M AND V MARKETING AND SALES PRIVATE LIMITED

Employee Benefit Insurance

 Group Mediclaim Insurance Policy

Employee Benefit Policy 2

 Scope of Insurance Coverage

 Includes:
 Only “In-Patient” hospitalization expenses like Room charges, Nursing charges, Surgeon, Anesthetist,
Medical Practitioner, Consultant, Operation Theatre, Medicine & Drugs and other similar expenses.
 Active line of treatment with minimum 24 hours of hospitalization.
 Pre hospitalization expenses of 60 days before admission and Post hospitalization expenses of 90 days
after discharge for an eligible hospitalization.
 Excludes:
 Non Medical Expenses like Registration/Admission fees, hospital surcharge, food bills for attendants,
telephone charges, pharmacy charges for non-medical items etc.
 Other General exclusion (Please refer Page No.9)

Employee Benefit Policy 3

 Policy Benefit

Commencement Date 25th June 2023

Renewal Date 24th June 2024
Sum Insured Type Family Floater (Self + Spouse + 2 dependent children)
Sum Insured 5 Lac
Members Covered Self + Spouse + 2 dependent children
Pre Existing Ailment Covered from day 1
Rs.60,000/- for Normal & Rs.75,000/- for C-Section Delivery per
Maternity Sub-Limit
family
Normal room: Single Standard AC Room
Applicability of Room Rent/Boarding Expenses
ICU: As per actual

Employee Benefit Policy 4

 Other Benefits
 First 30 Days of waiting period is waived off
 1st/ 2nd/ 4th Year exclusions are waived off
 Pre Hospitalization Period - 60 days & Post Hospitalization Period - 90 days
 9 months waiting period in respect of Maternity claims is waived off
 Pre/Post natal expenses cover: Covered within maternity limit upto INR 5,000/-.
 Congenital internal disease cover Covered for within floater SI. External Congenital
covered for Life Threatening Conditions
 Ayurvedic/Homeopathic/ Unani treatment will be 25% of sum inusred provided the
treatment is taken in the govt hospital.
 Day Care Diseases : Covered
 Sub-Limit/Disease capping (Ailment Capping) : Not applicable
 Emergency Ambulance Charges : Covered up to Rs. 2,500/- per event
 Addition & Deletion of members : On prorate basis
 Claim intimation 30 days from the date of admission.
 Claim documents must be submitted within 30 days from the date of discharge.

Employee Benefit Policy 5

 Addition Benefit

 Dependents covered in case employees dies.

 LGBTQ and Live-in Partner / DEFACTO SPOUSE - Partners can be included during day one /date of
joining, changing the partner in between the policy period is not allowed (Live in partners).
 We Will Cover the below Specified Modern Treatment with 50% CO Pay on IPD basis:
▪ 1. Oral chemotherapy
▪ 2. Uterine Artery Embolization and HIFU
▪ 3. Balloon Sinuplasty, Deep Brain Stimulation
▪ 4. Bronchial Thermoplasty
▪ 5. Cochlear Implant
▪ 6. Vaporisation of the prostrate (Green laser treatment or holmium laser treatment)
▪ 7. Cyberknife/ Robotic Surgery
▪ 8. Stem Cell Therapy
 Disabled child covered without age limit.
Employee Benefit Policy 6
 Insurance Partners

Insurance Acko General Insurance Ltd.

Company

Insurance Broker Emedlife Insurance Broking Services

Limited

TPA Family Health Plan (TPA) Ltd.

Employee Benefit Policy 7

 Definition
Pre-hospitalization Expenses

Definition If the Insured Person is diagnosed with an Illness which results in his
Hospitalization and for which the Insurer accepts a claim under a) above, the
Insurer will reimburse the Insured Person’s Pre-hospitalization. Expenses for up
to 30 days prior to his Hospitalization as long as the 30 day period commences
and ends within the Policy Period. Not applicable for maternity claim.

Post-hospitalization Expenses

Definition If the Insurer accepts a claim under a) above and, immediately following the
Insured Person’s discharge, he requires further medical treatment directly
related to the same condition for which the Insured Person was Hospitalized,
the Insurer will reimburse the Insured Person’s Post-hospitalization Expenses.
Not applicable for maternity claim.

