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Employee Health Insurance Program

User Manual2015-16

This presentation is a summary of the employee benefit insurance policies offered to the employees by 3i INFOTECH LTD. It contains the necessary details related to your insurance policies like benefits available, claims procedures, enrollment process,.

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Employee Insurance Program

Agenda

Coverage

Exclusions

Points to remember

Reimbursement claims

Cashless claims

Important IL Healthcare details

Contact details

Obtaining Health Cards

Tacking a claim (queried)

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The Group Health Insurance Program provides pre-defined insurance coverage to

all employees & their dependents for expenses related to hospitalization due to

illness, disease or injury.

In the event of a hospitalization claim (more than 24 hrs), the insurance company

will pay the insured person the amount of such expenses as would fall under

different heads mentioned below, and as are reasonably and necessarily

incurred thereof by or on behalf of such insured person, but not exceeding

the sum insured in aggregate mentioned in the policy:

- Room Charges,

- Nursing expenses,

- Surgeon, Anesthetist, Medical Practitioner, Consultant, Specialists Fees,

- Anesthesia, Blood, Oxygen, Operation Theatre Charges Surgical Appliances,

Medicines & Drugs, & similar expenses.

Employee Health Insurance Policy

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Health Insurance Policy - Features

Sum Insured type Family Floater with graded sum insured

Sum Insured (Floater)T – G2: INR 2,00,000-Self+ any 3 dependentsG3–G7: INR 4,00,000-Self+ any 4 dependentsG8 & above: INR 6,00,000-Self + any 5 dependents

Members Covered

Employee + Spouse + 2 Dependent children + 2 dependent Parents (Parents are covered for employees who have completed 5 years or more in the organization

Pre - Existing Ailments Covered

30 days waiting period for non - accidental claims

Waived Off

Ambulance Charges Subject to a maximum of RS.1000/-

Domiciliary Hospitalization Not Covered

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Maternity Benefit Covered for the first 2 living children

Maternity limitSum insured subject to maximum of INR 35,000 for normal and INR 50,000 caesarian delivery

9 Months waiting period for Maternity

Waived Off

Baby Cover Covered from Day 1 up-to Family Sum Insured

Maternity BenefitsMaternity Benefits

RestrictionsRestrictions

Room Rent Limit1% of the SI, in case of Normal room max upto 5000/- & 2% of the SI to max upto 10000/- in case of ICU admission

Applicability of Co-payment 10% on Employee, Spouse & Children claims

20% on Parental Claims

Domiciliary Hospitalization Benefit

Not Covered

Health Insurance Policy - Features

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Existing Associates

+ Dependent

s

Existing Associates

+ Dependent

s

New Joiners +

Dependents

New Joiners +

Dependents

New Dependents on account

of Marriage /

Birth

New Dependents on account

of Marriage /

Birth

Commencement Date 01st -April-2015

Termination Date 31st -March-2016

Commencement DateDate of Joining (Subject to availability of Funds in CD Account)

Termination Date 31st -March-2016

Commencement DateDate of such event (subject to declaration of dependent within 30 days from happening of event)

Termination Date 31st -March-2016

Health Insurance Policy - Features

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Pre-existing diseases refers to condition or ailments that may have been contracted before the start of the policy. There is usually a waiting period of 4 years for covering such ailments in standard individual policy.

Covered from day 1Covered

from day 1

30 Day Waiting

Period for new joiners

30 Day Waiting

Period for new joiners

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

Waived off for all

Waived off for all

1st/2nd/3rd/4th Year

Waiting Period

1st/2nd/3rd/4th Year

Waiting Period

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

Waived off for all

Waived off for all

Pre- existing Disease

Pre- existing Disease

General Hospitalization Benefits

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Domiciliary hospitalization means treatment done at home in India for a period exceeding three days for disease, illness or injury, which in the normal course, would require hospitalization. This could happen if either the condition of the patient is such that he/she cannot be moved to Hospital/ Nursing Home, or the patient cannot be admitted to Hospital/Nursing Home for lack of accommodation.

