1. Group Medical Insurance
Client
ASHOKA TRUST FOR RESEARCH IN ECOLOGY AND THE ENVIRONMENT
Contents
Group Medical Insurance 1 1

2. Disclaimer:
This benefit summary will serve as a guide to the benefits provided by ASHOKA TRUST FOR RESEARCH IN ECOLOGY AND THE ENVIRONMENT. The information contained here is only a summary of the policy documents which are kept by the company. If there is a conflict in interpretation, terms & conditions of the policy will prevail.
Prepared by
Emedlife Insurance Broking Services Ltd
No. 862, 3rdFloor
Prabhat Arcade, 80 Ft Road
Koramangala 8th Block 
Bangalore –
Tel:   Fax:
Copyright © All rights reserved. No part of this publication may be reproduced, stored in the retrieval system, or be transmitted in any form or by any means, electronic or mechanical, photocopying, recording or otherwise, without the prior written permission of the publishers. 2 2

3. Help Line Numbers
For all queries and assistance, please contact Emedlife Insurance
Praveen Raj S. (Sr. Executive - Client Services) – (
Arjun (Escalation 1) – (
Ramani (Escalation 2) (
The Insurance Third Party Administrator is Medi Assist India TPA and their contact details are:
Tel: Fax:
Toll free number:
Website:

4. Agenda Group Medical Insurance TPA Service Offerings Log in Procedure
Process for Hospitalization
Escalation Matrix 4

5. Group Medical Insurance Broker
Emedlife Insurance Broking Services Limited
Insurer
National Insurance Company Ltd
TPA
Medi Assist India TPA Pvt Ltd 5

6. Group Health Plan
Policy Holder ASHOKA TRUST FOR RESEARCH IN ECOLOGY AND THE ENVIRONMENT
Period of the Cover 12 months
Inception Date 21th May 2015
Expiry Date th May 2016
Insurer National Insurance Company Ltd
TPA Medi Assist India TPA Pvt Ltd.
Sum Insured Limits INR 2 Lacs, 3 Lacs and 4 Lacs Sum Insured per Employee.
Members Covered Self only
Geographical Limits India (Covers treatment in India only) 6

7. Group Mediclaim Coverages
Pre-existing Diseases covered
Waiver of Time exclusion for diseases (30 days/1 Year/2 Years/4 Years )
Maternity Benefit of INR 25,000 for Normal and 35,000 for C-Section.
Maternity benefit covered from day one.
New Born baby cover.
30 and 60 days Pre & Post hospitalization covered.
Ambulance Charges covered up to 1% of Sum Insured with maximum limit of INR 1,000/- per incidence .
Room rent (Including Nursing charges) charges payable up to 1% of Sum Insured for normal and 2% of Sum Insured for ICU with max limit of INR 5,000 per day. 7

8. Scope of Insurance Cover
Includes:
Only “in-patient” hospitalization expenses.
Active treatment with minimum 24 hours hospitalization.
Pre-hospitalization expenses of 30 days before admission and post hospitalization expenses for 60 days after discharge for an eligible hospitalization
Cashless facility against Pre-Authorisation at Network hospital only
Excludes:
Non - Medical Expenses - Registration/Admission fees, hospital surcharge, food bills for attendants, telephone charges, pharmacy charges for non-medical items etc.
Other standard exclusions
Stay in hospital without undertaking any treatment or where there is no active regular treatment 8

9. Standard exclusions to the Insurance Cover
Injury or disease directly or indirectly caused by or arising from or attributable to war or war like situations and by nuclear weapons.
Circumcision unless necessary for treatment of diseases
Congenital ailments or defects/anomalies
Hospitalization for convalescence, general debility, intentional self-injury, use of intoxicating drugs/ alcohol.
Venereal diseases, HIV and AIDS, Infertility treatment and Naturopathy
 Cost of spectacles, contact lenses, hearing aids
Any cosmetic or plastic surgery except for correction of injury
Hospitalization for diagnostic tests only even if prescribed by a medical practitioner 9

10. Voluntary termination of pregnancy during first 12 weeks (MTP)
Pre and Post Natal expenses are not covered unless admitted in Hospital/Nursing Home for active line of treatment
Unproven or experimental treatment not approved by Indian Medical Council
Any Dental treatment or surgery except arising out of an accident, which requires Hospitalization for treatment

11. Enrollment in the program
Existing employees are covered under the policy from 21th May 2015.
All New joiners must enroll themselves within 20 days of joining the company.
Provide required details of yourself to the HR
HR sends the data to the EMEDLIFE to upload their system
EMEDLIFE will upload this data and inform ATREE on the activation of all facility for employees
TPA will upload
E cards on their Website for all employees
Employee verifies details of the E card on TPA website
Error in data on E card
Send mail to EMEDLIFE / HR with
ID Card Nos.
Use E card/Physical card for cashless hospitalization authorization
E Card Ok 11 11

