Group Mediclaim Insurance:

Benefit Manual 2024

Prepared By

Aon Risk India Insurance Brokers Private Limited (formerly GIB an

Aon company)
CIN:U67200MH2002PTC137954, , Composite Insurance Broker,
IRDAI License No.119, Valid till 02/03/2027
Registered Office - A wing, 5th floor, One Forbes, Dr. V. B. Gandhi
Marg, Kala Ghoda, Fort, Mumbai – 400001, Maharashtra, India

Benefit Manual 2024

This Benefits Manual Includes

01 02 03 04
The current benefits in Key exclusions The limits of each How to claim?
your Insurance plan benefit covered

2
Know Your Insurance Policies

Group Medical Insurance : Base

Covers in-patient hospitalization and day care expenses incurred by an employee and his insured dependents for a
diagnosed ailment with an active line of treatment. 24 hours of hospitalization is compulsory to register a valid claim under
the group Mediclaim policy.

Group Medical Insurance : Top-up

Top-up health insurance works as a supplement to your primary health cover. These plans offer you the desired medical
coverage in case the sum insured amount of your current health insurance policy gets exhausted .

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GROUP MEDICAL
INSURANCE
PLAN

BASE & TOPUP

CLIENT NAME Benefit Manual 2024 4

 GMC: Base

Group Medical Insurance Plan – What’s Covered

Room rent & boarding Anaesthesia, blood, oxygen, Nursing expenses, surgeon, Medicines and drugs,
expenses Intensive Care Unit, operation anaesthetist, medical consumables such as dressing,
theatre charges and surgical practitioner, consultant & ordinary splints and plaster
appliance specialist fees casts

Diagnostic procedures (such as Costs of prosthetic devices if Organ transplantation including Day care procedures e.g.
laboratory, x-ray, diagnostic implanted internally during a the treatment costs of the donor dialysis, chemotherapy etc
tests) surgical procedure but excluding the costs of the
As per ICICI Lombard day Care
organ
List.

Reasonable and Customary charges

Please note that your insurance benefit plan (like all insurance plans) covers medical expense charges that are reasonable and customary in nature
Reasonable and Customary charges means the charges for services or supplies, which are the standard charges for the specific provider and consistent with
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the prevailing charges in the geographical area for identical or similar services, and considering the nature of the Illness / Injury involved
 GMC: Base

Group Medical Insurance Plan – What’s Changed

Family Definition Sum insured Age Limit

▪ Family definition: Employee, Spouse, ▪ Basis of sum insured – Family Floater ▪ Child: up to 25 Years
First 2 Children’s & 3rd Child is Sum Insured ▪ Parents : No restriction (Enhanced)
covered in case of Twin or Triplet Child ▪ Fixed sum insured- INR 400,000 Per
& Parents or Parent in Laws (Any one ▪ Physically / Mentally challenged kids to
Family (Parents/In-laws is restricted to INR
set. Cross combination not allowed) be considered as dependents even if they
300,000). (Enhanced)
cross the age limit
▪ Exceptional Cover: LGBTQ Covered.
(Condition: Emp Can either add Legal ▪ Disabled child : 3rd & 4th Child (Subject
Spouse / Same Sex / Domestic to submission of disability certificate/
Partner - Live in Relation) medical proof) (Addon)

Dependents Declaration: Dependents are to be declared at the time of Enrolment Window, Watchout for an email for no-reply@getvisitapp.com .