Not Covered

Not Covered

Day CareDay Care

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

Day Care treatment can be taken in network hospitals –

on a cashless basis or in the form of reimbursement

CoveredCovered

Ambulance Charges

Ambulance Charges

Ambulance charges are provided for emergency hospitalization wherein the patient needs to be rushed to the hospital. Under this extension the policy will reimburse such expenses as per the pre decided limits.

SUBJECT TO A

MAXIMUM OF

RS.1000/-

SUBJECT TO A

MAXIMUM OF

RS.1000/-

DomiciliaryHospitalizat

ion

DomiciliaryHospitalizat

ion

General Hospitalization Benefits

Sub Limits for Ailments/Treatments Disease Wise Capping

Appendix - 20,000 Eye related - 20,000 Hernia - 20,000 Hydrocele - 12,000 Hysterectomy - 50,000 Piles - 15,000 Cholecystectomy - 35,000 Tonsilectomy - 15,000 Kidney/Urinary Stones - 25,000 FESS – 35000

50% Co-Pay for cyberknife treatment/Stem Cell Transplantation

Cochlear Implant treatment shall be restricted to 50% of the SI

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Pre Hospitalization Expenses

Pre Hospitalization Expenses

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

Covered for 30 days prior to date of

admission

Covered for 30 days prior to date of

admission

Post Hospitalisation Expenses

Post Hospitalisation Expenses

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

Covered for 60 days post the date of

discharge

Covered for 60 days post the date of

discharge

Pre/Post Hospitalisation

The expenses incurred in relation to the condition of hospitalization, generally 30 days prior to the date of hospitalization as well as 60 days post the discharge are reimbursed under the Pre & Post Hospitalisation Clause.

These expenses include things like medication prescribed at the time of discharge, follow up treatment etc.

Please Note: Pre & Post Hospitalization expenses is applicable in case of Maternity in this policy only in Inpatient basis.

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Maternity ExpensesMaternity Expenses

Maternity or pregnancy related expense of hospitalization other than those excluded (like voluntary termination of pregnancy in the first 12 weeks of delivery) will be payable. The maternity benefit is applicable for Normal / Cesarean delivery within the overall Sum Insured for the first two live births

Covered up to a limit of INR 35,000 for Normal

& INR 50,000 for Caesarean

Covered up to a limit of INR 35,000 for Normal

& INR 50,000 for Caesarean

9 Month Waiting Period

9 Month Waiting Period

The 9 month waiting period waived off for new joiners to claim Maternity Benefits under Group Health Policy.

Waived off. Maternity benefit available to all employees from day 1.

Waived off. Maternity benefit available to all employees from day 1.

Maternity Benefits

The Maternity expenses limit allowable is INR 35,000 per Normal delivery & INR 50,000 per Caesarean Delivery within the overall Sum Insured for the first two live births . There are special conditions applicable to the Maternity Expenses Benefits as below:

Claim in respect of delivery for only first two live births and/or operations associated therewith will be considered.

Expenses incurred in connection with voluntary medical termination of pregnancy during the first 12 weeks from the date of conception are not covered

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

Covered from Day 1. The normal baby expenses like pediatrician visit, nursery charges, etc. prior to discharge from hospital post delivery is covered within the family Sum Insured.

Vaccination charges are not payable.

Covered from Day 1. The normal baby expenses like pediatrician visit, nursery charges, etc. prior to discharge from hospital post delivery is covered within the family Sum Insured.

Vaccination charges are not payable.

Baby Coverage

Exclusions Mid term addition of dependents except

Spouse (should be intimated within 1 month of marriage)

New born (should be intimated within 1 month of delivery)

Hospitalization for investigation only not covered

Lasik surgery, Septoplasty, Infertility treatment are not covered

Administration, registration, miscellaneous and service charges are not covered

Treatment on experimental/trial basis is not covered

Dental treatment is not covered except in case of an accident

Exclusions cont

Holter Monitoring are outside the scope of the policy

Treatment on account of or related to psychiatrist ailment

Expenses related to Prosthesis is outside the scope of the policy

Expenses related to the external medical devices are out of the scope of the policy

Infertility & Related ailments including male sterility is out of the scope of the policy

Cashless claims

For planned hospitalization it is recommended that cashless approval is taken one day prior to hospitalization

Please ensure that pre authorization form has correct UHID along with the updated mobile no.

