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Voluntary Mediclaim Policy : Parents & Parents In-law
Benefits Manual 1st April 2016 – 31st March 2017 Vidal Health TPA Pvt Ltd.
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Summary Page No Section I- Policy Benefits 03 - 08 Section II-
Processes 09-13 What are cashless and Reimbursement procedures? Whom can I contact in case of claim related support ? Section III- Forms & Formats 15 What are the Exclusions in the Mediclaim Program ? Vidal Health TPA Pvt Ltd. Vidal Health TPA Pvt. Ltd.
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Voluntary Mediclaim Policy For Parents :Comparison
Section I Policy Benefits Benefit Details Members Covered Sum Insured Pre-existing ailments Medical Checkup Room Rent eligibility Before Employee, Spouse, Children, Parents 1lakh,3lakh & 5lakh Covered Not required 2% for normal room and 4 % for ICU Going Forward 2 Separate policies: 1. Employee Spouse & Children(ESC) 2. Parents (Set 1) or Parents in-law (Set 2), (separate premium) Sum Insured will be same for Employee, spouse & Children policy. For Parents policy Sum Insured will be 1lakh (covered under ESC policy), 2lakh & 3Lakh For ESC : 2% for Normal & 4% for ICU Section II Processes Section III Forms & Formats Vidal Health TPA Pvt Ltd. Vidal Health TPA Pvt. Ltd. 3
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What Is Covered Under Voluntary Parents Policy?
WHAT DOES YOUR MEDICLAIM POLICY COVER? Section I Policy Benefits POLICY DETAILS DESCRIPTION Policy Holder MEDITAB SPL PVT LTD Policy Start & End Date 1st April 2016 to 31st March 2017 Insurer The New India Assurance Co. Ltd. Third Party Administrator (TPA) Vidal Health TPA Pvt Ltd Sum Insured (Floater) The mentioned Sum Insured is for 2 parents or single parent as per enrollment Members Covered Employees joined before 31st March’16 will be eligible to add any 2 parents or parents in law with the single floater premium deduction Employee joining after 31st March 16 will get the option to add 2 sets of parents & parents in law with the payment of twice the premium Entry Age limit Parents upto the age of 100 years can be covered under the policy Co Payment No Co-pay on any claims Pre Existing Diseases Covered from day 1 Section II Processes Section III Forms & Formats Vidal Health TPA Pvt Ltd. Vidal Health TPA Pvt. Ltd. 4
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What Is Covered Under Voluntary Parents Policy?
WHAT DOES YOUR MEDICLAIM POLICY COVER? Section I Policy Benefits 30 Days Waiting Period for New Joiners Waived off Cataract Eligibility Room Rent Pre & Post Hospitalization Cover 30 days pre & 60 days post hospitalization expenses covered. Ambulance Charges Covered upto Rs. 2,000 in case of emergency only S. No Sum Insured Eligibility 1 200,000 INR 23,000 2 300,000 Section II Processes Section III Forms & Formats Vidal Health TPA Pvt Ltd. Vidal Health TPA Pvt. Ltd. 5
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Parents Premium Chart WHAT DOES YOUR MEDICLAIM POLICY COVER? Section I
Policy Benefits PARENTS SUM INSURED PREMIUM (SINGLE PARENT) (BOTH PARENTS) 200,000 7800 8300 300,000 9,000 12900 Note : The premium mentioned is for 2 parents/parents-in law excluisve of service tax. If the age of parents is less than equal to 50 yrs a discount of 5% will be there on the mentioned premium whereas if the age of both the parents is less than 50 yrs then a discount of 10% will be given. Employees shall not have the option to replace parents with in laws or in laws with parents. An exception shall be for female employees who would be permitted to replace their parents with parents in law (only after marriage). But this option can be exercised only at the time of the enrolment year following the year of marriage, and not thereafter Premium will be deducted from salary in three equal monthly installments. Only one time option will be given for parents enrollment, employees who will miss the enrollment during the window period will not be eligible to cover the dependents in the current year or in the subsequent years New recruits can opt to cover their parents at the time of recruitment (during the stipulated window period), or at the time of enrolment year immediately following the year of their recruitment Section II Processes Section III Forms & Formats Vidal Health TPA Pvt Ltd. Vidal Health TPA Pvt. Ltd. 6