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 GMC: Base

Group Medical Insurance Plan – Key Information

Policy Period Voluntary Top-up Medical Insurance Cover

Your policy is active from 12th Aug 2024 till Sublimit of INR 100,000 to INR 18,00,000 on
11th Aug 2025. voluntary (With Wallet OPD & Health Checkup
Benefits) (Addon)

Insurance company Age Limit

The insurance company for the Children – 0 – 25 years
group medical policy is ICICI Parents –No Restriction
Lombard General Insurance
Company Limited

Third Party Assistance

Mediassist TPA will be servicing
Family Definition
Employee, Spouse/ LGBT, First 2 Living
all claims
Children, Either set of Parents/Parent – In
laws

Sum Insured Limits Type of cover

INR 4,00,000 Family Floater Sum The policy is on a floater Sum Insured basis
Insured Limit per (Parents/In-laws is for your enrolled family members
restricted to INR 300,000)

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 GMC: Base

Benefits Summary

Pre-Existing diseases Covered Ambulance services Covered

Pre-Post hospitalization Covered Day Care procedures Covered

Waiting period Waived off Ayush & Ayurvedic Treatment Covered

Maternity Covered Dental & Vision OPD Not Covered

Pre-Post Natal expense Covered Room Rent Covered

Co-payment

Applicable for all

New-born baby coverage Covered Co-payment Parental Claims only

Benefit descriptions in this benefit manual are to be treated as indicative only.

For a complete list of benefits and exclusions, please also refer to the policy document.

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 GMC: Base

Benefits Summary
Benefits Coverages & Condition's

Standard Hospitalization Covered

Geographical Limits India (Treatment Taken Within the Geographical limit of India under Register Hospital are eligible to claim under policy)

▪ Pre-Hospitalization Expenses Covered up to 60 days (Before date of admission)

Pre & Post Hospitalisation limits ▪ Post Hospitalization Expenses Covered up to 90 days (after date of discharge)
▪ Note : Subject to main claim is admissibility

▪ No deduction in claim amount in case of death of patient.

Nil Deduction - Claims/ Bereavement ▪ Applicable only for Employees for admissible Claims.
Cover ▪ Non-Medical expenses agreed subject to a maximum of Rs.10,00,000/- for entire policy within FSI (Enhanced from
INR.5 Lakhs to INR.10 Lakhs)

People with Disability Coverage Any inpatient hospitalization is covered.

Emergency ambulance charge covered per hospitalization. Ambulance charges will be applicable for transferring patient to
Hospital or between Hospitals in the Hospitals ambulance or in an ambulance provided by any ambulance service provider
only.
Ambulance Expenses limits
▪ Within City- INR.5,000 (Enhanced)
▪ InterCity- INR.10,000 (Addon)
▪ Air Ambulance- INR.25,000 (Addon)

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 GMC: Base

Benefits Explained: Room Rent

▪ INR.6,000 for Normal

Benefit ▪ INR. 15,000 of SI for ICU
Room Rent
▪ No Room rent capping for Covid claims.
Room Rent means the amount
charged by a Hospital for the
occupancy of a bed per day
(twenty-four hours) basis and shall
include associated medical ▪ Choosing a higher category of room than your entitlement will
expenses. Sub-limit on room rent incur additional/ Proportionate charges which needs to be borne
would mean that the insurer by you.
defines the maximum amount it will ▪ Proportionate clause is applicable. If the Insured occupies a room
pay towards the room rent. Mostly, Note with a room rent limit other than his eligibility as per the insurance
this limit is defined as a policy, all the other charges shall be limited to the charges
percentage of sum insured. applicable for the eligible room rent or actuals, and whichever is
lower.

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 GMC: Base

Benefits Explained: Co-pay

Co-Pay

A co pay is the amount of the

claim that is borne by the
employee. Benefit ▪ Co-pay- 10% for all Parental Claims only.
For.eg during a claim process, ▪ Co-Pay applied on Admissible amount
the admissible claimed amount is ▪ No copay for parents for Covid claims
INR 100,000. The policy has a
10% co pay, INR 10,000 will be
borne by the employee and rest
INR 90,000 will be paid by the
insurance company.

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 GMC: Base

Benefits Summary
Benefits Coverages & Condition's

Any Animal / serpent attack Any Animal / serpent attack resulting in treatment on inpatient.

▪ Autism combined limit of Maximum 50 cases with a per Family cap of Rs.25,000 per family on IPD and OPD basis
(Enhanced from only IPD to IPD & OPD)
Autism
▪ Overall policy limit of INR. 10,00,000
▪ Exclusion: External aids is a standard.

