JUST DIAL LIMITED

Group Mediclaim Policy

EMPLOYEE HEALTH INSURANCE PROGRAM

The Group Health Insurance Program provides pre-defined insurance coverage to all employees for expenses related to hospitalization due to illness, disease
or injury.

In the event of a hospitalization claim (more than 24 hrs),if admissible 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:

Surgeon, Anesthetists, Anesthesia, Blood, Oxygen,

Room Charges and Medical Practitioner, Operation Theatre Charges,
Nursing Charges Consultant, Surgical Appliances, Medicines
Specialists Fees & Drugs, & similar expenses

This presentation is a summary of the employee benefit insurance policies offered to the employees by M/S.JUST DIAL LTD. It contains the necessary
details related to your insurance policies like benefits available, claims procedures, enrollment process, as well as contact details of ARIBL
Representatives.

If you have questions or need any additional information, ARIBL team will be happy to assist in all matters concerning to your Insurance Benefits.

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HEALTH INSURANCE : POLICY DETAILS

Policy No.

• Policy No. : 2816/69408405/00/000

Existing Associates

• Commencement Date : 24/01/2023

• Termination Date : 23/01/2024

New Joiners

• Commencement Date : Date of Joining

• Termination Date : 23/01/2024 or date of leaving the organization whichever is earlier

Members Covered
• Employee , Spouse, 2 Dependent Children (Upto 25 Years)

Sum Insured Details

• Family Floater Sum Insured – Rs. 75,000/-, Rs. 2,00,000/-, Rs. 4,00,000/-, Rs. 5,00,000/-

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HEALTH INSURANCE : POLICY DETAILS

Insurance Company TPA Services

Universal Sompo General HealthIndia Insurance TPA
Insurance Services Pvt. Ltd.

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GENERAL HOSPITALIZATION BENEFITS

• The hospitalization should be for more than 24 hours along with line of treatment which justify the
hospitalization. (In certain cases, this time is relaxed due to advancement of treatment, please go
through details of policy)

Hospitalization
Benefits • In case if the hospital is empaneled with the TPA & Insurance Co, Insured can avail cashless facility by
paying security deposit & by forwarding the cashless request form from the hospital to the TPA .
(hospitals take deposit amount at the time of admissions for nonmedical expenses which are not
covered in insurance policy and will return to employee after TPA settles hospital claim ( timeline 60 days
after receipt of physical file)
• IMP - The list of hospitals/ nursing homes shown on the webpage vary from time to time depending
Cashless upon the tie-ups. It is advisable to check at the time of hospitalization.
Benefits

• In case if the hospital is not empaneled with the TPA, then the Insured can avail the hospitalization
benefits in a registered hospital with Municipal authority.
• Employee needs to provide the intimation within 15 days from date of admission. If
intimation of claims is made after 15 days , co-pay of 10% will be applicable . At the time of
Reimbursement discharge Insured has to settled the payment to the hospital & needs to collect all the original documents
Benefits & same needs to be submitted in original within 30 days from date of discharge to ARIBL.

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GENERAL HOSPITALIZATION BENEFITS

• Pre-existing diseases refers to condition or ailments that may have been contracted before the start of
the policy.
• Pre-existing Disease are covered from Day 1
Pre- existing Disease
Covered for all enrolled
members from day 1

• 30 days waiting period waived off.

• Everything is covered from day 1
30 Day Waiting Period
for new joiners
Waived off for all

• Medical insurance policies have waiting period of 1/2/3/4 years for reimbursement of medical
expenses for treatment of certain specified ailments.
• This Waiting period is waived Off
1st/2nd/3rd/4th Year
Waiting Period
Waived off for all
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GENERAL HOSPITALIZATION BENEFITS

• Under the family floater, the insurance cover will be available to all members of the family unit.
• The sum insured is available for utilization by any member of the family with or without any sub limit
inter se.
• It is however subject to the overall family sum insured for all members put together.
Family Floater Applicable

• Day care procedures refers to such treatment which does not necessarily require 24 hrs.
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 Covered

• Ambulance charges are provided for emergency hospitalization wherein if the patient needs to
admitted to ICU or emergency ward in the hospital shall be restricted up to a sum of Rs. 2000 per
Ambulance charges hospitalization / per claim. Cardiac ambulance charges covered upto 8000/- per event.

