KOCH Benefits Manual Agnity

Benefits Manual 2023
Agnity Communications Pvt Ltd
Prepared By
Aon India Insurance Brokers Pvt. Ltd.
Registered Office - Vaishnavi Silicon Terraces, First Floor, No.30/1
Koramangala 5th Block, Industrial Area, Hosur Main Road
Bengaluru – 560095 Karnataka, India
Composite Insurance Broker, IRDAI License No.624
License Validity - 16/10/2020 to 15/10/2023
Agnity Benefits Manual 2023

Contents
KOCH Group | Agnity
01 02 03
Group Medical Group Personal Accident Benefits Summary
Insurance Plan Insurance Plan
Agnity Benefits Manual 2023 2

This Benefits Manual Includes
KOCH Group | Agnity
01 02 03 04
The current benefits in Key exclusions The limits of each How to claim?
your Insurance plan benefit covered

Know Your Insurance Policies
KOCH Group | Agnity
Group Medical Insurance

covers in-patient hospitalisation and day care expenses incurred by an employee and his insured dependents for a
diagnosed ailment with an active line of treatment. 24 hours of hospitalisation is compulsory to register a valid claim
under the group Mediclaim policy.
Group Personal Accident

insurance policy covers expenses by the insured persons (employee covered) on account of death or
permanent/partial/temporary, total or partial disability due to an accident.

GROUP MEDICAL
INSURANCE
PLAN

GMC
Group Medical Insurance Plan – What’s Covered
KOCH Group | Agnity
Room rent Anaesthesia, blood, oxygen, Nursing expenses, surgeon, Medicines and drugs,
Intensive Care Unit, operation anaesthetist, medical consumables such as
theatre charges and surgical practitioner, consultant & dressing, ordinary splints and
appliance specialist fees plaster casts
Diagnostic procedures (such Costs of prosthetic devices if Organ transplantation Day care procedures e.g.
as laboratory, x-ray, implanted internally during a including the treatment costs dialysis, chemotherapy etc.
diagnostic tests) surgical procedure of the donor but excluding
the costs of the organ

GMC
Group Medical Insurance Plan – What’s Changed In 2023
KOCH Group | Agnity
Other add on Benefits & Advance Procedure
• HIV AIDS – Covered up to 100% of Sum Insured.

• Mental Illness- Mental illness/ psychiatric disorders/ psychological disorders/anxiety, stress covered for all insured members up to the
Sum Insured (BASE+TOP UP) on IPD basis. OPD treatment is covered up to INR 30,000/-
• Disability Cover-Coverage provided for the person with disabilities up to the Sum Insured.

GMC
Group Medical Insurance Plan – Key Information
KOCH Group | Agnity
Voluntary Parental & Top Up Medical Insurance

Policy Period
Your policy is active from 1st October 2023
Cover
INR 1,00,000 to INR 5,00,000 as family floater .
till 30th September 2024, 00:00 hrs.
Age Limit
Insurance company Employee : 18 – 65 years
The insurance company for the
Spouse: 18 – 65 years
group medical policy is Aditya
Birla Health Insurance Co Ltd Children – 0 – 25 years
Parents/Parent-in-Laws – up to 90
years
Third Party Assistance

Medi Assist Insurance TPA will Family Definition
be servicing all claims Employee, Spouse, First 2 Living Children
Sum Insured Limits Type of cover

INR 5,00,000 Floater Sum Insured per family The policy is on a floater basis for your
enrolled family members
**Parents/Parent-in-Laws are covered under voluntary options. It must be opted by an employee with additional premium for availing services of
insurance program.
GMC
Benefits Summary
KOCH Group | Agnity
Pre-Existing diseases Covered Ambulance services Covered
Pre-Post Hospitalisation Covered Day Care procedures Covered
Waiting period Waived off Ayurvedic Treatment Covered
Maternity Covered Dental & Vision OPD Not Covered
Pre-Post Natal expense Covered Room Rent Covered
New-born baby coverage Covered Co-payment Applicable
Benefit descriptions in this benefit manual are to be treated as indicative only.

For a complete list of benefits and exclusions, please also refer to the policy document.

GMC
Benefits Summary
KOCH Group | Agnity
Ailment capping Yes Terrorism Covered
Cyber Knife treatment Covered Domiciliary Hospitalization* Covered

(Refer Slide No. 36 & 37 for detailed note)
Stem Cell Transplantation/

Covered Internal Congenital Covered
Robotic Surgery
Lasik Treatment Covered External Congenital Covered
Advance Procedures covered up to 100% of Sum Insured:

