Group MediClaim Policy

for Management Employees

Aditya Birla Group - India

Group refers to the Aditya Birla Group in this document. This policy is meant exclusively for the perusal of,
and strictly for circulation within, the Aditya Birla Group. Please note that sharing of information contained in
this policy, other than with employees of the Aditya Birla Group without written consent from Group Human
Resources, would be construed as a breach of the Groups Code of Conduct.
 Group MediClaim Policy (GMC) for Management
FY 16-17
Employees

1. Eligibility& Applicability

This policy will be applicable to all Business Units in India and to all Aditya Birla Group management
cadre employees in Job Bands 11 & above working in India.

Earlier, businesses have also included non-management cadre employees in the Group Mediclaim
Policy. To provide segregation between Management and Non-Management employees that are
covered in the Group MediClaim, a separate Non-Management GMC Policy with varying terms was
introduced on 1st April 2015.

For employees for who have not been assigned a Job Band, Business HR is required to segregate
them into management or non-management employees for the purpose of the GMC policy.

2. GMC Policy Sum Insured

GMC Policy has the following sum insured for the job band.

Job Band Family Floater (in INR)

JB 5 & above 5,00,000
JB 6 to JB 9 3,00,000
JB 10 - JB 11 2,00,000

3. GMC Premium
The annual premium payable for GMC policy for the Year 16-17 as mentioned below
Premium Applicable for FY 16-17 [1st April 2016 31st March 2017]

Sum Insured Premium per family

(Without Service Tax)
(in INR)
Rs. 2 Lakhs 17,107
Rs. 3 Lakhs 23,183
Rs. 5 Lakhs 34,263

Note:
Service Tax is applicable and charged extra on the premium.
The premiums for GMC Policy are negotiated by the CIP committee. There may be an
increase/decrease in the premium value in the future basis the portfolio behavior and claims out
go at renewal. The same will be communicated to the employees before the renewal date.

4. BENEFICIARY (Definition of Family)

Employee + Spouse + 2 Dependent Children / Siblings (Unmarried & Non-earning only) (Combination
allowed) + 2 Dependent Parents / Parents in-Law (Combination allowed). Family Size should not
exceed 6 members.

New Born baby / adopted child is covered from DOB / date if adoption and newly married spouse
from date of marriage, provided enrolment request is shared with Insurer by 10th of subsequent
month of event. In case their addition is not provided within timeframe, New Born baby / adopted
child and newly married spouse can be covered from 1st day of the month for which endorsement
data is shared with Insurer. (i.e. 1st day of the endorsement data month)

Swapping of any member already covered is not allowed during the course of the year. The list once
submitted will be valid for the currency of the policy. The additions during currency of the policy will
be permissible only in cases like marriage of employee, birth / adoption of child. The deletion during
currency of the policy will be permissible only in case of dependent losing dependency, death and
change in marital status.

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 Group MediClaim Policy (GMC) for Management
FY 16-17
Employees

Below table gives few illustrative scenarios for better understanding of Family definition:

Particulars Married Married Married Unmarried

Employee (Self) 1 1 1 1
Spouse 1 1 1 -
Dependent Children 2 1 - -
Max 2
Dependent Siblings - 1 2 2
Dependent Parents 2 1 - 2
Dependent Parents in Max 2
- 1 2 -
Law
Total 6 6 6 5

5. DURATION:
The term of the policy is one year and it will be renewable on an annual basis.

6. BROKER:
Aditya Birla Insurance Brokers Limited.

7. POLICY ADMINISTRATOR:
This policy will be serviced through different Third Party Administrators for different Businesses.
The TPAs servicing the policy are:
Medi Assist India
Family Health Plan Limited
United Health Care Parekh Ltd.
Please connect with your Unit Administrator for information on the TPA servicing your Business Units.

8. NATURE AND SCOPE OF COVER:

The policy primarily covers expenses incurred for hospitalization due to accident or disease and
cover:

Expenses for medical/surgical treatment at any Nursing Home/Hospital in India as an inpatient

or
Domiciliary hospitalization treatment in India under Domiciliary Hospitalization Benefits.

The Insurer will pay the amount of such expenses under different heads mentioned below as are
reasonably and necessarily incurred by or on behalf of the Insured Person/s but not exceeding the
floater Sum Insured per family in any one period of insurance.

