Group Health Insurance Policy

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Purpose :-- Group Health Insurance also known as Mediclaim, or Group Mediclaim insurance Scheme, Health insurance
is the foundation of a comprehensive benefits package of employees. Employers of choice provide a comprehensive
employee benefits package to make a competitive salary of an employee.

Objective:-- This policy provides health insurance to our employees. As an employer, ensuring the well-being of our
employees is not just a responsibility but important for the success of the business. Group medical covers provide
monetary support for your employees if there is a crisis without putting a financial burden on the business.

Scope:-- The scope of this document is applicable to all employees in Iotechworld Avigation Pvt Ltd

Eligibility: -- Sum Insured Chart for "GROUP MEDICLAIM

Designation Sum Insured with life cover status
10 Lacks (With Family Floater including
Director
parents)
GM
3 Lakhs & for GM 5 Lakhs with Family
DGM (Dy. General Manager)
Floater)
AGM (Asst. General Manager)
Sr. Manager
M (Manager) / Lead Engineer – R&D
DM(Deputy Manager) / Sr. Engineer – R&D
3 Lakhs & life cover @ self
AM (Assistant Manager)
Sr. Engineer / Sr. Executive/ Engineer / Executive / Jr Engineer
- R&D
About Policy:--
 ICIC Lombard Insurance company has issued Group Mediclaim Policy
 ICIC Lombard has its own TPA services (Third Party Administrator)
 The policy shall pay for hospitalization expenses for medical/surgical treatment at any Nursing
Home/Hospital in INDIA as an in-patient defined in the policy
 NO CO-PAY: All other terms and conditions as per standard Mediclaim Policy.
 Room rent for employees: ___ for Normal and ___for ICU with proportionate clause and for parents ___ for
Normal and ___for ICU with proportionate clause
 Pre-existing Diseases Waived, Waiver of 1st, 2nd & 4th Year Exclusions, Waiver of 30days waiting period
 Day-care procedures covered, Ambulance Charges- Rs.____________ per hospitalization, New joiners covered
from the date of joining subject to sufficient CASH DEPOSIT BALANCE.

What are the expenses Reimbursable ?

 The GMC Tailormade is the comprehensive coverage :-- The policy covers reasonable and customary charges in
respect of Hospitalization and / or Domiciliary hospitalization for Medically Necessary treatment only for
illnesses / diseases contracted/suffered or injury sustained by the Insured Person(s) during the Policy period,upto
the limit of Sum Insured.
 Room Charges __ of the Sum Insured per day
 Intensive Care Unit (ICU) Expenses as provided by the ____of the Sum Insured per day.
 All other expenses are eligible subject to the sum insured.
 Day one cover is available, all diseases are cover and no waiting period

Guidelines For Availing Mediclaim Benefits

Process of Pre Authorization

 Pre Authorization for cashless facility is normally given in 2 stages.

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  In the 1st stage, based on the diagnosis and line of treatment, an amount up to ___% of the estimated
expenses is approved.
 In the 2nd stage, on the date of discharge, the balance amount is approved after receiving copies of
Discharge summary and final bill from the hospitals.
 Please ensure at the time of discharge, either yourself or the patient signs the Hospital Bills.
 Please note :Cashless Hospitalization facility is available only at Network Hospitals listed by ICIC
Lombard.

Claims Settlement – Cashless

 ICIC Lombard will issue Identity Cards to each employee.

 Approach the Hospital which is in the network at least 24 hours in advance
 Request the hospital to send Cashless Request to Media Assist
 Make sure that the form is completely filled in all respects. This has to be signed by (1)Employee or the
patient (2)Treating doctor (3)Hospital authority.
 ICIC Lombard will send the Pre Authorization to the hospital
 ICIC Lombard will, depending on policy conditions, authorize or deny the request in 2 to 3 Hours
of receipt subject to the ICIC Lombard receiving complete details. In case of Emergency, Pre
Authorization will be given within 1 to 2 hours.
 Copies of the form for Cashless Hospitalization are available at www.iciclombard.com and Network
Hospitals

