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INSURANCE MANUAL
FOR MEDICLAIM & PERSONAL ACCIDENT
INSURANCE SERVICES

EMPLOYEE BENEFIT PROGRAM

The Elegant Marine Service Private Limited Officers Benefit Program is designed in
partnership with Shriissthy Insurance and Financial Services. This program has been created to
better serve, and most importantly meet the needs of the Seafarers and their families.
The Employee Benefit Program comprises two Insurance coverage schemes for the Seafarers
and their families:
Group Floater Mediclaim Policy: The Mediclaim Cover can be availed by any one or any
number of members in the family that are covered in the policy. The Seafarers family is
covered for a fixed Sum Insured and anyone in the family can avail the advantage till the limit
(Sum Insured) is exhausted.
Group Personal Accident Policy: The Group Personal Accident policy offers compensation in
case of death to the Insured persons nominee, directly and solely as a result of an accident.
POLICY DETAILS
PARTICULARS

MEDICLAIM POLICY

PERSONAL ACCIDENT POLICY

Policy Name

Group Floater Mediclaim Policy

(GFMP)

Group Personal Accident Policy

(GPA)

Insurer

The New India Assurance Company

Ltd.

The New India Assurance Company

Ltd.

Sum Insured

INR. 2 Lakhs

INR. 20 Lakhs

Policy Number

130400 / 34 / 15 / 04 / 00000009

130400 / 42 / 15 / 01 / 00000073

Policy Period

01/10/2015 TO 30/09/2016

01/10/2015 TO 30/09/2016

Third Party
Administrator

Health India TPA Services Pvt. Ltd

N.A

THE KEY COMPONENTS OF THE GROUP FLOATER MEDICLAIM POLICY

Sum Insured of INR. 2,00,000 per individual and their dependents

Family floater for self, spouse and two children (Up to 21 Age Childrens)
Availability of the Third Party Administrator (TPA) facility for Claim settlement
Availability of Cashless and Reimbursement facilities
Cashless
Reimbursement
Pre- Hospitalization (30 days before Hospitalization): Doctor consultation fees, medical
reports and related medication issued 30 days prior to hospitalization (admission ) can
be Reimbursed
Post- Hospitalization (60 days after Hospitalization): Doctor Consultation fees, medical
reports and related medication issued 60 days after hospitalization (Discharge) can be
reimbursed.
Room Rent & Nursing Charges: The hospital Room Rent + Nursing Charge (RR +NC)
should not exceed 1% of your Sum Insured amount per day (i.e: Rs.2000 per day)
Additional Room Rent + Nursing Charges over Rs.2000 per day is payable by the
Claimant (Insured).
If you opt for a higher Room Rent + Nursing Charge, the other charges are
deducted proportionate to the RR+NC. This means that higher the RR+NC, higher
are the Surgery Consultation, OT Charges, Investigation Charges, Bed Charges.
Does not include Medicine Charges, Implant Charges.

WHAT IS COVERED?

First year Standard Exclusions

Pre-existing diseases
30 days waiting period (Therefore, claims arising from the first day of the inception of
the policy will get paid)
Eye and Teeth treatment resulting ONLY out of an Accident
Cataract Surgery: The amount payable for Cataract Surgery is limited to actual or a
maximum of Rs.24, 000, whichever is less either for Cashless or Reimbursement.

WHAT IS NOT COVERED?

Maternity Benefit

MEDICLAIM MANAGEMENT

TYPES OF CLAIMS
CASHLESS : service wherein the insured is not required to pay any money at the time of
admission or discharge from the hospital. This benefit is provided only in the hospitals
empanelled by the Third Party Administrator. Non-Medical expenses and Service Tax is payable
by the Insured, for which a Security Deposit is required by the Hospitals

TPA Network of Hospitals: Cashless can be availed only at the TPA, Health Indias
network hospitals. List is available on TPA website : www.healthcare-india.com
NOTE: Shriissthy Insurance and Financial Services is the COORDINATOR between the
Claimant and the TPA, and is NOT the TPA.
Cashless Denial: Denial of Cashless Service should NOT be construed as a denial of
treatment. In such a case the insured is advised to file the claim for reimbursement and
the TPA will settle the claim subject to the policys terms and conditions.

REIMBURSEMENT : When you do not go to one of the hospitals thats not empanelled with
the TPA, you would usually end up paying hospital bills yourself. But you can produce the bills
later and get them reimbursed.
CLAIM INTIMATION REQUIREMENTS
Shriissthy must be intimated at the earliest for both planned and emergency hospitalizations.
For Claim Intimation, 1st Intimation for Reimbursement or Cashless should be sent to
Shriissthy Insurance and Financial Services via email at: shefale@shriissthy.com;
shefale1757@yahoo.com; salim.shaikh@shriissthy.com; salimsk09@gmail.com with the following
information:

Companys Name
Crew Name
Company Crew ID and Rank
Name of the Patient, Age and Relationship
Nature or Illness/Accident
Hospital Details, Doctors Name, Hospital Admission and Discharge date
Personal Contact information (Address and Number)
Commencement date of symptom of the disease in case of an illness
Accident Case : Date and time, location of accident, FIR Report, and Self Declaration

REIMBURSEMENT CLAIM PROCEDURE: IMPORTANT NOTES

Claim Intimation should be made within 7 working days after discharge from hospital.

