Managing Expectations

Handbook on Employee Insurance

 Employee Insurance

Group Health Insurance

Group Personal Accident Insurance
 Group Health Insurance
• The Policy covers reimbursement of Hospitalization Expenses for illness / diseases or injury sustained
• In the event of any claim becoming admissible under this scheme, the Insurance Company will pay to the
Insured Person the amount of such expenses as would fall under different heads mentioned below, and as
are reasonable and necessarily incurred thereof by or on behalf of such Insured Person, but not exceeding
the Sum Insured in any one period of Insurance
Room, Boarding Expenses as provided by the Hospital / Nursing Home
Nursing Expenses
Surgeon, Anesthetist, Medical Practitioner, Consultants, Specialists Fees
Anesthesia, Blood, Oxygen, Operation Theatre Charges, Surgical Appliances, Medicines & Drugs,
Diagnostic Materials and X-Ray, Dialysis, Chemotherapy, Radiotherapy, Cost of Pacemaker, Artificial
Limbs & Cost of Organs and similar expense
• Pre-existing Disease Coverage
• Maternity from Day One of joining the Insurance Policy but restricted up to a maximum Sum Insured of
Rs.25,000/- in case of Normal & Rs.35,000/- in case of C-section for 1st two children only
• Pre-natal & Post-natal expenses covered within the scope of Maternity Sum Insured provided the same is
taken in a hospital or a nursing home
• Procedural capping: Infectious Disease (Respiratory Tract Infection and similar diseases, Parasitic Infection,
Digestive system infection, UI infection) & various enteric fever capped at Rs.12,000/- per ailment
• Internal Congenital Disease to be covered under the Scope of Pre-existing Disease Coverage Condition
• Room Rent capped at 2% of the Sum Insured per day both for Normal & ICU
 Group Health Insurance
• 1st 30 days & 1st two year exclusions waived off for all. The Insurance Coverage commences from
date of notification about the Insured member to the Insurance Company. During the First Year of the
Operation of the Insurance Cover for any Insured Person, the expenses on treatment of diseases
such as Cataract, Benign Prostatic Hypertrophy, Hysterectomy for Menorrhagia or
Fibromyoma, Hernia, Hydrocele, Congenital Internal Diseases, Fistula in Anus, Piles, Sinusitis
and related disorders are not payable, however the same has been waived off by the Insurer in your
Policy
• Any hospitalization induced due to bodily injury sustained due to terrorist activity is generally an
exclusion under most Mediclaim Policies. In your case such type of hospitalization is covered
• Pre-hospitalization (30 days) & Post Hospitalization (60 days)
• Expenses on Hospitalization for a minimum period of 24 hours are admissible. However, this time
limit does not apply to specific treatments like – Dialysis, Chemotherapy, Radiotherapy, Eye
Surgery, Dental Surgery, Lithotripsy (Kidney Stone removal), Tonsillectomy, DNC taken in
Hospital / Nursing Home and the Insured is discharged on the same day, the treatment will be
considered to be taken under Hospitalization Benefit. Where hospitalization is less than 24 hours, the
following guidelines may be adopted:
a) The treatment should be such that it necessitates Hospitalization and procedure involved required
specialized infrastructure facilities which are available in the Hospital
b) Due to technological advancement, Hospitalization period required is less than 24 hours
• Day Care Surgeries / Procedures are covered
• Cashless facility through Third Party Administrator (TPA) on all India basis at more than 3000
network hospitals / establishments
 Group Health Insurance
Exclusions:
The Insurance Company shall not be liable to make any payment under this Policy in respect of any
expenses whatsoever incurred by any Insured person in connection with or in respect of: -

