FREQUENTLY ASKED

QUESTIONS
INSURANCE BENEFITS

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Q1. What is medical insurance?
Medical insurance is a pure hospitalisation policy which provides coverage to
you as an employee and covers your family (spouse, 2 dependant children up to
25 years, and parents/parents-in-law) towards treatment in case of a medical
emergency, as per policy terms and conditions.
Q2. What is the meaning of hospitalisation?
Hospitalisation means admission in a hospital for a minimum period of 24
consecutive hours for in-patient care except for specified procedures/treatments
as mentioned in annexure I, where such admission could be for a period of less
than 24 consecutive hours.
Note: Procedures/treatments usually done in the out-patient department are not
payable under the policy even if converted as an in-patient in the hospital for
more than 24 consecutive hours.
Q3. Who can be added under the mediclaim policy?
Family floater - employee + spouse + 2 dependant children + parents and
parents-in-law (only for female employees).
Q4. From which portal can dependants be added?
Employees need to update details on the CUBE portal.
Q5. What is the meaning of injury?
It means accidental physical bodily harm excluding illness or disease solely and
directly caused by external, violent, visible, and evident means which is verified
and certified by a medical practitioner.
Q6. What is the meaning of illness?
It means a sickness, or disease or pathological condition leading to the
impairment of normal physiological function and requires medical treatment.
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FREQUENTLY ASKED QUESTIONS
• Acute condition means a disease, illness or injury that is likely to respond
quickly to treatment which aims to return the person to his or her state of
health immediately before suffering the disease/illness/injury, which leads to
full recovery
• Chronic condition means a disease, illness, or injury that has one or more of
the following characteristics
1. It needs ongoing or long-term monitoring through consultations, examinations,
check-ups, and/or tests
2. It needs ongoing or long-term control or relief of symptoms
3. It requires rehabilitation for the patient or for the patient to be specially trained
to cope with it
4. It continues indefinitely It recurs or is likely to recur
Q7. What is the meaning of in-patient care?
In-patient care means treatment for which the insured person must stay in a
hospital for more than 24 hours for a covered event.
Q8. What is the meaning of an insured person?
Insured person means you and each of the others who are covered under this
policy as shown in the policy schedule.
Q9. What is the meaning of ICU (Intensive Care Unit)?
It means an identified section, ward or wing of a hospital which is under the
constant supervision of a dedicated medical practitioner(s), and which is specially
equipped for the continuous monitoring and treatment of patients who are in
critical condition or require life support facilities and where the level of care and
supervision is considerably more sophisticated and intensive than in the ordinary
and other wards.

Q10. What is the meaning of ICU charges?
ICU charges means the amount charged by a hospital towards ICU expenses
which shall include the expenses for ICU bed, general medical support services
provided to any ICU patient including monitoring devices, critical care nursing,
and intensivist charges.
Q11. What is the meaning of medical advice?
Medical advice means any consultation or advice from a medical practitioner
including the issue of any prescription or follow-up prescription.
Q12. What is the meaning of medical expenses?
Medical expenses mean those expenses that an insured person has necessarily
and actually incurred for medical treatment on account of illness or accident on
the advice of a medical practitioner, as long as these are no more than would
have been payable if the insured person had not been insured and no more than
other hospitals or medical practitioner in the same locality would have charged for
the same medical treatment.
Q13. What is the medically necessary treatment?
• Medically necessary treatment means any treatment, tests, medication, or stay
in the hospital or part of a stay in hospital which is required for the medical
management of the illness or injury suffered by the insured
• It must not exceed the level of care necessary to provide safe, adequate and
appropriate medical care in scope, duration, or intensity
• Must have been prescribed by a medical practitioner
• Must conform to the professional standards widely accepted in international
medical practice or by the medical community in India
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FREQUENTLY ASKED QUESTIONS
Medical practitioner is a person who holds a valid registration from the medical
council of any state or Medical Council of India or Council for Indian Medicine or
for Homeopathy set up by the Government of India or a state government and is
thereby entitled to practice medicine within its jurisdiction; and is acting within the
scope and jurisdiction of his/her license.
Note: The medical practitioner should not be the insured or a close family
member.
Q15. What is the Group Mediclaim policy-wise sum insured?
Sum insured are graded ranges from INR 1,00,000, INR 2,00,000, INR 3,00,000,
and INR 5,00,000
Q16. Is the 24-hour rule applicable to all ailments?
Yes, 24-hour hospitalisation is a must. However, this time limit is not applied to
specific treatments which do not necessarily require 24 hours due to
technological advancement in treatment. Some of these treatments include
dialysis, chemotherapy, radiotherapy, cataract, etc. taken in the hospital/nursing
home.
Q17. Is chemotherapy covered?
Chemotherapy is covered.
Q18. Is radiotherapy covered?
Radiotherapy is covered.
Q19. Is continuity/portability benefit applicable?
Employees covered under the existing policy can avail of the individual mediclaim
policy with the same benefit as per the standard individual mediclaim policy
(retail - individual/floater) subject to the last three claim-free years. The individual
mediclaim policy coverages can opt for without any medical check-ups.
 FREQUENTLY ASKED QUESTIONS

Q20. Is the newborn covered from day one?

