Document Identifier

Effective Date
Version

HR/00/GMIP
19.02.2014
1.0

GROUP MEDICLAIM INSURANCE POLICY

1. Objective
Group Mediclaim Policy provides for reimbursement of hospitalization expenses for illness,
disease or injury sustained by employee and eligible family members.
Expenses for hospitalization are payable only if 24 hour hospitalization has been availed (except
for select day care procedures which do no not require a full day hospitalization)

2. Eligibility
All India based WBPO employees are covered under this Policy.

3. Policy
a.
b.
c.
d.

Policy Period 19th Feb 2014- 30th Sept 2014

Insurer National Insurance Company limited
Third Party Administrator (TPA) VipulMedCorp TPA Pvt. Ltd.
Sum Insured: Mentioned below is the coverage of Mediclaim Insurance:
Career Band
Band AA & Band B1

Sum Assured( in INR)

1,00,000

Covered Members
Employee Only

Band B2 & Band B3

2,00,000

Employee, Spouse and Dependent Children

Band C1 & Band C2

4,00,000

Employee, Spouse and Dependent Children

Band D1 & Band D2

6,00,000*

Band E

10,00,000*

Employee, Spouse, Dependent Children

and Parents**
Employee, Spouse, Dependent children and
Parents**

*For Bands D1 to Band E, the Sum Insured is for the entire family, however the maximum
reimbursable expenses shall not exceed Rs. 5, 00, 000/- per person .
** Please note that Parents does not include Parents-in-laws.
Dependent Children shall mean:
Children not exceeding two in number and not over 23 years of age and/or as long as
they are dependent on the Employee.

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4. Benefits:
a. The GPAIP has been taken to provide benefit of insurance to the employee. Following is the
brief consolidation of coverage and the Benefit payable in the respective category under the
Policy:
Hospitalization

Expenses of Hospitalization for minimum period 24

hours are admissible. (Except for Day Care
procedures).

Pre-Post Hospitalization Expenses

The policy covers pre-post hospitalization expenses

incurred 1 month prior & 2 months after the
hospitalization.

Pre-existing

Congenital disease

Pre-existing diseases are covered for existing

members and new joinees
Not Covered

Dental

Surgery due to Accident

First 30 days Waiting

Covered

Maternity

Maternity Benefit of INR 40,000 for Caesarian / INR

30,000 or normal delivery is provided.

New born baby

New Born Child coverage and maternity coverage

starts from day one.

Pre and Post-Natal

Not Covered

Ambulance

1% of sum assured upto a maximum of INR 1000 per

annum. Not applicable on transfers from Hospital to
Home.

Day care Procedures

Please refer to Section C below

Invitro fertilization

Not Covered

Ayurveda

Not Covered

Homeopathy

Not covered

HIV

Not Covered

Mental ailment

Not Covered

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Please note that the Mediclaim expenses claimed under this Policy should not be claimed under
MAP Policy.
b. Room Rent Limits:
Band
AA to Band B3

Amount
Rs.2000 per day

C1 to D1

Rs.3500 per day

D2 & E

Rs. 5000 per day

Remarks
In case member opts higher Room Rent then all the
increased associated charges and Room Rent
difference will be born by Employee/Patient.

c. Day Care Procedures Covered:

For the purpose of this definition, Day Care procedures include treatment for specific
procedures where the period of hospitalization is less than 24 hours. Though expenses of
Hospitalization for minimum period 24 hours are admissible under this Policy, however this
time limit is not applied to the following procedures where the employee is discharged the
same day:
Dialysis, Parenthral Chemotherapy, Radiotherapy, Eye Surgery, Lithotripsy (kidney stone
removal), D & C, Tonsillectomy, Dental Surgery due to accident, Hysterectomy, Coronary
Angiography, Surgery of Gall Bladder, Pancreas & Bile duct, surgery of Hernia, Surgery of
Hydrocele, Surgery of Prostate, Gastrointestinal surgery, Genital Surgery, Surgery of nose,
Surgery of Throat, Surgery of Appendix, Surgery of Urinay System, Arthroscopic knee
surgery, Laparoscopic Therapeutic Surgeries, Treatment of Fractures / Dislocation excluding
hairline fracture, Contracture releases & minor reconstructive procedures of limbs which
otherwise require hospitalization taken in the hospital .
The above treatments will be considered under hospitalization Benefit.

