
hdfclife@mediassist.in Mobile:
(these details are available on flip side of Digital ID Card) 9930885699
Email:
Sachin.Tathare@ajg.com
Policy Coverage
Hospitalization expenses incurred towards treatment of Major ailments or any other Ailments including
COVID-19, for the Insured member, up to the Sum Insured. Hospitalization expenses in Government
administered Ayurvedic Hospital and Homeopathic Hospital are covered

Minimum hospitalization of 24 Hours, at Govt registered hospitals with minimum of 15 beds,

is mandatory requirement except in case of day care procedures for specific treatments such
as dialysis, chemotherapy, radiotherapy, eye surgery, tonsillectomy and lithotripsy. Refer the
complete day care list
Cashless hospitalization (only in network hospitals) & Reimbursement of expenses in case of
treatment at Non-Network hospitals. Documents for Reimbursement claim needs to be submitted
within 20 days of discharge. Delayed claims will not be processed by TPA / Insurer. All Non
Cashless Mediclaim Documents should be sent to TPA Mediassist branch at the following address:
Mediassist TPA Pvt. Ltd.
4th Floor, Aarpee chambers, Opp. Times Square Building,
Marol Naka, Andheri East, Mumbai – 400059

Treatment of any Pre-Existing ailment except Congenital conditions, from day one of the policy

Pre-Post hospitalisation covered for 30 & 60 Days respectively

Policy Pays for

• Room, Boarding, Nursing expenses as provided by the Hospital/Nursing Home
• Surgeon, Anesthetist Medical Practitioner, Consultant’s Special fees
• Anesthesia, Blood, Oxygen, OT charges, Surgical appliances, Medicines, drugs, Diagnostic
Material & X-Ray, Dialysis, Chemotherapy, Radiotherapy, cost of pacemaker and cost of
stent and implant. Expenses of artificial limbs will be paid, if required due to accident will
be reimbursed.
• GST expenses. (Note: Service charges & Surcharge are not payable)
Maternity Coverage
Policy covers medical expenses relating to the first two deliveries, payable for female members
(Employee / Spouse) insured in the policy.
• This is a sub limit within the overall Sum Insured.
• There will be no waiting period for maternity except the employment confirmation clause as
applicable.
• No room capping under maternity claims.
• Pre and post natal expenses are covered.
• Sum insured applicable for maternity cover based on hospital’s location:
Employee’s Spouse Woman Employee
Location
Normal Delivery Caesarean Section Normal Delivery Caesarean Section
Metro INR 40,000 INR 60,000 INR 50,000 INR 70,000
State Capital INR 30,000 INR 50,000 INR 40,000 INR 60,000
Branch Location INR 25,000 INR 40,000 INR 35,000 INR 50,000
Spoke Location INR 25,000 INR 40,000 INR 35,000 INR 50,000

New born baby: Covered from day one within the overall floater sum insured subject to the
availability of the scope for addition and declaration of the child within 45 days from the date of
birth.

Surrogacy cover: Covered under maternity limits. Only the cost of delivery is covered, pre and
post natal expenses are not covered.
Ailment Capping
Ailment wise capping (includes – pre-hospitalization, hospitalization and post-hospitalization)* for all
Band:

Name of Sub Limit as per City category (in INR)

Ailment/Surgery/Procedure A B C D
Cataract (each eye) 30,000 25,000 25,000 20,000

Ambulance charges allowed during hospitalization for all Band of employee upto INR 2,500 in case
of Normal Ambulance and INR 3,500 in case of Cardiac/Covid Ambulance

Hospitalization expenses in Government administered Ayurvedic Hospital and

Homeopathic Hospital will only be reimbursed.

Gender reassignment surgery - covered upto 100% of Sum Insured till 5A Band and maximum
upto INR 8 Lacs for 5B and above band. This cover is applicable for Employee only & not for
dependents.
Co-payment Condition

Co-pay of 20% applicable for all parental claims (on the admissible amount duly approved by TPA)
which would include cashless and reimbursement, as well as pre and post hospitalization claims. No co-
pay on all Cardiac related treatments except Parents for which 20% co-pay will be applicable.

