Employee, Spouse & Children Group Mediclaim Policy 1 st April - PowerPoint PPT Presentation

Employee, Spouse & Children Group Mediclaim Policy 1 st April 2016 – 31 st March 2017 Almondz Insurance Brokers Private Ltd. Employee Benefits Practice

SUMMARY Page No. Section I- • What is covered as part of the CIPLA Mediclaim Program? 02-05 Policy Benefits • What are the Exclusions in CIPLA Mediclaim Program ? • How do you bring your dependents under coverage? Section II- • What are cashless and Reimbursement procedures? 06- 19 Processes • Whom can I contact in case of claim related support ? Section III- • Which all forms would you require for Claims under this policy? Forms & • What are the list of Documents required for reimbursement claims ? 20 - 22 Formats • Which hospitals are empanelled for Cashless Facility ? 1

GROUP MEDICLAIM PROGRAM POLICY DETAILS DESCRIPTION  Policy Holder CIPLA LTD Section I- Policy Benefits  Policy Start & End Date 1 st April 2016 to 31 st March 2017  Insurer The New India Assurance Co. Ltd.  Third Party Administrator (TPA) Medi Assist India TPA  Sum Insured Section II- Sum Insured Eligibility Criteria Processes Rs 1.00 lakhs Per Family Basic Salary below & up-to Rs 10,000 p.m Rs 3.00 lakhs Per Family Basic Salary Rs 10,001 - Rs 30,000 p.m Rs 5.00 lakhs Per Family Basic Salary Rs 30,001 p/m & above Employee +Spouse + Children Section III- Forms & Employee & Spouse Covered  Covered Members Formats Children Covered (as Male child up to 25 yrs and female child till age of 25 yrs or till she is married whichever is earlier.) Go to Main Menu 2

WHAT DOES YOUR MEDICLAIM POLICY COVER ? Benefits Details  Pre-existing Diseases Covered Section I- Policy Benefits Domiciliary Hospitalisation Excluded  Pre & Post Hospitalization Expenses Covered (30 days & 60 days respectively)  Room Rent 2% of Sum Insured for Normal and 4% of Sum Insured for ICU  Section II- Maternity Covered (only as reimbursement upto maximum of Rs. 30,000)  Processes New Born Baby Cover from Day 1 Covered  Co-Payment  Not Applicable Section III- Terrorism  Hospitalization due to terrorism is covered. Forms & Ambulance  Formats Upto Rs.2000/- to be paid (To & Fro - Both way home/accident site etc) There are 172 day care procedures covered under the policy, which do  Day Care Procedures not require 24 hours hospitalization. List of all such procedures is available on Sambandh. Go to Main Menu 3

WHAT DOES YOUR MEDICLAIM POLICY COVER ? Benefits Details Section I- Policy Benefits Terrorism related prolonged treatment/other wise covered, Robotic surgery, Stem Cell therapy & Cyber Knife procedures/hospitalization to  Other Benefits be covered. RMO charges, Surgery attendants charges, consultation fees for the Dr, registration charges up to Rs. 500 covered. Section II- Processes 1. Upfront payment of Rs. 25,000 on diagnosis of Critical Illness 2. Infertility treatment for employees to be covered upto Rs. 100,000 including OPD 3. Loss of pay coverage for the on duty accidental claims upto Rs. 5,000 per week ( Maximum limit upto 25 weeks) 4. OPD benefit to be extended to disabled children upto the age of 5 Section III- Additional Covers  years Rs. 5000 Forms & 5. Sleep Apnoea and pulmonary disorder to be covered for employees Formats only 6. Bariatric surgery is covered for employees with BMI > 35 7. Ayurvedic, homeopathy & unani treatments are covered if hospitalization is done in government hospitals Go to Main Menu 4

WHAT IS EXCLUDED FROM YOUR MEDICLAIM POLICY ?  Natural Disasters & National Emergencies: Cosmetics & Non Medically required procedures  Intentional self injury and use of intoxicating drugs/alcohol  Section I- Congenital external disease or defects or anomalies except life threatening  Policy Benefits Treatment done with no active line of treatment   Cost of Spectacles, Contact Lenses, Hearing Aids Voluntary medical termination of pregnancy during first 12 weeks from the date of conception  Naturopathy treatment  Vaccination & Inoculation  Section II- Hospitalization done for diagnostic purposes  Processes  All types of Dental treatments except arising out of an accident Vitamins and tonics unless forming part of treatment for injury or disease as certified by the  attending physician Any Domiciliary Hospitalization / Treatment  Treatment taken outside India  Section III- Forms & Detailed file with the list of all the exclusions is available in Sambandh. Formats Go to Main Menu 5

