 Zone opted : I (Mumbai)

 It is hereby declared and agreed at the request of the insured to extend additional benefit of Domi
hospitalisation ie the Home Healthcare Package(HHP),INR 15,000/- per insured to TCS Families
for covid positive cases only, where the hospital may deny admission due to unavailability of bed.
This additional cover is being offered at an additional premium of 25Lakhs + GST with a policy
aggregate not exceeding 2crore, valid upto 31st March 21 These claims will be debited to
Corporate Buffer of 2020-21 HIS policy and for every such claim, the family SI shall stand
reduced by such amount. Whether these settlements will be on cashless or reimbursement, will
depend upon the Hospital / TPA tie -up, as this is not part of PPN arrangement ( as per end no
83000477 Effective Date 19 August 2020 )
 There is a coverage for claims under home healthcare package up to Rs.15000/- per insured
covered under the policy. This coverage is only for members who are COVID positive & has been
advised by hospital for home isolation and chosen health care package from specified hospital.
Any regular consultation and investigation done independently ( Not as package from any
provider) during Home quarantine will be considered under OPD benefits ( Condition added as
per mail from Vasu sir dtd:7-9-20 )
 It is hereby declared and agreed at the request of the insured to extend additional benefit of Domi
hospitalisation ie the Home Healthcare Package(HHP),INR 15,000/- per insured to TCS Families
for covid positive cases only, where the hospital may deny admission due to unavailability of bed.
This additional cover is being offered at an additional premium of 25Lakhs + GST with a policy
aggregate not exceeding 2crore, valid upto 31st March 21 These claims will be debited to
Corporate Buffer of 2020-21 HIS policy and for every such claim, the family SI shall stand
reduced by such amount. Whether these settlements will be on cashless or reimbursement, will
depend upon the Hospital / TPA tie -up, as this is not part of PPN arrangement ( as per end no
83000477 Effective Date 19 August 2020 )
 speicific package will be applied as per the MOU with the hospital for specific surgeries-
Additional amount should be not payable in case hospital is insisting for over and above the
package - Ref the approval letter for remarks.
 Experimental and unproven treatments are not admissible under the policy. Any advance
treatements and Robotic surgeries will be restricted to conventional methods of surgeries.
 "Domi – Exclusions a. Vaccinations b. Baby vaccinations c. Health check up for visa d. Treatment
related to menopause, general debility e. Beauty treatment, skin , hair , cosmetic treatments,
alopecia, pimples, weight gain, dry skin, skin tags, warts – etc are not payable f. Congenital
illness g. External aids ( instruments ) nebulizer, walking stick etc h. Maternity treatment i.
Diagnostic procedures j. Allopathic treatment done by AYUSH doctors k. Naturopathy,
acupuncture, pancha karma , herbal treatments and patanjali treatments.
 Lasik is covered in cases where refractive error is greater than or equal to +7/-7, Patient diet
charges are covered. Robotic surgeries are payable Upto 50% of Sum Insured. To get more
information on specific conditions / Ailment write to corporate.his@tcs.com along with available
medical documents.
 Any long term and medicine purchased for more than 7 days then supportive investigation reports
are mandatory and doctor opinion will be final on admissibility of the claims.
 Abnormal quantity of medicines, serious infections , medicine purchased over & above the
standard dosage will be reviewed by the doctors team and will be compared with standard
treatment protocols.
 Dental coverage with valid consultations and supportive investigation reports excludes - crown,
polishing, scaling and cosmetic treatments
 Domi policy covers all Normal ailments including vitiligo and Infertility
 Domi coverage only in India , all original Doctor prescription with registration number, pharmacy
bills with GST/ DL number and supportive investigation reports are must to consider the claim
 Home healthcare (home care) :-Rs.15000/- per insured for COVID19 positive cases only where
hospital denies admission due to unavailability of beds (home care claims for COVID19 covered).
 Children should be covered within 90 days from DOB and Children max age restricted to 25 year.
Married children are not covered.
