Objective and Scope

This insurance scheme is to provide adequate insurance coverage for employees and their families for expenses related to hospitalization due to illness, disease or injury.

An employee is eligible to claim for his / her mediclaim from the date of joining.

Coverage

To know the entitlement of your medical insurance benefits of GMC and co-pay ratio, please refer the attachment in the mail.

A. Group Mediclaim

Mediclaim Scheme reimburses the expenses incurred in hospitalization for treatment of illness or injury sustained or contracted during the policy period. Coverage is for self and 5 family members.

Note : Family refers to self, parents / parents-in-law, spouse and two children.

The coverage is provided as per the nominations received from you. Inclusion of parents in addition to your existing nominations earlier given will be effective from next renewal (February 2023).

However, employees can provide nomination of spouse in case of marriage and new born baby in case of childbirth as applicable. However, children who are above the age of 25 years are not covered in this scheme.

Maternity benefit is covered in this scheme. Maternity benefit is covered under this scheme. The cover for normal delivery is 25,000/- and for C-section is 40,000/-

Details of the Mediclaim – Basic Cover

The policy gets triggered only in case of HOSPITALISATION for a minimum period of 24 hours. The coverage is purely on hospitalization expenses. Coverage starts from the date of admission to the hospital and closes on the date of discharge from the hospital. For any injury or illness sustained or contracted during the policy period minimum hospitalization of one day is required for the claim. However, this does not apply for daycare procedures. The hospital needs to be registered with the local authority.

Standard Hospitalization

Reimbursement of expenses related to:

• Room and boarding
• Doctors fees
• Intensive Care Unit
• Nursing expenses
• Surgical fees, operating theatre, anesthesia and oxygen and their administration
• Physical therapy
• Drugs and medicines consumed on the premises
• Hospital allied services (such as laboratory, x-ray, diagnostic tests)
• Dressing, ordinary splints and plaster casts
• Costs of prosthetic devices if implanted during a surgical procedure
• Radiotherapy and chemotherapy

The expenses shall be reimbursed 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.

Features Of The Cover

• All claims would be settled on re-imbursement mode. 
• Co-pay: It refers to the part of the claim amount in an insurance policy which is borne by the insured out of pocket. 
• It is applicable for every admissible medical claim.
• Limits defined for room rents per day:  
  • Room rent capped upto Rs. 3,000/- for sum insured of 1.5 – 3 lakhs
  • Room rent for ICU is Rs. 6000/-
• Team members are encouraged to stay in comfortable yet not luxury or deluxe rooms, since all the other charges like O.T. Charges, surgeon’s charges, bed charges, nursing and consultation charges etc., would be proportional to the room rent selected. The higher the room charges, there would be a corresponding increase in the other charges. 
• Any additional medical charges will have to be borne by the patient above the room rent limit.
• Ambulance services – The Insurer will pay for Emergency ambulance by a licensed ambulance service to the nearest Hospital where Emergency Health Services can be rendered. Coverage is only provided in the event of an Emergency. Covered Up to maximum of 5000 per claim.

Benefits

Pre existing diseases – Covered

Any Pre-Existing Condition or related condition for which care, treatment or advice was recommended by or received from a Doctor or which was first manifested prior to the commencement date of the Insured Person’s first Health Insurance policy with the Insurer

First 30 day waiting period – Waived

Any Illness diagnosed or diagnosable within 30 days of the effective date of the Policy Period if this is the first Health Policy taken by the Policyholder with the Insurer. If the Policyholder renews the Health Policy with the 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

First Year Waiting period – Waived

During the first year of the operation of the policy the expenses on treatment of diseases such as Cataract, Benign Prostatic Hypertrophy, Hysterectomy for Menorrhagia or Fibromyoma, Hernia, Hydrocele, Congenital Internal 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

Day Care – Applicable, subject to pre authorization

Day care procedure means the course of medical treatment/surgical procedure in specialized day care canters which enables the insured to be discharged on the same day. Example: Cataract, Chemotherapy, Dialysis, radiotherapy etc

Benefits not covered

• Diagnostics Expenses – Charges incurred at Hospital or Nursing Home primarily for diagnostic, X-Ray or laboratory examinations or other diagnostic studies not consistent with or incidental to the diagnosis and treatment of the positive existence of any ailment, sickness or injury for which confinement is required at a Hospital/Nursing Home or at home under Domiciliary Hospitalization as defined.
• Domiciliary Hospitalization – Domiciliary Hospitalisation benefit means medical treatment for a period exceeding three days for such an illness/disease/injury taken at home 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 moved to the hospital/nursing home or
  • The patient cannot be moved to the hospital/nursing home for lack of accommodation therein
  • Expenses incurred for pre and post hospital treatment, and
  • Any hospitalisation which does not include active line of treatment

General Exclusions

• Circumcision unless necessary for treatment of disease
• Dental treatment of any kind unless requiring hospitalization
• Congenital external diseases or defects/anomalies
• HIV and AIDS
• Hospitalization for convalescence, general debility, intentional self-injury, use of intoxicating drugs/ alcohol.
• Venereal diseases (Sexually Transmitted Diseases)
• Injury or disease caused directly or indirectly by nuclear weapons
• Injury or disease directly or indirectly caused by or arising from or attributable to War or War-like situations
• 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
• Hospitalization 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)
• Mental, nervous or emotional disorders or rest cures

In case of hospitalization claims, the following non-medical expenses are not payable as per the policy:

• Admission Charges, Admission Registration Charges, Pass/Attendant Charges, Medico Legal Charges, Nutrition Planning Charges, Birth Certificate, Telephone Charges, Diet Charges, Medical Certificate
• Crutches, Arm Sling, Cervical Collar, Lumbo-Sacral Belt, Pelvic Traction Belt, Walker, Abdominal Belt, Knee Braces (Long/Short/Hinged), Wheel Chair
• Medication/ Treatment Not Pertaining To The Illness For Which Hospitalised
• Tissue Roll, Diapers, Sanitory Napkins, Water Bed, Cd/Video Cassette, Spectacles, Themometer, Nebulizer Kit, Oxygen Cylinder (For Usage Outside The Hospital), Urine Can/ Commode.

Hospitalization & Claims Procedure

Reimbursement facility

All claims are settled through re-imbursement mode.

In order to avail reimbursement claim, they will go through the hospitalisation and will collect all the Original Bills, receipts, reports, discharge summary, investigation reports and doctor’s prescriptions, on discharge from the hospital. The employee makes the payment on all the bills. 

Then the employee will submit the bills along with the reimbursement forms as per the document checklist (the required documents for smooth claim processing is provided in the checklist) to The Oriental Insurance Company LTD at the below address within 15 days of discharge and intimate HR about the same. In order to get your claims processed, it is important for the employee to adhere to this timeline. 

After receipt of the documents, The Oriental Insurance Company LTD checks them for sufficiency by medical doctor scrutiny if claim is liable for clearance. Any insufficiency in documents would be intimated to the employee directly which may delay the claims process. The employee needs to submit the requested documents to ensure closure on the query. 

Note: It is important to submit the original documents of hospitalisation and a copy to be retained with the employee. 

The employees can contact the following SPOC for follow-up on the claim intimation and status. 

Below is the escalation matrix.

The insurance company will settle the claim to H.R. who will then transfer it to the claimant.