EMPLOYEE INSURANCE BENEFITS

MANUAL
Disclaimer:

This manual is intended to be general summary of the benefits provided by Worley should be regarded as guide only.
While HR shall make every reasonable effort to ensure the accuracy and validity of the information provided here in
this document. HR accepts no liability or responsibility for any errors or omissions in the content or for any loss or
damages arising out of your reliance on information provided here. If there is a conflict in interpretation or benefit
applicability, then the terms & conditions of the policy will prevail.

Copyright © 2010. All rights reserved. No part of this publication may be reproduced, stored in
the retrieval system, or be transmitted in any form or by any means, electronic or mechanical,
photocopying, recording or otherwise, without the prior written permission of MARSH.
Employee Benefits Programs
Policy Period :- 1st July, 2023 to 30th June, 2024

WIPL Insurer Policy Number

Group Mediclaim Policy Bajaj Allianz General Insurance Company Ltd OG-24-1919-8403-00000146

Voluntary Parental Policy Bajaj Allianz General Insurance Company Ltd OG-24-1919-8403-00000150

Group Personal Accident Policy Bajaj Allianz General Insurance Company Ltd Policy Awaited

Group Term Life Policy HDFC Life Insurance Company Ltd Policy Awaited

WSIPL Insurer Policy Number

Group Mediclaim Policy Bajaj Allianz General Insurance Company Ltd OG-24-1919-8403-00000148

Voluntary Parental Policy Bajaj Allianz General Insurance Company Ltd OG-24-1919-8403-00000149

Group Personal Accident Policy Bajaj Allianz General Insurance Company Ltd Policy Awaited

Group Term Life Policy HDFC Life Insurance Company Ltd Policy Awaited

*No Individual should be covered as dependent of more than one employee

 Provides insurance coverage to employees for expenses related to hospitalization
Group Medical due to illness, disease or injury

Provides insurance coverage against the risk of death / injury during the policy
Group Personal Accident period sustained due to an accident caused by violent, visible and external means

Provides insurance coverage to parents for expenses related to

Voluntary Parental Policy hospitalization due to illness, disease or injury

FAQs & Common Definitions Frequently Asked Questions & Annexure

Medical Benefits
Coverage Details (Employee)

Cashless Process

Non-Cashless

Claims Process

Claims Document List

Benefits Extensions – Definitions

General Exclusions

GMC Contact Details

Prudent Utilization of Benefit

Coverage Details For Employee Policy
Policy Parameter
Insurer Bajaj Allianz General Insurance co. Ltd.
TPA In-house HAT (Health Administration Team)
Policy Start Date 1st July 2023
Policy End Date 30th June 2024
Coverage Type Family Floater
Sum Insured Graded SI of INR 3 Lacs, INR 4 lac, INR 6 Lacs, INR 7 lacs, INR 10 Lacs
WIPL – Base policy number - OG-24-1919-8403-00000146
Policy Numbers
WSIPL – Base policy number - OG-24-1919-8403-00000148

Maximum no of Members insured in a family 1+3 Siblings No

Employee Yes Others No

Spouse Yes Mid Term enrollment of existing Dependents Disallowed

Children (up to 25 year age, especially abled Yes
Mid Term enrollment of new joiners (New
children covered with out age limit) Allowed
employees +their Dependents)
Parents No
Mid term enrollment of new dependents
Parents-in-Law No (Spouse/Children) Allowed

*No Individual should be covered as dependent of more than one employee

Coverage Details For Employee Policy
Benefits / Extensions Coverage Benefits / Extensions Coverage

Standard Hospitalization Yes Domiciliary

Not Covered
Hospitalization
TPA services Yes Pre-Post
30 days and 60 days
Hospitalization Exp.
Pre-existing diseases Yes
Pre and Post Natal INR 5000 within the maternity limit
Waiver on 1st year exclusion Yes
For Sum Insured 3 lac & 4 lac up to
Waiver on 1st 30 days excl. Yes Room Rent Capping INR 5,000 rest of Sum Insured 1%
for Normal & No capping on ICU
Normal -50K & C-Sec –
Maternity benefits
70K Copay Not Applicable
Baby cover day 1 Yes Up to INR 4,000 (Emergency only)
Ambulance Services Cardiac Ambulance for INR 8,000 per
incident

Policy Period

Existing Employees + Dependents New joiners + Dependents New Dependents (By Marriage / Birth)

Commencement Commencement Commencement

1sth July ’2023 Date of joining Date
Date of such event
Date Date
Last day of
Termination Date 30st June ’2024 Termination Date Declaration Within 21 days
employment
Benefits contd..

Benefits / Extensions Coverage

Hospitalization due to terrorism Covered

Pre & Post Natal Covered within maternity limit up to INR 5000

New Bon Baby Cover Covered from Day One under Floater Sum Insured

Oral chemotherapy Covered

Infertility treatment and related ailment including male sterility Not Covered

Congenital Internal Diseases Covered

Lasik surgery Correction of refractive errors for eye correction Covered for eye power more than +/- 5.

Psychiatric Treatment Covered up to INR 30,000 on IPD basis

Covered subject to medical reason only and not for

Age Related Macular Degeneration and Septoplasty
cosmetic reason.
Cyber Knife Treatment, Gamma Knife Treatment, Stem Cell
Transplantation, Robotic Surgery, Femto Laser Treatment for each eye Covered with 50% co-pay
event
Benefits contd..

Benefits / Extensions Coverage

Modern treatments – 100% of SI Covered

LGBTQ
Lasik Surgery to be covered for eye power more than +/-5.
Coverage for external congenital in case of life threatening & where it
effects the lifestyle of the member
Internal Congenital
Mental Health cover on IPD basis up to full sum insured.
No deduction from admissible claim amount payable up to sum insured
in case of death during hospitalization, applicable for employee &
dependent claims.
Coverage for HIV AIDS
Dependent child in case of dependency more than 25 years of age
(disabled)Covered up to 30 years
Existing employees should enroll their same gender partner
at the time of inception. Employees cannot change their
same gender partner mid term. No Mid term inclusion will
be considered
Covered
Covered
Covered
Covered
Covered
Covered on IPD basis, outpatient basis are excluded from
the scope of cover. Claims for acute infections like fever,
gastroenteritis etc which are the commonest illness
occurring in persons infected with HIV are covered.
Antiretroviral or other treatment protocols specifically for
HIV and AIDS are excluded.
Covered
Benefits contd..