Employee Benefit Policy 8

 Definition
Pre existing diseases
Definition Any Pre-Existing Condition or related condition for which care, treatment or advice was
recommended by or received from a Doctor or which was first manifested prior to the
commencement date of the Insured Person’s first Health Insurance policy with the
Insurer

First 30 day waiting period

Definition Any Illness diagnosed or diagnosable within 30 days of the effective date of the Policy
Period if this is the first Health Policy taken by the Policyholder with the Insurer. If the
Policyholder renews the Health Policy with the Insurer and increases the Limit of
Indemnity, then this exclusion shall apply in relation to the amount by which the Limit of
Indemnity has been increased

First Year/Second Year Waiting period

Definition During the first year of the operation of the policy the expenses on treatment of diseases
such as Cataract, Benign Prostatic Hypertrophy, Hysterectomy for Menorrhegia or
Fibromyoma, Hernia, Hydroceie, Congenital Internal Diseases, Fistula in anus, Piles,
Sinusitis and related disorders are not payable. If these diseases are pre- existing at the
time of proposal they will not be covered even during subsequent period or renewal too

Employee Benefit Policy 9

 General Exclusions
 Circumcision unless necessary for treatment of disease
 Dental treatment of any kind unless any accidental case
 HIV and AIDS
 Hospitalization for convalescence, general debility, intentional self-injury, use of intoxicating
drugs/ alcohol.
 Venereal diseases (Sexually Transmitted Diseases)
 Injury or disease caused directly or indirectly by nuclear weapons
 Injury or disease directly or indirectly caused by or arising from or attributable to War or War-like
situations
 Naturopathy
 Any non-medical expenses like registration fees, admission fees, charges for medical records,
cafeteria charges, telephone charges, etc
 Cost of spectacles, contact lenses, hearing aids
 Any cosmetic or plastic surgery except for correction of injury
 Hospitalization for diagnostic tests only
 Vitamins and tonics unless used for treatment of injury or disease
 Voluntary termination of pregnancy during first 12 weeks (MTP)
Employee Benefit Policy 10
 List of Non Medical Expenses
Administrative
Expenses
▪ Admission Charges
▪ Registration Charges
▪ Medical Records/Medico
legal charges
▪ Attendant Stay charges
▪ Relative Stay charges
▪ Additional Stay
▪ Gate Pass/Attendant pass
▪ Overhead charges
▪ Establishment Charges
▪ Tax
▪ Surcharge
▪ Incidental charge
▪ Waste disposal Charge
Employee Benefit Policy
Documentation
Services
Expenses
▪ Documentation charges ▪ Private nurse charges
▪ Medical records charges ▪ Telephone Charges
▪ Discharge summary ▪ Fax Charges
▪ Birth Certificate ▪ Food/Beverages
▪ Death Certificate ▪ Diet
▪ Medical Certificate ▪ Electricity Charges
▪ Water Charges
Consumables ▪ T.V/Internet Charges
▪ News Paper/Magazines
Charges
▪ Antiseptic/disinfectant
▪ Stationery Charges
solutions
▪ Linen/Laundry Charges
▪ Soaps
▪ Mortuary/Coffin Charges
▪ Powder
▪ Ambulance Charges
▪ Oil/Cream
▪ Sanitary pads/Diapers
▪ Cassette/CD/Film charges
▪ Oxygen Cylinder
▪ Health Foods
11
 Cashless Hospitalization Process-
Planned
Pre-authorisation form to be sent before 24 hours of hospitalization

Employee Benefit Policy 12

 Cashless Hospitalization Process-
Emergency
Pre-authorisation form to be sent within 6 hours from the time of admission

Employee Benefit Policy 13

 Denial Claim Reasons

➢ Admission for investigations/ observation / evaluation only .