CONDITION OF MEMBERSHIP The Insurance cover will be extended to:  All CIPLA employees and their Nominated Family Members as per eligibility  Coverage will be as per the policy and guidelines presented above and any other guideline to be Section I- issued in due course of time. Policy Benefits Cover Expiries :  The moment an Employee leaves the organization  Death of the employee Section II- Processes All employees will be required to provide necessary information regarding their family members to  be covered under the policy, within the allowed enrolment window This will be a one time option for all the existing employees (joined/eligible for mediclaim cover on  or before 31st March 2016) for the policy period i.e. 1st April 2016 to 31st March 2017 In case any employee miss to enroll the dependents during the stipulated window then he/she will  Section III- not be eligible for mediclaim cover for this policy period i.e April 2016-March 2017 for his/her dependents. Forms & Formats Go to Main Menu 6

PROCESS TO GENERATE E-CARD Steps to Login Please use the following link and login your MediBuddy portal Section I- Link: https://cipla.medibuddy.in Policy Benefits Login Details: Username: EmployeeCode@cipla.com Password: your date of birth in DDMMYYYY format (this password is only applicable for employees who are logging in for the first time, others have to login using their changed password) Section II- For Example if your employee ID is 1234 and date of birth is 01 June 1980 than your user ID and password will be as Processes follow Username: 01234@cipla.com Password : 01061980  Refer to the detailed visual guide available in Sambandh for enrolment of spouse & children .  In case of newly married employee, name of spouse needs to be enrolled within 30 days from the date of marriage Section III-  In case of new born child, enrolment needs to be done within 30 days from the date of birth Forms & Formats Go to Main Menu 7

PROCESS TO GENERATE E-CARD- STEP 1 Click here for login Section I- Policy Benefits Section II- Processes Section III- Forms & Formats Go to Main Menu 8

PROCESS TO GENERATE E-CARD- STEP 2 Section I- Policy Benefits Section II- Processes Section III- Forms & Formats Username: EmployeeCode@cipla.com Password: your date of birth in DDMMYYYY format Go to Main Menu 9

PROCESS TO GENERATE E-CARD- STEP 3 Section I- Policy Benefits Click here to download E cards Section II- Processes Section III- Forms & Formats Go to Main Menu 10

PROCESS TO GENERATE E-CARD - STEP 4 E-Cards generated in .pdf format Section I- Policy Benefits Section II- Processes Section III- Forms & Formats Go to Main Menu 11

Group Mediclaim Policy NETWORK HOSPITALISATION - CASHLESS Emergency Hospitalization Section I- Visit hospital Insurance Help Hospital will seek approval Policy Benefits Identify Network Hospital via desk & fill the pre- from Medi Assist mobile app/ website /helpline authorization form (Provided within 2 hrs) You will receive SMS confirmation Section II- Processes At the time of discharge On successful approval Pay for Non Medical Expenses Hospital will send final request admission happens & if any to Medi Assist for approval treatment starts (Provided within 2 hrs) Section III- You will receive SMS confirmation Forms & Planned Hospitalization Formats In case of Planned Hospitalization, authorization should be taken prior, which will be valid for 15 days to avoid delay /inconvenience at the time of hospitalization. Go to Main Menu 12

NETWORK HOSPITALISATION – CASHLESS Before Admission : • Check for the nearest network hospital for availing the Cashless hospital. Section I- • Pre-authorization form is mandatory to be sent to Medi Assist by network hospital Policy Benefits During Admission : • Inform the Medi Assist call center immediately about the hospitalization & seek pre- Section II- authorization. • Medi Assist will send pre-authorization letter for the minimum amount of expected Processes expenses to the hospital • In case of denial, the same will be communicated to the Hospital with proper reasoning During Discharge : Section III- Forms & The bill will be sent by Hospital to Medi Assist • Formats Upon final approval on cashless by Medi Assit to hospital you/patient can proceed • with discharge by paying for Non Medical Expenses. Go to Main Menu 13