1. Employee Benefits Manual
Helping our clients manage employee benefits 24 x 7 x 365 days a year
GMS ALUMNI
Employee Benefits Program for the year
Policy Period – 09-Nov-17 to 08-Nov-18

2. Disclaimer Disclaimer:
This Benefits Manual will serve as a guide to the benefits provided by GMS ALUMINI. The information contained herein is only a summary of the terms and conditions agreed with the insurer. If there is a conflict in interpretation, then the terms and conditions of the policy will prevail.

3. Main Menu 1. 0 Group Mediclaim 2.0 Contacts at Prudent Insurance
Brokers Pvt. Ltd

4. 1.0 Group Mediclaim Insurance

5. Benefit Summary Policy Parameters Insurer TPA
THE ORIENTAL INSURANCE CO LTD.
Mediassist India TPA Services Pvt. Ltd
Family Coverage
+ + + Self + Spouse + 3 Dependent Children + 2 Dependent Parents OR 2 In Laws, combination is not allowed. (The Age of dependent children is limited up to 25 Years, unmarried/ divorse/ widow dependent girl child - no age limit,Special care child - no age limit)3rd & 4th Child to be included
Sum Insured
Family Floater Sum Insured of INR 600,000
Copay
10% Copay on all Claims
Limit Per Event
A cap of Rs. 3 lakhs per disease / ailment is applicable during the policy period per insured individuals.

6. Standard Hospitalization: 24 hours
Reimbursement of expenses related to
Room and boarding
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
Hospital or nursing home means any institution in India established for indoor care and treatment of sickness and injuries and which has been registered either as a hospital or nursing home with the local authorities and is under the supervision of a registered and qualified medical practitioner, or complies with minimum criteria, as follows:
Has a minimum of 10 beds if located in towns having a population of less than 10 lacs (Class C towns) or a minimum of 15 in-patient beds in other towns, 2) has a fully equipped operation theatre, 3) has a fully qualified doctor in charge and nursing staff around the clock, and 4) maintains a daily medical record for each of its patients.

7. Day Care Procedures: 140+ Radiotherapy Dialysis Kidney stone removal7

8. Pre- and Post-Hospitalization Expenses Period
Reimbursement of expenses related to
30 days
60 days
The policy covers pre-hospitalization expenses made prior to 30 days of hospitalization and incurred towards the same illness/ disease due to which hospitalization happens (Eg. Investigation, Medicines, and Consultations). It also covers all medical expenses for up to 60 days post discharge as advised by the Medical Practitioner. All the bills with summary have to be submitted within 10days after 60days.

9. OTHER BENIFITS CONGENITAL INTERNAL DISEASE PRE AND POST NATAL EXPENSES
Foreign Nationals to be covered with the Geography of India
Covered for all
Covered within the Maternity Limit
Yes (It means, ex-students holding citizenship of any other country can also apply for medical insurance)

10. Pre Existing Ailments Exclusion
Pre-existing Diseases Exclusion
Any pre-existing ailment such as diabetes, hypertension, etc., or related ailments for which care, treatment or advice was recommended by or received from a doctor or which was first manifested prior to the commencement date of the Insured Member’s first Health Insurance policy with the Insurer, is not covered. However, in this Policy, this exclusion is waived.

11. First 30 Days Exclusion First 30 Days Exclusion
Any illness diagnosed or diagnosable within 30 days of the effective date of the Policy Inception Date if this is the first Health Policy taken by the Policyholder with the Insurer is not covered. If the Policyholder renews the Health Policy with the Insurer and increases the Limit of Indemnity, then this exclusion should apply in relation to the amount by which the Limit of Indemnity has been increased. However, in this Policy, this exclusion is waived.  

12. First, Second Year and Fourth Year Diseases Exclusions
1st, 2nd and 4th Year Diseases Exclusions
During the 1st, 2nd and 4th Year of the operation of the policy, the expenses on treatment on diseases such as Cataract, Benign Prostratic Hypertrophy, Hysterectomy for Fibromynoma, Hernia, Hydrocele, Congenital internal disease, Piles, Sinusitis and other related disorders, and Fistula in anus, are not payable. If these disease are pre-existing at the time of proposal, they will not be covered even during the subsequent period or renewal. However, in this policy this exclusion is waived.

