A Brief into Medical Insurance Policy 2016 – 2017

  1. Our Insurer for 2016-2017 is National Insurance Company, the TPA is Vipul Medcorp and our Broker for all Medical Insurance related queries and claim is Emedlife Life Insurance Services
  2. Family Coverage includes Employee + Spouse + 2 Children + Parents of the employee.
  3. Sum Insured is Rs. 3, 00,000/-. The employees can increase the sum insured to Rs. 5,00,000/- by bearing the extra premium charges only during the renewal. Permanent employees joining after 26th March are eligible for Rs.3,00,000/- SI
  4. For an employee to either avail the cashless facility or reimbursement of medical expenses, standard hospitalisation i.e 24 hours of hospitalization is must.
  5. The expenses related to reimbursement or cashless benefit are Room and boarding (Bed + Nursing Charges), doctors 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.
  6. There are certain day care procedures which are also covered in the Mediclaim. Eg: Kidney stone removal, dialysis, radiotherapy etc. There are total 140 such day care procedures that has been covered.
  7. In the policy First 30 Days Exclusion of pre existing disease is waived off.
  8. Room Rent and boarding charges are covered upto 1.5% of the Sum Insured for Normal Hospitalisation & 2% of sum insured for ICU Hospitalisation.
  9. Maternity (IPD) & Pre & Post Natal Expenses are covered upto Rs. 50,000 for C-section Delivery. Any Pre & Post Natal Expenses are covered within the maternity limit.
  10. New Born Child of the Employee is covered from Day 1 for Hospitalization under the Family Floater Sum Insured from the date of birth. Expenses Incurred for a Normal baby after the birth till discharge are covered within maternity limit.
  11. Cataract surgery expenses are restricted to Rs. 25000/- per eye.
  12. Oral Chemo Therapy is covered under the policy.
  13. Ambulance Services are payable up to 1% of Sum Insured subject to a maximum of INR 1,000/- whichever is less per occurrence on admission only.
  14. The ratio of payment of claims between the insurance company and employee is 80:20 i.e co-payment is 20%.
  15. Below is the list of general exclusions as per the policy.
  • Circumcision unless necessary for treatment of disease
  • Cosmetic & dental treatment
  • HIV and AIDS
  • Hospitalization for convalescence, general debility, rest cure, intentional self-injury, use of intoxicating drugs / alcohol.
  • Venereal diseases
  • Dental Treatment
  • Injury or disease caused directly or indirectly by nuclear weapons
  • Any non-allopathic treatment (if unani and homeopathic treatment have not been covered)
  • Infertility treatment
  • Congenital external diseases
  • Any non-medical expenses like registration fees, admission fees, charges for medical records, cafeteria charges, telephone charges, and disposable items, etc.
  • Any cosmetic or plastic surgery except for correction of injury caused by accident
  • Charges incurred primarily for diagnostic, X-Ray or laboratory examinations or other diagnostic studies not consistent with or incidental to the diagnosis and treatment of any ailment, sickness or injury.
  • Vitamins and tonics unless used for treatment of injury or disease
  • Injury or disease directly or indirectly caused by or arising from or attributable to War or War-like situations

Pre Hospitalization expenses up to 30 days and post hospitalization expenses up to 60 days are covered. Pre-Hospitalization expenses and hospitalization expenses are to be submitted within 15 days of the discharge and all Post-Hospitalization expenses claims are to be submitted on completion of post hospitalization period or completion of treatment whichever is earlier.

All the bills have to be submitted to the concerned HR.

Pre-Authorization Process for Planned Hospitalisation:

At least 48 hours prior to planned hospitalization, your treating doctor must complete the pre-authorization form and the hospital’s TPA Help Desk should fax it to the TPA. The TPA will approve cashless within 7-8 working hours, subject to the prescribed protocol meeting policy coverage terms and conditions. Should the TPA raise any queries, the treating doctor must answer them before the TPA can approve cashless hospitalization.

Emergency Hospitalization Process:

In the event of an emergency, admit the patient immediately and submit the pre-authorization form within 24 hours, regardless of whether the hospital is empanelled. If the hospital is empanelled, the TPA will authorize cashless as per the process described in the previous slide. If the hospital is not empanelled, the TPA can still advise on the admissibility of expenses. You can file for reimbursement after the patient is discharged within 15 days of the date of discharge.

Reimbursement Claims Process:

Submit all reimbursement bills, original reports, and prescriptions along with the claim form and checklist within 15 days of the date of discharge for pre-hospitalization claims and hospitalization claims, and within 10 days of discharge for post-hospitalization claims. The claim forms and the checklist for all the above process are available with the concerned HR. Prudent will shortly share a personalized web link with every employee, from where the forms can also be obtained. Please find below the contact details of the SPOC from Emedlife who will be available at our service for any medical insurance related queries during medical emergencies or any kind of hospitalization.

Mr. Zabiullah Khan , Sr. Executive, Client Servicing
+91 9008028424

For any further assistance or escalations, please contact:
Ms. Vindhya Prabhu,
HR Executive,
IDrive Software India Pvt Ltd.
+91 96 20 521464