1. Continuous Peritoneal Ambulatory Dialysis (C.A.P.D.)
2. Uterine Artery Embolization and HIFU
3. Deep Brain Stimulation
4. Immunotherapy –Monoclonal Antibody to be given as injection
5. Bronchical Thermoplasty
6. IONM (Intra Operative Neuro Monitoring),
7. Balloon Sinuplasty Covered
8. Oral Chemotherapy
9. Intra Vitreal Injections
10. ARMD Treatment including OPD/IPD/Day-care procedures
11. Stereotactic Radio Surgeries
12. Vaporisation of the Prostrate (Green laser treatment holmium laser treatment)
13. Puberty & menopause disorder
14. Genetic disorder
GMC
Benefits Summary
KOCH Group | Agnity
*Cataract Covered **Organ Donor Covered
Note:
*Cataract: Though no capping for cataract surgery, however, as per standard process the insurer would approve the claim for mono focal
lenses which is commonly used during cataract surgery. If opted for premium category lenses like Multi focal or Toric lenses, insurer
would not approve.
**Organ Donor Expenses: Medical Expenses incurred for an organ donor’s treatment for the harvesting of the organ donated up to the
limit as specified in the Policy Schedule or Certificate of Insurance provided that: (i) The donation conforms to The Transplantation of
Human Organs Act 1994 and the organ is for the use of the Insured Person; (ii) The organ transplant is medically required for the Insured
Person as certified in writing by a Medical Practitioner; (iii) We will not cover: (1) Pre-hospitalization Medical Expenses or Post-
hospitalization Medical Expenses of the organ donor; (2) Screening expenses of the organ donor; (3) Any other Medical Expenses as a
result of the harvesting from the organ donor; (4) Costs directly or indirectly associated with the acquisition of the donor’s organ; (5)
Transplant of any organ/tissue where the transplant is experimental or investigational; (6) Expenses related to organ transportation or
preservation; (7) Any other medical treatment or complication in respect of the donor, consequent to harvesting.

GMC
Maternity Benefit
KOCH Group | Agnity
• Normal Delivery: INR 50,000

• C-Section Delivery: INR 75,000
Maternity
Benefit • Pre-post natal expenses are covered up to INR 10,000 within
maternity limit
Pregnancy is the most
• Newborn baby is covered from day 1
cherish moment of one’s life.
• Well Baby Care Expenses INR 10,000 over and above the maternity limit
Agnity wants to ensure that
you are adequately covered
for this moment.
• Applicable only for the birth of first 2 children
Maternity benefit covers the • Expenses incurred in connection with voluntary medical termination
cost related to the birth of Exclusions of pregnancy during the first 12 weeks from the date of conception
the child are not covered.
• Infertility Treatment are not covered.

GMC
Benefits Explained: Room Rent
KOCH Group | Agnity
• Room rent restricted up to INR 6,000 per day for normal.

Room Rent - (If you are opting for a higher normal room category, then you
Benefit will have to bear the proportionate increase in cost on all
Room Rent means the amount categories/heads)
charged by a Hospital for the • Actuals for ICU.
occupancy of a bed per day
(twenty-four hours) basis and
shall include associated medical
expenses. Sub-limit on room rent
would mean that the insurer Choosing a higher category of room than your entitlement will
Note
defines the maximum amount it incur additional charges which needs to be borne by you
will pay towards the room rent.
Mostly, this limit is defined as a
percentage of sum insured.

GMC
Benefits Explained: Co-pay
KOCH Group | Agnity
Co-Pay
A co pay is the amount of the

claim that is borne by the
employee. For.eg during a Benefit • 10% Co-pay applicable for dependent claims only.
claim process, the admissible
claimed amount is INR
100,000. The policy has a 10%
co pay, INR 10,000 will be
borne by the employee and rest
INR 90,000 will be paid by the
insurance company.

GMC
Advanced Medical Treatments
KOCH Group | Agnity
Stem cell/Robotics transplant therapy
is a procedure in which a patient receives healthy stem cells (blood-forming cells) to replace Benefit
their own stem cells that have been destroyed. The cause for the same could be radiation or Stem cell transplant cost covered
high doses of oral chemotherapy medication etc. Please refer to the policy terms and under policy.
condition for limits and co-pay for this benefit.
Lasik surgery
Benefit
is a form of vision correction surgery. It is a form of refractive surgery for the correction of Lasik surgery covered for +/- 7.5 &
myopia, hyperopia etc. above refractive index correction
Cyber Knife treatment
Benefit
is a radiation therapy used as non-invasive treatment for cancerous tumors anywhere in Cyber Knife Treatment cost
the body. covered with a 50% co-pay

GMC
Voluntary Plans
KOCH Group | Agnity
Voluntary Parental Cover
Colleague to bear a subsidized premium rate for Parents cover.
The portion of the premium to be paid by employees and the same will be deducted from payroll (As per
your internal policy)
Should a colleague opt in and then leave employment during the policy period, the pro-rated premium for
the remaining period will be settled in the Full and Final exit settlement. Subject to no claims.
Colleague can avail tax benefits for Voluntary Parental Cover payments made, under Section 80 (D) of the
Income Tax Act. Please do speak to your HR for better understanding.

GMC
Voluntary Plans
KOCH Group | Agnity
Voluntary Parental Plan Vs

Retail Plan
Sl. No. Point of Difference Corporate Plan Retail Plan
1 Employees can opt for parental policy on voluntary Various sum insured in a retail plan (with many
Sum Insured
basis. (Please refer the premium chart in next slide) restrictions)
2 Pre-Existing Diseases All pre-existing diseases covered No pre-existing disease covered

3 Waiting Period All Waiting Periods Waived Off All waiting periods applicable
4 Points of contact &

Same point of contact and Insurer Different Point of contacts
Insurer
5 Trust of Corporate This will be viewed in the light of strong relationship This will be looked at as a standalone retail
Business between Insurer and KOCH Group. policy.
6 Cover for all age bands Cover for all age bands up-to 90 years. Does not offer cover beyond 70 years of age
7 You will have to coordinate directly with the

