1. AN INTRODUCTION TO THE EMPLOYEE BENEFIT PROGRAM FOR THE EMPLOYEES OF
ITTI PVT LTD

2. Group Mediclaim Policy
This insurance scheme is to provide adequate insurance coverage of employees and their families for expenses related to hospitalization due to Disease or Injury
Group Mediclaim
Policy Number :

3. Definitions …
Hospital : means any institution established for In-patient Care and Day Care Treatment of Illness and/or Injuries and which has been registered as a Hospital with the local authorities under the Clinical Establishments Act, 2010 or under the enactments specified under the Schedule of Insured Member on which the Insured Member's cover under the Policy expires. Section 56(1) of the said Act OR complies with all minimum criteria as under
15 In-Patients Bed
Has qualified Medical Practitioner(s) in charge round the clock
Fully equipped operation theatre of its own where Surgical procedures are carried out
Network Hospital : Hospital which has agreed to extend support on Cashless procedure & paneled by TPA/Service provider.
Non-Network Hospital : Within the definition of hospital but don't avail cashless facility. Claims from non-network hospitals are processed on reimbursement basis

4. Definitions…
Hospitalization : Minimum period of 24 hrs of admission in a hospital for a proper medical/ Surgical management.
Day Care procedures are
Undertaken under general or local anesthesia in a Hospital/ Day Care Centre in less than 24 hours because of technological advancement, and which would have otherwise required a Hospitalization of more than 24 hours

5. Group Mediclaim Policy
Benefit Details
Enrollment in the program
Cashless Hospitalization
Non - Cashless Hospitalization

6. Benefit Details Policy Parameter Insurer
The New India Assurance Company Limited
TPA
Family Health Plan Insurance TPA Limited
Policy Start Date
16th November 2016
Policy End Date
15th November 2017
Coverage Type
Group Health Insurance Cover – Family Floater
Family Definition
1+5(Self + Spouse,+2 Kids +2 Dependent Parents)
Sum Insured
Various Sum Insured

7. Coverage Details Coverage Details
Waiver of 30 days,1st Yr, 2nd Yr, 3rd Yr & 4th Year Exclusions
Waived Off
9 Month Waiting Period NA
Maternity Coverage
Rs. 25,000 for Normal & Rs.35,000 for C-section (Applicable for first 2 Children only)
Baby Day 1 Cover
New born baby is covered from date of birth within overall Family Sum Insured
Pre and Post natal expenses
in-patient basis up to the Maternity Limit
Lasik surgery, Oral Chemotherapy
Covered (Refractive index for Lasik is +/- 7.5)
Room Rent Eligibility
2% for Normal & 4% for ICU.
Room charges includes nursing, RMO charges, iv fluids transfusion

8. IF Admitted Higher Room Rent
Particulars
4000 per day (eligibility)
6000 per day (Exceeds Room Limit)
Proportionate Deduction has to paid by the Employee
Room + Nursing Charges (5 days)
20000
30000
10000
Visiting Doctor Charges (5days)
3750
5000
1250
Surgery fees
25000
Lab Fees
3000
4000
1000
Medicines
Non Medical Expenses
2500
Total
53250
70500
17250
If patient admitted in higher room category than proportionate deduction will be applied on all the expenses exclusive of medicine and consumables as per room proportionate

9. Coverage Details….. Coverage Details
Pre and Post Hospitalization Expenses (Except Maternity)
Pre 30 days & post 60 days respectively
Day Care Procedures
Yes to be covered in network & non-network hospitals, without any pre-auth. Any new medical procedure or drugs that replace less than 24 hour of hospitalization to be included as day care procedure
Congenital internal
covered
Ayurvedic Treatment
Yes. Covered in government recognized hospitals with Active line of treatments
Cataract Surgery
covered up to a limit of INR 30,000 per eye
Co-payments & sub limits for diseases
10% Copayment applicable on all claims. No other sublimit or copayments. All ailments & diseases covered can be claimed up to the full family sum insured. No capping on Surgeon Charges, Anesthetic charges, Stent charges etc

10. Enrollment Process
Employees must enroll in order to obtain coverage for themselves and your eligible dependants. Employee has to provide to the HR who will in turn provide relevant enrolment data to MIBL as and when there are additions or when employee family status changes because of marriage, birth or adoption of a child.
Provide required details of Employees and your dependents to the HR Representative immediately
Hr/Controller sends the data to the MIBL for endorsements
Insurer updates their data, endorses member and includes the active member database and prints the cards
MIBL sends the endorsement to HR

11. Cashless Hospitalization
Cashless hospitalization means the Administrator may authorizes upon a Policyholder’s request for direct settlement of eligible services and it’s according charges between a Network Hospital and the Administrator. In such case the Administrator will directly settle all eligible amounts with the Network Hospital.
List of hospitals in the insurers network eligible for cashless hospitalization
Contact Call centre at

12. Points to remember-Cashless Facility
Please carry below documents :-
Health Card
Company identification card
Any photo identity proof
Identify nearby network hospitals , do not wait for an emergency
Please provide full information in Pre- auth Form, check pre-auth form.
And remember we just a call away to help in case of any emergency .

