Employee Benefits Manual

Helping our clients manage employee benefits 24 x 7 x 365 days a year

CLIENT NAME: SMARTPLAY TECHNOLOGIES
Insurance Benefits Manual
Policy Period : 04-Apr-14 To 03-Apr-15
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Disclaimer:

This Benefits Manual will serve as a guide to the benefits provided by SmartPlay Technologies 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.




Disclaimer
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1. Group Mediclaim
Main Menu
2.Contacts at Prudent Insurance
Brokers Pvt Ltd
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1.Group Mediclaim Insurance
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Benefit Summary
Policy Parameters
Insurer / TPA / Insurance
Broker
United India Insurance Company Ltd
Medi Assist India TPA Pvt. Ltd
Prudent Insurance Brokers Pvt Ltd
Family Coverage
(Employees)
+ +
Employee + Spouse + 2 Dependant Children
Family Coverage (Parents)

Parents and Parents in-laws
Sum Insured Varied Sum insured: 2 lac,3 lac & 4 lac
Note: Each represents one member (employee, spouse, dependent child, dependent parent/in-law, or other dependent as defined in
the policy.
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Standard Hospitalization:24 hours
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
Reimbursement of expenses related to
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:
1)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.
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Co-Payment Clause
Co-Payment Clause Applicable for Parents & Parents In Law's
10% Copay on all parental claims
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Day Care Procedures: 140+
Radiotherapy
Kidney stone removal
Dialysis
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Pre- and Post-Hospitalization Expenses Period
Reimbursement of expenses related to
30 days 60 days
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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 Members first
Health Insurance policy with the Insurer, is not covered. However, in this Policy, this
exclusion is waived.
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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.
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First, Second Year and Fourth Year Diseases
Exclusions
1
st
, 2
nd
and 4
th
Year Diseases Exclusions
During the 1
st
, 2
nd
and 4
th
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.
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Room Rent
Room Rent and Boarding
2% of sum insured for Normal Hospitalisation and 4% for ICU Hospitalisation.
Should you opt for a room of a higher category or rate, you are responsible for bearing the
additional proportional charges associated with such room.
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Maternity
Maternity (IPD)
Rs. 50,000/-for normal delivery or for C-section Delivery
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Baby Expenses
Baby Expenses (for a healthy baby)
Employee should intimate HR within 15 Days from the Date of Birth of
the baby to cover the baby under the policy.
New Born baby is expenses are covered only if the baby has any
complications and requires treatment under hospitalization longer
than 24 hours.
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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.
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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 15 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.
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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
Injury or disease caused directly or indirectly by nuclear weapons
Naturopathy any non-allopathic treatment
Any type of Dental Procedures
All forms of family planning surgeries
Infertility treatment
Psychiatric diseases
Lasik treatment
Hospitalization for diagnostic tests only
Robotic surgeries, stem cell transplantation, bone marrow transplant, Cochlear implant or related aids, RFQMR -Cytotron, C3R, Balloon sinoplasty,
Bariatric surgery, LUCENTIS & AVASTIN injections, Macugen ozone therapy, Enhanced external counter pulsation therapy(EECP), rejuvenation therapy
etc.
Congenital external diseases
DNS-Septoplasty
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
And all other expenses which are not payable as per policy terms and condition.
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Cashless Hospitalization
List of hospitals in the TPAs network eligible for cashless
hospitalization: www.mediassistindia.com

Toll free Help Line for Employees: 1800 425 9449
( 24 x 7 )
Please note that TPA empanels and dis-empanels hospitals
throughout the year. Look up the latest hospital list online at the link
given above.
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Planned Hospitalization: Pre-Authorization Form
and Process
At least 1 week prior to planned hospitalization, your treating doctor must complete the pre-authorization form and
the hospitals TPA Help Desk should fax it to the TPA. The TPA will approve cashless within 8 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.
1 week prior to
hospitalization
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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 25days of the date of discharge.
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Submit all Pre & Post Hospitalization expenses within 60 days of the
date of discharge and all Post-Hospitalization expenses within 90 days
from the date of discharge
Documents along with completed claim form should be
submitted to HR Dept
Submission of Pre- and Post-Hospitalization Claims
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Reimbursement Claims
Submit all reimbursement bills, original reports, and prescriptions along with the claim form and checklist within 20 days of
the date of discharge for pre-hospitalization claims and hospitalization claims, and within 60 days of discharge for post-
hospitalization claims.
Ensure the name in which your bank account is held matches the name which youve given to HR to avoid re-issuance of
cheques, which can result in delays in your finally receiving your claim.
Claim Submission
Checklist

Form


Reimbursement
Claim Form

Form


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FAQs, Definitions etc.
Documents and links
FAQs

IRDA (Insurance Regulatory and
Development Authority)

www.irdaindia.org

Prudent Insurance Brokers Private
Limited


www.PrudentBrokers.com

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Thank You
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Contacts at Prudent Insurance Brokers Pvt Ltd
Contact First Level Contact

Ms. Chitra. M
Senior Manager Employee Benefits Practice
E-mail id: smartplayin@prudentbrokers.com
Mob Number: +91 96111 32772



Escalation : 2nd Level

Mr.Anil.K
Vice President
E-mail id: smartplayin@prudentbrokers.com
Mob Number: +91 90081 00753