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Last Updated: 01-Nov-2012


Group Mediclaim Insurance Program FAQs

Definitions:
Q1: What is the definition of Hospital/Nursing Home?
A: Hospital/Nursing Home, means any institution in India established for indoor care and
treatment of sickness and injuries and which has been registered either as a hospital or
Nursing Home with the local authorities and is under the supervision of registered and
qualified medical practitioner
OR
Should comply with minimum criteria as under:
It should have at least 15 inpatient beds.
Fully equipped Operation Theatre of its own wherever surgical operations is carried out.
Fully qualified nursing staff under its employment round the clock.
Fully qualified doctor(s) should be in charge round the clock.
The term, `Hospital/Nursing Home, shall not include an establishment, which is a place
of rest, a place for the aged, a place for drug addiction or place of alcoholics, a hotel
or a similar place.

Q2: What does Immediate Family floater cover mean?


A: Immediate family Floater indicates the total sum insured for your family (spouse + 2
children) within a given year. The same can be either claimed entirely by one member
or shared within the family upto the maximum limit.
Q3: What is copay and how is the same applicable?
A: Copay is a defined deductible to be paid by the insured person upon availing
medical services. This usually represents as a percentage of the coverage amount
different from non admissible.

Copay is applicable in your policy as mentioned below

Co pay will be applicable on spouse and children hospitalization claims only. The
Co pay percentages are as follows

For all Hospitalization Claims- in non- PPN Hospitals


For negotiated surgical procedures in PPN Hospitals
For non-negotiated surgical procedures in PPN Hospitals
Link to hospital & procedures

20%
10%
20%

Example:
If the admissible claim Rs.10,000 then Rs.2000 will be deducted and only Rs.8000 will be
paid.
There is no co-pay for claims in respect of hospitalization of employees
Given below are the examples for co-pay in case of spouse & dependent children
claims.
a) Considering a sum coverage of 2, 00,000. If the admissible amount is 2, 50,000 then
the copay would be applied on 2,00,000.
b). Under Maternity section. - Sum assured Rs.50000.
Maximum expense limit reimbursable for Maternity is Rs.50,000/- per
occasion/pregnancy, irrespective of whether the pregnancy is for one child or twins.
If both employee & spouse are working in HP the Maternity benefit of Rs.50,000/- each
will be available for both employees.
Employee claim will be 100% paid by the insurer; a co-pay of 20% will apply on the
claim for spouse.
c). under other hospitalization section.
For agreed surgical procedures in Preferred Provider Network Hospitals - A Co-pay of
90:10 will be applicable
For non-agreed surgical procedures in Preferred Provider Network Hospitals A Co-pay
of 80:20 will be applicable

Q4: Under what conditions can I avail the buffer?


A: Buffer Utilisation will be available only for Critical Illnesses/Accident
Critical illness means the following:
1. Cardiac Surgeries

2. Cancer Surgeries
3. Brain Tumor Surgeries
4. Pace-maker implantation
5. Hip replacement
6. Renal surgeries
7. Hospitalization due to any serious/grievious injury arising out of an accident
8. RFA for cardiac arrhythmia apart from Pacemaker implantation
9. Hospitalization due to any other life threatening disease/condition as mutually
agreed by HP HR and UIIC.

Maternity FAQs:
Q1: What is the maximum amount allowable under the Maternity benefit?
A: The maximum amount allowable under the Maternity benefit is Rs. 50,000 per child
for a max of 2 children.
Q2: Is baby covered from day one of birth?
A: Yes, baby is covered from day one up to the family floater.
Q3: Both my wife & I work for HP, how does the maternity benefit apply to us?
A. If both employee & spouse are working in HP the Maternity benefit of Rs.50,000/each will be available for both employees
Claims FAQs:
Q1: What is the time frame within which the Claim has to be submitted?
A: The claim must be filed within 15 days from date of discharge from the Hospital in
case of hospitalization and within 67 days in case of post hospitalization claims.