Administration Aon India will help at all policy administrative levels.
insurer.
8 Medical Tests No Medicals required Medicals required

GMC
Voluntary Plans
KOCH Group | Agnity
Voluntary Parental Plan premium chart
Parental policy premium

Renewal Policy -ABHI
2023-2024
Single Parent Premium Both Parents Premium

Sum Insured Single Parent Premium exclusive GST Both Parents inclusive GST
inclusive GST exclusive GST
100,000 28,702 33,868 48,884 57,683
200,000 42,132 49,716 61,795 72,918
300,000 46,966 55,420 70,038 82,645
400,000 54,542 64,360 83,413 98,427
500,000 65,300 77,054 93,114 109,875

GMC
Voluntary Plans
Voluntary Top-up plan and Additional children policy
Voluntary Top up Plan Vs

Retail Plan
Sl. No. Point of Difference Retail Plan Voluntary Top Up Plan
1 Various sum insured in a retail plan (with INR 100,000, INR 200,000, INR 300,000,
Sum Insured
restrictions) INR 400,000 and INR 500,000
2 Pre-Existing Diseases No pre-existing disease covered All pre-existing diseases covered

3 Waiting Period All waiting periods applicable All Waiting Periods Waived Off
4 Points of contact & Insurer Different Point of contacts Same point of contact and Insurer
This will be viewed in the light of strong
5 This will be looked at as a standalone retail
Trust of Corporate Business relationship between Insurer and KOCH
policy.
group.
Does not offer cover beyond 70 - 80 years of
6 Cover for all age bands age. Child in certain policy are covered after Cover for all age bands from 0 to 90 years
1 year.
7 You will have to coordinate directly with the Aon India will help at all policy administrative
Administration
insurer. levels.
8 Medical Tests Medicals required No Medicals required

GMC
Voluntary Plans
Voluntary Top-up plan and Additional children policy premium details
• Voluntary Top-up policy coverages : As per GMC Base policy.
• Capped ailments- including maternity, will not fall under top up policy.
• It can be utilized only once the base policy Sum Insured get exhausted.
Top-up policy premium Additional children policy premium per child
Sum Insured Premium Inclusive of GST Sum Insured Premium Inclusive of GST
100,000 3,452 100,000 2,230
200,000 4,660 200,000 2,549
300,000 6,058 300,000 2,867
400,000 7,390 400,000 3,186
500,000 8,720 500,000 3,387

Special Note:
• Add on children policy is strictly for the 3rd and 4th child who are not covered under base policy. Those who opt for the same children as
per base will not be considered for policy.
• Members covered under add on children policy will not be eligible for Top-up.
• Above mentioned are annual premium. For Mid Term Joiner premium will be calculated on prorate basis from date of joining till end of
policy.
• Top-up is a voluntary policy and the premium for same will be deducted from the payroll. For voluntary top-up policy post enrolment, the
premium will be deducted from your next payroll cycle. Once the enrolment is closed there will not be any option to change the
conclusion opted.
GMC
General Terms And Conditions
KOCH Group | Agnity
• The expenses shall be reimbursed provided they are incurred in • Please remember, higher the room category higher is the cost of
India and are within the policy period. treatment. This may result in faster exhaustion of your total
• Expenses will be reimbursed to the insured member depending on available eligibility.
the level of cover that he/she is entitled to. • If you are opting for a higher room category, then you will have to
• Expenses that are incurred for standalone diagnostic or preventive bear the proportionate increase in cost on all categories/heads.
tests without any active line of treatment and do not warrant a • Dental treatment is not covered. However only in case of accident,
hospitalisation admission are not covered under the plan. the mandatory expenses will be payable.
• No Individual should be covered as a dependent of more than one • Vision Treatment which are undertaken for regular maintenance of
employee. eyes are not covered.
• Parents/in Laws cover is voluntary, and the employee needs to pay • Colleague to bear a subsidized premium rate for Parents/Parent-
an additional premium for their coverage. in-law's cover.
• In case an employee has not covered his/her dependents during • The portion of the premium to be paid by employees and the same will
enrolment, they will be able to add them only during the next be deducted from payroll(As per your internal policy)
renewal. • Should a colleague opt in and then leave employment during the
• Mid-Term enrolments are only allowed for life events. For example: policy period, the pro-rated premium for the remaining period will
new-born baby or marriage. These new additions need to be be settled in the Full and Final exit settlement.
intimated within 60 days of event. • Colleagues can avail Tax Benefit for Voluntary Parental Cover
• You are requested to use prudence and proper negotiation with payment, under Section 80 (D) of the Income Tax Act.
Hospital/Nursing home in availing the eligible room category.


GMC
General Exclusions
KOCH Group | Agnity
• War, War like operations (whether war be declared or not) or by • Doctor’s home visit charges, Attendant/Nursing charges during
nuclear weapons/materials pre- and post-hospitalisation period.
• Surgery for correction of eyesight, cost of spectacles, contact • Naturopathy treatment, unproven procedure or treatment,
lenses, hearing aids etc. experimental or alternative medicine.
• Dental treatment is not covered. However only in case of accident, • External and or durable Medical/Non-Medical equipment of any
the mandatory expenses will be payable. kind used for diagnosis.
• Expenses incurred at Hospital or Nursing Home primarily for • Change of treatment from one pathy to another pathy unless being
evaluation/diagnostic purposes which is not followed by active agreed/allowed and recommended by the consultant under whom
treatment for the ailment during the hospitalised period. the treatment is taken.
• Expenses on vitamins and tonics etc. unless forming part of • Treatment of obesity or condition arising therefrom (including
treatment for injury or disease as certified by the attending morbid obesity) and any other weight control program, services or
physician. supplies, etc.
• Miscarriage, abortion or complications of any of these including • Any treatment required arising from Insured’s participation in any
changes in chronic condition as a result of pregnancy except, hazardous activity. Any treatment received in convalescent home,
where covered under the maternity section of benefits. convalescent hospital, health hydro, nature care clinic or similar
establishments.
• Any cosmetic or plastic surgery except for correction of injury.


