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GROUP MEDICLAIM POLICY FEATURES 2017-18

Policy Period : 18 May 2017 to 17 May 2018

GROUP MEDICLAIM POLICY

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.

GROUP MEDICLAIM POLICY

POLICY AT GLANCE

Insurance Company Iffco Tokio General Insurance Co Ltd

TPA Emeditek Insurance TPA Ltd

Policy Start Date 18th May 2017

Policy End Date 17th May 2018

Coverage Type Family Floater Sum Insured

Sum Insured Grade-wise (INR)Floater Sum Insured as per Grade

1,00,000 / 2,00,000/ 3,00,000/ 5,00,000.

Dependent CoverageFloater 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)

GROUP MEDICLAIM POLICY

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.

Incremental Cost Associated to Room Rent

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.

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.

GROUP MEDICLAIM POLICY

POLICY AT GLANCE

Pre Existing Diseases Hospitalisation during policy period for any pre-existing disease is covered.

Waiting Period for any Treatment Not Applicable

Dental Not Covered (Except Surgery arising out of accident)

Only Diagnostics / Evaluation Hospitalisation Not Covered

Out Patient Department (OPD) Benefit / Domiciliary Treatment

Not Covered

Maternity Benefit (For 1st two living children)

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

Pre & Post Natal Expenses Covered upto Maternity Sub Limit on Hospitalisation.

New Born Baby ExpensesExpenses incurred for the hospitalisation treatment of New Born Baby is covered underFamily Sum Insured. Except Vaccination Charges & Wellcare Normal Baby Charges.

Emergency Ambulance ChargesAmbulance 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.

Pre and Post Hospitalization Expenses30 days pre hospitalization and 60 days post hospitalization expenses are covered relevant to admissible hospitalisation claim.

GROUP MEDICLAIM POLICY

POLICY AT GLANCE

Disease-wise Sub limits Applicable as per Annexure

Claim Intimation Time Line

Hospitalisation Intimation to be given within 7 Days from Date of Admission.

Intimation can be email to intimation.mumbai@emeditek.commediclaim@primefocus.com

Claim Submission Time lineAll original hospitalisation documents along with claim form to be submitted within 15 days to HR Department – Prime Focus

Day Care Procedures

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.

GROUP MEDICLAIM POLICY

POLICY AT GLANCE

DISEASEDISEASE-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) 150,000 225,000

TONSILITIS, TONCILLECTOMY 25,000 40,000

Note: Above Disease-wise sublimit is overall limit for said ailment inclusive of hospitalisation & Pre-Post Hospitalisation Expenses.

GROUP MEDICLAIM POLICY

ADDITIONAL BENEFITS

Benefits CoveragesInternal 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. 25000

Loss of PayIf 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) BenefitFor 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 of the policy period

Covered

Lasik Surgery for Eye Sight Correction Treatment Lasik surgery to be covered if refractive index is beyond +5.5

Cyber knife TreatmentCovered, 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

GROUP MEDICLAIM POLICY

STANDARD HOSPITALIZATION

Particulars Coverage

Room and Nursing

(as per policy terms)

Doctors fees

Intensive Care Unit

(as per policy terms)

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

# All other charges payable in proportionate basis as per eligible room rent limit, if admitted in higher room than eligible limit.

Common Disallowed Charges1. Registration Fees/Admission Fees2. Non Medical Expenses / Miscellaneous Charges.3. Telephone charges4. Cafeteria charges etc.5. Dietician Charges.

GROUP MEDICLAIM POLICY

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Under the family floater, the insurance cover will be available to all members of thefamily unit. The sum insured is available for utilization by any member of the familywith or without any sub limit inter se. It is however subject to the overall family suminsured for all members put together.

ApplicableFamily Floater

Sum Insured – Family Floater

EmployeeFloater Sum Insured (INR) as per Grade –1,00,000 /2,00,000 /3,00,000/ 5,00,000Dependents (Dependent's coverage subject to them being

enrolled in the policy within the given timelines)

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. 300.000/- , the sum insured can be utilized for hospitalization expenses of any of the enrolled family member, maximum upto Rs. 300,000/-.

COVERAGE TYPE

GROUP MEDICLAIM POLICY

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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 timelinesiii) New born baby and newly married spouse addition data to be forwarded to HR department with in 15 days from the event of

happening.

