Professional Documents
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EMPLOYEE INSURANCE
COVERAGE GUIDE
GROUP MEDICLAIM
E M P L O Y E E I N S U R A N C E C O V E R A G E G U I D E
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EMPLOYEE INSURANCE COVERAGE GUIDE
Group Mediclaim Policy
Group Mediclaim
Employee Policy details The Group Medical policy covers expenses by the insured persons & family members covered) on account of hospitalization due to
sickness or accident.
Enrollment Procedure
The policy covers expenses incurred on
Claims Procedure ➢ Room rent, medicines, surgery etc. Expenses for hospitalization
➢ Payable only if a 24 hour hospitalization has been taken (Except for named day care procedures, which do not require a 24 hour
Exclusions
hospitalization).
FAQ’s, Contacts & Links ➢ Typical expense heads covered are the following: room/boarding expenses as provided by the hospital or nursing home ; nursing
expenses ; surgeon, anesthetist , medical practitioner, consultant , specialist fees; anesthesia, blood, oxygen, operation theater
charges, surgical appliance, medicines and drugs. diagnostic material and X-Ray; dialysis, chemotherapy, radiotherapy, cost of pace
maker, artificial limbs and cost of organs and similar expenses.
E M P L O Y E E I N S U R A N C E C O V E R A G E G U I D E
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EMPLOYEE BENEFITS GUIDE
Group Mediclaim Policy
Policy Details
Group Mediclaim
Policy Details
➢ Policy Holder Course5 Intelligence Limited
➢ Policy Start & End Date 26th MARCH 2022 – 25th MARCH 2023
Enrollment Procedure ➢ Sum Insured 1,00,000, INR 2,00,000,INR 3,00,000, INR 4,00,000 ,INR 5,00,000 , INR
6,00,000 and INR 7,00,000
Claims Procedure Covered Members Description Special Condition if any
E+S+2C+2 dependent
Exclusions ➢ Total Members Covered per Family
Parents/In Laws This is applicable for all employees
(Including Employee)
FAQ’s, Contacts & Links ➢ Employee Covered
Policy Features
➢ Spouse Covered
Age Limit : 2 Children covered up to 25
➢ Dependent Children Covered
years
➢ Dependent Parents
Covered Age Limit - Covered up to 100 years
E M P L O Y E E I N S U R A N C E C O V E R A G E G U I D E
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EMPLOYEE BENEFITS GUIDE
Group Mediclaim Policy
Benefits Details
Group Mediclaim ➢Standard Hospitalization Covered for all
Policy Details
➢Pre & Post Hospitalization Expenses Covered (30 days & 60 days respectively)
➢Pre-existing Diseases Covered for all
➢First 30-days & First Year Waiting Period Covered from Day 1
INR. 50,000/- for Normal delivery and Rs.75,000/- for C-
➢Maternity
Employee Policy details Section delivery
➢9 months Waiting Period (Maternity) Not Applicable ( Covered from day 1 of the policy )
Benefits Details
Enrollment Procedure ➢New Born Baby Cover from Day 1 Covered within family sum insured
➢Hospitalization due to Terrorism Covered for all
Claims Procedure
Room Rent Restriction Per Day ( Bed charges + Nursing + Duty Doctor )
Rs. 3,000/- Per Day for Normal Hospitalisation & Rs. 6,000/-
Exclusions ➢Rs. 1,00,000/- & Rs. 2,00,000/-
for ICU Hospitalisation
➢Rs.1,00,000/- ; Rs. 4,00,000/- ; Rs. 5,00,000/- ; Rs. 1% of Sum Insured for Normal Hospitalisation & 2% of Sum
FAQ’s, Contacts & Links 6,00,000/- & Rs. 7,00,000/- Insured for ICU Hospitalisation
Policy Features
In case if the employee opts for a higher room rent than his
eligibility, the proporationate increase in the cost of room rent
➢Proportionate charges linked to room rent
and other incidental charges will have to be borne by the
employee
➢Day Care procedures Covered for all
➢Congenital Internal Covered for all
E M P L O Y E E I N S U R A N C E C O V E R A G E G U I D E
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EMPLOYEE INSURANCE COVERAGE GUIDE
Group Mediclaim Policy
Policy Details
Benefits Details
Day Care Procedure means the course of medical treatment
or a surgical procedure listed in the Schedule which is
undertaken under general or local anesthesia in a Hospital
➢Day Care Treatment by a Doctor in not less than 2 hours and not more than 24
Employee Policy details
hours. (i.e. Dialysis, Chemotherapy, Radiotherapy, Eye
surgery, Lithotripsy (kidney stone removal), Tonsillectomy,
Benefits Details
Policy Details
In case of the death of an employee during the course of the policy, the coverage will be extended
➢Widow Widower Cover to the
employees dependents till the expiry of the policy
➢Co-pay 10% co-pay on Self + Spouse + 2 Dependent Children & 30% co-pay on all parental claims.