• 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
hospitalization clause.
Pre-Post Hospitalization • The documents should be related to the ailment hospitalize.

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RESTRICTIONS

Room Rent
Capping
No Room Rent Capping

Co-Payment Deduction
15% Co-Pay is applicable on admissible amount or Sum Insured whichever is higher for all claims
On All Claims

There is no Capping on Room Rent & on any ailment for which hospitalisation is done under Reimbursement
as well as for Cashless Claims

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MATERNITY & NEW BORN BABY BENEFITS

Maternity Expenses Baby Cover

The maternity benefit is applicable for Normal / Cesarean On delivery of a child, the child is prone to many health
delivery within the overall sum insured for the first two live disorders like jaundice or expenses incurred for incubator for
births applicable only for the Employee or Dependent Spouse pre-mature births or any other complication to the child.

Covered up to a limit
Normal Delivery 75,000 & for LSCS / C- Section – 75,000 Payable/Covered up to full floater sum insured from day 1
for First 2 child

. 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.

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Additional Coverage

FEATURES Details

Ayurvedic Treatment Any Ayurvedic Treatment taken in government recognized hospital will be covered
Dental Surgery to be covered only under General Anaesthesia and for Wisdom tooth
Dental Surgery
extraction only, onace a year/per family
Co-Payment of 15% applicable on admissible amount or Sum Insured whichever is
Co-Payment
higher for all claims

Congenital Internal Diseases Covered

15 days from date of admission, If intimation of claims is made after 15 days , co-pay
Claim Intimation of 10% will be applicable . This co-pay will be over and above all other conditions of
policy.

Claim Submission within 30 days from date of discharge

Day Care Procedures Covered

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CASHLESS CLAIMS : ADMINISTRATION SUPPORT

Cashless service ensures that the employee and the covered family members get
treatment at the hospital empanelled in Network Hospital.
Cashless Facility is available only in Network Hospital

You may contact ARIBL representative on the following

For Updated List of hospitals number:
please visit :
https://www.healthindiatpa.com/Hos Mr. Vivek Ghogare - 7400468190
pital_Search.aspx Email ID – vivekghogare@rathi.com
And/or
Ms. Arati Dhamapurkar – 8657963867
Email Id – aratidhamapurkar@rathi.com

IMP - The list of hospitals/ nursing homes shown on the webpage vary from time to time depending upon the tie-ups.
It is advisable to check at the time of hospitalization
Note : Hospitals take deposit amount at the time of admissions for nonmedical expenses not covered in insurance and will return to employee after Insurer
/TPA settles hospital claim ( timeline 60 days after receipt of physical file) 11
HOSPITALIZATION : CASHLESS PROCESS

Planned Hospitalization In case, Cashless is Denied

by the TPA – Please follow
non-cashless process

Below mentioned documents

Member intimates TPA / ARIBL needs to be carried at the time
of the planned hospitalization in Member produces ID Card of Cashless Hospitalization
Claim registered by the
a specified pre-authorization at Network hospital & gets
TPA
form 48 hours prior to admitted
hospitalization E-card copy

Aadhar Card &

Member gets treated and Pan Card Copy
discharged after paying for
TPA issues approval letter
all non-entitled expenses like
Cashless request forwarded within 24 hours for Doctor’s
the deductions based on the
to TPA from the hospital planned hospitalization to consultations
policy terms, the cost of non
the hospital papers
payable items etc. to the
hospital. All investigations
reports
supporting to the
Diagnosis

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HOSPITALIZATION : CASHLESS PROCESS

Emergency Hospitalization In case, Cashless is Denied

In case of a sudden requirement of Hospitalization, the cashless process is as follows: by the TPA – Please follow
non-cashless process

Below mentioned documents

Member get admitted in the needs to be carried at the time
Member / Hospital applies
hospital in case of emergency TPA verifies applicability of of Cashless Hospitalization
for pre-authorization to the
by showing his health card the claim to be registered
TPA within 24 hrs. of
and ID Card. Treatment and issue pre-authorization
admission E-card copy
starts.

