Group Mediclaim Policy

Objective: To provide monetary assistance to all Management staff employees and their nominated
dependents in the event of hospitalization.

Similar to last year, this year also we are having a customised maternity plan option along with the
default Mediclaim plan. The employees can now choose their own plan and verify their details.

Policy document details

Effective Date 01.04.2022
Version Number 1
Date Last Changed 01.04.2022
Next Review 01.04.2023
Interpretation Authority in case of requirement CHRO / Finance Head

The policy details pertain to following business: Piramal Enterprises Ltd.; Piramal Pharma Ltd;
Convergence Chemicals Pvt. Ltd.; Hemmo Pharmaceuticals Pvt. Ltd. & Piramal Trusteeship Services
Pvt Ltd

Policy Details:

 Eligibility: All Management Staff

 Policy Period: 1-Apr-2022 to 31-Mar-2023
 Insurer: ICICI Lombard General Insurance Co Ltd
 IL: ICICI Lombard's IL-Health Care Services ( In-House )
 Broker: Gallagher Insurance Brokers Pvt Ltd.
 There would be a nominal monthly charge to employees in lieu of actual premium paid by
company, as shown below:

Band Family Floater Coverage Deductions Per Month

Amount (Rs.) Amount (Rs.)
Band 1 & 2 4,20,000 600
Band 3 & 4 6,00,000 970
Band 5 & 6 9,00,000 1,420
Band 7 30,00,000 1,865

Employees have been given the flexibility to choose the most suitable Mediclaim policy for
themselves. The two options being –
1. Existing Group Mediclaim Plan ( General Plan)
2. Customized Maternity Plan
Employees shall need to choose their preferred plan FY23 and register through the portal/enrol during
joining.
(I) Policy Features - Existing Group Mediclaim Plan

Coverage, Conditions and Exclusions

A) Coverage:
Covers employees and their dependants for expenses related to hospitalization due to illness, disease
or accidental injury.

Family coverage: Family is defined as 1 + 5 i.e. Self, Spouse/LGBT partner (married/live-in), 2

dependent children (up to 25 years) and 2 dependent parents and or in-laws. The data for the
family shall remain confidential and be circulated only with relevant stakeholders.

Dependents to be covered at the time of inception only. In case of newly married employee, mid-
term addition can be made for spouse or in-laws (if parents are not covered at the time of joining).
New born child can be added from date of birth. The declaration for addition of new dependents
should be sent within 15 days from marriage or child birth. Dependents declared by employee will
remain till expiry of the policy in force. It is at the discretion of insurer to give a continuation of the
policy to individual employees after retirement. Once all five dependents are declared no addition is
possible even after death of any of the dependent during policy period and policy will continue with
remaining dependents only. Addition is not allowed once dependents are declared and employee
is required to declare all dependents at the time of his/her joining.

 All pre-existing diseases are covered from day one. Prior Medical check-up is not required
 30 days pre-hospitalization expenses and 60 days post hospitalization expenses are covered
 Maternity Expenses benefit extension – Expenses related to Maternity hospitalization are
covered under this policy for first 2 Living children.
General Plan: Upto 'Rs.' 50,000/- for Normal and 'Rs.' 1,00,000/- for Caesarean

The hospitalization expenses in respect of the new born child:

o These Benefits are admissible only if the expenses are incurred in a hospital/nursing
home as in-patients in India.
o Claim in respect of delivery for only first two living children and/or operations associated
therewith will be considered in respect of any one Insured Person covered under the
policy or any renewal thereof.
o Those Insured Persons who are already having two or more living children will not be
eligible for this benefit.
o Expenses incurred in connection with voluntary medical termination of pregnancy are
not covered.
o Expenses incurred in connection with Infertility treatment are not covered
o Pre-natal and postnatal expenses are not covered.
o Pre and post hospitalization expenses are not covered for Maternity and related
expenses

 New Born Baby Covered From Day One: New born baby is covered under the policy from
day one, subject to declaration
B) Conditions:

 Per room rent is restricted to 1% of Sum insured per day in case of Normal room and 2% of
sum insured per day in case of admission in ICU. Corresponding expenses would be capped
in the same proportion or as per package for the eligible room rent

