Employee Benefits Manu

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Disclaimer:

This manual is intended to be general summary of the benefits provided by Xavient & should be regarded as guide
only. While HR shall make every reasonable effort to ensure the accuracy and validity of the information provided
here in this document. HR accepts no liability or responsibility for any errors or omissions in the content or for any
loss or damages arising out of your reliance on information provided here. If there is a conflict in interpretation or
benefit applicability, then the terms & conditions of the policy will prevail.

Prepared by

Marsh India Insurance Brokers Private Ltd.

Unit-I, 7th Floor, Tower-A,
DLF Infinity Towers, DLF Cyber City,
Gurgaon 122002, India

Copyright 2010. 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 MARSH. Next

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Program Details

Provides insurance coverage to employees for expenses related to hospitalization

Group Medical due to illness, disease or injury

FAQs & Common Definitions Frequently Asked Questions & Common Definitions

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Medical Benefit

Coverage Details (Employee) Claims Document List

Cashless Process Benefits Extensions Definitions

Non-Cashless General Exclusions

Claims Process GMC Contact Details

Prudent Utilization of Benefit

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 Medical Benefit Coverage Details For Employee Policy

Policy Parameter
Insurer Star Health and Allied Insurance Company Ltd.
Star Health and Allied Insurance Company Ltd.
TPA
(In house TPA)
Policy Start Date 20-Jan-2017
Policy End Date 19-Jan-2018
Coverage Type Family Floater
Dependent Coverage Employee + 3 Dependents (including Spouse , Children & Parents)

Sum Insured INR 2Lac

Benefits / Extensions Benefits / Extensions Coverage

Coverage
Domiciliary Hospitalization No
Standard
Yes Day Care Yes
Hospitalization
TPA services Yes Pre-Post Hospitalization Exp. Yes

Pre existing diseases Yes Room Rent Capping Yes

Waiver on 1st year Emergency

Yes
exclusion ambulance charges
up-to a sum of
Waiver on 1st 30
Yes Rs.750/- per
days excl. Ambulance charges
hospitalization and
Maternity benefits Yes overall limit of
Rs.1,500/- per 6policy
Baby cover day 1 Yes
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Medical Benefit Dependant Coverage

Maximum no of Members insured in a family 1+3

Employee Yes
Spouse Yes

Children Yes
Parents Yes
Siblings No

Others No
Mid Term enrollment of existing Dependents Disallowed

Mid Term enrollment of New Joinees (New employees +their

Dependents) Allowed

Mid term enrollment of new dependents (Spouse/Children) Allowed

*No Individual should be covered as dependent of more than one employee

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Medical Benefit Policy Period

Existing Employees + Dependents

20-Jan-2017
Commencement Date

19-Jan-2018
Termination Date

New Joinees + Dependents on intimation through HR

Commencement Date Date of joining

19-Jan-2018
Termination Date

New Dependents (due to Marriage / Birth) on intimation through HR

Commencement Date Date of such event

19-Jan-2018
Termination Date

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Medical Benefit Coverage Levels

Sum Insured Family Floater

Employee, Spouse, dependent children ,Dependent parents INR 2Lac

Co-payment Applicable

20 % copay when the employee exhaust 1.5 lacs

Employee, Spouse, dependent children's, dependent Parents from Sum Insured, copay will be applicable on
amount exceeding 1.5 lacs Capping

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 Medical Benefit Standard Coverage
Covers expenses related to
Room and boarding

Normal/ICU Restricted to For Normal-Rs.3500 . For ICU- Rs.5000.

Doctors/Medical Practitioner fees

Intensive Care Unit

Nursing expenses

Surgical fees, operating theatre, anesthesia and oxygen and their administration

Drugs and medicines consumed on the premises

Hospital miscellaneous services (such as laboratory, x-ray, diagnostic tests)

Costs of prosthetic devices if implanted during a surgical procedure

Radiotherapy and chemotherapy

A) The expenses are payable 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.
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, 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.

