Group Mediclaim Cover for

EMCURE PHARMACEUTICAL LTD.

Agenda

Cover

Terminology

Exclusions

Settlement

Scope of cover

Disease / Injury Treated medically /surgically By Hospitalisation Only At Nursing home / hospital in India as

in-patient

Age limit 91 Days – 65 years

Scope of cover

The sum Insured available per Family• Rs. 200,000

Who are Covered :

• Employee + Spouse +2 Children• Unmarried employees – Self• Married employees –Self, Spouse, First 2

Living Children

Benefits

Family Floater cover

Pre – Existing diseases are covered for existing employees but 2 years exclusion for New joinee after 30th April 2010.

New born baby cover from 91st Day

Room rent is restricted to 1% of the sum insured subject to maximum of Rs 2000 and for ICU 2% of SI subject to max of Rs. 4000. In the event of the insured getting admitted in a category higher than capped mentioned above per day, then the insured will bear the difference of all the medical expenses as in the final hospital bill in the same proportion.

First year exclusion waived off for existing employees but applicable for New joinee after 30th April 2010.

First 30 days waiting period waived off.

Benefits- contd.

Pre and post hospitalisation covered for 30 days and 60 days respectively.

Domiciliary Hospitalization is an exclusion

Coverage for hospitalization arising on account of  or related to Psychiatric ailments would be limited to Rs 30,000.

“Disease sub-limit for kidney stone including DJ stent removal (for the same stone) –even if at a later admission – would be Rs. 25,000.

Septoplasty not covered but In case of FESS, the maximum liability would be up to Rs 35,000.

Terms and Conditions

Maximum age is 65 years

Maximum Age for children is limited upto 25 Years.

The family shall comprise of the insured employee his/her legally wedded spouse first 2 living children only

Lasik treatment not covered.

Terms and Conditions Contd…

Ayurvedic treatment, naturopathy and Homeopathy are not covered.

Administration/administrative, registration/admission, service charges & miscellaneous charges not payable.

50% co-payment is applicable in case of Cyber knife treatment & Stem Cell Transplantation treatment.

Warranted that treatment on trial/experimental basis are not covered under the scope of the policy.

Terms and Conditions Contd…

All the Claims documents needs to be submitted to the insurance co. within 30 days from the date of discharge.

Any device/instrument/machine that does not become part of the human anatomy/body but would contribute/replace the function of an organ, is not covered.

Expenses on fitting of Prosthesis is outside the scope of the policy.

Infertility and related ailments including “Male sterility” is outside the scope of the policy.

Compensation Payable Reasonable and necessarily incurred

Room Expenses in Hospital/Nursing Home Nursing Expenses Medical Practitioner Fee Treatment cost

MedicinesBlood / OxygenCost of Pacemaker / Artificial Limbs / Cost of OrgansOperation Theatre ChargesSurgical AppliancesDiagnostic cost Dialysis, Chemotherapy, Radiotherapy

Pre Hospitalisation and Post Hospitalisation expenses Max of Sum Insured

Agenda

Cover

Terminology

Exclusions

Settlement

Hospital / Nursing home

Institution in India for indoor care

For treatment of sickness & injuries

Registered with local authorities

Supervision of medical practitioner

Minimum criteria for hospital

Min 15 in-patient beds

Min 10 when population < 1 million

Fully equipped functional operation theatre

Round the clock availability of nursing staff/ doctor.

Institutions which are not hospitals

Place of restOld age homeDe-addiction centresHotel & similar institutions

Hospitalisation

Min period of 24 hrs Time limit not applicable for specific

treatment Dialysis Chemotherapy Tonsillectomy D & C Eye surgery Dental surgery (Only in case of an

accident)

Agenda

Cover

Terminology

Exclusions

Settlement

General exclusions War / war group Nuclear perils Plastic surgery Spectacles / Contact lens / Hearing aid Pre Natal and Post Natal Expenses Convalescence / general debility Sterility / veneral disease / circumcision Intentional self injury

General exclusions

Diagnostic / laboratory expenses not consistent with treatment

Vitamins / tonic inconsistent with treatment Naturopathy/ Ayurvedic Homeopathy Use of intoxicating drugs / alcohol Aids

Agenda

Cover

Terminology

Exclusions

Settlement

Time Line

Activity Details Expected TAT

Cashless Sanction Emergency 4-5 Hours- from receipt of request at i-healthcare

Planned 24 Hours- from receipt of request at i- healthcare

Re-Imbursement Claim

21 Working Days from receipt of Complete Claim Docs in Hyderabad

Query Letter 10 Working Days

Procedure for Cash-less Treatment Planned treatment in Network hospital

Intimation to TPA for approval

Intimation minimum 24 Hrs in advance for approval

Emergency Provide I-Healthcare membership no.

Intimate I-Healthcare for approval

Intimation to hospital with in 4-5 hrs from receipt of request at i-healthcare

Re-Imbursement Process The claimant sends the claim file to i-Healthcare with all relevant documents: (with in 30 days of the date of discharge)

Claim form duly signed

Original detailed discharge summary

All Payment receipt (s) in original

Copy of Health card and supporting Photo ID (wherever applicable)

Original hospital bill (s) with break up—Interim bills and Final Bill

Package break-up (if applicable)

Re-Imbursement Process

Original investigation reports and Bills

Pharmacy bills with supporting prescription

Consultation Papers with Treatment details

Indoor Case Sheet (wherever applicable) ,etc.Hospital bill with paid receipt (Revenue stamp if bill amount is more than Rs. 5000).All the relevant deficiency documents towards the claims have to be submitted within 30 days from the date of deficiency intimated by I-Healthcare. In case of delay in submission of claims or deficiency within time limit, claim stands repudiated.

Standard Policy Exclusions

Record/documentation charges

Attendant/Visitor pass charges

Extra bed charges for attendant etc

Special nursing charges not authorized by the attending doctor

Vitamins, tonic if not forming part of the room rent

Service charges not forming a part of the room rent

Sanitary items

Standard Policy Exclusions

Charges for extra bed for attendant

Bed retaining charges

Charges for T.V, Laundry, radio etc

Telephone/Fax charges

Food and Beverages for attendant and visitors

Toiletries etc

Purchase of Medicines not related to the treatment

Stationery, Xerox or certifying charges

Third Party Administrator

I- HealthcareICICI Lombard Healthcare, ICICI Bank Tower, Plot No.

12, Financial District, Nanakram Guda, Gachibowli, Hyderabad-500032

Fax: 040-66989160/61Toll free Fax no: 1800-209-8880

Website: http://www.icicilombard.com/app/ilom-en/icar

e

Hearty wishes for a Healthy life

Thank you