12. Medi Assist India TPA Pvt Ltd – Service Offerings
Online access to view self details, claim status and e card download
Cashless Hospitalization
SMS facilities for Pre-authorizations.
24 hour telephonic Nurse line.
Claims Administration. 12

13. Procedure for Online Access Procedure for Online access
Please follow the below steps to Login
Log on to https//: .
Select “Login” option present on the top Right of the screen
Select “Corporate Employee”.
User ID:
Password:

14. How does the plan work ? Hospitalization event can be:
Planned or Emergency
In a Network hospital or Out of Network
Hospitals have details of TPAs - please check with hospital helpdesk if they accept Medi Assist Insurance card to avail cashless hospitalization
For updated list of Network hospitals, see 14

15. Network Hospitalization (Planned)
Fill up the Pre-Authorisation form with the help of the treating Doctor and fax it to the Medi Assist Nurse line with the assistance of the hospital staff 48 hours prior to Admission
Medical Management Team assesses the Pre- authorisation request and after it is approved, Medi Assist Nurse line sends Credit letter to Network Hospital
All Medical Expenses including Room Rent would be covered under Cashless 15

16. Call up Medi Assist Nurse line if possible
Network Hospitalization (Emergency)
Call up Medi Assist Nurse line if possible
Or else, get hospitalized into the nearest Network Hospital with the medical E- card/Physical card
Get the Patient treated and after the patient has stabilized, complete the Pre-authorisation process
You can also identify yourself as a member of TPA so that they can assist you with the Pre-authorisation formality. 16

17. Possibility of Denial of Cashless - examples
Admission for investigations/ observation / evaluation only .
Admission beyond a certain number of days apart from the normal package stay.
Treatment not matching with disease mentioned on pre-authorisation form.
Any treatment which otherwise could have been taken on OPD basis.
Any congenital external disease.
Hospital not sending proper query reply raised by TPA on time.
Active line of treatment not mentioned in the pre-authorisation form 17

18. Non-Network Hospitalization (Planned & Emergency)
Claim Intimation has to be provided to Emedlife/Medi Assist
Kindly make the arrangements for the admission and pay all expenses at the hospital
Collect all original documents from the Hospital including the Hosp. & Doctor Reg- istration No.
Claim needs to be sent to Emedlife within 20 days from the Date of Discharge
Pre & Post Hospitalization Bills
Pre Bills: 30 days prior to Date of Admission
Post Bills: 60 days after Date of Discharge 18

19. Procedure of Discharge & Claim without Cashless facility
The employee should arrange for the admission and all other payments required by the hospital.
Collect and submit to Emedlife the following documents (in original) after discharge
Discharge Card/Summary
Main pre-numbered Hospital Bill
Signed Claim Form
Pre-numbered payment Receipt
Prescriptions, reports and bills for all investigations done.
Prescriptions and bills for medicines consumed during hospitalization.
Break-up of the medicines bills amount of Rs. 200/- or more.
Sticker of lens in the case of cataract cases
GPLA certificate in maternity cases
Medico-legal certificate and FIR in accident cases
Hospital’s registration number is required and Mandatory
Claims will not be assessed if all the documents mentioned are not submitted.
Claim Submission Timeline - All claims to be submitted to Emedlife within 20 days from date of discharge.
NOTE : Any delayed submission beyond the timeline mentioned above will not be processed. In such cases, letter from the employee would be required with a valid reason for delay in submission. It is at the discretion of the Insurer to provide the approval for such cases. 19

20. Claims Administration Process
Claims Administration Team
Document handling
Registration of claim with insurer
Liaison with insurer for payment
Explanation of paid amounts and rejection
Document Recovery Team (DR Team)
Sends reminders for the missing/required document(s). In case of non-receipt of the same, may send the entire claim back to the employee or deduct the appropriate amount and send the balance claim for QC
Quality Check Team (QC Team)
Re-assesses the claim to ensure that the claim is complete in all respect before sending it for payment to the insurance company.
Claim settlement
Approximate time to settle claim is working days after receipt by TPA of complete documentation 20

21. Some Important Do’s & Don'ts
Submit the Reimbursement claim documents to Emedlife Helpdesk within 20 days from date of Discharge
Always carry photo ID proof along with your medical card.
Photo ID proof can be: Driving license / PAN Card / Passport / Voter ID.
For Planned hospitalization: take approval before getting admitted in hospital
For Reimbursement cases, always collect all originals from Hospital including final bill with
break up and payment receipt.
Any issues in getting cashless approval, please contact the Account Manager (Emedlife).
On leaving ATREE, the Insurance card is to be returned to HR Deptt. 21

22. For any kind of clarification, please contact:
Emedlife
Medi Assist
Account Manager
Praveen Raj S.
Gajendra
Phone no
Mail ID
1st Escalation
Arjun K
Venkatakrishnan
2nd Escalation
Ramani 22

23. THANK YOU 23