GMC
Group Medical Insurance Plan
KOCH Group | Agnity
The Hospitalization Procedure
You can avail either cashless facility or submit the claim for reimbursement.
Cashless
Cashless hospitalization means the TPA may authorize (upon an Insured person’s request) for direct settlement of eligible
services and the corresponding charges between a Standard Network/PPN Network Hospital and the TPA. In such case,
the TPA 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 these services are
covered under the Policy. Denial of cashless does not mean that the treatment is not covered by the policy.

GMC
Claims Process – Cashless Claims
KOCH Group | Agnity
Planned Claims Emergency Claims
Approach the hospital minimum 48 hours prior to If possible, check which is the closest network hospital in
hospitalisation, produce TPA card with Govt. Photo Id and the area. Once admitted, initiate treatment and within 24
complete pre-authorisation formalities hours, start the process of pre-authorisation
Fax pre-authorisation letter for approval. If documents are If in order, TPA will issue authorisation letter within 3
in order, TPA will issue authorisation letter within 3 hours. hours. If declined (unlikely in emergencies), a denial letter
will be issued
If the case is declined, a denial letter will be issued to the Post discharge, if you believe the denied claim is payable,
hospital. However, do note that denial of cashless does do submit the claim as a reimbursement for a secondary
not mean denial of claim or denial of treatment review.

GMC
Group Medical Insurance Plan
KOCH Group | Agnity
The Hospitalization Procedure
You can avail either cashless facility or submit the claim for reimbursement.
Reimbursement
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 preauthorisation procedure and intimate the TPA about the claim to ensure eligibility for
reimbursement of hospitalisation expenses from the insurer.
To know about cashless or reimbursement, please visit the desired section mentioned below:
Note:
If member is getting admitted to Network hospital and submits the documents for reimbursement the discount provided by
hospital need to be borne by employee.

GMC
Reimbursement claim documents check list
Reimbursement Hospitalization | Indicative Check List | Medi Assist TPA address
Sl.No. Document Required (All in ORIGINAL)

1 Signed Claim form (KYC form is mandatory for claims above INR 100,000)
2 Main Hospital bills in original (Original Hospital Payment Receipt with serial number, with bill no; signed and stamped by the hospital) & itemized bills.
3 Discharge Card/Summary (original).

4 Attending doctors’ bills and receipts and certificate regarding diagnosis (if separate from hospital bill)
5 Original investigation reports or attested copies of Bills & Receipts for Medicines, Investigations along with Doctors prescription in Original & Laboratory
6 Follow-up advice or letter for line of treatment after discharge from hospital, from Doctor.
7 Break up with details of 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
8
the clock.
In non- network hospitalization, please get the hospital and doctor’s registration number in Hospital letterhead and get the same signed and stamped by the
9
hospital.
10 In case of accidents, please note FIR or MLC (medico legal certificate) is mandatory. Original Death Summary: In case of Death Claims
11 One Personalized Cancelled Cheque with Employee Name printed to settle the claim to Employee Bank account.
TPA Address Note:

(To Send Original Documents for Reimbursement Claims): Reimbursement claim will be processed on soft copy basis, The soft copy of the claim documents must be
Medi Assist Insurance TPA Pvt Ltd submitted on Medi Assist TPA portal. All documents must be attested by the claimant “Claiming with ABHI”
# 58 /1A ,Singasandra village Hosur main road, statement. On case-to-case basis, the Insurer/TPA reserves rights to request original documents
Aishwarya Crystal Layout, Singasandra.
Hobli Bengaluru South Taluk,
Karnataka 560068.
In situation where original claim documents are requested. Please mention Employee ID/Member ID number on the claim documents. When the complete claim
documents are sent to the TPA address, make a note of Air Way Bill/POD Number and date of sending the claim documents for your future reference. Please maintain
scan copy of all documents at your end.
GMC
Key Contacts
Cashless Hospitalization – Network List | Medi Assist Insurance TPA | Aon India | Contact Details
Hospital Network List Link Contact – Toll Free No. TPA Address
Medi Assist India TPA Private Limited

Click on Website – List of Network Hospitals | No. 58/1A,Singhasandra Village,
01206937348-
Cashless Network Hospitals covered by Hosur Main Road,
Koch@mediassist.in
Insurer (mediassist.in) Begur Hobli, Bangalore South Taluk,
Bangalore - 560068
Medi Assist TPA contact details

Level – 1 (First point of
Level contact) Level – 2 (Escalation -1) Level - 3 (Escalation- 2)
Name Mr. Mirza Naseer Hussain Mr. Subramanya SP Ms. Nandini Deekshith
Mobile Number +91 - 6366422989 +91 – 9902652089 +91-9731224244