Family Definition

1+5

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 LimitSpouse Yes No Limit

Children Yes (up to 2 Child are covered) 25 years

Parents (Father & Mother)

Yes90 years

ENROLLED MEMBERS

GROUP MEDICLAIM POLICY

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Pre-existing diseases refers to condition or ailments that may have been contracted beforethe start of the policy. There is usually a waiting period of 4 years for covering suchailments under individual Mediclaim policy.

Covered for all enrolled members

from Day 1

Pre- existing Diseases

COVERAGES

Any hospitalization expenses during the first 30 days from the commencement date of thePolicy is not covered for the new joiners. This exclusion is however, not applicable to anyemergency hospitalization occurring due to an accident.

.

Not Applicable30 Day Waiting Period for new

joiners

Medical insurance policies have waiting period of 1/2/3/4 years for reimbursement ofmedical expenses for treatment of certain specified ailments. The specified ailmentsmainly include Cataract, Benign Prostatic Hypertrophy, Hysterectomy or prolapsed ofuterus, Hernia, Hydrocele, Fistula in anus, Piles, Sinusitis, Joint Replacement due toDegenerative condition, Age related osteoarthritis and Osteoporosis, among others.

Not Applicable1st/2nd/3rd/4th

Year Waiting Period

Day care procedures refers to such treatment which does not necessarily require 24hospitalization due to medical technological advancement. Such list of ailments areavailable with insurance companies and are referred to as Day care ailments.

CoveredDay Care

Procedures

GROUP MEDICLAIM POLICY

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COVERAGES

If the Insured member is diagnosed with an Illness which results in his / herHospitalization and the claim is admissible, the Insurer will also reimburse the InsuredMember’s Pre-hospitalization Expenses.

Covered for 30 days prior to date of

admission

Pre-Hospitalisation

Expenses

Relevant expenses for 60 days post discharge from hospital for an admissiblehospitalization claim will be reimbursed in the policy.

These expenses include medicines prescribed at the time of discharge, follow uptreatment consultation charges..etc.

Covered for 60 days post the date of

discharge

Post-Hospitalisation

Expenses

Ambulance charges are covered for shifting any Insured Person to Hospital for admissionin Emergency Ward or ICU, or from one Hospital to another Hospital for better medicalfacilities.

Upto Rs. 2500/- or actual whichever is

lower

Emergency Ambulance

charges

GROUP MEDICLAIM POLICY

Any Maternity or pregnancy related hospitalization expense other than thoseexcluded (like voluntary termination of pregnancy in the first 12 weeks ofdelivery) 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 FocusGMC 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

Maternity Expenses

COVERAGES

Expenses incurred due to hospitalization during pre & post natal period ofMaternity.

Covered within Maternity Sublimit incase of In-Patient

Hospitalisation

Pre & Post Natal Expenses

On Delivery of a child, the child is prone to many health disorders likejaundice or expenses incurred for incubator for pre-mature births or anyother complication to the child. Usually there is a 90 days waiting period forcovering baby in the policy.

In this benefit Vaccination Expenses & Well Baby Charges are not covered.

Covered from Day 1.

New Born Baby Expenses

GROUP MEDICLAIM POLICY

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OPD CoverThis 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

Dental treatment as a result of hospitalization due to an accidental injury is covered in thepolicy. However, extension for dental treatment in the policy will cover dental expensesfor a fixed specified limit defined in the policy which is otherwise an exclusion under thehealth policy.

Not CoveredDental Cover

Evaluation / Diagnostic Related

Hospitalisation

Expenses incurred towards hospitalization only for Evaluation / Diagnostic Purpose is notCovered.

Not Covered

EXCLUSIONS

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GENERAL EXCLUSIONS

• War invasion, Act of foreign enemy, War like operations, Nuclear weapons, ionizing radiation, contamination by radio activity, by anynuclear 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 intoxicatingdrugs/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 self-inflicted 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 anysyndrome 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 ofany 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.

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GENERAL EXCLUSIONS

• Change of treatment from one pathy to other pathy unless being agreed / allowed and recommended by the consultant underwhom 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.) andOxygen 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 servicesand similar incidental expenses

• Treatment related to eyes for Age Related Macular Degeneration with administration of Lucentis / Avantis / Macugen / Avastin andother 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.

THANK YOUHEALTH IS NOT VALUED TILL

SICKNESS COMES