Benefits / Extensions Coverage

Sleep Apnea Covered on IPD basis. Purchase of Instrument charges are not covered
Gender Reassignment Surgery Covered
Genetic Disorder Covered up to 50% of sum insured

Surrogacy Covered up to maternity sum insured

Treatment to organ donor as part of insured sum insured covered. Only

Organ Donor hospitalization expenses will be covered. Pre & Post hospitalization expenses
are not covered
Autism Covered on IPD and OPD basis
Peritoneal dialysis Covered on IPD basis and hospitalization is covered

Differently abled children covered without age limit Yes

Covered if hospitalization in Government hospitals or any institute recognized

Ayurvedic treatment (AYUSH)
by Government / NABH

In case of death of insured in hospital No deduction in admissible claim and payable up to sum insured

Cochlear implant Covered up to 50% of sum insured

 Covers expenses related to :
Please Note :
➢ Room and boarding- For Sum Insured 3 lac & 4 lac up to INR 5,000 rest of Sum
A) The expenses are payable Insured 1% for Normal & No capping on ICU
provided they are incurred in
India and within the policy ➢ (Hospital billing is based on the room category opted by the patient, hence the
period. Expenses will be
reimbursed to the covered cost of investigations, surgery, doctor’s fees is incremental as you go to a higher
member depending on the level room category . Proportionate deduction due to stay in higher room category is
of cover that he/she is entitled
to. applied during claim settlement. No Room Rent proportionate deductions to be
applied for ICU hospitalization and also for Normal Room in hospitals where there
B) Expenses on Hospitalization is no differential billing adopted by the hospital based on room category)
for minimum period of 24 hours
are admissible. ➢ Doctors/Medical Practitioner fees
However this time limit will not
➢ Intensive Care Unit
apply for specific treatments i.e.
Dialysis, Chemotherapy,
➢ Nursing expenses
Radiotherapy, Eye surgery,
Lithotripsy (kidney stone
➢ Surgical fees, operating theatre, anesthesia and oxygen and their administration
removal), Tonsillectomy, D & C
taken in the Hospital/Nursing
➢ Drugs and medicines consumed on the premises
home and the insured is
discharged on the same day of
➢ Hospital miscellaneous services (such as laboratory, x-ray, diagnostic tests)
the treatment will be considered
to be taken under
➢ Radiotherapy and chemotherapy
Hospitalization Benefit.
Pre & Post Hospitalization Expenses
Pre-Hospitalization Expenses
• If the Insured member is diagnosed with an Illness which results in his / her
Hospitalization and for which the Insurer accepts a claim, the Insurer will also
Definition
reimburse the Insured Member’s Pre-hospitalization Expenses for up to 30 days prior
to his / her Hospitalization.
Covered • Yes
Duration • 30 Days

Post-Hospitalization Expenses
• If the Insurer accepts a claim under Hospitalization and immediately following the
Insured Member’s discharge, further medical treatment directly related to the same
Definition condition for which the Insured Member was Hospitalized is required, the Insurer will
reimburse the Insured member’s Post-hospitalisation Expenses for up to 60 day
period.
Covered • Yes
Duration • 60 Days

*Any One Illness: A claim is considered as a single illness if it has a continuous period of illness or results in a relapse
within 45 days of the earlier treatment.
Maternity Benefits
Benefit Details
Benefit Amount
Restriction on no of children
9 Months waiting period
Pre and Post Natal
Benefit applicable to
Life Threatening Maternity
• INR 50,000 for Normal & INR 70,000 for C-
section
• Maximum of two children
• Waived off
• INR 5000 within maternity limit
• Employee and Spouse only
• Covered up to Family Sum insured

• These benefits are admissible in case of hospitalization in India.

• Covers first two children only. Those who already have two or
more living children will not be eligible for this benefit.
• Expenses incurred in connection with voluntary medical
termination of pregnancy during the first 20 weeks from the date
of conception are not covered.
 Check for Excluded hospitals on the below link

https://www.bajajallianz.com/branch-locator.html

Pls click on Blacklisted Hospital List

Note - That no planned hospitalization in the blacklisted/Excluded hospitals will be allowed.

*
 Enrolment
Enrolment
- Employee has to enrol their dependent’s for
Mediclaim policy on Benefitme Portal
- Employee can download e-cards from benefityou
portal.
- In case of any discrepancy or any family member
details are missing please send an email to
Vijay.jha@marsh.com
This e-card is not transferable. Each insured life will
be issued an e-card. This card is a form of
identification only.
Mid-term inclusions
▪ Family details of New joinee to be shared with Marsh
Team via defined process in the portal
▪ Employee marriage – Spouse should be enrolled
within 30 days of marriage
▪ New born baby – New Born Baby should be enrolled
within 30
days of the birth (e.g. Baby of (<<Employee Name>>)
▪ Adoption of a child - Child should be enrolled within
30 days from date of adoption
Things to remember
▪ Please declare your family members within the
stipulated time frame to HR team.
▪ Failing to do so will lead to the family
member being uninsured until the next
renewal i.e. in July 2024.
▪ Any claim towards the un-insured family member
will not be registered for the current policy period.
Inclusions & exclusions
Includes Excludes

The expenses are payable provided they are incurred in

India and within the policy period.
Only “in-patient” hospitalization expenses – Room rent, doctors
fees, OT charges, medicines, consumables , Costs of
prosthetic devices if implanted during a surgical procedure
Non - Medical Expenses - Registration/Admission fees,
hospital surcharge, food bills for attendants, extra bed,
private nurse, telephone charges, pharmacy charges for
non-medical items etc.