Room, Boarding Expenses as provided by the hospital/nursing home, subject to Individual

entitlements.
Nursing Expenses.
Surgeon Anesthetist Medical Practitioner, Consultants, Specialists Fees.
Anesthetist, Blood, Oxygen, Operation Theatre Charges, Surgical Appliances, Medicine & Drugs,
Diagnostic Material and X-Ray, Dialysis, Chemotherapy, Radiotherapy, Cost of Pacemaker,
Artificial Limbs & Cost of Organs and similar expenses.

Note:
No payment shall be made under C other than as part of the hospitalization bill.
However, the bills raised by Surgeon, Anesthetist directly and not included in the hospitalization
bill may be reimbursed in the following manner:
1. The reasonable, customary and necessary Surgeon fee and Anesthetist fee would be
reimbursed, limited to the maximum of 25% of Sum Insured. The payment shall be
reimbursed provided the insured pays such fee(s) through cheque and the Surgeon /
Anesthetist provides a numbered bill. Bills given on letter-head of the Surgeon, Anesthetist
would not be entertained.
2. Fees paid in cash will be reimbursed up to a limit of Rs. 10,000/- only, provided the
Surgeon/Anesthetist provides a numbered bill.

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 Group MediClaim Policy (GMC) for Management
FY 16-17
Employees

9. GMC Policy Terms and Conditions

9.1. Scope of cover:
Pre-existing diseases/illness is covered from day one for existing employees and their
dependent members as well as for new joiners.
No waiting period: Any disease contracted by the insured person from commencement of the
policy will be covered.
Ambulance hire charges are allowed up to Rs.5000/- per hospitalization and maximum up to
3% of Sum insured per policy year.
Dental treatment claim is allowed only for root canal treatment (RCT) with routine and
reasonable cost of ceramic capping. The policy capping on dental care expenses as applicable
as per the table given below.
Treatment of Cataract will be covered to the extent of cost of Unifocal lens implants.
Hospitalization period: Expenses on Hospitalization for minimum period of 24 hours are only
admissible. However, this time limit will not apply if the treatment is such that
It necessitates hospitalization and the procedure involved requires specialized infrastructural
facilities available in Hospital.
Specific treatments i.e. Dialysis, Chemotherapy, Radiotherapy, Eye Surgery, Dental Surgery
resulting from an accident requiring hospitalization, Lithotripsy (Kidney stone removal),
Tonsillectomy, D&C taken in the Hospital/Nursing Home and the Insured is discharged on the
same day, the treatment will be considered to be taken under hospitalization Benefit.
Day care treatment as guided by IRDA guidelines.

9.2. Pre-Hospitalization
Relevant medical expenses incurred during period up to 30 days prior to hospitalization for the
same disease/illness/injury sustained will be considered as part of claim

9.3. Post-Hospitalization
Relevant medical expenses incurred during period up to 60 days after hospitalization for the same
disease/ illness/injury sustained will be considered as part of claim

9.4. Maternity Benefit

Maternity Benefit means treatment taken in Hospital/Nursing Home arising from or traceable to
pregnancy, childbirth including caesarean section.

Conditions applicable to Maternity Benefits: -

Cover up to maximum Rs.50,000/- per maternity claim under the Maternity Benefit in respect
of each insured family, it attaches from the date of entry in the scheme.
Maternity benefits will be available to employee & spouse only.
These benefits are admissible only if the expenses are incurred in Hospital/Nursing Home as
in-patients in India.
Claim in respect of delivery for only first 2 living children and/or operations associated there
with will be considered under the Policy. Those insured Persons who are already having two
or more living children will not be eligible for this benefit. Third maternity event due to prior still
birth or death of child will be covered under maternity.
Pre-natal and Post-natal expenses to be covered on 30/30 days basis within overall maternity
sum insured for hospitalization cases.
Expenses incurred in connection with voluntary medical termination of pregnancy during the
first 12 weeks from the date of conception are not covered.
Maternity complication like DIC (disseminated intravascular coagulation), embolisms, etc. will
be covered up to family floater basic sum insured.
IVF treatment taken under daycare/ hospitalization will be covered up to maternity limit of Rs
50,000/- only. This benefit is applicable only for 1st child.
New Born twin/triplet after the first child already been covered will be allowed coverage in the
policy for all employees, irrespective of the existing family size during the current policy period.
However at next renewal the employee will have to maintain his family count as 1+5, and in
case the count is exceeding 6, then the employee will have to delete the existing parent/In-
law or sibling and can cover more than 2 children.