 Minimum 24 hours of hospitalization is necessary for claim admissibility along with Active
management of treatment. However in case of following ailments only, 24 hours
hospitalisation is not required:
Adenoidectomy, Appendectomy, Auroplasty, Coronary angiography, Coronary angioplasty,
D&C, Endoscopy Surgery, Eye Surgery, Fracture/dislocation excluding hairline fracture,
Radiotherapy, Lithotripsy, Inclusion and drainage of abscess, FESS, Haemo dialysis,
Fissurectomy/Fistulectomy, Mastoidectomy, Hydrocele, Hysterectomy, Inguinal/
ventral/umbilical/femoral hernia, Parental Chemotherapy, Polypectomy,Piles , Prostrate,
Sinusitis

 25% Co-payment is applicable for Parental Claims

Co-payment is a cost-sharing requirement under a health insurance policy that provides the
policy holder/insured will bear a specified percentage of the admissible claim amount. In our
policy co-payment is fixed at 25% for parental claims only.

e.g.: Sum insured: Rs. 4.2 lakh, Admissible Claim amount - Rs. 1 lakh.
In this case, Insurance Co. / IL will approve 75% amount i.e. Rs. 75,000/-. Balance 25% of claim
i.e. Rs. 25,000 has to be borne by employee. This is applicable for Cashless and
Reimbursement. In case of cashless, employee will have to deposit his share of co-payment
during hospitalization. In case of reimbursement, only 75% (of Admissible Claim amount)
would be remitted by Insurance co./IL

 Ambulance Charges: Covered for- General plan Rs.1000/-

 Non- medical expenses are not cover under the policy.( e.g cotton, gloves, admission charges
etc )
 Mental Wellbeing cover
1. Psychiatric Cover Limit INR 50k per family both for IPD/OPD treatment
2. Consultation/ Counselling Session/ Therapy by psychiatric
b) Pharmacy
c) Diagnostic test
irequired
Exclusion: Psychosomatic Disorder, intentional self-injury (whether arising from an
attempt to suicide or otherwise) & Autism

3. Treatment for special children/ family member

a) Behavioural therapy
b) Speech Therapy
Autism excluded
  Air Ambulance cover

Air Ambulance is covered up to Rs 1 lac or actual whichever is lower in case of Accident event

(II) Policy Features - Customize Maternity Plan

Coverage, Conditions and Exclusions

A) Coverage:
Covers employees and their dependants for expenses related to hospitalization due to illness, disease
or accidental injury.

Family coverage: Family is defined as 1 + 5 i.e. Self, Spouse/LGBT partner (married/live-in) 2

dependent children (up to 25 years) and 2 dependent parents and or in-laws. The data for the
family shall remain confidential and be circulated only with relevant stakeholders.

Dependents to be covered at the time of inception only. In case of newly married employee, mid-
term addition can be made for spouse or in-laws (if parents are not covered at the time of joining).
New born child can be added from date of birth. The declaration for addition of new dependents
should be sent within 15 days from marriage or child birth. Dependents declared by employee will
remain till expiry of the policy in force. It is at the discretion of insurer to give a continuation of the
policy to individual employees after retirement. Once all five dependents are declared no addition is
possible even after death of any of the dependent during policy period and policy will continue with
remaining dependents only. Addition is not allowed once dependents are declared and employee
is required to declare all dependents at the time of his/her joining.

 All pre-existing diseases are covered from day one. Prior Medical check-up is not required
 30 days pre-hospitalization expenses and 60 days post hospitalization expenses are covered
 Maternity Expenses benefit extension – Expenses related to Maternity hospitalization are
covered under this policy up to a maximum of Rs.75,000/- in case of normal delivery and up
to Rs. 1,20,000/- for C-Section (i.e. caesarean) first 2 living children.