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Pre & Post Hospitalization Expenses
Pre-hospitalisation Expenses
Definition
If the Insured member is diagnosed with an Illness which results in his / her
Hospitalization and for which the Insurer accepts a claim, the Insurer will also
reimburse the Insured Members Pre-hospitalisation Expenses for up to 30 days prior
to his / her Hospitalization.

Covered Yes

Duration 30 Days

Post-hospitalisation Expenses
If the Insurer accepts a claim under Hospitalization and immediately following the
Insured Members discharge, further medical treatment directly related to the same
Definition condition for which the Insured Member was Hospitalized is required, the Insurer will
reimburse the Insured members Post-hospitalisation Expenses for up to 60 day
period.

Covered Yes

Duration 60 Days

*Any One Illness: A claim is considered as a single illness if it has a continuous period of illness or results in a relapse within 45 days of the
earlier treatment.

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Maternity Benefits

Benefit Details
For Normal Delivery & C Section / Cesarean Normal INR 25000
Delivery Caesarean- INR 35000

Restriction on no of children Maximum of 2 Children

9 Months waiting period Waived of

These benefits are admissible in case of hospitalisation in India.

Covers first two children only. Those 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.

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Medical Benefit Cashless Process
Cashless means the Administrator may authorize upon a Policyholders request for direct settlement of eligible services and its
according charges between a Network Hospital and the Administrator. In such case the Administrator 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.

Hospitals in the network (please refer to the website for the updated list)

For Updated List visit to: Toll Free nos.-

http://www.starhealth.in/network-hospitals Landline:(044)- 2830 2700 / 4230 670
Mobile:1800-425-2255 / 1800-102-4477
General Queries - Primary contact:
Manindra Singh
Landline no.-9953275200
Mobile No.-9873353081
Email id: Manindra.Singh@starhealth.in

Emergency Hospitalization Planned Hospitalization

Note : 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 the claims reimbursement.

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 Emergency Hospitalization & Process
Step 1
Get Admitted
In cases of emergency, the member
should get admitted in the nearest P
network hospital by showing their ID R
card. Member should register at the O
Star Health call center immediately
C Member gets admitted in No Non cashless
Pre-
E the hospital in case of
emergency by showing his
authorization Hospitalization
S given by TPA
Step 2 S ID Card Process
Pre-Authorization by hospital
Relatives of admitted member Yes
should inform the call centre within
24 hours about the hospitalization &
Seek pre authorization. The Member gets treated and
preauthorization letter would be Member/Hospital applies
discharged after paying all
directly given to the hospital. In for pre-authorization to TPA
non medical expenses like
case of denial member would be within 24 hrs of admission
refreshments, etc.
informed directly

Step 3 TPA verifies applicability of Hospital sends complete set

Treatment & Discharge the claim to be registered of claims documents for
and issue pre-authorization processing to TPA
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 TPA

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 Planned Hospitalization
Step 1 Member intimates Star Health Claim TPA authorizes cashless as
Pre-Authorization insurer of the planned hospitalization Registered by Yes per SLA for planned
in a specified pre-authorization TPA on same hospitalization to the
format at-least 48 hours in advance day hospital
All non-emergency
hospitalisation instances must No
Pre Authorization Form
be pre-authorized with Star
health, as per the procedure As attached
detailed below. This is done to
Follow non cashless Pre-Authorization
ensure that the best healthcare
process Completed
possible, is obtained, and the
patient/employee is not
inconvenienced when taking
admission into a Network
Hospital. Kindly get the claim
no.by dialing on toll free no.
Step 2 Member produces ID card Member gets treated and
Admission, Treatment & Hospital sends complete
at the network hospital discharged after paying
discharge set of claims documents
and gets admitted all non entitled benefits
for processing to TPA
like refreshments, etc.
After your hospitalisation has been
pre-authorized, you need to secure
admission to a hospital. A letter of
credit will be issued by Star Health
to the hospital. Kindly present your Claims Processing &
ID card at the Hospital admission Settlement by TPA &
desk. The employee is not required Insurer
to pay the hospitalisation bill in case
of a network hospital. The bill will be
sent directly to, and settled by TPA

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Non-Cashless
Admission procedure
In case you choose a non-network hospital you will have to liaise directly with the hospital 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 bills and submit the claim to TPA for
reimbursement from the insurer. Please ensure that you collect all necessary documents such as discharge
summary, investigation reports etc. for submitting your claim. Please find the discharge summary format
attached for your reference.
Microsoft Word
Document

Submission of hospitalisation claim

You must submit the final claim with all relevant documents within 30 days from the date of discharge from
the hospital.