20% co-pay is applicable for all claims on Employee, Spouse and Children for following ailments: (This 20
% co-pay on specific ailments will not be additionally applicable in case of Parental Claims): (* will be
waived off in case you buy Top Up Policy to an extent of reasonable and customary clause and policy
terms)
• Gastrointestinal system (Infectious gastroenteritis and colitis, Gastro-esophageal reflux disease,
Gastroduodenitis, Acute abdomen, gallbladder etc.)
• Infectious diseases (Urinary tract, fever, Dengue, Jaundice, Malaria, Pneumonia, COVID-19 etc.)
• Disorder of respiratory system (Acute upper respiratory infection, Sinus, Asthma problems, acute
bronchitis etc.)
• Fracture claims (including accidental fractures, Arthritis etc.)
• Disorder as musculoskeletal systems (Sprain of wrist, Injury of muscles/tissues, Ligaments etc.)
• Hydrocele, Hernia, Hydrocele, Inguinal Hernia, BPH, Tonsillectomy
• Tympanoplasty
• Fistula, Piles, Sinusitis, Appendicitis, Cholecystectomy, Lapchole
• Hysterectomy
• Knee Joint / Hip Replacement (per joint)

Additional 10% Co-Pay is applicable on final bill, in case the claim intimation is not
provided within 48 hours of hospitalization.
No deductions to be made in case of death during hospitalization; 100% bill gets paid in case of
demise. (Applicable only for an employee and not for dependents)
Room Rent Conditions and Inclusions
Per Day Limit for Room, Boarding and Nursing
Charges
For Grade 5B & Above : 1% of Sum Insured for Normal room & 2% of Sum Insured for ICU room.

For Grade 5A & Below :

Normal Room -The room entitlement would only be applicable as per the below table and will have a corresponding
effect on the other medical expenses reimbursable based on the room capping.
ICU Room - ICU eligibility will be 2% of Sum Insured.
Max. Bed charges Payable per
Class of City
day
A – Category (Metro) INR 3,250
B – Category (State
INR 2,750
Capital)
C – Category INR 2,500
D – Category INR 2,000
Note: List of City Category available on ESS >> HR Section >> Mediclaim >> City Category
Proportionate deduction will happen on the bill charges if actual room rent exceeds eligibility.

Inclusions

Medicines/pharmaceuticals and body implants will be paid on actual.

Illnesses like Appendicitis, Tonsillitis, Cataract Surgery, Eye Surgery, Radio Therapy, dental surgery
(due to accident), kidney stones, minor accidents involving fractures and also Chemotherapy and
dialysis & MTP Laparoscopic therapeutic surgery and surgery under anesthesia, laser treatments or
any surgeries under general anesthesia due to technological advancement requiring hospitalization
less than 24 hrs are covered
Major Exclusions
Refractive error surgery, contact lenses, cost of spectacles are specifically excludedv

Domiciliary Hospitalization is specifically excluded

Hospitalization expenses for the following will not be reimbursed.

▪ Alcoholic / Chain Smoking Induced Disease / Treatment
▪ Cosmetic Surgery/ Sight Correction (payable only in case of accidental case)
▪ Ayurvedic Treatment in the Private Hospital
▪ Depression Cases (Hospitalization arising from Depression related sickness)
▪ Family Planning Operation / Voluntary Medical Termination of Pregnancy
▪ Infertility Treatment
▪ Dental extraction & dental bridge work (Permanent/ Partial Cement, Silver Filling)
▪ All Cross Pathy treatments will not be payable. Example Ayurvedic doctor treating
Allopathic case and vice-versa

“No active line of treatment” cases will be excluded unless in case of life-threatening situation

No deductions to be made in case of death during hospitalization; 100% bill gets paid in case of
demise.
(Applicable only for an employee and not for dependents)
Member – Addition & Deletion
• New Joiners will be covered from Date of Joining however; the E-cards will be uploaded on portal within 1 month from Date of joining.
• New Joiners’ dependents would be covered post completion of 6 months from the date of joining and Smart Achiever’s dependents will be covered
from Date of Joining (Post completion of 1 year Internship).

