Employee Benefit Manual

Client

GREENPLY INDUSTRY LTD

Remark

Benefit Manual

Document No

TTIBI/EB/01

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Disclaimer:
This benefit summary will serve as a guide to the benefits provided by United India Insurance Co Ltd. The
information contained here is only a summary of the policy documents which are kept by the company. If there is
a conflict in interpretation, terms & conditions of the policy will prevail.

Copyright 2005. All rights reserved. No part of this publication may be reproduced, stored in the retrieval
system, or be transmitted in any form or by any means, electronic or mechanical, photocopying, recording
or otherwise, without the prior written permission of the publishers.

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Main Menu
A. Program Details

B. FAQs, Definitions & Links

Exit

1. Group Medical

1.1 Benefit Details

1.2 Enrollment in the program
1.3 Cashless Hospitalization
1.4 Non - Cashless Hospitalization
1.5 Contacts for GMC program
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1.1 Benefit Details

Policy Parameter
Insurer

United India Insurance Co. Ltd.

Policy Start Date

13th December 2014

Policy End Date

12th December 2015

Coverage Type

Family Floater

Dependent Coverage

Employee+ Spouse + Children + Parents (1+ 5)

Sum Insured

Various Sum Insured based on grade

Benefits covered

Benefits covered

Standard Hospitalization

Yes

Disease wise capping

Pre existing diseases

Yes

Waiver on 1st year exclusion

Waived

Co payment will not be applicable wherever disease wise capping is

applicable

Waiver on 1st 30 days excl.

Waived

Maternity benefits

Yes

Pre & Post Natal Expenses

Yes

Baby cover day 1

Yes

Ambulance Cost

Yes

Yes ( As per annexure )

Day care Surgeries

Yes

Pre & post Hospitalization

Yes

Co-Payment

10% for Self, spouse & children

15% for Parents

Room Rent

1.5% for Normal & 2.5 % for ICU

General Exclusions

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Applicable Members

Employee

Yes

Spouse

Yes

Children

Yes (Dependent children , Max 2)

Parents

Yes ( Either set of parents)

Mid Term enrollment of Existing Dependents

Disallowed

New Joinees (New employees + Dependents)

Allowed ( within 21 days of date of joining)

Acquisition of new dependents (Spouse/Children)

Allowed ( within 30 days of date of marriage or birth)

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Policy Period
Existing Employees + Dependents
Commencement Date

13th December 2014

Termination Date

12th December 2015

New Joinees + Dependents

Commencement Date
Enroll Online within 21 Days of date of Joining

Date of joining

Termination Date

12th December 2015

New Dependent (Marriage/Birth)

Commencement Date
Enroll Online within 30 Days of the event

Date of such event

Termination Date

12th December 2015

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Coverage Levels
Individual Sum Insured

Limits (INR)

Employee

Family Floater
Dependents

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Standard Hospitalization
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

A) The expenses shall be reimbursed provided they are incurred in India and within the policy period. Expenses will be
reimbursed to the covered member depending on the level of cover that he/she is entitled to.

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B) Expenses on Hospitalisation for minimum period of 24 hours are admissible. However this time limit will not apply
for specific treatments i.e. Dialysis, Chemotherapy, Radiotherapy, Eye surgery, Dental Surgery, Lithotripsy (kidney
stone removal), Tonsillectomy, D & C taken in the Hospital/Nursing home and the insured is discharged on the same
day of the treatment will be considered to be taken under Hospitalisation Benefit.

Maternity Benefits
Reimbursement of expenses related to maternity as per

The maximum benefit allowable will be INR 25,000 for normal delivery and INR 40,000 for C-section within the Sum
Insured limit, max up to 2 children. There are special conditions applicable to the Maternity Expenses Benefits as below:

These benefits are admissible only if the expenses are incurred in Hospital/Nursing Home as in-patients in India.