Yes, the newborn is covered from day one.

Q21. How can I add my newborn/newly-wed spouse?

You need to update your CUBE portal within 15 days from the date of the event/DOB.
Note: No mid-term addition will be taken between the policy period, except
for a newborn/newly-wed spouse. Claim matters details need to be shared on
capriglobal@prudentbrokers.com within 10 days from the date of the event.
• Please share the newborn’s details in the below format within 10 to 15 days from the date of birth
• If the newborn’s name is not decided yet, then please write as B/o. Mother’s name

Emp. No. Name of Employee Name of DOB Relation Gender

Dependant

• Please share spouse details in the below format within 10 to 15 days from the date of marriage
• Please share spouse’s name as per the Aadhar card copy only

Emp. No. Name of Employee Name of DOB Relation Gender Date of

Dependant Marriage

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 FREQUENTLY ASKED QUESTIONS

Q22. Is cataract covered?

Yes, cataract is covered.

Q23. Are there any special criteria for seeking admission/treatment in the hospital/nursing homes?
Hospital/nursing home means any institution established for in-patient care and daycare treatment of illness and/or injury or complies with all minimum criteria as under:
• Hospital/nursing home must be registered as a hospital with the local authorities under the Clinical Establishment (Registration and Regulation) Act, 2010 or under the
enactments specified under the schedule of Section 56(1) of the said Act
• Hospital must have a registration certificate (i.e., Form C)
• Has qualified nursing staff under its employment round the clock
• Has at least 10 in-patient beds, in those towns having a population of less than 10,00,000 and at least 15 in-patient beds in all other places
• Has qualified nursing staff under its employment round the clock
• Has qualified medical practitioner(s) in charge round the clock
• Has a fully equipped operation theatre of its own where surgical procedures are carried out
• Maintains daily records of patients and will make these accessible to the Insurance company’s authorised personnel
Note: It necessarily should not be blacklisted with the TPA & insurer. Blacklisted hospital list can be checked at below link
https://www.paramounttpa.com/Home/ExcludedList.aspx
Select insurance company – Aditya Birla Health Insurance Company Ltd.
** No claims will be entertained in blacklisted hospitals, be it reimbursement or cashless
Q24. Will my stay be covered under mediclaim if I have been admitted under the doctor’s instructions but there has been no proper line of treatment?
Any hospitalisation without any active line of treatment will not be covered under mediclaim insurance. Hospitalisation for observation, evaluation, and investigation is not
covered under the mediclaim policy.
Q25. What are pre-existing diseases? Are they covered in the policy?
Pre-existing diseases refer to conditions or ailments that may have been contracted before the start of the policy. The policy covers pre-existing diseases from day one.
Examples of pre-existing conditions/diseases are blood pressure (hypertension), diabetes, cancer, heart ailment, hernia, and cataract, and this list can be un-ending as it
means any and every ailment for which medication or treatment is on or found to be manifested (without treatment) on the date of the policy inception.

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Q26. What if the cost exceeds the base policy sum insured?
In such a situation, you will be liable to pay the deduction amount, over and
above the sum insured limit, as per policy terms and conditions. The TPA will
inform the hospital about your balance sum insured and the hospital will recover
the amount over and above the balance sum insured from you.
Q27. Is there any limit for reimbursement of expenses incurred in a laboratory or
a diagnostic centre as part of hospitalisation?
No, if the expenses form a part of the main hospitalisation process and if the
amount is approved and payable as per the terms and conditions of the policy,
then they are reimbursable up to the sum insured amount.
Q28. What are the room rent eligibility criteria, and how does it impact claim
settlement?
• Hospital room limit (available for NON-ICU) 2% of SI for normal
• Hospital room limit (available for ICU/ICCU) 4% of SI for ICU
If an employee/dependent opts for a room higher than the eligibility, then the
difference in room charges will be deducted, and all other charges will be
deducted in proportion to the room opted
Q29. What expenditures will generally be covered under the pre-hospitalisation
clause?
Medical expenses incurred for laboratory tests, pathological tests, and such
similar expenses which are usually incurred for the same ailment prior to
hospitalisation, will be covered under the pre-hospitalisation clause. Pre-
hospitalisation expenses are payable only if it is followed by at least 24-hour
hospitalisation within 30 days of expense and there should be an active line of
treatment given based on the investigation.
Q30. Are congenital external diseases covered?
Covered only in case of life-threatening situations.
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FREQUENTLY ASKED QUESTIONS
Q31. What expenditures will generally be covered under post-hospitalisation
clause?
Medical expenses incurred for the treatment after release from hospitalisation
and other such similar overheads will be covered under post-hospitalisation
clause. Post-hospitalisation expenses are covered up to 60 days from the date of
discharge.
Q32. What is the meaning of reasonable and customary charges?
Reasonable and customary charges mean the charges for services or supplies,
which are the standard charges for the specific provider and consistent with the
prevailing charges in the geographical area for identical or similar services,
considering the nature of the illness/injury involved.
Q33. What is the meaning of surgery or surgical procedure?
Surgery or surgical procedure means manual and/or operative procedure(s)
required for treatment of an illness or injury, correction of deformities and
defects, diagnosis and cure of diseases, relief from suffering and prolongation of
life, performed in a hospital or daycare centre by a medical practitioner.
Q34. What is the meaning of TPA (Third-party Administrator)?
TPA means any person who is registered under the IRDAI (Third-party
Administrators – Health Services) Regulation, 2016, notified by the authority, and
is engaged for a fee or remuneration by us for the purposes of providing health
services defined in those regulations.
Q35. What is the meaning of unproven/experimental treatment?
It means treatment, including drug experimental therapy, which is not based on
established medical practice in India.
Q36. Is dental treatment covered?
Dental treatment is not covered.

