Employee Health Insurance FY20

Health Insurance Policy

The Group Health Insurance Program provides pre-defined insurance coverage to all employees & their family members for expenses related
to hospitalization due to illness, disease or injury.
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:
1) Room Charges, 2) Nursing expenses, 3) Surgeon, Anesthetist, Medical Practitioner, Consultant, Specialists Fees, 4) Anesthesia, Blood, Oxygen,
Operation Theatre Charges Surgical Appliances, Medicines & Drugs, & similar expenses.

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Star Health & In-house TPA Prudent Insurance
Allied Insurance (Star Health) Broker Private
Company Limited

Policy period: 1st April 2019 – 31st March 2020

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Policy Features- Segregation of policies for FY’19-20
The Base Policy is segregated into “Primary” & “Secondary” Policy. (details shared on the next slide).
•The Secondary policy covers the remaining set of parents or parents in law.
•The Top Up facility will be applicable for family members covered under the primary policy .

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Coverage Details

Primary Policy : Family Definition : Employee + Spouse + 2 kids (3rd and 4th child can be
included at an additional premium) Children upto the age of 25 years only will be covered
1 Parent /parent-in-laws (only one set of parents are covered in the primary policy. Cross selection of
parents i.e. choosing ‘father in law’ & ‘mother’ is not allowed) The lock in period
for both existing and
Details of sum insured (as per management level/local business card title) has been mentioned in
new enrolment of
next slide parents/parents in
law (for both

2 Secondary policy : Family Definition : It provides the employee with an option to cover the
remaining set of parents (those who are not covered under primary policy) under a separate
policy.  There is a flat cover provided for the parents/parents-in-law enrolled in the secondary
Primary policy and
secondary policy),
will continue till 31
policy. The flat sum insured options provided are INR 2 lakhs, INR 3 lakhs, INR 5 lakhs or INR March 2020. There
10* lakhs at an additional premium. will be a nominal co-
pay of 5%

3 Top Up : The top up will only be applicable on the family members covered in primary policy.
The employee has the flexibility of increasing his/her total sum insured (for the family members
applicable in case of
claim settlement
related to parents or
covered in the primary policy) by availing Top Up facility with the flexibility to choose from additional parents in law .
slab of INR 2 lakhs, INR 3 lakhs, INR 5 lakhs, INR 10 lakhs, INR 15* lakhs or INR 20* lakhs at an
additional premium.

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*Applicable only for employees with local business card title -Senior Director & above
Coverage Details
Sum Insured applicable on self and family members covered in the Primary policy

Management Level Local Business Card Title Sum Insured (INR)

Partner Partner / COO

Managing Director Executive Director / CFO / CPO / CCO / CIO / CISO / GC 1,500,000

Senior Director
Director
Director
Senior Manager Associate Director 500,000
Manager Manager / Principal Consultant
Senior Associate* Assistant Manager / Senior Consultant
Associate / Experienced Associate / Consultant / Associate
Associate
Manager 300,000
Specialist Trainee (P) / Analyst / Senior Analyst
Administrative Executive Assistant / Secretary/Administrative
Intern/Trainee Articled Trainee# 150,000

* Senior Associates in Strategy& with current sum insured coverage (primary policy) of INR 5 lacs will continue to have the sum insured value as INR 5 lacs
#Applicable for Self coverage only

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Premium Chart
Premium per parent*

Primary Policy Coverage of

INR 300,000 INR 500,000 INR 1,500,000
Employee#

Employee Share Employer Share Employee Share Employer Share Employee Share Employer Share
Premium Share (%)
(50%) (50%) (70%) (30%) (80%) (20%)

Premium including GST INR 5,464.5 INR 5,464.5 INR 9,563.4 INR 4,098.6 INR 14,380 INR 3,595

Premium per Parent in law*

Primary Policy Coverage of

INR 300,000 INR 500,000 INR 1,500,000
Employee#

Premium Share (%) Employee Share (100%) Employee Share (100%) Employee Share (100%)

Premium including GST INR 10,929 INR 13,662 INR 17,975

Note:
• Above Premium will be pro rated for New Joiners. The enrollment is available only at the inception of the Programme and No mid term
inclusions will be entertained.
• The Premium paid by employee for Parents cover and top up would be eligible for Tax rebate under Section 80 D
• Premium paid for Parents In Laws is not eligible for any Tax Rebate
• The top up will only be applicable for the family members covered in the primary policy
• There is 3 years lock in period for covering parents/parent in laws as explained in Slide 4. The lock in period clause ceases to exist in case of
demise of the said family members or in case the employee exits from the organization
• There will be a co-pay of 5% applicable for claims related to parents/parents in law hospitalization claims

PwC *Deductions will happen in four equal installments through payroll in four consecutive months 6
#For Local Business Tile- ‘Articled Trainees’ only self-coverage is allowed
Premium Chart (contd)
Premium for 3rd and 4th child (The premium share is per child)*

Primary Policy Coverage

INR 300,000 INR 500,000 INR 1,500,000
of Employee#

Premium Share (%) Employee Share (100%) Employee Share (100%) Employee Share (100%)

