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Paramount Health Services & Insurance

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 GROUP HEALTH POLICY 2018-19

POLICY PERIOD – 1JULY18 TO 30JUNE19

Presented by Paramount Health Services & Insurance TPA Pvt.

Ltd

In Conjunction with
SBI General Insurance Co. Ltd
What is Medical Insurance & Criteria For
Hospitalisation Claim?

Medical Insurance: Cashless/ reimbursement of

hospitalization expenses incurred in India for the treatment
of illness/diseases or injuries sustained by the employee and
other beneficiaries during the period of insurance

THE BASIC CRITERION FOR TRIGGER OF THIS HOSPITALIZATION POLICY ARE :

• The hospitalization should be for more than 24 hours (in certain cases, this time is relaxed, please go
through details of policy to know for which ailments lesser time is acceptable)

• It should not be only for evaluation or diagnosis of disease. A positive / active treatment is must
during the hospitalization. No hospitalization will be considered if the patient is only on oral medication
during the period he or she is hospitalized.

• It’s necessary that hospitalization is must for the treatment & the ailment could not have been treated on
Out Patient basis.
Definition of Hospital / Nursing Home

Any institution in India established for In-patient care & day care treatment of
sickness and/or injuries and which has been registered as a hospital with the
local authorities, wherever applicable, and is under the supervision of a
registered and qualified medical practitioner OR must comply with all minimum
criteria as under:

Has at least 10 inpatient beds, in those towns having a population of less than
10,00,000 and 15 inpatient beds in all other places;
has qualified nursing staff under its employment round the clock;
has a fully equipped Operation Theatre of its own where surgical procedures
are carried out.
maintains daily records of patients and will make these accessible to the
insurer’s authorized personnel.
POLICY
PARAMETERS

Insurance Company SBI GENERAL INS CO LTD.

TPA Paramount Health Services & Insurance TPA Pvt. Ltd

Policy Start Date 01-Jul-18

Policy End Date 30-Jun-19

Coverage Type Floater

EMPLOYEES POLICY – Covers Family , Employee , Spouse & Max 2 Children

PARENTS POLICY – Covers Father , Mother , Father in Law, Mother in Law

Dependent Coverage TOP UP POLICY – Covers Family

Note : Dependants Siblings , Relatives cant be covered. Disabled dependents has no age
restrictions & covered in the policy.

Ambulance NOT COVERED (As per RFQ)

Claim Type Cashless/Reimbursement

Sum Insured Category As per policy T&C

Mid term enrolment of new joinees

Allowed
(New employees and their dependants)
EXCLUVE POLICY
FEATURES
• The policy is family floater in nature

• Covered from day 1 – no waiting period

• All Pre-Existing disease covered

• Critical illness covered from day 1

• No sub-limit for any disease.

• No capping on Room charges

• Can be obtained any cities /towns / villages of Indian Territories.

Note: Hospital need to registered by government authority

POLICY
PARAMETERS
STANDARD HOSPITALIZATION
Particulars
Room and Nursing 

Doctors fees 

Intensive Care Unit 

Surgical fees, operating theatre, anesthesia and 

oxygen and their administration
Drugs and medicines consumed at the hospital 

Hospital miscellaneous services (such as 

laboratory, x-ray, diagnostic tests)
Radiotherapy and chemotherapy 

Disallowed Charges

1.Registration /admission Fees

2.Non Medical Exp.
3.Telephone charges
4.Cafeteria charges etc.
5. Standard Deductions By IRDA
POLICY
PARAMETERS
Expenses for Standard Hospitalization Covered
Pre Existing Diseases Covered
Waiting Period for any Treatment Not Applicable
Normal - 50,000/-
Maternity
Caesarian - 50,000/-

Pre& Post Natal expences Covered with in Maternity benefit limit subject to hospitaliszation

9 Month waiting period Not Applicable

Accomendation/Room Rent Not ristricted /No Capping

Expenses relevant to Hospitalization for Pre Hospitalization Period of

Pre & Post Hospitalisation Expenses 30 Days from Date of Admission & Post Hospitalization Period of 60
Days from Date of Discharge are Covered.

Only Diagnostics / Evaluation Hospitalisation

Not Covered
Out Patient Department (OPD) Benefit

Homeopathic Medicine & Unani Treatment Not Covered

Co-payment 10% Co-payment on all claims except Maternity

Congenital Internal Diseases Covered within Flaoter Sum Insured

Ayurvedic Treatment
Covered on Ipd basis under government authoriszed hospitals only.
 What is Covered in the
policy?
• What is Covered in the policy?
For example:
• Tonsillectomy.
• Appendectomy
• Cataract.
• Total knee replacement or total hip replacement surgery.
• Hernia repair surgery.
• Any fractures or dislocations. Other than OPD tratment.
• Angioplasty or open heart surgery for HEART ATTACK.
• Kidney stone problems
• Stroke
• Any problems arising out of pre-existing diseases like hypertension, diabetes,
• convulsions/Epilepsy
• Asthma/bronchitis
• Any problems arising out of accident
What is NOT Covered in the
policy
• Sexually transmitted diseases, any condition directly or indirectly caused due to or associated with Human T-Cell
Lymph tropic Virus Type III (HTLB-III) or lymphotropathy Associated Virus (LAV) or the Mutants Derivative or
Variation Deficiency syndrome or any syndrome or condition of a similar kind commonly referred to as AIDS

• Diagnosis, X-Ray or Laboratory examination not consistent with or incidental to the diagnosis of positive existence and
treatment of any ailment, sickness or injury, for which confinement is required at a Hospital/Nursing Home.

