1. Foreword
GROUP HEALTH INSURANCE

2. Foreword
This document lays out the benefits offered under the Group Health Insurance Policy offered to the Employees . It contains the necessary details on the following:
Policy Terms and Conditions
Claims procedures – Cashless and Reimbursement
Enrollment process – New Hires
Point of Contact
General Policy Exclusions
If you have any questions or need any additional information, InsuranceManager.com team will be happy to assist in all matters concerning to your Insurance Benefits.

3. GROUP HEALTH INSURANCE - MEANING
Group Health Insurance provides pre-defined insurance coverage to all members in the group for expenses related to hospitalization due to illness, disease or injury.
In the event of a hospitalization for more than 24 hours and an active line of treatment for such hospitalization, the insurance company pays to the insured person the amount of such expenses up to the Sum Insured, as per the terms and conditions mentioned in the policy. The typical heads of expenses are as follows:
Room Charges,
Nursing expenses,
Surgeon, Anesthetist, Medical Practitioner, Consultant, Specialists Fees,
Anesthesia, Blood, Oxygen, Operation Theatre Charges Surgical Appliances, Medicines, etc,
In addition to the above, the insurance company also covers Day care Procedures, which are treatments which do not require 24 hours of hospitalization due to medical technological advancement

4. Know Your Health Insurance Policy
Your Policy at a Glance
Benefits Offered
Claims - Cashless
Claims – Non – Cashless / Re-imbursement
Enrolment Process – New Hires
Exclusions
FAQs
Exit
Contact InsuranceManager.com

5. Health Insurance Policy - Summary General Hospitalization Benefits
Members Covered
Self + Spouse+ 2 Kids + 2 Dependent Parents
Members Covered
Pre - Existing Ailments
Covered
Waiting period for non - accidental claims
Not Applicable
Ambulance Charges
Covered up to INR 1,000 per claims, in case of emergency
Domiciliary Hospitalization
Not Covered
Day Care Procedures
Pre & Post Hospitalization expenses
Covered for 30 and 60 days respectively
General Hospitalization Benefits

6. Health Insurance Policy - Summary
Maternity Benefit
Covered
Maternity sub-limit
35k for Normal & 45K C- Section
Waiting period for maternity NA
Pre and Post natal expenses
Not Covered
Maternity Benefits
Applicability of Room Rent Limit
1% of SI or 5000/- whichever less for normal room & 2% of SI or 5000/- whichever less for ICU .
Applicability of Co-payment
Not Applicable
Deductible
Ailment-wise capping
Applicable for cataract i.e.75000/- per eye
Restrictions
Other Benefits
OPD expenses
Not Covered
Dental Cover
Not Covered. Covered only in accidental cases wherein surgery
is required along with the hospitalization

7. Applicable for Supreme Employees Sum Insured Type – Floater
Sum Insured Details
Applicable for Supreme Employees
Sum Insured Type – Floater
Under Family Floater policy each employee is entitled for hospitalsation expenses subject to Sum Insured Limit . However he should take care of the room rent limit entitlement which is in proportion of the Sum Insured
Room rent (1% of SI or 5000/- whichever less for normal room & 2% of SI or 5000/- whichever less for ICU ).In event of the insured getting admitted in a category higher than capped above per day , then the Insured will bear the difference of all the medical expenses as in the final hospital bill in the same proportion.
Doctors Fees.
Intensive care Unit.
Nursing expenses (should be part of room charges)
Surgical fees, operating thearte, anesthesia & oxygen & their administration.
Drugs & Medicines consumed in premises
Hospital Miscellaneous Services (such as laboratory, x-ray, diagnostic tests) a

8. General Hospitalization Benefits
Pre- existing Disease
Pre-existing diseases refers to condition or ailments that may have been contracted before the start of the policy. There is usually a waiting period of 4 years for covering such ailments.
Covered for Supreme
Employees from day 1
Hospitalization expenses during the first 30 days from the commencement date of the Policy is not covered for the new joiners. This exclusion is however, not applicable to any emergency hospitalization occurring due to an accident.
Waived off for Supreme
Employees
30 Day Waiting Period for new joiners
Medical insurance policies have waiting period of 1 / 2 / 4 years for reimbursement of medical expenses for treatment of certain specified ailments. The specified ailments mainly include Cataract, Benign Prostatic Hypertrophy, Hysterectomy, Hernia, Hydrocele, Fistula in anus, Piles, Sinusitis, Joint Replacement due to Degenerative condition, Age related osteoarthritis and Osteoporosis, among others.
Waived off for Supreme
Employees
1st / 2nd / 4th Year Waiting Period