The employee would be allowed to include any of the dependents during the policy year in the event
of following reason only:

▪ Inclusion of spouse within 45 days from Date of Marriage during the policy year, subject to no
replacement, no withdrawal of existing dependent.

▪ Inclusion of child within 45 days from Date of Birth in event of new birth during the policy
year subject to no replacement, no withdrawal of existing dependent.

▪ Inclusion of new dependent in event of death of existing nominated dependent during the
policy year provided no claim made in respect of the deceased member.

▪ Inclusion of Parents if they attain age of 58 is permissible only if there is a vacant position.
Replacement is not allowed. All inclusions in between the policy period should in informed to
HR Operations team on email along with supporting documents like Marriage/Birth/Death
Certificate or Age Proof.

The dependents will be continued to be covered till the end of policy period in case of demise of employee.

All inclusions in between the policy period should in informed to HR Operations team on email along
with supporting documents like Marriage/Birth/Death Certificate or Age Proof
 EMPLOYEE BENEFITS-
VOLUNTARY PROGRAMS
 Top-Up on Base Policy
Features of Top-Up Policy*
Benefits:
▪ Top-up benefits will be applicable only for Self and dependents enrolled under Base Mediclaim Policy.
▪ Employees will have an option to buy Top-up Plans to increase Sum Insured and additional benefit to their
Mediclaim Policy.
▪ Top-up can be bought maximum up to 100% of actual Sum Insured as per your Band.
▪ The Additional Sum Insured policy (Top-up) will trigger after exhausting threshold limit of Base Policy.
▪ All existing medical conditions will also be covered in this policy.

Conditions:
▪ Any claim exceeding capping limits (excluding maternity & cataract) as defined in the Base Policy is admissible
subject to Reasonable Customary clause.
▪ Co-pay claims on ailments not payable under Base policy are payable subject to Reasonable Customary Clause.
▪ Deductions with respect to co-pay, proportionate room rent and other linked charges & capping (excluding
maternity & cataract) on Base Policy are payable subject to Reasonable & Customary clause.
▪ No medical checkup is required for enrolment.
▪ Top-Up Policy can be bought only during enrollment window and will not be available throughout the year.

Note: In case employee moving out of HDFC Life, there will be no refund.

Top Up- Rate Card

Sum Insured in INR Premium In INR
* Lock-in for 3 years applicable, 2 Lakhs 5,753
unless waived under special circumstances. 4 Lakhs 11,505
8 Lakhs 21,730
12 Lakhs 32,598
15 Lakhs 40,828

Above premium is inclusive of GST.

 Add-On Policy For Dependents
Features
BENEFITS of Add-On Policy*
OF ADD-ON
Additional coverage can be voluntarily be purchased by the employees for their Dependent s who are not
covered in the Base Policy:
Spouse, 2 Children OR a set of dependent parents (Father / Mother / both).
Parent-in-laws are not eligible

Benefits:
▪ No co-pay deductions or capping limit (except for cataract operation) are applicable in this policy
▪ All existing medical conditions will also be covered under this policy
▪ Under the Add-on policy for Spouse and 2 children, all 3 will be covered under the same sum insured in the
mentioned premium.
▪ Parents below the Age of 58 can also be covered under Additional Parental Policy
▪ If Single Parent is enrolled under Add-On, only 80% premium will be charged. Premium calculations will be
automated from back-end.
▪ No medical check up is required.

Conditions:
▪ For Add-On Policy, Room Rent is capped at 1% for normal and 2% for ICU rooms on sum insured.
▪ Proportionate deduction will happen on the Bill charges. However, medicines/pharmaceuticals and body
implants will be paid on actual.
▪ Maternity claims are not covered under this policy
Lock-in for 3 years applicable, ▪ Cataract operation is capped till Rs. 30,000 per eye
unless waived under special ▪ Knee Joint Replacement capped at Rs. 175,000 per knee
circumstances. ▪ Dependents enrolled under the Base Policy cannot be considered for Add-On Policy. Sum Insured can be
selected as per the slabs provided by Insurer.
Premium Chart For Voluntary Add-on Policy*
Parents Premium in INR
Age Group in years
Sum Insured < 60 61 to 70 71 to 80 81 to 120
2 Lakhs 12,703 18,430 22,291 25,678
4 Lakhs 21,839 29,598 35,801 41,248
8 Lakhs 37,620 50,805 61,456 70,806
12 Lakhs 43,274 58,087 70,160 80,760
15 Lakhs 50,268 67,947 82,068 94,466
* 80% Premium applicable if single parent enrolled
* Premium of higher age band will be applicable
* Parent-in-laws are not eligible