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 Group MediClaim Policy (GMC) for Management
FY 16-17
Employees

9.5. Domiciliary Hospitalization Benefit

Medical treatment for a period exceeding three days for such illness/disease/injury 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.
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 hospital/nursing home for lack of accommodation therein.

Subject however that domiciliary hospitalization benefits shall not cover the following
Expenses incurred for pre and post hospital treatment and
Expenses incurred for treatment for any of the following diseases.
Asthma
Bronchitis
Chronic Nephritis and Nephritic Syndrome
Diarrhea and all type of Dysenteries including Gastro-enteritis.
Diabetes Mellitus and Insipidus
Epilepsy
Hypertension
Influenza, Cough and Cold
All Psychiatric or Psychosomatic Disorders
Pyrexia of unknown Origin for less than 10 days
Tonsillitis and Upper Respiratory Tract Infection including laryngitis and Pharyngitis
Arthritis, Gout and Rheumatism.

9.6. Premium Co-Pay (Employee Contribution)

Employee contribution to the premium shall be as per the table below:

Type of Insured Contribution % age of

a) Employee / Spouse / Dependent children < % of TOTAL

Age 30 years / Dependent Siblings < Age 10% family
25 years premium
b) Parents / Parents in Laws 50% % of premium
PER FAMILY
MEMBER
c) Dependent children age 30 years & above/ assuming
100%
sibling age 25 years and above family size of 4
members**
*Total employee contribution towards co-pay shall be limited 50% of family premium + Service Tax extra
**The family size shall be taken as 4 members irrespective of actuals for premium co-pay calculation
purposes

Employees can claim benefit under section 80D of the Income Tax Act as per current tax
regulations for the premiums deducted as employee contribution. The employee may check for
any change in the Income Tax regulations for benefits in future years.

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 Group MediClaim Policy (GMC) for Management
FY 16-17
Employees

Premium Co-Pay Applicable for Policy Year 1st April 2016 to 31st March 2017

Sum Assured Category

Particulars
(Figures in INR)
Sum Assured Category (in
2,00,000 3,00,000 5,00,000
INR)
Premium per Family for 2016-17 17,107 23,183 34,263
Per family member (assuming
4,277 5,796 8,566
family size of 4)
Employee contribution %
a. Employee, spouse, dependent % of total
children < age 30 yrs, dependent 10% family 1,711 2,318 3,426
siblings < age 25 yrs premium

% of
b. Parents / Parents- in-law 50% premium 2,138 2,898 4,283
per
family
member
c. Dependent children age 30 yrs assuming
& above/ sibling age 25 yrs and 100% family 4,277 5,796 8,566
above size of 4
members

Example:
Below table gives few illustrative scenarios on the co-pay model (Figures in INR per annum unless
specified otherwise)
Employee Employee Employee
Particulars
A B C
Family Size E/S/C: 3 E/S/C: 3 E/S/C: 4
Key : P: 2 P: 2 P: 2
Employee ,Spouse & Children (E/S/C) S>25: 1
Parents / Parents-in Law (P) Total : 6 Total : 5 Total : 6
Sibling above 25 years (S>25) members members members
Sum Assured Category (in
2,00,000 3,00,000 5,00,000
INR)
Premium per Family for 2016-17 17,107 23,183 34,263
Per family member (assuming
4,277 5,796 8,566
family size of 4)
Employee contribution %
a. Employee, spouse, dependent % of total
children < age 30 yrs, dependent 10% family 1,711 2,318 3,426
premium
siblings < age 25 yrs
% of
premium
b. Parents / Parents- in-law 50% per family
4,277 5,796 8,566
member
c. Dependent children age 30 yrs assuming
family size
& above/ sibling age 25 yrs and 100% of 4 4,277 Nil Nil
above members

Total ( I + II) 10,264 8,114 11,992

Maximum limit : 50% of total

8,554 11,592 17,132
family premium
Final Co-pay Premium to be
8,554 8,114 11,992
paid

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*All clarifications / changes appear in red font in the policy
 Group MediClaim Policy (GMC) for Management
FY 16-17
Employees