Psychiatric ailments Hospitalization arising out of Psychiatric ailments Covered up to INR.30,000 within FSI Limit.

Oral chemotherapy Covered for all within family floater Sum Insured.

Congenital internal disease Covered Subject to Standard Hospitalization

▪ Covered for all Standard Hospitalization claim Upton FSI (Enhanced from life threatening to Standard Hospitalization)
Congenital External disease
▪ Excl- Cosmetic Procedure

Lasik Treatment if power of eye is equal to or above +/- 7.5, is payable

▪ Policy cover only Unifocal Lens as per reasonable & customary charges (or) agreed rates with Hospital
Cataract ▪ Exclusion: Multifocal & Cost of Spectacles

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 GMC: Base
Benefits Summary

Benefits Coverages & Condition's

Organ donor charges ▪ Organ transplantation treatment covered for insured
(Enhanced) ▪ Organ Donor's Hospitalization cost also covered
▪ Cover Septoplasty Upto INR..70,000 in IPD, OPD, Day care etc.
Septoplasty (Addon) ▪ Only in case of accidental and medical related reasons.
▪ Exclusion: cosmetic reasons

Hysterectomy Procedure for Menorrhagia ▪ Covered up to NR.70,000 under Day care and IPD for Age above 40+
or Fibromyoma (Addon) ▪ Excluding OPD

Benign Prostatic Hypertrophy (Addon) Covered IPD & Day care only

Ayush & Ayurvedic Treatment ▪ Covered upto 25% of the sum insured.
▪ Expenses incurred for Ayurveda, Yoga, Unani, Siddha etc. Treatment are admissible
(Enhanced from Ayurvedic to Ayush) ▪ Subject to only when treatment taken in Government Hospital or in any institute recognized by the government
and / or accredited by the Quality Council of India/ National Accreditation Board.

▪ Modern treatment will be at 50% of the sum insured (Both Base and Top Up put together)
▪ 50% Co-Pay for cyber knife treatment / Robotic Surgery.
Modern Treatments
▪ Cochlear Implant treatment shall be restricted to 50% of the FSI Limit.
▪ Modern day care treatment up to 50% of FSI Limit.

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Benefits Summary GMC: Base

Benefit Coverages & Condition's

MATERNITY Maternity Applicable Maternity Benefit is available only for Self and Spouse
RELATED
Maternity Benefits limits Normal - ₹ 50,000 & C-Section- ₹ 75,000
BENEFITS
▪ Covered ₹ 5000/-
Pre & Post natal (Enhanced)
▪ Applicable for both IPD & OPD as part of above-mentioned maternity limits.

▪ Newborn Baby covered from Day one Subject to employee Enrolment within 30 Days
New-Born Baby Eligibility from date of Birth in Visit Portal.
▪ Coverage is subject to Policy Terms & Condition

Well mother expenses Covered within Maternity Limit

▪ Covered for Expenses Incurred for a Normal baby after the birth till discharge.
▪ Automatic coverage for necessary expenses related to the newborn wellbeing after birth
Healthy Baby Expenses / Well
and before discharge.
Baby Care Expenses
▪ Expenses like doctors check- up and any other check-up tests performed to ensure that the
baby is well at birth, to be covered within Maternity Limit

▪ Policy covers the Maternity cost of Surrogate mother only in case of First Child.
▪ Applicable only in case of employee /spouse unable to conceive naturally due to medical
Surrogacy (Addon) reasons such as MRKH, unicornuate-uterus, multiple IVF failure, miscarriage/abortion, or
any other appropriate medical reason are eligible for surrogacy.
▪ Above coverage is subject to Surrogacy (Regulation) Rules in India

▪ Expenses incurred in connection with voluntary medical termination of pregnancy during

Exclusion the first 12 weeks from the date of conception are not covered.
▪ Surgical Infertility treatment including IVF Treatment
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Benefits Summary GMC: Top-up

WHAT'S NEW THIS YEAR-2024-25?