9. General Hospitalization Benefits
Domiciliary
Hospitalization
Domiciliary hospitalization refers to treatment done at home in India for a period exceeding three days for disease, illness or injury, which in the normal course, would require hospitalization. This could happen if either the condition of the patient is such that he / she cannot be moved to Hospital / Nursing Home, or cannot be admitted to Hospital / Nursing Home.
Not Covered for Supreme
Employees
Day Care Procedures
Day care procedures refers to treatments which do not necessarily require 24 hospitalization due to medical technological advancement. Insurance companies have their list of day care procedures available with them.
Generally, Day Care treatment can be taken in network hospitals only on a cashless basis.
Covered for Supreme
Employees
Ambulance charges
Covered for Supreme
Employees up to a maximum of INR 1000/- per person
Ambulance charges are provided for emergency hospitalization wherein the patient needs to be rushed to the hospital. Under this extension the policy will reimburse such expenses as per the pre decided limits.

10. General Hospitalization Benefits
Pre Hospitalisation Expenses
If the Insured member is diagnosed with an Illness which results in his / her Hospitalization and the claim is admissible, the Insurer also reimburses the Insured Member’s Pre-hospitalization Expenses incurred for various investigation.
Covered for Supreme Employees for 30 days prior to date of admission
Post Hospitalisation Expenses
Relevant expenses for 60 days post discharge from hospital for an admissible hospitalization claim gets reimbursed by the Insurer. These expenses include things like medication prescribed at the time of discharge, follow up treatment etc.
Covered for Supreme Employees for 60 days post the date of discharge
Please Note: Pre & Post Hospitalization expenses are not applicable in case of Maternity.

11. Maternity Benefits
Maternity Expenses
Any Maternity or pregnancy related expense other than those excluded (like voluntary termination of pregnancy in the first 12 weeks of delivery) will be payable. The maternity benefit is applicable for Normal / Cesarean delivery within the overall Sum Insured for the first three live births. These benefits are admissible only if the expenses are incurred in Hospital/Nursing Home as in-patients in India.
Covered for Supreme Employees
9 Month Waiting Period
Waived off for Supreme Employees
There is usually a 9 month waiting period for new joiners to claim Maternity Benefits under Group Health Policy.
Pre & Post Natal Expenses
This cover is similar to that of Pre & Post hospitalization expenses. While Pre & Post hospitalization expenses excludes expenses incurred prior to and after Delivery of child, the same is covered under Pre & Post Natal expenses.
Not Covered for Supreme

12. Policy Restrictions
Room Rent Restrictions
Room rent is capped to a certain limit in the policy. Employees / dependents choosing to go for higher room category than what is specified in the policy will need to bear the incremental room rent amount. This would also apply to related expenses such as nursing charges, doctor’s fees, etc. which is associated with the room category. This limit may differ for ICU.
1% of SI or 5000/- whichever less for normal room & 2% of SI or 5000/- whichever less for ICU .
Co-Payment
Co-pay is a cost containment measure, wherein claimant has to pay a certain % of the claim amount mentioned in the policy. Parents Sum Insured is restricted to 2 lac
Not Applicable for Supreme Employees
This restriction is being applied to cap the maximum amount payable under insurance for a particular ailment.
Applicable on Cataract for Supreme Employees
Ailment wise Capping

13. Not Covered for Supreme Not Covered for Supreme
Other Benefits
OPD Cover
This extension provides for expenses which does not necessarily require hospitalization. It is however, not applicable to ailments / treatment which is excluded in the policy.
Not Covered for Supreme
Employees
Dental treatment as a result of hospitalization due to an accidental injury is covered in the policy. However, extension for dental treatment in the policy will cover dental expenses for a fixed specified limit defined in the policy which is otherwise an exclusion under the health policy.
Dental Cover
Not Covered for Supreme
Employees

14. Claims Administration – Cashless Claims
Cashless service ensures that the employee and the covered family members get treatment at the hospital empanelled in the TPA Network without having to pay any money. This is however, subject to approval from the TPA based on the benefits covered under the policy.
For Updated List of hospitals please visit
24 X 7 Customer Care no. for R Care Toll Free Nos.
Call Center Toll:
You may also contact InsuranceManager.com representative at the following contact points:
Bhagyashree
Ashwini

