1

BENEFITS DETAILS

2

BENEFITS DETAILS

3

Kindly Note that New Joinee/Newly Wedded Spouse / New Born child can be covered with in 15 days from date of Joining/ date of marriage or date of birth of the child.

Hospitalization- What is covered

4

Reimbursement of expenses related to

•Room Rent fees

•Doctors fees

• Intensive Care Unit

• Nursing expenses

• Surgical fees, operating theatre, anesthesia and oxygen and their administration

•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

•Expenses on Vitamins and Tonics forming part of treatment as certified by the attending Medical Practitioner

• Organ transplantation including the treatment costs of the donor but excluding the cost of the organ

continue………….

Hospitalization- What is covered

5

PLEASE NOTEThe 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.

NOTE:- All other charges will commensurate with respective room rent capping. This means incase an employee opts for a higher category room, all additional expenses on account of the difference in the room category will be borne by the employee including doctor’s fees, nursing and investigations charges, surgeon charges , OT charges, procedure charges and any other charges associated with the room rent. This will be calculated on the percentage difference in the room rent eligibility Vs the actual room rent opted by the employee.

For e.g. in case an employee opt for a room of Rs.4000 against his eligibility of Rs.2000, Insurance Company will settle only 50% of the total bills and all other capping in this policy will be applicable on this 50% amount. This amount is inclusive of nursing care, RMO Charges, OT charges, I.V. Fluids / Blood Transfusion / Injection and administration charges. However, this will not be applicable on drugs .

ICU Charges= There will same applicable for ICU charges.

6

Hospitalization Period

7

Minimum Duration of Hospitalization

Definition •Expenses on Hospitalization are admissible only if hospitalization is for a minimum period of 24 hours with active line of treatment, except in cases of specialized treatment as detailed here below (commonly known as Day Care Procedures): i. Dialysis

ii. Chemotherapy iii. Radiotherapy iv. Eye Surgery v. Dental Surgery

vi. Lithotripsy (Kidney Stone Removal)

vii. Dilation & Cuterrage

viii. Tonsillectomy

The condition of 24 hours hospitalization will not be applicable if: i. the treatment is such that it necessitates hospitalization and the procedure involves specialized infrastructural facilities available only in hospitalization

ii. due to technological advances hospitalization is required for less than 24 hours

NOTE: Procedures / treatments usually done in Out Patient Department (OPD) are not payable under the policy even if converted to day care surgery / procedure or as in patient in the hospital for more than 24 hours.

Customized Benefits- Add-on features

8

Pre-hospitalization Expenses

Definition If the Insured Person is diagnosed with an Illness which results in his Hospitalization and for which the Insurer accepts a claim then the Insurer will reimburse the Insured Person’s Pre-hospitalization Expenses for up to 30 days prior to his Hospitalization as long as the 30 day period commences and ends within the Policy Period. Not applicable for maternity claim.

Applicable Yes

Duration 30 Days

Post-hospitalization Expenses

Definition If the Insurer accepts a claim and, immediately following the Insured Person’s discharge, he requires further medical treatment directly related to the same condition for which the Insured Person was Hospitalized, the Insurer will reimburse the Insured Person’s Post-hospitalization Expenses. Not applicable for maternity claim.

Applicable Yes

Documents submission deadline

60 days from date of discharge

Duration 60 Days

Pre existing diseases

Definition 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

√

√

√

Covered

Covered

Covered

Customized Benefits- Add-on features

9

First 30 day waiting period- Waived off

Definition 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

√

√

Waived

Waived

First Year Waiting period- Waived off

Definition During the first year of the operation of the policy the expenses on treatment of diseases such as Cataract, Benign Prostatic Hypertrophy, Hysterectomy for Menorrhegia or Fibromyoma, Hernia, Hydroceie, 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

Customized Benefits- Add-on features

10

Day Care

DefinitionDay Care Procedure means the course of medical treatment or a surgical procedure listed in the Schedule which is undertaken under general or local anesthesia in a Hospital by a Doctor for not less than 2 hours and not more than 24 hours. These are the treatments which take less than 24 hours due to medical advancements.

Dental Treatment

Definition Any dental treatment or surgery of a corrective, cosmetic or aesthetic nature unless it requires Hospitalization; is carried out under general anesthesia and is arising only out of Accidental Bodily Injury.

Vision & Hearing aid

Definition Charges incurred at Hospital or Nursing Home primarily for diagnostic, X-Ray or laboratory examinations or other diagnostic studies only if incidental to the diagnosis and treatment of the positive existence/presence of any ailment, sickness or injury for which confinement is required at a Hospital/Nursing Home.