Active treatment with minimum 24 hours

Hospitalization for diagnostic tests only not followed by
hospitalization, however for certain day care procedures like
active line of treatment even if prescribed by a medical
cataract, chemotherapy, dialysis, lithotripsy this condition
practitioner
does not apply

Pre-hospitalization expenses of 30 days before admission and

post hospitalization expenses for 60 days after discharge for Other standard policy exclusions
an eligible hospitalization except maternity cases.
Exclusions
Exclusions
Injury or disease directly or indirectly caused by or arising from or attributable to Out-patient diagnostic/medical/surgical procedures/treatments, non-
war or war-like situations and by nuclear weapons is not within the scope of the prescribed drugs/medical supplies/hormone replacement therapy, sex
policy change or any treatment related to this is not within the scope of the policy

Diagnostic, X-Ray or Laboratory examination not consistent with or incidental to

Circumcision, vaccination, inoculation, cosmetic treatment, plastic surgery,
the diagnosis of positive existence and treatment of any ailment, sickness or
unless required to treat injury or illness.
injury, for which confinement is required at a Hospital or Nursing Home.

Spectacles, multi-focal lens, contact lenses, hearing aids; external

Vitamins and tonics unrelated to treatment
prosthetic devices etc

Voluntary termination of pregnancy & Procedures related to

Dental treatment without hospitalization unless arising due to an accident
contraception

Convalescence, general weakness, congenital external disease, obesity

treatment, sterility, venereal disease, all psychiatric and psychosomatic
Ambulatory devices and equipments used for diagnosis and or treatment
disorders, use of intoxicating drugs/ alcohol, self injury, psychiatric treatment,
Expenses related to AIDS, use of tobacco leading to cancer

Domiciliary Hospitalization, Experimental Treatment, change of treatment Naturopathy, unproven procedure/treatment not approved by Indian Medical
from one system to another unless recommended by doctor, treatment Council, experimental or alternative medicine/treatment including acupuncture,
taken outside India acupressure, magneto- therapy etc

Injury arising from any hazardous activity including scuba diving, motor racing,
parachuting, hand gliding, rock or mountain climbing etc or participating in any
crimal act

Note: Above are general exclusions and should not be interpreted as exhaustive or
conclusive in nature
 Cashless Process
Hospitals in the Cashless means the Administrator may authorize upon a Policyholder’s request

network (please for direct settlement of eligible services and it’s according charges between a

refer to the Network Hospital and the Administrator. In such case the Administrator will

website for the directly settle all eligible amounts with the Network Hospital and the Insured

updated list) Person may not have to pay any deposits at the commencement of the treatment
or bills after the end of treatment to the extent as these services are covered
For Updated List visit to under the Policy.

TPA link as below:

Note : Patients seeking treatment under cashless hospitalization are eligible to

https://general.bajajallianz make claims under pre and post hospitalization expenses. For all such expenses
.com/BagicNxt/hm/hmSea the bills and other required documents needs to submitted separately as part of
rchState.do the claim's reimbursement.
Cashless Hospitalization- Emergency

Step 1: Get Admitted Pre-

Member gets admitted authorization Non cashless
In cases of emergency, the member in the hospital in case
should get admitted in the nearest given by the Hospitalization
of emergency by Administrator
network hospital by showing theirID showing his ID Card NO Process
card. Um vis. Opiorus ses, nocaet

YES
Step 2: Pre-Authorization by hospital
Relatives of admitted member should Member/Hospital Member gets treated
inform the call centre within 24 hours applies for pre- and discharged
PROCESS

about the hospitalization & Seek pre authorization to the after paying all non-
authorization. The preauthorization Administrator within 24 medical expenses like
letter would be directly given to the hrs of admission refreshments, etc..
hospital. In case of denial member
would be informed directly

Step 3: Treatment & Discharge Administrator verifies Hospital sends

To Access
After your hospitalization has been pre- applicability of the complete set of
claim to be registered claims documents https://general.bajajall
authorized the employee is not required
to pay the hospitalization bill in case of and issue pre- for processing to the ianz.com/BagicNxt/h
a network hospital. The bill will be sent authorization Administrator m/hmSearchState.do
directly to, and settled by Administrator
 Cashless Hospitalization- Planned

Step 1: Pre-Authorization Member intimates Claim Administrator

All non-emergency hospitalization Administrator of the Registered by the authorizes cashless
instances must be pre-authorized planned Administrator on as per SLA for
with the Administrator , as per the hospitalization in a same day YE
planned
procedure detailed below. This is authorization
specifiedpre-
format S
hospitalization to the
done to ensure that the best at- least 48 hours in
hospital
healthcare possible, is obtained, advance
and the patient/employee NO
is not inconvenienced when
taking admission into a Follow non cashless Pre-Authorization
Network Hospital. process Completed

Step 2: Admission, Member gets treated and Hospital sends

Treatment & discharge Member produces ID
discharged after paying complete set of
card at the network
After your hospitalization has all non entitled benefits claims documents for
hospital and gets
been pre-authorized, you need like refreshments, etc.. processing to
admitted
to secure Administrator
admission to a hospital. A letter of
credit will be issued by Administrator
Please Note: At the time of discharge when the
to the hospital. Kindly present your
Administrator receives the final bill, they try to renegotiate with
ID card
the Hospital for a better price. Hence it may take some
at the Hospital admission desk. The
time for Administrator to revert back with final approval. This
employee is not required to pay the
exercise checks the hospital to overcharge you and Claims
hospitalization bill in case of a
helps keep your sum insured utilization optimized for Processing &
network hospital. The bill will be
any future exigencies .. Please be patient Settlement by
sent directly to, and settled by
Administrator Administrator &
Insurer
Caringly Yours App :- CDC Health (Claim by Direct Click)
This app allows the faster claim settlement of admissible claims up to INR 20,000/-

