GROUP MEDICLAIM POLICY FEATURES Policy Period : 18 May 2017 to 17 May 2018

Transcription

1 FEATURES Policy Period : 18 May 2017 to 17 May

2 THE BASIC CRITERION FOR TRIGGER OF THIS HOSPITALIZATION POLICY ARE : The hospitalization should be for more than 24 hours (in certain cases, this time is relaxed, please go through details of policy to know for which ailments lesser time is acceptable) It should not be only for evaluation or diagnosis of disease. A positive / active treatment is must during the hospitalization. No hospitalization will be considered if the patient is only on oral medication during the period he or she is hospitalized. It s necessary that hospitalization is must for the treatment & the ailment could not have been treated on Out Patient basis. Hospitalisation expenses incurred during hospitalisation within India only.

3 POLICY AT GLANCE Insurance Company TPA Iffco Tokio General Insurance Co Ltd Emeditek Insurance TPA Ltd Policy Start Date 18 th May 2017 Policy End Date 17 th May 2018 Coverage Type Sum Insured Grade-wise (INR) Dependent Coverage Family Floater Sum Insured Floater Sum Insured as per Grade 1,00,000 / 2,00,000/ 3,00,000/ 5,00,000. Floater Sum Insured : Family Members : Self + Spouse + 2 Dependant Children (max age of 25 years) + 2 Parents (father & Mother) / 2 Parents-In-Laws (only in case of female employees). Date of Coverage for New Dependants (i.e. Spouse by Marriage & New Born baby by Birth) Date of such event (subject to declaration of dependent within the given timelines)

4 POLICY AT GLANCE Mid term enrolment of existing dependents Mid term inclusion of dependant not allowed except spouse by marriage & new born baby by birth from date of event subject to intimation of addition within 15 days from the date of event. Per Day Room Rent + Nursing Limit For Sum Insured Rs.1 Lac : Rs.2,000 for Normal Room and Rs.4,000 for ICU / ICCU, For Sum Insured above Rs.1 Lac : 1% of Sum Insured for Normal and 2% of Sum Insured for ICU / ICCU. If patient is admitted in higher room than the eligible room rent limit permissible as per policy. All other charges associated to room opted i.e. investigation/ diagnostic charges, doctor fees, anesthetist fees, operation theatre (OT) charges will be payable in accordance to room rent eligibility. except medicine bills. Incremental Cost Associated to Room Rent E.G If patient is admitted in room rent of Rs. 5,500 per day and his/her policy limit is Rs. 5,000 per day, than the claim will be paid on proportionate basis in accordance to eligible room rent limit. In this case the difference of 10% in room rent eligibility of Rs. 5,000 & Room Opted for Rs. 5,500 will be deducted along with all other associated charges linked to room opted like investigation, doctor fees, anesthetist fees, operation theatre (OT) charges. All other non-payable items will also be deducted as per policy terms.

5 POLICY AT GLANCE Pre Existing Diseases Waiting Period for any Treatment Dental Only Diagnostics / Evaluation Hospitalisation Out Patient Department (OPD) Benefit / Domiciliary Treatment Maternity Benefit (For 1 st two living children) Pre & Post Natal Expenses New Born Baby Expenses Emergency Ambulance Charges Pre and Post Hospitalization Expenses Hospitalisation during policy period for any pre-existing disease is covered. Not Applicable Not Covered (Except Surgery arising out of accident) Not Covered Not Covered For Normal Delivery : Covered upto Rs.30,000 in case of Single Delivery and Rs.45,000 in case of Twins For Caesarian Delivery: Covered upto Rs.60,000 in case of Single Delivery and Rs.75,000 in case of Twins Covered upto Maternity Sub Limit on Hospitalisation. Expenses incurred for the hospitalisation treatment of New Born Baby is covered under Family Sum Insured. Except Vaccination Charges & Wellcare Normal Baby Charges. Ambulance Charges necessarily incurred for shifting Patient to Hospital for admission in Emergency Ward or ICU, or from one Hospital to another Hospital for better medical facilities - Rs. 2,500 per person per incidence. 30 days pre hospitalization and 60 days post hospitalization expenses are covered relevant to admissible hospitalisation claim.