The hospitalization expenses in respect of the new born child

o These Benefits are admissible only if the expenses are incurred in hospital/nursing home
as in-patients in India.
o Claim in respect of delivery for only first two living children and/or operations associated
therewith will be considered in respect of any one Insured Person covered under the
policy or any renewal thereof.
o Those Insured Persons who are already having two or more living children will not be
eligible for this benefit.
o Expenses incurred in connection with voluntary medical termination of pregnancy are
not covered.
o Pre-natal and postnatal expenses are not covered
o Pre and post hospitalization expenses are not covered for Maternity and related
expenses

 New Born Baby Covered From Day One: New born baby is covered under the policy from
day one, subject to declaration
B) Conditions:

 Per room rent is restricted to 1% of Sum insured per day in case of Normal room and 2% of
sum insured per day in case of admission in ICU. Corresponding expenses would be capped
in the same proportion or as per package for the eligible room rent

 Minimum 24 hours of hospitalization is necessary for claim admissibility with Active line of
treatment. However in case of following ailments only, 24 hours hospitalisation is not
required:
Adenoidectomy, Appendectomy, Auroplasty, Coronary angiography, Coronary angioplasty,
D&C, Endoscopy Surgery, Eye Surgery, Fracture/dislocation excluding hairline fracture,
Radiotherapy, Lithotripsy, Inclusion and drainage of abscess, FESS, Haemo dialysis,
Fissurectomy/Fistulectomy, Mastoidectomy, Hydrocele, Hysterectomy, Inguinal/
ventral/umbilical/femoral hernia, Parental Chemotherapy, Polypectomy,Piles , Prostrate,
Sinusitis

 30% Co-payment is applicable for Parental Claims

Co-payment is a cost-sharing requirement under a health insurance policy that provides the
policy holder/insured will bear a specified percentage of the admissible claim amount. In this
customize maternity plan co-payment is fixed at 30% for parental claims only.

e.g.: Sum insured: Rs. 4.2 lakh, Admissible Claim amount - Rs. 1 lakh.
In this case, Insurance Co. / IL will approve 70% amount i.e. Rs. 70,000/-. Balance 30% of claim
i.e. Rs. 30,000 has to be borne by employee. This is applicable for Cashless and
Reimbursement. In case of cashless, employee will have to deposit his share of co-payment
during hospitalization. In case of reimbursement, only 70% (of Admissible Claim amount)
would be remitted by Insurance co./IL

 Ambulance Charges: Covered for Rs.2500/- per person

 Infertility treatment: Covered up to 1 lac per family

 Disease wise capping: Urinary Stones-Rs.35000/-, Hernia-Rs.30000/-, Appendicitis-Rs.45000/-

, Piles Rs. 50000/-, TKR-Rs.100000 Per knee

 Well Mother expenses: Covered up to Rs.5000/- within maternity benefit limit.

 Non medical expenses are not cover under the policy ( e.g cotton, gloves, admission charges
etc )
 Cervical Cancer Vaccination: Covered up to 2500 per employee for females up to 18 years

(III) Exclusions:

The Insurance Company shall not be liable to make any payments under this policy in respect of any
expenses whatsoever incurred by any Insured Person in connection with or in respect of:
 War: Injury or Disease directly or indirectly caused by or arising from or attributable to War,
Invasion, Act of Foreign Enemy, war like operations (whether war be declared of not).

 Nuclear Weapons/Material: Injury or Disease directly or indirectly caused by or contributed

to by nuclear weapons/materials.

 Treatment for Age Related Macular Degeneration (ARMD), treatment such as Rotational Field
Quantum Magnetic Resonance (RFQMR), Enhanced External Counter Pulsation (EECP)

 Circumcision: unless necessary for treatment of a disease not excluded hereunder or as may
be necessitated due to an accident, vaccination or inoculation or change of life or cosmetic
or aesthetic treatment of any description, plastic surgery other than as may be necessitated
due to an accident or as a part of any illness.

 Cost of spectacles, contact lenses and hearing aids

 Dental treatment or surgery of any kind unless requiring hospitalization.

 Convalescence, general debility, “run-down” condition or rest cure, congenital external

disease or defects or anomalies, sterility, venereal disease, intentional self-injury and use of
intoxicating drugs / alcohol.