• Download Bajaj Allianz’s ‘Caringly Yours’ mobile App from Play Store/App Store.
• Login to the ‘Caringly Yours’ app.
• Ad your policy details in the app.
• Click on “My Claims.”
• Select State, City & Hospital name where patient is/was hospitalized.
• Select details of the patient.
• Select the Policy Number under which the claim is to be registered.
• Enter the hospitalization details – DOA, DOD & Diagnosis
• Read the disclaimer and click on proceed.
• On all the bills to be attached, do write “Claimed with Bajaj Allianz with 20,000/-“
• Upload the photographs of Claim form, Discharge Summary, Hospital Bill, Investigation reports, Pharmacy
Bills, etc.
• It is mandatory to write “CLAIMED WITH BAJAJ ALLIANZ GENERAL INSURANCE COMPANY LIMITED”
in bold letters on all claim documents.
• As soon as the company receives the document, a verification call will be made to you and the hospital to
confirm hospitalization.
• If the claim is admissible & claimed amount is up to 20000/- then it will get approved and paid to the
beneficiary.
Non-Cashless

Admission procedure
• In case you choose a non-network hospital you will have to liaise directly with the hospital for admission.
• However you are advised to follow the pre authorization procedure to ensure eligibility for reimbursement of
hospitalization expenses from the insurer.

Discharge procedure
• In case of non network hospital, you will be required to clear the bills and submit the claim to TPA for
reimbursement from the insurer. Please ensure that you collect all necessary documents such as – discharge
summary, investigation reports etc. for submitting your claim.

Submission of hospitalization claim

• You must submit the final claim with all relevant documents within 15 days from the date of discharge from
the hospital.
 Non-Cashless Claims Process
Member intimates TPA before Insured admitted as per Insured Submits relevant
Claim registered by TPA after
or as soon as hospitalization hospital norms. All payments documents the Help desk A
receipt of claim intimation
occurs made by member within 30 days of discharge

Is document
received •Insured will create the
Is claim TPA performs medical scrutiny
within 30 summary of Bills (2 copies)
payable? of the documents
Yes days from and attach it with the
Yes discharge original bills
No No
•The envelope should
contain clearly the
Claim Rejected Employee ID & Employee
e-mail

Is Payment to be Employee at the

TPA checks document documentatio Claims processing done as per help desk. The discharge
sufficiency n complete Yes SLA voucher and copy of payment
as required receipt to be sent to HR.

No
Receives mail about deficiency
A
and document requirement

Note :- Pls intimate Bajaj Allianz on the reimbursement claims within 48 hours of admission
Call Center – 18001032529
Email id – health.admin@bajajallianz.co.in
Claims Document List
Day Care List
➢ Completed Claim form with Signature

➢ Hospital bills in original (with bill no; signed and stamped by the hospital)
with all charges itemized and the original receipts
Day Care List
➢ Discharge Report/Certificate/card (original)

➢ Attending doctors’ bills and receipts and certificate regarding diagnosis (if
separate from hospital bill)
➢ Original reports or attested copies of Bills and Receipts for Medicines, Claims Form
Investigations along with Doctors prescription in Original and Laboratory

➢ Follow-up advice or letter for line of treatment after discharge from hospital,
from Doctor.
➢ Provide Break up details including Pharmacy items, Materials, Investigations
even though it is there in the main bill
➢ In case the hospital is not registered, please get a letter on the Hospital
letterhead mentioning the number of beds and availability of doctors and Non Medical List
nurses round the clock.
➢ In non- network hospital, you may have to get the hospital and doctor’s
registration number in Hospital letterhead and get the same signed and
Non Medical
stamped by the hospital, if required. Expenses List

*Please retain photocopies of all documents submitted

 Medical Benefit – General Exclusions

• Injury or disease directly or indirectly caused by or arising from or attributable to War or War-like situations
• Circumcision unless necessary for treatment of disease
• Congenital external diseases or defects/anomalies
• Hospitalization for convalescence, general debility, intentional self-injury, use of intoxicating drugs/ alcohol.
• Venereal diseases
• Injury or disease caused directly or indirectly by nuclear weapons
• 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)
• OPD Claims not payable under the base Group Mediclaim Policy
• Claims (of high value) submitted without prescriptions/diagnosis
• Health foods
• Costs incurred as a part of membership/subscription to a clinic or health center
• Naturopathy
• Cost of appliances, spectacles, contact lenses, hearing aids
• Non-medical expenses like Hospital surcharge, telephone bills, cafeteria bills
Prudent Utilization of Benefit
• Health Insurance is a benefit for the employee and their dependents. One has to utilize the benefit with utmost
caution and prudence.
• The ever-increasing cost for the benefits require a proactive involvement from all of us.
• The following steps are recommended, ensuring the benefits is prudently utilized by the employee and dependents
✓ Please ensure to crosscheck the final bill sent to the TPA for the following:
✓ You are Billed only for the services utilized for e.g. category of room, diagnostics undergone , medicines
consumed
✓ Total of the bill
✓ In case of any planned hospitalization, approach the hospital in advance (24 hrs) and request pre
✓ authorization- this enables TPA to further negotiate the rates
✓ To approach hospitals with caution – most expensive is not necessarily the best.
✓ To cross check the tariff with the Benchmark Rates provided- the benchmark rates would give an idea
✓ the general spend for the treatment or procedure.
✓ Try to negotiate
✓ Ask WHY & WHAT is billed to you ( as a consumer , we have the right to know)
Contact Details
TPA : In-House (Health Administration Team)

Address : Bajaj Allianz General Insurance Co Ltd

952/954, Appa Saheb Maratha Marg, Prabhadevi, Mumbai - 400025

Toll Free No :1800 10 32 529

Level- 1 Level- 2 Level- 3

Cashless assistance Uday Sarpole Jatin Negi
1800 20 95 858 /+91 22 3030 585 8657526886 8657545060
preauth@bajajallianz.co.in / Uday.sarpole@bajajallianz.co.in Jatin.negi03@bajajallianz.co.in
hat@bajajallianz.co.in

Insurance Broker : Marsh India Insurance Broker

Escalation- 2
Escalation- 1
Shashikant Dingankar
Vijay Jha
9833806360
9833806354
shashikant.dingankar@marsh.com
Vijay.jha@marsh.com
Group Personal Accident Policy

Coverage Details (Employee)

Benefits Extensions – Definitions

Claims Procedure

Document Checklist

General Exclusions

Contact Details
GPA Benefit Details
All employees will be provided with a Personal Accident insurance policy through- Bajaj Allianz General Insurance Co. Ltd. based on
company rules (you may contact your HR for further details). This insurance provides compensation/payment up to a financial limit
as assigned by the company, to the insured person or his legal personal representative, if the insured person suffers death or
disablement due to an accident. The cover is world wide but payment of claim can only be made in India and in Indian Rupees.