Employee Policy details
a) Employees and family members who are presently covered under GMC Policy of Course5i will
be allowed to buy Individual Health Policy with the existing insurance company Course5i as per
Benefits Details
Exclusions d) Waiver of clauses to be applied from the Date of Joining of the Employee to Course5i (Eg . : If
➢Continuity Benefit the employee has completed 4 years of service at Course5i he will be allowed to carry forward the
waiver of PED / 30 days / 1st 2nd & 4th Year Exclusion)
FAQ’s, Contacts & Links
e) Intimation will be provided by the client 15 Days in advance from the last Date of
Policy Features
E M P L O Y E E I N S U R A N C E C O V E R A G E G U I D E
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EMPLOYEE INSURANCE COVERAGE GUIDE
Group Mediclaim Policy
Policy Details
➢Ambulance Charge Covered up to a 1% of the S.I or INR 2,000, whichever is lower
Enrollment Procedure
In the event of death of a claimant during the hospitalisation, no
Claims Procedure ➢Bereavement Coverage deductions or co payor sub limits will be applied including non-
medical expenses
Exclusions ➢Claim Intimation No Claim intimation / not mandatory
FAQ’s, Contacts & Links All Claim documents for reimbursement should be submitted
Policy Features
➢Claim Submission
Pre & Post hospitalization claim documents will have to be
submitted within 7 days from the date of completion of medication
or within 7 days post completion of post hospitalization period
E M P L O Y E E I N S U R A N C E C O V E R A G E G U I D E
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EMPLOYEE INSURANCE COVERAGE GUIDE
Group Mediclaim Policy
Pre-hospitalization Expenses
Group Mediclaim
Policy Details
• If the Insured member is diagnosed with an Illness which results in his / her
Hospitalization and for which the Insurer accepts a claim, the Insurer will also
Definition
reimburse the Insured Member’s Pre-hospitalization Expenses for up to 30
days prior to his / her Hospitalization.
Covered • Yes
Employee Policy details
Duration • 30 Days
Benefits Details
Enrollment Procedure
Post-hospitalization Expenses
Claims Procedure
• If the Insurer accepts a claim under Hospitalization and immediately
following the Insured Member’s discharge, further medical treatment directly
Exclusions Definition related to the same condition for which the Insured Member was Hospitalized
is required, the Insurer will reimburse the Insured member’s Post-
hospitalization Expenses for up to 60 day period.
FAQ’s, Contacts & Links
Policy Features
Covered • Yes
Duration • 60 Days
E M P L O Y E E I N S U R A N C E C O V E R A G E G U I D E
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EMPLOYEE INSURANCE COVERAGE GUIDE
Group Mediclaim Policy
Group Mediclaim You must enroll in order to obtain coverage for yourselves and your eligible dependents. Please contact your HR and provide relevant enrollment
data (viz. name, date of birth, gender). Your enrollment data must reach the Insurer within 30 days of your joining the company.
Please notify HR each time you acquire a new dependent i.e. when your family status changes because of marriage, birth or adoption of a child. The
inclusion of a new spouse must be declared within 30 days of the marriage. Similarly, information about new-born child has to be declared
immediately after the first discharge after the child-birth.
If you fail to enroll within the defined timelines, the next enrollment can be done only at next renewal.
