Group Medical Insurance Policy

Definitions:

Hospital / Nursing Home:

a. Hospital / Nursing Home means any institution in India established for indoor care and
treatment of sickness and injuries and which either:

- Has been registered as a Hospital or Nursing Home with the local authorities and is
under the supervision of a registered and qualified Medical Practitioner.

OR

- Should comply with minimum criteria as under:

It should have at least 15 inpatient beds (10 for class C towns).

Fully equipped operation theatre, wherever surgical operations are carried out.
Fully qualified Nursing Staff under its employment round the clock.
Fully qualified Doctor (s) should be in-charge round the clock.

The term Hospital / Nursing Home shall not include an establishment which is a place of rest,
a place for the aged, a rehabilitation centre, a hotel or a similar place.

Surgical Operation:

Surgical Operation means manual and / or operative procedures for correction of deformities and
defects, repair of injuries, diagnosis and cure of diseases, relief of suffering and prolongation of
life.

Expenses on Hospitalisation for minimum period of 24 hours are admissible. However, this
time limit is not applied to specific treatments, i.e. Dialysis, Chemotherapy, Radiotherapy, Eye
Surgery, Dental Surgery, Lithotripsy (Kidney Stone removal), D&C, Tonsillectomy taken in
Hospital / Nursing Home and the Insured is discharged on the same day, such treatment will be
considered to be taken under hospitalisation benefit. This condition will also not apply in case
of stay in Hospital of less than 24 hours provided, the treatment is such that it necessitates
hospitalisation and the procedure involves specialized infrastructural facilities available in
hospitals. Due to technological advances, hospitalisation is required for less than 24 hours only.

Note: Procedures/treatments usually done in out patient departments are not payable under the
policy even if converted as an in-patient in the hospital for more than 24 hours.

Network Hospital:

This is a hospital that has agreed with the TPA to provide cashless health services to the insured
persons. This list is maintained by and available with the TPA and the same is subject to
amendment from time to time.
Cashless Facility:

The TPA may authorize upon the Insured request for direct settlement of admissible claim as per
agreed charges between network hospitals and the TPA. In such cases the TPA will directly
settle all eligible amounts with the network hospitals and the Insured Person may not have any
bills at the end of the treatment at Hospital, to the extent the claim is covered under the policy.

Pre-Hospitalisation:

Relevant medical expenses incurred for a period of 30 days prior to Hospitalisation on disease /
illness / injury sustained will be considered as part of claim.

Post Hospitalisation:

Relevant medical expenses incurred for a period of 60 days after hospitalisation on disease/
illness / injury sustained will be considered as part of claim.

Medical Practitioner:

Medical Practitioner is a person who holds a degree / diploma of a recognized institution and is
registered by Medical Council of a respective State of India. The term Medical Practitioner
would include Physician, Specialist and Surgeon.

Qualified Nurse:

Qualified Nurse is a person who holds a certificate of recognized Nursing.

Maternity Expenses and New Born Child cover benefit extension:

Maternity Expenses Benefit means treatment taken in Hospital/Nursing Home arising from or
traceable to pregnancy, childbirth including normal and Caesarean Section. The hospitalisation
expenses in respect of the new born child can be covered within the Mothers Maternity
expenses subject to an overall limit of Rs.50,000/-.

Claim in respect of delivery for only first two children and / or operations associated therewith
will be considered in respect of any one Insured Person covered under the policy or any renewal
thereof. Those Insured Persons who are already having two or more living children will not be
eligible for this benefit. Expenses incurred in connection with voluntary medical termination of
pregnancy during the first 12 weeks from the date of conception are not covered. Pre-natal and
postnatal expenses are not covered unless admitted in Hospital / Nursing Home and treatment is
taken there.

Third Party Administrator ( TPA )

Third Party Administrator (TPA) is an agency which holds a valid License from Insurance
Regulatory and Development Authority to act as a THIRD PARTY ADMINISTRATOR and is
empanelled by the Company for the provision of health services as specified in the agreement
between the Company and the TPA. Our TPA is VIDAL Healthcare Services Pvt. Ltd (referred
to as VIDAL/TTK or TPA in the rest of this document).

