GROUP HOSPITALISATION & MEDICAL BENEFITS INSURANCE SCHEME EFFECTIVE 1st

JULY. 2009

¾ COVERAGE:
™ Policy will cover self, spouse, dependent children & dependent parents. Parents are not
covered in case the employee is under ESI. Please note that mother-in-law or Father-in-
law is not covered. However, Female employees can have the option to cover
mother-in-law or father in law, in case they are dependent on her.
™ Policy covers all employees up to grade P-9 for Hospitalisation and Domiciliary benefits.
™ Directors are covered for Hospitalization only.
™ Employees covered under ESI have also been covered under the Medical Group
Insurance Policy but they should prefer to use existing ESI facilities.
™ Newborn children will be covered after attaining the age of 7 weeks. Expense up to the
age of 6 weeks will be covered under the Maternity expenses.
™ Policy does not cover the treatment taken under systems other than Allopathic,
Ayurvedic & Homeopath. Treatment must be taken from qualified Doctors. Treatment
taken under other systems such as Kerala massage is not covered under the policy,.
™ Policy does not cover congenital diseases (Disease by birth).

¾ HOSPITALISATION:
™ Maximum Limit for Hospitalization will be equal to 20 months of basic salary for the
policy period.
™ First 10% of Hospitalization expenses will have to be borne by the employees.
™ In case, the employee is under ESI, the dependent parents are not covered under the
policy.
™ Maternity benefit under Hospitalization is restricted to Rs.15000/= for Normal and
Rs.30,000/= for Caesarean.
™ Minimum stay at Hospital for Hospitalization claim is 24 hrs. NIC has the right to reject
the claim, if the stay at Hospital is less than 24 hrs.
™ Maximum limit of room rent charges are 1% of Basic Insurance for Hospitalisation and
2% of Basic insurance in case of ICU. (Basic Insurance is the hospitalisation limit i.e.
Basic salary x 20). However, the taxes are extra.
™ Pre/Post Hospitalisation expenses covered under the policy are for 15 days of Pre
hospitalisation and 30 days of Post Hospitalisation.
™ Pacemaker, Artificial Limbs, etc will be covered by the scheme once in a life time up to
 75% of the cost and only if it is not a pre-existing condition at the time of joining the
company.

¾ DOMICILIARY
™ The maximum limit for reimbursement for domiciliary treatment will be up to 90% of the
one month basic salary. Reimbursement of expenses for Dental treatment is Rs.3000/=
per Policy period per member as part of Domiciliary limits.
™ Reimbursement of expenses for Specs excluding Goggles is Rs.2000/= per member
per policy period as part of Domiciliary limits. Vaccination expenses is restricted to
Rs.1000/= per month within Domiciliary limits.
™ All abortion cases, if otherwise, are payable as part of the domiciliary limits.
™ Medicine Bills without name & Doctor Fee bills not accompanied by prescription will not
be paid.
™ Health check up expenses will be reimbursed out of the domiciliary limits for employees
having attained the age of 45 years and above once in policy period.
™ Bills without prescription will be accepted by National Insurance Company up to Rs.
250/= per month.

¾ GUIDELINES FOR FILING CLAIM:

™ Employee should claim domiciliary bills on monthly basis on one claim form. Claim for
Hospitalisation and Domiciliary must be claimed on separate claim forms.
™ Medical Bills are to be submitted on Monthly basis
™ All claims should be signed duly by department head.
™ Claims received after 90 days of expenses incurred will not be entertained for
reimbursement from NIC.
™ Attach Doctor’s latest prescription along with the bills for purchase of Medicines and
Consultation fee receipt. Bills without latest prescriptions will be treated as without
prescription and NIC will pass the claims accordingly.
™ Medicine quantity purchased & claimed must be in accordance to the latest prescription
of the Doctor.
™ Name of the Patient & the Doctor prescribing the medicine must be clearly mentioned
on the bills.
™ Test report copies & prescription/recommendation of the Doctor must be attached along
with the bills where the money is spent for medical tests.
™ Hospital claims must accompany with Discharge Summary of Hospital where treatment
is taken & copies of the test reports. In case of Death in the Hospital, Death Certificate
 copy must be enclosed.
™ Hospitalization claims less than 24 hrs stay in Hospital will be considered under
domiciliary limits.
™ Room rent under hospitalization is 1% of entitlement and minimum of Rs.2000/- or
actual whichever is lower

¾ PROCESS FOLLOWED AT HO:

™ Claims received at HO up to last day of the month are given to NIC for processing and
finalising the amount payable to each employee. List is prepared by them and given to
HO-Accounts for payment through Payroll.
™ Rejected claims, if any are returned back to RAOs for returning back to employees.