Policy Parameter
Insurer Bajaj Allianz General Insurance Co. Ltd.
Policy Start Date 1st July 2023
Policy End Date 30th June 2024
Coverage Death & Disability arising out of an accident
Sum Insured 2 times of CTC subject to minimum 10 Lacs
Accidental Death 100% of the Capital Sum Insured is payable
Permanent Total Disability Covered
Permanent Partial Disability Covered
Temporary Total Disability Employment or occupation then 1% of the Sum Insured or INR 5,000 per week whichever is
lower is payable for up to 104 weeks
Medical Extension Medical Expenses up to 40% of claim amount or 10% of Sum insured or actual medical bills
submitted which ever is lower. This is applicable only when the claim is admissible under
Terrorism Covered
Geographical Limit Worldwide
Benefit Extensions
• This policy covers the following benefits-
• Accidental Death
• Permanent Total Disability (PTD)
• Permanent Partial Disability (PPD)
• Temporary Total Disability (TTD)- up to 100 weeks. 1% of Sum Insured subject to maximum of INR 5000
per week, which ever is lower
• Medical Extension- 10% of SI or 40% of admissible claim or actuals, whichever is less
• Coverage operates world wide on 24 hours basis.
• Terrorism cover.
• Education benefit @ 10% of SI max up to INR 5000 for one Child & INR 10,000 for two children
• Carriage of dead body : 2% of sum insured, max of INR 5,000
• Family travel expenses: up to a maximum of INR 25,000
• Repatriation of remains: Up to INR 5,000/-
• Disappearance: Covered (subject to policy terms and conditions)
GPA Claims Process

Claimant / Nominee notifies HR, who in

turn would intimate Insurer and submit
required claim documents within 30 Is claim Yes Cheque is sent to Employer (HR), from
Days of the event payable? where it is given to the Claimant/ Assignee

On obtaining all relevant documents,

Insurance Co. will begin processing No
the claims

Insurer provides a valid reason for the

rejection to HR (death) no death
(Claimant)

Claim Investigation and Review of

submission of all the required
documents
Group Personal Accident – Claims Document Checklist
Weekly Benefit Claims Death Claims Dismemberment/ Disablement Claims

1. Completed Claim form 1. Completed claim form 1. Completed claim form

2. Doctor's Report 2. Attending Doctor's report 2. Doctor's Report
3. Disability Certificate from the 3. Death Certificate 3. Disability Certificate from the
Doctor, if any 4. Post Mortem/ Coroner's report Doctor
4. Investigation/ Lab reports (x-ray 5. FIR ( First Information Report) 4. Investigation/ Lab reports (x-ray
etc.) 6. Police Inquest report, wherever etc.)
5. Original Admission/discharge applicable 5. Original Admission/ discharge
card, if hospitalized card, if hospitalized.
6. Employers Leave Certificate & 6. Police Inquest report, wherever
Details of salary applicable

GPA Claim Form

GPA General Exclusions

1. Service on duty with any armed force

2. Insanity
3. Venereal disease
4. For claiming in Medical extension PPT,TTD,PPD criteria to be fulfilled & claimed.
5. Influence of intoxicating drink or drugs, abiding traffic rule & invalid license.
6. Aviation other than as a passenger (fare paying or otherwise) in any duly licensed standard type of
aircraft any where in the world
7. Nuclear radiation or nuclear weapons material
8. Any consequence of war, invasion, act of foreign enemy, hostilities (whether war be declared or
not), civil war, rebellion, revolution, insurrection, mutiny, military, or usurped power, seizure,
capture, arrest, restraint, detainment’s of all kings, princes, and people of whatever nation,
conditions and qualities so ever
9. Childbirth, pregnancy or other physical causes peculiar to the female sex
10. While committing any breach of law with criminal intent
Contact Details - GPA Claims
ESCALATION 1

Name – Vijay Jha

Contact No - 9833806354
Email ID: Vijay.jha@marsh.com

ESCALATION 2

Name – Shashikant Dingankar

Contact No - 9833806360
Email ID – shashikant.dingankar@marsh.com
 Provides insurance coverage to parents for expenses related to
Voluntary Parental Policy hospitalization due to illness, disease or injury
Medical Benefits
Coverage Details (Parents)

Cashless Process

Non-Cashless

Claims Process

Claims Document List

Benefits Extensions – Definitions

General Exclusions

GMC Contact Details

Prudent Utilization of Benefit

Coverage Details For Voluntary Parental Policy
Policy Parameter
Insurer Bajaj Allianz General Insurance Co. Ltd.
TPA In-house HAT (Health Administration Team)
Policy Start Date 1st July 2023
Policy End Date 30th June 2024
Coverage Type Family Floater
Sum Insured Graded SI of INR 1 lac , INR 2 lac, INR 3 Lacs, INR 5 lac, INR 7 lacs
M/s. Worley India Pvt Ltd – VPP - Policy Number - OG-24-1919-8403-00000150
Policy Numbers
M/s. Worley Services India Pvt Ltd – VPP - Policy Number - OG-24-1919-8403-00000149

Maximum no of Members insured in a family 4 Siblings No

(Parents or Parents in law - both sets
allowed) Others No

Employee No Mid Term enrollment of existing Dependents Disallowed

Spouse No Mid Term enrollment of new joiners (New

Allowed
employees +their Dependents)
Children ( up to 25 year age) No
Mid term enrollment of new dependents
Yes NA
Parents (Spouse/Children)
Parents-in-Law Yes

*No Individual should be covered as dependent of more than one employee

Coverage Details For Voluntary Parental Policy
Benefits / Extensions Coverage Benefits / Extensions Coverage
Standard Hospitalization Yes Domiciliary Hospitalization Not Covered