Premium including GST INR 532 INR 818 INR 2,272

Top Up rates (Applicable to family members covered in primary policy)*

Top Up Sum Insured INR 200,000 INR 300,000 INR 500,000 INR 1,000,000 INR 1,500,000** INR 2,000,000**

Employee Share Employee Share Employee Share Employee Share Employee Share Employee Share
Premium Share
(100%) (100%) (100%) (100%) (100%) (100%)

Premium including GST INR 4,478.2 INR 6,717.3 INR 11,185.3 INR 22,373 INR 33,556 INR 45,111

Secondary Policy (The premium share is for a set of Parents/Parents in law)*

Sum Insured INR 200,000 INR 300,000 INR 500,000 INR 1,000,000**

Employee Share Employee Share Employee Share

Premium Share Employee Share (100%)
(100%) (100%) (100%)

Premium including GST INR 8,248 INR 12,372.5 INR 20,619 INR 41,249.2

*Deductions will happen in four equal installments through payroll in four consecutive months
**Applicable only for employees having primary coverage of INR 1,500,000
#For Local Business Tile- ‘Articled Trainees’ only self-coverage is allowed

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 Policy Benefits
 Pre-existing diseases are covered from day 1 - (Pre-existing diseases refers to condition or ailments that may have been contracted before the start of
the policy. There is usually a waiting period of 4 years for covering such ailments.)

 30 Day Waiting Period waived off for new joiners- Any hospitalization expenses during the first 30 days from the commencement date of the Policy
is not covered for the new joiners. This exclusion is however, not applicable in this policy.
 Room rent capping-
• There is no room rent capping for ICU/ICCU/ITU.
• For normal room
• Below Director level - Capped at 1.5% per day of base sum insured ( in case of higher room occupancy , proportionate deduction is
applicable)
• Director & above level - Standard single AC (non sharing) room (in case of higher room occupancy , proportionate deduction is
applicable)

 Pre & Post Hospitalization Expenses - Pre 30 days & Post 60 days covered. 120 days of post hospitalization in case of accidental claims only

 Maternity Benefits- Benefit covered for the first two children

• Capped at INR 70,000 for normal and  INR 90,000 for C-Section deliveries
• Pre and post-natal expenses covered up to INR 10,000 within the maternity limit
• New born baby expenses covered up to INR 5,000 within the maternity limit
• No waiting period applicable
• Baby Day 1 cover
• 9 months waiting period is waived off for the new joiners
PwC • Extra uterine pregnancy is covered up to family floater sum insured 8
Policy Benefits (contd)
 Ailment capping* - Cap on Cataract surgery - INR 30,000 per eye
Appendicitis / Hernia / Prostate / Hysterectomy / Gall bladder / Tonsillectomy/ Dental surgery / Removal of Kidney Stone: 25% of Applicable Sum Insured ;
(Taking top up does not increase any limits on capped  diseases, maternity  cover, room rent  & any rates in relation to base sum insured)
 Domiciliary Hospitalisation- Not covered
 Ambulance Charges - Covered up to INR 5,000/- in case of only Medical Emergency
 Terrorism - Hospitalization due to terrorism is covered
 Day Care Procedures – Day Care procedures are covered as per the policy terms conditions.
 Other coverage (up to family floater sum insured):
• Oral Chemotherapy ( cover only in network hospital, under cashless facility)
• Stem Cell therapy
• Cyberknife treatment
• Lasik Surgery (for correction of refractive error of +/- 7.5)
• Septoplasty (for non cosmetic cases only)
• Life threatening external congenital disease for new born babies

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*This limit is not applicable in cancer related treatment of these organs and if there is a comorbid complication.
 Policy Exclusions
 Injury/ Disease directly or indirectly caused by or arising from or attributable to War, Invasion, Act of Foreign Enemy, Warlike operations (whether
war be declared or not)

 Circumcision, vaccination or inoculation or change of life or cosmic or aesthetic treatment of any description, plastic surgery other than as may be
necessitated due to an accident or as a part of any illness

 Cost of spectacles and contact lens, hearing aids, walkers, crutches wheel chairs and such other aids

 Dental treatment or surgery of any kind unless necessitated due to accidental injuries and requiring hospitalization

 Convalescence, general debility, Run-down condition or rest cure, congenital external disease or defects or anomalies, sterility, venereal disease,
intentional self injury and use of intoxicating drugs/alcohol

 All expenses arising out of any condition directly or indirectly caused due to or associated with human Tcell Lymph tropic Virus type III (HTLV-III) or
Lymphadinopathy Associated Virus (LAV) or the Mutants Derivative or Variations Deficiency Syndrome or any Syndrome or condition of a similar kind
commonly referred to as AIDS.

 Charges incurred at Hospital or Nursing Home primarily for Diagnostic, X-ray or laboratory Examinations not consistent with or incidental to the
diagnosis and treatment of the positive existence or presence of any ailment, sickness or injury, for which confinement is required at hospital / nursing
home.

 Expenses on vitamins and tonics forming part of treatment for injury or disease as certified by the attending Physician.