6 POLICY AT GLANCE Disease-wise Sub limits Claim Intimation Time Line Claim Submission Time line Day Care Procedures Applicable as per Annexure Hospitalisation Intimation to be given within 7 Days from Date of Admission. Intimation can be to intimation.mumbai@emeditek.com mediclaim@primefocus.com All original hospitalisation documents along with claim form to be submitted within 15 days to HR Department Prime Focus Day Care treatment refers to medical treatment, and/or Surgery which are: - Undertaken under General or Local Anesthesia in a Hospital/Day Care Centre in less than twenty four hours because of technological advancement, and - Which would have otherwise required a Hospitalization of more than twenty four hours. - Treatment normally taken on an out-patient basis is not included in the scope of this definition.

7 POLICY AT GLANCE DISEASE DISEASE-WISE SUB-LIMIT (CAPPING) For Sum Insured of Rs.1 Lac & 2 Lacs For Sum Insured of Rs.3 Lac & 5 Lacs APPENDIX 45,000 50,000 CAG (Coronary Angiography) 25,000 25,000 CATARACT (Per eye) 25,000 30,000 FESS SURGERY / SEPTOPLASTY 45,000 60,000 FISSURES 35,000 60,000 FISTULA 35,000 60,000 HERNIA 45,000 75,000 HYDROCELE 20,000 40,000 HYSTERECTOMY 50,000 75,000 CHOLECYSTECTOMY, LAPCHOLE 50,000 60,000 PILES 45,000 70,000 JOINT REPLACEMENT (PER JOINT) 150, ,000 TONSILITIS, TONCILLECTOMY 25,000 40,000 Note: Above Disease-wise sublimit is overall limit for said ailment inclusive of hospitalisation & Pre-Post Hospitalisation Expenses.

8 ADDITIONAL BENEFITS Benefits Coverages Internal Congenital Ailments - Ailments/ Deformity detected since birth & not visible to eyes. Covered External Congenital Ailments - Ailments/ Deformity detected since birth & visible to eyes. Covered upto 20 % of Family Sum Insured or Rs. 50,000 whichever is less Terrorism Related Hospitalisation Claim Covered Critical Illness Benefit If any employee gets diagnosed with a critical illness during the year, one time payment of Rs Loss of Pay If any employee is on Loss of Pay following an accident, 1% of SI per week will be allowed for a maximum of 10 weeks Out Patient Department Treatment (OPD) Benefit For fracture cases OPD treatment upto INR 2000 allowed for employees only If employee dies in hospital, no deductions for non consumables Covered On death of employee, dependents will remain covered upto the end Covered of the policy period Lasik Surgery for Eye Sight Correction Treatment Lasik surgery to be covered if refractive index is beyond +5.5 Cyber knife Treatment Covered, 50% Co-Pay for cyber knife treatment/stem Cell Transplantation. Cochlear Implant Cochlear Implant treatment covered upto 50% of the Sum Insured Treatment for Genetic Disorder Covered

9 STANDARD HOSPITALIZATION Particulars Room and Nursing Doctors fees Intensive Care Unit Surgical fees, operating theatre, anesthesia and oxygen and their administration Drugs and medicines consumed at the hospital Hospital miscellaneous services (such as laboratory, x-ray, diagnostic tests) Radiotherapy and Chemotherapy Coverage (as per policy terms) (as per policy terms) # All other charges payable in proportionate basis as per eligible room rent limit, if admitted in higher room than eligible limit. Common Disallowed Charges 1. Registration Fees/Admission Fees 2. Non Medical Expenses / Miscellaneous Charges. 3. Telephone charges 4. Cafeteria charges etc. 5. Dietician Charges.