Please note that stand alone investigation/ diagnostic procedure for evaluation is not covered under the policy.

Once the fax is sent, it is advisable to confirm the receipt of the same from the call centre

If a revert is not received in 4-5 hours from the time of confirmation of fax receipt, please get in touch with HR team who in turn will ensure co-ordination with ICICI Lombard.

Please also note that initial approval from insurance company comes for a part of the estimated cost of treatment, which will be enhanced as per the progress in the treatment based on the progress report provided by the hospital to IL Healthcare.

At the time of discharge final bill should be sent to ILHealthcare 3-4 hours before the time of discharge so that last minute problems can be avoided.

Cashless claims conti…

Reimbursement claims

Main hospitalization claims documents should be submitted within 30 days from date of discharge.

Post hospitalization claim can be submitted within 60 days from date of discharge or 30 days from date of end of treatment whichever is earlier

Please ensure that claim form is filled properly and signed. Please also do not forget to mention the UHID on claim form along with your latest mobile no.

In some cases indoor case papers might be required hence it is advisable that a copy of indoor case papers is collected at the time of discharge from the hospital.

Reimbursement claims cont…

Please ensure that following documents are submitted in original along with the claim form (additional documents may be required depending on the case):Original Discharge card mentioning date of

admission, date of discharge, investigations done, findings, detailed line of treatment

Original bills & paid receiptBills & paid receipt should be

supported by: Medicine bills,Prescriptions for medicinesOriginal Investigation reports

IL Healthcare contacts

Toll Free Call Center No.: 1800 2666 Fax: 040-66989160/61

Toll free Fax no: 1800-2666 E mail: ihealthcare@icicilombard.com Address for sending the reimbursement claims:

ICICI Lombard General Insurance Company Ltd.ICICI Lombard Health Care, ICICI Bank Tower, Plot No. 12, Financial District, Nanakram Guda, Gachibowli, Hyderabad, Andhra Pradesh- 500032

Obtaining Health Cards Follow the below mentioned path:

www.icicilombard.com >claims corner >IL Healthcare

Click on Print I card, mentioned under the head claims, subhead services.

Enter your UHID no. in the box and click on search.

You can take a print out of the card displayed or save it as a PDF document for your future reference.

You can also click on or copy the below mentioned URL to go directly to the print I card page:

http://24x7.icicilombard.com/ghi/iHealthCare/iCare_Wfrm_SearchPrintICard.aspx?Login=N

Tracking a Claim (queried)

You can track the status of your claim by following the below mentioned path, in case the claim is queried:www.icicilombard.com >claims corner >IL Healthcare

Click on Track your claim, mentioned under the head claims, subhead services.

Enter the claim number provided to you at the time of the query & click on search.

You can also click on or copy the below mentioned URL to go directly to the print I card page:

http://24x7.icicilombard.com/ghi/iHealthCare/iCare_wfrm_ClaimStatus.aspx?Login=N

I Healthcare important links I health care- https://www.icicilombard.com/IL-Health-Care/icare.html

Process for claims: https://www.icicilombard.com/health-insurance/floater-claims.cms

Claim Form- https://www.icicilombard.com/Content/ilom-en/Hospital_list/click2mail/sendDetails.asp?val=claims_form

Claim form(PDF): https://www.icicilombard.com/Content/ilom-en/Downloads/Health/Claim_Form_iHealthcare.pdf

Network hospital list : https://www.icicilombard.com/Content/ilom-en/Hospital_list/search.asp

Track your claim : http://24x7.icicilombard.com/ghi/iHealthCare/iCare_wfrm_ClaimStatus.aspx?Login=N

Print I card : http://24x7.icicilombard.com/ghi/iHealthCare/iCare_Wfrm_SearchPrintICard.aspx?Login=N

Thank You