Spouse & Upto 2 Children

Sum Insured Premium In INR
2 Lakhs 3,237
4 Lakhs 5,904
8 Lakhs 10,763
12 Lakhs 13,549
15 Lakhs 15,731

Premium in above tables are inclusive of GST.

* Lock-in for 3 years applicable for Add-On Policies, unless waived under
special circumstances.
 Group Health Shield Features and Benefits
▪ The policy can be bought by any employee in1,1B band and above and for Self or Self and Spouse however, cannot be bought only for Spouse
▪ Existing employees and their spouses covered under this policy will be Auto Renewed, anyone who doesn’t want to renew the policy for next year, can OPT
OUT
▪ Existing employees covered under this policy who had completed the 180 days waiting period, then for this year renewal waiting period will be waived off
▪ Any Additional Sum Insured or Adding new benefit in existing cover, waiting period shall be applicable as per the Product Benefit Terms & Conditions
▪ Employee are eligible to buy these benefits for their spouse under following conditions:
1. Employee have to enroll for self then only he/she can enroll spouse for same benefit
2. Spouse cover Sum Insured shall not exceed the employee Sum Insured of same benefit

Features Cancer Cover Cardiac Cover Personal Accident Cover(PAC)

Coverage Self & Spouse Self & Spouse Self & Spouse

Sum Insured(SI) 1,1B, and 2: Rs 2.5 lakh 1,1B, and 2: Rs 2.5 lakh 1,1B, and 2: Rs 5 lakh
3A and 3B: Rs 5 lakh 3A and 3B: Rs 5 lakh 3A and 3B: Rs 10 lakh
4 to 5B: Rs 10 lakh 4 to 5B: Rs 10 lakh 4 to 5B: Rs 20 lakh
6B and above: Rs 20 lakh 6B and above: Rs 12.5 lakh 6B and above: Rs 50 lakh

Payout Conditions Early Stage Cancer or CIS (25% SI) High Severity (100% SI) Accidental Death (100% SI)
Major Cancer(100% SI) Moderate Severity (50% SI) Accidental Total Permanent
Mild Severity (25% SI) Disability (1% SI for 10 years)
Accidental Partial Permanent
Disability (10%-75% SI)

Multiple Conditions Possible for Early Stage Cancer of CIS, up to Only for condition/s falling under the Possible under APPD subject to
extent of SI (subject to T&C) Group B and C severity. max of 100% of Personal Accident
SI
Waiting Period 180 Days 180 Days NIL

Survival Period 7 Days 30 Days N.A

* Pre-existing diseases are not covered in Cancer, Cardiac and Personal Accident Policy of Group Health Shield
Premium Chart For Group Health Shield

Group Health Shield Cover

(Premium in INR)
Male Female

Personal Personal
Age Cancer Cardiac Accident Age Cancer Cardiac Accident
Cover Cover Cover Cover Cover Cover
5 Lakhs 5 Lakhs 10 Lakhs 5 Lakhs 5 Lakhs 10 Lakhs
25 171 384 625 25 348 242 625
30 212 425 625 30 655 248 625
35 271 578 625 35 1145 266 625
40 389 1121 625 40 1611 425 625
45 620 2142 625 45 2089 861 625
50 1062 3540 625 50 2567 1640 625
55 1847 5263 625 55 3180 2991 625
60 3198 7233 625 60 3988 4991 625

* Please visit ESS to know your & spouse premium as per Age wise and Sum
Insured Applicable as per Band.
Above premium is inclusive of GST.
 Policy Disclaimer

▪ Any Medical Practitioner authorized by the Insurer, shall be allowed to examine the Insured person in case of any alleged injury or disease
requiring hospitalization when and so often as the same may reasonably be required on behalf of the HDFC Life Insurance Co. Ltd.

