GROUP MEDICAL INSURANCE BENEFITS MANUAL

CONFIDENTIAL—FOR INTERNAL USE ONLY.

Employee Benefits Guide

Group Mediclaim Policy

Group Mediclaim

Employee Policy details

Claims Procedure

Exclusions

Contacts & Links The Group Medical policy covers expenses by the insured persons & family members covered) on account of hospitalization due to sickness or accident.

The policy covers expenses incurred on

❑ Room rent, medicines, surgery etc. Expenses for hospitalization

❑ Payable only if a 24 hour hospitalization has been taken (Except for named day care procedures, which do not require a 24 hour hospitalization).

❑ Typical expense heads covered are the following: room/boarding expenses as provided by the hospital or nursing home ; nursing expenses ; surgeon,
anesthetist , medical practitioner, consultant , specialist fees; anesthesia, blood, oxygen, operation theater charges, surgical appliance, medicines and
drugs. diagnostic material and X-Ray; dialysis, chemotherapy, radiotherapy, etc.

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Employee Benefits Guide 2

Group Mediclaim Policy
Policy Details Benefits Details Restrictions

Group Mediclaim

Policy Details
Employee Policy details
➢ Insurer Religare Health Insurance Co. Ltd.

Claims Procedure
➢ Policy Date 22nd January 2020 – 21st January 2021

Exclusions ➢ Sum Insured INR 400,000 Family Floater

Contacts & Links

Covered Members Description Special Condition if any

✓ Total Members Covered per Family (Including Employee) 1+5

✓ Employee Covered

✓ Spouse Covered

✓ Child Covered Only First Two Living Children are Covered

✓ Parents Covered

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Employee Benefits Guide 3

Group Mediclaim Policy
Policy Details Benefits Details Restrictions

Group Mediclaim

Policy Benefits
Employee Policy details

First 30-days & 1st & 2nd Year Waiting Periods Waived off
Claims Procedure
Pre-existing Diseases Covered

Exclusions
Maternity cover from Day-1 Up to INR 50,000 for Normal & C-Section (sub-limit of family floater SI)

Contacts & Links

Covered up to INR 2500 within the overall maternity limit for a period of 30 days
Pre & Post natal expenses
Pre & Post Delivery

Pre & Post Hospitalization 30 days pre-hospitalization / 60 days post-hospitalization

New Born Baby Covered from Day 1

Ambulance Services Up to INR 1,000 per claim – for emergencies only

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Employee Benefits Guide 4

Group Mediclaim Policy
Policy Details Benefits Details Restrictions

Group Mediclaim

Restrictions
Employee Policy details
Room Rent Restricted 1% of the Sum insured for non-ICU and 1.5% for ICU

Claims Procedure

Exclusions

Contacts & Links

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Employee Benefits Guide 5

Group Mediclaim Policy

Planned Hospitalization Emergency Hospitalization Reimbursement

Group Mediclaim Cashless Process

Hospital informs Religare and sends Pre-
Employee Policy details Start Employee Approaches Network Hospital with E-card
Authorization request with approximate cost of the
well in advance
treatment for approval

Claims Procedure

Exclusions Yes
Member gets admitted and at the time of Discharge Religare issues letter of credit (for cashless) to the
hospital sends the final bill and the discharge hospital with approval for partial / full amount as per
summary to Religare for the final approval eligibility, coverage and admissibility of claim
Contacts & Links

No

Religare will re-assess the complete claim Is claim Member gets discharged after the treatment by
documents for admissibility as per policy terms admissible? paying the entire amount and may apply for the
No probable reimbursement

Yes

Religare sends the final approval to hospital which

allows the employee to get discharged by paying all
non-medical / non-payable expenses

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Employee Benefits Guide 6

Group Mediclaim Policy

Planned Hospitalization Emergency Hospitalization Reimbursement

Group Mediclaim
Cashless Process

Employee Policy details

Member gets admitted in the hospital in Religare verifies admissibility of the
Start case of emergency by showing his E-
Member / Hospital applies for pre-
claim to be registered and issues pre-
authorization to Religare
Claims Procedure Card. Treatment starts authorization

Exclusions
Member gets treatment and at the time of Yes
Is claim Discharge, hospital sends the final bill and the Is claim
Contacts & Links admissible? discharge summary to Religare for the final approval admissible?