Q2: What are the documents that are required to be submitted for availing
reimbursement?
A: Following are the documents that are required to be submitted:
Claim form, all original Bills, receipts and Discharge Summary/Certificate/Card from the
Hospital.
Cash Memos from the Hospital/Chemist(s), supported by the proper prescription,
investigation reports etc.
Q3: Can I claim hospitalization expenses incurred abroad ?

A: No, the Program covers only those hospitalization expenses that are incurred in India.
Q4: Is there a waiting period before I can make a claim?
A: No. There is no waiting period for submission of claims provided it pertains to the
same coverage period.
Q5: I have diabetes, blood pressure and heart problems. I got admitted for angioplasty.
Investigations for related problems of diabetes were done. Can I claim the investigation
costs as I was admitted for a heart problem?
A: In case the main hospitalization claim is an eligible claim, medical expenses 30 days
prior to hospitalization and 60 days post hospitalization related to the main
hospitalization, could be claimed.
Q6: I have been advised to undergo an operation for defective nasal septum. I also
wanted to have plastic surgery done on my nose. Are expenses for the same
reimbursable?
A: Hospitalization costs for the operation performed for defective nasal septum is
claimable under the program. In this case though plastic surgery is not covered.
Q7: I have been advised to undergo a kidney organ transplant. Can I claim the cost of
the organ?
A: No this is not payable as per policy terms and conditions.
Q8: I have been advised to undergo kidney dialysis every week. I will be hospitalized for
less than 24 hours. Can I claim the expenses incurred under this program?
A: Yes. However, only hemodialysis is covered.

Q9: I am currently on special medication for reducing my weight. Can I claim the
expenses incurred under this program?
A: No, this is not payable as per policy terms and conditions.
Q10: I have paid for the hospitalization expenses in foreign currency. Will the insurance
company reimburse the equivalent amount in rupees to me?
A: Even if the amount paid is in foreign currency, the bill receipt should be in Indian
rupees for the same to be claimed from the insurer.
Q11: One of my colleagues dependent was hospitalized for heart ailment and passed
away. Are the costs involved for the treatment claimable under the program in case
the member expires?

A: Yes, if there was hospitalization involved, the expenses would be payable as per
policy terms and conditions.
Q12: I need to travel to Mumbai for a Kidney transplant. Is my air fare reimbursable?
A: No.

Exclusions:
Q1: What are the diseases/illness that are excluded from the Program?
Please click here for policy details section & refer Section 5.7 Exclusions under the policy.
Q2: Is Outpatient treatment like common cold, asthma etc covered at the hospital?
A: No. Outpatient treatment at the hospital is not covered under the program. The
expenses incurred have to be claimed under the company medical program as
mentioned under the FBP.

FAQs on MediAssist Services:

Q1: What is MediAssist?


A: Medi Assist India TPA Pvt. Ltd. is a Third Party Administrator licensed by the Insurance
Regulatory and Development Authority (License No. 003). The company is managed by
a group of committed professionals with several years of experience in the Insurance,
Healthcare, Finance and Information Technology domains. They enable cashless
hospitalization at pre designated points of healthcare delivery like hospitals and nursing
homes, and in case of reimbursement claims, they assure speedy settlement of the
same.
Q2: How do I enroll for MediAssistservices?
A: You would need to fill the form available @ HP HR portal under Employee Resources
>> Compensation/ Benefits >> Benefits Summary >> Health/ Medical
Q3: Is a MediAssist card a necessity?
A: Yes. But in case of an emergency, if you dont have your MediAssist Card you may
use your HP ID Card too.
Q4: Which are the empanelled hospitals, where cashless facility is available?
A: The updated list of empanelled hospitals is available with the MediAssist
representative or Log on to www.mediassistindia.com