On claim intimation, Shriissthy will e-mail a list of Original Reimbursement

Documents to be completed and couriered to us within 25 days of discharge
from the hospital for claim settlement

Claim payments are now being made through NEFT/ RTGS, therefore a copy of a
cancelled cheque of your resident bank account (not NRE) is compulsory along with the
submission of the claim documents. Send Shriissthy an acknowledgement on receipt of
payment
Please retain a copy of all claim related documents submitted in case queries are raised
regarding the claim or as a back-up in case documents are misplaced etc.
Claim settlement takes a minimum of 1 month to process, however if deficiencies in
document submissions arise then the settlement can be delayed
Doctors Fees paid in cash should not exceed the limit of Rs. 10000. As per the rules of
the insurance company cash paid above Rs.10000 is not payable.
Pre-hospitalization: All the Original Claim documents, bills and reports of Prehospitalization must be couriered to Shriissthy within 25 days of discharge for
reimbursement
Post hospitalization: All bills accrued 60 days Post-hospitalization must be couriered to
Shriissthy within 90 days of discharge for reimbursement

CASHLESS CLAIM PROCEDURE: IMPORTANT NOTES

Claim Intimation: Intimate Shriissthy and patient/relative must proceed to the TPA desk
at the respective hospital with ID Proof & e-card (access to download e-card is provided)
Pre-authorization Procedure:

Collect pre-authorization form from the TPA desk and proceed to the treating
doctor to be filled and then return to the TPA desk
The TPA desk will fax the form and relevant documents to Health India TPA
(Ensure that the TPA desk faxes/e-mails the documents and patient/relative
must inform Shriissthy via phone or e-mail. Shriissthy will help facilitate a
smoother cashless authorization)
Health Indias panel of Doctors will scrutinize the documents to authorize the
cashless (In case of any document deficiencies Health India will inform the
Hospitals TPA Desk. It is important that the patient /relative constantly monitor
the developments between the TPA and Hospital)

On Cashless authorization the TPA will sanction an initial amount to the hospital before
admission (Please note it will not be the full amount)
Security Deposit: The patient will be charged a security deposit by the hospital. This
deposit is maintained in the event that cashless is denied or non-payable items which
are not payable by the insurance company will be deducted.
Discharge:
Take the discharge documents to the hospitals TPA Desk, who will send it across
to the TPA. Again, ensure that the Hospitals TPA desk sends the documents to
the TPA and inform the same to Shriissthy via phone or e-mail
On receipt of the documents the TPA will take few hours to verify the
documents. In case of any document deficiencies Health India will inform the
Hospitals TPA Desk. It is important that the patient /relative constantly monitors
the developments between the TPA and Hospital
After clearance of deficiencies (if any) the Final bill amount will be sanctioned to
the hospital after deductions of non-payable items.
Security Deposit: The deposit will not be reimbursed until the hospital receives the
claim settlement cheque from the Insurance Company (This procedure may take a
months time)

NOTE: THROUGH EVERY STEP OF CASHLESS PROCEDURE INTIMATE SHRIISSTHY VIA

PHONE / EMAIL TO FACILITATE SMOOTH COORDINATION WITH THE TPA.

MANDATORY DOCUMENTS
While submitting the claims (Reimbursement and Cashless) for the below listed Ailments, the
corresponding mandatory documents must be submitted along with other essential claim
relevant documents:

Cataract Surgery: A' Scan report & IOL Sticker (If lens is above Rs. 10,000 then a
purchase invoice is required)
Fractures: X-ray reports with plates (Including Hip & Knee Replacement)
Accidents: MLC / FIR / Self-declaration from patient
Angiography: Final Report with the Diagram
Implants in Bones/Hernia Mesh: If it is above Rs. 10,000 then a purchase invoice is
required
Ear Surgery: Audiometry report
Pneumonia: X-ray Chest report
Pre-existing Disease: Detailed History with duration of Ailments like Diabetes,
Hypertension, Asthma, Fits/Epilepsy, Heart Diseases, Kidney Stones, Arthritis, TB
Paralysis: CT scan / MRI Report

GROUP PERSONAL ACCIDENT POLICY: CLAIM SETTLEMENT PROCEDURE

Claim Intimation: Should be sent to Shriissthy within 48 hours after the officers death,
so that Shriissthy can guide the deceased's family for the best steps forward. A formal
letter should also be sent from the company's end providing the relevant information
The same intimation is sent to the claim hub of the Insurance company
Requirements:
Post Mortem Report is mandatory
Death Certificate is mandatory
F.I.R if applicable
Latest salary slip (sent by the company)
Claim form duly filled by the deceaseds family member
Declaration by a family member stating the case of death
If the claim is payable, then the claim amount for Personal Accident will be raised in the
name of the company, and not the deceaseds family directly

ONLINE: E-CARD AND CLAIM STATUS, FAMILY MEDICLAIM

The insured can access the E-Card or Claim Status with the following:

Log on to https://www.healthindiatpa.com/DownloadEcard.aspx
Select Corporate
Enter EMP ID
Click on Print E-Card
If the details on the e- card are incorrect, then e-mail Shriissthy with the correct details.
Any additions such as marriage and child birth must be informed, so that new family
members can be included in the insurance coverage

TPAS NETWORK HOSPITALS

The TPA Health Indias hospitals in its network can be accessed with the following:

Log on to www.healthindiatpa.com
Click on Hospital on the Right hand side of the webpage
Select State, City, Location

SHRIISSTHY INSURANCE AND FINANCIAL SERVICES CONTACT INFORMATION

Primacy contact: Mrs. Shefale Patra - Managing Director

E-mail: patrashefale@gmail.com, shefale1757@yahoo.com
Phone: +91 9892009036 / +91 9820103003
Secondary Contact : Mr. Salim Shaikh Operations Manager
E-mail: salimsk09@gmail.com

Phone: +91 9987206258 / Landline : +91-22-26334291

Working Hours : ( Mon - Fri ) ( 10am 6pm ) Sat (10am 1pm )
Address : 207/C, Vriddhi, Kalyan Complex, Yari Road, Versova, Andheri West,
Mumbai 400 061