Yes No
No

Religare sends the final approval to Member gets discharged after the treatment by
hospital which allows the employee to get paying the entire amount and may apply for the Rejection letter sent to Hospital
discharged by paying all non-medical / probable reimbursement
non-payable expenses

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Employee Benefits Guide 7

Group Mediclaim Policy
Planned Hospitalization Emergency Hospitalization Reimbursement

Group Mediclaim

Employee submits all the documents Yes

Employee Policy details to Religare along with filled claim form Is Claim Religare will ask for the additional / missing
within 30 days from the date of admissible? documents, if any
discharge from the hospital

Claims Procedure
No

Start
Exclusions
On rejection of the claim, Religare would
send the rejection letter stating the Employee submits the required shortfall
Contacts & Links reason for rejection documents to Religare

No

Yes
Religare will process the claim and the
reimbursement would be made via NEFT as
Is Claim Religare will re-assess the complete claim
per the eligibility admissible? documents for admissibility as per policy terms

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Employee Benefits Guide 8

Group Mediclaim Policy

Claim Check – List for Reimbursement

Group Mediclaim
Documents GMC Claim
Employee Policy details Original Claim Form fully filled up and duly signed ✓
Cancelled cheque (with name of the account holder printed on it) ✓
Claims Procedure Original Main Hospital bill with Bill No. & break-up (with detailed break-up of various heads like Room Rent / OT
Charges / Nursing Charges etc.)
✓

Exclusions
Original Discharge Summary (Gives the summary of diagnosis and treatment in hospital) ✓
Contacts & Links
Original Death Summary (Only in case of death of patient during hospital stay) ✓
Original Hospital Payment Receipt with Receipt No. ✓
Hospital Registration No. (Registration No. & No. of beds on hospital letterhead with signature) Only in-case of Non-
Network hospital
✓

Doctor’s Registration No. (On Doctor’s letterhead with signature) ✓

Original Pharmacy & Investigation bills ✓
Original Prescriptions ✓

Investigation Reports in Original / Attested from hospital (reports for all tests done along with images) ✓

*This is not a exhaustive list. Religare will call for the additional documents wherever required.
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Employee Benefits Guide 9

Group Mediclaim Policy

General Exclusions

Group Mediclaim o Any cosmetic or plastic surgery except for correction of injury
o Any non-medical expenses like registration fees, admission fees, charges for medical records, cafeteria charges, telephone charges, etc
o Circumcision unless necessary for treatment of disease
Employee Policy details
o Congenital external diseases or defects / anomalies, sterility, intentional self-injury / suicide, all psychiatric and psychosomatic disorders and
disease / accident due to and or use, misuse or abuse of drugs / alcohol or use of intoxicating substances or such abuse or additions etc.
Claims Procedure o Domiciliary Hospitalization Benefit
o Hospitalization for convalescence, general debility, rest cure, intentional self-injury, use of intoxicating drugs / alcohol.
o HIV and AIDS & Venereal diseases
Exclusions o Injury or disease directly or indirectly caused by or arising from or attributable to War or War-like situations or directly or indirectly caused by
nuclear weapons

Contacts & Links o Infertility treatment

o Naturopathy
o Vitamins and tonics unless used for treatment of injury or disease
o Voluntary termination of pregnancy during first 12 weeks (MTP)

*This is not an exhaustive list. For any further questions which is not part of this list please contact Religare.
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Employee Benefits Guide 10

Group Mediclaim Policy

Contacts Links

Group Mediclaim

Employee Policy details

Claims Procedure
For Claims related queries- Inhouse TPA only

Exclusions Escalation level Name E-mail ID Phone Number Designation

Level 1 Corporate Team [email protected] 1860-500-4488 Central team

Contacts & Links
Level 2 Mr. Saroj Swain [email protected] + 91 88845 77366 Manager-Claims

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Employee Benefits Guide 11

Group Mediclaim Policy
Contacts Links

Group Mediclaim

Employee Policy details

Pre- Authorization Form for Cashless claim

Claims Procedure

Exclusions

Contacts & Links

Claim Form for reimbursement claim

Network hospitals list for cashless claims http://www.religarehealthinsurance.com/health-plan-network-hospitals.html

Disclaimer

This manual is intended to be general summary of the benefits offered by your company & should be regarded as guide only. While Almondz shall make every reasonable effort to ensure the accuracy
and validity of the information provided here in this document. Almondz accepts no liability or responsibility for any errors or omissions in the content or for any loss or damages arising out of your Bharti
Home AXA on information provided here. If there is a conflict in interpretation or benefit applicability, then the terms & conditions of the policy will prevail.

Employee Benefits Guide 12