Benefits Coverages & Condition's

Insurer ICICI Lombard General Insurance Company Limited

SUM INSURED 1-18 LAKHS SUM INSURED 9-18 LAKHS

TPA Medi Assist TPA

Policy Period 12-Aug-24 to 11-Aug-25

OPD Benefits - Rs.3,000 per

Pre- Existing Health check-up worth family
Day one coverage
Disease coverage Rs.1,500 per family

Sub limited : Rs1,000

• Restricted to 6000/- for normal and ICU 15000/- each(within OPD Limit)
Room Rent limits • If the Insured occupies a room with a room rent limit under Consultation &
Pharmacy, Vision and Dental
including other than his eligibility as per the insurance policy, all
Boarding, Nursing the other charges shall be limited to the charges Eligible: Only ESC
Charges, etc, applicable for the eligible room rent or actuals whichever
is lower. Eligible -Only Emp

Co-pay Co-pay- 10% for all Parental Claims only

Not Eligible: Parents or
30 days waiting Not Eligible: Spouse, Child &
Waived Off Patents/In-law
period Parents or Patents/In-law

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Benefits Summary GMC: Top-up

Base policy sublimit/ Capping Ailment/

Member Covered
Benefits & Condition’s Maternity Limit
Same set Member enrolled is Base
All the terms and conditions are as per the Covered Subject to Base Sum Insured
Mediclaim policy is default covered under
base policy. Exhausted for any other
Top-up.
Hospitalization/Claim/Ailments

Enrolment
Claims
Policy can only be opted during the initial Exclusion
Being a Voluntary super Top-up policy.
Enrolment window - Visit Health Portal .
The claim can only be entertained under As per Standard Exclusion of IRDA /
Once after the enrolment closure there is
the said policy If the Sum Insured under Insurer
no exceptional Mechanism to Enroll/ opt
the base policy is completely exhausted.
TOPUP during the present/existing policy.

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Benefits Summary GMC: Top-up

Inception Employee: Annual Premium Incl. GST @

18%
TOP-UP POLICY ANNUAL PER FAMILY Premium
Payable
New Joiner : Prorate premium from date of Joining to
Annual Premium Annual Premium end of policy
Sum Insured
Excl. GST @ 18% Incl. GST @ 18%

100000 3,599 4,247 Policy can only be opted during the initial Enrolment
window in Visit Health Portal. Once after the
200000 3,999 4,719 Enrolment:
enrolment closure there is no exceptional Mechanism to
Enroll/ opt TOPUP during the present/existing policy.
300000 5,204 6,141

400000 7,645 9,021

500000 9,938 11,727 Mid Term Allowed only for New Joiner within given Enrolment
Enrolment: window
600000 12,920 15,246

700000 14,212 16,770

In case an employee quits during the policy period,
he/she will be deleted from the main policy and top-up
800000 15,633 18,447 Resignation policy effective from the date of leaving the company
: & the insurance company will refund the pro-rata
900000 16,796 19,819 premium for the remaining policy period subject to nil
claims from the members covered under the policy.
1200000 23,827 28,116
Addition
Newborn Baby & Newly married Spouse (From DOJ /
1500000 30,853 36,407 Newborn &
Policy Inception/ Post enrolment closure- Which ever is
Newly
later) Subject to intimation in Visit Health Portal within
Married
1800000 45,440 53,619 30 Days
Spouse:

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 GMC Both Base & Top-up
Benefits Summary

Benefit Coverages & Condition's

In case of any hospitalization (Example-Maternity, heart, cancer, etc.) if member is infected with COVID
and if there is a treatment involved.
Co Morbidity
Member will be covered up to total sum insured.