Aadhar Card &

Pan Card Copy

Member gets treated and

Pre-authorization given by discharged after paying all non Doctor’s
the TPA entitled benefits like consultations
refreshments, etc. papers
All investigations
reports
supporting to the
Diagnosis

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CLAIMS – REIMBURSEMENT PROCESS

Once the Documentation is

Claim registered by TPA TPA checks document completed Note:
after receipt of claim Deficiency and raise query to
• Claims processing done within • Please send all original physical
intimation within 15 days employee for additional
7-10 working days claim documents at shared address.
of Hospitalization documents if required
• Claims Amount is credited to
Corporate bank Account within Corporate & Registered Office:
5-7 working days after Anand Rathi Insurance Brokers Ltd
processing Vivek Ghogare / Arati D
Insured admitted as per Regent Chambers, 10th
hospital norms. All TPA performs medical Floor,Jamnalal Bajaj Marg,
payments made by scrutiny of the documents for Nariman Point,Mumbai - 400021,
member admissibility of the claim India.

Note:
• Incase of deficiency of documents, TPA
intimates via email / SMS for re-
Documents will be submitted to Documents to be submission of remaining documents.
Anand Rathi Ins Brokers at submitted by employees • If deficiency is not submitted within 30
Helpdesk or Via Courier within 30 days from date days, the same will be considered as
of discharge to ARIBL closed and is subject to insurance co
approval for reconsideration

Incase of any discrepancy found in the claim documents or any documents submitted doesn't not fit as per the policy terms and
conditions, the claim will be inadmissible or closed/ rejected
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CLAIMS INTIMATION – REIMBURSEMENT PROCESS

Claim All Claims must be Intimated to ARIBL VIA Phone/Email within 15days From Date of Hospitalization
Intimation Its Mandatory to strictly adhere to Claim Intimation timelines, to ensure smooth claim processing and to avoid any
Compulsory deduction.
Claim Intimation Guidelines
The employee has the option to intimate claims to the ARIBL/TPA via Phone/Mail.

Planned Hospitalization Emergency Hospitalization

should be intimated two days prior to admission. should be intimated within 15 days of admission.
For all claims, members can send an intimation mail To : frd@healthindiatpa.com.
CC : vivekghogare@rathi.com & namrata.mandal@healthindiatpa.com with the
following details:
 Name of the Employee  Address of the hospital
 Name of the Corporate  Date of admission
 Name of the Patient  Estimated cost of hospitalization
 Employee ID/Insurer /TPA ID  Diagnosis
 Name of the Hospital/Provider
Note: - Violation of above-mentioned timelines may result in denial of claims by the Insurer/Insurer /TPA & any exception will be at the sole discretion of the
Insurer only.
For further assistance /clarification, you can contact: : Mr. Vivek Ghogare, Cell - +91 7400468190
Ms. Arati Dhamapurkar Cell - +91 8657963867 15
CLAIMS – REIMBURSEMENT DOCUMENTS

All reimbursement claims must be submitted within 30 days from date of discharge
All reimbursement claims must be submitted to the ARIBL within 30 days from the date of discharge. Pre-hospitalization bills can be submitted along with
hospitalizations bills in case of reimbursement & in case of cashless claims, the pre-hospitalization bills can be submitted within 30 days from the date of discharge.
In case of post-hospitalization the timeline wound be 30 days from the completion of the treatment or 60 days from the completion of hospitalization, whichever is
earlier.
REIMBURSEMENT CLAIM PROCESS
Signed Claim form of the insurance company - Part A to be filled by the employee & Part B stamp & sign by the hospital is mandatory
In reimbursement claim along with declaration form

Original discharge card /summary or death summary ( In case of death )

Original final hospital Bill (with bill no; signed and stamped by the hospital) with all charges itemized and the original payment receipts

Indoor case papers Attested by hospital Authority

Original bills & receipts for investigations done outside hospital along with doctor prescription. Pathology reports should be signed &
stamp of MD Pathologist.