15. Claims Administration – Cashless – Planned Hospitalization
Member intimates TPA / IM.com of the planned hospitalization in a specified pre -authorization form 48 hours prior to hospitalization
Claim Registered by the TPA
TPA issues letter of Approval within 24 hours for planned hospitalization to the hospital
Pre-Authorization Completed
Yes No
Member produces ID card at the network hospital and gets admitted
Follow non cashless process
Member gets treated and discharged after paying for all non-entitled expenses like the deductions based on the policy terms, the cost of non payable
items etc, to the hospital

16. Claims Administration – Cashless – Emergency
In case of a sudden requirement of Hospitalization, the cashless process is as follows:
Member get admitted in the hospital in case of emergency by showing his health card and ID Card. Treatment starts
Member / Hospital applies for pre-authorization to the TPA within 24 hrs of admission
TPA verifies applicability of the claim to be registered and issue pre-authorization
Pre-authorization given by the TPA
Follow non cashless process No
Yes
Member gets treated and discharged after paying all non entitled benefits

17. Claims Administration – Reimbursement Claims
Claims procedure
In case of a non-network hospital, the patient will need to be admitted to the hospital and take the treatment.
Discharge procedure
In case of non network hospital, employee will be required to clear the bills and submit the claim to TPA through IM.com helpdesk for reimbursement. Please ensure that all necessary documents such as discharge summary, investigation reports, payment receipts, reports etc. are collected in original for submitting your claim.
Submission of hospitalization claim
After the hospitalization is complete and the patient has been discharged from the hospital, the claim must be submitted within 25 days from the date of discharge from the hospital.
Under hospitalization claims, you are also permitted to claim for treatment expenses 30 days prior to hospitalization and 60 days after the date of discharge. This is applicable for both network and non-network hospitalization.

18. Claims Administration – Reimbursement - Documents
Claim form duly filled and signed by the claimant
Original Discharge Summary
Main Hospital bills in original (with bill no; signed and stamped by the hospital) with all charges itemized and the original receipts
Attending doctors’ bills and receipts (if separate from hospital bill) and certificate regarding diagnosis
Original reports of Bills and Receipts for Medicines, Investigations along with Doctors prescription in Original
All original payment receipts must be taken from the hospital including invoices for implants and stickers for lenses
Follow-up advice or letter for line of treatment after discharge from hospital, from Doctor
Break up details of Pharmacy items, Materials, Investigations even though it is there in the main bill
In case the hospital is not registered, a letter on the Hospital letterhead mentioning the number of beds and availability of doctors and nurses round the clock
In non-network hospitalization, please get the hospital and doctor’s registration number in Hospital letterhead and get the same signed and stamped by the hospital
Note: there may be additional documents other than the above mentioned list, required by the TPA, based on specific treatments.

19. Enrolment Process – New Joiners
Provide required details of your dependents to the HR. HR in turn send the details to IM.com
IM.com sends the data to the insurer for endorsements
Insurer updates their data, endorses member and sends the detail to the TPA
TPA updates the active member database and prints the cards
E-Cards uploaded on TPA’s website within 7 working days
E card received by employee
Employee verifies details on the E card
Notify HR / IM.com with revised details
Uses card for cashless hospitalization
Error in data printed on card
E Card Ok
You need to enroll in order to obtain coverage for yourself and eligible dependants. Please contact your HR and provide relevant enrollment data (viz. name, date of birth, gender). Your enrollment data must reach the Insurer within 30 days of your joining the company. Please notify HR each time your family status changes because of marriage, birth or adoption of a child. The details on marriage and child births must be declared within 30 days of the event. If you do not enroll within the defined timelines, the next enrollment can be done only at next renewal.

20. Standard Policy 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
Naturopathy
Any non-medical expenses like registration fees, admission fees, charges for medical records, cafeteria charges, telephone charges, etc
Cost of spectacles, contact lenses, hearing aids
Any cosmetic or plastic surgery except for correction of injury
Hospitalisation 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)

21. Submission of Claim Documents
Kind Attn:-
Reliance General Insurance Co. Ltd.
No.1:89/3/B/40 to 42/ks/301,
3rd floor, Krishe Block,
Krishe Sapphire,
Madhapur,
Hyderabad
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22. InsuranceManager.com Contacts
Role
Name
Contact Number ID
Mumbai
Claims & Enrolment
Ashwini
Escalation 1
Bhagyashree

23. Thank you