√

R

R

Covered

Restricted

Restricted

Diagnostics Expenses

DefinitionCharges incurred at Hospital or Nursing Home primarily for diagnostic, X-Ray or laboratory examinations or other diagnostic studies only if incidental to the diagnosis and treatment of the positive existence/presence of any ailment, sickness or injury for which confinement is required at a Hospital/Nursing Home.

XNot Applicable

Customized Benefits- Add-on features

11

x

√

Not Applicable

Applicable

Co-Pay

Definition Co-pay again is a special cost containment measure, wherein claimant has to pay a certain % of the claim amount mentioned in the policy. For example if the policy say a co payment of 15% on all claims by parents means claims made by parents has to have a co-payment of 15% of the amount claimed from the employee or claimant.

Co-Pay Amount

NOT APPLICABLE

Room Rent and Ailment Wise Capping

Definition Per Day Rent for Room/ICCU are generally capped and so is limit applicable for certain ailments. The nursing, doctor and other charges which are directly related with Room Rent charges also gets reimbursed in this proportion only.

Status under the policy

Room Rent 1.5% for Normal and 3% ICU of Sum Insured

12

Exclusions

13

What is not Covered1) Any kind of Service charges, Surcharges, Admission fees / Registration charges, etc. levied by the hospital. So at

the time of admission you may check the % of these expenses on total bill, to make necessary financial arrangement.

2) Outdoor Patient Treatment(OPD)

3) Pre-natal and post-natal expenses are not covered unless admitted in Hospital/nursing home and treatment is taken there.

4) Expenses incurred on Diagnosis, X-Ray, or Laboratory examinations not followed by Hospitalization to cure a sickness or an injury

5) Circumcision, Vaccination or Inoculation or change of life or cosmetic or aesthetic treatment of any description, plastic surgery except for relating to treatment of injury or illness.

6) Cosmetic surgery for correction of eye sight, cost of spectacles, contact lenses, hearing aids, etc.

7) All non medical expenses including Personal comfort and convenience items or services such as telephone, television, aya / barber or beauty services, diet charges, baby food, cosmetics, napkins, toiletry items etc, guest services and similar incidental expenses or services etc.

8) Dental treatment or surgery of any kind unless requiring hospitalization on account of accident cases

9) Convalescence, General Debility, Run down condition or rest cure, congenital External Disease or defects or anomalies, sterility, venereal disease, intentional self injury and use of Intoxicating drugs/alcohols.

Exclusions

14

What is not Covered10) Acquired Immuno Deficiency Syndrome (AIDS), HIV and its complications including sexually transmitted diseases.

11) Expenses on vitamins and tonics etc. unless forming part of treatment for injury or disease as certified by the attending physician.

12) Any Expenses on treatment of Insured person as outpatient in the Hospital.

13) Naturopathy treatment, unproven procedure or treatment, experimental or alternative medicine and related treatment including acupressure, acupuncture, magnetic and such other therapies etc.

14) Any Expenses under Domiciliary Hospitalization

15) Genetical disorders and stem cell implantation / surgery.

16) External and or durable Medical / Non medical equipment of any kind used for diagnosis and or treatment including CPAP, CAPD, Infusion pump etc., Ambulatory devices i.e. walker, Crutches, Belts, Collars, Caps, splints, slings, braces, Stockings etc of any kind, Diabetic foot wear, Glucometer / Thermometer and similar related items etc and also any medical equipment which is subsequently used at home etc.

17) Change of treatment from one pathy to other pathy unless being agreed / allowed and recommended by the consultant under whom the treatment is taken.

18) Treatment of obesity or condition arising there from (including morbid obesity) and any other weight control program, services or supplies etc.

19) Any treatment required arising from Insured’s participation in any hazardous activity including but not limited to scuba diving, motor racing, parachuting, hang gliding, rock or mountain climbing etc.

Exclusions

15

What is not Covered20) Any treatment received in convalescent home, convalescent hospital, health hydro, nature care clinic or similar

establishments.

21) Any stay in the hospital for any domestic reason or where no active regular treatment is given by the specialist.

22) 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.

23) Massages, Steam bathing, Shirodhara and alike treatment under Ayurvedic treatment.

24) Doctor’s home visit charges, Attendant / Nursing charges during pre and post hospitalization period.

25) Treatment which is continued before hospitalization and continued during and after discharge for an ailment / disease / injury different from the one for which hospitalization was necessary.

26) Expenses incurred for investigation or treatment irrelevant to the diseases diagnosed during hospitalization or primary reasons for admission. Private nursing charges, Referral fee to family doctors, Out station consultants / Surgeons fees etc.

27) Infertility treatment28) Voluntary termination of pregnancy during first 12 weeks (MTP)

NOTE: For complete list, kindly refer the policy copy.

16

Know your Policy.... What are the important timelines?

Know your Policy.... What to do in case of an emergency?