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Retail Policy Available Outside
Parents Policy Comparison : WHAT DOES YOUR MEDICLAIM POLICY COVER? Section I Policy Benefits Retail Policy Available Outside Our Value Proposition Waiting period of 3 – 4 yrs for all Pre-existing Diseases. Need for Pre enrollment medical check beyond the age of 45 yrs Ailment wise capping applicable Maximum Entry Age for Parents – 65 yrs Age limit for coverage – 80 yrs 30 days, 1st & 2nd Year Exclusions Applicable Coverage for Pre-Existing Diseases from day one – No waiting period No need of Pre enrollment medical check No ailment wise capping Maximum Entry Age – 100 yrs Age limit for coverage – 100 yrs 30 days, 1st & 2nd Year exclusions – Waived off Section II Processes Section III Forms & Formats Vidal Health TPA Pvt Ltd. Vidal Health TPA Pvt. Ltd. 7
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Tax Benefit WHAT DOES YOUR MEDICLAIM POLICY COVER? Section I
Policy Benefits Tax Benefits The policy offers Tax Benefit under Sec 80 D. Tax benefit will be applicable only towards premium paid towards coverage only of dependent parents and not for payment made towards coverage of Parent In Laws Section II Processes Will I be eligible for Tax Benefit for contribution made towards covering my dependent parents in this policy? The policy offers Tax Benefit under Sec 80 D of the IT Act for premium contributed towards covering your parents in this policy. No Tax benefit will be available for premium payment made towards coverage of Parent In Laws. Tax Benefit norms will be as per applicable & prevailing Income Tax norms. You may seek advice from your tax consultant in this regards. Section III Forms & Formats Vidal Health TPA Pvt Ltd. Vidal Health TPA Pvt. Ltd. 8
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Condition Of Membership
WHAT DOES YOUR MEDICLAIM POLICY COVER? Section I Policy Benefits The Insurance cover will be extended to: Enrolled Parents and Parents in Law (Not exceeding four) Definition of Parent = Biological or Legal Parents Definition of Parents-in-law = Parents of Legally Married Spouse Section II Processes What if employee leaves?: In an event of separation, policy certificate will be given to the employee. He/she will be eligible to claim under the policy for the entire duration of the coverage period. Section III Forms & Formats Vidal Health TPA Pvt Ltd. Vidal Health TPA Pvt. Ltd. 9
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Network Hospitalisation - Cashless
Group Mediclaim Policy Network Hospitalisation - Cashless Emergency Hospitalization Identify Network Hospital via mobile app / website / helpline Visit hospital Insurance Help desk & fill the pre- authorization form Hospital will seek approval from Vidal Health TPA (Provided within 2 hrs) Section I Policy Benefits You will receive SMS confirmation Section II Processes Pay for Non Medical Expenses if any At the time of discharge Hospital will send final request to Vidal Health TPA for approval (Provided within 2 hrs) On successful approval admission happens & treatment starts Section III- Forms & Formats You will receive SMS confirmation Planned Hospitalization In case of Planned Hospitalization, authorization should be taken prior, which will be valid for 15 days to avoid delay /inconvenience . Vidal Health TPA Pvt Ltd. Vidal Health TPA Pvt. Ltd. 10
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Network Hospitalisation - Cashless
Before Admission : Section I Policy Benefits Check for the nearest network hospital for availing the Cashless hospital. Pre-authorization form is mandatory to be sent to Vidal Health TPA by network hospital. During Admission : Section II Processes Inform the Vidal Health TPA call center immediately about the hospitalization & seek pre- authorization. Vidal Health TPA will send pre-authorization letter for the Initial amount to the hospital. In case of denial, the same will be communicated to the Hospital with proper reasoning. During Discharge : Section III- Forms & Formats The bill will be sent by Hospital to Vidal Health TPA After hospitalization has been pre-authorized you/your dependents can proceed with discharge by paying for Non Medical Expenses . Vidal Health TPA Pvt Ltd. Vidal Health TPA Pvt. Ltd. 11