Q37. Is termination of pregnancy-related expenses covered?
Voluntary medical termination of pregnancy is not covered under mediclaim.
Only in case of life-threatening maternity, will it be covered up to the family sum
insured
Q38. What about pre and post-hospitalisation expenses with respect to
delivery?
Pre and post-natal expenses are not covered for OPD as well as IPD basis
Q39. Is infertility-related treatment covered?
No, expenses for male and female fertility-related treatment are not covered.
Q40. What is the co-pay under stem cell transplantation?
50% co-pay for stem cell transplantation.
Q41. Ayurvedic treatment coverage?
AYUSH Treatment: Expenses incurred on treatment under Ayurveda, Unani,
Siddha, and Homeopathy systems of medicines in a government hospital or in
any institute recognised by the government and/or accredited by the Quality
Council of India/National Accreditation Board on Health has up to 25% of the
sum insured covered subject to a maximum of INR 25,000 per policy period.
Q42. Coverage for cancer care?
Restriction: INR 45,000 per family on an IPD basis
Q43. Will the location of dependant family members matter?
No. The policy provides coverage for treatment taken within India. Employees
and their dependant family members can avail of the benefit as per the policy
terms and conditions at any approved/registered hospital in India.
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FREQUENTLY ASKED QUESTIONS
Q44. Are daycare treatments covered in the mediclaim policy?
Yes, in the case of medical treatment and/or surgical procedure, which is
undertaken under general or local anaesthesia in a hospital/daycare centre in
less than 24 hours because of technological advancement and which would have
otherwise required a hospitalisation of more than 24 hours. A treatment normally
taken on an out-patient basis is not included in the scope of this definition.
Daycare centre means any institution established for daycare treatment of
illness and/or injury or a medical setup within a hospital which has been
registered with the local authorities, wherever applicable, and is under the
supervision of a registered and qualified medical practitioner and must comply
with all minimum criteria as under:
• Has qualified nursing staff under its employment
• Has qualified medical practitioner/s in charge
• Has a fully equipped operation theatre of its
own where surgical procedures are carried out
• Maintains the daily record of patients and will
make these accessible to the insurance
company’s authorised personnel
 FREQUENTLY ASKED QUESTIONS

Q45. What are the COVID-19 care benefits? Q48. Do I need to carry my mediclaim e-card when I go to the hospital?
Home quarantine – INR 10,000 per person Ideally, you should always carry a print of the e-card with yourself, when getting
• Covid-19 PCR test admitted to the hospital from the available list of network hospitals with the TPA.
• Doctor consultation But, if you do not have a cashless card, you should contact Prudent’s claims
• Essential medical kit including thermometer, pulse oximeter, mask, sanitizer, representative who will provide the required assistance. It is advisable to carry a
etc. valid photo ID proof (employee ID Card, driving license, election card, or any
• Telereview with qualified medical experts & nurses card which is approved by the Govt. Of India), irrespective of whether you are
carrying the cashless card or not.
Quarantine expenses following discharge:
• After a duration of hospitalisation, if the patient is advised to undertake: Q49. From where can I download medical e-cards?
Please find below the login credentials for your reference to download the
Home quarantine, then:- e-cards:
• INR 333 per day for the period of quarantine, is admissible, irrespective of the
sum insured Link: https://www.paramounttpa.com/Home/index.aspx
• The duration of hospitalisation and home quarantine together, should not • Select the insurance company : Aditya Birla Health Insurance Company Ltd.
exceed 15 days • Select & enter your Emp ID
• No further post-hospitalisation expenses will be admissible • Group code – CAPR - CAPRI GLOBAL CAPITAL LIMITED
Documents to be submitted for claims: • Group code – CGHP - CAPRI GLOBAL HOLDING PRIVATE LIMITED
• Group code – CGHF - CAPRI GLOBAL HOUSING FINANCE LIMITED
• Treating physician letter on his/her letterhead. Daily activity chart with vital signs
• Bill breakup and receipts. Monitoring the essential kit delivery and home Q50. My e-card does not have my photograph - how can the hospital identify
isolation through CRC and field visit personnel and their reports to form part of me?
the claim documents The hospital will cross-check all the details using the medical card number with the
• As of now, home care treatment claims will be entertained in reimbursement TPA network. However, hospital will also ask for a photo identity proof (employee
mode only ID card, driving license, election card, or any card which is approved by the
Government of India) as a part of general verification.
Q46. What are healthy baby expenses?
Expenses incurred for well baby care are excluded from the policy. Q51. The information on my e-card is incorrect. What should I do now?
Please update the correct details on the CUBE portal and write to
Q47. In how many days will I get my mediclaim (medical insurance) card? capriglobal@prudentbrokers.com with a copy of your employee ID Card, Aadhar
Mediclaim cards will be available within 10-12 days from the date of receipt of card, driving licence, PAN card, election card, or any card which is approved by the
monthly data from corporate HR. Government of India for correction of the error.