 HIV / Aids: All expenses arising out of any condition directly or indirectly caused to or
associated with Human T-Cell Lymphotropic Virus type III (HTLB-III) or Lymphadinopathy
Associated Virus (LVA) or the Mutants Derivative or Variations Deficiency Syndrome or any
Syndrome or condition of similar kind commonly referred to as AIDS.

 Diagnostic/Investigations: Charges incurred at hospital/Nursing home primarily for

diagnostic, X-ray or laboratory examinations not consistent with or incidental to the diagnosis
and treatment of the positive existence or presence of any ailment, sickness or injury, for
which confinement is required at a hospital/nursing home.

 Vitamins/Tonics: Expenses on vitamins and tonics unless forming part of treatment for injury
or disease as certified by the attending Physician.

 Naturopathy treatment

 External and durable medical/non-medical equipment of any kind used for diagnosis and or
treatment and/or monitoring and/or maintenance and/or support including CPAP, CAPD,
Infusion pump, Oxygen Concentrator etc. Ambulatory-devices i.e. walker, crutches, belts,
collars, caps, splints, slings, braces, stockings, etc., of any kind. Diabetic footwear, Glucometer
/ Thermometer and similar related items, and also any medical equipment, which
subsequently used at home.

 All non-medical expenses including convenience items for personal comfort such as charges
for telephone, television, ayah, private nursing/barber or beauty services, diet charges, baby
food, cosmetic, tissue paper, diapers, sanitary pads. Toiletry items and similar incidental
expenses

 Any kind of service charges, surcharges, admission fees, registration charges levied by the
hospital.
 Claims Process

Reimbursement
Cashless Facility Facility

Reimbursement facility
Cashless facility can is generally availed if
be availed or granted the hospital is not in
when the hospital is network list of IL or
registered as Network due to unclear
hospital of IL requests cashless is not
granted by IL or if the
insured voluntarily
does not opt for
Cashless facility.
Unplanned/ Emergency
Planned Hosptialisation
When the Cashless Hosptialisation
request process is When the request for
completed in advance Cashless is given at the time
of admission only

A. Cashless Claims

List of Network Hospital: website: ilhc.icicilombard.com/

How to avail cashless:

Cashless facility is only applicable if the member goes to a network hospital

 • Employees should carry their medi-claim cards/medi-claim ids along with a photo id proof to
the hospital.
• Once in the hospital, go to the Help desk/IL Desk/Reception, and inform that you are covered
under Group Mediclaim Insurance Policy serviced by ICICI Lombard, the IL and get the pre
authorization form filled by the doctor/hospital.
• Get the filled form faxed to the IL
– If everything is ok, within 3-4 hours the IL will sanction the amount
– If IL requires more clarification, it will re-fax/E-mail the letter of
requirement/clarification. The query needs to be answered satisfactorily via fax. If the
query is resolved then IL will sanction the cashless
– The cashless may be rejected if IL is of the view that ailment/ hospitalisation is not
covered under the policy
• The same procedure is to be repeated at the time of discharge
• Employee will have to bear non-medical expenses, co-payment & if opted for higher category
than the room eligibility, proportionate deduction will be applicable.
• There are hospitals which will ask for certain deposit amount at the time of admission which
will be refunded to you once the hospital gets it payment from the Lombard.

Important advisory to ensure smooth cashless settlement:

• Keep patient’s IL e-card and photo-id proof ready. Ensure name on photo id proof matches
with IL e-card (especially regarding lady’s maiden name). In case of minor, employee’s photo
id proof to be provided
• Faxing /E-mail of pre- authorization form may be followed by a phone call to IL call centre
within 30 minutes to ensure that fax has been received by them.
• Please ensure that the form is completely filled, signed and stamped before sending it to IL.
Incomplete form will only delay in authorization. The form is to be filled by treating
doctor/consultant.
• IL may revert with some more clarification on nature of ailment, past ailment, proposed
treatment, expense, etc. Kindly ensure that the queries are replied immediately and faxed /e-
mail to IL.
• Cashless will be granted and the Authorization Letter (AL) will be faxed/E-mail to the hospital.
• If the process is taking too long and not to your satisfaction then you may get in touch with
representatives at Gallagher Insurance Brokers Private Limited. or at Medi Assist IL
• The IL Desk generally functions only till 5.30-6.00 in the evening. If hospitalization is in late
evening then the cashless request needs to be sent next morning (this will not hinder the
treatment and it can be initiated)
• For planned surgery, it is recommended to complete initial approval process at least 3-4 days
in advance.