Employee Policy details
HR needs to be Intimated with the required details for HR sends the data to the UIB & UIB sends the data to
Start
Enrollment Procedure Employee & their dependants insurer to include the member into the policy
Claims Procedure TPA updates the active member database and prints the Insurer updates the data & generate the endorsement
cards details & sends the details to the TPA
Exclusions
Notify UIB with revised details and mailing address for
ID Cards mailed to the HR within 15 working days
correction
FAQ’s, Contacts & Links
No Employee Yes
Error in the printed card,
verify the ID card OK, Use card for
correction endorsement to
card details cashless hospitalization
be processed
?
E M P L O Y E E I N S U R A N C E C O V E R A G E G U I D E
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EMPLOYEE INSURANCE COVERAGE GUIDE
Group Mediclaim Policy – Planed Hospitalization
Planned Hospitalization
Group Mediclaim Company Employee Approaches Network Hospital with Hospital Intimates TPA and sends Pre-Authorization
Start Mediclaim Insurance card Request with approximate cost of the treatment
Employee Policy details TPA issues letter of credit (for cashless) with approval for
At the time of Discharge hospital sends the final bill and
partial amount as per Eligibility and Coverage to the
the discharge summary for the final approval to the TPA
Emergency Hospitalization
hospital
Enrollment Procedure
Claims Procedure
TPA send the final approval to hospital which allows the
Exclusions employee to get discharged by paying all non medical
expenses, if any
E M P L O Y E E I N S U R A N C E C O V E R A G E G U I D E
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EMPLOYEE INSURANCE COVERAGE GUIDE
Group Mediclaim Policy – Emergency Hospitalization
Planned Hospitalization
TPA verifies applicability of the
Group Mediclaim hospital in case of emergency by
authorization to the TPA within 24 claim to be registered and issue
Start showing his Mediclaim Insurance
hrs pre-authorization
Card. Treatment starts.
E M P L O Y E E I N S U R A N C E C O V E R A G E G U I D E
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EMPLOYEE INSURANCE COVERAGE GUIDE
Group Mediclaim Policy - Reimbursement
Planned Hospitalization
Group Mediclaim documents to the Company Insurance check for the eligibility and
Start
Helpdesk within 30 days from the admissibility of the claim as per policy
discharge from the hospital terms
Enrollment Procedure
Yes
Claims Procedure
Ms.
Company Insurance Helpdesk will Company Insurance
process the claim and sends the
Yes
Helpdesk will check,
Manjula
Exclusions reimbursement By ECS, along with the (+91 96866
whether all the
settlement letter documents are in order? 53339 )
FAQ’s, Contacts & Links
SINGLE
Mr. Subbu (
POINT OF +91 89769
Reimbursement
No
CONTACT 98001 )
Submits the shortfall documents to OF UIB
Company Insurance Helpdesk within 7 Company Insurance Helpdesk will ask Ms.
working days from the receipt of for the additional/missing documents Sunitha (
intimation +91 97315
19026 )
E M P L O Y E E I N S U R A N C E C O V E R A G E G U I D E
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EMPLOYEE INSURANCE COVERAGE GUIDE
Group Mediclaim Policy - Exclusions
➢ Injury or disease directly or indirectly caused by or arising from or attributable to War, Invasion, Act of Foreign Enemy, Warlike operation
(whether war be declared or not) and by Nuclear Weapons / materials
Group Mediclaim
➢ Cost of Spectacles, Contact Lenses, Hearing Aids, cost of buying any external device
➢ Circumcision unless necessary for treatment of a disease not excluded hereunder or as may be necessitated due to an accident
➢ Cosmetic or aesthetic treatment of any description.
➢ Dental treatment or surgery of any kind unless necessitated by accident and requiring hospitalisation.
Employee Policy details ➢ Treatment of illness or injury arising out of misuse or abuse of drugs / alcohol or use of intoxicating substances.
➢ Bodily Injury due to wilful or deliberate exposure to danger (except in an attempt to save human life), intentional self-inflicted Injury, attempted
suicide
Enrollment Procedure
➢ Treatment of any Injury or Illness sustained whilst or as a result of committing or attempting to commit breach of law with criminal intent
Claims Procedure ➢ Plastic surgery other than as may be necessitated due to an accident or as a part of any illness.
➢ Convalescence, general debility ‘Run-down' condition or test cure, defects or anomalies, venereal disease, intentional self injury and use of
intoxicating drugs / alcohol.
