Emerge Products Group

Employee Health Insurance Plan

FEATURES & BENEFITS

Know Your Vendors

Insurer
Oriental Insurance Company Ltd.
Risk carrier
TPA
Mediassist
Hospital network owner
Cashless provider
Claims settler
Service Provider
Medimanage Insurance Broking
Your contact for all health insurance related
Needs.
Facilitator of enrolments, cashless authorizations, reimbursement claims settlements, query
management and the entire gamut of health
insurance administration for the Nasscom
TechieHealth Plan.

The Deal - Base Cover

Plan

1,00,000

A
B
C

2,00,000

2,50,000

3,00,000

Employee

Employee

Employee

Employee

E+S+2C

E+S+2C

E+S+2C

E+S+2C

E +S + 2 C + 2P /PIL

E +S + 2 C + 2P /PIL E

E +S + 2 C + 2P /PIL E

E +S + 2 C + 2P /PIL

E +S + 2C +2P+2 PIL

E +S + 2C +2P+2 PIL

+S + 2C +2P+2 PIL E

+S + 2C +2P+2 PIL E

E + 2P

E + 2P

+ 2P

+ 2P

Each member company shall select one of the options from A to D as

the base cover. For e.g.
A company selects 1 Lac and E+S+2C as base cover, pays premium.
Employee can opt for coveringE+S+2C+2P by paying the differential premium.
Sum insure upgrade is not permitted.
E+2P is permitted for unmarried employees only. Married employees must
cover parents/parents-in laws under E+S+2C+2P/2PILorE+S+2C+2P + 2PIL

The Deal - Add-on cover

Plan

2,00,000

3,00,000

Parents

Parents

Parents in law

Parents in law

An add-on cover for Parents / Parents-in- Law on optional basis.

Sum insured will on a floater basis covering either parents or parents in law.
Example
An employee has a 1 Lakh E+S+2C+2P plan.
He/she can take an add-on cover or either 2 L or 3 L for his/her
parents over and above the base plan.
So, it can be base plan 1 Lakhs + 2 Lakhs parents cover.
This means the total cover for the family is 3 lakhs where the
cover for E+S+2C is limited to 1 lakh.
Room rent will be as per base plan.

The Deal - Terms

Sum insured on a floater basis.

Employee, spouse, first 2 children and parents/parents-in-law can
enrol. It will either be parents or parents in law under plan C.
Coverage will be from policy inception or DOJ in case of new joiners
subject to premium adequacy in CD account.
Pre-existing ailments covered
(4.1, 4.2, 4.3 clauses deleted).
Congenital internal ailments covered.
All covers from day 1.There will be no waiting periods.
Day care procedures are covered.
Room rent 2% of sum insured limited to INR 5 k / day.
ICU rent 4% of sum insured limited to INR 10 k / day.
Room rent linked charges (Doctor fees, Surgeon fees etc).
Maternity is covered from day 1 for INR 50 K.
Baby cover from day 1 in the main policy.
Pre & Post hospitalization covered (30 days & 60 days).
Cashless facility available.
Co-pay of 10% on parent claims. No co-pay for employee, spouse
and kids.

The Deal - Terms

2 children upto 21 years can be covered. Children above 21 yrs who

currently covered will continue to be covered.
Parents covered upto 80 years.
Terrorism covered.
Additions & deletion on pro-rata basis (adjust against additions /
refund balance premium yr end.
Limits on procedures per life per year will be as follows:
Cataract
: INR 20,000 per eye
Hernia
: INR 40,000
Hysterectomy
: INR 45,000
Joint replacement : INR 1,25,000 per joint
TURP for BPH
: INR 42,000
Coronary angiogram: INR 18,000
The co-pay will not be applicable for above procedures where the
maximum pay-out is limited.
Non tertiary care procedures carried out in tertiary care centres will
have a 10% co-pay.

Non Tertiary Procedures

List of some Non Tertiary Care Ailments / procedures:
01. Surgical cases
a. Hysterectomy
b. FESS
c. Septoplasty
d. Fistulectomy
e. Hernia
f. Tonsillectomy
g. Adenoidectomy
02. Fractures / Injuries / Dislocations requiring surgery
03. Uretroscopy, PCNL, TURP , ESWL, Etc.
04. Fever - Viral, P.U.O, etc.
05. Lower back pain
06. Infections - Lower respiratory, upper respiratory, ear infections, etc.
07. Non-acute gastritis.
08. Physiotherapy
09. Fractures / Injuries / Dislocations not requiring surgery
10. Prostatitis

The Deal - Terms

10% co-pay clause does not apply if patients condition is critical/life

threatening (addressed to satisfaction of TPA) & needs tertiary care
admission.