Email ID mirza.naseer@mediassist.in Subramanya.sp@mediassist.in nandini.yadav@mediassist.in
Aon India contact details
Level Level – 1 (First point of contact)Level – 2 (Escalation -1) Level - 3 (Escalation- 2)

Name Ms. Chitra Ramanathan Mr. Jayanth R Ms. Shilpashree M V
Mobile Number 91 - 636 080 2616 91 – 99011 72828 91 – 99013 42164
Email ID chitra.ramanathan@aon.com jayanth.ravikumar@aon.com shilpashree.m.v@aon.com
Benefits Summary

Benefits Summary
KOCH Group | Agnity
In the event of a hospitalization claim (more than 24 hrs.), the insurance company will pay the insured person the
amount of such expenses as would fall under different heads mentioned below, and as are reasonably and
necessarily incurred thereof by or on behalf of such insured person, but not exceeding the sum insured in
aggregate mentioned in the policy:
Standard • Room Charges,
Hospitalization
• Nursing expenses,
• Surgeon, Anesthetist, Medical Practitioner, Consultant, Specialists Fees,
• Anesthesia, Blood, Oxygen, Operation Theatre Charges Surgical Appliances, Medicines & Drugs, & similar
expenses.
Pre-existing diseases is a condition for which the insured has been diagnosed with or treated for before the policy
Pre-existing commencement date. The most common examples of such conditions are diabetes, hypertension, thyroid etc.
diseases
Your policy covers pre-existing diseases from day 1.
Pre-hospitalization expenses include various charges related to consultation fees, medical tests and medicine cost
before an individual gets hospitalized. Doctors/physicians conduct a slew of tests to accurately diagnose the medical
Pre- condition of a patient before prescribing treatment. However, in most cases, charges incurred by an individual 30 days
Hospitalization prior to his or her hospitalization fall within the ambit of pre-hospitalization expenses. For instance, several tests such
as blood test, urine test and X-ray among others are categorized as pre-hospitalization expenses.
Your policy covers 30 days of pre-hospitalization benefit.

Benefits Summary
KOCH Group | Agnity
Post hospitalization expenses include all expenses or charges incurred by an individual after he or she is discharged
from the hospital. For instance, the consulting physician may prescribe medicine along with certain tests to ascertain
Post- the progress or recovery of a patient. Expenses related to various therapies, namely, acupuncture and naturopathy
hospitalization are not included by insurance providers in the category of post hospitalization expenses. However, diagnostic
charges, consulting fees and medicine costs are covered.
Your policy covers 60 days of post-hospitalization benefit.
A waiting period is the amount of time an insured must wait before some or all their coverage comes into effect.
The insured may not receive benefits for claims filed during the waiting period. In a corporate group policy, waiting
Waiting period period of 30 days , 1 year and 9 months are waived off. However, in a retail policy most of the waiting period continue
to exist.
Your policy has no waiting period.
Maternity benefit covers the cost related to the birth of the child. It includes the delivery charges for both normal and
c-section. Maternity benefit can be availed for the birth of first two children. Maternity benefit will not be applicable in
Maternity case two biological children already exist in the family.
Benefits • Expenses incurred in connection with voluntary medical termination of pregnancy during the first 12 weeks from
the date of conception are not covered.
• Infertility Treatment and sterilization are excluded from the policy.

Benefits Summary
KOCH Group | Agnity
Pre and Post natal expenses are those which are incurred pre delivery and post delivery e.g., Ultrasound, regular
Pre/Post Natal checkups, doctor's consultation fee, medicines and so on.
Your policy covers Pre/Post Natal expenses within the maternity limit up to INR 10,000.
A Newborn baby is covered in the family floater sum insured limits from day 1. However, the birth of the child needs to
Newborn baby
be intimated to the HR team or updated on the benefits portal within 60 days of date of event.
cover
Your policy covers newborn baby cover from day 1.
Ambulance charges include emergency transport of the patient from the residence/place of accident/illness to the
Ambulance
hospital where treatment is undergone.
Services
Your policy covers ambulance charges for INR 2,000 per incidence only during emergency.

Benefits Summary
KOCH Group | Agnity
Due to medical advancement, a list of treatments do not require 24 hours of hospitalization.

Day Care
For example : Cataract operation, kidney stones removal etc.
Services
Your policy covers list of day care procedures as per the Aditya Birla Health Insurance Co list
Ayurvedic is a form of non-allopathic treatment. Under insurance policy ayurvedic treatment undertaken in a
Government Hospital or in any Institute recognized by the Government and/or accredited by Quality Council of
Ayurvedic India/National Accreditation Board on Health is only admissible. The ayurvedic treatment is covered only on
treatment in-patient basis.
Your policy covers ayurvedic treatment up to 25% of sum insured undertaken only in a government registered hospital.
Dental treatment is treatment carried out by a dental practitioner including examinations, fillings (where appropriate),
crowns, extractions and surgery excluding any form of cosmetic surgery/implants. The dental cover is a standard
Dental cover exclusion under the policy except treatment undertaken in case of an accident.
Your policy covers dental treatment only in case of accident. No other form of dental treatment is covered in the policy.