TPA services Yes Pre-Post Hospitalization

30 days and 60 days
Exp.
Pre-existing diseases Yes
Pre and Post Natal NA
Waiver on 1st year exclusion Yes
For SI 1 lac & 2 lac ,
INR 3000 per day & for
Waiver on 1st 30 days excl. Yes all others 1% of SI for
Room Rent Capping Normal & ICU no
Maternity benefits NA capping, all charges in
accordance with Room
Baby cover day 1 NA Rent restriction.
up to 1000 10% Applicable on all
Ambulance Services Copay
(Emergency only) admissible claims

Policy Period
Existing Employees + Dependents New joiners + Dependents New Dependents (due to Marriage /
Birth)
Commencement Commencement Date of
1sth July ’2023 Date joining
Date Commencement Date NA
Last day of
Termination Date 30th June’2024 Termination Date
employment Declaration NA
Benefits contd..

Benefits / Extensions Coverage

Hospitalization due to terrorism Covered

Minimum lock in period 2 years once enrolled in policy

Psychiatric ailments Capping at INR 30,000

Nasal Sinus surgeries Capping at INR 35,000

Disease wise capping Not Applicable

Congenital Internal Diseases / Defects Covered

Sum Insured selection criteria for parents policy is linked with Employee Base Sum
Insured as under.

Employee Policy – Base SI Parents Sum Insured

Allowed
3,00,000 1L/2L/3L/5L

4,00,000 2L/3L/5L

6,00,000 3L/5L/7L

7,00,000 3L/5L/7L

10,00,000 3L/5L/7L
This is an optional plan for employees to enrol to cover your parents and parents in law
for medical insurance.

Employee can select single parent and/or double parents and/or single parent in law
and/or double parent in law. For Floater sum insured premium rate, Criss cross
selection between single parent and single parent-in-law is NOT allowed.

Please note below mention premium including GST.

Sum Insured Single Parent/In Law 2 Parent/In Law Rate

Rate (Floater Sum Insured)
(Individual Sum
Insured)
100000 22,106 39,791
200000 28,739 51,729
300000 34,486 62,075
500000 44,832 80,699
700000 58,281 104,910
Example for parent/in laws selection by employee and premium calculation
Father Mother Father in Mother in Premium Details (Including GST Figures)
Selection Selection law law
Selection Selection
Employee 1 – Base SI INR 3 Lac and VPP Yes Yes Yes Yes Employee will have to pay INR 39,791 for parents
selection of INR 1 Lac and INR 39,791 for parent in laws

Employee 2 – Base SI INR 3 Lac and VPP Yes No Yes Yes Employee will have to pay INR 22,106 for Single
selection of INR 1 Lac parent and INR 39,791 for parent in laws

Employee 3 – Base SI INR 3 Lac and Yes Yes Yes Yes Employee will have to pay INR 62,075 for Parents
Parents / in law sum insured of INR 3 Lacs and INR 62,075 for parent in laws

Employee 4 – Base SI INR 7 Lac and VPP Yes Yes Yes No Employee will have to pay INR 80,699 for both
selection of INR 5 Lac parents and INR 44,832 for Single Parent in law

Employee 5 – Base SI INR 7 Lac and VPP Yes No No No Employee will have to pay INR 44,832 for single
selection of INR 5 Lac parent

Employee 6 – Base SI INR 7 Lac and VPP No No Yes Yes Employee will have to pay INR 80,699 for parents
selection of INR 5 Lac in law and no premium payable for parent (As not
selected.)

Please Note :
A) The expenses are payable
provided they are incurred in
India and within the policy
period. Expenses will be
reimbursed to the covered
member depending on the level
of cover that he/she is entitled
to.
Covers expenses related to :
➢ Room and boarding-For SI 1 lac SI 2 lac INR 3000 per day & for all
others 1% of Sum insured for Normal & for ICU no capping
➢ (Hospital billing is based on the room category opted by the patient, hence
the cost of investigations, surgery, doctor’s fees is incremental as you go to
a higher room category . Proportionate deduction due to stay in higher
room category is applied during claim settlement.)

➢ Doctors/Medical Practitioner fees

B) Expenses on Hospitalization
for minimum period of 24 hours
are admissible. ➢ Intensive Care Unit

However this time limit will not ➢ Nursing expenses

apply for specific treatments i.e.
Dialysis, Chemotherapy,
➢ Surgical fees, operating theatre, anesthesia and oxygen and their
Radiotherapy, Eye surgery,
Lithotripsy (kidney stone administration
removal), Tonsillectomy, D & C
taken in the Hospital/Nursing ➢ Drugs and medicines consumed on the premises
home and the insured is
discharged on the same day of
➢ Hospital miscellaneous services (such as laboratory, x-ray, diagnostic
the treatment will be considered
to be taken under tests)
Hospitalization Benefit.
➢ Radiotherapy and chemotherapy
 Enrolment
Enrolment
▪ Employees will have to add their parent's information on
Benefit Me Portal, once they receive the access code
▪ An e-mail will be sent from Benefit Me giving the log in
credentials to access their Portal
▪ Please exercise your option on the sum insured.
▪ One set of Parents or parents in law will be allowed
(Combination is not allowed)
▪ You need to do it within 15 days from the receipt
of emails
Mid-term inclusions
▪Parent details of New joinee to be shared with Marsh
Team via defined process in the portal within 30 days
from date of joining
Things to remember
▪ Please enroll your parents within the stipulated time
frame.
▪ Failing to do so will lead to the dependent being
uninsured until the next renewal i.e. in July 2023.
▪ Any claim towards the un-insured parent will not be registered
for the current policy period
Inclusions & exclusions
Includes Excludes

The expenses are payable provided they are incurred in

India and within the policy period.
Only “in-patient” hospitalization expenses – Room rent, doctors
fees, OT charges, medicines, consumables , Costs of
prosthetic devices if implanted during a surgical procedure
Non - Medical Expenses - Registration/Admission fees,
hospital surcharge, food bills for attendants, extra bed,
private nurse, telephone charges, pharmacy charges for
non-medical items etc.