10% co-pay clause does not apply for the capped ailments.

Flexibility to cover spouse midterm in case of marriage.

An employee is covered under E plan, he/she can add spouse by

opting for the E+S+2C after marriage by paying the differential
premium on a pro-rata basis. This has to be done within 30 days
of marriage and /or child birth. Additions will not be accepted later.
Flexibility to cover parent/s/parent/s-in-law midterm.
An employee is covered under the E+S+2C cover, he/she can add
parent/s/parent/s-in-law by opting for the E+S+2C+2P cover by
paying the differential premium on a pro-rata basis.
Exclusions of specified ailments applicable during the currency of
the policy year when such inclusion happens. This is applicable
for Add-on covers as well.

Cover to continue for retired employees.

Claims to be submitted within 30 days from the date of discharge.

Exclusions - Midterm Parent Inclusion

Benign ENT disorders and surgeries i.e tonsillectomy, adenoidectomy,

mastoidectomy, tympanoplasty etc.,
Surgery of Hernia
Surgery of hydrocele
Non-infective Arthritis
Undescendent testes
Cataract,
Surgery of Benign prostatic hypertrophy,
Hysterectomy due to menorrhagia or fibromyoma or myomectomy or
prolapse of uterus,
Fissure/fistula in anus
Piles
Sinusitis of related disorders
Surgery of gallbladder and bile duct excluding malignancy,
Surgery of genito-urinary system excluding malignancy,
Pilonidal sinus,
Gout and rheumatism

Exclusions - Midterm Parent Inclusion

Hypertension
Strokes & Heart conditions as well
Diabetes
Calculus diseases,
Removal of benign tumours,
Congenital internal diseases / defects,
Cholecystectomy,
Renal stones,
Diseases of gums,
Joint Replacement due to degenerative condition
Age related osteo-arthritis and osteoporosis,
Surgery of varicose veins and varicose ulcers,
Surgery for prolapsed inter vertebral disk unless arising from
accident,

The Deal - Terms

Corporate buffer can be availed by a company. The limits, based on

the total sum insured of the group are as follows
3 Cr to 5 Cr
: INR 5 Lakhs.
6 Cr to 10 Cr
: INR 5 Lakhs or INR 10 Lakhs.
Greater than 10 Cr : Mutually agreed upon by insurer and company. The
buffer is applicable only to employees, not limited to any specific ailment and
limited in such a way that the maximum pay-out including the base sum insured for
an individual using the buffer will be INR 5 Lakhs per year (AOY) subject to
availability of residual buffer amount for that company.
For e.g. If an employee is covered for 1 Lakh then he/she can use a buffer of 4
lakhs. If an employee is covered for 2 lakhs then he/she can use a buffer of 3
lakhs.

A buffer cannot be used in the absence of a base sum insured.

Claim intimation time of 48 hours. Claims intimated beyond this time will be rejected.

30 days allotted for enrolment.

Domiciliary care is excluded.

The Deal - Add-on cover

This sum insured will be over and above the base cover.
The sum insured will cover a set of people, either parents or parents
in law.
1 parent and 1 parent in law to make a set is not allowed.
Add on cover is not available for members not covered under the
base sum insured.
This cover can be used in tandem with the base cover.
If an employee has an E+S+2C+2P plan for 3 lakhs, he/she can
take an add-on cover for 2P.
Say, Emp chooses 2 L as ad-on cover for 2P, total cover for 2P
shall be :- base plan 3 L + 2 L add-on = 5 Lakhs cover for 2P.
The employee is free to use the add-on cover or the base cover
jointly or separately as per his/her choice.
To use the add-on cover, it is mandatory to cover the add-on
members in the base plan.

5 Reasons Why TechieHealth

Better benefits
Pre-existing ailments cover from day 1 (parents included).
Maternity cover upto 50 K.
Parents cover from day 1.
Greater flexibility
Selection of sum insured.
Selection of dependents.
Lower premiums
Large group premium rating.
Option of selecting members lowers the premium by 30%.
Better predictability
Allows losses to be spread over large numbers keeping it in reasonable limits.
End to end support
One stop shop for all queries & facilitation
Web interface for all administration
Enrolment communication & enrolment
Query management
Re-imbursement claims facilitation
Cashless co-ordination