Reasonable and Customary Clause Applicable

PPN / GIPSA rates • Applicable, In case of Reimbursement claims from Network Hospital

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 GMC Both Base & Top-up
Claim Intimation

Timelines Applicable for all Mediclaim Policy

Benefit Benefits/Coverages & Condition's

▪ Reimbursement Claims to be intimated to Medi-Assit within 72 Hours of Admission/Discharge which ever is earlier,
except for Accidental claims
Claim Intimation ▪ Intimation Process: Please send an email-to-Email Id bharathi.s@mediassist.in with following details
(Emp ID/ Date of admission / Date of discharge/ Patient Name / relation/Ailment/Hospital Name)

Main Hospitalization
Claim Submission Within 30 Days from the Date Of Discharge Document must reach the TPA Mediassit.
(Mandatory)

Pre -Post
• Pre to be submitted with in 7 days from date of discharge (Main Claim)
Claim Submission
• Post to be submitted within in 7 days on completion of 90 days post hospitalization limit.
(Mandatory)

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 GMC Both Base & Top-up
General Terms And Conditions

• The expenses shall be reimbursed provided they are incurred in India • Please remember, higher the room category higher is the cost of
and are within the policy period. treatment. This may result in faster exhaustion of your total available
• Expenses will be reimbursed to the insured member depending on the eligibility.
level of cover that he/she is entitled to. • If you are opting for a higher room category, then you will have to bear
• Expenses that are incurred for standalone diagnostic or preventive the proportionate increase in cost on all categories/heads.
tests without any active line of treatment and do not warrant a • Dental treatment is not covered. However only in case of accident, the
hospitalization admission are not covered under the plan. mandatory expenses will be payable.
• No Individual should be covered as a dependent of more than one • Vision Treatment which are undertaken for regular maintenance of
employee. eyes are not covered.
• In case an employee has not covered his/her dependents during • Should a colleague opt in and then leave employment during the policy
enrolment, they will be able to add them only during the next renewal. period, the pro-rated premium for the remaining period will be settled in
• Mid-Term enrolments are only allowed for life events. For example: the Full and Final exit settlement.
new-born baby or marriage. These new additions need to be intimated • Colleagues can avail Tax Benefit for Voluntary Parental Cover payment,
within 30 days of event. under Section 80 (D) of the Income Tax Act.
• You are requested to use prudence and proper negotiation with
Hospital/Nursing home in availing the eligible room category.

Benefit descriptions in this benefit manual are to be treated as indicative only.

For a complete list of benefits and exclusions, please also refer to the policy document.

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 GMC Both Base & Top-up
General Exclusions

• War, War like operations (whether war be declared or not) or by nuclear • Doctor’s home visit charges, Attendant/Nursing charges during pre-
weapons/materials and post-hospitalization period.
• Surgery for correction of eyesight, cost of spectacles, contact lenses, • Naturopathy treatment, unproven procedure or treatment, experimental
hearing aids etc. or alternative medicine.
• Any dental treatment or surgery unless arising from disease or injury • External and or durable Medical/Non-Medical equipment of any kind
and which requires hospitalization for treatment. used for diagnosis.
• Expenses incurred at Hospital or Nursing Home primarily for • Change of treatment from one pathy to another pathy unless being
evaluation/diagnostic purposes which is not followed by active agreed/allowed and recommended by the consultant under whom the
treatment for the ailment during the hospitalised period. treatment is taken.
• Expenses on vitamins and tonics etc. unless forming part of treatment • Treatment of obesity or condition arising therefrom (including morbid
for injury or disease as certified by the attending physician. obesity) and any other weight control program, services or supplies,
• Miscarriage, abortion or complications of any of these including etc.
changes in chronic condition as a result of pregnancy except, where • Any treatment required arising from Insured’s participation in any
covered under the maternity section of benefits. hazardous activity. Any treatment received in convalescent home,
convalescent hospital, health hydro, nature care clinic or similar
establishments.
• Any cosmetic or plastic surgery except for correction of injury.

Benefit descriptions in this benefit manual are to be treated as indicative only.

For a complete list of benefits and exclusions, please also refer to the policy document.