▪ Insurer or HDFC Life Insurance Company Ltd. shall not be liable to make any payment under this policy in respect of any claim, if such
claim in any manner is fraudulent or supported by any fraudulent means or device whether by the Insured person or by any other person
acting on his behalf.

▪ The payment to the insured would be payable only in case of ailment covered under the policy. HDFC Life Insurance Company Ltd. would
not be liable for reimbursement of any claim, if the same is not coverable/payable under the Floater Mediclaim Policy.

▪ Insurer shall disclaim liability to the Insured for any claim hereunder and if the Insured shall not within 12 calendar months from the date
of receipt of the notice of such disclaimer notify the Company in writing that he does not accept such disclaimer and intends to recover his
claim from the Company, then the claim shall for all purposes be deemed to have been abandoned and shall not thereafter be recoverable
hereunder.

▪ Pre-existing diseases are not covered in Cancer , Cardiac and Personal Accident Policy of Group Health Shield

Note: In case employee moving out of HDFC Life, there will be no refund.
CLAIM PROCESS
Ways to avail Mediclaim Benefits
Option 1 Option 2

Mediclaim
Cashless

Cashless Facility Reimbursement Facility

Cashless facility can be availed or granted Reimbursement facility is generally availed
when the hospital is registered as Network if the hospital is not in network list of TPA
hospital of TPA or due to unclear requests cashless is not
Cashless generally lower hospitalisation granted by TPA or if the insured voluntarily
expenses due to tie up between Insurance does not opt for Cashless facility.
company and Hospitals
Important note on documents submission:

Documents for Reimbursement claim needs to be submitted within 20

days of discharge. Delayed claims will not be processed by Insurer /
Unplanned/Emergency TPA.
Planned
Hosptialisation Hosptialisation
All Non Cashless Mediclaim Documents should be sent to TPA
Mediassist branch
When the When the request at the following address:
Cashless request for Cashless is
process is given at the time Mediassist TPA Pvt. Ltd.
completed in of admission only 4 Floor, Aarpee chambers, Opp. Times Square Building,
th
advance
Marol Naka, Andheri East, Mumbai – 400059
We recommend Option 1 for our employees
Cashless Claim Process
Once in the hospital, go to
Claimant should the Help desk/TPA
Cashless facility is carry their Desk/Reception, and inform
only applicable if Claimant Visits mediclaim cards that you are covered under
the member goes Network Hospitals or mediclaim ids Group Mediclaim Insurance
to a network along with a Policy and get the pre-
hospital photo id proof to authorization form filled by
the hospital. the doctor/hospital.

1 2 3 4

The cashless may If TPA requires more clarification, it will If everything is ok,
be rejected if TPA within 3-4 hours Get the filled
re-Mail the letter of requirement/
is of the view that clarification. The query needs to be the TPA will 5 form Mailed
ailment/ answered satisfactorily via Mail. If the sanction the to the TPA
hosptialisation is query is resolved then TPA will sanction amount
not covered under the cashless
the policy 7 6

There are few If the final bill is

hospitals which may more than initial
ask for certain sanctioned amount
deposit amount at then at the time of
the time of discharge follow the
admission which will above process again.
be refunded to you Additional limit will
once the hospital be granted if things
Note: gets it payment from are in order.
the TPA
Denial of “Cashless Service” is not denial of treatment. You can continue with the treatment, pay for the services to the
hospital, and later send the claim to TPA for processing and reimbursement.
 Pre-authorisation (Cashless)
The process of approval of Cashless request is called Pre-authorization

Cashless request is to be sent on the The TPA Desk generally functions only
day of admission or next day only. till 5.30-6.00 in the evening. If
Cashless cannot be initiated on the hosptialisation is in late evening then
day of discharge. the cashless request needs to be sent
next morning (this will not hinder the
treatment and it can be initiated)

However kindly note that you / your

Mailing of pre-authorisation form representative is the best person to get
may be followed by a phone call to the Pre-authorisation form filled from
TPA call centre within 30 minutes to the doctor/hospital authorities.
ensure that Mail has been received EGIBL/TPA will only be able to assist
by them. after the form has been Mailed to TPA.