5. Important Definitions
a) Hospital / Nursing Home: Any institution in India established for indoor care and
treatment of sickness and injuries registered either as a hospital or nursing home with
the local authorities and is under the supervision of the registered and qualified medical
practitioner or should comply with minimum criteria as under:
It should have at least 15 inpatient beds. In class C towns condition of number of beds
may be reduced to 10.
Fully equipped operation theatre where surgical operations can be carried out.
Fully qualified nursing staff employed 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.
Note: The above mentioned criteria need to be met even in cases of dental (only due to
accident) and eye treatments.

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b) Special Conditions applicable to Maternity Expenses Benefit:

These benefits are admissible only if the expenses are incurred in Hospital / Nursing
home as in-patient in India.
Claim in respect of delivery for only first two children and/or operations associated
therewith will be considered in respect of any one Insured Person covered under the
Policy or any renewal thereof. Those Insured Persons who are already having two or
more children will not be eligible for this benefit.
Expenses incurred in connection with voluntary medical termination of pregnancy during
the first 12 weeks from the date of conception are not covered. Pre-natal and post-natal
expenses are not covered unless admitted.

Domiciliary Hospitalization benefit means medical treatment for a period exceeding

three days for such illness, disease / Injury which in the normal course requires care &
treatment at the hospital / nursing home but actually taken whilst confined at home in
India under any of the following circumstances namely:
The condition of the patient is such that he/she cannot be removed to the hospital /
nursing home, or the patient cannot be removed to a hospital / nursing home for lack of
accommodation therein.
However, Domiciliary Hospitalization benefit shall not cover expenses incurred on pre &
post Hospitalization treatment & for treatment of any of the following diseases:
Asthma
Bronchitis
Chronic nephritis & Nephritic syndrome
Diarrhea and all types of dysenteries including gastro- enteritis
Diabetes Mellitus & Insipidus
Epilepsy
Hypertension
Influenza, cough & cold
All psychiatric or psychosomatic disorders
Pyrexia of unknown origin for less than ten days
Tonsillitis & Upper Respiratory Tract infection including Laryngitis & Pharingitis
Arthritis, Gout & rheumatism

c) Any one illness will be deemed to mean continuous period of illness & it includes
relapse within 45 days from the date of last consultation with the hospital / nursing
home where Treatment may have been taken else it shall be deemed as fresh illness.
d) Pre & Post Hospitalization -Medical expenses incurred during period up to 30 days prior
& 60 days after hospitalization & domiciliary hospitalization on disease / illness / injury
sustained shall be considered as part of claim under Hospitalization.
e) Exclusions in the Policy:
The following general exclusions will apply to the policy:
Circumcision unless necessary for treatment or 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 as accident or as part of any illness.
Surgery for correction of eye sight, cost of spectacles, contact lenses, hearing aids
etc. (LASIK surgery is not covered)
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Dental treatment or surgery-corrective, cosmetic or aesthetic procedure, filling of

cavity, root canal, wear & tear unless arising due to an accident and requiring
hospitalization.
Convalescence general debility Run Down condition or rest cure, congenital external
disease or defects or anomalies, sterility, infertility / sub fertility or assisted
conception procedures, venereal disease, intentional self-injury, suicide, all
psychiatric & Psychosomatic disorders / diseases, accidents due to misuse or abuse
of drugs / alcohol or use of intoxicating substances.
All expenses arising out of any condition directly or indirectly caused to or
associated with Human T-Cell Lymphotrophic Virus Type III (HTLB-III) or
LymphadinopathyAssociated Virus (LAV) or the mutants Derivative or variations
deficiency Syndrome or any syndrome or condition or a similar kind commonly
referred to as AIDS, complications of AIDS and other sexually transmitted diseases
(STD). However, during any surgery, if an HIV test is conducted, the same is payable)
Expenses incurred primarily for evaluation diagnostic purposes not followed by
active treatment during hospitalization.
Expenses on vitamins and tonics unless forming part of treatment for injury or
disease as certified by the attending physician.
Naturopathy, unproven procedure/treatment, experimental or alternative medicine
/ treatment including acupuncture, acupressure, magneto-therapy etc.
Expenses on irrelevant investigations / treatment; private nursing charges, referral
fee to family physician, outstation Doctor / Surgeon /consultants fees etc.
Genetical disorders / stem cell implantation / surgery.
External / durable medical / Non-medical equipments of any kind used for diagnosis
/ treatment including CPAP, CAPD, infusion Pump etc., ambulatory devices like
walker / crutches / belts / collars / caps/ splints/slings / braces / stockings / diabetic
foot-wear / glucometer / thermometer & similar related items & any medical
equipments which could be used at home subsequently.
Non-medical expenses including personal comfort/ convenience items/ services such
as telephone / television / aya / barber / beauty services / diet charges / baby food /
cosmetics / napkins / toiletries / guest services etc.
Change of treatment from one pathy to another unless being agreed/allowed &
recommended by the consultant under whom treatment is taken.
Treatment for obesity or condition arising there from (including morbid obesity) and
any other weight control program / services / supplies.
Arising from any hazardous activity including scuba diving, motor racing,
parachuting, hand gliding, rock or mountain climbing etc. unless agreed by insurer.
Treatment received in convalescent home / hospital, health hydro / nature care
clinic & similar establishments.
Stay in hospital for domestic reason where no active regular treatment is given by
specialist.
Out-patient diagnostic/ medical / surgical procedures / treatments, non-prescribed
drugs / medical supplies / hormone replacement therapy, sex change or any
treatment related to this.
Massages / Steam bath / Surodhara & alike Ayurvedic treatment.
Any kind of service charges / surcharges, admission fees / registration charges etc.
levied by the hospital.
Doctor's home visit charges / attendant, nursing charges during pre & post
hospitalization period.

