GROUP HEALTH INSURANCE PRESENTATION

M/S JUNGLEE GAMES INDIA PRIVATE LIMITED – Parents Policy

Disclaimer :
The benefits manual will serve as a guide to the benefits provided to Junglee Games. The information
contained herein is only the summary of the terms & conditions agreed with the Insurer. If there is a
conflict in interpretation, the terms & conditions on the policy will prevail.

Prepared By
Unison Insurance Broking Services Private Limited
 SALIENT FEATURES

S NO BENEFITS UNDER THE POLICY

1 Policy Start date 7th November 2019

Policy Expiry date 6th November 2020

2 Sum Insured Slab INR 300,000 per family

Unison Insurance Brokering Services/

3 Broker/ Insurer
Star Health And Allied Health Insurance Company Limited
4 Hospitalisation 24 hours hospitalization with Active treatment is mandatory

5 Family Definition Parents/Parents In Law

Pre hospitalisation
6 30 Days
Expenses
Post hospitalisation
7 60 Days
Expenses
STANDARD HOSPITALIZATION: 24 HOURS

Reimbursement of Expenses Related to

• Room and boarding
• Doctor Fees
• Intensive Care Unit
• Nursing Expenses
• Surgical fees, operating theatre, anesthesia and oxygen
and their administration
• Physical Therapy
• Drugs and medicines consumed on the premises
• Hospital miscellaneous services (such as laboratory, x
ray, diagnostic tests)
• Dressing, ordinary splints and plaster casts
• Costs of prosthetic devices if implanted during a surgical
procedure
• Radiotherapy and chemotherapy
• Organ transplantation charges

Hospital or Nursing home means any institution in India established for indoor care and treatment of sickness and injuries and which
has been registered either as hospital or nursing home with the local authorities and is under the supervision of a registered and
qualified medical practitioner, or complies with minimum criteria as follows :
1)Has a minimum of 10 beds if located in towns having a population of less than 10 lakhs (Class C Towns) or a minimum of 15 in
patient beds in other towns
2)Has a fully equipped operation theatre
405 Day Care List
3)Has a fully qualified doctor in charge and nursing staff around the clock
4)Maintains a daily medical record for each of its patients
 PRE EXISTING AILMENTS EXCLUSION
Pre Existing Diseases Exclusion

Any pre existing ailment such as Diabetes, Hypertension etc. or

related ailments for which care, treatment or advice was
recommended by or received from a Doctor or which was first
manifested prior to the commencement date of the Insured member’s
first Health Insurance Policy with the Insurer is not covered.

However, in this policy, this exclusion is waived

DAY CARE PROCEDURES

Please Note:-
Expenses on Hospitalizations for minimum period of 24 hours are admissible. However this time limit will not applicable for
specific treatments i.e. Dialysis, Chemotherapy, Radiotherapy, Eye Surgery, Lithotripsy (Kidney Stone removal), D & C,
Tonsillectomy, Dental Surgery due to accident, Hysterectomy, Coronary Angioplasty, Surgery of Gall bladder, Pancreas & Bile
duct, surgery, of Hernia Surgery of Hydrocele, Surgery of Prostate, Gastro Intestinal surgery, Genital Surgery, Surgery of Nose,
Surgery of Throat, Surgery of Appendix, Surgery of Urinary system, Arthroscopic Knee Surgery, Laparoscopic Therapeutic
Surgeries, Any surgery under Anesthesia, Treatment of Fractures/Dislocation excluding hairline fracture, Contracture releases &
minor reconstructive procedures of-limbs.
PRE- AND POST-HOSPITALIZATION EXPENSES PERIOD
Pre Hospitalization
Definition: 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
reimburse the Insured Member’s Pre- hospitalization
Expenses prior to his / her Hospitalization.
Post Hospitalization
Definition: Immediately following the Insured
Member’s discharge, further medical treatment
directly related to the same condition for which the
Insured Member was Hospitalized is required, the
Insurer will reimburse the Insured member’s
Expenses
 BOARDING CHARGES

NORMAL ROOM
2% of Sum Insured maximum up to INR 7,500

ICU ROOM
4% of Sum Insured maximum up to INR 12,000
DISEASE CAPPING

Sub limits only for Cataract INR 40,000 per eye

 CASHLESS HOSPITALIZATION

List of Hospitals in the TPA’s network eligible for cashless hospitalization :

www.starhealth.in/network-hospitals

PAN INDIA
NETWORK LIST OF HOSPITAL _ 6.11

For detailed information related to Policy administration / claim assistance kindly contact your

Account Manager/Claims Manager

 PLANNED HOSPITALIZATION

TPA intimates the hospital/

Claim Yes Insured within 3 hours & issues
Member intimates TPA of authorization letter within for
Registered by
the planned hospitalization planned hospitalization to the
insurance
in a admission request form hospital.
company on
48 hours prior to
same day
hospitalization

No
Pre – Authorization Form
Pre-Authorization
Follow non cashless Completed
At process
web: Claim Form
 EMERGENCY CASHLESS HOSPITALIZATION