Please ensure that the form is If the process is taking too long and not
completely filled, signed and to your satisfaction then you may get in
stamped before sending it to TPA. touch with representatives at Marsh
Incomplete form will only delay in India Broker or at TPA
authorisation. The form is to be filled
by treating doctor/consultant.

TPA may revert with some more

clarification on nature of ailment, Cashless will be granted and the
past ailment, proposed treatment, Authorisation Letter (AL) will be Mailed
expense, etc. Kindly ensure that the to the hospital.
queries are replied immediately and
Mailed to TPA.
 Dos and Don’ts for Cashless Facility
In case of Planned hospitalization, it is The original documents must be submitted
1 advisable to complete the Cashless 6 within 20 days of discharge to theTPA,
formalities in advance. The cashless otherwise the claim will be rejected. The
approval is valid till 8 days of issue. list of documents is as per previous slide.
Fill the pre- authorization form completely
2 before mailing it to TPA. All the Bills, Reports, Discharge Card, etc.
7 would be required in original
TPA generally reverts in 2-3 hours of
3 receipt of Mail. If it takes more time you
8
Ensure that Claimant /patient’s name is
written on each bill purchased for outside.
may contact TPA/EGIBL and apprise about
it. Preferably the Mail may be followed by Unnamed bills will be rejected
a phone call to TPA after 30 minutes to
check receipt of it. If any deficiency is noted in documents
Initial approval will be given. If the 9 submitted, TPA will send Deficiency Letter
4 expenses increase during stay then at within 3-4 days of receipt of documents,
the Deficiency letter will have 7days grace
the time of discharge final bill, etc. needs
to be Mailed to TPA again. The total period. This will be followed by 2
admissible amount will be approved and Reminder letters with another 7 days
you will need to pay non-admissible grace period each. In all circumstances
amount. the document pendency should be
Kindly note that additional amount cannot complete within 45 days of date of
5 be sanctioned after the discharge. If any discharge. If additional documents are still
amount remain pending then it needs to not submitted then the claim will be
be brought up for Reimbursement. rejected.
Note:
The cashless generally gets delayed for non-
submission of following documents. Please ensure The Reimbursement generally gets delayed for non-
that these are submitted at the first instance itself submission of following documents. Please ensure
that these are submitted at the first instance itself

• Investigation reports • Original Discharge Card

• Photo id card of patient • Original Bills/Receipt
• Detailed line of treatment • Investigation report
 Reimbursement (Non Cashless) Process
The process for reimbursement is as follows
At the time of intimation, On receiving the claim Member shall collect
In case of The employee following details need to be
admission at Non- has to notify the intimation, a unique claim original copies of
furnished to the TPA:
Network hospital, TPA within 48 number is generated by hospitalization
the employee will hours of • TPA ID Card
TPA. documents, at the
NOT get Cashless admission • Nature of illness and
A communication is sent to time of discharge
Facility. through call, • Name of the hospital
email, in person the employee with the claim
• Name of the treating
Employee Has to or SMS. This will number, copy of claim form
physician
compulsorily lodge be considered as and list of documents
for intimation • Date of admission
required.
Reimbursement

