Employee Benefits Practice Almondz Insurance Brokers Private Ltd.

Voluntary Group Mediclaim Policy for Parents

Coverage

Premium

Tax Benefit

Exclusions

Cashless and Reimbursement Process

Claim Support

SUMMARY

Section I-

Policy Details

Section II-

Processes

Section III-

Exclusions

3 - 8

Page No.

2

9 - 13

14 - 16

Our Approach for Mediclaim Policy 2016-17

3

Current To Be

Members Covered

Sum Insured

Pre-Existing Ailments

Medical Checkup

Room Rent Eligibility

Employee, Spouse,

Children, Parents

Basic <10K : 1 Lakh

10K<=Basic <30K : 3 Lakh

Basic >=30K : 5 Lakh

Covered

Not Required

2% for normal room and

4 % for ICU

Two Separate policies:

• Employee Spouse &

Children (ESC)

• Parents (set I) or Parents

in-law (Set II), (separate

premium)

Covered

For ESC : 2% for Normal & 4% for

ICU

For Parents : Mentioned on slide 5

Basic ESC Parents

X<10K 1,00,000 Covered in ESC

10K<=X<30K 3,00,000 200,000

X >=30K 5,00,000 300,000

Not Required

Section I-

Policy Details

Section II-

Processes

Section III-

Exclusions

POLICY DETAILS DESCRIPTION

Policy Holder Cipla Ltd

Policy Start & End Date 1st April 2016 to 31st March 2017

Insurer The New India Assurance Co. Ltd.

Third Party Administrator (TPA) Medi Assist India Ltd.

Sum Insured (Floater)

The mentioned Sum Insured is for

2 parents or single parent as per

enrollment

Members Covered

•Employees joined before 31st March’16 will be eligible to add any 2 parents or parents in law

with the single floater premium deduction

•Employee joining after 31st March 16 will get the option to add 2 sets of parents & parents in

law with the payment of twice the premium

Entry Age limit Parents upto the age of 100 years can be covered under the policy

Co Payment No Co-pay on any claims

Pre Existing Diseases Covered from day 1

Details of our policy

4

Section I-

Policy Details

Section II-

Processes

Section III-

Exclusions

EMPLOYEE SUM INSURED PARENTS SUM INSURED

100,000 Covered in employee spouse children policy

300,000 200,000

500,000 300,000

Voluntary Parents Policy Coverage

5

Section I-

Policy Details

Section II-

Processes

Section III-

Exclusions

30 Days Waiting Period for New

JoinersWaived off

Cataract Eligibility

Room Rent

Pre & Post Hospitalization Cover 30 days pre & 60 days post hospitalization expenses covered.

Ambulance Charges Covered upto Rs. 2,000 in case of emergency only

S. No Sum Insured Eligibility

1 200,000 INR 23,000

2 300,000 INR 23,000

S. NoSum

InsuredEligibility (Normal

room)Eligibility (ICU)

1 200,000 INR 3000 per day INR 5000 per day

2 300,000 INR 4500 per day INR 7500 per day

Parents Premium Chart

6

Section I-

Policy Details

Section II-

Processes

Section III-

Exclusions

The premium mentioned is for 2 parents/parents-in law exclusive of service tax.

If the age of parents is less than equal to 50 yrs a discount of 5% will be there on the mentioned

premium whereas if the age of both the parents is less than 50 yrs then a discount of 10% will be

given.

Employees shall not have the option to replace parents with in laws or in laws with parents. An

exception shall be for female employees who would be permitted to replace their parents with

parents in law (only after marriage). But this option can be exercised only at the time of the

enrolment year following the year of marriage, and not thereafter

Premium will be deducted from salary in three equal monthly installments.

Only one time option will be given for parents enrollment, employees who will miss the enrollment

during the window period will not be eligible to cover the dependents in the current year or in the

subsequent years

New recruits can opt to cover their parents at the time of recruitment (during the stipulated window

period) . In case for some reason an employee does not enroll his parents for the policy during the

window period , then he/she can enroll them in the next year’s policy (contingent to policy terms of

next year)

PARENTS SUM INSUREDPREMIUM

(Single Parent)PREMIUM

(Both Parents)

200,000 8,700 9,200

300,000 10,000 14,300

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Section I-

Policy Details

Section II-

Processes

Section III-

Exclusions

Policy Comparison

Waiting period of 3 – 4 years for all Pre-

existing Diseases.

Need for Pre enrollment medical check

beyond the age of 45 years

Ailment wise capping applicable

Maximum Entry Age is 65 years

30 days, 1st & 2nd Year Exclusions

Applicable

Coverage for Pre-Existing Diseases from

day one – No waiting period

No need of Pre enrollment medical check

No ailment wise capping except for

Cataract.

Maximum Entry Age is 100 years

30 days, 1st & 2nd Year exclusions –

Waived off

Retail Policy Cipla Policy

8

Section I-

Policy Details

Section II-

Processes

Section III-

Exclusions

Tax Benefit

Will I be eligible for Tax Benefit for contribution made towards

covering my dependent parents in this policy?

The policy offers Tax Benefit under Sec 80 D of the IT Act 1961 for

premium contributed towards covering your parents in this policy. No Tax

benefit will be available for premium payment made towards coverage

of Parent In Laws. Tax Benefit norms will be applicable as per prevailing

Income Tax norms.

Enrolled Parents and Parents in Law (Not exceeding four)

Definition of Parent = Biological or Legal Parents

Definition of Parents-in-law = Parents of Legally Married Spouse

Pre Requisites of Membership

9

Section I-

Policy Details

Section II-

Processes

Section III-

Exclusions

The Insurance cover will be extended to

In an event of separation, policy certificate will be given to the employee. He/she will

be eligible to claim under the policy for the entire duration of the coverage period.