 Air Ambulance :-1 lakh per event 20 lakh (aggregate) financial year
 Ambulance:- 2500/- per family / year in case patient shifted from home to ICU or from hospital to
hospital
 Enrollment :- Employee enrollment done by TCS only - HR to contacted for any clarification (
employee covered since day one and other dependents should be added with in 90 days )
 Morbid Obesity treatment :- covered only for employee If BMI > 40 or > 35 with multiple
complications. Admission only for investigations like MRI, CT , bone scan etc and inpatient
treatment with IV fluids and oral medications during stay are not admissible under the policy even
hospitilsiation is noted. OPD treatements are covered only under domi
 Ultimatix -> Learning & Collaboration-> Know max -> My HR -> India -> Health, Safety &
Wellness -> Health & Insurance -> TCS India Policy - Health Insurance.
 Documents need to be submitted within 90 days from the date of discharge. This is including Pre-
Post hospitalization claim. If 90 days have been crossed then please get in touch with
corporate.his@tcs.com with specific reasons for late submission. Note: For Domiciliary claims -
Documents need to be submitted within 90 days from the treatment date.
 after online submission of RI and Domi claims employee has to submit the original documents at
Help desk for further processing of claims.
 Dental treatments are admissible only if treatment taken as an inpatient for RTA and other
treatment like dental cyst, impacted tooth etc are not covered.
 LWP, trauma care and critical care are payable – based on HR data ( the amount payable per
week 66% or max 40000/-). Health check up – age 40+ and senior employees are eligible and
further TCS has discretion to enable to any employees - employee can buy the health check ups.
 AIDS is covered
 Infertility treatment taken as inpatient for IVF/ other surgeries covered upto 2 Lakh over and
above maternity coverage - for employee and spouse ( supportive investigation reports etc are
must)
 If employee not covered under OMP – claim can be considered upto Base Sum insured for
Employee, spouse and children – only on official work
 Treatment outside India – If employee covered under OMP ( overseas mediclaim policy) then
claim should be availed first from OMP and balance can be claimed under HIS, Max payable will
be BASIC SUM INSURED ( Non floater)
 Both employees are working in same company ( TCS) – Double coverage will not be provided as
per the policy
 Cancer care :- convetional chemotherapy, surgery, radiotherpay payable upto eligible full Sum
insured and other supportive non chemo treatments like -ORAL chemo/ TARGETED therapies/
BIOLOGICAL therpaies etc are payable upto basic sum insured ( Non floater Sum insured )(till
base sum insured aggregate per family) & for ESIC grade 1lac limit
 Parents / In-laws coverage :- PED and waiting period - 1 year ( is applicable if parents/ inlaws is
covered less than 12 months in system (ref beneficiary remarks indicating PED covered or not for
each parent and not applicable for newly joined employees who added parents in system )
 Pre / post :- 30 days and 60 days for employees , spouse and children and in case of parents and
inlaws - pre / post is covered for only 30 days from DOA and DOD . Pre post natal limit 30-30
days
 Ectopic pregnancy admissible under Normal Sum insured ( investigation reports are must)
 Any complication of maternity which is Life threatening then covered upto full SI ( Pre -
eclampsia,eclampsia and post LSCS complications etc) which is life-threatening to mother
 In case of maternity related hospitalization for treatment like cervical encirclage, Gestational
hypertension, diabetes, infections, /chromosomal anomalies screening amniotic fluid complication
etc will be restricted to maternity limit ( If first hospitalization claim is paid for 20000 and
subsequently patient admitted for normal delivery then all maternity related to charges will be
restricted to 75000/- ie 20000 ( previous admission)+ 55000 ( normal delivery) and similar to
LSCS - max to 100000/-
 Normal deliveries up to Rs. 75,000 & C-Section up to Rs 1 lakh
 Covered – delivery only for first three children / surgeries
 AYUSH – 25 % of basic SI limit– claim is admissible only in govt, institute accrediated by Govt,
accreted by QCI, NABH etc
 Modern treatment methods & advancement in technologis :-(1)Uterine Artery Embolization and
HIFU (High intensity focused ultrasound)-Upto 20% of Sum Insured subject to a Maximum upto
Rs. 4 Lakh. (2).Balloon Sinuplasty-Upto 20% of Sum Insured subject to a Maximum upto Rs. 4
Lakh.(3)Deep Brain stimulation Upto 50% of Sum Insured subject to a maximum upto Rs. 10
Lakh (4)Immunotherapy- Monoclonal Antibody to be given as injection upto 25% of Sum Insured
subject to a Maximum of Rs 4 Lakh.(5)Robotic surgeries Upto 50% of Sum Insured subject to
Maximum of Rs. 10 Lakh (6)Stereotactic radio surgeries Upto 50% of Sum Insured subject to
Maximum Rs. 6 Lakh (7) Bronchial Thermoplasty Upto 50% of Sum Insured )subject to Maximum
of Rs. 5 Lakh (8) IONM - (Intra Operative Neuro Monitoring)Upto 10% of Sum Insured subject to
Maximum of Rs.1 Lakh (9) Intra-vitreal injection upto 10% SI subject to maximum of Rs.1.5 Lakh/-
.