Benefits Summary
KOCH Group | Agnity
Vision cover refers to the maintenance of the health and wellness of the eyes or eye care and includes routine
Vision preventive eye care and prescription of glasses. This remains as a standard exclusion under the medical insurance.
cover
Your policy does not cover vision benefit.
A co pay is the amount of the claim that is borne by the employee. For.eg during a claim process , the admissible
claimed amount is INR 100,000 and the policy has a 10% co pay . The employee will have to bear INR 10,000 and the
Co-pay
insurance company will pay the remaining INR 90,000.
Your policy has a 10% co-pay on all dependent claims.
Ailment capping in form of cost containment method to ensure only reasonable and customary charges are payable
under the insurance policy.
Ailment capping The most common form of ailment capping are cataract, knee replacement surgery, oral chemotherapy etc.
Please refer to your policy terms and conditions to understand the ailment caps under your corporate policy.
No Ailment capping applicable except for Maternity claim.

Benefits Summary
KOCH Group | Agnity
Room Rent means the amount charged by a Hospital for the occupancy of a bed per day (twenty-four hours) basis and
shall include associated medical expenses. Sub-limit on room rent would mean that the insurer defines the maximum
amount it will pay towards the room rent. Mostly, this limit is defined as a percentage of sum insured.
As an example, a 1% (of Sum Insured) per day cap for a normal room in a policy with a sum insured of INR 3 lakh
means that the insurer will only pay INR 3,000 per day towards room rent. In other words, you would be eligible to stay
in a room with a tariff of up to INR 3,000 per day.
If you choose a room with higher tariff, the insurer will not pay, and you will pay the difference. But that’s not all. You
Room don’t only pay the difference in the room rent alone, but the associated difference in cost of doctors’ fees, nursing fees
Rent and surgery costs. This is so because the cost of medical procedures is linked to the room that you choose. So, for the
same line of treatment a person with a twin-sharing room will pay less compared to a person with a single room.
Your policy eligibility is: INR 6,000 per day for normal room category and actuals for ICU/CCU/NICU room category per
day.
Employee, spouse and 2 children:
• Normal room category limit : INR 6,000 per day

• ICU/CCU/NICU room rent limit : Actuals

Benefits Summary
KOCH Group | Agnity
Stem cell transplant therapy is a procedure in which a patient receives healthy stem cells (blood-forming cells) to
replace their own stem cells that have been destroyed. The cause for the same could be radiation or high doses of oral
chemotherapy medication etc. Please refer to the policy terms and condition for limits and co-pay for this benefit.
Your insurance policy covers Stem cell transplant cost.
Robotic surgery are performed by robots. This type of surgery is believed to have delivered precision, flexibility and
control during the process of an invasive surgery as compared to a conventional from of surgery. The cost of such
surgery is costly and hence, the insurance policy covers it with co-pay or sublimit. Please refer to the policy terms and
Advanced conditions for more details.
Medical Your insurance policy covers robotic surgery cost.
Treatment
Lasik surgery is a form of vision correction surgery. It is a form of refractive surgery for the correction of myopia,
hyperopia etc.
Your insurance policy covers Lasik surgery for +/- 7.5 and above refractive index correction.
Cyber Knife treatment is a radiation therapy used as non-invasive treatment for cancerous tumours anywhere
in the body.
Your insurance policy covers cyber knife treatment up to 50% Co-pay.

Benefits Summary
KOCH Group | Agnity
Congenital Disease means anomaly at the time of birth. This I of two types : Internal and External.
Internal Congenital anomaly is a type of birth defect which is invisible in accessible parts of the body. For example:
Atrial septal defect.
Congenital
Ailments External Congenital Anomaly is a type of birth defect which is in the visible and is in accessible parts of the body. For
example: Cleft lip/palate
Your policy covers internal congenital defects and external congenital defects up to six years only in case of life-
threatening conditions.
Domiciliary hospitalisation is a conditions where in the insured is treated as hospitalised even when he is at home
Your policy does cover domiciliary treatments provided the following conditions are met:
Domiciliary Hospitalization means medical treatment for an illness/disease/ injury which in the normal course would
Domiciliary require care and treatment at a hospital but is actually taken while confined at home under any of the following
Hospitalization circumstances:
i) The condition of the patient is such that he/she is not in a condition to be moved to a hospital, or
ii) The patient takes treatment at home on account of non-availability of room in a hospital.
Refer detailed note on Domiciliary Hospitalization in next slide.

Benefits Summary
KOCH Group | Agnity
Insurer will cover Medical Expenses incurred for the Insured Person’s Domiciliary Hospitalization during the Policy
Period following an Illness or Injury that occurs during the Policy Period provided that:
(i) The Domiciliary Hospitalisation continues for at least 3 consecutive days in which case insurer will make payment
under this Benefit in respect of Medical Expenses incurred from the first day of Domiciliary Hospitalisation;
(ii) The treating Medical Practitioner confirms in writing that Domiciliary Hospitalization was medically required and
the Insured Person’s condition was such that the Insured Person could not be transferred to a Hospital or the Insured
Person satisfies insurer that a Hospital bed was unavailable;
If a claim is accepted under this Benefit then, insurer shall not pay any Post-hospitalization Medical Expenses, but
insurer will accept a claim for Pre-hospitalization Medical Expenses subject to the terms and conditions;
(iv) Insurer shall not be liable to pay for any claim in connection with:
Important Notes
(1) Asthma, bronchitis, tonsillitis and upper respiratory tract infection including laryngitis and pharyngitis, cough and
cold, influenza;
(2) Arthritis, gout and rheumatism;
(3) Chronic nephritis and nephritic syndrome;
(4) Diarrhea and all type of dysenteries, including gastroenteritis;
(5) Diabetes mellitus and insipidus;
(6) Epilepsy;
(7) Hypertension;
(8) Pyrexia of unknown origin.