21
 GTL
Claims Process

Making a Claim

CLIENT NAME Benefit Manual 2024 22

 GMC Both Base & Topup
Group Medical Insurance Plan
The hospitalization Procedure

You can avail either cashless facility or submit the claim for reimbursement.

Cashless

Cashless hospitalization means the TPA may authorise (upon an Insured person’s request) for direct settlement of eligible services and the
corresponding charges between a Standard Network/PPN Network Hospital and the TPA. In such case, the TPA will directly settle all eligible
amounts with the Network Hospital and the Insured Person may not have to pay any deposits at the commencement of the treatment or bills
after the end of treatment to the extent these services are covered under the Policy. Denial of cashless does not mean that the treatment is not
covered by the policy.

Reimbursement

In case you choose a non-network hospital, you will have to liaise directly with the hospital for admission. However, you are advised to follow
the preauthorisation procedure and intimate the TPA about the claim to ensure eligibility for reimbursement of hospitalization expenses from the
insurer.
To know about cashless or reimbursement, please visit the desired section mentioned below:

23
 GMC Both Base & Topup
Claims Process – Cashless Claims

Planned Claims Emergency Claims

Approach the hospital minimum 48 hours prior to If possible, check which is the closest network hospital in the
hospitalization, produce TPA card with Govt. Photo Id and area. Once admitted, initiate treatment and within 24 hours,
complete pre-authorisation formalities start the process of pre-authorisation

Fax pre-authorisation letter for approval. If documents are in If in order, TPA will issue authorisation letter within 3 hours. If
order, TPA will issue authorisation letter within 3 hours. declined (unlikely in emergencies), a denial letter will be
issued

If the case is declined, a denial letter will be issued to the Post discharge, if you believe the denied claim is payable, do
hospital. However, do note that denial of cashless does not submit the claim as a reimbursement for a secondary review.
mean denial of claim or denial of treatment

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 GMC Both Base & Top-up
Reimbursement
No. Reimbursement Claim Documents

1 Duly filled and signed Insurance Claim Form Part A & Part B IMPORTANT:- Intimation and Submission Timeframes:
Original Discharge Summary stating the date of admission, date of discharge, presenting complaints with
2 duration, clinical condition, detailed line of treatment, final diagnosis and past medical and surgical history
with duration.. Intimation of claim:- 48 hours prior to getting hospitalized
Original Hospital Bill giving detailed break up of all expense heads mentioned in the bill. Clear break ups for planned hospitalization and 24 hours within
3 have to be mentioned for OT Charges, Doctor’s Consultation and Visit Charges, OT Consumables, hospitalization for emergency hospitalization
medicines, Transfusions, Room Rent, etc.
Original Paid Receipt with revenue stamp, hospital seal and signature towards the final hospital bill of Submission of claim :- TPA must receive the claim
4
Hospital for hospitalization period. documents for all reimbursements within 30 days of
discharge from hospital.
5 All Laboratory and Diagnostic Test Reports In Original E.g. X-Ray, E.C.G, USG, MRI Scan, Hemogram etc.

In case the hospital is not registered, please get a letter on the hospital letterhead mentioning the number Kindly retain photocopies of all the documents. KYC –
6 of beds and availability of doctors and nurses round the clock along with the treating doctor registration no Government issued Photo ID and Address proof
on hospital letter head duly signed and stamped

In case of Surgeries where Implant and Stent has been used ,copy of invoice /stickers/Barcode of Implant
7
used will have to be enclosed. The above is an indicative list and additional documents
can be requested to process a claim.
Obstetric History (in case of maternity) [Gravida-Para-Living-Abortion and LMP & EDD]. Time of Admission
8
& Time of Discharge (it is MUST for 24hrs hospitalizations).
9 In case of accidents, please note FIR or MLC (medico legal certificate) is mandatory. Kindly retain photocopies of all the documents. KYC –
Government issued Photo ID and Address proof
Completely filled NEFT Details stating Branch MICR Code, IFSC Code & Account type, Complete Account
Number duly signed by Policy Holder/proposer with Preprinted canceled cheque (Note :First page of Bank
passbook or statement would be mandatory if account number is ink stamped and name of the account
10
holder is not printed. All Fields in the form are mandatory to process)for claim disbursement purpose and The above is an indicative list and additional documents
Aadhaar & Pan card / Form60 is mandatory in all type of claim as per IRDA Guideline and needs to be can be requested for to process a claim.
complied