Active treatment with minimum 24 hours

Hospitalization for diagnostic tests only not followed by
hospitalization, however for certain day care procedures like
active line of treatment even if prescribed by a medical
cataract, chemotherapy, dialysis, lithotripsy this condition
practitioner
does not apply

Pre-hospitalization expenses of 30 days before admission and

post hospitalization expenses for 60 days after discharge for Other standard policy exclusions
an eligible hospitalization except maternity cases.
Exclusions
Exclusions
Injury or disease directly or indirectly caused by or arising from or attributable to Out-patient diagnostic/medical/surgical procedures/treatments, non-
war or war-like situations and by nuclear weapons is not within the scope of the prescribed drugs/medical supplies/hormone replacement therapy, sex
policy change or any treatment related to this is not within the scope of the policy

Diagnostic, X-Ray or Laboratory examination not consistent with or incidental to

Circumcision, vaccination, inoculation, cosmetic treatment, plastic surgery,
the diagnosis of positive existence and treatment of any ailment, sickness or
unless required to treat injury or illness.
injury, for which confinement is required at a Hospital or Nursing Home.

Spectacles, multi-focal lens, contact lenses, hearing aids; external

Vitamins and tonics unrelated to treatment
prosthetic devices etc

Voluntary termination of pregnancy & Procedures related to

Dental treatment without hospitalization unless arising due to an accident
contraception

Convalescence, general weakness, congenital external disease, obesity

treatment, sterility, venereal disease, all psychiatric and psychosomatic
Ambulatory devices and equipments used for diagnosis and or treatment
disorders, use of intoxicating drugs/ alcohol, self injury, psychiatric treatment,
Expenses related to AIDS, use of tobacco leading to cancer

Domiciliary Hospitalization, Experimental Treatment, change of treatment Naturopathy, unproven procedure/treatment not approved by Indian Medical
from one system to another unless recommended by doctor, treatment Council, experimental or alternative medicine/treatment including acupuncture,
taken outside India acupressure, magneto- therapy etc

Injury arising from any hazardous activity including scuba diving, motor racing,
parachuting, hand gliding, rock or mountain climbing etc or participating in any
crimal act

Note: Above are general exclusions and should not be interpreted as exhaustive or
conclusive in nature
 Cashless Process
Hospitals in the Cashless means the Administrator may authorize upon a Policyholder’s request

network (please for direct settlement of eligible services and it’s according charges between a

refer to the Network Hospital and the Administrator. In such case the Administrator will

website for the directly settle all eligible amounts with the Network Hospital and the Insured

updated list) Person may not have to pay any deposits at the commencement of the treatment
or bills after the end of treatment to the extent as these services are covered
For Updated List visit to under the Policy.

TPA link as below:

Note : Patients seeking treatment under cashless hospitalization are eligible to

https://general.bajajallianz make claims under pre and post hospitalization expenses. For all such expenses
.com/BagicNxt/hm/hmSea the bills and other required documents needs to submitted separately as part of
rchState.do the claim's reimbursement.
Cashless Hospitalization- Emergency

Step 1: Get Admitted Pre-

Member gets admitted authorization Non cashless
In cases of emergency, the member in the hospital in case
should get admitted in the nearest given by the Hospitalization
of emergency by Administrator
network hospital by showing theirID showing his ID Card NO Process
card. Um vis. Opiorus ses, nocaet

YES
Step 2: Pre-Authorization by hospital
Relatives of admitted member should Member/Hospital Member gets treated
inform the call centre within 24 hours applies for pre- and discharged
PROCESS

about the hospitalization & Seek pre authorization to the after paying all non-
authorization. The preauthorization Administrator within 24 medical expenses like
letter would be directly given to the hrs of admission refreshments, etc..
hospital. In case of denial member
would be informed directly

Step 3: Treatment & Discharge Administrator verifies Hospital sends

To Access the
After your hospitalization has been pre- applicability of the complete set of
claim to be registered claims documents https://general.bajajall
authorized the employee is not required
to pay the hospitalization bill in case of and issue pre- for processing to the ianz.com/BagicNxt/h
a network hospital. The bill will be sent authorization Administrator m/hmSearchState.do
directly to, and settled by Administrator
 Cashless Hospitalization- Planned

Step 1: Pre-Authorization Member intimates Claim Administrator

All non-emergency hospitalization Administrator of the Registered by the authorizes cashless
instances must be pre-authorized planned Administrator on as per SLA for
with the Administrator , as per the hospitalization in a same day YE
planned
procedure detailed below. This is authorization
specifiedpre-
format S
hospitalization to the
done to ensure that the best at- least 48 hours in
hospital
healthcare possible, is obtained, advance
and the patient/employee NO
is not inconvenienced when
taking admission into a Follow non cashless Pre-Authorization
Network Hospital. process Completed

Step 2: Admission, Member gets treated and Hospital sends

Treatment & discharge Member produces ID
discharged after paying complete set of
card at the network
After your hospitalization has all non entitled benefits claims documents for
hospital and gets
been pre-authorized, you need like refreshments, etc.. processing to
admitted
to secure Administrator
admission to a hospital. A letter of
credit will be issued by Administrator
Please Note: At the time of discharge when the
to the hospital. Kindly present your
Administrator receives the final bill, they try to renegotiate with
ID card
the Hospital for a better price. Hence it may take some
at the Hospital admission desk. The
time for Administrator to revert back with final approval. This
employee is not required to pay the
exercise checks the hospital to overcharge you and Claims
hospitalization bill in case of a
helps keep your sum insured utilization optimized for Processing &
network hospital. The bill will be
any future exigencies .. Please be patient Settlement by
sent directly to, and settled by
Administrator Administrator &
Insurer
Caringly Yours App :- CDC Health (Claim by Direct Click)
This app allows the faster claim settlement of admissible claims up to INR 20,000/-