13. Room Rent Room Rent and Boarding
INR 12,000 for Normal Hospitalization & INR 24,000 for ICU Hospitalization
(Opting for a room of a higher category than the eligible category will result in higher cost for all hospitalization services, which must be borne by the claimant)

14. Maternity INR 50,000 for Both Normal Delivery & for C-Section Delivery
Maternity (In patient treatment only)
INR 50,000 for Both Normal Delivery & for C-Section Delivery
Pre-Post Natal Expenses covered within Maternity Limit

15. Baby Cover from Day 1 Baby Cover (illness-related) from Day 1- Covered
New Born Child of the Employee is covered from Day 1 for Hospitalization under the Family Floater Sum Insured from the date of birth, subject to intimation to the insurer and availability of sufficient advance premium with the insurer.

16. Mid-Term Enrollment for New Joiners, Newborns and Spouses
Mid Term Enrollment – only for new joiners and new dependents
Existing Dependent can not be enrolled.
HR will to enroll your new dependents (spouse and new born baby) in the Health Policy within 25 days from the day of event. Enrollment is from date of the event, provided the information is intimated to H.R. within the stipulated time.

17. Customized Benefit: Ambulance Services
Ambulance Services (Road)
Definition
Road Ambulance – to hospital, back home where medically necessitated
Sub-limit
Covered for INR 2,500 Per Incident

18. General Exclusions
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
Laser treatment
Injury or disease caused directly or indirectly by nuclear weapons
Naturopathy
Any non-allopathic treatment
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

19. Cashless Hospitalization
List of hospitals in the TPA’s network eligible for cashless hospitalization:
Help Line for Employees: (24x7)

20. Planned Hospitalization: Pre-Authorization Form and Process
48 hours prior to hospitalization
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 2 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.

21. Emergency Hospitalization: Pre-Authorization Form and Process
24 HRS
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 20 days of the date of discharge.

22. 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 30 days of the date of discharge for pre-hospitalization claims and hospitalization claims, and within 10 days of discharge for post-hospitalization claims.

23. Reimbursement Claim Procedure
Kindly send all the below mentioned mandatory documents along with the dully filled & signed claim form attached within 20 days form the Date of Discharge:
1. Original Discharge Summary
2. Original Inpatient Bill
3. Original Inpatient Bill break up
4. Original Receipt for the Inpatient Bill
5. All original medicine bills
6. All original prescription for the submitted bills
7. Original Laboratory reports with the requisitions.
8. Cancelled cheque for NEFT with the account name printed on it
Please do courier or hand over to the below address-
To,Miss.Nikitha BG
Prudent Insurance Brokers Pvt Ltd,3rd Floor,
"Sai Shakti",2207 HAL Stage III, 80 Ft Road,
Kodihalli, Bangalore
Note: Please retain a copy of all the documents submitted.

24. Claims Process A
Insured admitted as per hospital norms. All payments made by member
Insured sends relevant documents to Prudent office within 25 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
Is claim liable (coverage/ applicability)
Is document received within 30
days from discharge
TPA performs medical scrutiny of the documents
Yes
Claim Rejected No No
Yes
Is documentation complete as required
TPA checks document sufficiency
Claims processing done within 21 working days
Payment to be made to employee thru NEFT
Yes
TPA will send mail about deficiency and document requirement A No

25. Prudent Insurance Brokers Pvt Ltd – Contact Details
Single Point Of Contact
Nikitha B G
Support Manager – Employee Benefits Practice
Mobile :
Mail Id-
Escalation:
Ms. Sarita Nair
Asst. Vice President-Employee Benefits Practice
Mobile Number :
Mail Id-
For Cashless claims assistance: Level one :
Level two :
For all Reimbursement claims assistance, please write to us on :
Group ID :

26. Thank you.