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Q52. Post my marriage, my surname has been changed, although my e-card has
my maiden's name. How do I get the name changed on my e-card?
Please update it in your internal CUBE system and write to
capriglobal@prudentbrokers.com with a copy of the PAN card or Aadhar card
where the name change has happened or the marriage certificate.
Q53. If I avail of the cashless facility or file a reimbursement claim, will the
insurer pay the entire amount, or will I be required to bear part of the bill at
the hospital?
All expenses that are covered under the insurance policy will be paid for by the
insurer. However, you will be required to pay for non-admissible expenses, if
any, such as registration charges, charges incurred on account of person
accompanying you, non-medical consumables, etc.
Q54. Can I file more than one claim in a year?
You can claim as many times as you are hospitalised during the period of
insurance but the insurance company’s liability in respect of all claims put
together shall not exceed the sum insured.
Q55. What if I undergo major hospitalisation in two different hospitals? Will the
policy reimburse the expenses incurred?
Yes. The expenses are reimbursed up to the limit of the sum insured, and they
must satisfy the terms and conditions of the policy. Proper documents, such as
discharge summaries from both hospitals, are a must.
56. What is meant by a network/empanelled hospital?
Network/empanelled hospitals are hospitals or health care providers enlisted
by an insurer, TPA, or jointly by an insurer and TPA to provide medical services
to an insured by a cashless facility. The list is available with the insurer/TPA, and
it is subject to amendment from time to time.
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FREQUENTLY ASKED QUESTIONS
For network hospital details, please find the below link; please select your
location & insurer name as “Aditya Birla Health Insurance Company Ltd.”
https://www.paramounttpa.com/Home/ProviderNetwork.aspx
Q57. What is meant by a PPN Hospital?
Preferred Provider Network (PPN) means network providers in specific cities
which have agreed to a cashless packaged pricing for specified planned
procedures for the policyholders of the company. The list of planned procedures
is available with the company/TPA and subject to amendment from time to time.
Reimbursement of expenses incurred in PPN for the procedures (as listed under
the PPN package) shall be subject to the rates applicable to PPN package
pricing.
Q58. Do I need to get treatment at a network hospital only?
• You can get treated in any registered hospital which meets the hospital criteria
within the country, but the cashless facility will be available only at network
hospitals
• It is recommended that cashless treatment is taken in the network hospital,
and it is mandatory for cashless to be availed in the network hospital
• If the cashless facility is not availed in the network hospital, then in
reimbursement, the applicable hospital discount will be deducted, and the
claim settled
• Expenses incurred at non-network hospitals will be reimbursed to you after
following the applicable reimbursement process and as per the terms and
conditions of the policy