9.7. Claim Co-Payment

The claims co-payment shall be applicable as per the table below:
For Parents/ Parents-in-Law Employee, spouse, child, sibling

Claims co-pay % 15% of the total claim amount 10% of the total claim amount

Capping on Claims Co-Pay for different sum insured is as follows:

Sum Insured For Parents/ Parents-in-Law Employee, spouse, child, sibling

Rs. 2 Lakhs Rs. 15,000 Rs. 10,000
Rs. 3 Lakhs Rs. 35,000 Rs. 25,000
Rs. 5 Lakhs Rs. 45,000 Rs. 25,000

Note:
i. Co-pay will not be applicable on dental claim coverage.
ii. Co Pay will be applicable on each claim separately including buffer claims (eligible admissible
claim amount), and will not be restricted to above given limits of co-pay in case of multiple
claims.
Example: Single claim of Rs 2 lakhs on parents for a SI of Rs 2 lakhs will have co-pay deduction
of Rs 15,000 only. However if there were 4 claims of Rs.50, 000/- each on parents then the co-
pay deducted will be per claim basis and the total value that will get deducted will be Rs. 30,000.
Co Pay will not reduce Sum Insured.
Example: If the eligible medical expenses incurred is 4 lakhs in an employee with Rs 2 lakhs
of SI, he will get entire 2 lakhs payable as the balance after the co-pay would still be Rs.
3,60,000 which is higher than the SI.

9.8. Room Rent Eligibility:

The room rent eligibility for the insured person will be as per following table:
Sum Insured Category Type of Room entitlement
Rs. 2 Lakhs I A/C / Air Cooled Sharing Room
Rs. 3 Lakhs II A/C single / Air Cooled Room
Rs. 5 Lakhs III A/C Deluxe Single Room
i. The above entitlement, however, does not prohibit an insured person from availing the lower
category rooms.
ii. In the event of the person getting admitted in higher category room, all other related charges
like OT Charges, Surgeon fee, Anesthesia fee, Doctor Charges & Nursing Charges etc., will
be restricted to the eligibility limit as per the room entitlement.

9.9. Dental Benefits

Dental treatment (Root canal with routine and reasonable cost of Ceramic capping) is covered as
per below given limits.
Sum Insured Category Maximum Limit per Family*
Rs. 2 Lakhs I 3,000
Rs. 3 Lakhs II 3,500
Rs. 5 Lakhs III 5,000
*No co-pay applicable on dental claims.

9.10. Small Value Claims

Any claim, where the claim amount is less than 1% of the sum insured shall not be admissible
under the policy. The same shall not be applicable in case of pre/ post hospitalization expenses
and dental care expenses.

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 Group MediClaim Policy (GMC) for Management
FY 16-17
Employees

9.11. Provision for Corporate Buffer and Guidelines for Utilization

1. The Corporate Buffer is available to take care of Tertiary Diseases (as listed below),

List of Tertiary diseases

i. Renal failure of any etiology requiring Kidney Transplantation or Dialysis.
ii. Cerebro-Vascular Strokes
iii. Open and Close Heart Surgery (inclusive of C.A.B.G.)
iv. Malignancy disease which are confirmed on Histopathological report.
v. Encephalitis of any origin
vi. Neuro Surgery
vii. Total Replacement of joints
viii. Liver disorder associated with complications like Cirrhosis of Liver except as a
resultant of Alcohol intake.
ix. Grievous injury including multiple fractures of long bones, head-injury leading to
unconsciousness, burns of more than 40% injury requiring artificial ventilator
support plus Vertebral Column injury.
x. As per IRDA List.

2. Buffer Utilization Guidelines:

Overall INR 10 Lakhs per family, with a sub limit of maximum INR 5 lakhs for all family
members excluding the employee.
Example: Overall Maximum Buffer per family is INR 10 Lacs, within this, maximum INR
10 Lacs for the employee and maximum INR 5 Lacs for the other family members
excluding the employee.
Corporate Buffer can be made available to employees at management discretion. This is
not an entitlement and cannot be claimed by the employees as a right. It should be noted
that any buffer utilization is subject to overall corporate buffer limits and utilization
guidelines.