17

1. Approach the nearest empanelled Network Hospital with your employee ID card / Mediclaim e-card, if you want to avail the cashless facility. If there is no empanelled institutions close by, go to a non empanelled hospital and the claim can be reimbursed later.

2. In case of an empanelled hospital, your hospital can follow up with the TPA Helpdesk which is open 24 hrs a day for the cashless facility with the TPA.

3. Also can get in touch with HIBS for any assistance at 011-45121212 or write to assist@hibsprotect.com. 

4. Claim Intimation - For planned treatments: 48 hours prior to hospitalization and for emergency Treatment: 24 hours within hospitalization. This is applicable for both cashless & reimbursement claims. Please send the intimation to assist@hibsprotect.com

CASHLESS PROCESS

HIBS Contact numbers : 01145121200 (9.30 AM to 6.30 PM) After Office Hours : 09873925551, 9873676755,09953006241 Escalation :- 09873841041 and 9958833330

CASHLESS CLAIM PROCESS

18

Planned/Unplanned cashless request

• Cashless facility is only applicable if the member goes to a network hospital• Employees should carry their mediclaim cards or mediclaim ids along with a photo id proof to the hospital. • Once in the hospital, go to the Help desk/TPA Desk/Reception, and inform that you are covered under Group

Mediclaim Insurance Policy serviced by, the TPA (pls. do not mention Oriental Insurance or Edelweiss Brokers as they are the insurer/broker )

• Ask for the pre authorization form and get it filled from the doctor you or your dependent is being treated by. • Get the filled form faxed to the TPA

– If everything is ok, within 12 hours (generally 2-4 hours) the TPA will sanction the amount – If TPA requires more clarification, it will re-fax the letter of requirement/clarification. The query needs to be

answered satisfactorily via fax. If the query is resolved then TPA will sanction the cashless– The cashless may be rejected if TPA is of the view that ailment/ hosptialisation is not covered under the

policy• If the final bill is more than initial sanctioned amount then at the time of discharge follow the above process again.

Additional limit will be granted if things are in order.• There are few hospitals which may ask for certain deposit amount at the time of admission which will be refunded to

you once the hospital gets it payment from the TPA NOTE: Denial of “Cashless Service” is not denial of treatment. You can continue with the treatment, pay for the services to the hospital, and later send the claim to TPA for processing and reimbursement.

CLAIM PROCESS

19

Cashless Facility Reimbursement Facility

Cashless facility can be availed or granted when the hospital is registered as Network

hospital of TPA

Reimbursement facility is generally availed if the hospital is not in network list of TPA or due to unclear requests cashless is not granted by TPA or if the insured voluntarily does not opt

for Cashless facility.

Planned Hospitalization

When the Cashless request process is

completed in advance

Unplanned/ Emergency Hospitalization

When the request for Cashless is made at the time of admission only

REIMBURSEMENT CLAIM PROCESS

At the time of discharge, collect all bills (stamped and

signed), supporting investigation reports, medical bills, original discharge card,

etc from hospital.

Keep a copy of every document with you for further

reference

Within 15 days of discharge send the completely filled

claim form along with documents (in original) to

HIIBS office

HIIBS sends the documents to TPA after noting and verifying

the details

Is document received by

TPA within 30 days from discharge

Claim RejectedNo

TPA performs medical scrutiny of the documents

Is claim liable

(coverage/ applicability)

Yes

TPA checks document sufficiency

NoYes

Is documentation complete as required

Claims processing done within 15-21 days

Send mail/letter about deficiency and document

requirement

Payment cheque sent to HR Department and claim is settled

Yes

No

The deficient documents

are submitted within

stipulated time

No

Yes

A

A

Know your Policy.... Under what conditions would re-imbursement be provided?

21

HIBS Contact numbers :01145121200 (9.30 AM to 6.30 PM) After Office Hours : 09873925551, 9873676755,09953006241 Escalation :- 09873841041 and 9971730454Final Escalation :- 9958833330

Reimbursement under the scheme is provided for expenses incurred for medical treatment on or after the date of joining of the employee anywhere in India on or after the effective date of coverage for the following conditions: •There has to be a 24 hour hospitalization to claim medical expenses.•The treating hospital should be a registered one with the local authorities having at least 15 beds.•No investigation expenses are covered in case an ailment is not coming out of the investigations.•Reimbursement claims should reach HIBS for processing within 30 days from the discharge date of the patient from hospital.•Employee should intimate the TPA within 24 hours of hospitalization in case of unplanned treatment and before 48 hours of hospitalization in case of planned treatments

REIMBURSEMENT CLAIM PROCESS

22

23

OUR SERVICES

Services offered by HIBS

24

HII Insurance Broking Services Pvt. Ltd. (HIBS) has been appointed as the Broker for GMC Policy this year. HIBS will be the single point of contact for our employees for all queries / coordination and consultancy related to insurance benefits.