Q4: a) What are PPN Hospitals


A: PPN hospitals are the preferred provider network hospitals where the insurers have
prenegotiated packages for various treatments. You can view the list of PPN hospitals
by visiting www.mediassistindia.com and selecting the PPN hospital for PSU list
appropriately
Q4: b) What is copay and how is the same applicable?
A: Copay is a defined deductible to be paid by the insured person upon availing
medical services. This usually represents as a percentage of the coverage amount
different from non admissibles.
Copay is applicable in your policy as mentioned below

Co pay will be applicable on spouse and children hospitalization claims only. The
Co pay percentages are as follows

For all Hospitalization Claims- in non- PPN Hospitals


For negotiated surgical procedures in PPN Hospitals
For non-negotiated surgical procedures in PPN Hospitals

20%
10%
20%

Link to hospital & procedures

Q5: Do I need to visit only MediAssist-empanelled hospitals?


A: No, though it is preferred to use the MediAssist empanelled hospitals as you can avail
the credit facility and discounts. Employees can still go to any other hospital, pay for the
hospitalization expenses and have the same reimbursed with the help of MediAssist.
Please Q4 a and b for more details on discounts and co-pay applicability depending
on the hospital opted for.
Enrolment FAQs:
Q1: What is enrollment?
A: Enrollment refers to the process whereby an employee updates his/her details along
with dependent details on the Mediassist website. This is done after receiving an
enrollment email from Total Rewards and from Mediassist for new joinees
Q2: Whom can I enroll?
A: Employees can enroll their spouse and up to 2 dependent children only.

Q3: When does enrollment open?


A: Enrollment opens in the month of October
Q4: How do I enroll a dependent?
A: You can enroll a dependent by clicking on the link in the enrollment mail and
updating the requested details.
Q5: I have not enrolled when the window opened, what can I do?
A: Addition/deletion/modification of dependents or changes in Top-Up cover cannot
be accommodated post closure of window period.
Q6: I have just got married/ had a baby, how do I enroll my new dependent?
A: Newly married employees have to enroll their spouses as dependents within 30 days
of the wedding date. Employees who had a baby need to add the new-born child as
a dependent in the Mediassist website within three months from the date of birth.

Q7: How do I deactivate/remove my dependents?


A: Deactivation/removal of dependents can only be performed during the opening of
the enrollment window during October every year. Mid term removal of dependents
under any circumstances is not allowed.
Q8: I did not enroll my dependents this year and yet premium is being deducted, can I
de-activate now?
A: Dependents enrollment is carried over from the previous year if no changes have
been made to dependents data during the current enrollment window. Therefore
deactivation of dependents & reimbursement of premium deducted is not allowed in
such cases.
Q9: I have lost/ got separated from one of my dependents and have deactivated it in
the system, how do I get my premium back?
A: You can deactivate dependents due to death or separation reasons. The premium
paid in such cases on a prorate basis only in case there are no claims filed for the policy
period.

Q10: How do I enroll my third child?


A: Please raise a Contact HR case and through Mediassist enroll the child by paying the
additional premium.
Q11: Can I add my dependent sibling?
A: No, because family as defined by the insurance policy consists of spouse, children,
dependent parents & in laws.
Q12: I had enrolled my dependents for top-up cover and am leaving HP during the
year how do I recover my premium?
A: In case there are no claims made in the current policy period, then the prorated
premium would be paid out to you.
Q13: Is there an age limit to cover any dependents under this program?
A: No there is no upper limit.
Q14: Can I include my dependent family members under the Program during the
course of the year?
A: Midterm inclusions are now allowed in the policy. However, in case of any life
events like marriage or childbirth, spouse or new born could be added within 30 days
from the date of event.
Q15: Can I include other relatives/friends under this Scheme, by personally paying the
premium amount?
A: No, this program is only limited to self, spouse and max 2 children.
Q16: Can I get the coverage amount enhanced by paying extra premium?
A: Yes, please refer to the top-up cover schedule mentioned in the policy (section 5.6)
Q17: How will the premium for Voluntary option be deducted?
A: It will be deducted in 3 equal installments from month of Nov-2014 to Jan-2015

Q18: In case of separation, can I continue to avail the benefit by paying the premium
directly to the insurance company?