Documentation

DOUCUMENTATION REQUIRED – FOR CLAIM

 Pre numbered or serial numbered Cash Paid receipt  Itemized Break up details of Main hospital bill
 Investigation Original Reports and itemized Break up  Detailed Discharge Summary
 Doctor Prescription / Medicine break up

Imp Points – Documentation

 Please retain a copy of all documents submitted to us for further reference

 Please retain POD copy of the courier for tracking your consignment in case of any delay etc.
 For implants used in Cataract, Heart Valve Surgeries, CABG,Abdominal Surgeries, Knee replacement
surgeries. Please submit the bill (in case purchased outside) from the vendors for the prosthetic devices used
along with Sticker
 Please arrange the documents as per checklist.

What are the expenses Reimbursable?

REIMBURSABLE ITEMS
 Room Rent, Boarding Expenses & Nursing  Medicines, drugs and consumables
 Intensive care Unit  Diagnostics procedures
 A Medical practitioner,  The cost of prosthetic and other devices or equipment
if implanted internally during a surgical procedures
 Anesthesia, Blood , Oxygen, Operation theatre
charges , surgical appliances

Hospitalization: Admission into hospital for medically necessary treatment as an inpatient for continuous
period of at least 24 hours

Pre and Post Hospitalization

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Pre-Hospitalization: 30 Days
 The Medical Expenses incurred due to an Illness in the 30 days immediately before the Insured Person was
Hospitalized, provided that:
 Such Medical Expenses were in fact incurred for the same condition for which the Insured Person‟s subsequent
Hospitalization was required

Post-Hospitalization: 60 Days
 The Medical Expenses incurred in the 60 days immediately after the Insured Person was discharged post
Hospitalization provided that:
 Such costs are incurred in respect of the same condition for which the Insured Person‟s earlier Hospitalization
was required

Day care procedure Treatment undertaken in a hospital/Nursing Home on the recommendation of medical Practitioner
for the following diseases, Illness or injury which requires hospitalization for less than 24 hours:

TREATMENT
 Dialysis  Dilatation & Curettage
 Chemotherapy  Hydrocele Surgery
 Radiotherapy  Hernia Repair Surgery
 Eye Surgery  Sinusitis
 Lithotripsy (Kidney stone removal)  Coronary Angiography
 Tonsillectomy

Policy Exclusion
 LASIK surgery for correction of eyesight, Contact lens, Spectacles, Hearing aids including Cochlear implants
 Dental treatment unless arising due to accident
 Medical termination of pregnancy / abortion within 12 weeks
 Sterilization procedures, treatment of infertility/sub-fertility/ Assisted conception procedures
 Plastic and cosmetic surgery, vaccination, inoculation, circumcision
 External “congenital” disease, anomalies, defects
 Intentional self injury / suicide attempt, psychiatric and psychosomatic disorders
 Direct / indirect effects of use of alcohol / intoxicating drugs
 AIDS and related syndromes
 “Technical admission” –Admission for diagnostic/evaluation without active line of treatment
 Expenses on vitamins or general tonics
 Naturopathy treatment
 Acupressure, acupuncture, magnetic therapies, experimental and unproven treatments/procedures/therapies.
 Pre and post expenses related to maternity claim
 Unproven procedure/ treatment, experimental or alternative medicine/treatment including acupuncture,
acupressure, magneto-therapy, RFQMR, etc.
 Robotic Surgery
 Genetic disorders/stem cell implantation/surgery
 External equipment's like CPAP, CAPD, infusion Pump etc., ambulatory devices like walker/ crutches/ belts/
collars/caps/ splints/ slings/ braces/ stockings/ diabetic foot-wear/ glucometer/ thermometer & similar related
items & any medical equipment which could be used at home subsequently
 Treatment for obesity or condition arising therefrom (including morbid obesity) and any other weight control
program/ services/ supplies.
 Massages/ Steam bath/ Surodhara & alike Ayurvedic treatment.
 Any kind of service charges/surcharges, admission fees/registration charges etc. levied by the hospital.

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