➢ Admission beyond a certain no. of days apart from the normal package stay.
➢ Treatment not matching with disease mentioned on pre-auth form.
➢ Any treatment which otherwise could have been taken on OPD basis.
➢ Any congenital external disease except life threatning.
➢ Hospital not sending proper query reply raised by TPA on time.
➢ Active line of treatment not mentioned in the pre-auth form.

Employee Benefit Policy 14

 Non Cashless Hospitalization Process

Employee Benefit Policy 15

 Communication Matrix

Emedlife Insurance Broking Services Ltd.

Level – 1
• Name: Substeen Massey
• Mob Number:7669203136
• Mail ID: substeen_massey@emedlife.in
Level – 2

• Name: Neha Singh

• Mob Number: 9999213469
• Mail ID: neha_singh@emedlife.in

Escalation Point

• Name: Manu Sharma

• Mail ID: manu_sharma@emedlife.in

Employee Benefit Policy 16

 FAQs

Employee Benefit Policy 17

 What is room rent capping in Group Health?

Hospital costs are dependent upon the type of room selected by the insured and also based on availability at
the time of admission. Hence doctor consultation in Single AC for normal at actuals for ICU would be higher
when compared to the shared room in the hospital. All related costs thereafter are payable as per the eligible
room rent.

Is abortion covered under the Group Health?

Group Health Insurance generally does not cover self-inflicted or voluntary abortion under Group Health
Insurance offered by most insurers. However, emergency abortion which is medically required, i.e. for the life-
saving purpose is covered

What is Pre & Post Hospitalization Expenses?

Expenses incurred during a time period prior to hospitalization are covered and known as Pre Hospitalization
expenses. Similarly Post Hospitalization expenses are those incurred by the insured for a specified period from
the date of discharge. These expenses are considered as part of the claim provided the expenses relate to the
disease / sickness for which treatment was sought and a claim filed by the insured

Employee Benefit Policy 18

 Is there any minimum period of stay in the hospital ?

Yes, in order to become eligible to make a claim under the health insurance policy, the minimum stay in the
Hospital is at least 24 hours for all treatments following an accident/sickness. This time limit however may not
apply for some specific named treatments known as Day Care Procedures/Treatment

What is the Day Care Procedure ?

A day care procedure is a minor surgery or medical procedure that can be completed in less than 24 hours and
doesn’t require prolonged hospitalization of the insured. Thus, while the patient is in hospital for a short
period of time, he/she does not spend a full 24 hours in the hospital, which is the minimum period for which
claims can be filed. This is primary on account of technology advances in medicine and many surgeries these
days are being conducted in short durations

Can the insured get admitted to a Non-Network Hospital ?

Yes the insured can get admitted in Non-network hospital in an emergency situation, and insured must be
aware that on such non-network hospitals cashless facility is not available, hence reimbursement procedure
shall be followed.

Employee Benefit Policy 19

 Which are the places where insured can get hospitalized ?

Member can get hospitalized in any city in India. Cashless service is available only in network hospitals of the
TPA/Insurance company. The list of the network hospitals can be traced at website of Ericson Insurance TPA Pvt.
Ltd. TPA.

Is there a time limit within which I am expected to submit the pre & post hospitalization bills ?
Yes you are advised to submit the bills with respect to pre hospitalization & post hospitalization, within 15
days of discharge from hospital. Post Hospitalization bills must be submitted within 7 days of completion of
the treatment or completion of 60 days post discharge, whichever is earlier.

Will I get my claim papers back ?

No, you will not get original claim documents back even after settlement. You may keep a Xerox copy of all the
documents with your good self for future reference before submitting the original documents to the
TPA/Insurance Company.

Employee Benefit Policy 20

 What is cashless authorization Letter ?

Authorization letter is the communication authorizing extension of cashless hospitalization to the insured. The
same is issued by the TPA subject to admissibility of the claim and availability of balance sum insured for the
member and active line of treatment.

What documents shall be carried while admission in the hospital ?

It is advisable to carry the cashless health cards, Photo ID proof (Photo Identity card, Adhaar card, Voter ID
Card, which is approved by Government of India) and pre doctor consultation letter or advise letter for the
hospitalization.

Employee Benefit Policy 21

Thank you