The claim status can be Please note that In case of any If there’s some deficiency in If all the documents
checked on the website of the original clarification / documentation, it will be informed are in order then the
TPA documents will be inability to furnish to the Employee in the form of claim will be settled
retained by the documents, the Deficiency Letter. Employee is within 21 working
TPA and hence Employee may requested to submit the days of receipt of
Claimant is get in touch with documents as per deficiency letter documents by TPA
requested to keep TPA/EGIBL to TPA within 7 days of issue of
a copy of letter. If the documents are not
Important Note : document with arranged then 2 reminder letters
him/her each with 7 days grace period will
Documents for Reimbursement claim needs to be submitted be sent, if still pending the claim
within 20 days of discharge. Delayed claims will not be processed will be rejected and the file will be
by Insurer / TPA. closed permanently.
List of Documents For Reimbursement Claim Submission
Documents to be submitted for Reimbursement claim
All the documents mentioned below should be submitted to avoid any delay in
claim or repudiation of claim
1 Original hospital final 8 Photo ID card copy of claimant
bill
2 Original pre-numbered 9 TPA Card copy
receipts for payments
made to the hospital
10 Intimation mail copy/ Claim
3 Complete breakup of the Registration no.
hospital bill
Paginated copy of Indoor
4 Original Discharge 11
Case papers
Card/Summary
All original investigation 12 FIR/MLC copy incase of Road
5 accidents. If MLC is not applicable
reports
then written confirmation from
All original medicine bills Doctor/Hospital that the patient was
6 not under influence of alcohol or
with relevant prescriptions
drugs
13 Cancelled Cheque of a/c
7 Original signed claim belonging to Main member /
form Dealer & Aadhar card copy.
All Non Cashless Mediclaim Documents should be sent to TPA Mediassist branch
at the following address:
Mediassist TPA Pvt. Ltd.
4th Floor, Aarpee chambers, Opp. Times Square Building,
Marol Naka, Andheri East, Mumbai – 400059

Note: All the bills/reports/prescription are to be submitted in

original
Additional Services from MediBuddy (TPA)
1) Doctor on Call:
• This 24/7 online consultation service by specialized panel of doctors is available free for you and your family. You can avail unlimited free online
consultations and the appointments can be set within 30 minutes post the online booking.
• Doctor on Call can be accessed through MConnect >> Mediclaim (App Navigation) >> Medibuddy >> Talk to Doctor.
• Support: hdfclife@mediassist.in or dial the toll free helpline no. 9999991555 for queries (Booking can be done only on App. Helpline is only for
tech support if needed).

2) Medicines and laboratory tests at discounted rates:

• You can buy medicines online and get them home delivered or book lab tests at diagnostic centers available nearby through the MediBuddy app.
• The MediBuddy app can be accessed directly through MConnect >> Mediclaim (App Navigation) >> Medibuddy.

3) Mediclaim e-cards & hospitalization:

• These e-cards can be used to avail cashless benefits for yourself and your declared dependants as per our company's mediclaim policy.
• E-Cards can be accessed through MConnect >> Mediclaim > > E-CARD path.
• In the unfortunate event of you or your declared dependants being hospitalised, you can even search for Network Hospitals on the MConnect App.
• Support: hdfclife@mediassist.in / 9513360003 (Toll Free No.)
 Frequently Asked Questions
1 Q. Can Parents in Law be covered under Mediclaim policy (Base, Top-Up or Add-On)?
A. No

Q. Are Top-Up and Add-On policies available to be bought throughout the year?
2 A. No. Top-Up and Add-On policies are available only during enrollment window in the beginning of the year. Employee
joining mid- year can only do so in the next year.

3 Q. Why is a claim rejected?

A. There are certain common reasons due to which claims get rejected by Insurer / TPA. Some of the common reasons are listed
below:
• Delayed submission of original claim documents and claim form (Beyond 20 days from Date of Discharge)
• No active line of treatment and/or hospitalization of less than 24 hours
• Hospital is not registered, or the Registration License of Hospital expired before admission of patient. This means ideally
Hospital should not have been functional. In case of such rejection, if the hospital provides registration certificate later but
within 30 days of hospitalization, the claim is considered
• Claim submitted for ailment or surgery or treatment that is not covered under the policy terms and conditions (As part of
exclusions in policy coverage)
• Claim documents provided of dependent who is not enrolled in the policy