 Age Related Macular Degeneration covered upto 10% of Sum Insured, maximum upto Rs.
75,000 per policy period.Only for intravitreal injections & anti-VEGF medication
 Transurethral electro-vaporization of prostate/ Green laser or holmium laser treatment covered
upto 50% of Sum Insured subject to Maximum of Rs. 5 Lakh.
 Puberty and Menopause related Disorders covered upto 25% of Sum Insured per policy period.
 Genetic diseases or disorders are covered with a sub-limit. 25% of Sum Insured per policy- only
hospitalization
 DIVYAANG benefit for children with disabilities. Rs.10,000/- per child per annum (expenses
include physio, training, counselling, equipment, medicines etc)
 Multiple sclerosis – OPD/ IPD - Max 2.5 Lks for employees only
 Stem cell therapy:Haematopoietic stem cell for bone marrow transplant for haematological
conditions to be covered upto 50% of SI subject to maximum Rs.5 Lakh
 For retired employees – eligible room rent is – Single AC room. Retire employee can choose to
continue in the same grade.
 Only for employees.Sex reassignment surgeries are capped at Rs.5 lacs. Hormone replacemnet
therapy ,psychiatry visits, counselling for gender realignment included only under OPD cover.
 Obstructive Sleep Apnea 50% payable- Only for Employees
 Psychiatric treatment covered for all – Limited to 2 lakh per family
 Cochlear implant covered upto 50% of actual expenses or 50% of total SI ( F+NF) – whichever is
less
 Hysterectomy arises due to maternity complication is payable upto SI ( maternity related
complication only)
 Hysterectomy – capped to 100000/- ( including pre/ post and with or without salpingo
oophorectomy)
 Any joint replacement – single joint 2.5 lakhs and Both joints 4 Lakhs ( knee joint, Hip joints etc )
including pre / post and complications
 Cataract is capped for 40000/- per eye ( including pre and post claims) - No capping for platinum
plus grade
 Cashless & RI:10% copay in case of no prior intimation at least 72 hours before admission for
planned admission (like cataract, planned surgeries).
 10% deduction for Non intimation of claims from Non network hospitals
 10% of deduction on Reimbursement claims from Network hospital
 In case eligible room was not available during emergency admission then employee can opt just
above the eligible room with proper confirmation from hospital
 For retired employees – eligible room rent is – Single AC room. Retire employee can choose to
continue in the same grade.
 PLATINUM PLUS (VIP) - SINGLE A/C ROOM FOR ALL BENEFICIRIS AND NO AILMENT
CAPPING, NON MEDICAL ITEMS ARE PAYABLE
 ICU No capping
 Room rent eligibility :Employees insured under the Gold Plan are eligible for twin sharing AC
rooms and those insured under Gold Plus, Platinum and Platinum Plus are eligible for single
occupancy AC rooms. Parents/parents-in-laws are eligible for twin sharing AC rooms for Gold ,
Gold plus plans. Parents/parents-in-laws are eligible for single occupancy AC rooms in Platinum
 and Platinum Plus. In case employee chooses a room ( Room + Nursing) which is higher than
his/ her eligibility, the additional charges of room and other related hospital charges (
investigations, consultation, Surgery charges etc) will have to be borne by an employee. Note:
ESIC/Silver Plan- Eligible for Twin sharing AC Room.
 Breach Candy Hospital Trust – Mumbai – cashless facility is not available for TCS employees for
all grade except platinum plus