Q59. What if we get admitted to a hospital outside the network list?
• If you get admitted to a hospital outside the network list, you will not get the
cashless facility. You can always file the claim under the reimbursement mode
• Non-network provider means any hospital, daycare centre, or other provider
that is not part of the network
• The insurer also has blacklisted hospitals wherein no cashless or
reimbursement claims will be entertained. The list can be downloaded from
the below-mentioned link post selecting the state, city, and insurer company
name on the portal
Note: It necessarily should not be blacklisted with the TPA & insurer. Blacklisted
hospital list can be checked at below link:
https://www.paramounttpa.com/Home/ExcludedList.aspx
** No claims will be entertained in blacklisted hospital, be it
reimbursement or cashless
Q60. What is a cashless request form?
The cashless request form is a document which must be duly filled up, signed,
and stamped by the treating doctor. Thereafter, the hospital will mail it to TPA on
the e-mail ID given on the cashless request claim form (pre-auth. request
letter).
Q61. How to fill the cashless request form?
Part A: To be filled in by the insured/patient
Part A: To be filled in by the treating doctor/hospital.
Information required: ID no. as mentioned on e-card, signs and symptoms of the
present ailment, duration of the ailment, diagnosis, pre-existing conditions if any,
proposed line of treatment, approximate date of admission/discharge,
approximate duration of stay and approximate cost of hospitalisation, estimated
expenditure, etc.
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FREQUENTLY ASKED QUESTIONS
Q62. How do I know whether my claim has been admitted for cashless
reimbursement or not?
The authorisation letter or denial letter shall be e-mailed directly to the hospital
with a copy to the employee e-mail ID, and the hospital will inform you about the
same. You can also do the necessary follow up with a Prudent representative to
check the status.
Q63. What is an authorisation letter?
Authorisation letter is the communication authorising the extension of cashless
hospitalisation to the insured. The same is issued by the TPA, subject to
the admissibility of the claim and availability of the balance sum insured for the
member.
Q64. Is it possible to have cashless approval for pre & post-hospitalisation?
Cashless will not be possible for pre & post-hospitalisation claims.
Reimbursement of the expenses is possible on submission of complete bills &
documents relating to the claim within specified timelines.
Q65. What is the maternity limit?
• Maternity limit: INR 50,000 for normal and C-section is covered up to two
living children
• Pre and post-natal expenses are not covered on an OPD as well as IPD basis
Q66. Are there any restrictions on the number of claims I can file for maternity
expense?
Maternity benefits can be claimed for the first two children and/or operations
associated therewith.
Q67. Is there a time limit within which I am expected to submit the pre & post-
hospitalisation bills?
Yes, you are advised to submit bills with respect to pre & post-hospitalisation
expenses, within 60 days of discharge from the hospital.

Q68. What is the document submission timeline in case of reimbursement
claims?
After completion of treatment, when the patient has been discharged from the
hospital, you must submit the final claim within 45 days from the date of
discharge from the hospital.
Q69. Will I get my claim papers back?
No, you will not get the claim papers back after settlement of the claim. You are
expected & advised to keep a photocopy of the same for your future reference
before submitting the papers. However, rejected claim documents will be
available on request.
Q70. What are the key reasons for deduction in COVID-19 claims?
• If the hospital has not followed the govt. circular, then the claim will be
processed as per the govt. circular only, and the expenses over & above the
excess package amount will be borne by the employee
• If you are going to get admitted for COVID-19 treatment, then please check
with your insurance SPOC for room rent limits for the hospital. And please opt
for a room within the limit which was decided by the govt. guideline. If you opt
for a higher room rent, then excess charges over & above the package
amount will be borne by the employee
• Non-medical expenses, including Personal Protective Equipment (PPE) kit,
plasma therapy, sanitiser, sanitisation/fumigation of room, etc.
• Excess medical charges
• Excess bed/ICU charges, over & above the COVID-19 package, will get
deducted as per the govt. circular
• Consultation charges will get deducted as it is part of the isolation package as
per the govt. circular
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FREQUENTLY ASKED QUESTIONS
• Monitor is not payable
• Nursing is part of room charges
• RMO is not payable
• Care & hygiene charges are not payable
• BMW charges are not payable
• Staff management charges are not payable
• Excess COVID-19 test charges will be deducted as per the govt. circular
• Visit charges included in per day package as per the govt. circular
• Excess PPE kit charges are not payable as per the govt. circular
• Medical service charges are not payable
• Nutritional charges are not payable
• Duty doctor charges are not payable
• Registration & administration charges are not payable
• Excess dengue charges will get deducted as per the govt. circular
• Intensive Care Unit (ICU) visiting charges are not payable
• Post-hospitalisation COVID-19 tests are not payable
• Investigation charges will get deducted as they are unauthorised reports
• Medicine charges will get deducted as they are already included in the
package as per the govt. circular
• Oxygen charges are not payable as per the govt. circular
• Over and above the package limit as per the govt. circular are not payable
 FREQUENTLY ASKED QUESTIONS