Claim Docs

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 Non-Cashless Claims Process
Member intimates Star Health Insured admitted as per hospital Insured Submits relevant
Claim registered by Star Health
before or as soon as norms. All payments made by documents the Help desk A
after receipt of claim intimation
hospitalization occurs. member within 30 days of discharge

Is document
Star Health insurer performs received
Is claim
medical scrutiny of the within 30 days
payable?
Yes documents from Insured will create the
Yes discharge summary of Bills (2 copies)
No and attach it with the orignal
No
bills
The envelope should
Claim Rejected contain clearly the
Employee ID & Employee e-
mail

Is
Payment to be Employee at the
documentatio
Star Health insurer checks Claims processing done as per help desk. The discharge
n complete
document sufficiency Yes SLA voucher and copy of payment
as
receipt to be sent to HR.
required
No

Receives mail about deficiency

A
and document requirement

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Claims Document List

Duly completed claim form (Intimation to toll-

free number is mandatory before the form is
filled).
Original bills, receipts and discharge certificate/
card from the hospital.
Original bills from chemists supported by proper
prescription.
Receipt and investigation test reports from a
pathologist supported by the note from attending
medical practitioner/ surgeon prescribing the
test.
Nature of operation performed and surgeon's bill
and receipt.
Self-declaration/MLC/FIR in case of accident
cases.
Treating doctor's certificate.
If less than 15, BED to provide hospital
registration certificate.

*Please retain photocopies of all documents submitted

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Benefit Extensions Definitions
For
Benefits Definition
Marsh
Covered Any Pre-Existing ailments such as diabetes, hypertension, etc or related ailments for which care, treatment or
Pre existing
diseases
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

Not Any Illness diagnosed or diagnosable within 30 days of the effective date of the Policy Period if this is the first
First 30 day waiting Applicable Health Policy taken by the Policyholder with the Insurer. If the Policyholder renews the Health Policy with the
period
X 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

Not During the first year of the operation of the policy the expenses on treatment of diseases such as Cataract, Benign
First Year Waiting Applicable Prostatic Hypertrophy, Hysterectomy for Menorrhagia or Fibromyoma, Hernia, Hydrocele, Congenital Internal
period
X 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

Covered In consideration of additional premium, this policy is extended to cover the new born child of an employee covered
Baby Cover Day 1
under the Policy from the time of birth till 30 days. Not withstanding this extension, the Insured shall be required to
cover the newly born children after 30 days as additional member as mentioned elsewhere under this Policy.

Covered Day Care Procedure means the course of medical treatment or a surgical procedure listed in the Schedule which is
Day Care undertaken under general or local anesthesia in a Hospital by a Doctor in not less than 2 hours and not more than
24 hours. Generally 8 aliments (i.e. Dialysis, Chemotherapy, Radiotherapy, Eye surgery, Dental Surgery, Lithotripsy
(kidney stone removal), Tonsillectomy, D & C)

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Benefit Extensions Definitions
Benefits For Marsh Definition

DOMICILIARY HOSPITALISATION BENEFIT means Medical treatment for a period exceeding three days for
such illness/disease/injury which in the normal course would require care and treatment at a hospital/ nursing
home but actually taken whilst confined at home in India under any of the following circumstances, namely:
The condition of the patient is such that he/she cannot be removed to the hospital/nursing home
or
The patient cannot be removed to the hospital/nursing home for lack of accommodation therein

Benefits not covered

X Expenses incurred for pre and post hospital treatment, and

Expenses incurred for the treatment for any of the following diseases:
Domiciliary Asthma
Not Applicable
Hospitalization Bronchitis
Chronic Nephritis and Nephritic Syndrome
Diarrhea and all types of dysentries including Gastroenteritis
Diabetes Mellitus and Insipidus
Epilepsy
Hypertension
Influenza, Cough, and Cold
All Psychiatric or Psychosomatic disorders
Pyrexia of unknown origin for less than 10 days
Tonsillitis and upper respiratory tract infection including Laryngitis and Pharyngitis
Arthritis, Gout and Rheumatism

Note: When treatment such as Dialysis, Chemotherapy, Radiotherapy is taken in the Hospital/Nursing Home/Clinic and the insured is discharged the same day the
treatment will be considered to be taken under Hospitalisation Benefit section and thus covered.

