Employee Insurance Guide Client Supreme Universal Remark Benefit Manual

ABOUT GENERAL ALLIANCE

About General Alliance Risk Advisory Services We provide international quality risk advisory services including insurance audits, insurance portfolio analyses and risk assessment studies. As your partners in managing risk we help you understand where risk lies and how to address them. We also help in negotiation for customized coverage and pricing negotiations on behalf of our clients. Faster Documentation and Training. We provide the checklist of documents to be submitted for claims processing well in advance, we also brief and train employees on the health policy covered ensuring the employees are educated on what is covered and do’s and don’t in case of insurance claim. Claims Servicing & Dedicated Relationship Manager We bring superior claims servicing team. We have a dedicated Relationship Manager for servicing your account who also looks after the renewal and retention vertical, he/she will be in charge of Monthly Additions/Deletions and Claims management in assistance with the Health Administration team.

Supreme Universal Policy Details GHI

Policy Details Group Health Insurance Floater Policy Family Definition: Self + Spouse + 2 Dep. Kids Sum Insured: Grade - wise Underwriting Co.: ICICI Lombard TPA: I Health

Medical Compensation Payable for

Compensation Payable Reasonable and necessarily incurred Room Expenses in Hospital/Nursing Home Nursing Expenses Medical Practitioner Fee Treatment cost Medicines Blood / Oxygen Cost of Pacemaker / Artificial Limbs Operation Theatre Charges Surgical Appliances Diagnostic cost Dialysis, Chemotherapy, Radiotherapy Pre Hospitalisation (30 days) and Post Hospitalisation (60 days) expenses Max of SI Minimum 24 hrs of hospitalization compulsory

Important Extension Pre existing disease covered First year exclusion waived off 30 Days waiting period waived off

Important Cappings Co-pay of 10% in each & every reimbursement Room rent capping restricted to 1% of SI max Rs 3000/- & for ICU 2% of SI max Rs 5000/-

EXCLUSIONS

EXCLUSIONS Injury or disease directly or indirectly caused by or arising from or attributable to War or War-like situations Circumcision unless necessary for treatment of disease Dental treatment of any kind unless requiring hospitalisation Congenital external diseases or defects/anomalies HIV and AIDS Hospitalisation for convalescence, general debility, intentional self-injury, use of intoxicating drugs/ alcohol. Venereal diseases Injury or disease caused directly or indirectly by nuclear weapons

EXCLUSIONS Naturopathy Any non-medical expenses like registration fees, admission fees, charges for medical records, cafeteria charges, telephone charges, Surcharge etc Cost of spectacles, contact lenses, hearing aids Any cosmetic or plastic surgery except for correction of injury Hospitalization for diagnostic tests only Vitamins and tonics unless used for treatment of injury or disease Infertility treatment Voluntary termination of pregnancy during first 12 weeks (MTP)

Claim Process

Claim Settlement & Process Planned Network Hospitalization (Cashless) Emergency Network Hospitalization (Cashless) Non Network Hospitalization ( Re-imbursement)

Planned Network Hospitalization Claim Registered by I Health on same day Member intimates I Health of the planned hospitalization in a specified pre-authorization format 48 hours prior to hospitalization I Health issues letter of credit within 12 hours for planned hospitalization to the hospital Yes No Pre-Authorization Completed Pre – Authorization Form AT web www.I Healthtpa.com Follow non cashless process

Emergency Hospitalization Process Member get admitted in the hospital in case of emergency by showing his ID Card Member/Hospital applies for pre-authorization to the I Health within 24 hrs of admission I Health verifies applicability of the claim to be registered and issue pre-authorization Pre-authorization given by the I Health Hospital sends complete set of claims documents for processing to the I Health Member gets treated and discharged after paying all non entitled benefits like refreshments, etc. No Claims Processing by I Health & Insurer Release of payments to the hospital Follow non cashless process

Non cashless Hospitalization Process Member intimates I Health before or as soon as hospitalization occurs Claim registered by I Health after receipt of claim intimation Insured admitted as per hospital norms. All payments made by member Insured sends relevant documents to I Health office in Mumbai within 20 days of discharge Insured will create the summary of Bills (2 copies) and attach it with the bills The envelope should contain clearly the Employee ID & Employee e-mail Is claim liable (coverage/applicability) Is document received within 20 days from discharge I Health performs medical scrutiny of the documents Yes Claim Rejected No No Yes Is documentation complete as required I Health checks document sufficiency Claims processing done within 15-20 days Payment to be directly made to Employees Bank Account. The discharge voucher and copy of payment receipt to be sent to Controllership. Yes Send mail about deficiency and document requirement A No Back

Re-imbursement Claim Documentation Signed Claim form Main Hospital bills in original (with bill no; signed and stamped by the hospital) with all charges itemized and the original receipts Discharge Card (original) Attending doctors’ bills and receipts and certificate regarding diagnosis (if separate from hospital bill) Original reports or attested copies of Bills and Receipts for Medicines, Investigations along with Doctors prescription in Original and Laboratory Follow-up advice or letter for line of treatment after discharge from hospital, from Doctor. Break up with details of Pharmacy items, Materials, Investigations even though it is there in the main bill In case the hospital is not registered, please get a letter on the Hospital letterhead mentioning the number of beds and availability of doctors and nurses round the clock. In non- network hospitalisation, please get the hospital and doctor’s registration number on Hospital’s letterhead and get the same signed and stamped by the hospital. Claims Form AT web www.icicilombard.com

Important Web Links Cashless Hospital Link: https://www.I Healthtpa.com/ProviderNetwork/ProviderNetwork.aspx Claim Form Link: https://www.I Healthtpa.com/DownloadForms/downloadforms.aspx Pre Authorization Claim Form: Pre Authorization E-cards download: https://www.I Healthtpa.com/CardStatus/CardStatus.aspx