• Download Bajaj Allianz’s ‘Caringly Yours’ mobile App from Play Store/App Store.
• Login to the ‘Caringly Yours’ app.
• Ad your policy details in the app.
• Click on “My Claims.”
• Select State, City & Hospital name where patient is/was hospitalized.
• Select details of the patient.
• Select the Policy Number under which the claim is to be registered.
• Enter the hospitalization details – DOA, DOD & Diagnosis
• Read the disclaimer and click on proceed.
• On all the bills to be attached, do write “Claimed with Bajaj Allianz with 20,000/-“
• Upload the photographs of Claim form, Discharge Summary, Hospital Bill, Investigation reports, Pharmacy
Bills, etc.
• It is mandatory to write “CLAIMED WITH BAJAJ ALLIANZ GENERAL INSURANCE COMPANY LIMITED”
in bold letters on all claim documents.
• As soon as the company receives the document, a verification call will be made to you and the hospital to
confirm hospitalization.
• If the claim is admissible & claimed amount is up to 20000/- then it will get approved and paid to the
beneficiary.
Non-Cashless

Admission procedure
• In case you choose a non-network hospital you will have to liaise directly with the hospital for admission.
• However you are advised to follow the pre authorization procedure to ensure eligibility for reimbursement of
hospitalization expenses from the insurer.

Discharge procedure
• In case of non network hospital, you will be required to clear the bills and submit the claim to TPA for
reimbursement from the insurer. Please ensure that you collect all necessary documents such as – discharge
summary, investigation reports etc. for submitting your claim.

Submission of hospitalization claim

• You must submit the final claim with all relevant documents within 15 days from the date of discharge from
the hospital.
 Non-Cashless Claims Process

Member intimates TPA before Insured admitted as per hospital Insured Submits relevant
Claim registered by TPA after
or as soon as hospitalization norms. All payments made by documents the Help desk A
receipt of claim intimation
occurs member within 30 days of discharge

Is document
received
Is claim TPA performs medical scrutiny of •Insured will create the
within 30 days
payable? the documents summary of Bills (2 copies)
Yes from
Yes discharge and attach it with the
original bills
No No
•The envelope should
contain clearly the
Employee ID & Employee e-
Claim Rejected
mail

Is Payment to be Employee at the

TPA checks document documentatio Claims processing done as per help desk. The discharge
sufficiency n complete Yes SLA voucher and copy of payment
as required receipt to be sent to HR.

No

Receives mail about deficiency

A
and document requirement
Claims Document List
➢ Completed Claim form with Signature

➢ Hospital bills in original (with bill no; signed and stamped by the hospital)
with all charges itemized and the original receipts
Claims Form
➢ Discharge Report/Certificate/card (original)

➢ Attending doctors’ bills and receipts and certificate regarding diagnosis (if
separate from hospital bill)
➢ Original reports or attested copies of Bills and Receipts for Medicines,
Investigations along with Doctors prescription in Original and Laboratory

➢ Follow-up advice or letter for line of treatment after discharge from hospital,
from Doctor.
➢ Provide Break up details including Pharmacy items, Materials, Investigations
even though it is there in the main bill
➢ In case the hospital is not registered, please get a letter on the Hospital
letterhead mentioning the number of beds and availability of doctors and
nurses round the clock.
➢ In non- network hospital, you may have to get the hospital and doctor’s
registration number in Hospital letterhead and get the same signed and
stamped by the hospital, if required.

*Please retain photocopies of all documents submitted

 Medical Benefit – General Exclusions
• Injury or disease directly or indirectly caused by or arising from or attributable to War or War-like situations
• Circumcision unless necessary for treatment of disease
• Congenital external diseases or defects/anomalies
• HIV and AIDS
• Hospitalization for convalescence, general debility, intentional self-injury, use of intoxicating drugs/ alcohol.
• Venereal diseases
• Injury or disease caused directly or indirectly by nuclear weapons
• Naturopathy and AYUSH
• 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)
• OPD Claims not payable under the base Group Mediclaim Policy
• Claims (of high value) submitted without prescriptions/diagnosis
• Health foods
• Costs incurred as a part of membership/subscription to a clinic or health center
• Naturopathy
• Cost of appliances, spectacles, contact lenses, hearing aids
• Non-medical expenses like Hospital surcharge, telephone bills, cafeteria bills
Prudent Utilization of Benefit
• Health Insurance is a benefit for the employee and their dependents. One has to utilize the benefit with utmost
caution and prudence.
• The ever-increasing cost for the benefits require a proactive involvement from all of us.
• The following steps are recommended, ensuring the benefits is prudently utilized by the employee and dependents
✓ Please ensure to crosscheck the final bill sent to the TPA for the following:
✓ You are Billed only for the services utilized for e.g. category of room, diagnostics undergone , medicines
consumed
✓ Total of the bill
✓ In case of any planned hospitalization, approach the hospital in advance (24 hrs) and request pre
✓ authorization- this enables TPA to further negotiate the rates
✓ To approach hospitals with caution – most expensive is not necessarily the best.
✓ To cross check the tariff with the Benchmark Rates provided- the benchmark rates would give an idea
✓ the general spend for the treatment or procedure.
✓ Try to negotiate
✓ Ask WHY & WHAT is billed to you ( as a consumer , we have the right to know)
Contact Details
TPA : In-House (Health Administration Team)

Address : Bajaj Allianz General Insurance Co Ltd

952/954, Appa Saheb Maratha Marg, Prabhadevi, Mumbai - 400025

Toll Free No :1800 10 32 529

Level- 1 Level- 2 Level- 3

Cashless assistance Uday Sarpole Jatin Negi
1800 20 95 858 /+91 22 3030 585 8657526886 8657545060
preauth@bajajallianz.co.in / Uday.sarpole@bajajallianz.co.in Jatin.negi03@bajajallianz.co.in
hat@bajajallianz.co.in

Insurance Broker : Marsh India Insurance Broker

Escalation- 2
Escalation- 1
Shashikant Dingankar
Vijay Jha
9833806360
9833806354
shashikant.dingankar@marsh.com
Vijay.jha@marsh.com
FAQ’s & Common Definitions

Documents and links

FAQ’s

Annexure

IRDA (Insurance Regulatory

http://www.irdaindia.org/
and Development Authority)
Thank You