Exclusions:

The company shall not be liable to make any payment under this policy in respect of any
expenses whatsoever incurred by any Insured Person in connection with or in respect of:

1. Injury / disease directly or indirectly caused by or arising from or attributable to invasion, Act
of Foreign enemy, War like operations (whether war be declared or not).

2. Circumcision unless necessary for treatment of a disease not excluded hereunder or as may be
necessitated due to an accident, vaccination or inoculation or change of life or 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.

3. Surgery for correction of eye sight, cost of spectacles and contact lenses, hearing aids etc.

4. Any dental treatment or surgery which is corrective, cosmetic or of aesthetic procedure,

filling of cavity, root canal including wear and tear etc unless arising from disease or injury
and which requires hospitalization for treatment.

5. Convalescence, general debility, run-down condition or rest cure, Congenital external disease
or defects or anomalies, Sterility, any fertility, sub-fertility or assisted conception procedure,
Venereal disease, intentional self injury, suicide, all psychiatric and psychosomatic disorders
and diseases / accident due to and or use, misuse or abuse of drugs / alcohol or use of
intoxicating substances or such abuse or addiction etc.

6. All expenses arising out of any condition directly or indirectly caused to or associated with
Human T-Cell Lymphotropic Virus Type III (HTLB III) or lymphadinopathy 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.

7. Expenses incurred at a hospital or nursing home primarily for evaluation/diagnostic purposes

which is not followed by an active treatment is not covered. For example someone goes
through an Angiogram and the results do not indicate need for a treatment (say bypass
surgery), the cost of angiogram cannot be claimed through insurance. But if the person goes
through surgery post angiogram, the cost of both the angiogram and surgery can be claimed
together.

8. Expenses on vitamins and tonics unless forming part of treatment for injury or diseases as
certified by the attending physician.

9. Any treatment arising from or traceable to pregnancy, childbirth, miscarriage, caesarean

section, abortion or complications of any of these including changes in chronic condition as
a result of pregnancy.

10. Naturopathy Treatment, unproven procedure, experimental or alternative medicine and

related treatment including acupressure, acupuncture, magnetic and such other therapies etc.
11. Expenses incurred for investigation or treatment irrelevant to the diseases diagnosed during
hospitalization or primary reasons for admission. Private nursing charges referral fee to
family doctors, out station consultants / surgeons fees etc.

12. Genetical disorders and stem cell implantation / surgery.

13. External and or durable Medical / Non-medical equipment of any kind used for diagnosis
and or treatment including CPAP, CAPD, Infusion pump etc. Ambulatory devices i.e.
walker, crutches, Belts, Collars, Caps, Splints, Slings, Braces, Stockings, etc., any kind.
Diabetic footwear, Glucometer / Thermometer and similar related items etc., and also any
medical equipment, which is subsequently used at home etc.

14. All non medical expenses including personal comfort and convenience items or services
such as telephone, television, Ayah (hospital assistant), / barber or beauty services, diet
charges, baby food, cosmetic, napkins, toiletry items etc., guest services and similar
incidental expenses or services, etc.

15. Change of treatment from one form or medicine to another (say allopathy to Ayurveda)
unless being agreed / allowed and recommended by the consultant under whom the treatment
is taken.

16. Treatment of obesity or condition arising therefrom (including morbid obesity) and any other
weight control programme, services or supplies etc.

17. Any kind of Service charges, Surcharges, Admission Fees/Registration Charges levied by
the hospital.

18. Out patient diagnostic, medical or surgical procedures or treatments, non-prescribed drugs
and medical supplies, hormone replacement therapy, or treatment which results from or is in
any way related to sex change.

19. Massages, Steam bathing, Shirodhara and similar treatment under Ayurvedic treatment.

20. Any kind or service charges, surcharges, admission fees / registration charges etc levied by
the hospital.

21. Doctors home visit charges, Attendant / Nursing charges during pre and post hospitalization
period.

Frequently Asked Questions

What is Group Mediclaim Policy (GMC)?

Group Mediclaim Policy is a Policy where the company covers all the employees and their
dependants to meet Medical emergencies.

Who all are considered as dependants?

Dependant parents, Spouse and up to 3 children can be covered under the policy.
What is the insured amount?
The amount insured under this policy is Rs. 2,00,000/- per family (on family floater basis).