Q71. What are the quick solutions to avoid deduction on COVID-19 claims? Q73. Where can I check for network hospitals?
Know Your State COVID-19 Ceiling: All major states in India, like Maharashtra, For network hospital details, please find the link below. Please select your
Karnataka, West Bengal, Tamil Nadu, and Delhi, have issued guidelines to both location and insurer name as “Aditya Birla Health Insurance Company Ltd.”
private & government hospitals informing the ceiling rates that the provider can Network Hospital Link:
charge for treatment as per the national protocol for Covid-19 care & standard https://www.paramounttpa.com/Home/ProviderNetwork.aspx
care for co-morbidities. If it is observed that the hospitals are not following the
**Disclaimer: The list gets updated on a daily basis. Hence, it is recommended to
ceiling limit, you are requested to check the amount and be in touch with
search the network hospitals from the above link only whenever needed.
insurance SPOC for the right guidance.
Preferred Hospitals: Do remember to speak with your insurance SPOC and The insurer also has blacklisted hospitals wherein no cashless or reimbursement
inquire for the preferred provider network following the right billing mechanism. claims will be entertained. The list can be downloaded from the given link,
The TPA maintains a dynamic list of providers giving the right treatment with the https://www.paramounttpa.com/Home/ExcludedList.aspx post selecting the
right amounts. state, city, and insurer company name on the portal.
Room Rent Limit: Majority of rejections are seen in the bills because of patient Q74. Do I have to do claims intimation?
opting for a higher room rent category. It is advisable that you talk to the Yes, claim intimation is mandatory. Please share the details below within seven
insurance SPOC & understand the room rent limit of hospitals as per the govt. or days from the date of admission for claim intimation and before discharge for all
state level guidelines. reimbursement claims on the below-mentioned IDs to get the reimbursement
Check Your Bill Charges: It is also observed that hospitals are charging for claim processed.
experimental drugs not related to COVID-19. All these charges are outside the To, mumbaiclaims@prudentbrokers.com and
scope of the insurance program and are not payable. Please engage in a capriglobal@prudentbrokers.com
dialogue with doctor/hospital from time to time for clarification.
• Employee name -
Q72. Can I opt for a reimbursement claim even if the hospital is covered in the • Employee no. -
network list? • Employee mobile no. -
The MOU discount will get deducted as per the IRDAI rules & regulations. If an • Patient name -
employee is submitting the claim file for reimbursement from the network • Relation -
hospital, then the MOU discount will be borne by the insured. • Hospital name & address - Claim process
• Date of admission -
• Diagnosis -

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 FREQUENTLY ASKED QUESTIONS

Q75. What is the TAT for reimbursement? • Instrument used in the treatment of sleep apnea syndrome (C.P.A.P.) and
After submission of all documents, and when there are no pendingings, including Continuous Peritoneal Ambulatory Dialysis (C.P.A.D.) and oxygen
the declaration on claims settlement based on the submitted claim file, the TPA concentrator for bronchial asthmatic condition
will settle the claim within 10 working days.
• All non-medical expenses, including convenience items for personal comfort
Q76. Is advance treatment covered? such as telephone, television, governess, private nursing/barber or beauty
As per policy there is no coverage for advance treatment. services, diet charges, baby food, cosmetics, tissue paper, diapers, sanitary
pads, toiletry items, and similar incidental expenses
Q77. Organ donor expenses?
Organ costs shall not be covered. • Service charges or any other charges levied by the hospital, e.g.,
registration/admission charges, RMO charges, etc.
Q78. What are non-admissible expenses?
• Monitor charges not payable
These include the following:
• As per the insurance company’s guideline, surgeon, anaesthetist, medical
• Vaccination & inoculation practitioner, consultant, and specialist fees must form part of the final hospital
• Cost of braces, equipment or external prosthetic devices, non-durable bill. In case not, the charges paid directly will not be admissible under our
implants, eyeglasses, cost of spectacles and contact lenses, bi-focal lenses, policy.
multifocal lenses, torex Lenses, hearing aids, including cochlear implants and
Q79. Are ambulance charges covered?
durable medical equipment
Road ambulance charges are covered up to INR 2,000 per incident in case of
• Vitamins and tonics, unless forming part of treatment for injury or disease as emergency.
certified by the attending physician
• Voluntary medical termination of pregnancy during the first 12 weeks from the
date of conception