In case of accident claims –X-ray film along with report, FIR/MLC copy and incident report (How, When and where the injury
has occurred (if MLC / FIR not done, required declaration from treating doctor), Declaration from treating doctor stating alcohol history

In case of Cataract claims – Please mention Phaco charges and Anesthesia charges in O.T. charges

Please mention equipment charges which are used in Operation Theatre in surgical cases needs to be mentioned in O.T. Charges
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CLAIMS – REIMBURSEMENT DOCUMENTS

Original bills of medicines and surgical appliances if purchased

Doctors' prescription, pre & post hospitalization bills (in original)

Proof of identity with photo, address proof required for claims - (Identity proof - PAN Card, Aadhar Card of Patient & Employee)

Stickers & invoice of Lens / Implant / Stent required in case of Cataract claim and surgery for Implant / Angioplasty

Latest Ultrasound report / Sonography report is required confirming pregnancy in case of Maternity claim.

Hospital Registration Certificate (form “C”) If Registration is not there then declaration from hospital stating no’s of beds in the hospital, 24hrs
nursing staff, fully equipped Operation Theater & qualified doctors in the hospital.

Claiming for balance amount (Contribution claims ) -

A) Settlement letter / Certificate from earlier TPA/ Insurance Co.
B) Complete set of documents attested from earlier TPA / Ins Co. C) Original payment receipt of balance amount

Documents submitted after stipulated time shall NOT be considered for claim processing under any condition
COPY OF SET OF ALL SUBMITTED DOCUMENTS INCLUDING BILLS SHOULD BE KEPT WITH EMPLOYEE
Note: There may be additional documents other than the above-mentioned list, required by the TPA, based on specific treatments.
Violation of the above-mentioned timelines during the claims submission process may result in denial of claims by the Insurer/TPA & any exception
will be at the sole discretion of the Insurer only
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EXCLUSIONS

Evaluation / Diagnostic Related Hospitalization

• Expenses incurred towards hospitalization only for Evaluation / Diagnostic purpose is not covered
but not followed by any active line of treatment necessitating stay within hospital.

Dental Cover
• Dental treatment as a result of hospitalization due to an accidental injury is covered in the policy.
However, extension for dental treatment in the policy will cover dental expenses for a fixed
specified limit defined in the policy which is otherwise an exclusion under the health policy.

Ailment Conditions
• Robotic surgery/treatment done using this technology, Stem Cell transplantation/bone marrow transplant,
Septoplasty, Cochlear Implant or related aids, RFQMR - Rotational Field Quantum Magnetic Resonance Device -
Cryotron, C3R, Balloon Sinuplasty, Bariatric surgery, Inj. Avastin /Lucentis/ Macugen, Ozone Therapy, Enhanced
External Counter Pulsation Therapy (EECP), Rejuvenation therapy, Multifocal Lens, Hormonal Therapy /
Adjuvant Therapy / Immune modulators in Cancer treatment .

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WHAT TO DO

Do keep photocopies of E-Card with you in office & with family member’s at home or save image of ID Card on your smart phone
for immediate reference.

Do carry photo ID of Patient (Pancard / Aadhaar Card) during admission in hospital along with photo copy of insurance ID
Card.

Do carry all previous consultation papers / reports prior to hospitalization along with you at the time of admission.

Do carry cash even for cashless claim, since as per hospital process minimum refundable deposit to be kept with hospital
as security. This deposit will be refunded once hospital receive payment from the hospital. Till claim settlement of claim
employee should keep refundable deposit receipt safely.

Do keep one set of photocopy of all documents submitted for reimbursement. Also for cashless hospitalization claim,
collect photocopies of all documents related to hospitalization.