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Treatment which the insured was on before hospitalization and required to be on after
discharge for the ailment / disease / injury different from the one for which hospitalization
was necessary.

6. Process for Claim Submission

a. Cashless Claim Procedure:
The Cashless facility is applicable only to the case when patient is being hospitalized under
Vipul Med Corp s networking List and while availing the cashless, the employee should
make sure to follow the mentioned steps :

To avail cashless facility, the member has to visit any of the network hospital (network
hospital list available on Vipul MedCorp website taps.vipulmedcorp.com).

Insured has to produce his TPA card at the reception/TPA desk. He/She will have to fill a
pre-authorization request form. The pre-authorization form will be duly signed by the
treating doctor and will be faxed/ emailed to Vipul by the hospital.

Vipul doctor will process the documents based on eligibility/policy condition and send a
final authorization to hospital. There may be some deductions of non-payable items like
registration fees, personal items etc. for which the hospital may insist on a refundable
nominal deposit.

On the date of discharge, hospital will fax/email the final bill and discharge summary to
TPA and patient/dependents of patient needs to sign all original documents, which will
be retained by the hospital for onward submission to TPA. Patient should retain Xerox of
all documents for future reference.

b. Reimbursement Procedure:
Reimbursement will be applicable to those cases when Insured person is getting hospitalized
or being treated into the hospital which is not penalized under Vipul s networking list than
the employee can avail the facility for reimbursement.
There should be intimation prior to or within 7 days of admission to the hospital for
incurring a claim to Vipul MedCorp that an employee / dependent has used Mediclaim
and would be filing for reimbursement within next 30 days of discharge*.

Intimation can be given on email id: gi@vipulmedcorp.com or online

http://taps.vipulmedcorp.com and claim submission can be done during helpdesk
organized by Vipul.

Employee

Employee should submit the original numbers bill (with break-up), proper numbered
receipt of payment, discharge summary, investigation report and films, prescriptions,
pharmacy bills etc. to VipulMedCorp within 30 days from the date of discharge along
with a cancelled cheque.

Employees are advised to retain a copy of their bills & reports for their own records.

Vipul MedCorp would settle the claim within 30 business days of receipt of these
documents if documents are sufficient. In case of a deficiency, Vipul MedCorp shall raise
a query for the employee to furnish.

form
(available
at
http://taps.vipulmedcorp.com/public/docs/claim_form.pdf). In case, the claim is
for a non-network hospital and then it is mandatory to get the specified portion in claim
filled by treating doctor.

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should

fill

up

the

claim

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In cases where post hospitalization treatment is not completed after the discharge the
claim should be submitted within 7 days from the date of completion of Posthospitalization treatment up to a limit of 60 days from date of discharge.

In case of partial settlement claim (where a part of the bill has been settled by another
agency and balance being claimed in Wipro policy), the employee shall have to submit
an original signed and stamped settlement letter from the first Insurance
company/TPA/ECHS/CGHS body along with the claim.

Taxation, if any, is as per the existing tax laws.

In case at any point of time it is found that the employee has submitted false details of
the dependents, the company reserves the right to initiate disciplinary action against the
said employee.

