Group Mediclaim Insurance Program FAQs - Parent

Q1: What is the definition of Hospital/Nursing Home? A: Hospital/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 registered and qualified medical practitioner OR Should comply with minimum criteria as under: It should have atleast 15 inpatient beds. Fully equipped Operation Theatre of its own wherever surgical operations is 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 place for drug addiction or place of alcoholics, a hotel or a similar place. Q2: Is there any time limit for Hospitalisation? A: Yes, The admissible minimum period of hospitalization is 24 hours. 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, Tosillectomy taken in the Hospital/Nursing Home and the Insured is discharged on the same day. Q3: Are Pre and Post Hospitalisation expenses covered? A: Yes, all relevant medical expenses incurred during a period upto 30 days prior to and 60 days after hospitalization on disease/illness/injury sustained will be considered as part of claim. Q4: What are the diseases/illness that are excluded from the Program? A: Broadly the following diseases/illness/situations are not covered: Injury or disease directly or indirectly caused by or arising from or attributable to War Invasion Act or Foreign Enemy Warlike operations (whether war be declared or not). Circumcision unless necessary for treatment or 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 my be necessitated due to as accident or as part of any illness. The Cost of Spectacles and contact lenses hearing aids are not reimbursable. Dental treatment or surgery of any kind unless arising due to an accident and requiring hospitalization. Convalescence general debility Run Down condition or rest cure, congenital external disease or defects or anomalies, sterility, venereal disease, intentional self-injury and use of intoxicating drugs/alcohol. AIDS.

Naturopathy treatment and all other diseases /illness/situations as explained in the Insurance policy. Refer policy document for more details.

Q5: What is the time frame within which the Claim has to be submitted? A: The claim must be filed within 75 days from date of discharge from the Hospital in case of post hospitalization and 15 days for normal hospitalization. Q6. What are the documents that are required to be submitted? A: Following are the documents that are required to be submitted: Claim form: All original Bills, receipts and Discharge Summary/Certificate/Card from the Hospital. Cash Memos from the Hospital/Chemist(s), supported by the proper prescription, investigation reports etc,. Q7: Is the claims applicable to those Hospitalisation expenses incurred abroad ? A: No, the Program covers only those Hospitalisation expenses that are incurred in India. Q8: What does Immediate Family floater cover mean? A: Immediate family Floater indicates the total sum insured for your family (as declared by you) within a given year. The same can be either claimed entirely by one member or shared within the family upto the maximum limit. Q9: What is the maximum amount allowable under the Maternity benefit? A: Not applicable under this program Q10: Is there an age limit to cover any dependents under this program? A: For any new entrants into this program the upper age limit is 80. There is no minimum age limit. Please note that the upper age limit does not apply for those who joined the program prior to attaining the age of 80. Q11: Can I include my parents/ parents in law under the Program during the course of the year? A: In case you have got married during the course of the year, you can include only your parents in law into the policy. Please note this has to be done within 45 days of the date of marriage and the same time as including your spouse. Parents cannot be added to the policy during the course of the year. Q12: Can I include other relatives/friends under this Scheme, by personally paying the premium amount? A: No, this program is only limited to 4 members - parents & parents in law. Q13: Will I be reimbursed all the expenses that I incurred during hospitalization? A: The following expenses can be reimbursed as per Insurance policy norm: Room, Boarding Expenses as provided by the Hospital/Nursing Home. Nursing Expenses, Surgeon, Anesthetist, Medical Practitioner, Consultants Specials fees

Anesthesia, Blood, Oxygen, OT Charges, Surgical appliances, Medicines, Drugs Diagnostic material and X-Ray, Dialysis, Chemotherapy, Radiotherapy, Cost of pacemaker, artificial limbs, cost of organs and similar expenses.

Q14: Can I get the coverage amount enhanced by paying extra premium? A: Yes you can opt for additional sum insured by paying additional premium as per section 6.4 in the policy document. Q15: I am a heart patient. Can I claim hospitalization expenses under this program? A: Yes, this illness is covered within the permissible pre existing disease/illness. Q16: Is there a waiting period before I can make a claim? A: No. Q17: My mother has diabetes, blood pressure and heart problems. I got admitted for angioplasty. Investigations for related problems of diabetes were done. Can I claim the investigation costs as I was admitted for a heart problem? A: Yes, you can. You will need to produce a letter/prescription from the doctor prescribing the tests. Q18: My father has been advised to undergo an operation for defective nasal septum. I also wanted to have plastic surgery done on my nose. Are expenses for the same reimbursable? A: Hospitalization costs for the operation performed for defective nasal septum is claimable under the program. In this case though plastic surgery is not covered. Q19: My mother in law has been advised to undergo a kidney organ transplant. Can I claim the cost of the organ? A: Yes. Provided the organ is already available at the hospital. Q20: My father in law has been advised to undergo kidney dialysis every week. He will not be hospitalized. Can I claim the expenses incurred under this program? A: Yes. Q21: My father is currently on special medication for reducing my weight. Can I claim the expenses incurred under this program? A: No. Q22: I have paid for the hospitalization expenses in foreign currency. Will the insurance company reimburse the equivalent amount in rupees to me? A: Even if the amount paid is in foreign currency, the bill receipt should be in Indian rupees for the same to be claimed from the insurer. Q23: In case of separation, can I continue to avail the benefit by paying the premium directly to the insurance company?