 If the Insured occupies a room with a room rent limit other than his/her eligibility as per the insurance policy, then all the other charges shall be
limited to the charges applicable for the eligible room rent or actuals, whichever is lower

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 Policy Exclusions (contd)

 Injury or Disease directly or indirectly caused by or contributed to by nuclear weapons/ materials

 Naturopathy Treatment

 Hospital registration charges, record charges, telephone charges and such other similar charges.

 Expenses incurred on weight control services including surgical procedures for treatment of obesity, medical treatment for weight control/loss
programs

Note: The above list is an illustrative list of exclusions and not an exhaustive list of exclusions.

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 Points to Remember

 In case of reimbursement claim, claim should be intimated on pwcclaims@prudentbrokers.com within 24 hours from date of
admission
 Reimbursement claim documents should be submitted within 15 days from date of discharge.
 In case of cashless claim, pre-authorization request to be sent to TPA within 24 hours from the date of admission.
 During cashless hospitalization, please carry photo id proof (issued by Govt. of India) , PwC ID card, print out of e-card of employee &
patient.
 Once you get the e card, please check you should get e-cards of all declared members and also check their Name, Gender and Age. In
case of any discrepancy, please write to Prudent SPOC on to : utsab.mitra@prudentbrokers.com ; cc-
pwc@prudentbrokers.com
 In terms of new born baby and newly married, please inform HC team through email to gobind.singh@pwc.com/
anwar.hussain@pwc.com within 45 days from the event date.
 In case of any insurance claim, first the coverage under “Primary Policy” is utilized. The “Top Up” policy gets triggered only once the
coverage under the “Primary Policy” is exhausted. Hence any insurance claim first needs to be registered under primary policy.
 In order to smoothen the discharge process from the hospital (where the length of stay in the hospital is more than 2 days), employee
should get the interim bill from the hospital and reach out to Prudent (our GMC Insurance Broker) representative for assistance and
share
PwC the bill with Star Health Insurance 3-4 hours before the discharge. 12
Point of Contact & Helpdesk Schedules
City Contact Person Contact Number Email Id
Gurgaon Utsab Mitra* 9958100281 utsab.mitra@prudentbrokers.com
Mumbai Ganesh Raorane 9987900022 ganesh.r@prudentbrokers.com
Chennai Satish Chandra Kumar 7550011857 sathish.r@prudentbrokers.com
Kolkata Angela Baptist 9831323480 angela.baptist@prudentbrokers.com
Hyderabad P Yogesh Yadav 7032706307 yogesh.yadav@prudentbrokers.com
Pune Sachin Kumar  8600900633 sachin.kumar@prudentbrokers.com
Bangalore Vinay  9535555791 vinay.v@prudentbrokers.com

PwC Office Prudent Helpdesk

City Office location Day Timing Contact Person
Gurgaon Novus Tower Tuesday to Thursday 10.30 AM to 1.30 PM Utsab Mitra
Gurgaon 10C Friday 10.30 AM to 1.30 PM Utsab Mitra
Mumbai Shivaji Monday 10.30 AM to 1.30 PM Akash (Star – 8652778175)
Mumbai Bandra Tuesday 10.30 AM to 1.30 PM Akash (Star – 8652778175)
Mumbai Nesco Thursday 10.30 AM to 1.30 PM Akash (Star – 8652778175)
Mumbai Bandra Thursday 3:00 PM to 5:00 PM Akash (Star – 8652778175)
Mumbai Shivaji Friday 10.30 AM to 1.30 PM Akash (Star – 8652778175)
Chennai Chennai Friday 11:00 AM to 12:00 PM Satish Kumar
Hyderabad Hyderabad Friday 10.30 AM to 1.30 PM P Yogesh Yadav
Pune Pune Thursday 10.30 AM to 1.30 PM Sachin Kumar
Bangalore Bangalore Friday 10.30 AM to 1.30 PM Vinay
Kolkata Y-14 Wednesday 10.30 AM to 1.30 PM Angela Baptist
Kolkata DN -57 Friday 10.30 AM to 1.30 PM Angela Baptist

Please note: Utsab Mitra will also attend queries related to Ahmedabad, Bhopal, Raipur & Jamshedpur
locations
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 Escalation Matrix

Escalation
Prudent Insurance Brokers PwC- Human Capital
Level
Utsab Mitra
Email: utsab.mitra@prudentbrokers.com
Gobind Singh
Ph: 9958100281
1st Level Email: gobind.singh@pwc.com
For ED/Partner Cases-Kapil Dev Mehta
Ph: 9999793920
Email: kapil.dev@prudentbrokers.com
Ph: 99717-30011
Giriraj Singh Anwar Hussain
2nd Level Email:giriraj.singh@prudentbrokers.com Email:anwar.hussain@pwc.com
Ph: 84487-89972 Ph: 9810729430
Dr Manisha Singh Abhishek Jha
3rd Level Email: manisha.singh@prudentbrokers.com Email: abhishek.y.jha@pwc.com
Ph: 9971795065 Ph: 7763807848

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Thank you!

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