What is Family floater?

Employee and his/her family is covered for a fixed amount and anyone in the family can avail
the insurance benefit upto the extent of the insured amount, which is 2,00,000/-. For example, if
one of those covered (say spouse) avails a treatment for 30,000/- in a year, the remaining limit
for that year for the employee and/or his family will reduce to 1,70,000/-.

Are Pre-existing diseases covered under GMC?

Yes.

Are newborns covered under this policy?

Yes, new borns are covered from the day they are born.

What is the maximum amount one can claim against room rent in case of hospitalization?
Cap on room rent in normal cases is Rs. 3,000/- per day and for ICU admission it is Rs.5,000/-
per day.

What are the various expenses that can be claimed under this policy?
List of expenses that can be claimed under this policy:
a. Room, Boarding Expenses as provided by the Hospital / Nursing Home.
b. Nursing Expenses.
c. Surgeon, Anaesthetist, Medical Practitioner, Consultants, Specialists Fees.
d. Anesthesia, Blood, Oxygen, Operation Theatre Charges, Surgical Appliances, Medicines
& Drugs, Diagnostic Materials and X-ray.
e. Dialysis, Chemotherapy, Radiotherapy Cost of Pacemaker, Artificial Limbs & Cost of
organs and similar expenses.
f. For claims arising out of persons aged more than 35 years, the expenses on following
illnesses would be limited to:

Sl.No Hospitalisation Benefits Limits restricted to

Cataract 10% of Sum Insured or Max. Rs.20,000/-
1 whichever is less.
2 Hernia 15% of the SI or Max. Rs.30,000/-
3 Hysterectomy 20% of the SI or Max. Rs.40,000/-
4 Major surgery-Angioplasty 70% of the SI or Max. Rs.2,00,000/-
5 Pre & Post Hospitalisation Maximum 10% of the sum insured

Who do we contact in case of Hospitalisation?

Marvy (our service provider) has assigned Single Point of Contact (SPOC) for any kind of
assistance with respect to our Group Medical Insurance & Group Personal Accident Policies.
For the other locations where there is no coordinator specified in the list, employees are
requested to contact the SPOC of Bangalore. The list of contact people is available here.
How does the Cashless facility work?
Each person covered under the Policy will be issued an identity card. Whenever there is a need
for hospitalisation, the policyholder should obtain an Authorization Letter from VIDAL. The
authorization letter will indicate the name of the insured/patient, the name of the hospital where
treatment is required, the nature of illness / disease for which treatment is required and the
monetary limit above which, the insured/ patient will have to pay. The policyholder will have to
submit this authorization letter along with the identity card given by VIDAL to the
admission counter in the hospital. The hospital will then start treatment.

How does one obtain the Authorization letter?

Authorization Letter is a Request for Cashless Hospitalization. This letter is the Communication
ascertaining the Admissibility or Acceptance of the Cashless Service. The same is issued by
VIDAL Health Services subject to admissibility of the claim and availability of balance sum
insured for the member. The letter has to be duly filled up, signed and stamped by the Treating
Doctor. Thereafter, the hospital will fax it to VIDAL Health Services on the number given on
the reverse of the card. The Contact details of VIDAL Health Services are available in the
Insureds Guide available in the Cashless Docket.

Can a request for Authorization for cashless be declined?

Yes, a request for authorization for cashless access may be declined if,

a. Inadequate/vague/wrong information is provided and the TPA is unable to get access to

further information.
b. The ailment/disease for which hospitalisation is required is not covered by insurance.
c. The person does not have adequate insured amount left to cover the hospitalisation costs.

The denial of pre-authorization letter shall not be construed to mean that the policyholder cannot
claim under the terms, exclusions and conditions of the policy from VIDAL. In such cases you
are advised to file your claim for reimbursement and VIDAL will settle the claim as per your
policy terms and conditions and subject to balance limit available to the individual.

How does planned hospitalisation work in case of planned treatment?