A: Yes, you may continue this benefit even once you leave the organization by converting it to a retail plan and paying the premium for the same. For more details on this, raise a Contact HR query. Q24: My father in law was hospitalized for heart ailment and passed away. Are the costs involved for the treatment claimable under the program in case the member expires? A: Yes, the expense incurred is claimable under the insurance program by the employee/nominee. Q23: My mother needs to travel to Mumbai for a Kidney transplant. Is my airfare reimbursable? A: No. Q24: What is co-pay ? A:Co-pay means out of the entire payable amount 90% will be borne by the insurance company and 10% will be borne by the employee. This co-pay is only for the basic sum Insured and not applicable on the buffer amount sanctioned/utilized. Example If the Sum Insured is Rs. 1 lakh and the claim amount is Rs.80,000/- insurance company will pay Rs.72,000/- and employee will bear Rs.8,000/-. If the claim amount is Rs. 1,10,000/- and Rs.10,000/- is granted from buffer, then insurance company will pay Rs.1,00,000/- i.e., Rs.90,000/- out of sum insured and Rs.10,000/- (without applying co-pay on buffer), i.e., totally Rs.1,00,000/-. And If the claim amount is Rs.2,00,000/- and Rs 1,00,000/- is granted out of buffer, then the insurance company will pay Rs.1,90,000/- i.e., Rs.90,000/- out of sum insured and Rs.1,00,000/- out of buffer and employee will bear Rs.10,000/-. The balance sum insured after applying co-pay remains for subsequent claims, if any. For Eg. Sum Insured-Rs.1,00,000/-, Claim for 1,00,000/-. Balance Rs.10,000/- would be available for next claim, if any. However on this also if and when a claim is received, co-pay of 10% is applicable. For Eg if the claim is for Rs.10,000/- Rs 1000 has to be borne by the employee. FAQs on MediAssist Services Q1: What is MediAssist? A: We have partnered with MediAssist who are healthcare services provider. At their empanelled hospitals you need not pay for hospitalisation expenses as they provide you with a credit facility. Q2: How do I enroll for MediAssistservices? A: You would need to fill the form available @ HP HR portal under Employee Resources >> Compensation/ Benefits >> Benefits Summary >> Health/ Medical Q3: Is a MediAssist card a necessity? A: Yes. Q4: Which are the empanelled hospitals, where cashless facility is available? A: The updated list of empanelled hospitals is available with the MediAssist representative or Log on to www.mediassistindia.com

Q5: Do I need to visit only MediAssist-empanelled hospitals? A: No, though it is preferred to use the MediAssist empanelled hospitals as you can avail the credit facility and discounts. Employees can still go to any other hospital, pay for the hospitalization expenses and have the same reimbursed with the help of MediAssist. Q6: Is Outpatient treatment like common cold, asthma etc covered at the hospital? A: No. Outpatient treatment at the hospital is not covered under the program. The expenses incurred have to be claimed under the company medical program as mentioned under the FBP. Q7: What do I do in case of a planned hospitalisation at an empanelled hospital? A: You would need to fill a pre-authorisation form(available with MediAssist). The preauthorisation form includes details of the patient, hospital and estimated expenses. On receiving the pre-authorisation form, MediAssist would issue an authorisation letter to the hospital. Thereafter, the patient shows the MediAssist card and gets admitted at the hospital. No upfront security deposit is required. At the time of discharge, the patient needs to ensure to sign the bill. You would not need to pay for any of the expenses covered under the program. Any auxiliary expenses (not covered under the program) like telephone calls would be charged to you. You would need to sign on an insurance claim form at the time of discharge. All relevant documents should be handed over to MediAssist. Q8: What do I do in case of an emergency hospitalisation? A: In the case of an emergency, the employee or his/her dependents can undergo hospitalization without the pre-authorization letter from MediAssist. Empanelled hospitals have been instructed to admit the patient under emergency with only the photo-ID card. MediAssist should be contacted in order to avoid paying at the time of discharge. In case it is a non-empanelled hospital, MediAssist will help the employee settle the bill at the time of discharge in case the employee is in trauma or is no position to make arrangements for the money.