Major responsibilities of HIBS is to ensure the following;•Manage the employee experience. Help in documentation, query resolution and emergency assistance.•Dedicated call center support (011-45121212)•Guaranteed Claim settlement as per the policy•Assist in the painful process of cashless & reimbursements•Provide an integrated portal for enrollment, claim status, policy details and all other information related to health insurance benefits•Monitor the policy performance and challenge genuine but denied claims including partial settlements •Mobile App - for accessing the software from mobile phones

Services offered by HIBS

25

We are the industry leaders and experts in providing following corporate

specific services;

•Explain policy benefits & Terms and Conditions to employees

•Manage the SLAs and ensure claim settlement as per the policy features

•Assistance on cashless facility across the country

•Claim and query handling through dedicated call centre

•Integrated portal – for enrolment & real time claim status. Online HR login for

360 degree view of the policy for HR

•Mobile apps - Get your e-card, policy features on mobile phones.

•Health insurance consultation by industry specialists / health benefits experts

Integrated web portal

Our integrated web portal is a one stop solution for all client requirements starting from enrolment to claim payment. Major features are given below;• Enrolment of self & family members

• View real time claim status

• Upload ECS documents for fund transfer

• View policy details

• Online claim intimation

• Download E-card, Network Hospital List, Claim Form, etc.

• FAQs

• Customized HR Login for a 360 degree view of the policy

• Detailed MIS on a click of a button any time

Policy Enrollment

Please log on to www.befikar.com/insurance/c/OssCube or policy enrolment. Following features are available in the portal;

• Enrolment of self & family members

• View online claim status

• Upload ECS documents for fund transfer to the employees account

• View policy details

• Online claim intimation

• Download E-card, Network Hospital List, Claim Form, etc.

Login to the Portalwww.befikar.com/insurance/c/LavaInternational

Please go to this URL www.befikar.com/insurance/c/OssCube

Login to the Portal

Please select company name

Login to the Portal

Please Key in your log in details, Login ID is your Emp Code, for e.g. G001.Password is your DOB in dd/mm/yyyy format

Click on Login to access portal

Login to the Portal

Post Insured you can again login your details and Click on “Download” for get “E-Cards/policy details/claim form etc. It will be opened on your desktop.

My Mediclaim…Mobile APP

Mobile Application has been launched for Android based mobile phones. WAP version has been created for other mobile platforms

Android users can download the app directly from Google play by browsing “HIBS Healthcare”

 Other mobile platform users can access our “wap” application by browsing “app.befikar.com”. All features except “SOS” facility will be working in “wap” applications.  A detailed tutorial is attached for your reference.

We are in the process of developing this application for Blackberry and iPhones. We will intimate you as soon as this application is ready and available in the respective app stores for download.

Mobile APP

Mobile APP

Mobile APP

This app has got the following features including download options for mediclaim e-cards & policy document;

1)SOS - From the push of this button, your mobile will send a rescue calls to your ICE contact. Mobile will also send SMS messages to your predefined contacts with your location. This also has the feature of posting on your face book and twitter accounts once that is configured in your mobile phone.

2) My policy – You can update the details of all kind of insurance policies in one place including but not limited to health, life, accident and motor policies.

Mobile APP

3) Contact us – for contacting with HIBS claim service team.

4) Claim intimation – this will enable users to comply with 24 hrs claim intimation

(as per insurance policy).

5) Healthcare – In this option, user can make search of hospital, Fitness centers,

clinics, pharmacies, wellness centers, blood banks, etc.

6) My Favorites – You can add your frequently visited hospital and other health

care facilities to favorites for quick access next time.

7) Feedback- this options allows you to share your experience with our claim

servicing team which will be shared with Indus on a monthly basis. This will also

help us to improve our services.

8) Enrollment – this will help the employees to do mediclaim enrollment at ease

from mobile phone rather than accessing the web page.

Contact Details Please use the following mail IDs for communication:

37

TIME LINES

Please intimate us on hospitalization as follows:

• Emergency- Claim Intimation is required with in 24 hours from the time of admission

•Planned Treatment - Claim Intimation is required prior 48 hours from the time of admission

•Claim Submission: Within 15days of discharge for reimbursement claims

•Claim Documents should be reach to Below Mentioned Address

HII Insurance Broking ServicesReimbursement Team,Plot No- 87 B, 3rd Floor, Shahpur Jat,New Delhi-110049. Near Asiad TowerContact:- 01145121212/9873676755

•Pre Post claims: Within 75 days of completion of treatment or within 15 days of completion of 60 days of post hospitalization treatment. Kindly Note that New Joinee/Newly Wedded Spouse / New Born child can be

covered with in 15 days from date of Joining/ date of marriage or date of birth of the child

39

Thank you