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Non Network Hospitalisation - Reimbursement
Activity done by employee Activity done by Vidal Health TPA Intimate Vidal Health TPA regarding claim on the day of Hospitalization or within 7 Days from the date of Discharge. Section I Policy Benefits Submit Claim documents within 30 days from the date of discharge. Documents to be handed over to your Local HR who will courier same to Vantage Mumbai office You will receive SMS confirmation Vidal Health TPA will check for the eligibility and admissibility of the claim as per policy terms. Section II Processes Claim not permissible Reason of Rejection will be communicated. Is Claim payable ? Section III- Forms & Formats No Vidal Health TPA will ask for the additional/missing documents Yes Documents incomplete Reminder mails sent every 15 days Vidal Health TPA will process the claim and send the reimbursement by ECS, along with the settlement letter Deficiency Documents are sent Vidal Health TPA Pvt Ltd. Vidal Health TPA Pvt. Ltd. 12
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Contact Details Section I Policy Benefits Section II Processes
Claim intimation to be give on within 7 days of hospitalization. should contain : Corporate Name, Vidal Card No. Unique Employee ID No. Name of employee Name of patient Date of Admission Name of hospital & Location Approximately claim amount etc. This intimation can be given through various modes like /call centre/mobile app or may be via letter or any other suitable mode. For claim intimation you may inform Vidal Health TPA as below. CONTACT POINTS FOR CLAIMS - Vidal Health TPA – Customer Care Details id for claim intimation – 24 x 7 Help line for cashless and Reimbursement intimation – press 4 for insurance ESCALATION POINT: 1. Centralized helpdesk : press4 for insurance (9am to 6pm) id 2. Name – Nirzara Salvi (Ast Manger) & Sudesh Patankar (Sr. Manager) ID – & Phone No: & 2. Reimbursement claim documents should be submitted within 15 days to Vidal Health. Section I Policy Benefits Section II Processes Section III Forms & Formats Vialealth TPA Pvt Ltd. Vidal Health TPA Pvt. Ltd. 13
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Helpdesk Assistance: (mediclaimsupport.iservice@cipla.com)
Section I Policy Benefits Section II Processes To understand Enrollment Procedure To understand Claim Procedure Assistance during cashless claims Assistance for Submitting Reimbursement claims Knowing your Claim Status Section III Forms & Formats Vidal Health TPA Pvt Ltd. Vidal Health TPA Pvt. Ltd. 14
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Escalation Matrix Any Assistance ? (Claim /Enrollment) Section I
Policy Benefits Call the Toll Free No : press 4 for insurance Query Resolved Query Unresolved Section II Processes Write to : Query Resolved Query Unresolved Section III Forms & Formats Write to : Location HR and Ms Nirzara Salvi Vidal Health TPA Pvt Ltd. Vidal Health TPA Pvt. Ltd. 15
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Please note that all the forms are also available with the Local HR.
Pre-Authorization Form for Cashless claim : Claim Form for Reimbursement claim : Hospital List for Cashless Hospitalizations : (The hospital list is dynamic will be updated on monthly basis also available on our website Section I Policy Benefits Section II Processes This form is filled by the Hospital Authorities. The Employee/ members accompanying the patient has to sign the Authorization letter. Section III Forms & Formats Please note that all the forms are also available with the Local HR. Vidal Health TPA Pvt Ltd. Vidal Health TPA Pvt. Ltd. 16
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Hospital List for Cashless Hospitalisation
For the updated list of hospitals please visit on and click on the link titled Mediassist Network of Hospitals Section I Policy Benefits Section II Processes While the soft copy version of this list is also available with the Local HR, it is recommended you use the online link to check for your preferred hospital since it would be the most updated. Section III Forms & Formats Vidal Health TPA Pvt Ltd. Vidal Health TPA Pvt. Ltd. 17
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What is excluded from your policy ?