Important Points
KOCH Group | Agnity
• REASONABLE AND CUSTOMARY CHARGES are not payable.
Reasonable charges means the charges for services or supplies, which are the standard charges for the specific
provider and consistent with the prevailing charges in the geographical area for identical or similar services, taking into
account the nature of the Illness / Injury involved.
In India, there is no regulation that places a limit on how much a hospital can charge for a particular service. Hence, a
hospital can charge exuberantly for a treatment. To protect themselves from having to pay unreasonable and
excessive hospital bills, insurance companies have ‘Reasonable and Customary Clause’ in their policies. It is the
amount of money that health insurer determines as the acceptable range of payment for a specific health-related
service or medical procedure.
In case of a planned treatment, it is advised to check the charges of the hospital before getting admitted. Depending
on the type of room member select, the hospital will give an estimate of the charges that will apply. Member can then
Important Notes
compare the charges with similar grade hospitals.
If member feels that hospital is over charging | Negotiate and work it out with the first hospital:
Member can speak to the management and ask for a revision in the estimate. Let them know about the standard
charges for similar hospitals nearby. If they don’t negotiate and member still want to get treated there, he/she will have
to be prepared to pay the balance out of his/her own pocket.
As an alternate option, member can check more reasonable hospital of a similar grade:
After comparing the hospital rates, member will find alternate ones that provide the same treatment at much more
reasonable rates. If member is comfortable with any of the above can opt for it.

Important Points
KOCH Group | Agnity
• Member admitted in Delisted/Excluded hospital are not payable.
Please check the below link for ABHI Delisted hospital list:
https://www.adityabirlacapital.com/healthinsurance/assets/BlacklistHospitals.pdf
Expenses incurred towards treatment in any hospital or by any medical practitioner or any other provider specifically excluded
by the Insurer and disclosed on its website/notified to the policyholders are not admissible. However, in case of life-
threatening situations or following an accident, expenses up to the stage of stabilization are payable but not the complete
claim.
• Hospitalisation for evaluation/ diagnostic purpose are not Payable.

Investigation charges/expense that is not related to the ailment for which you are getting admitted may not be paid by
Important Notes the insurer.
• Room Rent | Proportionate clause or proportionate deduction.
If the opted room rent is higher than the eligibility, apart from the medicine charges rest all expenses will be deducted
as per the proportion deduction.
• OPD Treatment vs Day Care Treatment Hospitalization:
The main difference between OPD and Day Care treatment is hospital admission. While day care procedures require a
few hours of hospitalisation, OPD does not require any hospitalisation. ABHI - your insurer cover day care treatments
and OPD is not covered under policy.

GROUP PERSONAL
ACCIDENT INSURANCE
PLAN

GPA
Group Personal Accident Insurance Plan
KOCH Group | Agnity
Plan Details
Policy Period Insurance Company Basis of Sum Insured Members Covered

1st October 2023 to Aditya Birla Health 3 times of multiple of Employee
Annual Base Salary with
30th September 2024 Insurance Co Ltd
minimum of INR 1,000,000.
midnight

GPA
KOCH Group | Agnity
1 2 3
Accidental Permanent Disablement Accidental Temporary Total Accidental Permanent Partial
means disablement caused due to Disablement means disablement Disablement is a doctor certified
an accident which entirely prevents caused due to an accident which total and continuous loss or
an insured person from attending to temporarily and totally prevents the impairment of a body part or
any business or occupation of any Insured Person from attending to sensory organ caused due to an
and every kind and which lasts 12 the duties of his usual business or accident , to the extent specified in
months and at the expiry of that occupation and shall be payable the chart provided by the insurer.
period is beyond hope of during such disablement from the
improvement. date on which the Insured person
first became disabled.

GPA
KOCH Group | Agnity
Plan Benefits
Permanent Total Permanent Partial

Accidental Death
Disability Disability
100% of 100% of Covered up to a specified

Sum Insured Sum Insured percentage of the full sum
insured limit.

GPA
KOCH Group | Agnity
Plan Benefits
Temporary Total Medical

Disablement Expenses
Accident Only: (Weekly Benefit) 1% of the Accident Only: The max amount payable shall
sum insured limit or INR 15,000 per week be 40% of the valid personal Accident claim
whichever is lesser for a maximum of 104 amount or 20% of the relevant sum insured or
weeks. actual claims whichever is less subject to
maximum of INR 500,000/-

GPA
KOCH Group | Agnity
Plan Benefits
Dependent Child Carriage of Dead Cremation Charges

Education Fund Body
INR 10,000/- for a child Covered up to

maximum for 2 children INR 5,000

GPA
KOCH Group | Agnity
Key Terms
Temporary Total
Disablement means
Permanent disablement which
Disablement means temporarily and
Permanent
disablement which entirely prevents an
Disablement
permanently and Insured Person from
entirely prevents an engaging in or giving
Insured Person from attention to the
engaging in or giving Insured Person’s usual
attention to the Insured occupation.
Person’s usual Temporary Total
occupation resulting in Disablement
losing of his/her
earning capacity.