A: No, in case of separation the company program ceases to exist. Please take a letter
from MediAssist mentioning that you were covered under the companys program to
receive continuity benefits while taking an individual program.
Q19: Under the program, only 2 of my children can be covered. What should I do in
case I want to cover my third child?
A: You can cover your third child by paying an additional premium of Rs 500/-. The total
floater coverage for your family the buffer would continue to remain same.
Q20. I got married during the year. What is the timeframe by which I should add my
spouse to the policy?
A. You would require to add your spouse as a dependent to the policy within 30 days of
your marriage.
Q21: I had not added my dependents under current year policy(2013-14) if I Add now
(October 2014) can I get reimbursement ?
A: The enrollment drive is for 2014-2015 policy whereas the claim is for the policy year
2013-14 hence the claim would not be payable.
Q22: What happens to premium paid for Employee voluntary options ?
A: Premium will be refunded on Prorata basis if there is no claim registered.

Hospitalization FAQs:
Q1: Is there any time limit for Hospitalization?
A: Yes, The admissible minimum period of hospitalization is 24 hours. However, this time
limit is not applied to specific treatments i.e. Dialysis, Chemotherapy, Radiotherapy, Eye
Surgery, Dental Surgery, Lithotripsy (Kidney Stone removal), D&C, Tosillectomy taken in
the Hospital/Nursing Home and the Insured is discharged on the same day.
Q2: Are Pre and Post Hospitalization expenses covered?
A: Yes, all relevant medical expenses incurred during a period upto 30 days prior to and
60 days after hospitalization on disease/illness/injury sustained will be considered as part
of claim.
Q3: Will I be reimbursed for all the expenses that I incurred during hospitalization?

A: The following expenses can be reimbursed as per Insurance policy norm:


Room, Boarding Expenses as provided by the Hospital/Nursing Home.
Nursing Expenses, Surgeon, Anesthetist, Medical Practitioner, Consultants Specials
fees
Anesthesia, Blood, Oxygen, OT Charges, Surgical appliances, Medicines, Drugs
Diagnostic material and X-Ray, Dialysis, Chemotherapy, Radiotherapy,
Cost of pacemaker, artificial limbs, cost of organs and similar expenses.
Q4: I am a heart patient. Can I claim hospitalization expenses under this program?
A: In case of hospitalization with an active line of treatment, you could claim the
medical expenses. The claim would be settled as per policy terms and conditions.
Q5: What do I do in case of a planned hospitalization at an empanelled hospital?
A: You would need to fill a pre-authorization form(available with MediAssist). The preauthorization form includes details of the patient, hospital and estimated expenses.
On receiving the pre-authorization form, MediAssist would issue an authorization letter
to the hospital. Thereafter, the patient shows the MediAssist card and gets admitted at
the hospital.
At the time of discharge, the patient needs to ensure to sign the bill. You would not
need to pay for any of the expenses covered under the program. Any auxiliary
expenses (not covered under the program) like telephone calls plus 20% co pay in case
of spouse & children claims would be charged to you. You would need to sign on an
insurance claim form at the time of discharge. All relevant documents should be
handed over to MediAssist.

Q6: What do I do in case of an emergency hospitalization?


A: In the case of an emergency, the employee or his/her dependents can undergo
hospitalization without the pre-authorization letter from MediAssist. Empanelled hospitals
have been instructed to admit the patient under emergency with only the photo-ID
card. In case it is a non-empanelled hospital.
Q7: I have been advised to get admitted by the doctor. How can I find out if my illness
will be covered?
A: Patients generally get admitted to Hospital/Nursing Home upon the advice of the
medical consultant. The reasons for such admission could be for diagnosis, treatment,
observation & evaluation etc based on symptoms and signs of ailments or injuries.
If the admission of the patient is primarily for diagnostics and investigation and / or
observation and evaluation, the Hospitalisation expenses are not reimbursed. The