The request for Authorization (Pre-Authorization) for planned treatment has to be filled up. This
form has to be filled up by the doctor recommending hospitalisation. The form must be filled
fully in Block letters indicating the Doctors Name, Registration Number and Telephone
number. If the VIDAL Medical Officer needs any clarification he may contact your doctor
before he initiates action on your request. This request must reach VIDAL office at least 4
days before such hospitalisation.

Any change in the date of hospitalisation, hospital, nature of illness or surgeon who is going to
perform the procedure will make the authorization invalid. A fresh authorization will have to be
taken.

The authorization is valid only for Network Hospitals. The authorization will be addressed to the
hospital and sent to the patients address or faxed to the hospital as desired by the policyholder.

What are the points one must note while getting Hospitalised under cashless scheme?
In order to secure admission on the appointed day, you are advised to register your name with
the hospital well in advance. Contact the admission desk of the Hospital / VIDAL Branch
office.
Show your VIDAL identity card and the Authorization letter given by VIDAL. The hospital
will check the ID card and authorization letter. However, in case of an emergency
hospitalisation, these formalities can be completed post admission.

Some network Hospitals may charge you registration fees / admission fees, etc. These will have
to be paid by the policyholder. These expenses are not reimbursable under your policy. In case
the amount approved is less than the estimate given by the hospital you may be required to make
arrangements for the difference. In addition to the above, you will also have to pay expenses
towards telephone charges, ambulance charges, etc. In case you wish to know more on expenses
that is not covered by your policy please contact the SPOC of Marvy.

How does Emergency Hospitalisation under cashless access scheme work?

In case of admission to a Network Hospital the hospital will admit the patient as per the
procedure of the hospital. The hospital will then check with VIDAL and send a request for
authorization. At times the policyholder / relative may be required to contact SPOC of Marvy/
VIDAL for clarification.
The policyholder/relative must send the pre-authorization request completely filled. VIDAL
will revert within 6 hours of receipt of the request.

If the authorisation is given, the policy holder may:

1. Pay for the non-medical expenses before leaving the hospital.
2. Sign on relevant documents which will be sent to VIDAL by the hospital.

In case the policy holder gets admitted to a non-network hospital then the hospitalisation bills
will be reimbursed subject to Terms, Exclusions, Conditions and Limitations of your Policy.

How does Billing and discharge under cashless access scheme work?
Sign the final bill and check the bill for correctness. VIDAL reserves its right of recovery of
any amount due to it from the insured person for billed services, which are not covered by the
policy. Ensure that all supporting documents are attached to the bill. You must pay all bills not
associated with the condition for which hospitalisation was authorized and the amount in excess
of the approved limit.
Retain a copy of the final bill and discharge summary. Sign a claim form filled in all respects
and give it to the hospital along with other authorization letter given.

Claim Settlements:

How does one get Reimbursement in case of treatment in non- network hospitals?
Cashless Hospitalisation can be used only if the treatment is at Empanelled/Network hospitals.
While it is recommended that you choose a network hospital, you are at liberty to choose a non-
network hospital also. In case you avail a treatment in a Non Network hospital, VIDAL will
reimburse you the amount of bills subject to the policy taken by the policy holder.

The claim form must be completed and handed over to HR along with the following documents
in original within 7 days of discharge from the Hospital / Nursing Home.

a. Original bills, receipts and discharge certificate / card from the hospital.
b. Medical history of the patient recorded by the hospital.
c. Original Cash-memo from the hospital (s) / chemist (s) supported by proper prescription.
 d. Original receipt, pathological and other test reports from a pathologist / radiologist
including film, etc. supported by the note from attending medical practitioner / surgeon
demanding such tests.
e. Attending consultants / Anaethetists / Specialist certificates regarding diagnosis and bill
/ receipts, etc.
f. Surgeons original certificate stating diagnosis and nature of operation performed along
with bills / receipts, etc.
g. Any other information required by TPA / Insurance company.

All documents must be duly attested by the Insured.

Note: Only expenses relating to hospitalisation will be reimbursed as per the policy taken.
Non-medical expenses will not be reimbursed.

Can I use this card outside India?

All medical / surgical treatments under this policy shall have to be taken in India and admissible
claims thereof shall be payable in Indian currency. Payment of claim shall be made through
TPA to the Hospital / Nursing Home or the Insured Person as the case may be.

Claim Settlement Flow Chart