13. Planned Hospitalization
72 hours prior to hospitalization
Click Here

14. Emergency Hospitalization
Click Here
24 HRS

15. Possibility of Denial of Cashless - examples
Admission for investigations/ observation / evaluation only.
Treatment not matching with disease mentioned on pre-auth form.
Any treatment which otherwise could have been taken on OPD basis.
Any congenital external disease.
Hospital not sending proper query reply raised by TPA on time.
Active line of treatment not mentioned in the pre-auth form

16. Reimbursement Process
Claim Form duly filled and signed by you. (Fill the claim amount in Signed Claim Form)
Original Main Hospital Bill with break up.(Detailed Breakup of various heads like OT Charges, Nursing Charges and Room Rent etc)
All Original Hospital Payment Receipts with serial number. (With seal and signature of the hospital if the main hospital bill does not carry bill number)
Original Detailed Discharge Summary from the hospital. (Gives the summary of diagnosis, period of admission and treatment in the Hospital)
Original Receipts with serial number (For Consultation/Surgeon charges if charged outside the main hospital bill)
Original Investigation bills and reports (Along with prescriptions & reports for all tests done along with images)
Original Pharmacy bills with original Doctors Prescriptions (On doctors letterhead mentioning duration and dosage for medicines)
Copy of the ID card –Self attested (Pan Card, Ration card, Passport, Driving License-Election Card –Company ID card etc.,)
Original Death Summary in case of a death claims. (In case of the death of patient during hospital stay)
Police FIR/ Medico Legal Certificate (Mandatory for all road traffic accident duly attested by Police)
In Case of Maternity: Letter from treating doctor with Gravida Details (G P L A; No. of Living children)
Frequently asked/raised objections from the Insurance company’s Processors
Ensure submission of the following supporting documents for processing the claim without raising any objection:
Pre numbered Cash Paid receipt
Investigation Original Reports – (Not required where the details are mentioned - in discharge summary)
Prescription
Break up details of Main hospital bill
Detailed Discharge Summary

17. Claim Submission Checklist Reimbursement Claim Form
Reimbursement Claims
Claim Submission Checklist
Form
Reimbursement Claim Form
Form
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 60 days of discharge for post-hospitalization claims.

18. General Exclusions[Not payable]…
Plastic Surgery, Dental Treatment/Surgery (Cosmetic Purpose)
Use of intoxicating drugs/ alcohol
Sterility/Infertility/Venereal Disease/Circumcision/AIDS
Intentional Self Injury, Mental disorder
Congenital Diseases (External) e.g. An operation to remove a 6th finger, Skin Grafting, Convalescence / General Debility
Admission for only Laboratory /Observation /Evaluation purpose. Less than 24 hours treatment,OPD treatment. Admission for more than 24 hours with no active line of treatment, Health Checks, Domiciliary Hospitalization
Vitamins & Health Drinks like Horlicks, Complan etc.. and Tonic inconsistent with treatment, Special diet and extra diet for patients (unless prescribed by the Doctor)
Non Medical Expenses, Telephone, Fax, Barber, Photocopy, Vaccinations, Toiletries and TV charges, Service Charges, Maintenance and Surcharges, Special Nursing, Duty Doctor Charges, Attendant Pass.
Abortion done for voluntary reasons & before 12 weeks

19. Non Medical Expenses[Not payable]
ADMINISTRATIVE EXPENSES
Admission charges
Registration charges
Medical Records/Medico-legal charges
Additional stay
Gate pass / Attendant pass
Overhead charges
Establishment charges
Tax
Surcharge
Incidental charge
Waste disposal charges
DOCUMENTATION EXPENSES
Documentation charges
Medical records charges
Discharge summary
Birth certificate
Death certificate
Medical certificate
CONSUMABLES
Antiseptic/disinfectant solutions Soap
Powder (talc)
Oil /Cream
Cream
Sanitary pads / Diapers
Health Foods
SERVICES
Telephone charges
Fax charges
Food / beverages
T.V. / internet charges
Newspaper / magazines
Stationery charges
Linen / laundry charges
Mortuary / coffin charges

20. Feel free to call us on any assistance on your Insurance Needs
Escalation Matrix : Mahindra Insurance Brokers Ltd
Name of Representative
Contact No
Address
Account Manager
Mr. Yuvaraj G
First Level
Ms. Shikha Choudhary
Escalation
Mr. Rajesh R