GROUP HOSPITALISATION & MEDICAL BENEFITS INSURANCE SCHEME

COVERAGE:

Policy will cover self, spouse, dependent children & dependent parents. Please note that mother-in-
law or Father-in-law are not covered. However, Female employees have the option to cover
mother-in-law or father in law, in case they are dependent on her.

Policy covers all employees up to grade P-9 for Hospitalisation and Domiciliary benefits.
- Directors are covered for Hospitalization only.
- Employees covered under ESI have also been covered under the Medical Group Insurance
Policy but they should preferably use existing ESI facilities.
- Newborn children will be covered after attaining the age of 7 weeks. Expense up to the age of 6
weeks will be covered under the Maternity expenses.
- Policy does not cover treatment taken under systems other than Allopathic, Ayurvedic &
Homeopathic. Treatment must be taken from qualified Doctors. Treatment taken under other
systems such as Kerela massage is not covered under the policy.
- Policy does not cover congenital diseases (Disease by birth).

HOSPITALISATION:
-
- Maximum Limit for Hospitalization will be equal to 20 months of basic salary for the policy period.
- First 20% of Hospitalization expenses will have to be borne by the employees for claims related
to Self, Spouse and Dependent Children.
- First 25% of Hospitalization expenses will have to be borne by the employees for claims related
to Dependent Parents.
- Maternity benefit under Hospitalization is restricted to Rs.15000/- for Normal and Rs.30,000/- for
Caesarean.
- For Hospitalization claim, minimum stay at hospital is 24 hrs. NIC has the right to reject the
claim, if the stay at hospital is less than 24 hrs.
- Maximum limit of room rent charges is 1% of Basic Insurance for Hospitalisation and 2% of
Basic insurance in case of ICU.(Basic Insurance is the hospitalisation limit i.e. Basic salary x 20).
However, the taxes are extra.
- Pre/Post Hospitalisation expenses covered under the policy are 15 days in case of Pre
hospitalisation and 30 days in case of Post Hospitalisation.
- Pacemaker, Artificial Limbs, etc will be covered by the scheme once in a life time upto 75% of
the cost and only if it is not a pre-existing condition at the time of joining the company.
-
DOMICILIARY
-
- The maximum limit for reimbursement for domiciliary treatment will be upto 80% of one month
basic salary. Reimbursement of expenses for Dental treatment is Rs.3000/- per Policy period per
member as part of Domiciliary limits.
- Reimbursement of expenses for Specs excluding Goggles is Rs.2000/- per member per policy
period as part of Domiciliary limits. Vaccination expenses is restricted to Rs.1000/- per month
within Domiciliary limits.

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 - All abortion cases, if otherwise, are payable as part of the domiciliary limits.
- Medicine Bills without name & Doctor Fee bills not accompanied by prescription will not be paid.
- Health check-up expenses will be reimbursed out of the domiciliary limits for employees having
attained the age of 45 years and above, once in policy period.
- Bills without prescription will be accepted by National Insurance Company up to Rs.250/- per
month.

GUIDELINES FOR FILING CLAIM:

- Employee should claim domiciliary bills on monthly basis on a single claim form. Claim for
Hospitalisation and Domiciliary must be claimed on separate claim forms.
- Medical Bills are to be submitted on Monthly basis.
- All claims should be duly signed by departmental head.
- Claims received after 90 days of expenses being incurred will not be entertained for
reimbursement from NIC.
- Attach Doctor’s latest prescription along with the bills for purchase of Medicines and
Consultation fee receipt. Bills without latest prescriptions will be treated as without prescription
and NIC will pass the claims accordingly.
- Medicine quantity purchased & claimed must be in accordance to the latest prescription of the
Doctor.
- Name of the Patient as well as name of the Doctor prescribing the medicine must be clearly
mentioned on the bills.
- Test report copies & prescription/recommendation of the Doctor must be attached along with the
bills where expenses are incurred on medical tests.
- Hospital claims must be accompanied by Discharge Summary of Hospital where treatment is
taken, along with copies of the test reports. In case of Death in the Hospital, Death Certificate
copy must be enclosed.
- Hospitalization claims where stay in hospital is less than 24 hrs will be considered under
domiciliary limits.
- Room rent under hospitalization is 1% of entitlement and minimum of Rs.2000/- or actual
whichever is lower

PROCESS FOLLOWED AT HO:

- Claims received at HO through respective RAOs up to last day of the month are given to NIC for
processing and finalising the amount payable to each employee. List is prepared by them and
submitted to HO-Accounts for payment through Payroll.
- Rejected claims, if any, are returned to RAO’s for returning to employees.

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