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 FREQUENTLY ASKED QUESTIONS
Q80. What are the general exclusions applicable?
• Expenses related to any admission primarily for diagnostics and evaluation
purposes
• Expenses related to any treatment, including surgical management, and to
change characteristics of the body to those of the opposite sex
• Expenses for cosmetic or plastic surgery or any treatment to change
appearance unless for reconstruction following an accident, burn(s) or cancer
or as part of the medically necessary treatment to remove a direct and
immediate health risk to the insured. For this to be considered a medical
necessity, it must be certified by the attending medical practitioner
• Any diagnostic expenses which are not related or not incidental to the current
diagnosis and treatment
• Expenses related to any treatment necessitated due to participation as a
professional in hazardous or adventure sports, including but not limited to,
para-jumping, rock climbing, mountaineering, rafting, motor racing, horse
racing, scuba diving, hand gliding, sky diving, and deep-sea diving
• Expenses for treatment directly arising from or consequent upon any insured
person committing or attempting to commit a breach of law with criminal intent
• Expenses incurred towards treatment in any hospital or by any medical
practitioner or any other provider specifically excluded by the insurer and
disclosed on its website/notified to the policyholders are not admissible.
However, in case of life-threatening situations or following an accident,
expenses up to the stage of stabilisation are payable, but not the complete
claim
• Treatment for, alcoholism, drug or substance abuse or any addictive condition
and consequences thereof
• Expenses related to sterility and infertility. This includes:
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• Any type of contraception and sterilisation
• Treatments received in health hydro, nature cure clinics, spas, or similar
establishments or private beds registered as a nursing home attached to such
establishments, or where admission is arranged wholly or partly for domestic
reasons
• Dietary supplements and substances that can be purchased without a
prescription, including but not limited to vitamins, minerals and organic
substances, unless prescribed by a medical practitioner as part of a
hospitalisation claim or daycare procedure
• Expenses related to the treatment for correction of eyesight due to refractive
error less than 7.5 dioptres
• Expenses related to any unproven treatment, services and supplies for or in
connection with any treatment. Unproven treatments are treatments,
procedures or supplies that lack significant medical documentation to support
their effectiveness
• Assisted reproduction services, including artificial insemination and advanced
reproductive technologies such as IVF, ZIFT, GIFT, and ICSI
• Gestational surrogacy and reversal of sterilisation
• Acupressure, acupuncture, and magnetic therapies
• Any expenses incurred on domiciliary hospitalisation
• Any kind of service charges, surcharges, luxury tax, and similar charges levied
by the hospital
• Bodily injury or illness due to wilful or deliberate exposure to danger (except in
an attempt to save human life), intentional self-inflicted injury, and attempted
suicide
 FREQUENTLY ASKED QUESTIONS
• Circumcision, unless medically necessary for treatment of an illness not
excluded here under or as may be necessitated due to an accident
• Convalescence, general debility, and venereal disease
• External and or durable medical/non-medical equipment of any kind used for
diagnosis and or treatment, including CPAP (Continuous Positive Airway
Pressure), CPAD (Continuous Peritoneal Ambulatory Dialysis), oxygen
concentrator for bronchial asthmatic condition, infusion pump, etc. Ambulatory
devices i.e., walker, crutches, collars, caps, splints, elasto crepe bandages,
external orthopaedic pads, subcutaneous insulin pump, diabetic footwear,
glucometer/thermometer, and similar related items, etc., and also any medical
equipment, which is subsequently used at home and outlives the use and life of
the insured person
• Naturopathy and Siddha treatments
• Nuclear, chemical, or biological attack or weapons, contributed to, caused by,
resulting from or from any other cause or event contributing concurrently or in
any other sequence to the loss, claim or expense. For the purpose of this
exclusion:
• Nuclear attack or weapons means the use of any nuclear weapon or device or
combustion of nuclear fuel or the emission, discharge, dispersal, release or
escape of fissile/ fusion material emitting a level of radioactivity capable of
causing any Illness, incapacitating disablement, or death
• Chemical attack or weapons means the emission, discharge, dispersal, release
or escape of any solid, liquid, or gaseous chemical compound which, when
suitably distributed, is capable of causing any Illness, incapacitating
disablement or death
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• Biological attack or weapons means the emission, discharge, dispersal,
release or escape of any pathogenic (disease-producing) micro-organisms
and/or biologically produced toxins (including genetically modified organisms
and chemically synthesised toxins) which are capable of causing any illness,
incapacitating disablement or death
• Treatment for sleep apnoea syndrome, treatments such as Rotational Field
Quantum Magnetic Resonance (RFQMR), External Counter Pulsation (ECP),
Enhanced External Counter Pulsation (EECP), Hyperbaric Oxygen Therapy,
and CPAD (Continuous Peritoneal Ambulatory Dialysis)
• Treatment taken outside the geographical limits of India
• War (whether declared or not) and war-like occurrence or invasion, acts of
foreign enemies, hostilities, civil war, rebellion, revolutions, insurrections,
mutiny, military or usurped power, seizure, capture, arrest, restraints, and
detainment of all kinds
• Hospitalisation due to war, invasion, act of a foreign enemy, war-like
operations, nuclear weapons, ionising radiation, and contamination by
radioactive material, nuclear fuel or nuclear waste
• Circumcision, cosmetic or aesthetic treatment, plastic surgery unless required
to treat any injury or illness
• Vaccination & inoculation
• Cost of braces, equipment or external prosthetic devices, non-durable
implants, eyeglasses, cost of spectacles and contact lenses, bi-focal lenses,
multifocal lenses, torex lenses, hearing aids including cochlear implants, and
durable medical equipment
 FREQUENTLY ASKED QUESTIONS
• Convalescence, general debility ‘run-down’ condition or rest cure, obesity
treatment and its complications, congenital external disease or defects or
anomalies (except in case of life-threatening circumstances) with a sub-limit of
INR 1,00,000 per incident, treatment relating to venereal disease, intentional
self-injury, accident due to misuse of drugs/alcohol or use of intoxicating
substance, use of tobacco leading to cancer
• Bodily injury or sickness due to wilful or deliberate exposure to danger (except
in an attempt to save human life), intentional self-inflicted injury, attempted
suicide and arising out of non-adherence to any medical advice
• Treatment of any bodily injury sustained whilst or because of active
participation in hazardous sports of any kind
• Diagnostic, X-ray, or laboratory examination not consistent with or incidental to
the diagnosis of positive existence and treatment of any ailment, sickness, or
injury, for which confinement is required at a hospital/nursing home
• Vitamins and tonics, unless forming part of treatment for injury or disease as
certified by the attending physician
• Voluntary medical termination of pregnancy during the first 12 weeks from the
date of conception
• Instrument used in the treatment of sleep apnoea syndrome, C.P.A.P,
Continuous Peritoneal Ambulatory Dialysis (C.P.A.D.), and oxygen
concentrator for a bronchial asthmatic condition
• Genetical disorders and stem cell implantation/surgery
• Any domiciliary hospitalisation/treatment except in case of COVID-19 or any
pandemic where the treatment at home is recommended by the treating doctor
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• Treatment taken outside India
• Experimental and unproven treatment
• Change of treatment from one system of medicine to another unless
recommended by the consultant/hospital under whom the treatment is taken
• All non-medical expenses, including convenience items for personal comfort
such as telephone, television, governess, private nursing/barber or beauty
services, diet charges, baby food, cosmetics, tissue paper, diapers, sanitary
pads, toiletry items, and similar incidental expenses
• Service charges or any other charges levied by the hospital, e.g.,
registration/admission charges, RMO charges, etc.
• Treatment of any bodily injury sustained whilst or
as a result of participating in any criminal act
• Monitor charges not payable
• As per the insurance company’s guideline,
surgeon, anaesthetist, medical practitioner,
consultant, and specialist fees must form part
of the final hospital bill. in case not, the charges
paid directly will not be admissible under
our policy
• Procedure/treatment usually done in the out-patient
department is not payable under the policy even
if converted as an inpatient in the hospital for more
than 24 hours
• RMO charges are not payable
 FREQUENTLY ASKED QUESTIONS

