GROUP HEALTH INSURANCE POLICY ICICI Venture Fund Management Co. Ltd

1
Employee Health Insurance ProgramUser
Manual2015-16
1
2
Employee Insurance Program
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,.
2
3
Agenda

• Coverage
• Exclusions
• Points to remember
• Reimbursement claims
• Cashless claims
• Important IL Healthcare details
• Contact details
• Obtaining Health Cards
• Tacking a claim (queried)

4
Employee Health Insurance Policy
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.
4
5
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 dependents G3G7 INR 4,00,000-Self any 4 dependents G8 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
5
6
Health Insurance Policy - Features
Maternity Benefits
Maternity Benefit Covered for the first 2 living children
Maternity limit Sum 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
Restrictions
Room Rent Limit 1 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
6
7
Health Insurance Policy - Features
Existing Associates Dependents
Commencement Date 01st -April-2015
Termination Date 31st -March-2016
New Joiners Dependents
Commencement Date Date of Joining (Subject to availability of Funds in CD Account)
Termination Date 31st -March-2016
New Dependents on account of Marriage / Birth
Commencement Date Date of such event (subject to declaration of dependent within 30 days from happening of event)
Termination Date 31st -March-2016
7
8
General Hospitalization Benefits
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 1
Pre- existing Disease
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
30 Day Waiting Period for new joiners
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
8
9
General Hospitalization Benefits
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
Domiciliary Hospitalization
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
Covered
Day Care
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/-
9
10
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

11
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.
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 Members
Pre-hospitalization Expenses.
Covered for 30 days prior to date of admission
Pre Hospitalization 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
11
12
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
Maternity 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
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.
12
13
Baby Coverage
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.
13
14
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

15
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

16
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.

17
Cashless claims
conti

• 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.

18
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.

19
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 receipt
• Bills paid receipt should be
• supported by
• Medicine bills,
• Prescriptions for medicines
• Original Investigation reports

20
IL Healthcare contacts

• Toll Free Call Center No. 1800 2666
• Fax [phone] Toll free Fax no 1800-2666
• E mail ihealthcare_at_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

21
Obtaining Health Cards

• Follow the below mentioned path
• www.icicilombard.com gtclaims corner gtIL
  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?LoginN

22
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 gtclaims corner gtIL
  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?LoginN

23
I Healthcare important links

• I health care- https//www.icicilombard.com/IL-Hea
  lth-Care/icare.html
• Process for claims https//www.icicilombard.com/h
  ealth-insurance/floater-claims.cms
• Claim Form- https//www.icicilombard.com/Content/i
  lom-en/Hospital_list/click2mail/sendDetails.asp?va
  lclaims_form
• Claim form(PDF) https//www.icicilombard.com/Cont
  ent/ilom-en/Downloads/Health/Claim_Form_iHealthcar
  e.pdf
• Network hospital list https//www.icicilombard.c
  om/Content/ilom-en/Hospital_list/search.asp
• Track your claim http//24x7.icicilombard.com/gh
  i/iHealthCare/iCare_wfrm_ClaimStatus.aspx?LoginN
• Print I card http//24x7.icicilombard.com/ghi/iH
  ealthCare/iCare_Wfrm_SearchPrintICard.aspx?LoginN

24
Thank You