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
already have 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 post natal Covered over & above maternity with restriction of INR 2,500

Benefit Details
Maximum Benefit allowable

INR 25,000 for Normal & INR 40,000 for C-Section

Restriction on no of children

Maximum of 2 children

9 Months waiting period

Waived off

Pre-Post Natal Expenses

Covered

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Applicable

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Customized Benefits
Pre existing diseases
Definition

Any Pre-Existing ailments 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 Persons first Health Insurance policy with the Insurer

Covered

First 30 day waiting period

Definition

Any Illness diagnosed or diagnosable within 30 days of the effective date of the
Policy Period if this is the first Health Policy taken by the Policyholder with the
Insurer. If the Policyholder renews the Health Policy with the Insurer and
increases the Limit of Indemnity, then this exclusion shall apply in relation to the
amount by which the Limit of Indemnity has been increased

Waived Off

Waived Off

First Year Waiting period

Definition

During the first year of the operation of the policy the expenses on treatment of
diseases such as Cataract, Benign Prostatic Hypertrophy, Hysterectomy for
Menorrhagia or Fibromyoma, Hernia, Hydrocele, Congenital Internal Diseases,
Fistula in anus, Piles, Sinusitis and related disorders are not payable. If these
diseases are pre- existing at the time of proposal they will not be covered even
during subsequent period or renewal too

Baby Cover Day 1

Definition

In consideration of additional premium, this policy is extended to cover the new

born child of an employee covered under the Policy from the time of birth till 90
days. Not withstanding this extension, the Insured shall be required to cover the
newly born children after 90 days as additional member as mentioned
elsewhere under this Policy.

Covered

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Ambulance Cost

Applicable

Ambulance Services
Definition

The Insurer will pay for Emergency ambulance and other road transportation by a
licensed ambulance service to the nearest Hospital where Emergency Health
Services can be rendered. Coverage is only provided in the event of an
Emergency.

Amount restriction

Transportation cost maximum up to INR 2,000 per hospitalization

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Customized Benefits

Restricted

Dental / Vision Treatment

Definition

Any dental / vision treatment or surgery carried out for preventative or

therapeutic purpose is payable.

Applicable

Day Care
Definition

Day Care Procedure means the course of medical treatment or a surgical procedure
listed in the Schedule which is undertaken under general or local anesthesia in a
Hospital by a Doctor in not less than 2 hours and not more than 24 hours.

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Pre & Post Hospitalization expenses

Applicable

Pre-hospitalisation Expenses
Definition

If the Insured Person is diagnosed with an Illness which results in

his Hospitalisation and for which the Insurer accepts a claim under
a) above, the Insurer will reimburse the Insured Persons Prehospitalisation Expenses for up to 30 days prior to his
Hospitalisation as long as the 30 day period commences and ends
within the Policy Period.

Applicable

Yes

Duration

30 Days

Post-hospitalisation Expenses
Definition

If the Insurer accepts a claim under a) above and, immediately

following the Insured Persons discharge, he requires further
medical treatment directly related to the same condition for which
the Insured Person was Hospitalized, the Insurer will reimburse
the Insured Persons Post-hospitalisation Expenses

Applicable

Yes

Duration

60 Days

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General Exclusions
Injury or disease directly or indirectly caused by or arising from or attributable to War or War-like situations
Injury or disease caused directly or indirectly by nuclear weapons

Circumcision unless necessary for treatment of disease

Dental treatment of any kind unless requiring hospitalisation
Congenital external diseases or defects / anomalies
HIV and AIDS or treatment for Venereal diseases
Hospitalisation for convalescence, general debility, intentional self-injury, use of intoxicating drugs/ alcohol.
Naturopathy - including spas, therapeutic massages etc.
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)
Natural calamities / acts of God floods, storms, earthquakes etc.

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1.2 Enrollment in the program

You must enroll in order to obtain coverage for yourselves and your eligible dependants. HR /TPA will provide you
with a direct link to upload relevant enrolment data. Please notify HR each time you acquire a new dependent i.e.
when your family status changes because of marriage, birth or adoption of a child. You must also update the data
directly (with help of the link) within 30 days of the occurrence of such an event. If you fail to enroll within 30
days, the next enrolment can be done only at next renewal.