objective of the Policy is to cover Hospitalisation expenses for curing the ailment/injury
(active line of treatment) and requiring in-patient care for 24 hours or more wherein the
treatment would not have been possible on an out-patient basis.
Q8: My dependents are in a different location and need hospitalization. Whom do I
approach?
A: Please refer Mediassist network of hospitals & PPN hospitals list if hospital is covered
under Mediassist network in the respective location. If not, then dependents can avail
treatment in non network hospitals and claim reimbursement.
Q9: I need hospitalization and have forgotten my Mediassist ID, what do I do?
A: You can use your HP Emp no.
Q10: Can I transfer the sum assured between the parents policy and my policy (and
vice-versa)?
A: No, the sum insured can be floated across only members of the respective policy.
a) Viz, employee spouse and children in the employee policy.
b) Parents and in-laws in the parents policy.

Q11: I wish to stay in a higher category room what can I do and will my bills be
covered?
A: Employees and the insured dependents are entitled to occupy Single Private A/c
Room. The maximum room rent, nursing charges and boarding charges allowed per
day is Rs 5,000/- whichever is less. If the insured patient occupies higher category room
costing more than Rs 5,000/- per day, the room rent difference will be borne by the
employee.
Q12: My dependent has to undergo treatment for cancer and the treatment is oral/
biological/ hormonal which is not covered, what do I do?
A: Under the current health insurance policy, only parenteral chemotherapy is covered.
Other lines of treatment such as oral and hormonal chemotherapy and adjuvant
therapies are covered except for biologicals which is not covered.
Q13: My hospital is not in the cashless network and the treatment is expensive, what do I
do?

A: Please connect with your HR Generalist to understand what help and resources can
be made available to you from the Company under such exceptional circumstances.
Q14: Can I pay additional premium and increase the coverage during the year?
A: Top up cover can only be availed and enhanced during the enrollment window in
October/ November during the start of policy period.
OPD FAQs:
Q1: What is OPD cover?
A: There are number of instances wherein the employee or his immediate dependents
such as spouse or child require consultation with a doctor for certain medical
conditions which do not require hospitalization and all such procedures are done on
outpatient basis. In such cases, the insured patient may be advised to undergo certain
investigations, laboratory Tests, purchase medicines etc. Such medical expenses are
termed OPD Expenses. Under HP employee policy, a part of such expenses are
reimbursed. The parental policy does not cover OPD expenses for reimbursement.

Q2: What are the conditions and limits for Claiming OPD Medical Expenses?
A: Claims for OPD Expenses are on reimbursement basis for self, spouse and children
only.
Amount admissible will be only for specialist consultation fee, Cost of Investigation and
Diagnostic procedures.
However, consultation or any related expenses for dental, vision, psychiatry and
maternity related treatments & disorders are excluded under OPD cover.
Medicine Charges or any other charges such as Health Check-up, Vaccination
Charges, Routine consultations etc are not admissible under OPD.
Specialist in this clause means a Medical Professional or Doctor having MD/MS or
equivalent qualification in the Allopathic system of Medicine.
Reimbursement will be to the extent of 50% of Actuals on each claim subject to overall
limit of Rs 15,000/- during the year per family. Year is reckoned as November of current
year to October of next year.