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 GMC Both Base & Top-up
Key Contacts
Cashless hospitalization – Network List And Contact Details

For Cashless: Hospital Network List For Reimbursement : Documents Dispatch TPA Address

To,
Click on Website – https://mediassisttpa.in/network-hospital-
Mediassist Insurance TPA Pvt Ltd.
search
Ms. Bharathi, Client Servicing No: 58/1A, Singha Sandra Village, Hosur Main
Select Insurer- ICICI Lombard
Road, Begur Hobli Bangalore South Taluk - 560068

Policy Terms, Benefits & Claims

Level Level - 1 Level - 2 Level - 3

Name Ms. Bharathi Ms. Yamuna AY Mr. Rajesh S

Mobile Number +91 9620859678 +91 6366764694 +91 9886167265

Email ID Bharathi.s@mediassist.in yamuna.ay@mediassist.in Rajesh.s@globalinsurance.co.in

Enrolment Portal/ Visit Health App Related Quires: corporate@getvisitapp.com

26
Definitions

CLIENT NAME Benefit Manual 2024 27

Benefits Summary

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:
Standard
Hospitalization • Room Charges,
• Nursing expenses,
• Surgeon, Anesthetist, Medical Practitioner, Consultant, Specialists Fees,
• Anesthesia, Blood, Oxygen, Operation Theatre Charges Surgical Appliances, Medicines & Drugs, & similar expenses.

Pre-existing diseases is a condition for which the insured has been diagnosed with or treated for before the policy
Pre-existing commencement date. The most common examples of such conditions are diabetes, hypertension, thyroid etc.
diseases
Your policy covers pre-existing diseases from day 1.

Pre-hospitalization expenses include various charges related to consultation fees, medical tests and medicine cost before an
individual gets hospitalized. Doctors/physicians conduct a slew of tests to accurately diagnose the medical condition of a
Pre- patient before prescribing treatment. However, in most cases, charges incurred by an individual 30 days prior to his or her
hospitalization hospitalization fall within the ambit of pre-hospitalization expenses. For instance, several tests such as blood test, urine test
and X-ray among others are categorized as pre-hospitalization expenses.
Your policy covers 60 days of pre-hospitalization benefit.

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Benefits Summary

Post hospitalization expenses include all expenses or charges incurred by an individual after he or she is discharged from the
hospital. For instance, the consulting physician may prescribe medicine along with certain tests to ascertain the progress or
Post- recovery of a patient. Expenses related to various therapies, namely, acupuncture and naturopathy are not included by
hospitalization insurance providers in the category of post hospitalization expenses. However, diagnostic charges, consulting fees and
medicine costs are covered.
Your policy covers 90 days of post-hospitalization benefits.

A waiting period is the amount of time an insured must wait before some or all their coverage comes into effect.
The insured may not receive benefits for claims filed during the waiting period. In a corporate group policy, waiting period of
Waiting period 30 days , 1 year and 9 months are waived off. However, in a retail policy most of the waiting period continue to exist.
Your policy has no waiting period.

Maternity benefit covers the cost related to the birth of the child. It includes the delivery charges for both normal and c-section.
Maternity benefit can be availed for the birth of first two children. Maternity benefit will not be applicable in case two biological
Maternity children already exist in the family.
Benefits • Expenses incurred in connection with voluntary medical termination of pregnancy during the first 12 weeks from
the date of conception are not covered.
• Infertility Treatment and sterilization are excluded from the policy.