10 COVERAGE TYPE Family Floater Under the family floater, the insurance cover will be available to all members of the family unit. The sum insured is available for utilization by any member of the family with or without any sub limit inter se. It is however subject to the overall family sum insured for all members put together. Applicable Sum Insured Family Floater Employee Dependents (Dependent's coverage subject to them being enrolled in the policy within the given timelines) Floater Sum Insured (INR) as per Grade 1,00,000 /2,00,000 /3,00,000/ 5,00,000 Eg: Sum insured for all the employees & their dependants will be on family floater basis. i.e. If an employee having family sum insured of Rs /-, the sum insured can be utilized for hospitalization expenses of any of the enrolled family member, maximum upto Rs. 300,000/-. 10

11 ENROLLED MEMBERS 1+5 Family Definition Per Family Includes- Self + Spouse + 2 Dependant Children (max age of 25 years) + 2 Parents OR 2 Parents-In-Law (only for female employees) under family floater sum insured. Insured Member Coverage Maximum Entry Age Employee Yes No Limit Spouse Yes No Limit Children Yes (up to 2 Child are covered) 25 years Parents (Father & Mother) Yes 90 years Note: i) No Individual should be covered as dependent of more than one employee. ii) Dependent's coverage subject to them being enrolled in the policy within the given timelines iii) New born baby and newly married spouse addition data to be forwarded to HR department with in 15 days from the event of happening. 11

12 COVERAGES Pre- existing Diseases Pre-existing diseases refers to condition or ailments that may have been contracted before the start of the policy. There is usually a waiting period of 4 years for covering such ailments under individual Mediclaim policy. Covered for all enrolled members from Day 1 30 Day Waiting Period for new joiners 1 st /2 nd /3 rd /4 th Year Waiting Period Any hospitalization expenses during the first 30 days from the commencement date of the Policy is not covered for the new joiners. This exclusion is however, not applicable to any emergency hospitalization occurring due to an accident.. Medical insurance policies have waiting period of 1/2/3/4 years for reimbursement of medical expenses for treatment of certain specified ailments. The specified ailments mainly include Cataract, Benign Prostatic Hypertrophy, Hysterectomy or prolapsed of uterus, Hernia, Hydrocele, Fistula in anus, Piles, Sinusitis, Joint Replacement due to Degenerative condition, Age related osteoarthritis and Osteoporosis, among others. Not Applicable Not Applicable Day Care Procedures Day care procedures refers to such treatment which does not necessarily require 24 hospitalization due to medical technological advancement. Such list of ailments are available with insurance companies and are referred to as Day care ailments. Covered 12

13 COVERAGES Pre- Hospitalisation Expenses If the Insured member is diagnosed with an Illness which results in his / her Hospitalization and the claim is admissible, the Insurer will also reimburse the Insured Member s Pre-hospitalization Expenses. Covered for 30 days prior to date of admission Post- Hospitalisation Expenses Relevant expenses for 60 days post discharge from hospital for an admissible hospitalization claim will be reimbursed in the policy. These expenses include medicines prescribed at the time of discharge, follow up treatment consultation charges..etc. Covered for 60 days post the date of discharge Emergency Ambulance charges Ambulance charges are covered for shifting any Insured Person to Hospital for admission in Emergency Ward or ICU, or from one Hospital to another Hospital for better medical facilities. Upto Rs. 2500/- or actual whichever is lower 13

14 COVERAGES Maternity Expenses Any Maternity or pregnancy related hospitalization expense other than those excluded (like voluntary termination of pregnancy in the first 12 weeks of delivery) will be payable. The maternity benefit is applicable for Normal / Cesarean delivery within the overall Sum Insured for the first two live births. There is no waiting period for availing Maternity Benefit under Prime Focus GMC Policy. Normal Delivery - Rs.30,000 in case of Single Delivery and Rs.45,000 in case of Twins. Caesarean Delivery - Rs.60,000 in case of Single Delivery and Rs.75,000 in case of Twins Pre & Post Natal Expenses New Born Baby Expenses Expenses incurred due to hospitalization during pre & post natal period of Maternity. On Delivery of a child, the child is prone to many health disorders like jaundice or expenses incurred for incubator for pre-mature births or any other complication to the child. Usually there is a 90 days waiting period for covering baby in the policy. In this benefit Vaccination Expenses & Well Baby Charges are not covered. Covered within Maternity Sublimit incase of In-Patient Hospitalisation Covered from Day 1.