II III
I
Pre-Authorization by Treatment &
Get Admitted
hospital Discharge

In case of emergency, Admitted member or Family members
the member should get should inform the Hospital TPA to send
admitted in the nearest cashless request within 24 hours of the
network hospital by hospitalization. The authorization letter
showing their ID card. would be directly given to the hospital. In
case of denial member would be
informed directly
After your hospitalization has
been authorized the employee is
not required to pay the
hospitalization bill in case of a
network hospital. The bill will be
sent directly to, and settled by,
Insurance company. The patient
will have to pay only for the non
medical expenses.
 HOSPITALIZATION @ NON NETWORK
HOSPITALS
At the time of discharge, collect all
bills (stamped and signed), supporting
investigation reports, medical bills,
discharge card, payment receipts etc in
original from hospital.
A
Within 7 days of discharge,
submit the Claim form along
with documents (in original) Keep a copy of documents with you for
to Unison Office / Helpdesk further reference

Is the claim Documents are sent to

Are document received
Yes Insurance Company and Yes
medically payable within Stipulated time No
as per terms of they performs medical
scrutiny of the documents from discharge
Policy?
Claim Rejected
No

No

No Query Letter mailed

Insurance Company Are documents
complete as about deficiency and Employee submits
checks document document
required ? balance documents
sufficiency requirement in time

Yes
Payment transferred through Yes
NEFT and UTR No Updated to Claims processing done within 21
corporate HR along with Settlement A
working days
Voucher
REIMBURSEMENT CLAIM FORMS
Claim Submission Reimbursement Claim
Checklist Form

Reimbursement Claim Form

Claim Documents
 STANDARD EXCLUSIONS (NOT COVERED)
 OPD Expenses
 Physiotherapy treatment on OPD basis ,Dental expenses
 Hospitalization under the influence of drugs/alcohol
 Congenital disorder
 Infertility/sterility related treatment
 Any hospitalization for observation/investigation
 Plastic Surgery or any treatment/surgery related to
beautification
 HIV/AIDS
 Self injury/ Suicide/ Poisoning
 Medical termination of pregnancy will not be paid unless a
case of emergency
Please note that the above list is indicative only and not exhaustive.
 Expenses on Vitamins and Tonics
 Expenses on correction of eyesight, spectacles, Contact
lenses, Hearing Aids
 Referral fee to the doctor, outstation expenses
 Plastic Surgery owing to any accident
 Naturopathy Treatment
 Only diagnostic services administered in hospital
 Registration charge /Personal Comfort charge
 Conditions arising owing to obesity
 Massage, Steam Bath, Shirodhara charge
LIST OF NON-PAYABLE
ITEMS
1. Admission/Registration Charges.
2. Telephone charges.
3. Vaccination charges etc.
4. Extra bed charges for attendant.
5. Expenses on vitamins, tonics if not directly related with the treatment.
6. Food & Beverages for attendant.
7. Xerox / certifying charges if any.
8. Sanitary items.
9. Diagnostic Equipment like Gluco Meter
10. Expenses on luxury items unless within the room package.
11. Expenses of external aid e.g. Spectacles, hearing aids, crutches etc.
12. Pre & Post hospitalization expenses in excess of defined period under the policy or irrelevant to disease (for
which patient was hospitalized).
13. Any other expenses as specified under the policy.
14. Cost of treatment that has been specifically or otherwise excluded under the policy

Please note that the above is indicative only and not exhaustive. List of Non-Payable items are updated on
IRDA/FICCI website as guideline for all the TPA/Insurers/Insured.
 REIMBURSEMENT CLAIM SUBMISSION

Submit all Pre-Hospitalization expenses within 60 days of the date of discharge and all Post –
Hospitalization expenses within 7 days of the completion of the post hospitalization period

Documents along with completed claim form should be couriered to the address mentioned below:
705-711 7th, JMD Regent Square,
M.G. Road,
Gurugram –122002,
Haryana
Phone: 0124-4961300 ; Fax: 0124-4370526

Claims Team
Unison Insurance Broking Services Private Limited
 ENROLLMENT PROCESS FOR NEW EMPLOYEES

1. Member details (Member Id, Name, Date of Birth, Date of Joining, Mail ID) are sent by HR to
Unison for endorsement.

2. Once the member’s endorsement has been issued, the insurer sends the endorsement to the TPA. The
TPA uploads the member’s information.

3. The HR is intimated about the endorsement and the endorsement copy is sent to the HR with the
cards of the new member enrolled in the policy.

4. In the event of a medical emergency, prior to HR intimating the Insurer of your enrollment or prior
to issuance of endorsement, a written confirmation from the Insurer to the TPA to permit cashless
hospitalization will suffice. Inform HR that you need emergency assistance. HR will coordinate with
Unison to ensure cashless approval is granted at a network hospital provided there is sufficient
balance in the CD account.

5. Employees should intimate newly married spouse or newborn baby’s name to HR within 30 days.
ESCALATION MATRIX
For Reimbursement and cashless claim related help :

Mr. Pradeep Pandey

Email id: pradeep.pandey@unisoninsurance.net Mobile : +91 96560021606

For endorsements
Level 1
Mr. Devender Dhingra
Email id: devender.dhingra@unisoninsurance.net Mobile : +919871551818

Level 2
Ms. Shilpa Srivastava
Email id: shilpa.srivastava@unisoninsurance.net Mobile : +91 9953237168

Level 3
Ms. Sonal Chaturvedy
Email id: sonal.chaturvedy@unisoninsurance.net Mobile : +91 9654954019

For Final Escalation

Mr. Rishi Tripathi (Branch Head)
Email id: rishi.tripathi@unisoninsurance.net Mobile : +91 9810800064
THANK YOU