9.12. Reinstatement of Sum Insured

Buffer Sum Insured can be used for the purpose of reinstatement of Basic Sum Insured only once
during the Policy Period after it is exhausted completely. Further, this is not an automatic
Reinstatement and it will be done only on specific request by Insured at the time of subsequent
admission /hospitalization with a condition that the disease causing the deficiency of Sum Insured
will be out of the scope of reinstated sum insured for the person who was affected with the said
disease. The reinstated Sum Insured will be available to other members of family for the same
disease as well as the entire family for any other disease. The particular disease will however, be
covered in subsequent renewals.

9.13. Plan Exclusions

Injury or Disease directly or indirectly caused by or arising from or attributable to War, War like
operations and Nuclear Perils
Circumcision unless necessary for treatment of a disease not excluded hereunder or as may
be necessitated due to an accident, vaccination or inoculation or change of life or cosmetic or
aesthetic treatment of any description, plastic surgery other than as may be necessitated due
to an accident or as a part of any illness.
Cost of spectacles and contact lenses, hearing aids.
Any Dental treatment or surgery of any kind unless requiring hospitalization. Cost of dentures,
crowns, bridges. (Except for root canal treatment (RCT) with routine and reasonable cost of
ceramic capping)
Convalescence, general debility, Run-down condition or rest cure. This condition is not
covered under any specific illness and does not mainly required treatment except rest. Hence
excluded under the policy.
Congenital external disease or defects or anomalies. This applies to deformity / defects of
external body parts like Cleft Lips Palate, Clubbed Foot etc. are excluded under the policy.
(However Congenital internal disease is covered under the policy)
Sterility, infertility (other than IVF)
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 Group MediClaim Policy (GMC) for Management
FY 16-17
Employees

Venereal disease
Intentional self-injury
Use of intoxicating drugs/alcohol. Any disease caused or aggravated due to consumption of
alcohol, drugs or any other narcotic substance is excluded under the policy.
All expenses arising out of HIV/AIDS.
Charges incurred at Hospital or Nursing Home primarily for diagnostic, X-ray or laboratory
examinations not consistent with or incidental to the diagnosis and treatment of the positive
existence or presence of any ailment, sickness or injury, for which confinement is required at a
Hospital/Nursing Home. Also only tests carried out like blood, urine, x-rays, sonography, etc.
for diagnostic purpose and which does not require hospitalization is excluded under the policy.
Expenses on vitamins and tonics unless forming part of treatment for injury or disease.
Voluntary medical termination of pregnancy during the first 12 weeks from the date of
Conception.
Naturopathy treatment.
Private Nursing or Aya, recommended / Non-recommended by doctor during hospitalization or
for management at home.
Treatment for Age related Macular Degeneration (ARMD), treatment such as Rotational Field
Quantum magnetic Resonance (RFQMR), Enhanced External Counter Pulsation (EECP),
etc.), Injection Avastin, Lucentis, Inj.Oxurdex(Retinal vein occlusion), Any epidural
injection(Steroid), Inj. Ritoxicaime/ Remicade /Mebthera (Rheumatoid Arthritis)
Service charges, surcharges or any other similar charges levied by hospital.
Non medical items as guided by IRDA.
Robotic Surgery is not covered however charges for conventional method of treatment will be
payable.

9.14. Claim Intimation and Submission (Important)

Upon the happening of any event which may give rise to a claim under this policy notice with
full particulars shall be sent to the Insurance Company, TPA with cc to ABIBL within 7 days
from the date of Hospitalization.
Claim must be filed complete set of claim document as per check list given by TPA within 15
days from date of discharge from the Hospital.
Insurance company will not be liable for any claims raised beyond the stipulated time period
specified above.
Note: Waiver of this Condition may be considered in extreme cases of hardship where it is
proved to the satisfaction of the Company that under the circumstances in which the insured
was place it was not possible for him or any other person to give such notice or file claim within
the prescribed time-limit.

10. Point of Contact

For more details on the policy applicability and features or any query, please get in touch with
your Unit HR - Benefits Administrator.

Name of Benefits Administrator: ____________________________

Email Id: ____________________________

Contact No: ____________________________

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Aditya Birla Group
*All clarifications / changes appear in red font in the policy
 Group MediClaim Policy (GMC) for Management
FY 16-17
Employees

End of Document

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Aditya Birla Group
*All clarifications / changes appear in red font in the policy