Q81. Who should I contact for assistance?

Prudent Team

Single point of contact - Reimbursement: Single point of contact – Cashless: Escalation point 1 for cashless claims:
Mr.Ambadas Palve/Kapil Chavan Mr. Vaibhav Nikam/Manish Joshi Ms.Reshma Gaikwad
080 6922 5457/+91 86574 91766 080 6922 5408 +91 96190 13270
mumbaiclaims@prudentbrokers.com cashless@prudentbrokers.com reshma.gaikwad@prudentbrokers.com

Level 2 for reimbursement & cashless or general queries:

Mr. Raheel Ansari Mr. Mayur Tote

+91 82919 88730 +91 86579 13249
raheel.ansari@prudentbrokers.com mayur.tote@prudentbrokers.com

Level 3 for reimbursement & cashless:

Mrs. Ashita Lotia Dr. Siddharth Jawale

ashita.lotia@prudentbrokers.com siddharth.jawale@prudentbrokers.com

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 FREQUENTLY ASKED QUESTIONS

www.prudentbrokers.com

Prudent Insurance Brokers Pvt. Ltd. - Registered Office

101, Tower B, Peninsula Business Park, G.K. Marg, Lower Parel, Mumbai 400 013 Maharashtra | Tel: +91 22 3306 6000

CIN No.: U70100MH1982PTC027681 | Composite Broker License No. 291 (Validity: 18th February 2023 to 17th February 2026)

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Prudent Insurance Brokers Pvt. Ltd. is the registered Composite Broker by IRDAI, with license number 291 and does not underwrite the risk or act as an insurer. Prudent’s team offers you a chance to compare
the best policies offered by leading insurance companies and then buy a plan. Moreover, Prudent’s team give you personalized assistance in buying the product so that you can buy the policy after complete
knowledge of its technical details. For more details on benefits, exclusions, limitations, terms, and conditions, please read sales brochure/policy wording carefully before concluding a sale of the respective
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regarding the availability, cost, or terms of insurance coverage. Prudent’s service obligations to you are solely contractual in nature. You acknowledge that, in performing services, Prudent and its affiliates are not
acting as a fiduciary for you, except to the extent required by applicable law, and do not have a fiduciary or other enhanced duty to you. Vital Enhancement benefits are not a service of Prudent and is outside the
control of Prudent. The redirected website is owned, managed, and controlled by BenefitHub India Pvt. Ltd. and any advertisements or statements contained therein, or products and services offer there are
solely by BenefitHub India Pvt. Ltd. with no connection to Prudent. Prudent shall not have any role to play or any liability in relation to any action taken by you from and after clicking accept below. Tax benefits
under the policy are subject to conditions of the Income Tax Act, 1961. Service tax and applicable Cesses will be charged extra as per prevailing rates. Tax laws are subject to amendments from time to time. For
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