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Medical Benefit General Exclusions
Injury or disease directly or indirectly caused by or arising from or attributable to War or War-like situations
Circumcision unless necessary for treatment of disease
Congenital external diseases or defects/anomalies
HIV and AIDS
Hospitalisation for convalescence, general debility, intentional self-injury, use of intoxicating drugs/ alcohol.
Venereal diseases
Injury or disease caused directly or indirectly by nuclear weapons
Naturopathy
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)
OPD Claims
Claims (of high value) submitted without prescriptions/diagnosis
Health foods
Costs incurred as a part of membership/subscription to a clinic or health centre
Naturopathy
Cost of appliances, spectacles, contact lenses, hearing aids
Non-medical expenses like Hospital surcharge, telephone bills, cafeteria bills

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 Prudent Utilization of Benefit

Health Insurance is a benefit for the employee and their dependents. One has to utilize the benefit with utmost caution and
prudence.
The ever increasing cost for the benefits require a proactive involvement from all of us.

The following steps are recommended, ensuring the benefits is prudently utilized by the employee and dependents covered 12

Please ensure to crosscheck the final bill sent to the TPA for the following:

You are Billed only for the services utilized for e.g. category of room, diagnostics undergone ,
medicines consumed

Total of the bill

In case of any planned hospitalization, approach the hospital in advance(48 hrs) and request pre
authorization- this enables TPA to further negotiate the rates

To approach hospitals with caution most expensive is not necessarily the best.

To cross check the tariff with the Bench Mark Rates provided- the benchmark rates would give an idea the
general spend for the treatment or procedure.

Try to negotiate

Ask WHY & WHAT is billed to you ( as a consumer , we have the right to know)

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 STAR HEALTH INSURER (Contact Details)

Contact Designati
Details Contact Person Dept. on Landline No. Mobile No. Email ID
First point of Narendra Singh / Endorsement/Policy 9717380208 / Manindra.Singh@starhealth.
SM 9873353081
contact Manindra Singh Query/Claims 9953275200 in
Endorsement/Policy Ass. arunkumar.mishra@starhealt
Level 1 Arun Mishra 011-69000623 9990268869
Query/Claims Manager h.in
Endorsement/Policy Brach
Level 2 Kapil Dua 011-69000621 9873436059 kapil.dua@starhealth.in
Query/Claims Head
gmcclaims.delhi@starhealth.
Claims Sandeep Ujlayan Cashlesh claim 9717113079
in
(044)- 2830 1800-425-
Customer
Toll Free customer care claims and other enquiry 2700 / 4230 2255 / 1800- support@starhealth.in
Care
6700 102-4477

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Medical Benefit Contact Details
Contact Details-Marsh India Insurance Brokers
Primary Contact
Marsh India Name-Shweta Chahal
Insurance
Brokers Contact no.+91 8376807015
Email id-
shweta.chahal@marsh.com
Second Point of Contact Third Point of Contact(For any
Escalations)
Name-Rohan Budhiraja Name-Dheeraj Sharma
Contact no.9643802863 Contact no.-9711976231
Email id- Email
Rohan.Budhiraja@marsh.co id:dheeraj.sharma@marsh.com
m
Name-Mohit Gulati
Contact no. 9643802957
Email id-
mohit.gulati@marsh.com
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FAQs & Common Definitions

Documents and links

FAQs
GMC

Definitions
Definitions

IRDA (Insurance Regulatory

and Development Authority) http://www.irdaindia.org/

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Thank You!

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