When can Cashless be denied by the hospital

 In case sufficient information in the prescribed format is not given.

 In case of vague symptoms when medical team of ICICI Lombard is not sure of eligibility under
the coverage due to inadequate medical information, pre-authorization for cashless can be
denied.
A) Reimbursement Claims:

Procedure for reimbursement of claim

• Reimbursement route can be availed if the hospital is not in Network list.

• Along with completely filled claim form, all documents/bills/reports in original are to be
submitted directly to IL within 7 days of date of discharge
• In case of any clarification/inability to furnish documents, the employee may get in touch with
HR/IL/Gallagher team.
• Please note that the original documents will be retained by the IL and hence employee is
requested to keep a copy of document with him/her
• The claim status can be checked on the website of IL or can be checked by calling the Toll free
no.

Intimation of hospitalization within 24 hours

Any event, which may give rise to a claim under this policy, a notice with full particulars shall be sent
to the IL by fax/email/letter within 24 hours from the time of injury/hospitalization.

In case of an employee himself/ herself meeting with an accident or falling ill and there is no one in
the family who can send intimation to IL within 24 hours, in such case, employee should inform the
concerned HR Manager who in turn will send an intimation in writing to IL on behalf of such
employee.

Intimation should be given immediately for all the claims and in case of emergency within 24 hours
of hospitalization. Claim papers need to be submitted to insurance company’s IL - ICICI Lombard's
IL-Health Care Services. within 15 days (Main file) and pre post claims within 7 days of completion
of treatment (maximum 60 days of treatment) at below mentioned address, in case of non-
submission in stipulated period of time then claim would invite additional 10% co-payment over &
above payable amount as per policy terms and conditions.

The intimation can be given in writing on to IL and/or Broker:

IL Broker
 Customised E-Mail-
ihealthcare@icicilombard.com Keep CC:

 Toll Free - Phone - 1800 2666 HCM@ajgindia.in

 Toll Free - Fax - 1800 2666
 Online- https://www.icicilombard.com/IL-
Health-Care

The following details should be made available with intimating on e-mail/phone

• Employee ID
• Employee Name
• Company Name
• Patient Name and Relation with Employee
• IL ID
• Hospital name and Location
 • Date of Hospitalisation
• Ailment type

Reimbursement of pre/post hospitalization

Relevant medical expenses incurred before admission (pre-hospitalization) and after discharge (post-
hospitalization) from the hospital will be reimbursed for 30 & 60 days respectively. Prescriptions and
bills/receipts of such services should be submitted to ICICI Lombard along with duly signed claim
form.

Documents required while submission:

 Original hospital final bill

 Original pre-numbered receipts for payments made to the hospital
 Complete breakup of the hospital bill
 Original Discharge Card/Summary
 All original investigation reports
 All original medicine bills with relevant prescriptions
 Original signed claim form
 Photo ID card copy of claimant
 IL Card copy
 Intimation mail copy/ Claim Registration no.
 Paginated copy of Indoor Case papers
 FIR/MLC copy in case of Road accidents. MLC is not applicable then written confirmation
from Doctor/Hospital that the patient was not under influence of alcohol or drugs
 Cancelled Cheque with IFSC code of account belonging to Employee

-All the bills/reports/prescription are to be submitted in original

ADDRESS OF IL for documents submission:

ICICI Lombard General Insurance Co Ltd.