4 Q. Should I retain scan copy of all original documents submitted for the claim?
A. Yes, you must retain scan copies of all original documents submitted along with claim form. TPA will not return the original
documents and is not liable to return the claim documents even in case of claim rejection. Hence it is important to retain
scan copies for future treatment and references and for partial claim
Frequently Asked Questions
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Q. What are the reasons when I may not get the full amount as expected?
A. There are multiple reasons due to which, certain amount will have to be paid by employee from their pocket. Some
common reasons mentioned below:
• In case of reimbursement claim, the Claim Intimation to TPA was not sent within 48 hours of hospitalization. In such case,
10% Co-Pay is applied (This is over and above other co-pay applied as per policy terms and conditions)
• 20% Co-pay applicable on all Parental claims (This Co-pay will not be applicable if employee buys Top-Up policy*)
• 20% Co-pay on treatment of certain diseases as mentioned in policy document (This Co-pay will not be applicable if
employee buys Top-Up policy*)
• Room availed for the patient is higher than the employee’s room rent eligibility as per policy terms. In such case,
proportionate deduction is applied on the entire bill excluding Medicines/pharmaceuticals and body implants which will be
paid on actual amount (This Co-pay will also not be applicable if employee buys Top-Up policy*)
• Treatments of ailments are capped for Maternity & Cataract.
*- Refer Top-Up policy terms and conditions

Q. Will I be able to opt-out from Top-Up or Add-On policy OR Change the Sum Insured?
6 A. No – Top-Up and Add-On policy has lock-in period of 3 years. This means you will have to pay premium for covered
dependents for 3 consecutive years.

You also cannot change the Sum Insured during the lock-in period of 3 years
Frequently Asked Questions
7 Q. What are the few things, I must be extra careful about during planned or unplanned hospitalization?
A. For planned hospitalization:

• Inform TPA in advance about the planned hospitalization

• Inform TPA desk of hospital where you have planned the treatment in advance to raise the cashless authorization so that
TPA can send the approval in advance and the treatment and claim experience is smooth, quick and hassle-free while you
can devote that important time to be with family members free from worry of claim settlement
• During discharge, as soon as treating doctor informs that patient can be discharged, inform the TPA desk in hospital so that
they can prepare for the billing and settle the final amount at earliest
• If you have paid refundable deposit to hospital, please follow up with TPA team after 2 months to ensure you get the refund
of your deposit

For unplanned hospitalization & reimbursement claims:

• Inform TPA (send claim intimation) within 48 hours from hospitalization. This will enable TPA to check the feasibility to
convert your claim into cashless
• Show the E-card on TPA desk in hospital so that they provide you benefits and treatment as per negotiated rates with
Insurer and hospital does not charge you as per open billing
• Before discharge from hospital, ensure you collect all original documents related to claim from the bill desk (Discharge card,
medical bills, itemized bill and all other relevant claim documents)
• Submit all original claim documents including X-Ray reports and claim form to TPA SPOC at HDFC Life Corporate office within
20 days from date of discharge
• Keep a scan of all the bills and papers
Frequently Asked Questions
8 Q. Will I be able to replace dependents in Base Policy?
A. As a one-time option this year, you can remove your dependent parents from base policy and replace them with
Spouse/Children who were not covered. If Spouse/Children are covered under an Add-On policy, you cannot put them because
Add-On policies have lock-in period of 3 years.

Note: You can NOT remove Spouse / Children covered in Base Policy and replace them with parents who are not covered.

Q. Can I buy Add-On Policy for my dependents who are not part of base policy?
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A. Yes. You can buy Add-On policies for Spouse/Children/Parents who are not covered in Base Policy. This option will be
available only during the enrollment window and the coverage will be provided for 11 months starting from 1st May. The
premium for the same
will be deducted in 2 EMIs of May and June

Q. Can I claim for same hospitalization under our company Mediclaim policy as well as personal Mediclaim
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policy?
A. Yes, you can claim it. It is preferable to claim where you have maximum sum insured first and then get a claim
settlement letter from TPA. Retain all Scan Copies of original documents and claim form. Submit the claim settlement letter
along with scan copies of claim documents to another Insurer/TPA so that the remaining payable amount is settled by the
2nd Insurer/TPA

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Q. Are pre-existing diseases covered in Cancer and Cardiac and Personal Accident Policy of Group Health Shield
A. NO
 Thank You

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