Post separation, claims should be routed directly to TPA

What if employee leaves?

Network Hospitalization - Cashless

Section I-

Policy Details

Section II-

Processes

10

Identify Network Hospital / website /helpline

Pay for Non Medical Expenses if any

At the time of discharge Hospital will send final

request to Medi Assist for approval

(Provided within 2 hours)

On successful approval admission happens &

treatment starts

Visit Hospital Insurance Help desk & fill the pre-

authorization form

Hospital will seek approval from Medi -Assist

(Provided within 2 hours)

Emergency Hospitalization

Planned Hospitalization

In case of Planned Hospitalization, authorization should be taken prior, which will be valid for 15 days to avoid delay /inconvenience

You will receive SMS confirmation

Section III-

Exclusions

You will receive SMS confirmation

Non Network Hospitalization -Reimbursement

Section I-

Policy Details

Section II-

Processes

Intimate Medi Assist regarding claim on

the day of Hospitalization or within 7 Days

from the date of admission

Medi -Assist will process the claim and send

the reimbursement by NEFT, along with the

settlement letter

Deficient document`s are sent

Reason of Rejection will be communicated

Documents can be submitted to Help Desk or

send it directly to central team (Cipla-HO)

Medi Assist will ask for the additional/missing

documents

Medi Assist will check for the eligibility and

admissibility of the claim as per policy terms

Is Claim

payable ?

No

Yes

Submit Claim documents within 30 days

from the date of discharge

You will receive SMS confirmation of receipt of documents.

You will receive SMS confirmation of receipt of documents.

You will receive SMS notification

You will receive SMS notification

11

Documents incomplete

Claim not permissible

Reminder mails sent every 7 days

To be done by Claimant Activity done by TPA

Section III-

Exclusions

Claim Intimation

Section I-

Policy Details

Section II-

Processes

12

Section III-

Exclusions

1. Claim intimation to be give on claimsupport@mediassistindia.com within 7 days of admission. Email

should contain following details.

This intimation can be given through various modes like email/in person/web portal/over a call .

I. Company NameII. Policy No.III. Mediassist ID no

(mentioned on health card):

IV. Employee code:

V. Name of employeeVI. Name of patientVII. Date of AdmissionVIII. Name of hospital IX. Approximate claim amount

etc.

CONTACT POINTS FOR CLAIMS (Cashless & Reimbursement) - Medi Assist TPA

– Customer Care DetailsI. Email id for claim intimation –

claimsupport@mediassistindia.comII. 24 x 7 Help line for cashless and

Reimbursement 1800-425-7476

ESCALATION POINT:I. Name – Ms. Suvarna Khandagale

(Mediassist team)II. Email ID – healthhelpdesk@cipla.comIII. Phone No: 022 - 24814786

Escalation Matrix

Section I-

Policy Details

Section II-

Processes

13

Any Assistance(Claim /Enrollment)

Toll free - 1800-425-7476

Speak to Local Help Desk Representative

Query Resolved Query Unresolved

Query Resolved Query Unresolved

Write : claimsupport@mediassistindia.com

Query Resolved Query Unresolved

Write : sunil.shinde@almondz.com

Section III-

Exclusions

Maternity is not covered

Cost of Spectacles, Contact Lenses, Hearing Aids

Treatment done with no active line of treatment

Dental Treatment or surgery of any kind unless requiring hospitalization on account of accidental cases.

Vitamins and nutritional supplements

Cosmetic or aesthetic treatment of any description, plastic surgery other than as may be necessitated due to

an accident or as a part of any illness.

Convalescence, general debility ‘Run-down' condition or test cure

Intentional self injury and use of intoxicating drugs/alcohol

Sterility (infertility), venereal disease

Congenital external disease or defects or anomalies

Policy Exclusions 1/3

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Section II-

Processes

Section III-

Exclusions

Section I-

Policy Details Injury or disease directly or indirectly caused by or arising from or attributable to War,

Invasion, Act of Foreign Enemy, Warlike operation (whether war be declared or not)

Injury or disease directly or indirectly caused by or contributed to by nuclear weapons/materials

Expenses incurred for disease declared as an Epidemic by Health Authorities

Natural Disasters & National Emergencies:

Cosmetics & Non Medically required procedures:

Policy Exclusions 2/3

Naturopathy treatment

Medical Expenses for Organ Donor

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 and durable medical equipment's

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 a human

life), intentional self-inflicted injury attempted suicide and arising out of non-adherence to any medical advice

Treatment of any Bodily injury sustained whilst or as a result of active participation in 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

Lymphotropic 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.

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Section II-

Processes

Section III-

Exclusions

Section I-

Policy Details

Policy Exclusions 3/3

Diagnostic, 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.

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.

Any Domiciliary Hospitalization / Treatment.

Treatment taken outside India.

Experimental and unproven treatment (not recognized by Indian Medical Council)

Change of treatment from one system of medicine to another unless recommended by the Consultant / Hospital

under whom the treatment is taken

All non-medical expenses including convenience items for personal comfort such as telephone, television, Aya,

Private Nursing / Barber or beauty services, diet charges, baby food, cosmetics, tissue paper, diapers, sanitary pads,

toiletry items and similar incidental expenses

Service charges or any other charges levied by hospital, except registration/admission charges

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Section II-

Processes

Section III-

Exclusions

Section I-

Policy Details

Employee Benefits Practice

THANKS & STAY HEALTHY