ICICI Bank Towers,
Plot No-12, Financial District,
Nankramguda, Gachibowli,
Hyderabad Pin – 500032
IL Portal for online access:

Network List of Hospitals- https://www.icicilombard.com/IL-Health-Care/Customer/GetHospitalList

Claim form -
https://www.icicilombard.com/Content/ilomen/Downloads/Health/Claim_Form_iHealthcare.pdf

ICICI Lombard Website - https://www.icicilombard.com/IL-Health-Care

Claim Process - https://www.icicilombard.com/IL-Health-Care/claims.html
Claim Status - https://www.icicilombard.com/IL-Health-Care/Customer/ClaimStatus

E- Card : https://ilhc.icicilombard.com/Customer/iCard
Contact Points & Escalation Matrix:

ICICI Lombard General Insurance Co Ltd (In-house IL)

Escalation Matrix at ICICI Lombard's IL-Health Care Services

Servicing Branch- Mumbai
ICICI Lombard General Insurance Co Ltd.
ICICI Bank Towers,
Plot No-12, Financial District,
Nankramguda, Gachibowli,
Hyderabad Pin – 500032.
Website: https://www.icicilombard.com/IL-Health-Care
Claim Status enquiry
Contact No: 1800 2666
Level 1
Email Id : ihealthcare@icicilombard.com

Name : Mr. Priyank Shah

Level 2 Contact No: +91 7045051089
Email Id: priyank.shah@icicilombard.com
Name : Mr Manoj Sethi
Level 3 Contact No: +91 7506351675
Email Id: manoj.sethi@icicilombard.com

Company Corporate Broker for any kind of help (Please keep them in loop in all your
communications):

Escalation Matrix at Gallagher Insurance Brokers Private Ltd.

Servicing Branch- Mumbai
Towe3, 3rd Floor, Kohinoor City Mall, Kurla – West , Mumbai – 400 070

Gallagher Escalation Name Cell No. Email id

Health Insurance
022 68591832 HCM@ajgindia.in
Claims Team
Riya.taware@edelweissfin.
First level contact Riya Taware 7400047879
com
Jignesh.Purohit@edelweiss
Escalation Mr. Jignesh Purohit 9167663206
fin.com
Enclosures:

 Reimbursement Claim Form

 Pre authorisation cashless claim form
 Mobile application presentation attached with process flow

List of network hospitals is available on ICICI Lombard website on homepage (The list is subject to
regular change; please refer the website https://www.icicilombard.com/IL-Health-
Care/Customer/GetHospitalList for updated list).

Frequently Asked Questions for Top Up policy

1. WHAT IS A TOP-UP POLICY?

A top-up policy is a health insurance plan that offers you additional coverage beyond the
coverage limits of your existing health plans. Such a plan is essentially used to enhance
existing health coverage. You can buy a top-up plan whether you have health insurance from
your workplace or an independent policy.

Once aggregate of all claims crosses Deductible Sum Insured (Existing corporate Sum
Insured) then the Top-up policy will cover expenses till the Sum Insured opted in Top-up
policy. The policy will have same terms and conditions, exclusions as per the base policy.
Even the list of dependents would remain same.

2. WHAT ARE THE SALIENT FEATURES OF THE POLICY?

This Policy covers In-Patient Hospitalisation Expenses incurred in India.

This Policy covers aggregate hospitalisation expenses in respect of covered hospitalisation of
members of M/s. Piramal Enterprises Limited/Piramal Pharma. Coverage would be applicable
if treatment is during the policy period and expenses are exceeding the Sum Insured under
Group Mediclaim policy.

3. WHAT ARE THE SUM INSURED OPTIONS AVAILABLE UNDER THE POLICY?

Sum Insured is available on family floater basis i.e Single Sum Insured for all family members
covered under the Policy.
 Details of Sum Insured is mentioned below –

Base SI (INR) Top-up SI (INR) FY22-23 (INR)

300000 2,303

420000 400000 2,501

500000 2,764

500000 2,534

600000 700000 2,764

1000000 3,094

750000 2,839

900000 1000000 2,962

1500000 3,423

500000 7,570

900000 8,064
3000000
1500000 9,176

2500000 11,470

4. IS THE LIMIT FOR INDIVIDUAL MEMBER OR FAMILY FLOATER?

It is Family floater. Thus in above case, the top-up sum insured is floating on all family
members

5. BY ADDING TOP-UP SUM INSURED, CAN I OPT FOR HIGHER ROOM RENT?
Room rent under base policy is 1% of Sum Insured per day for normal room and 2% of Sum
Insured per day for ICU. The limit does not change and room rent eligibility does not increase.