For planned hospitalization check in advance hospital network status with ARIBL representative.

 For planned hospitalization check for Pre-Auth (cashless process) approval 2 days in advance of admission date.

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WHAT NOT TO DO

Don’t forget to collect breakup of each amount mentioned in bill & to collect proper payment receipt of the hospital, as required for
reimbursement process.

Don’t forget to intimate the claim via email / call to ARIBL representative immediately within 15 Days from date of admission.

Don’t forget to share details of new born baby for enrollment within 7 days of date of birth for enrollment of baby in group
mediclaim policy. If baby’s name is not confirmed, mention the name as ‘baby of…’ as mentioned in hospital documents.
Intimation of enrollment of baby addition is mandatory for lodging the baby’s claim.

Don’t forget to share details of spouse (for newly married employee) for enrollment in group mediclaim within 7 days from
date of marriage.

Don’t forget to submit initial hospital documents along with claim form within 30 days from the date of discharge.

Deductible of room rent & non payable expenses deducted from cashless sanctioned amount to be paid by employee at the time of
discharge.

Note: In-case of late intimation, late submission of claim, late intimation for addition of new born baby / spouse not be considered.

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GENERAL EXCLUSIONS
Doctor’s home visit charges/attendant, nursing charges during pre and post hospitalization period except in case of domiciliary
hospitalization.

Expenses on irrelevant investigations/treatment; private nursing charges, referral fee to family physician, outstation
doctor/surgeon/consultant’s fees etc.

Genetic disorders/stem cell implantation/surgery.

External/durable medical/non medical equipment's of any kind used for diagnosis/treatment including CPAD, CAPD, infusion pump etc.,
ambulatory devices like walker/ crutches/ belts/ collars/ caps/ splints/ slings/ braces/ stockings/ diabetic foot wear/ glucometer/
thermometer & similar related items & any medical equipment which could be used at home subsequently.

Non medical expenses including personal comfort/ convenient items/ services such as telephone/ television/barber/ beauty services/
diet charges/ baby food/ cosmetics/ napkins/ toiletries/ guest services etc.

Treatment for obesity or condition arising there from (including morbid obesity) and any other weight control program services/supplies.

Injury arising from any hazardous activity including scuba diving, motor racing parachuting, hand gliding, rock or mountain climbing etc.

Treatment received in convalescent home/hospital, health hydro/nature care clinic and similar establishments.

Payment: All medical/surgical treatments under this policy shall have to be taken in India and admissible claims thereof shall be payable in Indian currency.
Note: The above list is an illustrative list of exclusions and not an exhaustive list of all exclusions.
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SOME POINTS TO REMEMBER

Intimation to HR
department within 7 days Claims should be intimated •Save the following details in
for the following; within 15 days from the your cellphone & your spouse’s
date of hospitalization via phone; •Carry a photo ID in your
Newly married spouse
email, phone or online to •Insurance company name wallet always
•Newborn baby ARIBL with CC to HR •Group policy number
•Change of name (proof department •Mobile no. of Mr Vivek Ghogare
should be present) – 7400468190 one-point contact
for any queries/ concerns

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SUPPORT CONTACT DETAILS

For any query related to Insurance, Associates are requested to follow the below mentioned Escalation Matrix:

Escalation Level Name Designation Contact Details Email ID

Fist Point Of Contact Mr. Vivek Ghogare Asst Manager +91 7400468190 vivekghogare@rathi.com

1st Escalation level Ms. Aarti Dhamapurkar Deputy Manager +91 8657963867
aratidhamapurkar@rathi.com

2st Escalation level Ms Garima Mehta Senior Manager +91 9004111479 garimamehta@rathi.com

Assistant Vice
3nd Escalation level Ms. Nivya Rai +91 9869722668 nivyarai@rathi.com
President

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10th Floor, Regent Chambers,
Jamnalal Bajaj Road, Nariman Point,
Mumbai - 400 021 India
Call: +91 22 4909 3000
E-mail: insurance@rathi.com

www.anandrathiInsurance.com