• Vitamins and tonics unless forming part of treatment for injury or disease as certified by the attending physician.

• Out patient Diagnostic, Medical and Surgical procedures or treatments, non prescribed drugs and medical supplies,
Hormone replacement therapy, Sex change or treatment which results from or is in any way related to sex change.

• Change of treatment from one pathy to other pathy unless being agreed / allowed and recommended by the consultant
under whom the treatment is taken.

• Naturopathy Treatment, unproven procedure / treatment, experimental or alternative medicine / treatment including
acupuncture, acupressure, magneto-therapy etc.

• Instrument used in treatment of Sleep Apnoea Syndrome (C.P.A.P.) and continuous Peritoneal

• Ambulatory dialysis (C.P.A.D.) and Oxygen Concentrator for Bronchial Asthmatic condition.
What is NOT Covered in the
policy
• Genetical disorders and stem cell implantation / surgery.

• Domiciliary treatment

• Home visit charges during pre and post hospitalization period of doctor, attendant and nurse

• Treatment outside India.

• Experimental and unproven treatment.

• All non-medical expenses including convenience items for personal comfort such as telephone, television, Aaya, Private
Nursing / Barber or beauty services, diet charges, baby food, cosmetics, tissue paper, diapers, sanitary pads, toiletry items etc.
guest services and similar incidental expenses.

• Treatment related to eyes for Age Related Macular Degeneration with administration of Lucentis / Avantis / Macugen /
Avastin and other related drug through intravertal injection are not covered.

• Surgery for correction of eye sight due to refractive error

• Doctor’s home visit charges, Attendant / Nursing charges during pre and post hospitalization period.

• Voluntary termination of pregnancy during first 12 weeks (MTP)

• Cost of organ when organ transplantation surgery is undertaken.

• Massages, Steam bathing, Shirodhara and alike treatment under Ayurvedic treatment.

• Service charges, surcharge, registration / admission charges or any other charges levied by hospital.
 ROLE OF
PARAMOUNT
ROLE OF PARAMOUNT

TPA SERVICES PROVIDED TO YOU BY Paramount Health Services &

Insurance TPA Pvt. Ltd
 Call Center Service (24 x 7)

 Customer Relations.

 Cashless Hospitalization Service (Pre-Authorization)

 Network Hospital Management Service

 Claim Processing & Settlement Service (Reimbursement claims)

Health ID Cards
 Paramount will issue Health ID Card to each employee and their dependants.

IMPORTANT:
 The card is issued only for identification purpose & should not be considered as an Authorization to the hospitals
to proceed with the treatment.
Reimbursement
Facility
Please submit the following documents in original for reimbursement claims:
• Original Hospital Final Bill
• Original Numbered Receipts for payments made to the Hospital
• Complete Break-up of the Hospital Bill
• Original Discharge Card / Summary
• All Original Investigation Reports
• All Original Medicine / Chemist Bills in Cash memo with relevant prescriptions
• Original Signed Claim Form of SBI Insurance Company.
• E-Card Copy

• Identity Proof (Aadhar card, Pan card/ Form 60) & In case of One lac above claim CKYC Form of employee.
• Paginated photo copies of Indoor Case papers of hospitalisation.
• Latest USG (Ultra-sound Sonography Report) / Sonography report in case of Maternity Related Claim.
• Stickers & Invoice of implants / Lens used during surgery.
• FIR (First Information Report) / MLC (Medico Legal Certificate) Copy, incase of Road Accidents. If MLC is not
applicable then written confirmation from Doctor / Hospital that the patient was not under influence of alcohol
or drugs along with Self Declaration of incident.

DON’T FORGET TO GET THE CLAIM FORM PART

– “B” STAMPED & SIGNED BY THE HOSPITAL
Reimbursement Facility
 Hospitalization Reimbursement

Claims should be submitted within 30 days from the date of discharge from Hospital/nursing home.

 Post Hospitalization claim documents

Post hospitalization documents to be submitted maximum 75 days from the date of discharge from the
Hospital /Nursing home.

Intimation Clause

Intimation should be given within 48 hours of hospitalization

Email id : sbi.intimation@paramounttpa.com
CLAIMS - CASHLESS

• Approach the TPA help desk of the hospital

• Produce your e-card at Network Hospitals

• Fill up the Pre-Auth Form.

• Submit Any Govt Photo ID proof of the patient

• Pay the cost of co-payment & Non Medical Consumables

Helpline Services In Mumbai

 TEL - +91 22 66620808

 Toll Free - 18002090221

 E-Mail - contact.phs@paramounttpa.com

 Website - www.paramounttpa.com

 For Any Medical Queries & Assistance Contact PHS Mumbai Office
THANK YOU

Be Healthy…
Stay Healthy…