• Injury or Disease directly or indirectly caused by or arising from or attributable to War, Invasion, Act of
Foreign Enemy, Warlike Operations (whether war be declared or not)
• Circumcision unless necessary for treatment of a disease not excluded hereunder or as may be
necessitated due to an accident, vaccination or inoculation or change of life or Cosmetic or Aesthetic
Treatment of any description, plastic surgery other than as may be necessitated due to an accident or
as a part of any illness
• Cost of Spectacles and Contact Lenses, Hearing Aids
• Any Dental treatment or Surgery which is a Corrective, Cosmetic or Aesthetic procedure, including
wear & tear, unless arising from disease or injury and which requires hospitalization for treatment
• Convalescence, General Debility, “Run-down” condition or rest cure, congenital external disease or
defects or anomalies, sterility, venereal disease, intentional self-injury and use of intoxicating drugs /
alcohol
• All Expenses arising out of any condition directly or indirectly caused to or associated with Human T-
Cell Lymph tropic Virus Type III (HTD-III) or Lymphadinopathy Associated Virus (LAV) or the Mutants
Derivative or Variations Deficiency Syndrome or any (HTBB_III) Syndrome or condition of a similar
kind commonly referred to as AIDS
 Group Health Insurance
Exclusions:

The Insurance Company shall not be liable to make any payment under this Policy in respect of any
expenses whatsoever incurred by any Insured person in connection with or in respect of: -

• Charges incurred at Hospital or Nursing Home primarily for Diagnostic, X-Ray or Pathological
Tests / Examinations not consistent with or incidental to the diagnosis or treatment of the
positive existence or presence of any ailment, sickness or injury for which confinement is
required at a Hospital / Nursing Home
• On Vitamins and Tonics unless forming part of treatment for injury or disease as Certified by the
attending Physician
• Injury or Disease directly or indirectly caused or contributed to by Nuclear Weapons / Materials
• Treatment directly or indirectly related to management of Infertility / IVF / GIFT (Gamete Intra
Fallopian Transfer) etc.
• Domiciliary Hospitalization & Out Patient’s Department
 Group Health Insurance

Insurance company
Insurance ID card printed and
sends
Company issues Policy dispatched along
Data to TPA H.Q. with Guide Book.

Health Card TAT –

Issuance 21 Working
Days

Hospital faxes Request received at TPA

Patient approaches
Pre Authorization to Pre Auth dept
Network hospital
TPA

Cashless TAT
Procedure
24 hours (Mon-Sat)

Authorization Medical Dept checks for Claims Dept checks

faxed to Hospital Treatment costs and for coverage and
Tariff. eligibility
 Group Health Insurance

Document Claims registered and

Insured submits Validation of
Completion Sum Insured
Claim to TPA customer Id
Verification Balance confirmed

TAT – 21 days
Re-imbursement After submission of
All Documents
Procedure

DV &/or Chq with Claim checked by

Claim checked By
computation Claim Approval Insurance trained
Medical Professionals
Dispatched executives.
 Group Health Insurance
REQUIREMENTS MANDATORY TO PROCESS CLAIM
(re-imbursement)
MAIN HOSPITALIZATION
• Intimation of hospitalization to the TPA within 72 hours is
COMPULSORY
• Filled up Claim Form mentioning TPA I.D. No. duly signed
• Original Discharge Summary must have Date of Admission and Date of
Discharge, presenting complaints & their duration, final diagnosis, line of treatment
given & advice on discharge.
• Time of admission & discharge should be mentioned in Discharge Summary
• Original final hospital bill in a proper bill format along with Original Receipt of
payment made by the patient to the hospital.
• Break up of medicine / pharmacy / drugs / Operation Theatre (OT) drugs charges
as mentioned in final bill.
• Break up of investigation amount along with original reports for the same.
• X-ray films mandatory in fracture/RTA & stone cases.
• USG / C.T. Scan / M.R.I films mandatory along with reports
 Group Health Insurance
REQUIREMENTS MANDATORY TO PROCESS CLAIM