6. WHO IS ELIGIBLE TO OPT FOR THIS TOP-UP COVER?

All the employees and their dependents as declared under Group Mediclaim Policy.
7. WHAT BENEFITS I WILL GET THROUGH TOP-UP MEDICLAIM POLICY?

 If the claim bills exceed the sum insured under GMC policy provided by your employer
then Top-Up Policy Sum Insured will be become available for settlement of claim as per
the terms and conditions of the policy
 All the coverages which are applicable to GMC policy are applicable to this policy as well

8. WHAT ARE THE GENERAL EXCLUSIONS OF TOP –UP POLICY?

All the exclusions which are applicable to GMC policy are applicable to this policy as well.
Additional exclusions are:

 Joint replacement expenses is not covered

 Maternity expenses are not covered

Any room rent capping, other capping, or non payable expenses made under GMC policy
cannot be claimed under Top-Up policy.

11. ANY MEDICAL TESTS TO AVAIL THIS BENEFIT?

No. Top-Up policy is not subject to any medical test.

12. DOES THE COVER START FROM DAY 1 OF POLICY?

Yes.

13. WHAT ARE THE EXPENSES THAT CAN BE CLAIMED UNDER THE POLICY?

All the expenses which stands payable as per GMC policy but are not payable due to
exhaustion of sum insured are payable under the Top-Up policy upto the sum insured opted.

14. HOW ARE CLAIMS REJECTED AND FOR WHAT REASONS?

 If the claims are rejected in Basic Mediclaim policy then the same will be rejected in this
policy as well.
 If the claim is below the sum insured of basic policy then it will not be registered under this
policy.

15. DO WE HAVE TO SUBMIT SEPARATE SET OF CLAIM DOCUMENTS TO IL?

 There is no need to submit separate claims documents to IL. Claiming under Top Up policy you
need to provide Top up policy card details.

ARE BOTH POLICIES IL SAME?

Yes. IL under ICICI Lombard Top-up Policy and GMC policy is their in-house IL

16. I HAVE CORPORATE POLICY OF RS. 6 LAKH AND PERSONAL POLICY OF RS. 5 LAKH. CAN I
UTILISE MY RS. 5 LAKH TOP-UP AFTER UTILSING BOTH THESE POLICIES

Yes.

17. I HAVE TWINS WHICH ARE ALREADY COVERED UNDER THR POLICY, I RECENTLY HAD MY
THIRD CHILD, WILL HE/SHE BE COVERED?
No, the policy covers only two of the dependent children

18. CAN I ADD FAMILY NAMES DURING MID TERM OF THE POLICY OR AT THE RENEWAL OF
POLICY?

No. You can’t add name of the family member except for new born baby & newly married
spouse under Top-up Policy.

19. AM I ELIGIBLE FOR REFUND, IF I CANCEL THE POLICY MID TERM?

No. Refund is only allowed in case of resignation from the organisation, subject to No claim
made by the employee or his family under Top-up policy. Pro-rata premium refund would be
allowed.

20. IF I LEAVE THE ORGANISATION DURING MID TERM OF THE POLICY, AM I STILL COVERED
UNDER THE POLICY?

No. HR will intimate insurance co. and the automatically cover would be terminated. There is
no provision of voluntary cover by paying additional premium.

21. CAN I ADD MY LGBT PARTNER FOR COVERAGE?

Yes, you may add LGBT partner (married/live-in) instead of spouse for the policy coverage.

22. WHAT IS THE ROOM RENT ELIGIBILITY?

Room Rent eligibility for 1 % of SI 420000 is 4200 inclusive of Nursing charges for normal room
 Room Rent eligibility for 1 % of SI 600000 is 6000 inclusive of Nursing charges for normal room

Room Rent eligibility for 1 % of SI 900000 is 9000 inclusive of Nursing charges for normal room

Room Rent eligibility for 1 % of SI 3000000 is 30000 inclusive of Nursing charges for normal
room

23. WHEN CAN I USE MY TOP-UP POLICY ?

The top-up policy gets activated when the base sum insured is exhausted

24. WHERE DO I GET MY E-CARDS ?

Ecards will be sent by the Insurance company on employees registered id.