1. Employee Health Insurance Program User Manual 2015-16

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 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
G3–G7: 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. Existing Associates + Dependents New Joiners + Dependents
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 Disease
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
30 Day Waiting Period for new joiners
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
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. SUBJECT TO A MAXIMUM OF RS.1000/-
General Hospitalization Benefits
Domiciliary
Hospitalization
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
Day Care
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
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.
Pre Hospitalization Expenses
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 Member’s Pre- hospitalization Expenses.
Covered for 30 days prior to date of admission
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. Waived off. Maternity benefit available to all employees from day 1.
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.:
Fax: /61 Toll free Fax no:
E mail:
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

21. Obtaining Health Cards
Follow the below mentioned path:
>claims corner >IL 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:
chPrintICard.aspx?Login=N

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:
>claims corner >IL 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:
mStatus.aspx?Login=N

23. I Healthcare important links
Process for claims: claims.cms
Claim Form- en/Hospital_list/click2mail/sendDetails.asp?val=claims_form
Claim form(PDF): en/Downloads/Health/Claim_Form_iHealthcare.pdf
Network hospital list : en/Hospital_list/search.asp
Track your claim : N
Print I card : ogin=N

24. Thank You
Keep it 24