Exclusions
➢ Expense on buying vitamins & tonics unless forming part of treatment & certified by treating Doctor
➢ Charges incurred at Hospital primarily for diagnostic, X Ray or laboratory examinations or any other diagnostic studies not consistent with or
FAQ’s, Contacts & Links incidental to the diagnosis or treatment of the disease, illness or injury for which the claim is payable will not be settled. Only related treatment
charges and diagnostic charges are payable.
➢ Diagnostic charges & treatment cost incurred for cases where no active line of treatment was followed stands excluded from coverage.
➢ Voluntary medical termination of pregnancy during first 12 weeks from the date of conception.
➢ Naturopathy Treatment, acupressure, acupuncture, magnetic therapies, experimental and unproven treatments/therapies. Treatment including
drug experimental therapy which is not based on established medical practice in India, is treatment experimental or unproven.
E M P L O Y E E I N S U R A N C E C O V E R A G E G U I D E
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EMPLOYEE INSURANCE COVERAGE GUIDE
Group Mediclaim Policy - Exclusions
➢ External and or durable Medical / Non-medical equipment of any kind used for diagnosis and/or treatment and/or monitoring and/or
maintenance and/or support including CPAP, CAPD, Infusion pump, Oxygen concentrator etc., Ambulatory devices i.e., walker, crutches, Belts,
Group Mediclaim Collars, Caps, Splints, Slings, Braces, Stockings, elastocrepe bandages, external orthopaedic pads, sub cutaneous insulin pump, Diabetic foot wear,
Glucometer/Thermometer, alpha/water bed and similar related items etc. and also any medical equipment, which are subsequently used at home
➢ Change of treatment from one system of medicine to another unless recommended by the consultant/ hospital under whom the treatment is
taken.
➢ Treatment for Age Related Macular Degeneration (ARMD), treatment such as Rotational Field Quantum Magnetic Resonance (RFQMR), Enhanced
External Counter Pulsation (EECP), etc.
Employee Policy details
➢ All non-medical expenses including convenience items for personal comfort such as charges for telephone, television, ayah, private
nursing/barber or beauty services, diet charges, baby food, cosmetic, tissue paper, diapers, sanitary pads, toiletry items and similar incidental
Enrollment Procedure expenses.
➢ Any kind of Service charges, Surcharges, Admission Fees/Registration Charges, Luxury tax and similar charges levied by the hospital
Claims Procedure ➢ Genetic disorders
➢ Anti-retroviral or any other treatment protocols especially for HIV and AIDS are excluded.
Exclusions Note:
1. Members must ensure that Hospital / Nursing Home where treatment is availed is a registered with local authorities & is under supervision of a
FAQ’s, Contacts & Links qualified Medical Practitioner.
2. All medical/surgical treatments under this policy shall have to be taken in India and admissible claims thereof shall be payable in Indian currency
only.
3. And all other Terms & Condition are remains same has per the NIA standard policy wordings.
E M P L O Y E E I N S U R A N C E C O V E R A G E G U I D E
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EMPLOYEE INSURANCE COVERAGE GUIDE
Group Mediclaim Policy
FAQ’s
•What is the duration of the policy?
One year effective from the date of inception of policy
•Is there a minimum time limit for stay within the hospital under Mediclaim?
Employee Policy details Under Mediclaim, the minimum stay within the hospital must be for a minimum of 24 hours. However for dialysis, chemotherapy,
eye surgery, etc (as per the defined list) – the stay can be for less than 24 hours.
Enrollment Procedure
•Who is a Third Party Administrator (TPA)?
Contacts
TPA is an agency appointed by the insurance company to take care of claim settlements in health insurance.
Claims Procedure
•Who is an Insurance Broker (UIB)?
An Insurance broker is appointed by the Customer or policy holder to handle his insurance requirements as agreed.
Exclusions
•What is a floater policy?
FAQ’s, Contacts & Links A Floater policy is a single policy that takes care of the hospitalization expenses of your entire family who has been declared at the
time of taking the policy. Any member of your family or all put together can claim up to the maximum sum insured.