Natural Disasters & National Emergencies: Section I Policy Benefits Injury or disease directly or indirectly caused by or arising from or attributable to War, Invasion, Act of Foreign Enemy, Warlike operation (whether war be declared or not) Injury or disease directly or indirectly caused by or contributed to by nuclear weapons/materials Expenses incurred for disease declared as an Epidemic by Health Authorities Section II Processes Cosmetics & Non Medically required procedures: Maternity is not covered Cost of Spectacles, Contact Lenses, Hearing Aids Treatment done with no active line of treatment Dental Treatment or surgery of any kind unless requiring hospitalization on account of accidental cases. Vitamins and nutritional supplements 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. Convalescence, general debility ‘Run-down' condition or test cure Intentional self injury and use of intoxicating drugs/alcohol Sterility (infertility), venereal disease Congenital external disease or defects or anomalies Section III Exclusions : Vidal Health TPA Pvt Ltd. Vidal Health TPA Pvt. Ltd. 18
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What is excluded from your policy ?
Other policy Exclusions: Naturopathy treatment Medical Expenses for Organ Donor Vaccination & Inoculation. Cost of braces, equipment or external prosthetic devices, non-durable implants, eyeglasses, Cost of spectacles and contact lenses, hearing aids including cochlear implants and durable medical equipment's All types of Dental treatments except arising out of an accident Convalescence, general debility, ‘Run-down’ condition or rest cure, obesity treatment and its complications, congenital external disease/defects or anomalies, treatment relating to all psychiatric and psychosomatic disorders, infertility, sterility, use of intoxicating drugs/alcohol, use of tobacco leading to cancer Bodily injury or sickness due to wilful or deliberate exposure to danger (except in an attempt to save a human life), intentional self-inflicted injury attempted suicide and arising out of non-adherence to any medical advice Treatment of any Bodily injury sustained whilst or as a result of active participation in hazardous sports of any kind Treatment of any bodily injury sustained whilst or as a result of participating in any criminal act Sexually transmitted diseases, any condition directly or indirectly caused due to or associated with Human T-Cell Lymphotropic Virus Type III (HTLB-III) or Lymphotropathy Associated Virus (LAV) or the Mutants Derivative or Variation Deficiency syndrome or any syndrome or condition of a similar kind commonly referred to as AIDS. Section I Policy Benefits Section II Processes Section III Exclusions : Vidal Health TPA Pvt Ltd. Vidal Health TPA Pvt. Ltd. 19
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What is excluded from your policy ?
Other policy Exclusions: Diagnostic, X-Ray or Laboratory examination not consistent with or incidental to the diagnosis of positive existence and treatment of any ailment, sickness or injury, for which confinement is required at a Hospital/Nursing Home. Vitamins and tonics unless forming part of treatment for injury or disease as certified by the attending physician. Instrument used in treatment of Sleep Apnoea Syndrome (C.P.A.P.) and Continuous Peritoneal Ambulatory Dialysis (C.P.A.D.) and Oxygen Concentrator for Bronchial Asthmatic condition Genetical disorders and stem cell implantation / surgery. Any Domiciliary Hospitalization / Treatment. Treatment taken outside India. Experimental and unproven treatment (not recognized by Indian Medical Council) Change of treatment from one system of medicine to another unless recommended by the Consultant / Hospital under whom the treatment is taken All non-medical expenses including convenience items for personal comfort such as telephone, television, Aya, Private Nursing / Barber or beauty services, diet charges, baby food, cosmetics, tissue paper, diapers, sanitary pads, toiletry items and similar incidental expenses Service charges or any other charges levied by hospital, except registration/admission charges Section I Policy Benefits Section II Processes Section III Exclusions : Vidal Health TPA Pvt Ltd. Vidal Health TPA Pvt. Ltd. 20
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Thank You Vidal Health TPA Pvt Ltd.
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