15 EXCLUSIONS OPD Cover This extension provides for expenses which does not necessarily require hospitalization. It is however, not applicable to ailments/treatment which is excluded in the policy. Not Covered Evaluation / Diagnostic Related Hospitalisation Expenses incurred towards hospitalization only for Evaluation / Diagnostic Purpose is not Covered. Not Covered Dental Cover Dental treatment as a result of hospitalization due to an accidental injury is covered in the policy. However, extension for dental treatment in the policy will cover dental expenses for a fixed specified limit defined in the policy which is otherwise an exclusion under the health policy. Not Covered 15

16 GENERAL EXCLUSIONS War invasion, Act of foreign enemy, War like operations, Nuclear weapons, ionizing radiation, contamination by radio activity, by any nuclear fuel or nuclear waste or from the combustion of nuclear fuel. Circumcision, cosmetic or aesthetic treatment, plastic surgery unless required to treat injury or illness. Vaccination & Inoculation. Cost of braces, equipment or external prosthetic devices, non-durable implants, eyeglasses, Cost of spectacles and contact lenses, hearing aids including cochlear implants, durable medical equipment. All types of Dental treatments except arising out of an accident. Convalescence, general debility, Run-down condition or rest cure, obesity treatment and its complications, congenital external disease/defects or anomalies, treatment relating to all psychiatric and psychosomatic disorders, infertility, sterility, use of intoxicating drugs/alcohol, use of tobacco leading to cancer. Bodily injury or sickness due to willful or deliberate exposure to danger (except in an attempt to save human life), intentional selfinflicted injury, suicide or attempt threat, or arising out of non-adherence to medical advice. Treatment of any Bodily injury sustained whilst or as a result of active participation in any hazardous sports of any kind. Treatment of any bodily injury sustained whilst or as a result of participating in any criminal act. Sexually transmitted diseases, any condition directly or indirectly caused due to or associated with Human T-Cell Lymph tropic Virus Type III (HTLB-III) or lymphotropathy Associated Virus (LAV) or the Mutants Derivative or Variation Deficiency syndrome or any syndrome or condition of a similar kind commonly referred to as AIDS. Diagnosis, X-Ray or Laboratory examination not consistent with or incidental to the diagnosis of positive existence and treatment of any ailment, sickness or injury, for which confinement is required at a Hospital/Nursing Home. Vitamins and tonics unless forming part of treatment for injury or disease as certified by the attending physician. Out patient Diagnostic, Medical and Surgical procedures or treatments, non prescribed drugs and medical supplies, Hormone replacement therapy, Sex change or treatment which results from or is in any way related to sex change. 14-Jul-17 16

17 GENERAL EXCLUSIONS Change of treatment from one pathy to other pathy unless being agreed / allowed and recommended by the consultant under whom the treatment is taken. Naturopathy Treatment, unproven procedure / treatment, experimental or alternative medicine / treatment including acupuncture, acupressure, magneto-therapy etc. Instrument used in treatment of Sleep Apnoea Syndrome (C.P.A.P.) and continuous Peritoneal Ambulatory dialysis (C.P.A.D.) and Oxygen Concentrator for Bronchial Asthmatic condition. Genetical disorders and stem cell implantation / surgery. Domiciliary treatment Treatment outside India. Experimental and unproven treatment. All non-medical expenses including convenience items for personal comfort such as telephone, television, Aaya, Private Nursing / Barber or beauty services, diet charges, baby food, cosmetics, tissue paper, diapers, sanitary pads, toiletry items etc. guest services and similar incidental expenses Treatment related to eyes for Age Related Macular Degeneration with administration of Lucentis / Avantis / Macugen / Avastin and other related drug through intravertal injection are not covered. Doctor s home visit charges, Attendant / Nursing charges during pre and post hospitalization period. Voluntary termination of pregnancy during first 12 weeks (MTP) Cost of organ when organ transplantation surgery is undertaken. Massages, Steam bathing, Shirodhara and alike treatment under Ayurvedic treatment. Service charges or any other charges levied by hospital, registration / admission charges. Note: These are only illustrative and not an exhaustive list. 17

18 THANK YOU HEALTH IS NOT VALUED TILL SICKNESS COMES