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Benefits Summary

Pre and Post natal expenses are those which are incurred pre delivery and post delivery e.g., Ultrasound, regular checkups,
Pre/Post Natal doctor's consultation fee, medicines and so on.
Your policy covers Rs. 5000/- both IPD & OPD expenses within the maternity limit

A Newborn baby is covered in the family floater sum insured limits from day 1. However, the birth of the child needs to be
Newborn baby
intimated to the HR team or updated on the benefits portal within 30 days of date of event.
cover
Your policy covers newborn baby cover from day 1.

Ambulance charges include emergency transport of the patient from the residence/place of accident/illness to the hospital
Ambulance where treatment is undergone.
Services Your policy covers ambulance charges for Within City- Rs.5000, InterCity- Rs. 10,000 & Air Ambulance- Rs. 25,000 per
incidence only during emergency.

30
Benefits Summary

Due to medical advancement, a list of treatments do not require 24 hours of hospitalization.

Day Care
For example : Cataract operation, kidney stones removal etc.
Services
Your policy covers list of day care procedures as per the ICICI Lombard list

Ayush/ Ayurvedic is a form of non-allopathic treatment. Under insurance policy ayurvedic treatment undertaken in a
Government Hospital or in any Institute recognized by the Government and/or accredited by Quality Council of India/National
Ayush/ Ayurvedic Accreditation Board on Health is only admissible.
treatment The Ayush & ayurvedic treatment is covered only on in-patient basis.
Your policy covers ayurvedic treatment up to 25% of sum insured undertaken only in a government registered
hospital.

Dental treatment is treatment carried out by a dental practitioner including examinations, fillings (where appropriate), crowns,
extractions and surgery excluding any form of cosmetic surgery/implants. The dental cover is a standard exclusion under the
Dental cover policy except treatment undertaken in case of an accident.
Your policy covers dental treatment only in case of accident subject to standard Hospitalization. No other form of
dental treatment is covered in the policy.

CLIENT NAME Benefit Manual 2024 31

Benefits Summary

Vision cover refers to the maintenance of the health and wellness of the eyes or eye care and includes routine preventive eye
Vision care and prescription of glasses. This remains as a standard exclusion under the medical insurance.
cover
Your policy does not cover vision benefit.

A co pay is the amount of the claim that is borne by the employee. For.eg during a claim process , the admissible claimed
amount is INR 100,000 and the policy has a 10% co pay . The employee will have to bear INR 10,000 and the insurance
Co-pay
company will pay the remaining INR 90,000.
Your policy has a 10% co-pay only on parental claims.

Ailment capping in form of cost containment method to ensure only reasonable and customary charges are payable under the
insurance policy.
Ailment capping The most common form of ailment capping are cataract, knee replacement surgery, oral chemotherapy etc.
Please refer to your policy terms and conditions to understand the ailment caps under your corporate policy.
Your policy has capped as per benefits schedule.

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Benefits Summary

Congenital Disease means anomaly at the time of birth. This I of two types : Internal and External.
Internal Congenital anomaly is a type of birth defect which is invisible in accessible parts of the body. For example: Atrial
septal defect.
Congenital
External Congenital Anomaly is a type of birth defect which is in the visible and is in accessible parts of the body. For example:
Ailments
Cleft lip/palate
Your policy covers internal congenital and external congenital Subject to standard hospitalization
Exclusion: Cosmetic Procedure

Domiciliary Domiciliary hospitalization is a conditions where in the insured is treated as hospitalised even when he is at home
hospitalization Your policy does not cover domiciliary treatments.

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Thank You

Disclaimer: The information contained in this document is intended to assist readers and is for general guidance only. This document is neither intended to address the
specifics of your situation nor is it intended to provide advice, including but not limited to medical, legal, regulatory, financial, or specific risk advice. While care has been
taken in the production of this document, Aon does not warrant, represent or guarantee the accuracy, adequacy, completeness or fitness for any purpose of the
document or any part of it and can accept no liability for any loss incurred in any way by any person who may rely on it. Any recipient shall be responsible for the use to
which it puts this document. This document has been compiled using information available to us up to its date of publication and is subject to any qualifications made in
the document”

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