Reimbursement will be to the extent of 75% of actual on each bill if the treatment is
taken at a Registered Hospital/Nursing Home subject to an overall limit of Rs 15,000/per family per year (November of current year to October of next year).
Q3: Is the OPD reimbursement the same as INR 15,000 in FBP?
A: No, OPD reimbursement is part of the medical insurance cover and is over and
above the INR 15,000 medical reimbursement available under FBP
Q4: What is the timeline to claim reimbursement of my OPD bills?
A: All OPD bills must be submitted for reimbursement within 15 days of availing the last
specialist consultation.
Claim FAQs:
Q1. My claim was rejected and I need all my papers back?
A: As per policy, regardless whether the claim is approved or denied, the documents
are not returned to the insured. The only exception situation for the documents to be
returned is if the insured wishes to submit the same claim through another insurance
cover. Under such situations, the documents will be returned with a company seal from
Mediassist and approval from HP.
Employees can write to hp@mediassistindia.com to retrieve the rejected claim
documents for the purpose mentioned above only.
Q2: What is the time frame by which I have to submit claims for reimbursement?
A: The claim documents need to be submitted within 7 days of completion of PostHospitalization Treatment (Max 60 days if Post Hospitalization continued upto max
period allowed) and if it is a pre-hospitalization claim, within 15 days of from the Date of
Discharge for reimbursement.
Documents with regard to OPD Claims have to be submitted within 15 days of
Consultation with the Specialist.
Q3: Where and how should I submit my claims?
A: 1. Enter your details in the reimbursement claim form available here
2. Attach all the necessary documents with the reimbursement claim form
3. Retain a scanned or photocopy of all the documents including the reimbursement
claim form, for your records

4. Reimbursement claims can be submitted at nominated Help Desks at the respective


locations. Details of Help Desk Locations, timings are given below:

DAY

LOCATION

TIME

Co-coordinator

Monday

Electronics City - 1

10.30 - 1.30

Mahesh

GRTECH PARK WHITEFIELD

11.00 13.30

Yogesh

Kalyani Tech Park, cosmos

3.00 - 4.00

Yogesh

Electronics City - 1

10.30 - 1.30

Mahesh

C V RAMAN NAGAR BAGMANE


PARK

3.00 - 4.30

Yogesh

10.30 - 1.30

Mahesh

MAHADEVAPURA

11.00 13.30

Yogesh

Electronics City - 1

10.30 - 1.30

Mahesh

Salapuria, ADUGODI

10.30 12.30

Yogesh

Electronics City - 1

10.30 - 1.30

Mahesh

PRITECH PARK, Bellandur

10.30 12.00

Yogesh

Tuesday

Wednesday Electronics City - 1

Thursday

Friday

HELPDESK LOCATION IN CHENNAI


DAY

LOCATION

TIME

Co-coordinator

Monday

OTP, Chennai

3.00 - 5.00

Baseeruddin
Ahmed

Friday

FSP (Alternate Friday)

4.00 - 6.00

Baseeruddin
Ahmed

Friday

TRILL PARK-OMR (Alternate Friday)

4.00 - 6.00

Baseeruddin
Ahmed

HELPDESK LOCATION IN MUMBAI


DAY

LOCATION

TIME

Co-ordinator

Thursday

Oberoi Commerze

3.00 - 4.00

Reema

5. Employees who do not have access to the above helpdesks can also submit
the reimbursement claims to Mediassist directly at the below address, by mailing
the documents through courier: Please mention employee number on the
documents if sending by courier

HP Team 3rd Floor


Medi Assist India TPA Pvt Ltd
Green Arch, "B" Block, 3rd Floor,
#45/A, 1st Main Road, J P Nagar 3rd Stage

Bangalore - 560 078

Q4: How will I be reimbursed?


A: In case of approval, the claims settlement shall be made by direct transfer to the
Employees account. Please furnish the correct bank account details in the
reimbursement form to ensure fast and efficient settlement of claims.
Q5: Some of my claimed amounts are rejected, how do I recover those?
A: In case your claim is denied, the denial letter is sent to you by email. The documents
will not be returned to you as per the policy.
Q6: Do I have to submit X-ray, CT, MRI films as well? I need these for future reference.
A: No. only the written reports, prescription & bills are to be submitted for X-ray, CT & MRI
films TPA may ask on case to case basis
Q7: I have lost my bills, how do I make a claim?
A: Reimbursement cannot be claimed without original bills.
Q8: I wanted to claim partially under HP policy and partially under another, what do I
do?
A: Yes, it is possible to do so only when the sum insured of one of the policy is exhausted.
Please mention the same while submitting the claims & inform the hospital of the same
while collecting the bills.