HR provides data to
insurer

Insurer passes
adequate
endorsement

Contact PHM
Healthcare Customer
service

Endorsement copy
forwarded by insurer
to client / TPA

Error in data
printed on
card

Employe
e verifies
details
on the E
- card

Cards printed by TPA

& dispatched to HR /
via help desk

Card Ok
Use card for cashless
hospitalization

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1.3 Cashless Hospitalization

Cashless hospitalization means the insurer may authorize upon a Policyholders request for direct settlement of
eligible services and its according charges between a Network Hospital and the insurer. In such cases the
insurer will directly settle all eligible amounts with the Network Hospital and the Insured Person may not have to
pay any deposits at the commencement of the treatment or bills after the end of treatment to the extent as these
services are covered under the Policy.
List of hospitals in the TPAs network eligible for cashless hospitalization
List at Website

Contact Call centre at

http://www.paramounttpa.com/providernetwork/providernetwork.
aspx

24 X 7 Customer Service Center

Tel : 91 22 56620808 /880

Planned Hospitalization

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Emergency Hospitalization

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Planned Hospitalization
Step 1
Pre-Authorization

Step 2
Admission, Treatment
& discharge

All non-emergency
hospitalisation instances
must be pre-authorized with
the insurer, as per the
procedure detailed below.
This is done to ensure that
the best healthcare possible,
is obtained, and the
patient/employee is not
inconvenienced when taking
admission into a Network
Hospital.

After your hospitalisation has

been pre-authorized, you
need to secure admission to
a hospital. Kindly present
your ID card at the Hospital
admission desk. The
employee is not required to
pay the hospitalisation bill in
case of a network hospital.
The bill will be sent directly to,
and settled by, insurer.

Process

Process

Patients seeking treatment

under cashless
hospitalization are eligible to
make claims under pre and
post hospitalization
expenses. For all such
expenses the bills and other
required documents needs to
submitted separately as part
of non cashless claims.

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Pre-Authorization

Member intimates insurer of

the planned hospitalization in
a specified pre-authorization
format 48 hours prior to
hospitalization

Pre Authorization Form

Pre Authorization
form

Claim
Registered
by insurer
on same
day

Yes

Insurer authorizes cashless

within 12 hours for planned
hospitalization to the hospital

No
Follow non cashless
process

Pre-Authorization Completed

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Admission, Treatment & Discharge

Member produces ID card at

the network hospital and gets
admitted

Member gets treated and

discharged after paying all
non entitled benefits like
refreshments, etc.

Release of payments to the

hospital

Hospital sends complete set of

claims documents for
processing to insurer

Claims Processing by Insurer

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Emergency Hospitalization
Step 1
Get Admitted

In cases of emergency, the

member should get admitted
in the nearest network
hospital by showing their ID
card.

Step 2
Pre-Authorization by
hospital

Relatives of admitted
member should inform the
insurer / HR within 24 hours
about the hospitalization &
seek pre authorization.
The preauthorization letter
would be directly given to the
hospital. In case of denial
member would be informed
directly

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Step 3
Treatment &
Discharge

After your hospitalisation has

been pre-authorized the
employee is not required to
pay the hospitalisation bill in
case of a network hospital.
The bill will be sent directly to,
and settled by, insurer.

Process

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Emergency Hospitalization Process

Member gets admitted in the
hospital in case of emergency
by showing his ID Card

Hospital sends complete set of

claims documents for
processing to the insurer

Member/Hospital applies for

pre-authorization to the
insurer within 24 hrs of
admission

Member gets treated and

discharged after paying all
non entitled benefits like
refreshments, etc.