GPA
KOCH Group | Agnity
Key Terms
If during the Period of

If, during the Period of Insurance an Insured Person
Insurance, an Insured sustains Bodily Injury which
Person sustains Bodily Emergency directly and independently
Injury, then the Company will Medical Expenses of all other causes results in
reimburse the Insured – Accident Only death within twelve (12)
Person the necessary Usual months of the Date of Loss,
and Reasonable Medical then the Company agrees to
Expenses, incurred within pay the education fees for
twelve (12) months from the the Insured Person’s
Dependent
Date of Loss up to the Sum surviving Dependent Child
Child Education
Insured stated in the up to the amount stated in
Benefit
Schedule, subject to the the Schedule per year up to
Terms and Conditions of this the number of years stated
Policy. The Deductible or in the Schedule
Franchise, if applicable, shall
be deducted from the
Compensation payable.
GPA
KOCH Group | Agnity
General Exclusions
• Suicide, attempted suicide (whether sane or insane) or • Operating or learning to operate any aircraft or performing duties
intentionally self-inflicted Injury or illness, or sexually transmitted as a member of the crew on any aircraft; or Scheduled Aircraft.; or
conditions, mental or nervous disorder, anxiety, stress or • Self exposure to needless peril (except towards saving human life)
depression, Acquired Immune Deficiency Syndrome (AIDS), Human • Loss due to childbirth or pregnancy.
Immune-deficiency Virus (HIV) infection; or • Bodily Injury or Sickness occasioned by Civil War or Foreign War
• Being under the influence of drugs, alcohol, or other intoxicants or
hallucinogens unless properly prescribed by a Physician and taken
as prescribed; or
• Participation in an actual or attempted felony, riot, crime,
misdemeanor, (excluding traffic violations) or civil commotion; or

GPA
Claims Process – GPA
KOCH Group | Agnity
Making A Claim
Employee/Beneficiary notifies HR, who in turn would

intimate Insurer and submit required claims documents On approval, the cheque is
within 14 days of the event sent to the HR or NEFT details shared
with HR, from where the information is
Yes shared to the Employee/Beneficiary
On obtaining all relevant documents, Insurer begins

processing the claims
Is claim
approved?
Claim Investigation and Review post submission of all the On obtaining all relevant documents,
required documents Insurer begins processing the claims
No

Thank You

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Benefits Manual 2023

Agnity Communications Pvt Ltd

Agnity Benefits Manual 2023

Agnity Benefits Manual 2023 2

Agnity Benefits Manual 2023 3

Group Medical Insurance

Group Personal Accident

Agnity Benefits Manual 2023 4

Agnity Benefits Manual 2023 5

Agnity Benefits Manual 2023 6

Other add on Benefits & Advance Procedure

• HIV AIDS – Covered up to 100% of Sum Insured.

Agnity Benefits Manual 2023 7

Voluntary Parental & Top Up Medical Insurance

Third Party Assistance

Sum Insured Limits Type of cover

Pre-Existing diseases Covered Ambulance services Covered

Pre-Post Hospitalisation Covered Day Care procedures Covered

Waiting period Waived off Ayurvedic Treatment Covered

Maternity Covered Dental & Vision OPD Not Covered

Pre-Post Natal expense Covered Room Rent Covered

New-born baby coverage Covered Co-payment Applicable

Benefit descriptions in this benefit manual are to be treated as indicative only.

Agnity Benefits Manual 2023 9

Ailment capping Yes Terrorism Covered

Cyber Knife treatment Covered Domiciliary Hospitalization* Covered

Stem Cell Transplantation/

Lasik Treatment Covered External Congenital Covered

Advance Procedures covered up to 100% of Sum Insured:

*Cataract Covered **Organ Donor Covered

Agnity Benefits Manual 2023 11

• Normal Delivery: INR 50,000

Agnity Benefits Manual 2023 12

• Room rent restricted up to INR 6,000 per day for normal.

Agnity Benefits Manual 2023 13

A co pay is the amount of the

Agnity Benefits Manual 2023 14

Stem cell/Robotics transplant therapy

Cyber Knife treatment

Agnity Benefits Manual 2023 15

Voluntary Parental Cover

Colleague to bear a subsidized premium rate for Parents cover.

Agnity Benefits Manual 2023 16

Voluntary Parental Plan Vs

2 Pre-Existing Diseases All pre-existing diseases covered No pre-existing disease covered

4 Points of contact &

7 You will have to coordinate directly with the

Agnity Benefits Manual 2023 17

Voluntary Parental Plan premium chart

Parental policy premium

Single Parent Premium Both Parents Premium

100,000 28,702 33,868 48,884 57,683

200,000 42,132 49,716 61,795 72,918

300,000 46,966 55,420 70,038 82,645

400,000 54,542 64,360 83,413 98,427

500,000 65,300 77,054 93,114 109,875

Agnity Benefits Manual 2023 18

Voluntary Top up Plan Vs

Sl. No. Point of Difference Retail Plan Voluntary Top Up Plan

2 Pre-Existing Diseases No pre-existing disease covered All pre-existing diseases covered

Agnity Benefits Manual 2023 19

Top-up policy premium Additional children policy premium per child

100,000 3,452 100,000 2,230

200,000 4,660 200,000 2,549