7. Top-Up Cover
a. Existing employees can select top-up cover. Summary table of Top-up and Premium
( in INR):

Career Band

Wipro Default Sum Additional Top-up

Assured

Band AA & Band B1

1,00,000

Premium for Topup cover(in INR)

50% or 100%*

254 for 50% top-up

or
508 for 100% top-up
Band B2 & B3
2,00,000
50%
508 per lac
Band C1 & C2
4,00,000
50%
508 per lac
Band D1 & D2
6,00,000
50%
508 per lac
Band E
10,00,000
50%
508 per lac
*For Level AA B1 Employee can either opt for 50% Top Up or 100% Top up. For all
other levels, the Top Up of 50% is available.
b. For new joinees/long term onsite return cases, policy will be effective from the DOJ or
return date.
c. The option of Top up would be available for Existing employees till 20th Mar14.
However, the Option would be available for 30 days for New Joinee during the period.
For Expat the option would be there for 30 days from date of Return.
d. Top-Up option, once selected on myWipro cannot be cancelled, there will be a one -time
deduction of the premium, from your salary in the month that you have chosen the TopUp option
e. An auto mail would be generated to employee if he opts for the Top Up Option giving all
the details.
f. Accessing Top-Up Application: To access Top-up coverage window, pls. logon to
myWipro - > Financials-> Claims and Benefits > My Financial Services > Top Up
Mediclaim
g. The Top-Up cover lapses in the event of separation due to resignation/termination from
the company. There will be no refund of Top- Up paid in such event.

8. Add-on Family Members:

Employee has the option to cover the following family members if they are not covered in
default coverage:
Spouse
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Children- Number of children up to two and aged 23 years of less

Mother Mother up to the age of 80 years
Father - Father up to the age of 80 years
Father-in-law - up to the age of 80 years
Mother-in-law- up to the age of 80 years

Expats who are not on india payroll however their parents/in-laws are residents of India can
also cover their Parents/In-laws under this scheme.
The insurance will be applicable till 30th September 2014. The Coverage amount mentioned is
the Sum Insured per member and is not a Floater amount. The premium will be charged for the
Policy period( up to 30th Sep14).
Please refer to Annexure A for Policy Benefits applicable to Add-on family member.
Premium slabs per family member are as mentioned below (Except for Children)

Coverage Amount

Premium per member for the Policy

Period

Rs 1,00,000/Rs 2,00,000/Rs 3,00,000/-

2,307
4,442
6,217

(*Premium is per family member covered. Service tax @12.36% have been included in
above amount).
Premium Amount for Children:
Coverage Amount
Premium per Child for Policy Period
Rs 1,00,000/1,356
Rs 2,00,000/2,712
Rs 3,00,000/4,067
(*Premium is per family member covered. Service tax @12.36% have been included in above
amount)

The Premium paid by the employee towards Top-Up of Add on Family member is debited by
way of deduction through salary. The contribution would be based on the Sum Insured and
Family member added in the Policy.
Accessing Family Add on Application link in myWipro: To access Top-up coverage window,
pls. logon to myWipro - > Financials-> Claims and Benefits > My Financial Services >
Mediclaim Insurance Family Add- on

9. Contacts:
Primary Contact for All Services (including escalations)

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Name

Designation

Email Id

Mobile No.

Ankita Mitra

Sr. Executive

corporateservices@vipulmedcorp.com

09311986326

Meenu Chopra

Astt. Manager

meenu@vipulmedcorp.com

09310161395

Abhishek Kr.
Singh

Manager

abhisheksingh@vipulmedcorp.com

09311986322

Pawan Choube

GM - Operations

pawanchoube@vipulmedcorp.com

09311986305

For any further clarification or information with regards to this Policy, please write to IESC Helpdesk
(iesc.helpdesk@wipro.com).

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ANNEXURE A
Salient Policy Features for Add-on Family Members:
A.
B.
C.
D.

Pre-Existing diseases are covered.

Pre-Post hospitalization Expenses (30 days and 60 days respectively) are covered.
First 30 days waiting is waived off.
Room rent is 1% of the sum insured subject to maximum of Rs 3000 and for ICU 1.5% of SI
subject to max of Rs. 4500
E. Following Ailments are capped with the below mentioned sub-limits:

F. Maternity Benefit is not available to Add-on family member.

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Revision History
Revised
Version
No.

Change Description

1.0

Renewal of the Mediclaim HR

Policy

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Revised
by

Date
Release

of Effective Date

5th March 2014 19th Feb 2014

Approved By

VP- HR

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