Insurer verifies applicability of

the claim to be registered and
issue pre-authorization

Preauthorizatio
n given by
the insurer

No
Claims Processing by insurer

Release of payments to the

hospital

Non cashless
Hospitalization
Process

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1.4 Non-Cashless Hospitalization

Admission procedure
In case you choose a non-network hospital you will have to liaise directly for admission.
However you are advised to follow the pre authorization procedure to ensure eligibility for reimbursement of
hospitalisation expenses from the insurer.
Discharge procedure
In case of non network hospital, you will be required to clear the bill and submit a claim to insurer for
reimbursement. Please ensure that you collect all necessary documents such as discharge summary,
investigation reports etc. for submitting your claim.
Submission of hospitalisation claim
1. After the hospitalisation is complete and the patient has been discharged from the hospital, you must submit
the final claim within 21 days from the date of discharge from the hospital. (Applicable in case of Non Network
hospital)

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Claims Process

Claim Docs

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Claims Process
Member intimates insurer
before or as soon as
hospitalization occurs

Claim registered by
insurer after receipt of
claim intimation

Insured admitted as per

hospital norms. All
payments made by
member

Insured sends relevant

documents to insurer
office within 21 days of
discharge

Is claim
liable
(coverage/
applicabilit
y)

Insurer performs medical

scrutiny of the documents

Yes

Insured will create the

summary of Bills (2
copies) and attach it with
the bills
The envelope should
contain clearly the
Employee ID & Employee
e-mail

No

No

Yes

Is
document
received
within 21
days from
discharge

Claim Rejected

Insurer checks document

sufficiency

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Is
documenta
tion
complete
as
required

Yes

No

Claims processing done

within 10 days

Send mail about deficiency

and document requirement

Payment to be made to HR.

The discharge voucher and
copy of payment receipt to be
sent to HR.

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Claims Document List

Signed Claim form
Main Hospital bills in original (with bill no; signed and stamped
by the hospital) with all charges itemized and the original
receipts

Standard Claims
Guide

Claims Guide

Discharge Card (original)

Attending doctors bills and receipts and certificate regarding
diagnosis (if separate from hospital bill)
Original reports or attested copies of Bills and Receipts for
Medicines, Investigations along with Doctors prescription in
Original and Laboratory

Claims Status
For claims status log on to:
www.paramounttpa.com

Follow-up advice or letter for line of treatment after discharge

from hospital, from Doctor.
Break up with details of Pharmacy items, Materials,
Investigations even though it is there in the main bill

Claims Documents to be sent to:

To Greenply Corporate Office at Kolkata

In case the hospital is not registered, please get a letter on

the Hospital letterhead mentioning the number of beds and
availability of doctors and nurses round the clock.

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In non- network hospitalisation, you may have to get the

hospital and doctors registration number in Hospital
letterhead and get the same signed and stamped by the
hospital, if required.

*Documents highlighted in red are mandatory. Claim will not be

processed without these

*Please retain photocopies of all documents submitted

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Contact Details
Group Mediclaim

Toyota Tsusho Insurance

Broker India Pvt Ltd

1st Level Contact

Escalation Point

Mr. Vinod Choudhary

Mobile: + 91 9650088020
Vinod.c@ttibi.co.in

Mr. T Srinivas
Mobile: + 91 97111 33621
t.srinivas@ttibi.co.in

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Contact Details
Group Mediclaim

Third Party Administrator

Paramount Health Group
Website:
www.paramounttpa.com
24 X 7 Customer Service
Center
Tel : 91 22 56620808 /880

1st Level Contact

Sharmila Bhattacharya,Account Manager
E-mail
sharmila.bhattacharya@paramounttpa.com
Office 033-2356 7005
M 09339960181
Fax 033 2356 7014

Escalation Point
Shamita Paul
Group Head Corporate relations
Email- shamita.paul@paramounttpa.com
Office 033- 2356 7005/08
M 093309 17499
Fax 033-2356 7037

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FAQs, Definitions etc.

Documents and links
Definitions
Microsoft
Word Document

IRDA (Insurance Regulatory and

Development Authority)

http://www.irdaindia.org

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