MAIN HOSPITALIZATION CLAIMS

• In Road Traffic Accident (RTA) / Fracture cases a certificate from doctor
required mentioning circumstances leading to injury / fracture. Was
patient under the influence of alcohol / epilepsy / intoxication? – Treating
Doctor to issue certification to this effect. Was Medico Legal Case
(MLC) registered / made? If Yes, certified copy of MLC has to be
attached
• All the bills must be submitted within 15 days from Date of Discharge
from the hospital
SUBMISSION OF PRE-POST HOSPITALIZATION CLAIMS
• Submit all the relevant bills related to investigation, consultation and any
other medical treatment done relating with the ailment for which
admission was taken in the hospital
• The pre and post hospitalizations bills submitted must relate to period 30
days prior to the main hospitalization and 60 days subsequent to
discharge after the MAIN HOSPITALIZATION
 Group Health Insurance
REQUIREMENTS MANDATORY TO PROCESS CLAIM

SUBMISSION OF DEFICIENCY RETRIEVALS

Please attach Xerox of Deficiency letter along with the documents required to
clear your file. The same has to be submitted within 15 days from the date of
deficiency letter

Note: Xerox Copy of the documents should be kept with the insured at all
times for the documents submitted to PHS
 Group Personal Accident Insurance
Permanent Partial Disability
1. Loss of toes – all 20%
2. Loss of toes great both phalanges 05%
3. Loss of toes other than great, if more than one toe lost each 01%
4. Loss of hearing - both ears 75%
5. Loss of hearing – one ear 30%
6. Loss of 4 fingers & thumb of one hand 40%
7. Loss of 4 fingers 35%
8. Loss of thumb – both phalanges 25%
9. Loss of thumb – one phalanx 10%
10. Loss of index finger – 3 phalanges or 2 or 1 phalanx 10%
11. Loss of middle finger – 3 phalanges or 2 or 1 phalanx 06%
12. Loss of ring finger – 3 phalanges or 2 or 1 phalanx 05%
13. Loss of little finger – 3 phalanges or 2 or 1 phalanx 04%
14. Loss of metacarpals – 1st or 2nd (additional) or 3rd, 4th or 5th (additional) 03%
15. Any other permanent partial disablement % as assessed by the panel of doctors of Insurance
Company
 Group Personal Accident Insurance

Validation of Document Papers handed to

Insured submits
customer Id Completion Investigation Team
Claim to Insurer
Verification

TAT – 8 weeks
Re-imbursement After submission of
All Documents
Procedure

Claim Papers
Payment released
Claim checked by checked by
to Claim Approval Insurance trained
Panel of Doctors
Insured executives.
 Group Personal Accident Insurance
Requirement mandatory for processing of a Claim
Accidental Death Claim
• Certified True Copy of the F.I.R lodged by Police Authorities
• Post Mortem Report in Original or certified true copy
• Certified True Copy of Death Certificate issued by the Municipal Authorities
• Local Newspaper clipping if the accident has been reported or Eye Witness’s
version of the accident (this is not mandatory but it’s presence reduces the TAT of
the Investigating Agency)
• Claim form duly filled in, certified
Temporary Total Disablement
• Original Certificate from the treating doctor certifying the circumstances & extent of
the injury & period of bed rest advised
• Original Fitness Certificate from the same doctor mentioning that the claimant is fit
to resume duty
• Original Certificate from the Employer acknowledging the leave of absence
 Group Personal Accident Insurance

• Death only - 100% of C.S.I (Capital Sum Insured)

• Loss of two limbs / two eyes or one limb & one eye - 100% of C.S.I
• Loss of one Limb or one Eye - 50% of C.S.I
• Permanent Partial Disablement - as % of C.S.I (mentioned in the Policy
Document)
• Permanent Total Disablement (other than those named above) - 100% of C.S.I
• Temporary Total Disablement - 1% of C.S.I per week or Rs.5,000/- which ever is
less for a maximum of 100 weeks
• Children Education Benefit up to Rs.10,000/- (Max.) per living child (max. 2
children)
• Carriage of Dead Body - 2% of C.S.I subject to a maximum Rs.5,000/-
• Exclusion on account of Loss / Damage / Liability due to terrorism activity shall
stand waived off
• Worldwide Coverage on 24X7 basis