Links
E M P L O Y E E I N S U R A N C E C O V E R A G E G U I D E
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EMPLOYEE INSURANCE COVERAGE GUIDE
Group Mediclaim Policy
Group Mediclaim
Links
FAQ’s
Policy details Email - info@mediassist.in
➢Call Centre * We would recommend you to reach out to UIB
Enrollment Procedure for any queries / claims
Contacts
Claims Procedure
➢Network Hospital List https://www.medibuddy.in/
Exclusions
E M P L O Y E E I N S U R A N C E C O V E R A G E G U I D E
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EMPLOYEE INSURANCE COVERAGE GUIDE
Group Personal Accident Policy
Policy Summary
Claims Procedure
Exclusions
Policy Details
Policy Holder Course5 Intelligence Limited
Exclusions
Sum Insured & Coverage’s Description Special Condition if any
Benefits Details
E M P L O Y E E I N S U R A N C E C O V E R A G E G U I D E
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EMPLOYEE INSURANCE COVERAGE GUIDE
Group Personal Accident Policy
Policy Details
Death due to Accident Covered (100% of capital Sum Insured)
Permanent Total Disablement Covered (125% of capital Sum Insured)
Permanent Partial Disablement As Per the Schedule
Policy Summary
Terrorism Covered
Geographical Area Worldwide 24 Hours basis
Terrorism clause Waived for all
E M P L O Y E E I N S U R A N C E C O V E R A G E G U I D E
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EMPLOYEE INSURANCE COVERAGE GUIDE
Group Personal Accident Policy
Claims Process
Start who in turn would intimate Insurer and submit On obtaining all relevant documents, Insurer begins
required claims documents within 7 days of the processing the claims
event
Claims Procedure
Exclusions
Claims Documents
Is claim
FAQ’s, Contacts & Links approved
Yes No
On approval, the payment is sent to Beneficiary On rejection of the claim, Insurer would provide a
within 15 working days. valid reason for the rejection to Beneficiary
E M P L O Y E E I N S U R A N C E C O V E R A G E G U I D E
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EMPLOYEE INSURANCE COVERAGE GUIDE
Group Personal Accident Policy
Claims Process
Disablement Disablement
Medical certificate from the treating docotor The documentation will vary
NA ✓ ✓ from case to case basis
specifing the duration of bed rest
FAQ’s, Contacts & Links
Certification letter from the HR specifying the
NA ✓ ✓
duration of loss of wages/pay ( LOP )
Salary Slip for the duration of LOP NA ✓ ✓
Attendance sheet for the duration of LOP NA ✓ ✓
E M P L O Y E E I N S U R A N C E C O V E R A G E G U I D E
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EMPLOYEE INSURANCE COVERAGE GUIDE
Group Personal Accident Policy
➢ Self-injury or suicide, any injury arising under the influence of liquor or drugs, injury arising out of insanity, injury arising when
Group Personal Accident committing breach of law.
➢ HIV (Human Immunodeficiency Virus) and/or any HIV related illness including AIDS (Acquired Immune Deficiency Syndrome)
and/or mutant derivatives or variations thereof however caused.
➢ Whilst engaging in aviation or ballooning, whilst mounting into, dismounting from or traveling in any balloon or aircraft other
than as a passenger (fare paying or otherwise) in any duly licensed standard type of aircraft anywhere in the world.
Policy Summary ➢ Any loss suffered by the member on account of his participation as the driver, co-driver or passenger of a motor vehicle during
motor racing or trial runs.
➢ The Insured’s participation in any naval, military or air force operations whether in the form of military exercises or war games
Claims Procedure
or actual engagement with the enemy, whether foreign or domestic. Service on duty with any armed force
➢ While committing any breach of law with criminal intent
Exclusions
➢ Injuries arising from War, Arrests etc.
FAQ’s, Contacts & Links ➢ Injuries arising from any form of radiation or nuclear weapons.
➢ Death caused by complications in pregnancy
➢ Naturopathy treatment, pranic healing, holistic healing, unani, yogic healing etc.
E M P L O Y E E I N S U R A N C E C O V E R A G E G U I D E
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EMPLOYEE BENEFITS GUIDE
Group Mediclaim Policy – Escalation Matrix
FAQ’s
Description Name Designation Contact No: E-Mail Id
Exclusions
E M P L O Y E E I N S U R A N C E C O V E R A G E G U I D E
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Thank You !!
E M P L O Y E E I N S U R AN C E C O V E R AG E G U I D E